Debriefing red cross disaster personnel: The multiple stressor debriefing model

Journal of Traumaiic Sim, VoL 4, No. 4, 1991

Debriefing Red Cross Disaster Personnel: The Multiple Stressor Debriefing Model

Keith Armstrong,’ William O’Callahan,2 and Charles R. Marmas Accepted January 24, I991

During the 1989 San Francisco earthquake, Red Cross disaster personnel were involved in providing services which put them at risk for developing stress reactwm including Post-traumatic Stress Disorder. This article describes the &aster relief e f f o r t in San Francisco and Oakland made by Red Cross workers and the debriefig which was provided to these personneL Mitchell’s Model for Critical Incident Stress Debriefing (CISD) was modified to fit the broad spectrum of nee& and stresses experienced by disaster relief personneL The Multiple Stressor Debriefing Model (MSDM) which evolved from this experience is discussed with specific recommendations for mental health workers involved in Lkbriejing Red Cross and other emergency personnel who face multiple stressors over an &ended period of relief operatwns. KEY WORDS debriefing; critical incident; stress disorder; disaster relief.

INTRODUCIION THE FVENT

At 5:12 a.m. April 18, 1906, the 410,000 residents of San Francisco were jolted from their sleep by the momentous lurching of the North American and Pacific tectonic plates along the San Andreas Fault. The earthquake, estimated at 7.8-8.3 on the Richter scale, and the subsequent

‘Post-traumatic Stress Disorder Program, Department of Veterans Affairs Medical Center (116-P), 4150 Clement Street, San FranciscO. California 94121; and The Stress Treatment Center, San Francisc0. California.

%an Matm County Regional Manager, American Red Cross, Burlingame. California. 3Post-traumatic Stress Disorder Program. Department of Veterans Affairs Medical Center, San Francisco. California; and Department of Psychiatry, University of California, San Francisco.

581

0894-9867/91/l~4561~M3 0 1991 Plenum Publishin5 Corporation

582 Armstrong ct el.

fire caused severe damage to the city and the surrounding area. Three thousand lives were lost and 28,000 buildings destroyed (Hansen and Condon, 1989; Mack, 1981). Thousands were made homeless and left in need of assistance. The American Red Cross, in its first national operation since its charter by Congress in 1905, responded to the crisis. Eighty-three years later, San Francisco was struck by another major earthquake. At 504 p.m., October 17th, the Loma Prieta Earthquake erupted on the San Andreas Fault south of Santa Cnu . The 7.1-Richter-scale trembler rocked through nine counties in the San Francisco Bay Area causing 66 deaths, approximately 3000 injuries including 368 victims who required hospitali- zation, and an estimated 7 billion dollars in damages. At the time the earthquake struck, the third game of the World Series between the Oakland A's and the San Francisco Giants was just about to begin. Twenty Red Cross volunteers were providing emergency first aid for the crowd and were among the first Red Cross Disaster Workers thrust into the 1989 northern California earthquake relief operation.

Volunteers and professionals aided the victims of the disaster throughout the Bay Area, while trauma experts provided psychological support for the relief workers. The purpose of this paper is to examine the theoretical and practical applications of Critical Incident Stress Debriefing (CISD) (Mitchell, 1983, 1984, pp. 105-118, 1986) for Red Cross volunteers and staff. Although these workers were usually not directly exposed to acute trauma, their long hours working with trauma victims under difficult conditions placed them at risk for developing stress reactions including Post-traumatic Stress Disorder (FTSD) (American Psychiatric Association Press, 1987). Debriefing personnel who are involved in aiding victims of traumatic events has been described as bene- ficial to these workers (Jones, 1985; Raphael et af., 1983; Wright et al., 1990). The following are suggestions and comments on the application of debriefing methods which may be useful to the Red Cross, the Federal Emergency Management Agency (FEMA), and other emergency agencies in the future.

