The Addiction Web Site of Terence T. Gorski

Best Practice Principles  - Articles  - Publications

Mission & Vision -  Clinical Model - Training & Consulting

Home - What's New - Site Map - Search - Book Reviews

 Links - Daily News Review 

  Research Databases  - Leading Addiction Websites -

Special Focus:  Mental Health, Substance Abuse, & Terrorism

Exposure To Traumatic Death: The Nature Of The Stressor

GORSKI-CENAPS Web Publications
www.tgorski.com
Published On: December 18, 2001          Updated On: December 18, 2001

Review These Books, Videos, & Manuals On Relapse

              

Visit GORSKI-CENAPS Books - www.relapse.org 1-800-767-8181

Training & Consultation: www.tgorski.com, www.cenaps.com, www.relapse.org  Gorski-CENAPS, 17900 Dixie Hwy, Homewood, IL 60430, 708-799-5000 

Exposure To Traumatic Death:
The Nature Of The Stressor

By Robert J. Ursano and James E. Mccarroll
http://www.usuhs.mil/psy/traumaticdeath.html

Trauma and disasters, both manmade and natural, are frequent occurrences in the present day world: terrorism, plane crashes; earthquakes, industrial accidents, combat and poison gas attacks to name but a few. Common to the occurrence of nearly all disasters and combat is the likelihood of violent death and the presence of human remains - burned, dismembered, mutilated, or relatively intact. Exposure to mass death as well as individual dead bodies is a disturbing and sometimes frightening event. The nature of the stress of exposure to traumatic death and the dead and its relationship to posttraumatic stress disorder and other posttraumatic psychiatric illnesses is not well understood (Breslau & Davis, 1987; Lindy, Green & Grace, 1987; Rundell et al., 1989; Ursano, 1987; Ursano & McCarroll, 1990).

The tasks of body recovery, identification, transport, and burial may require prolonged as well as acute contact with mass death. Recent research has shown that victims, onlookers, and rescue workers are traumatized by the experience or expectation of confronting death in disaster situations (Jones, 1985; Miles, Demi & Mostyn-Aker, 1984; Schwartz, 1984; Taylor & Frazer, 1982). Exposure to abusive violence (Laufer, Gallops & Frey  Woulters, 1984) and to the grotesque (Green et al., 1989) significantly contributes to the development of psychiatric symptoms in war veterans, particularly intrusive imagery (Laufer, Brett & Gallops, 1985; Lifton, 1973).

Despite the widespread recognition that exposure to dead bodies is one of the major stressors in disasters, few studies have examined the psychiatric effects of exposure to dead bodies and body parts. The major psychiatric textbooks do not mention the topic (Kaplan & Sadock,1985; Tatbot, Hales, & Yudofsky, 1988). Hersheiser and Quarantelli (1976) reported that, as of the time of their study, there were no empirical studies of the handling of the dead in disasters. Jones (1985) found little information on the psychological effects on rescuers of recovering live victims and almost nothing on the effects of exposure to the dead. Regardless of profession or past experience, exposure to violent death can create additional victims in those who assist after a disaster (Miles et al., 1984).

How individuals and groups prepare for, behave during, and, respond after, witnessing traumatic death has received little scientific scrutiny. Hersheiser and Quarantelli (1976) reported on how the dead were treated by the living following a flood. They observed increasing respect for the body through the phases of search, recovery, identification, and preparation for burial. Taylor and Frazer (1982) reported that about a third of the volunteers who recovered bodies from the Mount Erebus air crash in Antarctica experienced transient problems of moderate to severe intensity. Further, at three months, one-fifth continued to report high levels of stress related symptoms. In a survey of 592 US Air Force personnel involved in the recovery, transport, and identification of the bodies of the Jonestown, Guyana mass suicide, Jones (1985) found that youth, inexperience, lower rank, and the greater exposure to the dead were associated with higher levels of emotional distress. Higher rates of dysphoria were also found in blacks compared to whites, possibly due to greater identification with the black victims by the black body handlers.

Mediators Of The Stress Of Exposure To Mass Death - Anticipation And Previous Experience

The stress of anticipation can itself be debilitating, affecting performance, behavior, and health (Table 3.1). Research on the effects of exposure to death and the dead, however, has focused on rescue workers after a disaster. The period prior to exposure has rarely been examined. Ersland, Weisaeth and Sund (1989) reported that waiting time was a frequently reported stressor among professional fire fighters. The disaster worker anticipates the stress of upcoming work before it actually begins and may already begin work with a substantial stress burden. The work with the disaster casualties may be more or less stressful than what was anticipated. Disaster workers may wait minutes to days after notification before they actually begin their rescue work. In interviews of disaster workers, we have heard stories of extended periods of waiting and high levels of stress. For example, novice rescue workers recruited to remove bodies from a plane which had caught fire and burned after landing had to wait several hours while wooden supports were put under the wings of the plane so it would not collapse.

The stress of anticipation has important psychological and physiological elects. Mitchell, Sproule & Chapman (1958) showed that the physiological responses to anticipated exercise were qualitatively the same as those to exercise itself, differing only in magnitude. The stress of anticipation has also been found to cause changes in human skin conductance and heart rate (Susnowski, 1988). Arthur (1987) reported that adrenocortical hormones were secreted mainly during the anticipation of stressful events rather than during confrontation: Complex patterns of cortisol secretion have been found in patients prior to surgery. The highest levels were seen in the preoperative preparation of the patients (Czeisler et at., 1976). Sumova & Jakoubek (1989) found that, in rats conditioned to receive a painful foot shock, anticipated stress acted as a specific trigger. The anticipation produced stress induced analgesia which could be blocked by naloxone (an opioid blocking agent). They hypothesized that the endogenous opioid system played an important role in decreasing the self-destructive elects of stress. To our knowledge, gender differences in anticipated stress have not been studied. There is a large body of scientific literature on gender differences in illness reporting and in the use of health, care services by disaster victims (Cleary, Mechanic & Greenley, 1982; Solomon et al.,1987).

Previous experience with a stressful event has been shown to reduce the effects of the stressor. Inexperienced persons generally report higher levels of fear or anxiety then do experienced persons. This has been shown in studies of parachute jumpers (Fenz & Epstein, 1967) and in pilots (Drinkwater, Cleland & Flint, 1968; Meferd et al., 1971). The contributions of experience to psychological responses to disaster work have been noted by several authors but how experience specifically contributes has not been examined. Experienced disaster workers consistently show lower stress responses following a disaster than do nonexperienced workers. Ersland and colleagues (1989) found that a higher proportion of nonprofessional rescuers than professionals reported poor mental health nine months after recovering victims from an oil rig collapse at sea. The more experienced rescuers were less likely to have poor mental health than the less experienced rescuers. Weisaeth (1989) observed that a high level of disaster training or experience was significantly correlated with optimal behavior during the disaster. Hytten and Haste (1989) found that fire fighters experienced in mass disasters had lower stress responses after the event than did nonprofessional fire fighters. The long-term effects of past experience and training are less clear. Lundin (1990) found that during the first week after a disaster, professional rescue workers had significantly greater unpleasant feelings than nonprofessionals. However, after nine months, the reverse was true. Weisaeth's (1989) study of disaster behavior among survivors of an industrial explosion suggested that training and experience were extremely powerful variables in predicting health outcome. Norris and Murrell (1988) reported that persons who had experienced severe flooding in southeastern Kentucky had fewer symptoms than those who had not experienced floods. They reported these findings as evidence for stress inoculation and emphasized the advantages of prior experience with a stressor.

