Aftermath of disaster: effects on mental health professionals.
Article Type: Column
Subject: Disasters (United States)
Disasters (Influence)
Psychiatric personnel (Services)
Author: Ramsey, Sandy
Pub Date: 09/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2009 Source Volume: 12 Source Issue: 3
Topic: Event Code: 360 Services information
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 208639918
Full Text: I sat down without really noticing, wrapping the blanket around me as I slid to the end of the couch so that I could lean on the arm. I remained motionless; the time I sat was endless. I didn't remember when I sat down or how long I stayed there. There was no passing of time; there was only infinite, wordless space. Flashes of scenes kept rolling through my head like a slide show, and I couldn't make them stop or change them. I was suffering terribly, but I couldn't stop it or change its path. I sat for hours and days and weeks, trying to make sense of the horrors I had encountered. The image of the decapitated, dismembered bodies could not be erased from my memory. The silver tray of heads left behind a constant reminder of the victims' last moments of terror. Burned and blackened arms were reaching out as if they wanted someone to pull them from the plane, an image that joined forces with the others and haunted my nightmares.

This wasn't my first mass fatality; I had worked at others as a disaster mental health professional, but this one was the most intense. The heat was unbearable; it rained an inch a day and the moisture hung in the air. My clothes were wet the moment I put them on, and they stayed wet from sweat all day. The crash site was muddy and steep. The area around the plane had burned and was clear of vegetation, but jungle growth was thick around the perimeter. You didn't dare reach out to grab at a plant if you slipped because the swordgrass would tear open your hand like the blade of a knife.

[ILLUSTRATION OMITTED]

Young military personnel were swarming around trying to find body fragments or personal effects. They had on full Kevlar (which is plastic-coated and doesn't breathe), and their gloves were duct-taped to their wrists. The work conditions were so difficult that they worked for a short time and then were permitted to rest before they went out again. As they picked up personal effects from the ground, one of the men held up a baby shoe in a clear plastic bag, which threw me entirely off-balance. That baby shoe did not belong in an evidence bag.

Nearly three weeks after the plane crashed, everything seemed to be picked up. The workers "walked the grid" several times, and the site was finished.

After the disaster site, I was assigned to the huge metal facility being used for the plane crash victims' autopsies. The building was open to the heat and the bugs, and when the rain came down sideways in a torrent every afternoon, the rainwater ran into the facility on the floor into big puddles. There were open cans of coffee placed on the floor to try to mask the smell of decomposition, but nothing covers that smell; it permeates everything. The bodies were laying on silver gurney tables spread out in every direction. I was assigned to the morgue workers as a mental health debriefer. As I walked my rounds through the facility one day, I was distracted by movement on one of the silver gurneys. It startled me, but I forced myself to walk closer to see what was moving. I was horrified at what I saw: a mound of individual teeth was given the illusion of movement by the thousands of flies crawling around on the teeth at the same time.

One day at the end of my shift, I was drafted to debrief the local folks who had first responded to the plane crash. The locals had heard the noise of the crash and rushed to the site. They tried to pull the few injured survivors out of the plane, but were unable to do much before the ball of fire raced through the plane and killed anyone left inside. The townfolk had requested debriefings, and I was one of those asked to spend the evening providing them. I heard the stories about the first hint of trouble, the sound of the crashing plane, the heat of the fire ball, and the screams of the people who had survived the crash but were killed by the fire.

After my time at the morgue was finished, I was assigned to the families. I spent one full day at the outdoor memorial service. During the day we had a Protestant service, a Catholic service, a Buddhist service, and a shaman service. The heat continued and the air was full of moisture, clothes were soaked in sweat, and it felt like trying to breathe under water.

[ILLUSTRATION OMITTED]

I was then assigned to the hotel where the families of the plane victims were staying. The grief in the building was palpable; you could almost reach out and touch it. The weeping, moaning, and lamenting of the family members and paid mourners was continuous. I visited with the families of the plane crash victims and heard their stories of grief and loss.

The large ballroom of the hotel was used as a chapel. Incense constantly burned, filling the air with the smell of an overpowering perfume. One wall was filled with framed 8x10 pictures of every victim in the plane crash, about 200 total. One day, without realizing the consequences of what I was doing, I found myself standing in front of the wall of pictures. As I looked at the pictures of the victims, my mind started making connections that I didn't intend to make. Looking at the picture of the woman with grey hair, I started thinking things like "I recognize that grey hair; it was on one of the heads on the silver tray. Oh yes, and that curly hair, I remember seeing that burned body. And that baby, that is the one they put in the tiny casket and probably belonged to the little shoe I saw in the plastic bag. And that one, her legs were burned off, and I recognize her from the family picture her son and daughter showed me yesterday." At about that point, I went and sat quietly in a corner, hunched my shoulders, and tried to shut out what was going on around me.

I had worked the crash site, heard the stories of the crash, seen the grotesque dead, lived with the daily smell of decomposition, and visited with the grieving family members. I had an overall mental picture, and it overwhelmed my ability to detach and protect myself. I vaguely remember finishing my time on the job. I felt like an eggshell with cracks all around it; I needed to hold it together long enough to get home. I got on the plane to return to my home in the United States. Then the flashbacks and nightmares started.