Immediately following the earthquake, news helicopters were diverted from the World Series to broadcast the collapse of the Cypress section of the 1-880 freeway which leads to the Bay Bridge. At that time, estimates were that 250 people had died in this one location. Residents in the nearby housing projects were forced to evacuate. They joined hundreds of others from the residential hotels in Oakland that suffered extensive damage. The poor, the mentally ill and the disabled, all with limited resources, joined each other in the street as rexue efforts began. In San Francisco, the news media announced the collapse of a portion of the San Francisco-Oakland Bay Bridge. Smoke from the fire in San Francisco's Marina District began

Debriefing Red Cross Personnel 583

to drift upward after soil liquefaction generated by the quake caused many apartment buildings to collapse and ignite, leaving some residents trapped beneath the rubble. Many homes were unsafe to enter and later con- demned. Individuals and families with low incomes living in the extensively damaged hotels south of Market and in the Tenderloin district were forced to leave their rooms and move to shelters. Police, fire, emergency medical personnel, and Red Cross volunteers were mobilized to care for the injured and provide for the basic physical and emotional needs of the thousands of victims. For some emergency workers, stress began with the dangerous searches, rescues and medical assistance given to victims, while stress for most Red Cross workers began with the immediate need to mobilize care for the thousands of homeless victims.

The Red Cross chapters in all the Bay Area counties began assess- ing the problems and launching their plan to immediately shelter and feed those made homeless by the disaster. Shelters were opened by workers in the nine Bay Area counties. At a cost of 22 million dollars, the Red Cross sheltered over 69,159 people, served 642,785 meals, and provided medical assistance for 2,700 individuals. Over 14,000 families would receive financial assistance to help with food, clothing, rent, dishes, silverware, beds and bedding (American Red Cross, 1990; Tuttle, 1990). During the same time frame, the Red Cross continued to provide assistance to thousands of victims in five' states, Puerto Rico, and the Virgin Islands -all of whom were made homeless by Hurricane Hugo. Many volunteers and staff traveled directly from the Hurricane Hugo relief effort, where they were working long shifts under adverse conditions with limited resources, directly to the San Francisco earthquake relief operation. Additional workers from all over the United States came to support the staff in the Bay Area. The volunteers and staff ranged from direct service workers from the rural mid-west to disaster directors from Na- tional Red Cross Headquarters and large chapters. Some were highly trained and experienced while others had limited training and were on their first disaster assignment.

In San Francisco, the Red Cross workers initially were faced with providing aid to a varied socioeconomic population. The Manna district, populated mostly by the upper middle class, contrasted sharply with the Tenderloin and South of Market areas. Unlike Manna residents, many of whom had alternate housing facilities to turn to when their homes were destroyed, these lower-income victims had no place to go. The lack of af- fordable housing and the destruction of a portion of it, escalated an already critical problem.

The San Francisco Homeless Hotel Program was crippled as part of its housing supply was destroyed. In response, the Red Cross staffed

584 Armstrong et al.

the newly created shelters in cooperation with community mental health administration, the existing network of shelter providers and City Hall. These shelters served a vital purpose for a much longer period of time than in any recent disaster. Unlike the 1987 Whittier Narrows Earth- quake, after which most of the shelters closed by the 27th day, the shelters in San Francisco stayed open for over 60 days. In the shelters, the workers struggled with the wide variety of social problems, including mental illness, violence, substance addiction and child abuse. They com- forted victims with active TB and AIDS, and dealt with medical emergencies in the shelters on a regular basis. The administrators and supervisors had to direct an urban disaster relief effort never before experienced on this scale in the United States. Included in this effort were the delicate and sometimes frustrating negotiations with City Hall. At- tacks on the Red Cross by local politicians and newspapers constituted a further stressor that angered staff and supporters. For the directors, supervisors and line workers, the problems of the clients, long hours, and many weeks of the relief effort affected them both psychologically and physically.

In the second week of the disaster, the Office of Red Cross Disaster Headquarters for San Francisco, Alameda and San Mateo Counties established a mental health wing initially consisting of two professional social workers from out of state. They began a liaison with the three county mental health departments on victims’ problems and initi- ated several debriefings for Red Cross personnel. The problem of workers stress and the lack of trained professional debriefers to meet the needs of hundreds of workers in the Bay area complicated arrangements of debriefing sessions.

