Healing Emergency Workers' Psychological Damage

The stress on mental health professionals and volunteers involved with catastrophic disasters can linger long after those events have faded from the public's mind.

A FEW YEARS AGO, I was puzzled by the remark of a client at the close of a therapy session in which she had dealt with an intensely traumatic event. "You're awfully brave," she said. After I wondered about the meaning of this statement for two weeks, the client was asked to clarify it in the next session. In stating that "You have to listen to all of this," she displayed amazing insight into the work of the professional helper. A mental health professional can be affected by what is heard in the therapy session or experienced in crisis and disaster efforts.

Mental health professionals--counselors, social workers, psychologists, psychiatrists, therapists, psychiatric nurses, etc.--risk the possibility of becoming traumatized themselves as they treat the traumas of their clients. The vicarious experiencing of what is heard from clients can affect counselors as if the events were happening to them personally. Psychiatrists have been found to have the highest suicide rate of the medical specialties. Mental health workers are well-advised to recognize and treat their own stress as they do that of their clients.

The harmful effects of emotional stress have been recognized in war veterans. From "shell shock" in World War I to "battle fatigue" in World War II to "post traumatic stress disorder" in the Vietnam War, mental health professionals have been presented with the challenge of helping veterans deal with the horrors they met in battle. If the memories of such experiences are not recalled and processed, those individuals may suffer from the related stress for years. As the veterans of World War II appeared on television in news coverage of the 50th anniversary of the end of that war, a great number of them cried. Many had not talked about their experiences with anyone else in all that time.

More recently, attention has been given to the stress present in the jobs of emergency workers in the civilian arena. An organization, the International Critical Stress Foundation, has been founded to assist in the reduction of job stress of police, firefighters, emergency medical personnel, and employees in emergency dispatch centers. Job stressors in these occupations have been associated with substance abuse, divorce, suicide, and family violence.

One of the primary interventions of critical incident stress management is the providing of an opportunity for the workers to talk out their memories and emotions from traumatic situations occurring on the job. Usually within two or three days following a particularly traumatic event (e.g., death of a child, multiple casualties, injury or death of a colleague), they have an opportunity to meet individually or in a group setting. The debriefing is led by a mental health professional accompanied by one or more emergency services peers who were not involved in the critical incident. The debriefing process is structured and usually takes about two hours. Experience has shown that the debriefers then will need debriefing themselves. Intervention is a powerful tool in assisting mental health workers to handle their reactions to trauma and stress.

The concept of "talking out" the stress of emergencies, crises, disasters, catastrophes, etc. has been adopted in other venues. Mental health workers have been added to the American Red Cross disaster response services to tend to the emotional health of the Red Cross workers. They also provide emergency assistance to those directly affected by the disaster.

In the disaster area, mental health workers often are faced with dealing with people who have experienced loss of homes, property, health, jobs, and hope. Often, there are numerous deaths. Each Red Cross worker is expected to meet with mental health personnel for a debriefing as a part of exiting the disaster assignment. The need for such debriefings was recognized during the operation following Hurricane Hugo in 1989 and has become a regular part of American Red Cross disaster operations.

Follow-up debriefings are recommended at their home chapters as the disaster workers return from assignments. This opportunity to put experiences into perspective is important in avoiding continuing stress reactions. Mental health workers are expected to be debriefed as well when they leave the assignment. These debriefings allow them to recall and talk about their experiences and the feelings they have about those events. Suggestions are given for dealing with stress and for reentering life away from the disaster.

The provision of meetings with peers and mental health professionals has been extended to other settings in which workers regularly function under high levels of stress. These stress management processes can be found in hospital emergency rooms and intensive care units, and they are available to air traffic controllers. Dealing with stress before it becomes a physical or mental health problem allows workers to remain on the job and to be more effective. Entire communities at times are offered debriefing sessions following highly traumatic situations that affect large numbers of the population.

Mental health workers would be well-advised to arrange for such talking sessions for themselves. In these sessions, the focus needs to be on the individual therapists' experiences and the emotions associated with the experiences. Legal and ethical demands for confidentiality prevent mental health workers from being able to go home and talk about what is communicated in the therapy session. Such communication must be limited to another trusted professional.