We were interested in the effects of gender and past experience on the anticipated stress of disaster workers who would handle the dead of a disaster. We measured anticipated stress in male and female soldiers, a group with and without prior experience, and in college students, who were inexperienced in handling the dead. In both groups, we measured the anticipated stress of handling bodies using a questionnaire. Inexperienced females had higher anticipated stress scores than inexperienced males. Experience lowered the grand mean (62.34) by 8.32 points while inexperience raised it by 1.98. Being male lowered the grand mean by 2.83 points; being female raised it by 11.61. The gender difference was replicated in the college students. There were no gender differences when experienced groups were compared. We found no relationship between anticipated stress scores and age, race, or education in either of the two populations.

A second measure of anticipated stress was used in the soldier population. This second measure consisted of ratings of the anticipated stress of handling bodies which were presented in slides depicting traumatic death. Inexperienced male soldiers had a higher mean anticipated stress score (slides) than did the experienced males. There was a significant correlation r(108) = .66, < .001, between the mean anticipated stress score on the questionnaire and the mean anticipated stress score measured by the slides. The significant correlation between the two methods of measuring anticipated stress provides some support for the construct validity of the concept of anticipated stress (McCarroll et al., in press).

Although these data are cross-sectional, they suggest that at least part of the `inoculation' effect of experience, is achieved by lowering anticipated stress prior to a disaster. Such lowered stress may itself decrease the trauma of a disaster and increase successful disaster behavior and coping. Predisaster counseling (Myers, 1989) may also be effective in part through its effects on anticipated stress. High levels of anticipated stress may also contribute to fatigue and thus to other disease conditions. Lower anticipated stress may be a mechanism through which experience and training contribute to decreased fatigue, increased performance, and decreased risk of adverse psychological effects in experienced disaster workers.

Volunteer status, previous experience, and anticipated stress

Prior to Operation Desert Storm, the four military services were required to provide a contingent of personnel to staff the mortuary where the war dead would be identified and prepared for shipment home to their families for burial. Pre- and post-Desert Storm, questionnaires were given to military personnel who worked in the mortuary, and who were support personnel whose duties did not involve contact with remains.

In the pregroup, we were able to study the stress of anticipation of working with the fatalities from the war, for the mortuary workers, and the stress of deployment to a wartime mortuary for everyone. Those who agreed to participate in the study were asked to complete questionnaires as soon as possible after arriving and prior to leaving at the end of their duty. These questionnaires included demographic and background information and a number of standard psychometric instruments designed to measure the stress of working with the fatalities, psychological distress, social support, interpersonal relationships, and self-presentation. Two instruments were used to measure distress: the Impact of Events (IES) Scale (Horowitz, Wilner & Alvarez, 1979) and the Brief Symptom Inventory (BSI) (Derogatis & Melisaratos, 1983), a shorter version of the SCL-90-R (Derogatis, 1983). We used the Global Severity Index (GSI) as an overall indicator of psychological distress, and the five subscales of theoretical interest as responses to trauma: anxiety, depression, somatization, hostility, and interpersonal sensitivity (Green et al., 1989; Rubonis & Bickman, 1991; Rundell et al., 1989). A total of 562 people worked in the mortuary; 87% agreed to participate in the study (86°/a of the mortuary workers and 93% of the support workers).

Only 18% of the total group had previously participated in a mass casualty experience or a disaster; 37% had worked with dead bodies; and 52% had seen someone who had died by violent means. Sixty-four percent were volunteers. The difference between male volunteers (65%) and female volunteers (59%) was not statistically significant.

This study provided a unique opportunity to study nonvolunteers. When all subjects were examined (mortuary workers and support workers, both males and females), individuals who were not volunteers for this assignment had significantly higher scores than volunteers on the Global Symptom Inventory (GSI) of the BSI, as well as for the subscales of somatization, anxiety, and depression. This was also true for mortuary workers alone; there were no significant differences between scores for volunteers and nonvolunteers in the support worker group (McCarroll et al., 1992).

Experience was statistically significant only on measures of the stress of anticipation of handling bodies. Inexperienced mortuary workers had higher mean total IES scores compared to those with previous experience handling the dead. The same pattern was shown for IES intrusion scores, and IES avoidance scores.

Both volunteer status and experience were significantly related to the IES total, intrusion and avoidance for male mortuary workers. Mean scores of females were not statistically significant for either variable. The means of the nonvolunteers were always higher than the volunteers and the means of the inexperienced males were always higher than those who were experienced (McCarroll et al., 1992).

Thus, both experience and volunteer status predicted lower psychological distress and intrusive and avoidance symptoms in military personnel anticipating working with the dead of the Persian Gulf War. The findings on volunteer status are unique since this variable can rarely be studied. Anticipated stress is an important aspect of all disaster and rescue work. The stress burden clearly begins well before actual exposure.

Nature of the stress of exposure to traumatic stress

In order to better understand the nature of the stress experienced by exposure to traumatic death, we collected observations, interviews, and empirical data from various disaster body handlers (Ursano & McCarroll, 1990).

Our first observations were made at the Dover Air Force Base Mortuary following the military air disaster of December 1985 in Gander, Newfoundland where 256 people were killed. Over 400, mostly inexperienced, volunteers served as body handlers. Their duty often required close contact with severely burned and dismembered bodies over a period of days to months. Observations began at Dover within 48 hours of the plane crash and continued throughout the arrival of the bodies and body parts, including the most intense period of body identification (2 weeks). Interviews with individuals involved in the body identification process were conducted during the process and several months thereafter. These included the individuals responsible for  mental health consultation to the volunteer body handlers (Robinson, 1988), those providing support from the hospital and chapel, the mortuary workers (Cervantes, 1988), and those responsible for the overall body recovery and identification processes (Maloney, 1988a, b). Subsequent to these observations, extensive longitudinal observations, interviews and empirical data have been collected on other individuals exposed to traumatic death: the USS Iowa turret explosion in 1989; Ramstein Air Base Flugtag disaster of 1988 (Ursano et al., 1990); United Airlines Flight 232 air crash in Sioux City, Iowa in 1989; and Operation Desert Storm casualties of 1991 (Ursano et al., 1992). In most of these studies, the longitudinal follow-up has extended over 1 to 1/2 years.

