Exposure To Traumatic Death:
The Nature Of The Stressor
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).
