Worker Stress, Orientation,  Screening,

and Pre-Briefing

John D. Weaver, LCSW

In major disasters, working conditions are often poor and hours are long. Relief workers often put in 12-14 hour days and sometimes do so for weeks at a time. DMH team members and volunteers need to be mindful of stress management and self-care issues. Burnout is a serious hazard for disaster workers.

Use of peer support is one of the best methods that can be used to cope with the stresses of relief work - make friends and watch out for each other. Appropriate use of breaks, scheduled time off, humor, maintenance of proper diet and exercise, and careful attention to getting proper amounts of restful sleep are other critical elements in each worker's plan of care. Keeping a personal journal (a log of what was seen, thought, and felt) and writing a narrative at the end of the assignment can be of help too. Disaster work is not for everyone and workers need to learn to recognize and admit their limitations.

Once a disaster operation ends, workers need to make the transition back into their pre-disaster lives and responsibilities. This can be a challenging time for the worker, his/her family, and those with whom he/she works. It is often wise to try to schedule some time off before returning to normal duties. Workers and volunteers need a chance to reflect / vent once their relief roles end. Disaster relief work often changes people in a variety of ways.

Disasters never stop happening and no two seem to be exactly alike. DMH workers need to also be involved with preparedness planning, drills, and other plan review activities in between the occurrences of actual events.

GUIDELINES FOR MASS-CASUALTY ASSIGNMENTS

Airline accidents, bombings, and other mass-casualty events often result in some of the most intense, complex, and stressful disaster relief assignments workers will face. DMH workers offer emergency and preventive mental health services to people affected by disaster and to relief and recovery workers assigned to the operation. This includes providing educational information about current stresses (and future stresses that are predictable), their effects, and methods of coping. It includes offering crisis intervention, information and referral services, and support. DMH workers also provide similar education and support to families of workers that are out on an assignment.

PRE-BRIEFING

Given the unique and stressful nature of mass-casualty incidents, extra time must be taken to prepare all workers for what is to come. This becomes an excellent time for DMH involvement. Taking part in orientation sessions for all incoming staff, offered as workers arrive at the relief site, provides an opportunity to inoculate workers to some of the stresses they may encounter during their assignment. This will also allow DMH workers a chance to set the stage for later defusing and debriefing sessions. Here are some suggestions:

• Encourage people to take care of themselves (drink enough fluids, take breaks, etc.).
• Describe the work setting in detail, covering duties, schedule, ID process, and so on. Prepare everyone for the fact that the sights, sounds, and smells they encounter along the way will form memories that may come back to them from time to time.
• If serving workers/volunteers acting in recovery/identification roles (e.g., those working at a crash site or a morgue), offer education and special precautions on the psychological impact of things with which they may not be familiar. This may include explaining biohazard precautions, stressful working conditions, talking about the other organizations involved and their roles, etc. Offer a graphic description of the sights, sounds, and smells people will encounter.
• Allow an opportunity for anyone who may feel he or she cannot handle the job to gracefully exit (or be assigned less stressful duties). People already grieving a previous loss, folks who have recently handled another mass-casualty incident, and anyone who for any reason is having second thoughts should be encouraged to speak to their supervisor. They may need to explore a low-stress assignment or they may even need to stop now. If so, be sure to thank them for their concern and assure them they have made the right choice by stopping now. Have someone take them aside and process the feelings they have about their decision to stop.
• Remind everyone that they may reach that same point of wanting to end their involvement within a few minutes, hours, or days and that it is OK to stop at any time they feel they must do so.
• Tell everyone about the availability of support services and encourage them to attend defusing/support sessions. 
• ncourage use of a buddy system and group meetings, for peer support.

Also encourage people to consider journaling. It can help people externalize some things (self debriefing) and help them later, when things slow down and they want to review (and reflect upon) their assignment.

DEFUSING / DEBRIEFING / PSYCHOLOGICAL FIRST AID (PFA)

As important as the DMH role is in all relief operations, it is even more critical in mass-casualty situations. In most relief operations, workers are offered opportunities for receiving supportive exit interviews at the end of their assignment, both before they leave and after they have gotten home. The individual or group sessions are voluntary and, despite their importance, the sessions may be declined by workers who believe they are too healthy, too macho, too cool, too anxious, and/or too busy.

In addition to using PFA, for mass-casualty situations, daily defusing sessions and end-of-job debriefings are sometimes used for all workers. Attendance at such education and support sessions may be required for everyone involved in these assignments. This is especially true for those volunteers and staff who are serving in recovery rolls (e.g., trackers and scribes in morgue operations, persons picking up pieces of a crashed plane, and anyone handling personnel effects).