A final data set was obtained from group and individual interviews with approximately 50 civilian and military personnel with extensive experience with and exposure to handling bodies in rescue, recovery, identification, burial preparation and transport. These included hospital and forensic pathologists, military body handlers from the Viet Nam era, police and fire department personnel, emergency medical technicians, and Red Cross disaster relief workers. Participants were asked to describe the nature of their jobs, experiences, and their observations of the stress of handling dead bodies. Everyone was asked or spontaneously volunteered material on the following questions: `What types of bodies are the most troublesome to you?'; `What is it about dead bodies that affects your functioning or that of others?'; `How do you get yourself through rough spots?'; `How long does it take and how do you prepare yourself to go back to work after an exposure?'; `How do you deal with the stress of such incidents?'; `Have you seen people who were unable to function in the field and what seemed to happen?'

The Nature of the stress of exposure to traumatic death:

·        Children's bodies

·        Natural looking bodies

·        Sensory stimuli

·        Novelty, surprise, and shock

·        Identification and emotional involvement

·        Personal effects

·        Friendly fire death

·        Female combat deaths

·        Accidental deaths

·        Enemy dead

Disturbing Bodies

Nearly everyone experiences viewing and contact with children's bodies as stressful regardless of the age or sex of the body handler or whether he/she had children (see Table 3.2). Children's bodies were reported as difficult because they `appeared innocent', were `complete victims' or they had `untimely deaths'. `They have not yet lived'. 'They had no control over it'. Pathologists hated doing autopsies on children. In the Gander, Newfoundland, US Army plane crash of 1985, the discovery of toys in the wreckage sent waves of anxiety and concern through the disaster workers as they worried that children had been on the plane. None, in fact, were on board.

Natural looking bodies and ones with no apparent cause of death were also reported as disturbing. Bodies that were fully clothed and not obviously injured were described as `eerie'.

I would say that it was probably more difficult for me to deal with remains that had a single gunshot wound or single penetration that we knew were going to go home viewable; more so than an air crash where the remains were severely charred or decomposed. l think we key on the face of that person. If there isn't a face or a head, . . . it seemed like the whole focal point of expression was gone. In the case of ____ who had a single shrapnel wound to the neck, we knew he was going home, out of the war, because of a little damn piece of metal, a fragment. I think it probably bothered me to see how sensitive life is to foreign objects compared to a hell of a crash or an explosion which tears you up.

Pine (personal communication, 1988) reported that in cases of the `untouched, but dead, everybody stops'. He reported a case in which a beautiful young woman, who had died in a plane crash, appeared natural to a recovery worker. However, her feet had been underneath the seat rack and had been torn off leaving only two stumps for legs. When the disaster worker saw this, he yelled, `Jesus Christ!' Badly burned bodies, `floaters' (bodies that had lain in water for along time), and decapitated bodies were vivid in people's memory.

Rescuers may consciously avoid the fact of being in contact with a dead body. A police harbor unit diver recalled his first underwater contact with the foot of a body: `( hoped it was just a sneaker' . . . feeling the ankle I thought, `Let it be just a boot' . . . feeling the leg, `Please, God, let it just be a wader'.

This concern was also expressed by a fireman,

A lot of firemen don't want to recognize a dead infant. One fireman went into a room full of smoke and felt around, touched the dead infant, and said it was a dog.

Wearing gloves to handle the bodies, even by rescue workers unlikely to touch bodies, was reported by many. It seemed to serve both a real and an imagined protective role. The gloves, in some settings, also became a symbol of being a member of this special group - the body handlers.

Sensory stimulation

Profound sensory stimulation is an extremely bothersome aspect of body handling. The smell of the body(ies) was often noted; visual and tactile sensitivity were also reported. One body handler at Dover AFB was concerned about not being able to `wash the smell away'. He wondered if the odor was real or `in my head'. In fact, there was very little odor with these bodies since they were frozen due to the snow and cold in Gander. Individuals who reported working with the bodies from the Jonestown mass suicide and those who worked with the Marine bodies from the Beirut bombing in 1985 felt greatly disturbed by the overwhelming odor of these already decaying bodies. The rescuers frequently tried to mask the odor with burning coffee, smoking cigars, working in the cold or using fragrances such as peppermint and orange oil (Cervantes, 1988).

Even when a volunteer escorted only a single body through all the stages of an identification process, he or she was exposed to many more bodies. This contributed to the stress of the experience. The sight of a large number of bodies was described by some volunteers as `overwhelming', including those who had had experience with traumatic death in police or emergency service work. One man reported, `The bodies just kept coming and coming. It felt like you were surrounded', and another said, `It's hard not to look when you are surrounded; you are too tense to be bored. There were 15 dead bodies looking at me with their jaws cut open.'

The preparation and consumption of food was frequently difficult after exposure to traumatized bodies. Badly burned bodies were reported to look and smell like roast beef. After exposure to burned bodies, many individuals, including members of our research team, reported avoiding eating meat for several months. To one body handler, rice in brown gravy looked like maggots: In Sioux City, one rescue worker reported that he had lost all sexual interest in women because he could not look at their bodies without being reminded of the dead females he had recovered. Security police guarding the dead at Sioux City felt great discomfort when the wind blew blankets off the dead, exposing parts of the bodies.

One emergency medical service worker reported being particularly disturbed by the loud sound of a body thrown on a hard examining table, especially if the head struck the surface. She complained about the way the morgue workers handled the bodies of people she brought in. Many individuals reported persistent images of dead bodies or body parts, particularly if the bodies were burned or mutilated.

Novelty, surprise, and shock

In addition to the raw, offensive sensory stimulation, surprise, shock and fear of the unexpected are disturbing aspects of handling dead bodies. When we asked a group of experienced military body handlers how they would train a group of inexperienced people to retrieve bodies if they only had a day to do so, we were told, `Tell them the worst. Make it so there are no surprises. Let them know what they are getting in for.'

The surprise and shock of seeing the victim's face when the body bag is opened was described by one subject: `When our soldiers open that bag, they don't know what they are going to see!' Another man who handled bodies in Vietnam recalled that he was always upset when bodies were lying face down in body bags. The back of the head is very strong and usually intact regardless of the condition of the face. He was always frightened of what he might see when he turned the body over. Pathologists at Dover Air Force Base X-rayed the body bags before opening them in order to lessen the initial shock and surprise. They reported that seeing bodies at a crime scene was generally more difficult than seeing the same bodies in a laboratory where the setting was familiar and surprises were unlikely.

The opening of the first body bag at the mortuary after a disaster is nearly always a quiet, anxiety-filled event. One group of inexperienced body handlers during Operation Desert Storm physically moved I5-20 feet away from the body when the bag was opened, without anyone having spoken a word. When the body bag was fully open and there were no `surprises', they moved closer. One individual described having to recover a child's body for burial. When he initially picked up the body, he was disturbed by the way it felt in his arms because it reminded him of recently carrying one of his own children.

