When TWA Flight 800 crashed into the Atlantic in 1996 and SwissAir Flight 111 did so in 1998, Navy divers helped recover the remains of the victims. When 83 adults and children were killed in the Branch Davidian fire in Waco, Tex., in 1993, local forensic dentists helped identify their remains.

The task of collecting and identifying the remains at disaster sites also falls to mortuary attendants, funeral directors, and forensic pathologists.

While psychiatrists have long been concerned about posttraumatic stress disorder (PTSD) in survivors of disasters, some experts in disaster psychiatry are focusing on secondary victims.

Their studies on posttraumatic stress symptoms in mortuary workers, forensic dentists, and Navy divers show medium to high clinical levels of intrusive thoughts and flashbacks of the disaster site and avoidance of reminders of the disaster six months later.

"The workers may have intrusive flashbacks of the scene or parts of the scene that are emotionally charged. They may avoid talking to the media, watching newscasts of the event, or talking to family members or a therapist about their work," according to Captain Mark Dembert, M.D., a member of the Navy’s Special Psychiatric Rapid Intervention Team (SPRINT) that responds to military and civilian disasters including the TWA and Swissair plane crashes at sea.

His research on posttraumatic stress symptoms in TWA divers appears in the September 1998 Journal of Nervous and Mental Disease.

"They worked under hazardous conditions including poor visibility. Some bodies they saw were severely damaged and decomposing," said Dembert at the First International Congress on Disaster Psychiatry in New York City in October. The congress was sponsored by Disaster Psychiatry Outreach, an organization devoted to providing voluntary psychiatric services to individuals affected by disasters. The organization, which is based in New York City, also promotes education and research in the field of disaster psychiatry.

Dembert found that the divers’ most stressful event was seeing children’s personal effects and remains, followed by living at sea for the entire operation and exposure to adults’ remains.

Studies of mortuary workers and forensic dentists also show that seeing children’s personal effects and remains was the most distressing aspect of their work.

Forensic dentists reported that other distressing aspects of handling the Branch Davidian victims’ remains were exposure to decomposed and burnt bodies and to body parts, according to psychiatrist Robert Ursano, M.D., and his colleagues in an article in the June 1996 American Journal of Psychiatry. Ursano is a member and past chair of APA’s Committee on Psychiatric Dimensions of Disasters.

The coping strategies among the three occupational groups were similar. These were support from coworkers and spouses, a sense that their work was valued by families and the community, and a sense of humor.

"Navy divers are a tight-knit community and like to deal with problems among themselves. They socialize frequently and use gallows humor, which may help them cope with the more stressful aspects of their work," said Dembert.

Funeral directors and mortuary workers also reported that conducting practice drills beforehand was extremely useful.

Michael Blumenfield, M.D., a corresponding member of APA’s Committee on Psychiatric Dimensions of Disasters, recently described his conversation with funeral directors during his visit to a Delta plane crash site in Dallas in 1988. "The funeral directors said the practice drills they had done at the local airport prepared them to collect the bodies and remains from the wreckage," said Blumenfield at the international congress. However, "one funeral director told me that he was devastated when he was handed a bucketful of wrist watches and told to sort them. Because the owners were not identified, he couldn’t take professional pride in handling the deceaseds’ personal effects in a dignified manner, which was very important to him," said Blumenfield, who also is chair of APA’s Joint Commission on Public Affairs.

Blumenfield learned as well that many of the students assisting the funeral directors in recovering bodies and body parts found the experience too traumatic and resigned.

Ursano and his colleagues also reported that the younger, inexperienced forensic dentists were significantly more distressed by handling the remains of Branch Davidian children and adults than were the older experienced dentists.

Dembert suggested that inexperienced professionals be paired with experienced colleagues who can mentor them on site and provide an emotional and psychological buffer against the often-gruesome tasks they have to carry out.

He also recommended that an experienced supervisor brief the workers on site in stages that move from general to explicit descriptions of what they will see and do. This "staged desensitization" technique has been used effectively with divers, mortuary workers, and other health workers, said Dembert.

"For example, Navy divers assigned to the Swissair crash were shown a videotape of the wreckage and bodies that was taken by a camera mounted on a robotic underwater vehicle. Viewing the crash scene before they dove and [having] the opportunity to talk about it helped demystify what the divers saw and lessened the emotional impact," said Dembert.