Mental health professionals typically do not attend to their own needs nearly so well as they take care of their clients'. Much attention has been paid to the burnout among therapists. Specifically applying to them is the term "compassion fatigue." In A Perilous Calling: The Hazards of Psychotherapy Practice, various professionals describe the problems and dangers faced in conducting therapy. The book includes suggestions for prevention of burnout. A concluding chapter presents information obtained from interviews with a number of senior psychotherapists. One of the important elements for their success was the availability and utilization of a support system of teachers, supervisors, mentors, and colleagues. They found significant persons with whom they could share their therapy experiences. Some even had their own psychotherapists.

Hearing the awful things that have happened to one's clients can bring back to mind events which have occurred in the therapist's life. Along with the memories come the feelings that originally were present. If the past has not been effectively dealt with by the therapist, his or her past will interfere with working with the client.

These old emotional reactions were described by pioneering psychoanalyst Sigmund Freud as "counter-transference." Freud and his followers paid much attention to their own emotional baggage. All psychoanalysts were expected to go through personal psychoanalysis. Freud met with his original disciples in small groups to discuss their cases and experiences. This tradition of personal therapy for therapists almost has disappeared in mental health training programs.

Therapists who continuously deal with clients in hospices or AIDS centers and those who deal with clients who have been assaulted, raped, victimized, and/or abused can be affected eventually by this overload of the miseries of others. A paradox in the process of therapy contributes to this vicarious traumatization. If the therapist is empathetic, he or she may begin to have the same feelings as the client/victim and to experience the situation as if it were happening to the therapist. If the therapist remains at a safe, subjective distance from the client material, the client might not benefit from the therapy.

Following the Oklahoma City bombing, a family support center was established in a large church in the area. Family members gathered there daily and awaited word of rescue or recovery of their loved ones in the Federal Building. Hundreds of volunteer mental health workers came to the center to be of assistance to the families. All personnel, including the mental health volunteers, at the center were expected to attend a daily debriefing session. Group sessions were held hourly from early morning until the last workers left at night. These debriefings were coordinated by the American Red Cross disaster mental health team. Dealing with the loss and grief experienced by others triggered memories of personal loss in the mental health volunteers. These old emotions needed to be recognized and discussed so that the volunteers could return and be effective with the families the next day.

Disasters with multiple casualties have become all too commonplace and frequent. In recent years, the American Red Cross has responded to the TWA 800 crash in New York and the Korean Air Lines 801 crash in Guam. As in Oklahoma City, these tragic situations brought together large groups of family members. A mental health response was made in each of these mass casualty tragedies. In 1996, Congress enacted legislation to provide assistance for the families of casualties of air disasters. The American Red Cross has been designated as the agency to provide the mental health assistance to these family members.

The strain of dealing with the overwhelming amount of grief takes its toll on those in the mental health field. They need to talk with other professionals on a regular basis during the experience, rather than just at the end of it. These mental health workers find it necessary to take more days off than in other disaster operations and express more stress-related symptoms such as headaches, colds, irritability, and fatigue.

In one study of a mental health team in the early phase of a disaster, the workers reported experiencing shock, confusion, sadness, and fatigue. Many became ill and/or had accidents. The researchers noted that these workers demonstrated changes in eating, smoking, and drinking habits. They felt helpless and felt a need for team support. The writers suggested the provision of psychological debriefings for such workers.

Whether the mental health professional is working with a mass casualty disaster or is suffering accumulated stress from work in a practice or agency, the effects may be the same--burnout. Almost everyone in our culture should have someone who will listen to them. Saying this is much easier than finding those special persons who will give an hour or so of time just to listen. For the mental health professional, the buildup of stress must be prevented before it takes its toll in the form of illness, fatigue, or burnout.

It is proposed that every practicing therapist have an agreement with another professional to provide listening time on a regular basis. Such a professional "buddy" has to be available for non-scheduled sessions in times of critical incidents. Certainly, those mental health professionals who are involved in disaster relief efforts should be working in teams and giving and receiving regular debriefings. They must take care of their own needs if they are to be of help to victims and families.

Robert E. Hayes is professor of psychology-counseling, Ball State University, Muncie, Ind. As a volunteer in the American Red Cross' Disaster Mental Health Services program, he has worked in more than 10 national disasters, including the Oklahoma City Federal Building bombing.

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