Identification And Emotional Involvement

Identification or `emotional involvement' with the deceased produces a high degree of distress. Identification, a sense of kinship with the body, was described by many subjects in different ways. Some reified identification in a magical way with guidance of how to act: in the same way that a body handler took care of a body from the battlefield, someone would take care of him. A common reaction was, `It could have been me.' Children's bodies often stimulated a sense of emotional involvement. The viewers frequently reported thoughts such as, `I remember when my kids were about that age.'

In the body identification process, one of the most difficult jobs is working with the personal effects of the dead (Maloney, 1988h). It was reported that, during the Vietnam war, handling the personal effects of the dead was more stressful for soldiers than working in the area that processed the remains for shipment home. As in other wars, some soldiers carried extensive collections of letters and photographs from loved ones. Graves registration personnel had to screen these items for objectionable material and the presence of blood or body fluids before they could be sent home. In reading these letters, some workers became disturbed, bothered by the feeling of knowing the family and the fact that they knew the soldier was dead and the family back home did not.

In Vietnam, we lost more of our people who dealt with personal property, that had to read the letters and screen the personal effects, than the ones who actually worked with the hands on side of it . . . with human remains. That's something that a lot of people find hard to believe, but after you explain it to them, that a guy would sit there day after day reading those letters from a loved one. That would probably be more of a mental stress than those who worked with the deceased human remains from combat.

Say a guy got zapped after 11 months, he had 11 months worth of letters. Somebody had to sit down and physically read every one of those letters because they would be sent back to the next of kin. Those guys who worked on the personal property side, they would have to sit there and do that day after day, month after month, and finally, for some of them, the stress of getting emotionally involved with those people . . . anybody could. You know, you sit there day after day and read through a guy's stuff, especially if you've got children and if you've got any kind of feeling within you whatsoever .... But some of them just couldn't cope with it. Some had to be sent back to the mortuary side and some had to be put back for reassignment.

And another reported:

We were just taking the personal effects off the remains and we had the soldier’s billfold in our hands and here was a picture with his wife and two children. You know the impact that had on me! It just stopped me cold and I said something to the men. I said `Isn't this God-awful that we know this soldier is dead and his wife and children are going to get that news in a matter of hours or days'.

A body handler who participated in the Grenada operation reported,

Most of us had horrendous nightmares about escorting a friend or family member home in a casket.

The dead bodies of friends and acquaintances, as well as `brothers in uniform', were always disturbing. Pathologists had an unwritten rule that they would not do an autopsy on a friend. `I wanted to remember him the way he was.' An officer in charge of a large graves registration facility in Vietnam reported, `I always feared seeing somebody I knew.' A fireman said,

What makes the biggest impact is seeing a dead fire fighter - it brings it home. You have to deal with the realities: you're here and he is not.

A senior police official,

I had a cop die in my arms. I still cannot get it out of my head. I didn't know him. It was 19__, up in___ . He got shot in the back five times. I took him off the roof and got him down to the sixth floor and he died in my arms. I still can't get that out of my mind, still think about it once in awhile, if I hear a name or something comes out. But, I won't dwell on it. I just didn't like the idea that a brother I had worked with died in my arms.

At Dover Air Force Base, one group of body handlers became very upset after working for weeks with the personal effects of one victim. They developed the fantasy that they knew the victim and his family. Another group became anxious when they saw features of the body (soot in throat, posture) which they thought indicated the individual had been alive after the crash. Experienced personnel, professionals and nonprofessionals, cautioned newcomers against becoming `emotionally involved'. Most experienced workers could describe how they avoided emotional involvement. These body handlers gave tips to new personnel such as `Don't look at the face' or `Don't get emotionally involved.' `Don't think of it as a person.'

At Sioux City, rescue workers reported distress when they saw handwritten materials in the wreckage. `It meant someone wrote it. They had been alive.' Young workers, learning to work with the personal effects of Operation Desert Storm casualties, gingerly went through the personal effects, relaxing only when a more senior worker made it a standard routine with forms to complete.

Combat unique stresses

Death From Friendly Fire:  The death of a soldier caused by an error of his/her comrades in arms is termed death by friendly fire. Such deaths occasionally also occur in civilian police work. Military commanders and troops generally realize that friendly fire deaths are an unavoidable part of war. However, that does not remove the shock, remorse, and trauma of the experience. During ground combat, artillery fire may be called in by the assault force to hit a target that is very close. The artillery fire may fall short of the target and hit the assaulting troops. In extreme cases, assault troops have called in fire knowing that it would certainly hit them; they sacrificed themselves to accomplish their mission. Air crew are never perfectly accurate in the engagement of their targets. Bombs can misfire or friendly forces be mistaken for enemy.

At times during Operation Desert Storm, body handlers reacted to friendly fire deaths as expected combat deaths, expressing that the fire was not intentional. The dead were comrades who had fallen in battle. A military officer who supervised body handlers at Dover Air Force Base during Operation Desert Storm expressed his anger by directing it at the fact that personnel killed by friendly fire did not receive the Purple Heart upon their death. His assumption expressed his feelings of the wastefulness of the death. In fact, these men did receive the Purple Heart. In other friendly fire deaths, troops had been clearly marked by clothing, position, or vehicles and the deaths `should not have happened'. The body handlers reacted to these deaths with great anger and dismay.

Death Of Women In Combat:  The deaths of American military women in the Persian Gulf War stirred disquiet among the body handlers and supervisors. On looking back on the experience, one body handler remarked, `The first woman casualty was the hardest to handle.' The body handlers had seen an interview with her on TV. This made her more real. The female's personal belongings were kept separate from the men's and were not handled through the usual procedures. Supervisors insisted that a female be present when the body of a dead female soldier was being identified. This angered the male body handlers. Female bodies were kept completely wrapped and personnel involved in the identification procedures were kept to a minimum. The bodies of the men, although always treated with respect, were not required to have a male escort and the bodies were always left uncovered during the identification procedures.

The body of a pregnant woman killed in Panama in 1989 was kept separate from the other dead. The body handlers treated her wooden casket as special. It was placed to the side and no bodies or boxes were stacked on top.

Accidental Deaths:  Accidental deaths which are due to avoidable accidents or clear misconduct were termed `dumb deaths' by the observers. These deaths were reported to be particularly disquieting. The people had made it through combat and then were later killed while playing with munitions or handling weapons in an unsafe manner.

Enemy Dead:  American soldiers in Operation Just Cause in Panama reported few feelings about enemy dead. An exception was when several soldiers were going through the wallet of a dead Panamanian soldier and saw pictures of family, children, and a First Communion picture. They broke down and cried. They later went to see the chaplain to talk.

Coping

Coping strategies vary in the different stages of exposure to traumatic death and with the degree of experience of the body handler (Table 3.3).

