Multiple Stressor Debriefing and the American Red Cross

The East Bay Hills Fire Experience

by: Keith R. Armstrong, Patricia E. Lund, Laurie Townsend McWright, and Victoria Tichenor
January 1995

Workers who are mobilized to help with disaster relief are exposed to a multitude of stressors. Debriefing may prevent or minimize the negative consequences of stress reactions in relief personnel. The multiple stressor debriefing (MSD) intervention promotes the discussion of troubling aspects of the disaster work in a group format. This article discusses two models of debriefing and describes how the MSD model was used with American Red Cross personnel during the East Bay Hills firestorm in California. Specific recommendations are made for debriefing in large-scale, long-term disaster relief efforts.

Key words: acute stress reaction; disaster relief; debriefing; groupwork; posttraumatic stress disorder

On Sunday, October 20, 1991, a blaze of undetermined cause began in the populated Oakland-Berkeley hills on the eastern side of the San Francisco Bay. With winds of 30 to 50 miles per hour, the fire spread quickly throughout the hills, burning out of control for more than two days. At least 25 people died, and thousands were forced to flee. This was the worst fire in Northern California history, with more than 3,500 dwellings destroyed (American Red Cross, 1991a). Thousands of victims were left without homes, clothing, or food and were in desperate need of assistance.

In a disaster of this magnitude, numerous emergency workers are called in to help and are frequently exposed to events that cause them high levels of stress (Jacobs, Quevillon, & Stricherz, 1990; Jones, 1985). Because they are exposed to the stressors of relief work, emergency personnel are at risk for developing stress reactions including posttraumatic stress disorder (PTSD) (American Psychiatric Association, 1987). This article addresses a model of debriefing that ameliorates stress reactions among emergency workers after a lengthy disaster relief effort. The article discusses the Department of Veterans Affairs and American Red Cross collaboration, reviews two debriefing models that have been used for high-risk populations during disasters, and examines how the model of multiple stressor debriefing (MSD) was used with American Red Cross personnel during the East Bay Hills fire. Finally, this article provides recommendations for facilitating debriefing services in large-scale disaster relief work.

Department of Veterans Affairs and American Red Cross Collaboration

In 1983 the Department of Veterans Affairs (DVA) and several other agencies were mandated by executive order to create the National Disaster Medical System (NDMS) to transport and treat U.S. victims of disaster or casualties of war. The DVA provided services to disaster victims after Hurricane Hugo in South Carolina, the Loma Prieta earthquake in Northern California, Hurricane Iniki in Hawaii, and Hurricane Andrew in Florida and Louisiana. After the Loma Prieta earthquake, the posttraumatic stress disorder clinical team (PCT) at the San Francisco DVA and the American Red Cross developed a working relationship to debrief exiting Red Cross personnel before their release from duty. After the East Bay Hills fire, the PCT, with the help of other clinicians from the community, collaborated with the mental health disaster coordinator of the Red Cross to debrief Red Cross personnel before their departure from the job.

Debriefing Models

Debriefing groups have aspects of three major trends in group practice, defined by Papell and Rothman (1980) as the "mainstream model of social work practice with groups," "structured groups," and "psychotherapy groups." Debriefing is similar to the mainstream model in that members have a common goal and are encouraged to be active and leaders vary the amount of direction they give the group. Debriefing is similar to structured groups in that it has a predetermined goal and a plan to help each member reach that goal. As in the structured group, the debriefing group members are not considered ill. Debriefings, like structured groups, are preventive because they encourage those who have been exposed to stressful events to discuss their experiences to prevent long-standing problems from occurring. An educational component is also an integral part of a debriefing group, where leaders are teachers who provide a supportive atmosphere for processing difficult as well as positive experiences. Confidentiality, as in psychotherapy groups, is highly valued and strongly promoted.