By the third week, the pressure on Red Cross workers who fed and cared for those in the shelters was particularly acute. Low-cost housing to replace the 900 inexpensive hotel rooms which were lost was virtually im- possible to find. Many victims had psychosocial problems that were exac- erbated by the earthquake and shelter life. The shelter workers were unable to treat the chronic problems familiar to San Francisco and Alameda county mental health and social services departments. The victims vented their frustrations on volunteers who were new to the multiple needs of the urban poor. By the fourth week, volunteer Red Cross caseworkers who provided rent, clothing, food and medical care to victims were exhausted. While Red Cross directors sought to adapt their policies to the unique problems of an urban disaster, front-line personnel were confused by these continual policy changes which did not solve the socioeconomic conditions of the victims. Stress was experienced at all levels in the organization. Line workers were angry and frustrated at not being able to meet the needs of


the victims and at times directed these feelings toward their supervisors for not being better organized. Many felt abused and unappreciated by the victims and community. Others were shocked, disillusioned or depressed by the unresolvable problems of the victims. Some workers were frightened by the possibility of another earthquake, aftershocks confirming their belief that the “Big One” would strike at any moment.

CRITICAL INCIDENT STRESS DEBRIEFING

The Department of Veterans Affairs (DVA) Medical Center in San Francisco along with other Bay Area Medical Centers and Readjustment Counseling Service programs consulted with the Red Cross and offered resources to address the stress of workers and victims. A plan to utilize the San Francisco DVA’s Post-traumatic Stress Disorder Clinical Team as debriefers for Red Cross personnel was developed and implemented. The team is comprised of individuals trained in a variety of disciplines, all of whom are experienced group therapists. Five intervention models were reviewed: Crisis Intervention (Cohen and Ahearn, 1980), National Organization of Victim Assistance Debriefing (National Organization of Victim Assistance INOVA], 1987), Didactic Debriefing (Dunning, 1988, pp. 284-207), Critical Incident Stress Debriefing (Mitchell, 1983, 1984, pp. 105-1 18, 1986), and Psychological Debriefing (Raphael, 1986). Of the five models described, Mitchell’s work, advocated by disaster relief personnel, appeared most relevant to the needs of the Red Cross workers (Beaton, 1989; Bergmann and Queen 1986b; Barnett-Queen and Bergmann, 1988; Eby, 1984, pp. 119-125; Everly, 1989).

A critical incident is defined as “any situation faced by emergency service personnel that causes them to experience unusually strong emotional reactions which have the potential to interfere with their ability to function either at the Scene or later” (Mitchell, p. 36, 1983). The goals of stress debriefing are “to protect and support EMS personnel and to mini- mize the development of abnormal stress response syndromes which may cause lost time and effectiveness at work and problems within the family” (Mitchell, p. 37,1983). Four separate types of debriefing are defined which exist on a time continuum relative to the disaster: (1) On or near the scene debriefing, (2) Initial Defusing, (3) Formal CISD, and (4) Follow-up CISD (Mitchell, 1983).

1. The first type of debriefing is provided on the scene or near the scene of the incident. It is usually performed by someone who has been observing the relief operations and watches for any acute stress reactions from the event. The facilitator helps the rescue workers discuss their

586 Armstmng et 81.

feelings regarding their work. After venting their feelings, many times the workers are able to return to their tasks. The facilitator may also be in a position to suggest to the officer in charge that someone who is exhibiting strong reactions be temporarily relieved of duty or reassigned to a new less-stressful role within the relief operation.

2. The initial defusing takes place within a few hours after the incident. It can be led by a mental health professional but many times it is leaderless. This occurs as members of the rescue operation begin to relax and in an atmosphere of mutual support discuss their feelings regarding the event. To aid this process, a mandatory hour-long meeting occurs after conclusion of the disaster.