I wasn't sleeping. When I did sleep, I would wake up suddenly in a cold sweat with pictures in my head that I didn't want there. I would wander the halls of my house in the middle of the night, checking on my children. Once I was awake, I didn't want to go back to sleep, so in the dark quiet of the night I would spend time on the computer trying to figure out what to do to help myself. I spent time reading literature from trauma researchers. The studies that have been done and the reviews of stories of people who had similar symptoms helped me understand that I was not alone, which helped me to understand that I was not weak or crazy. I knew intellectually what was happening; after all, I am trained in mental health. Somehow, I had the belief that my knowledge should have made me invulnerable to these symptoms.

I went to my mental health colleagues for help. They were concerned and even told me they were afraid for me, but they gave me no hope. I went to one counselor who, when I started to tell details, told me to stop because she didn't want to hear them. I sat there thinking, "But I need to tell them. I need someone to listen and understand." Over a period of weeks I tried to tell my story to anyone who would listen, but I left out details because I didn't want to traumatize anyone else. I was sure the third counselor I went to would be the one who would help me. He was trained as a psychologist and was a member of the debriefing team. I spent an hour telling him my story, trying to explain the heat, the bugs, the jungle, the smells, and the sounds. I was exhausted at the end of the hour. He sat back in his chair and told me my problem was that my identity was too wrapped up in the agency I worked for. I was stunned. I told him he was full of it, that he didn't know what he was talking about, and I walked out the door. I just wanted him to say that I went through a horrible experience and that I would get through it. I wanted him to give me hope. I started dividing the world into those who "got it" and those who didn't.

I went home and seriously considered taking my own life. My anger was overwhelming, and I wanted to strike out and hurt someone. The depth of despair that I had reached was frightening me. I couldn't control the swings between the anger and the despair. But the worst of it was the lack of hope. I did not want to die; I wanted to stop the hurting inside of me. I wanted the nightmares and flashbacks to stop, but I had no hope that they would. In the deepest part of my gut it felt like it would always be this way and continuing to live like this was unthinkable.

A Vietnam vet briefly entered my life and was the first to give me a glimmer of hope. We sat in a restaurant while I cried and told him my story. It has been a decade since that lunch, but it is still so clear to me today. He reached across the table, patted my hand, and said, "I made it through this and so will you." I grabbed on to that promise, and I clung to it every day like a lifejacket that kept me from drowning. Several months had passed since I had come home, and for the first time, I had hope.

In the decade since my time at this disaster, I have been to crime scenes, watched autopsies, and worked many more disasters around the world. Nothing has ever affected me quite like this particular disaster, and I have some observations about my response to it. My first observation is the lack of preparation I had for the grotesque dead. I believe that seeing pictures ahead of time would have helped immensely. I was trying to file away what I saw into some type of mental file drawer that didn't exist. Once I arrived at the incident and was briefed, seeing pictures of what to expect at my work site would have given me a context in which to put these images.

I understand there is controversy about having mental health personnel in the same environment as the workers, and there has been discussion about having them wait and talk to workers in a "clean environment." I believe it is important for mental health personnel to be in the same work environment as the workers. This way, the workers don't have to spend time trying to make the debriefer understand their environment because it is understood by both of them; this saves time, energy, and provides an instant connection. Workers have said to me, "How can you debrief us if you don't know what we are doing?" Having done it for many years now, I agree. Also, workers who have told me they would not normally come for a debriefing have come to me because they know and trust me. That knowledge and trust is earned at the worksite. I don't believe my trauma came from being with the workers. In fact, that was a comfort. There was an understanding that comes from shared surroundings. Even now, when I see one of those workers at a disaster, I am recognized as someone who "gets it."

I love my work as a disaster responder; it is immediate, intense, and always challenging. I have the privilege of seeing people in their finest altruistic moments. Being there to listen when disaster survivors' grief or frustration overwhelms them allows me an opportunity to provide them with a moment of healing. The work can be emotionally draining and exhausting, but that does not mean it is necessarily traumatizing. I believe my trauma was caused by my involvement at every aspect of the scene--a kind of cross-contamination. If I had just been at one or two of the locations, I believe I would not have had the same response to the disaster. In fact, I have used this knowledge to protect myself at disasters since that time. If I work with first responders, I do not work with families. If I work with families, I do not work at the disaster site or the morgue. This personal rule has served me well, and I have worked disasters around the world for the past decade without any trauma effects.

It is important for those of us who work disasters and have responsibility for others to understand the consequences of our assignments. We need to take a look at the way we prepare workers for assignments. We are afraid of traumatizing them, so we don't share the information that, in reality, protects them. I just wish that someone had honestly shared information with me when I first started this work, and I hope sharing this story will create an honest and open dialogue about what is and is not helpful for disaster workers.

By Sandy Ramsey, MA, LPC, LMFT, FAPA

Sandy Ramsey, MA, LPC, LMFT, FAPA, is the President of Crisis Recovery International (www.CrisisRecoveryInternational.org). She is a Fellow of the American Psychotherapy Association, as well as a Fellow of the American College of Forensic Examiners Institute. Sandy, a licensed mental health therapist, took her first disaster mental health course in 1994 and has been responding to disasters ever since. She now responds to disasters on a fulltime basis.
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