Although debriefing emergency personnel is a recent practice, encouraging limited ventilation about trauma experiences has been used with soldiers in combat for at least 80 years (Mitchell, 1988). During World War I it was found that treating shell-shocked soldiers near the war front appeared to prevent psychological difficulties (Baker, 1975; Salmon, 1919, 1922). Artiss (1963) described the need to debrief soldiers exposed to combat who exhibited the symptoms of acute stress reactions: decreased concentration, hyperarousal, irritability, shock, disorientation, confusion, and overwhelming fear. Debriefing of personnel after natural disasters and accidents as a result of human error has been studied for the last decade (Armstrong, O'Callahan, & Marmar, 1991; Bergmann & Queen, 1986; Dunning, 1988; Manton & Talbot, 1990; Mitchell, 1983; Raphael, 1986; Solomon & Benbenishty, 1986; Wolfe, 1991). Providing debriefing services has been described as beneficial to workers' emotional well-being (Armstrong, O'Callahan, & Marmar, 1991; Eby, 1984; Mitchell, 1983). Mitchell first presented critical incident stress debriefing (CISD) as a method to decrease the potential effects of PTSD on emergency workers who were exposed to on-the-job trauma. These traumatic incidents are usually brief and highly stressful. CISD allows individuals or groups to re-experience the thoughts, emotions, behaviors, and physiological responses related to a single traumatic event and make sense of the event in a safe environment. The model has an educational component in which members are told about stress response syndrome and its typical course.

Disaster or rescue operations can last days, weeks, or even months. During a large-scale disaster response, which may last for more than three weeks, workers can experience different events as traumatic. The multiple stressor debriefing model, a modification of CISD, was developed for debriefing emergency personnel after a disaster relief operation (Armstrong, O'Callahan, & Marmar, 1991). MSD debriefings occur near or at the conclusion of the disaster response. All emergency personnel are encouraged to attend the debriefing sessions, not just those individuals with stress symptoms. MSD uses abreaction and psychoeducation formatted in four phases: (1) disclosure of events, (2) feelings and reactions, (3) coping strategies, and (4) termination. The participants are encouraged to describe a variety of experiences that were stressful and to begin integrating these events into their lives. The debriefing facilitates the processing of traumatic events, leading to resolution and completion of the experience.

The MSD model does not assume that group members will finish processing their experience at the completion of the group session. Therefore, MSD encourages members to continue to process the experience after they leave the debriefing. MSD provides education about normal stress response and coping strategies. CISD was designed for emergency personnel involved in a single, brief, stressful incident who are able to return home after their shift at work. Because disaster relief efforts are often lengthy and many personnel are unable to return home during their tour of duty, MSD, unlike CISD, was developed to address the transition to the home environment. It is currently cited by the American Red Cross as a model for debriefing their personnel (American Red Cross, 1991b, 1992).

Although individual debriefing is appropriate in certain circumstances, debriefing in a group format provides a cost-effective and productive intervention. The advantages of group debriefing include providing an environment in which members listen to others and describe what was difficult and what they were proud of during the relief effort; normalizing the stressors and the "symptoms" (for example, irritability, intrusive thoughts, emotional numbing, jumpiness, and guilt) that may accompany intensive relief work; and encouraging members to share coping strategies. Because much of relief work is conducted in a group environment, group debriefing is a logical intervention.

Multiple Stressor Debriefing Model

The first phase of MSD is disclosure of events. Leaders describe the parameters of the intervention, including the length and purpose of the group, and outline the limitations of confidentiality in accordance with state law. The facilitators communicate to the participants that debriefing is neither psychotherapy nor primarily a critique of the past events. Instead, debriefing provides individuals or members of a group time to take a break from their jobs and reflect on the positive and negative aspects of their work. It is important to set clear rules for group participation so that participants understand what they can expect from leaders and other members, particularly because some of the material disclosed can be sensitive.

In the disclosure of events phase, the group leaders encourage members to discuss one or two distressing events that occurred during their disaster work. One of the leaders writes the events on a blackboard. The use of a visual aid such as a blackboard enhances the educational component of the meeting, thereby decreasing participants' anxiety about being counseled or diagnosed during the debriefing process; communicates to the group members in a concrete way that their thoughts and feelings are important and significant; and places the event outside the participant (and on the board), which creates some distance so the event may be put in perspective by the individual and acknowledged by other group members. Significant positive events also are identified during this phase.

The second phase of the model is feelings and reactions. Here the group members discuss thoughts and feelings about the events written on the blackboard. Facilitators help participants associate their feelings with the troubling events. The use of a blackboard effectively allows group members to explore and describe their feelings and reactions to the distressing events. Time also is set aside for discussing feelings associated with positive events.