3. The formal CISD is a 7-stage 3-to-5 hour process which is led by a qualified mental health professional 24 to 48 hr after the incident. The leader requires skills and knowledge in group-work techniques and acute stress reactions as well as an understanding of the unique demands placed on emergency service workers. The use of a professional leader is highly desirable because the issues raised by the group may overwhelm an un- trained facilitator. The stages of the formal CISD are as follows:

In the introductory phase, the rules of the debriefing group are explained emphasizing that the information is confidential. It is made clear that this process is not a critique of the procedural response to the incident, but rather a supportive event in which members both express their feelings and listen to each other.

The leaders shift the group into the fact phase. Group members share facts about themselves and what they saw, heard, smelled, touched and did during the incident. The incident needs to be brought back to life so the group members can safely begin to process their experience.

The thought phase involves the facilitators asking group members to state their first thoughts in reaction to the most stressful part of the incident.

The feeling phase allows the group to discuss their emotional reactions about the incident. Questions about how the individuals felt at the time of the incident and how they feel in the here and now are thoroughly covered. In addition, members are asked if they have ever felt like this before. The leaders ensure that no single person dominates the discussion and that no one is left out.

During the fifth phase, the members are asked if they have had any particular physical or psychological symptoms since the incident occurred.

In the sixth phase, the group leaders teach the group about Stress Response Syndrome and explain that it is typicalhormal to initially have these reactiondsymptoms when exposed to a trauma event.


In the final phase, reentry, loose ends are tied up and any outstanding questions are answered. Referral information is also provided to members who feel they might benefit from additional counseling.

4. Follow-up CISD should take place whenever it appears there is unresolved material which is affecting the participant’s ability to function. This follow-up can be conducted with an individual or with a group.

THE SAN FRANCISCO EXIT GROUP DEBRIEFINGS

There are specific differences between working with rescue workers and Red Cross workers at a disaster. Traditional fire or police rescue work is intensive, focused and usually brief. The group of workers are exposed to very similar highly stressful experiences having to do with aiding the injured, removing dismembered bodies and briefly talking with survivors. There was no clearly defined critical incident for Red Cross and FEMA workers, most of whom arrived after the first round of casu- alties. The majority of the work for the Red Cross personnel occurred after the rescues had been completed and continued for 8 weeks after the earthquake.

Although the definition of “Critical Incident” is broad, CISD does not address certain unique needs of’Red Cross and/or FEMA workers. The response of Red Cross workers to the Loma Prieta Earthquake was characterized by the following stressors: (1) multiple contacts with trauma victims, (2) long hours, (3) poor work environment, (4) changes in Red Cross policy, ( 5 ) fear of aftershocks or a belief that a subsequent larger earthquake would strike, (6) inexperience of some Red Cross personnel, (7) recent exposure to trauma (Hurricane Hugo), (8) administration of an unusual disaster relief effort with no response precedent, (9) specific characteristics of an urban disaster, (10) being away from home, (11) hostile political environment, and (12) negative publicity. Al- terations in the CISD Model were required to adequately address these multiple stressors.

After the earthquake, the debriefing groups in San Francisco and Oakland consisted of workers, some of whom had been working long intensive hours since the first day after the quake, while others were brought in weeks later. The differing job roles of the workers also affected the process of the debriefing. Red Cross staff were involved in various positions, from administrative roles aiding the relief efforts, to working directly with clients. Consequently, the events that were most stressful to one person could have been very different from those that were stressful to another.

588 Armstrong e t al.

In our debriefings with Red Cross personnel we limited the groups to less than 20 persons. We attempted to include only people within the group that were in the process of exiting from the assignment. We utilized two co-leaders to actively facilitate all the groups we conducted. Workers were strongly encouraged by the mental health staff within the Red Cross to come to the debriefings. It was made clear that members were required to stay the entire 1 1/2 hr. The leaders explained the parameters and emphasized the confidentiality as well as the safety of the group. Groups varied, some combining administrative and line staff, others segregating the two groups. We noticed some advantages and disadvantages to both methods. In keeping administrative and line personnel separate, we felt both groups were able to freely express their feelings about the sources of their stress. Line workers could discuss their frustration with the client population as well as with problems in the administration. Administration, in their separate group could discuss their frustrations with line workers as well as having to run a one-of-a-kind operation. The benefits of having administration and line workers together allowed group members to see the kinds of stress under which both groups faced and how the entire organization was affected. Thus, the combined groups put forth a message of unity, although at times limiting the degree of disclosure.