Before The Exposure:  Few organizations practice their response to a disaster although such events are expectable. Only the timing is unpredictable. In the case of the crash of United Airlines Flight 232 in Sioux City, Iowa, in July 1989, an air crash disaster drill had been performed prior to the crash and was reported to have been very helpful. Inexperienced personnel who volunteer to help at a disaster site are rarely given more than a few hours to prepare themselves for what they will see and do. People often reported feeling frightened of their own reactions to the bodies, asking themselves, `Will I be able to handle it'?' People who volunteered in pairs or larger groups thought that they could help each other get through the experience. Initial preparation by a supervisor, usually by an inbriefing, is essential for inexperienced volunteers. Our subjects were unanimous in saying that when volunteers enter a disaster scene, such as a mortuary, they should be 'told the worst' so as to minimize the surprises at the crash site or mortuary. In a recent disaster, a supervisor provided a sequence of short, staged preparation briefings in which he became more explicit as he moved volunteers from an initial assembly area to their eventual work site. This technique was reported afterwards to have been very helpful.

 

Table 3.3. Coping strategies used in exposure to traumatic and disaster

related death

Stressor                                                                Coping Strategy

Before exposure (waiting)

Lack of information regarding tasks                  Practice drills

and roles                                                               Briefings

Anticipating one's reaction to bodies               Inbriefing

                                                                               Gradual exposure

During exposure (on site)                                    Avoidance or attenuation of strong

Sensory overload                                                    stimuli

Natural appearance of bodies                         Disidentification and use of role

Handling victims' personal effects                     Disidentification and use of role

Fatigue and overdedication                              Work breaks, food, sleep, supervision

Intense personal feelings                                     Pairing with experienced personnel

   (e.g. fear, aloneness)                                        Supervisory support

                                                                                Humor

                                                                                Talking

After exposure (postevent)                                 Debriefing

Need for information                                           Education

Intense feelings                                                    Debriefing

  (e.g. sadness, alienation)                                 Family and organizational support

                                                                               Awards

 

Little psychological preparation was reported by experienced personnel expecting to be sent on an operation. Nervousness was sometimes reported when they did not know what sort of trauma to expect, what condition the bodies were in, or how difficult it would be to extract or identify the victims. One experienced dental pathologist reported that, when he knew he had to go on a mission where he was the only professional, he had nightmares the night before; when lie knew he was going with others, he slept soundly.

During Exposure To The Dead (On Site):  Individuals defend against the multiple sensory stimuli associated with the dead: the sights of the bodies (grotesque, burned, and mutilated); the sounds during autopsy (heads hitting tables and saws cutting bone); the smells of decomposing and burned bodies; and the tactile stimuli experienced as bodies are handled.

Workers often reported that they did not see badly damaged bodies as human. Supervisors facilitated this process of 'disidentification' by telling inexperienced volunteers, 'Don't think of it as a body; think of it as a job.' Natural looking bodies were often seen as all too human. Such remarks as, 'He can't be dead; he hardly has a scratch on him', were common. People reported many internal, automatic strategies by which they distanced themselves from the bodies such as by not looking at faces.

As mentioned previously, many people attempted to mask odors by burning coffee, smoking cigars, working in the cold and using fragrances such as peppermint oil and orange?oil inside surgical masks (Cervantes, 1988). Most reported that such strategies did not help much in reducing the odors. Some olfactory adaptation did occur and workers generally dropped these strategies over time. Gloves were worn by personnel who touched the bodies or the body parts. This decreased the tactile contact with the remains which was particularly difficult with decomposed and burned bodies.

Past experience was frequently reported as helpful but it did not make one invulnerable. Even very experienced personnel could be shocked or surprised, by the sight of the grotesque. An experienced pathologist reported extreme discomfort at the sight of a body whose shoulder girdle had been cleanly sliced by a helicopter blade. When he first saw the body, he did not cognize what had happened. When he did recognize the injury, he wondered whether the individual had felt the cut, suffered, or lived long after the injury. He continued to have intrusive images of this scene. Even a nonhuman body can produce discomfort. Pine (personal communication, 1988) reported a person who was very distressed at finding a dead pet dog in the luggage compartment of a commuter aircraft crash. The person said that he ‘could not handle' the dead dog and was distressed because he knew others would not take it seriously.

Physical fatigue was a frequent and significant stressor due to the long and irregular hours, little sleep, poor eating schedules, moving heavy loads, and minimal time to recuperate. The stress of the experience was reported to be reduced when the individual took frequent breaks or the supervisor acted to decrease the visual contact with bodies, such as by providing chairs that faced away from the bodies, or putting partitions between the identification stations. Overdedication contributed to the tendency to go on working under conditions that normally would not be tolerated. Even though breaks were seen as desirable, at the Dover mortuary following the Gander air crash, for example, many individuals worked up to 20 hours per day. Managers had to require some people to leave the area.

Some workers voluntarily left the scene because of nausea, fatigue or psychological discomfort. This did not always mean that the person was going to be ineffective. A senior noncommissioned officer (NCO) reported:

I talked to some of the guys who worked Gander. There were days when they'd go in there and they would pick up an arm or a leg and they'd start thinking about what that arm used to be attached to and the fact that it was all burned up. They would have to walk outside of those plastic tents that they were working out of and sit down and have coffee, smoke a few cigarettes and just walk away for a day because on that particular day their psyche was not enough to deal with what they were seeing that day. The next day they were OK.

In general, grief and upset per se are not often observed on site because of feelings about one's public image. Most workers were concerned about flow they would look in front of the other workers, both supervisors and subordinates. No one wanted to look like they 'couldn't handle it'. In response to the question of `What if the leaders are not able to be macho that day? Do you lose faith in them? The answer from an experienced team leader was:

No, no, no! You can't lose faith in them. You have to talk to them and let them talk to you. 'What was it that bothered you on that case?' Tell them that it's OK to get sick or say 'Hey! I can't deal with it today.' Because their psyche won't allow them to deal with that body that day, we can't think any less of them because tomorrow it might be our turn.

Unfortunately, such an attitude is not always present. We heard stories of supervisors laughing when someone said they `couldn't take it'.

Humor was recognized by everyone as a substantial tension reducer during and after operations. Humor was more common when the workers were out of public view. Most humor was very respectful. Some body handlers were frightened of `black humor', feeling it reflected 'having gone over the edge', and become too hardened.

The professional role identity of individuals who handled the dead also facilitated coping with the psychological stress. The professional role was usually well defined. For nonprofessionals, roles had to be defined and reinforced by others. Often, a good time to define roles was during the inbriefing where the importance of each person's job was emphasized. For most volunteers, the idea that they were performing an important service for the dead, the families of the dead, and the community was very important.

The role of the medical examiner is well defined and of recognized importance. Curiosity and a sense of detective work helped sustain the medical examiners. They were frequently cautioned against becoming emotionally involved in their cases because their objectivity might be questioned in court. Their education to `be objective' served a protective function. In some situations, however, they were not able to avoid emotional involvement. Most reported that they did not like to do autopsies on children, friends, family members or torture deaths in which the suffering of the individual was obvious.