The focus for daily defusing should be on sharing the most important issues of the day and answering any specific questions the workers may pose (e.g., people often want to know what to say to their children about the disaster). Teaching about any predictable stresses/reactions that are to come is another important activity. For example, if cafeteria trays were used to carry body parts or if Vicks was used to mask foul odors, the next time folks use these items they will be reminded of this tragedy. Telling them about this now will offer some measure of stress inoculation. Save any in-depth discussions of feelings for the close-of-business (end-of-job) debriefings, so as to not lower needed defenses and healthy denial too soon to allow completion of the tasks at hand.

Sometimes there will be a wealth of people offering support services. There may be CISM team members and mental health workers that are assigned to FEMA, the FBI, police/fire rescue units, the military, and the airline, in addition to other local volunteers. Other times DMH team members may have little support and may need to help cover everyone else involved. It is always nice to have enough help available to offer a variety of support personnel (representative of gender, racial, ethnic, cultural, and religious diversity) and allow people to select the person with whom they feel comfortable. In fact, many times it seems people prefer to share things with a total stranger than someone they already know or someone they fear may represent interests other than their own.

DAILY MAINTANENCE FOR ALL WORKERS

DMH workers (and all others involved) must practice daily self-care, both for their own sake and to model healthy practices for everyone assigned to the operation. Here are some suggestions:

• Develop sensible work shifts and, when it is not your shift, stay away from the job.
• Take breaks, eat well (but try not to overeat), and watch out for excessive use of alcohol, tobacco products, caffeine, and over-the-counter medications.
• Take time off as needed.
• Establish a buddy system and then keep an eye (and a listening ear) on your partner(s).
• Try to get all of the team members to attend brief, daily staff meetings. Defuse by sharing the most significant stories of the day (or the previous day).

END OF ASSIGNMENT (RETURNING HOME)

DMH workers need to take special care of others and themselves as they end the assignment and return home. Here are some suggestions:

• Encourage everyone to wrap-up their duties and, if the job is not ending, try to spend a portion of their last day briefing their replacement (and offering him or her some stress inoculation).
• Everyone should schedule and attend an exit interview/ debriefing session before leaving for home.
• Everyone should also consider having a second interview / debriefing with someone in their local area a few days after they have returned home and had time to rest and reflect.
• Acknowledge that there will be ambivalent feelings regarding incomplete tasks and clients that remain while you get to go home and get on with your life.

LONG-TERM SELF-CARE

The process of taking care of oneself can begin even prior to acceptance of these difficult assignments, during the recruitment call. Think seriously about whether or not you need this amount of stress in your life right now. If you are already grieving another loss or if you have recently been on another mass-casualty operation (or any rough assignment), put your own health first and say "NO" this time.

Develop a connection to others who are doing these tough assignments and have your own buddy system in place. Research indicates that peer support is frequently rated as being the most effective method of support for people in stressful jobs. Your peers know what you have experienced and they are less likely to be traumatized by your disaster stories than your non-disaster friends and family members.

IMPORTANCE OF CAREFUL SCREENING

If I had to pick one major “lesson learned” from my disaster relief experiences, it would have to be the importance of careful screening, proactive supervision and daily self-care efforts to keep the entire workforce safe and sound.  My greatest frustration while serving in mass-casualty assignments usually comes from the troubling behaviors of a very small group of my fellow relief workers who end up requiring large amounts of administrative staff time.  Sadly, there have been many people who required investigation and intervention following incidents of sexual harassment – no big surprise, as this is an unfortunate part of our culture.  Nevertheless, it requires lots of careful work by skilled people to quickly and thoroughly resolve these distracting situations whenever they arise.

Even more troubling to me, though, were the self-proclaimed “trauma experts” who told me they had wasted their time coming to help, because they had not gotten to spend their entire assignment working at “ground zero.”  These same people had trouble following directions (and some seemed prone to freelancing).  In retrospect, it strikes me that tighter screening of personnel might be able to help with this in future operations.  Till we come up with a better vetting process, consider using this overly simple one.  Ask people:

“How do you think you can best help us with this relief operation?”

A. By working at or near “ground zero.”

B. By working anyplace but “ground zero.”

C. By working wherever you need me.

Those who answer “A” have a greater potential for becoming part of the problem rather than the solution – use with care (if at all).  Those who answer “B” probably have good insight into their own strengths, needs, and tolerances – use them in low-stress settings.  Those who answer “C” tend to be the best workers for sensitive and high-stress locations.

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