A component of the participants’ chronic stress was clearly related to the administration of the disaster relief effort. In our work with the Red Cross, we felt it necessay to discuss how this affected them. Discussing this topic was done delicately because some of the groups were composed of administrative, line staff and volunteer workers. In the combined groups, where most of the staff were line workers, the potential for administrative staff to be “scapegoated” was high. Consequently, the group facilitators carefully promoted the sharing of feelings regarding the stress events with- out blaming anyone.

In contrast to local police, fire, and rescue workers, the majority of workers we debriefed were volunteers who had been flown in from all over the United States. Some of the workers came directly from the stress of another disaster, Hurricane Hugo. Seventy percent of the workers were female, had less time together to process the disaster event, were a less cohesive group and were already at risk for developing symptoms of post-traumatic stress disorder due to their recent exposure to trauma.

Our proposed model, the Multiple Stressor Debriefing Model (MSDM) has four stages: I. Disclosure of events; II. Feelings and Reac- tions; III. Coping Strategies; and N. Termination. In the first stage of MSDM, “Disclosure of Events,” we acknowledged the stress experiences of the workers. Because of their long hours and vaned experience, group


members had a difficult time identifying a primary incident which troubled them. In our debriefing we allowed the workers time to discuss several incidents which affected them, a process which increased the group’s cohesion.

In the “Feelings and Reactions” stage, members were able to ventilate their feelings about incidents they were involved with. Many of our groups utilized a blackboard to write down different member’s feelings about “their incident” within the disaster. The leaders also taught members that strong feelings are a normal response to chronic stress experience and that it is safe and helpful to talk about them. By establishing that transient symptoms are a typical response to the disaster relief experience, we were able to create a supportive environment for groups members to discuss the symptoms which were bothering them.

Experiencing the victims’ dissatisfaction with the relief efforts was a high-stress incident for many Red Cross workers. In rescue attempts, victims many times are in shock and grateful for help the workers provide. By contrast, in this urban disaster, victims expressed anger toward an “in- different” bureaucracy represented by the Red Cross and FEW workers. If the workers we debriefed were local emergency personnel it would have been important to ask how the disaster was affecting their home life. How- ever, because the workers we debriefed had the stressor of being away from home and living in hotels in addition to working 16 hour days for up to 8 weeks, it was less relevant to ask about their home life during this stage.

During the “Coping Strategies,” stage, we discussed the normal and pathological responses to stress. We then worked with the participants to develop ways they could care for themselves while still in the chronic stress environment, as well as what they could do as they prepared to return home. The following coping strategies were recommended: (1) exercise, (2) good nutrition, (3) breaks from work, (4) engage in relaxing activities, (5 ) share feelings with coworkers, (6) participate in staff meetings, (7) stay in touch with family and friends, and (8) use those methods which helped to relieve stress prior to the earthquake. Since this group of care givers expressed reluctance and even guilt about spending time caring for themselves, it was emphasized how much help they could continue to provide to others if they were under less stress. Talking with group members about how they coped with other disasters was helpful in identifying ways for the group to best cope with the current catastrophe.

The development of close relationships through disaster work is in- evitable. In the “Termination” stage, it is important for group members to discuss the positive aspects of the relief operations as well as to say good-bye to each other (Raphael, 1986). In addition, it is vital to talk

590 Armstrong et al.

about the transition to home. Many times stress awaits the workers as they return home. Most workers return to numerous responsibilities both at home and at their jobs which need to be taken care of immediately, thus delaying any processing of the recent event. In some respects, experience of the Red Cross workers returning home from the San Francisco earthquake is analogous to the Vietnam veteran finishing his tour of duty and heading home. As with the veterans, many of the workers returned home alone with bad publicity preceding them, thereby adding to the already difficult task of assimilating the experience (Catherall, 1986). The need for the workers to continue to talk about their experience after returning home is emphasized. Follow-up individual or family counseling is suggested for those members who continue to have problems (Bergmann and Queen, 1986a). Encouraging the group members to ask for someone who will listen to their experience may aid in the positive integration of the disaster event within the self - thus stopping any fragmenting process from occurring.