In the third phase of the model, coping strategies are discussed. The leaders educate the group about stress response syndrome. Group leaders ask members to identify the coping strategies they used both during the disaster relief operation and with similar past experiences. The leaders aid group participants in identifying numerous effective coping strategies and encourage members to use these strategies. During this phase, group leaders assess members for potential maladaptive and self-destructive coping behaviors (Daniels & Scurfield, 1994).

In the model's last phase, termination, the members discuss the transition to their home lives and responsibilities. Participants are asked to reflect on what they remember as positive from their disaster response work. This process can help workers assess their entire experience rather than amplifying only the difficulties they encountered. Members are encouraged to discuss what the process of leaving the disaster will be like for themÑwhat difficulties they might encounter and what they are looking forward to. In this stage, the leaders encourage members to say good-bye to those with whom they have grown close. Recognizing this bond and discussing it openly can be important in aiding workers with the transition home, where a clear sense of purpose and teamwork may not be part of their daily lives. In addition, the traveling disaster worker may face a number of responsibilities or stressors in his or her work and social life when returning home. Group leaders strongly encourage workers to continue to discuss the troubling and positive aspects of the disaster work with their support systems after leaving the disaster site.

Multiple Stressor Debriefing and the East Bay Hills Fire

All four phases of MSD were incorporated into a single debriefing session for the American Red Cross personnel who responded to the East Bay Hills fire. The four phases help to move the group through a process that had a beginning, a middle, and an end within a single session (Block, 1985). Debriefings were scheduled for the Red Cross workers over a four-week period at the Red Cross base of operations in Oakland. Groups were scheduled for two hours twice a day so that workers finishing their tour would have easy access to a group. Paid emergency response staff and seasoned volunteers, both local and from outside the Bay Area, typically worked 16 hours per day, seven days per week. Debriefings occurred at the end of an individual's tour of duty, which for the Red Cross usually occurs three weeks after workers have been activated for disaster relief. Approximately 50 meetings were scheduled, and between one and five persons attended each meeting. Relief workers attended only one meeting before their departure. Red Cross staff and volunteers were encouraged but not required to attend a debriefing before leaving the disaster site. Debriefers were clinicians experienced in working with victims of trauma. Meetings were facilitated by one or two leaders.

During the East Bay Hills fire debriefings, stressors that Red Cross personnel identified in the first phase, disclosure of events, were the workers' experiences in aiding distraught disaster victims, administrative problems, personality conflicts between workers, and the ways mental health interventions were handled during the disaster. Some workers also disclosed non-disaster-related stressors that occurred at home while they were at the relief operation. Group leaders asked for the participants' positive experiences to enable group members to more fully integrate the experience. Late-night trips to local convenience stores, dinners with coworkers after working long hours, and reunions with old acquaintances were some of the positive events workers mentioned during this stage. A common stressor for relief workers in disaster work is the perception of how the operation has been coordinated (Armstrong, O'Callahan, & Marmar, 1991). This perception is especially significant when engaging in disaster work over a prolonged period. To fully process their experience as disaster personnel, direct service workers may need to discuss the style and effectiveness of the administration, whereas those in middle and upper management roles may need time to discuss the difficulties in coordinating the relief operation. There may be added stressors when the emergency relief worker is in an unfamiliar or hostile environment.

In the feelings and reactions phase of the debriefing, the fire disaster personnel described a variety of feelings. They expressed feelings of guilt and inadequacy about not doing enough for fire victims, anger and disappointment at the administrative staff for its disorganization, and frustration in dealing with difficult coworkers. They expressed distrust and criticism of the mental health professionals who were not familiar with Red Cross procedure or who "got in the way" during the disaster. Positive themes included camaraderie, helping others, and a sense of belonging to the group. During this stage, other significant events and feelings arose, including anger at the pressure to be involved in the debriefing groups and sadness and guilt for having to leave coworkers when rotating off assignment.

In the coping strategies phase, workers discussed setting realistic expectations of their work with victims, communicating feelings with coworkers, making themselves feel productive, praying, sleeping, taking baths, shopping, exercising, and reading. Some talked on the telephone with friends and family members, received back rubs, wrote letters to loved ones, or cried. Consciously blocking out memories or denying the impact of the experience were other strategies mentioned. Leaders helped to normalize the range of different coping strategies members expressed and promoted sharing these methods. Leaders helped members help each other with interpersonal difficulties they had with work colleagues. By instructing group members about stress response syndrome, the leaders helped to normalize the members' experiences and decrease their anxiety.