The mortician strives to do everything right because of the families. He takes pride in the cosmetic treatment of the deceased. This goal reinforced the idea that something memorable would be given to the survivors. Cassem (1977) noted that feelings of helplessness in the face of death could be decreased by working to provide something memorable for the survivors.

The fire, police, and emergency medical service personnel we interviewed were strongly motivated by the opportunity to save lives. Deaths often caused them to question their competence. In a fire rescue company, when occupants of a house were found dead, the fire fighters said to each other, 'They were dead before the bells went off! meaning that the victims had probably died before the fire alarm had even sounded and they were not to blame.

The leader and the work group were inevitably seen as sources of support during difficult operations. The professional work group was the primary source of support. The presence of an experienced coworker, especially for the uninitiated, was important. A new individual could share the tasks and the feelings with an experienced partner and decrease the shock and surprise of the initial exposure.

A large urban search and rescue fire company reported a very high level of social support and unit cohesion. During each shift, about 12 people lived together in a room that served as a kitchen, a dining room and a living room at the rear of the firehouse near the vehicles. They were proud of their comradery fact that:

We're like a family! We provide psychological first aid to each other - reassurance. All he [the guy next to you on the line] needs is the reassurance of someone else nearby.

The support or lack of support by senior leaders and the organization as a whole was always noticed by workers. Volunteer body handlers at Dover Air Force Base after the Gander disaster were alert to whether their supervisor visited or their senior commanders expressed support (Maloney, 1988b).

After Exposure (Postevent):  Often disaster workers needed help in the hours or days shortly after exposure to the dead. During this time, volunteers reported high levels of discomfort, both physical and psychological. Fatigue, irritability and a need for a transition `back to the real world' were commonly expressed. Experienced persons described themselves as doing what they had to in their mortuary work in order to get the job done; however, it was often at a high personal cost. The experience of professional support frequently came from a `critique' of the technical aspects of the work. One fireman pointed out that this sort of discussion had:

Two phases -- an individual phase and a group phase. You find out months or years later that something had bothered someone and you never found out about it before-he never talked about it. You argue about what had been wrong.

For almost everyone, professional counseling or psychiatric assistance, even if available, was generally viewed as unacceptable. Often this was due to fears that the person would be fired, could not successfully testify in court, would be ridiculed by fellow workers or would lose their job. Most said they did not really feel the need for counseling, however, almost all of those interviewed said they could have benefited from a brief talk about, the experience, particularly if it involved the work group. Some wished it had even been mandatory.

For the volunteer body handlers, unusual events often triggered intense feelings. While viewing a memorial service on television one man reported:

I felt the grief they [the families] were going through. They started naming names; when they came to mine [the body he had escorted through the identification process], I went in the bathroom and cried and cried.

Another reported:

Memorial services interfere with coping. At that point, it's no longer a job, it gets to be a name, a human being. You can't do both at the same time. You associate everything you do with each person. It all comes together.

Spouses of the body handlers were frequently unwilling to hear about the workers' experiences; other times, the workers themselves decided not to talk to their spouses about their disasters. One man reported that his wife required him to take his clothes off at the door and shower after any contact with remains. Others described their first (and sometimes only) attempt at telling their spouses how they felt about their work and reported that they were unlikely to repeat the experience.

The return to work was difficult for many, particularly when coworkers were not sympathetic or sensitive. Most workers appreciated some time off after the job was over. Some wanted to have time with their families; others wanted time alone. There was generally a feeling that those who had not been at the site could not understand what the volunteer had gone through. This contributed to the difficulty of talking about the experience, People who came by the mortuary for only a visit were called `turistas'.

Consistent with other reports (Maloney, 1988a, b; Robinson, 1988), in the aftermath of an incident, alcohol use was widely reported. Some workers reported that large amounts were consumed without intoxication while others reported that `getting smashed' was normal at the end of each day of an operation. Drinking also provided a social context for the work group, and an opportunity to receive and provide support to each other. Some military workers reported that when the troops were restricted to one beer per evening, the restriction did not apply to body handlers. When several individuals were ordered away from a disaster site for rest, they reported returning to their rooms and drinking alcohol.

Discussion

Exposure to traumatic death is common in natural and manmade disasters and is a significant psychological stressor that can make victims of rescuers. The rescue worker is traumatized through the senses: viewing, smelling and touching, experiencing the grotesque, the unusual, the novel and the untimeliness of the death. The stress of body handling begins prior to the exposure with the anticipation. Nonvolunteers and those with no previous experience appear to experience more distress during this time.

The extent and intensity of the sensory properties of the body such as visual grotesqueness, smell, and tactile qualities are important aspects of the stressor. It may be heuristically useful to consider exposure to human remains as a special category of toxic exposure in which such dimensions as the type of agent, frequency, intensity and duration of exposure all add to the risk of later stress reactions, (Bartone et al., 1989), breakdown, disease or even psychological growth. Exposure to a child's mutilated body appears to be extremely toxic regardless of the body handler's age or whether she/he has children.

Although all sensory modalities are involved in contact with a body, odor may have the highest potential to recreate significant past episodes in a person's life. The strength of memory appears to vary with the special involvement a person has with the odor (Engen, 1987). The amount of forgetting of olfactory recognition memory, both long and short term is very small and, thus, the accurate recognition of odors when encountered again is very high (Engen, 1987; Engen, Kuisma & Eimas, 1973). While odors are easily recognized, they are very difficult to recall at will which is fortunate for most persons exposed to the smells of death. One can easily remember the color and shape of an apple, but not its smell. There is a need for those who prepare food to be aware of the power of olfactory memory to vividly recreate a scene and for reliving some portion of the experience. Even though the recall of olfactory memory is relatively poor, we were informed of two cases of individuals who had served as body handlers at the Jonestown disaster who later received medical discharges from the military for posttraumatic stress disorder. A complaint common to both individuals was waking up at night with a vivid recollection of the smells of the bodies at Jonestown (Orman, personal communication, 1989).

The meaning or social context of a death is an additional dimension of the stress felt by the individual body handler. For example, the death of a drug dealer arouses less sympathy among policemen or medical examiners regardless of the condition of the body. The innocent, who are seen as victims, almost never fail to arouse feelings among those who deal with the remains. Interviewees who were body handlers during the Vietnam War talked about the stress of handling a large number of bodies of soldiers killed in action in an unpopular war. Deaths caused by friendly fire were similarly stressful. The deaths of these soldiers often seemed to have been a tremendous waste which contributed to feelings of depression and hopelessness among the disaster workers.

The role of identification and emotional involvement in the production and resolution of the stress of handling dead bodies requires further study. Working with personal effects is an infrequently recognized, powerful stimulus for identification and subsequent distress. Identification and feelings of `knowing' the dead appear to heighten the trauma of the experience: Identification may serve to eliminate the unfamiliar and the unknown qualities of the dead ?? changing what is new and novel into, something familiar and part of the past (Ursano & Fullerton, 1990). The `switching on' of these cognitive mechanisms ? identification, personalization and emotional involvement ? by the trauma of dead bodies requires further study. Whether certain individuals are more prone to this perceptual style or whether it represents a basic biological mechanism which all individuals activate to a various degree is unknown. Ways of decreasing identification and emotional involvement may be effective preventive measures for those who must be exposed to this traumatic stressor.