CONCLUSION AND RECOMMENDATIONS

It is our belief that the Multiple Stressor Debriefing Model (MSDM) was responsive to the specific dilemmas confronting Red Cross personnel. Obviously, ideal conditions rarely exist in disaster relief work. The debriefers must maintain flexibility in order to accomplish their task. In ret- rospect, there were other changes that we would have liked to initiate in our debriefing work.

The 1 1/2 hr groups we ran were too short. Two-hour debriefing sessions would have given the leaders more time to thoroughly work with all group members. The groups seemed to function best when the size was limited to 12-15. The smaller group allowed for more intimacy, but was still realistic given the level of available resources at this disaster. Groups must be conducted in a quiet place away from distractions. The groups we ran in the hotel where the Red Cross workers were staying allowed for less distractions than the ones we ran at the temporay administrative site of the Red Cross. The use of visual aids to record stressors, feelings and coping strategies was helpful in promoting the group to process their troubling events. Group leaders should work in pairs and be trained mental health professionals who are knowledgeable regarding Red Cross work. Red Cross and community mental health administration should coordinate services that include training mental health professionals to run debriefing groups (Fraser and Spicker, 1981). Ideally, mandatory groups would be a part of the work schedule of any Red Cross disaster relief effort. Workers


Table I. Multiple Stressor Debriefing Model

Total Time Approx 2 hr

Stage Leader Activity Member Activity

Disclosure of events (35 min)

Feelings and reactions (35 min)

Coping strategies (25 min)

Purpose of group outlined.

Rules of group outlined.

Ask about events that were most troubling.

Ask about feelings and reactions regarding diflicult events.

the use of visual aids. Help to identify feelngs with

Educate about normal and abnormal responses to stress through use of visual aids.

Ask how participants have coped with past stressors and how they are coping with current stresson.

Identify practical coping strategies for group participants.

Termination (25 min) Focus on what leaving the disaster will be like.

Emphasize saying goodbye to

Preparation for returning to

co-worken.

home and work responsibilities

Positive discussion of work accomplished as well as emphasis on the need to continue to talk with significant others.

Final questions answered.

Referrals provided as needed.

Identification of events that were most troubling.

Elaboration of feelings and reactions about events that were most troubling.

Discuss their past and current experiences in coping with stressors.

Discuss feelings about leaving the disaster and returning home.

Positive feelings regarding the disaster are expressed.

Plan of action regarding the transition discussed.

Need for referrals voiced.

592 Armstrong et el.

would be divided into groups according to their assignments within the disaster.

We also felt that since average Red Cross relief teams work 3 weeks postdisaster, one could build into their schedules three weekly group meetings run by mental health professionals. An Entry Group would focus as a structured briefing on the numerous expected stressors for the specific disaster. The leaders would discuss with the group the probable difficulties facing the Red Cross workers before they are sent out to their respective jobs. This group would also provide a chance for mental health professionals to talk about some of the stress symptoms the relief workers may expect to encounter while doing their work.

A Mid-assignment Group would focus on the effects the work is having on the personnel. This would allow for identification of anyone who may need a new, less stressful assignment. Helping the members focus on ways they can care for themselves during the disaster relief work would be important for the group to discuss. The Exit Group would function very similarly to the MSDM previously outlined.

Clearly, careful study needs to be conducted on the effectiveness of MSDM with Red Cross personnel. Replication of the MSDM and extension to controlled outcome studies with emergency services personnel is war- ranted. We believe that conducting Multiple Stressor Debriefing Model Groups will aid in the reduction of stress symptom disorders and increase the effectiveness of the workers. In addition, MSDM may be helpful in working with other groups which have high exposure to long-term chronic stress, allowing for adaptations in the model to fit the specific needs of the group.