In the termination phase, workers described similar themes while reviewing their experiences in the field and planning for the future by anticipating their return home and the problems awaiting them. Members also were able to identify and discuss their feelings about leaving friends and coworkers as they made the transition from the disaster site to home. Leaders encouraged members who had successfully coped with previous disaster work to aid "first timers" with their upcoming transition home by telling them what to expect. These members shared their own experiences and expertise while less-experienced members listened. The use of group members as a resource had the benefit of providing the experienced members with a role of expert while the less-experienced members received valuable information.

One common mechanism the group participants used to deal with leaving was to discuss possible reunions in the near future. Members also identified persons in their support system away from work with whom they would be able to share their experiences. In this stage, discussing the positive aspects of teamwork and reviewing the workers' accomplishments occurred in almost all of the debriefing groups. By helping members appreciate their efforts, group leaders attempted to instill hope for the future. At the end of the group session, handouts on stress response syndrome were provided to each worker. Disaster workers who appeared distressed were identified by the leaders, and an appropriate follow-up plan was created.

Recommendations

In the course of our exit debriefing work, we developed a number of guidelines to enhance group leader effectiveness and improve the delivery of service.

The purpose, rules, and phases of the session need to be outlined at the beginning of the meeting. Members value knowing what the norms or fundamental rules of the group are (Schopler & Galinsky, 1981). A lack of structure, confusion about norms, and low task orientation can lead to problems in any group and especially in a group that only meets once (Galinsky & Schopler, 1977). If possible, it is helpful to meet briefly, provide information about the group to the potential members, and make a contract with them before starting the session (Block, 1985).

Leaders must be prepared to be verbally active throughout the entire session (Armstrong, 1990; Yalom, 1983). Facilitators must be careful in managing the high level of anxiety associated with relief work. The session allows members to discuss troubling events and coping strategies and to provide information about acute stress reactions and concerns about leaving the disaster site. The leader encourages the exploration of troubling events while "maintaining the responsibility for providing conditions that will contain it" (Block, 1985, p. 92). Because debriefing occurs as workers are preparing to leave the disaster site, it is important to make debriefing a user-friendly experience and provide convenient services to workers. Because of the necessity to meet soon after the completion of the disaster event, members are not screened before attending a session. Leaders must carefully assess the ability of members to tolerate anxiety-laden material during the group. Depending on the composition of the group, the leaders may choose to emphasize educational components of the debriefing or the detailed discussion of troubling events.

Leaders should obtain as much information as possible (before the debriefing) regarding the specific tasks individual group members carried out during the response to the disaster events. Familiarity with workers' jobs during a disaster can aid in developing a better alliance with the group members. As with any specialty group of people exposed to trauma events, members tend to look suspiciously at outsiders. By letting the participants know that they are familiar with disaster work, leaders can speed the group process. This knowledge also can prepare leaders to aid the group in encouraging members to discuss what is troubling them rather than avoiding what is difficult. Unlike traditional outpatient therapy groups, in which there is little overlap among what people do outside the group, MSD sessions are conducted with people who have worked closely together during a highly stressful time and may have worked together at previous disasters. This can present a challenge to the group leaders because there may be unspoken issues that can mitigate the group's effectiveness.

Similar to many helping professionals, American Red Cross and other relief workers are comfortable identifying others who need help but have a difficult time asking for assistance for themselves. One way to effectively elicit this information is to reframe getting help for oneself as a way to be a more effective worker. Once group members begin to disclose personal experiences that are troubling, group leaders can encourage other members to empathize with and discuss difficult experiences related to the relief work.

Debriefing sessions using the MSD model work best when facilitated with a coleader. Discussing traumatic issues in any form of group can be potentially overwhelming for the leaders. A coleadership model may mitigate this potential problem. A balance of coleader personalities (for example, pairing thinkers and feelers) can also aid in the effectiveness of the group (Levine, 1980). Galinsky and Schopler (1980) described seven factors of coleadership that practitioners have associated with positive outcomes. Four of these factors are extremely relevant in facilitating one-session debriefing groups: Coleaders provide the opportunity to structure coworker relationships that meet individual and group needs, enhance the ability to manage the group, increase problem-solving ability, and increase support for therapeutic intervention.