The coping strategies used by rescue personnel differ in the pre, on site, and poststages of the disaster work. An informative and role setting inbriefing is critical to the adjustment of the volunteer. This briefing helps form the context for much of what is later felt and seen. When it is not provided, individuals have greater difficulty coping and often fare poorly. But no matter how well volunteers are briefed, there is always some shock to the reality of the situation.

The overwhelming nature of the sensory stimulation usually leads participants, particularly volunteers, to develop cognitive and behavioral distancing (avoidance) strategies. Failure to protect against emotional involvement with the victim is recognized by most workers as putting a person at risk for psychological distress. Scheduling is the job of the supervisor. Before fatigue sets in, which can contribute to emotional vulnerability, it is essential that managers establish schedules and insure that rescue workers follow them. While there is little that supervisors can do about alcohol abuse off site, they can inform participants that the potential for alcohol abuse is high following exposure to trauma.

Transition out of the rescue work after exposure appears to be facilitated by an out briefing (debriefing) where the workers can ask questions and information can be provided about the event, the body identification process, and community reactions. Statements of appreciation and recognition made at this time aid recovery. Family and organizational support is central during the transition period. When sensitivity and caring are shown by both the family and the primary work group, the participant appears more likely to verbalize his or her feelings regarding what has been seen and done. Many rescue workers and volunteers will not share everything with people who were not present with them through the ordeal.

Numerous strategies are used to cope with the stresses of body handling. Most appear to be effective in the short run; however, it is unclear which are more effective and what their long?term consequences are. Avoidance strategies appear to be effective during the initial exposure to the bodies. We do not know the effect of using such strategies over a longer time period. Reports from volunteers, as well as from experienced personnel, indicate, that, at some point, they can no longer avoid reminders of previous disasters. For example, names of the victims or the sight of an object bring the experience back. It is unclear whether such an experience is helpful or harmful. The triggering of memories may help to `metabolize' the experience. On the other hand, the recall of unwanted memories can be disturbing and interfere with the present tasks. It remains an open question when and under what circumstances the individual should be encouraged to talk or think about aspects of the disaster that she/he wishes to avoid.

Spouses of disaster workers need to be educated about their loved ones' experiences. Many workers claimed that they wished their spouses had been informed of the nature of their work. Information can be provided to spouses in order to allay their concerns. This will also reinforce this naturally occurring support system. Brief groups held for spouses can also be a useful intervention.

Nonexperienced workers may be at higher risk for acute effects than experienced personnel. The latter, however, are not immune from suffering the same psychological discomforts as the volunteers. Some experienced personnel reported becoming somewhat calloused through repeated exposure, but no one believed it possible to be totally desensitized.

Additional research of this powerful stressor is needed to further describe its components and better understand the role of sensory stimulation in recall, particularly in posttraumatic stress disorder, and the normal `metabolism' of traumatic events. Finally, it should be noted that not all effects from disaster rescue work and handling dead bodies are negative. Volunteers almost unanimously report that they would volunteer again if another disaster occurred. People were proud of their contribution and of having done an important job that others either could not do or would never have the opportunity to do. It has been previously reported that most people do quite well following exposure to massive trauma. An important theoretical as well as practical question is how people use trauma to move toward health (Ursano, 1987).

 References

Arthur, A. Z. (1987). Stress as a state of anticipatory vigilance. Perceptual and Motor Skills, 64, 75?85.

Bartone, P. T., Ursano, R. J., Wright, K. M. & Ingraham, L. H. (1989). The impact of a military air disaster on the health of assistance workers: a prospective study. Journal of Nervous and Mental Disease 177, 317?28.

Breslau, N. & Davis, G. C. (1987). Posttraumatic stress disorder ? the stressor criterion. Journal of Nervous and Mental Disease, 175, 255?64.

Cassem, N. (1977). Treating the person confronting death. In A. M. Nicholi, Jr. (ed.), Harvard Guide to Modern Psychiatry (p. 599). Cambridge, MA: The Belknap Press of Harvard University Press.

Cervantes, R. (1988). Psychological stress of body handling, Part II and Part III: debriefing of Dover AFB personnel following the Gander tragedy and the body handling experience at Dover AFB. In R. J. Ursano & C. Fullerton(eds.) Exposure to death, disasters and bodies. Bethesda, Maryland: F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences (DTIC: A 203163, pp.).

Cleary, P. D., Mechanic, D. & Greenley, J. R. (1982). Sex differences in medical care utilization: an empirical investigation. Journal of Health and Social Behavior, 23 106?19.

Czeisler, C. A., Ede, M. C. M., Regestein, Q. R., Kisch, E. S., Fang, V. S. & Ehrlich, E. N. (1976). Journal of Clinical Endocrinology and Metabolism, 42, 273?83.

Derogatis, L. R. (1983). Hopkins Symptom Checklist?90?Revised. Baltimore: Clinical Psychometrics, Inc.

Derogatis, L. R. & Melisaratos, N. (1983). The brief symptom inventory: an introductory report. Psychological Medicine, 13, 595?605.

Drinkwater, B. L., Cleland, T. & Flint M. M. (1968). Pilot performance during periods of anticipatory physical threat stress. Aerospace Medicine, 39, 944?99.

Engen, T. (1987). Remembering odors and their names. American Scientist, 75, 497?503.

Engen, T., Kuisma, J. E & Eimas, P. D. (1973). Short?term memory of odors. Journal of Experimental Psychology, 99, 222?5.

Ersland, S., Weisaeth, L. & Sund, A. (1989). The stress upon rescuers involved in an oil rig disaster. `Alexander L. Kielland' 1980. Acta Psychiatrica Scandinavica Supplementum, 80(355) 38?49.

Fenz, W. D. & Epstein, S. (1967). Gradients of physiological arousal in parachutists as a function of an approaching jump. Psychosomatic Medicine, 29, 33?51.

Green, B. L., Lindy, J. D., Grace, M. C. & Gleser, G. C. (1989). Multiple diagnosis in posttraumatic stress disorder. The role of war stressors. Journal of Nervous and Mental Disease, 177, 329?35.

Hersheiser, M. R. & Quarantelli, E. L. (1976). The handling of the dead in a disaster. Omega, 7, 195?208.

Horowitz, M., Wilner, N. & Alvarez, W. (1979). Impact of event scale: a measure of subjective stress. Psychosomatic Medicine, 41, 209?18.

Hytten, K. & Hasle, A. (1989). Fire fighters: a study of stress and coping. Acta Psychiatrica Scandinavica Supplementum, 80(355), 50?5.