ACKNOWLEDGMENT

The authors thank Vickie L Denton and Mia Laurence for their valu- able contributions to this article.

REFERENCES

American Psychiatric Associalion (1987). Diagnostic and Statistical Manual of Mental Disorders

American Red Cross (January 18th. 1990). Beaton. R. (1989). Approaches to stress management in firefighters and paramedics. Sun

Barnett-Queen, T., and Bergrnann, L (1988). Reducing the impact of duty-related trauma.

(rev., third edition), Washington, D C Author.

Francirco FLefightcr’s Main Line 18(7): 4-5.

F k Cf iJ March: 56-57.


Bergmann. L., and Queen, T. (1986a). Critical Incident Stress Part 2. F i n Command, May:

Bergmann. L, and Queen, T. (1986b). Responding to Critical Incident. Fire Chief, June: 43, 44, 49.

Catherall, D. (1986). The Support System and Amelioration of PTSD in Vietnam Veterans. Psychotheram 23(3): 472-482.

Cohen, R., and Ahearn, F. (1980). Handbook for Mental Health Care of Disaster victims, John Hopkins University Press, Baltimore and London.

Dunning, C. (1988). Intervention strategies for emergency workers in Lystad, M. Mental Healfh Response to Mars Emergencies, Brunner/Maze!, New York. pp. 284-307.

Eby, D. (1984). Role stressors and supports for emergency workers. Center for mental health studies of emergencies. Proceedings from a 1984 workshop sponsored by the National Institute of Mental Health and the Federal Emergency Management Agency, DHHS Publication No. ADM 85-1908. Printed 1985, US. Printing Office. ADM, Washington.

52-56.

D.C.. pp. 119-125. Everly, J. (1984). Debriefings defuse stress. Fire Command Nov: 34-35. Fraser. J., and Spicka, D. (1981). Handling the emotional response to disaster: The case for

American Red Cross/community mental health collaboration. Commun. Ment. Healfh J.

Hansen, G., and Condon, E. (1989). Denial of Disaster. Cameron and Company, San Francisco. Jones, D. (1985). Secondary disaster victims: The emotional effects of recovering and

identifying human remains. Am. I. Psychiatry 142(3): 303-307. Mack, G. (1981). Surviving Sun Francirco’s Greatest Earthquake and Fire, Chronicle Books,

San Francisco. Mitchell, J. (1983). When disaster strikes . . . The critical incident stress debriefing process.

I. Emerg. Med Sew. 8(1): 36-39. Mitchell, J. (1984). Role stresson and supports for emergency workers. Center for mental

health studies of emergencies. Pmeedngr from a 1984 workshop sponsored by the National Institute of Mental Health and the Federal Emergency Management Agency, DHHS Publication No. ADM 85-1908. Printed 1985, US. Printing Ofice, Washington, D.C., pp.

Mitchell, J. (1986). Critical incident stress management. Response! The Magazine of Rescue and EmeTency Management, SeptemberJOctober. 24-25.

Myers, D. (1985). Helping the helpers: Interventions. In Hartsough, D., and Myers, D. (eds.), Disaster Work and Mental Health: Prevention and Control of Stress Among Workers, DHHS Publication No. 85-1422 (Adm), U.S. Printing Office, Washington. D.C., pp. 122-136.

17(4): 255-264.

105-1 IS.

National Organization for Victim Assistance (1987). Raphael, B.. Singh, B., Bradbury. L., and Lambert, F. (1983). Who helps the helpers? The

effects of a disaster on the rescue workers. Omega 14(1): 9-20. Raphael, B. (1986). When Disaster Strikes, Basic Books, Inc., New York. Tuttle, H. (1990). American Red Cross commits 55.3 million for earthquake relief. Crossroads

Wright. K.. Ursano. R., Bartone, P., and Ingraham, L (1990). The shared experience of catastrophe: An expanded classification of the disaster community. Am. J. Orthopsychiatry 60(1): 35-42.

l(1): 1-4.

Debriefing red cross disaster personnel: The multiple stressor debriefing model

Documents

Transcript of Debriefing red cross disaster personnel: The multiple stressor debriefing model