Although a debriefing is not a therapy group, countertransference issues may arise within the group context. A single leader may respond to traumatic material in a way that is countertherapeutic for the participants. For example, subtle cues indicating that the group leader cannot tolerate the discussion of upsetting events may decrease the likelihood of the group participants discussing troubling events. A strict pathology orientation of a group leader may focus too much on the traumatic material and neglect the need to discuss the positive aspects of the disaster experience. A coleadership model may reduce the potential of countertherapeutic behaviors in a debriefing group.

Separate groups should be established for line workers and managers. Schopler and Galinsky (1981) asserted that groups are not always helpful for the participants. In one study they conducted, leaders ranked the composition of the group as the factor that is most likely to have the highest effect on negative interactions that may occur in the group. Our experience was that Red Cross personnel were more comfortable discussing what was distressing to them about the disaster work when the groups were segregated into line workers and managers. This separation allows a more cohesive and homogeneous group to emerge (Schopler & Galinsky, 1981).

The staff members who facilitate the debriefings should be closely linked to the existing mental health services for the workers. Many times there is a lack of communication between mental health workers who provide care for the relief workers and the leaders of the debriefing groups. The group leaders can provide better services for the workers if there is an established communication procedure with mental health workers who provide services to relief personnel during the disaster. Through this communication, the leaders may receive important information about the workers and be able to direct the debriefing group more effectively.

The groups should be safe for all members. The material discussed should remain confidential in accordance with professional standards. An important aspect of running an effective group is establishing the group as a safe place for members to discuss what was troubling to them without criticizing other group members. Some group members may find an element of the relief work troubling because of how it was implemented. This can potentially lead to the criticism of others in the group. Leaders must be adept in providing an atmosphere that allows members to discuss these events without other members feeling criticized about their work.

The positive aspects of the disaster should be discussed in the debriefing (Raphael, 1986). This positive discussion helps workers integrate the experience into their lives. Facilitators should be careful that talking about positive themes is not used by the members as a technique to avoid discussing the difficult events, but rather as a method to integrate the experience in its entirety.

Debriefing should be encouraged but should not be made mandatory. People have a multitude of effective ways of caring for themselves. These diverse strategies should be respected and promoted. Finally, group facilitators should be offered a debriefing by a nonfacilitator mental health professional to prevent secondary traumatization among group leaders (Talbot, Manton, & Dunn, 1992).

If qualified full-time staffing is available, the following continuum of mental health services should be provided:

• Predisaster briefings for relief workers could be conducted that focus on how to recognize stress response syndrome in themselves and others and to aid in preparing them for disaster work. This intervention could take place in a large group with a psychoeducational format before or early on in their work assignment.
• Informal meetings, referred to by Mitchell (1983) as "defusings" (individual or group), could be provided for workers who appear to be experiencing stress reactions or who just need someone outside of a particular work environment to discuss how things are going.
• Exit debriefings could be provided for workers leaving the disaster site. Those workers identified as interested in follow-up could then be referred for short- or long-term therapy.

Research on the effectiveness of MSD needs to be conducted. In addition, a more in-depth analysis of each phase of this model would provide useful information that could improve debriefing services for relief workers in future disaster operations.

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Keith R. Armstrong, MSW, LCSW, BCD, is assistant clinical professor of psychiatry, University of California at San Francisco, and social worker, Posttraumatic Stress Disorder Clinical Team, Mail Code SW122, Department of Veterans Affairs Hospital, 4150 Clement Street, San Francisco, CA 94121. Patricia E. Lund, PhD, is a psychologist in private practice, San Francisco and Menlo Park, CA. Laurie Townsend McWright, MSW, LCSW, is program coordinator, Northern Virginia Family Service, Herndon. Victoria Tichenor, PhD, is assistant clinical professor of psychiatry, University of California at San Francisco, and staff psychologist, Posttraumatic Stress Disorder Clinical Team, Department of Veterans Affairs Hospital, San Francisco.

Accepted May 28, 1993

From Social Work, January 1995, pp. 83-90.