Jones, D. J. (1985). Secondary disaster victims: the emotional effects of recovering and identifying human remains. American Journal of Psychiatry, 142, 303?7.

Kaplan, H.1. & Sadock, B. J. (1985). Comprehensive textbook of psychiatry. Baltimore: Williams & Wilkins.

Laufer, R. S., Brett, E. & Gallops, M. S. (1985). Dimensions of posttraumatic stress disorder among Vietnam veterans. Journal of Nervous and Mental Disease, 173, 538?45.

Laufer, R. S., Gallops, M. S. & Frey?Woulters, E. (1984). War stress and trauma. Journal of Health and Social Behavior, 25, 65?85.

Lifton, R. J. (1973). Home  from the war. New York: Simon & Schuster, Inc.

Lindy, J. D., Green, B. L. & Grace, M. C. (1987). The stressor criterion and posttraumatic stress disorder. Journal of Nervous and Mental Disease, 175, 269?72.

Lundin, T. (1990). The rescue personnel and the disaster stress. In J. E. Lundeberg, U. Otto & B. Rybeck (eds.), Proceedings of the Second International Conference on Wartime Medical Services. Stockholm, Sweden:

Frsvarets forskningsanstalt?FOA, pp. 208?16. (25?29 June)

Maloney, J. (1988a). The Gander disaster: body handling and identification process. In R. J. Ursano & C. Fullerton (eds.) Exposure to death, disasters and bodies. Bethesda, MD: F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences (DTIC: A 203163), pp. 41?66.

Maloney, J. (1988b). Body handling at Dover AFB: The Gander disaster. In R. J. Ursano & C. Fullerton (eds.) Individual and Group Behavior in Toxic and Contained Environments. Bethesda, MD: F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences (DTIC: A 203267), pp. 97?102.

McCarroll, J. E., Ursano, R. J., Fullerton, C. S. & Lundy, A. L. (June, 1992). Dimensions of stress among mortuary workers. Paper presented at the First World Conference, The International Society for Traumatic Stress Studies, Amsterdam, The Netherlands.

McCarroll, J. E., Ursano, R. J., Ventis, W. L. et al., (in press). Effects of experience and gender on anticipated stress of handling the dead. British Journal of Clinical Psychiatry.

Mefferd, R. B., Hale, H. B., Shannon, I. L., Prigmore, J. R. & Ellis, J. P. (1971). Stress responses as criteria for personnel selection: baseline study. Aerospace Medicine, 42, 42?51.

Miles, M. S., Demi, A. S. & Mostyn?Aker, P. (1984). Rescue workers' reactions following the Hyatt Hotel disaster. Death Education, 8, 315?31.

Mitchell, J. H., Sproule, B. J. & Chapman, C. B. (1958). The physiological meaning of the maximal oxygen intake test. Journal of Clinical Investigation, 37, 538?47.

Myers, D. G. (1989). Mental health and disaster. In R. Gist & B. Lubin (eds.) Psychosocial aspects of disaster. New York: John Wiley & Sons, p. 198.

Norris, F.H. & Murrell, S. A. (1988), Prior experience as a moderator of disaster impact on anxiety symptoms in older adults. American Journal of Community Psychology, 16, 665?83.

Penzien, D. B., Hursey, K. G., Kotses, H. & Beazel, H. A. (1982). The effects of anticipatory stress on heart rate and T?wave amplitude. Biological Psychology, 15,241?8.

Robinson, M. (1988). Psychological support to the Dover AFB body handlers. In R. J. Ursano & C. Fullerton (eds.) Exposure to death, disasters and bodies. Bethesda, MD: F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences (DTIC: A 203163, pp. 67?90).

Rubonis, A. V. & Bickman, L. (1991). A test of the consensus and distinctiveness attribution principles in victims of disaster. Journal of Applied Social Psychology, 21, 791?809.

Rundell, J. R., Ursano, R. J., Holloway, H. C. & Silberman, E. K. (1989). Psychiatric responses to trauma. Hospital and Community Psychiatry, 40, 68?74.

Schwartz, H. J. (1984). Fear of the dead: the role of social ritual in neutralizing fantasies from combat. In H. J. Schwartz (ed.) Psychotherapy of the combat veteran. New York: Spectrum Publications.

Solomon S. D., Smith, E. M., Robins, L. N. & Fischbach, R. L. (1987). Social involvement as a mediator of disaster?induced stress. Journal of Applied Social Psychology, 17, 1092?1112.

Sumova, A. & Jakoubek, B. (1989). Analgesia and impact induced by anticipation stress: involvement of the endogenous opioid peptide system. Brain Research 503, 273?80.

Susnowski, T. (1988). Patterns of skin conductance and heart rate changes under anticipatory stress conditions. Journal of Psychophysiology, 2, 231?8.

Talbot J. A., Hales, R. E. & Yudofsky, S. C. (eds.) (1988) Textbook of psychiatry. Washington, DC: American Psychiatric Association Press.

Taylor, A. J. W. & Frazer, A. G. (1982). The stress of post?disaster body handling and victim identification work. Journal of Human Stress, 8, 4?12.

Ursano, R. J. (1987). Commentary: Posttraumatic stress disorder: the stressor criterion. Journal of Nervous and Mental Disease, 175, 273?5.

Ursano, R. J. & Fullerton, C. S. (1990). Cognitive and behavioral responses to trauma. Journal of Applied Social Psychology, 20(21), 1766?75.

Ursano, R. J., Fullerton, C. S., Wright, K. M. & McCarroll, J. E. (eds.) (1990). Trauma, disasters and recovery. (DTIC: A225911: 104 pages), Uniformed Services University of the Health Sciences, Bethesda, MD.

Ursano, R. J., Fullerton, C. S., Wright, K. M., McCarroll, J. E., Norwood, A. E. & Dinneen, M. P. (eds.) (1992). Disaster workers: Trauma and social support. Uniformed Services University of the Health Sciences, Bethesda, MD.

Ursano, R. J. & McCarroll J. E. (1990). The nature of a traumatic stressor: handling dead bodies. Journal of Nervous and Mental Disease, 178, 396?8.

 Weisaeth, L. (1989). A study of behavioral responses to an industrial disaster. Acta Psychiatrica Scandinavica Supplementum, 80(355), 13?24.

 

Home - What's New - Site Map - Search Gorski's Site - Articles - Book Reviews

Mission & Vision - Training & Consultation Services - Publications - Links

Daily News Review  -  Addiction Databases  - Leading Addiction Websites

GORSKI-CENAPS Clinical Model --- Research-Based Best Practice Principles

Special Focus:  Mental Health, Substance Abuse, & Terrorism

Terry Gorski and Other Members of the GORSKI-CENAPS Team are Available To Train & Consult On Areas Related To Recovery, Relapse Prevention, & Relapse Early Intervention

Address: 6147 Deltona Blvd, Spring Hill, FL  34606
info@enaps.com; www.tgorski.com, www.cenaps.com, www.relapse.org