CRT Chapter 6

Chapter Six:

Crisis Intervention and Death Notification

I. Introduction

On a wall of Brasenose College at Oxford University hangs a letter from President Abraham Lincoln as a model of "purest English." It is also a model of written response to a grieving mother:

Dear Mrs. Bixby,

I have been shown in the files of the War Department a statement of the Adjutant General of Massachusetts that you are the mother of five sons who have died gloriously on the field of battle. I feel how weak and fruitless must be any word of mine which should attempt to beguile you from the grief of a loss so overwhelming. But I cannot refrain from tendering you the consolation that may be found in the thanks of the republic they died to save. I pray that our Heavenly Father may assuage the anguish of your bereavement, and leave you only the cherished memory of the loved and lost, and the solemn pride that must be yours to have had so costly a sacrifice upon the altar of freedom.

Yours very sincerely and respectfully,

A. Lincoln

_ Cook, R.J., ed., One Hundred and One Famous Poems, Contemporary Books, Chicago, 1958.

II. Purpose and Value of Crisis Intervention

Simple techniques for intervening in crisis can help survivors regain a sense of control over their lives and begin the process of reconstructing a new life. Much of crisis intervention rests on the idea of creative listening.

Catherine de Hueck Doherty spoke of the impact of good listening. She said, "With the gift of listening comes the gift of healing, because listening to your brothers or sisters until they have said the last words in their hearts is healing and consoling. Someone has said that it is possible, `to listen a person's soul into existence.' "

In the aftermath of a catastrophe, victims must deal with the physical and emotional impact of the crisis reaction, but also with the sense of helplessness, powerlessness and a loss of control. A common response in the shock of the moment is to retreat into a childlike state. The victim is vulnerable to any kind of intervention. Intervenors should use a great deal of care to avoid intrusive or harmful behavior or reactions to victim responses.

Death notification is a kind of crisis intervention that is particularly sensitive. No one wants to learn about the sudden death of a loved one. In most cases, the death notification itself is the traumatic event and the caregiver, initially, is perceived as the source of the trauma. The elements of crisis intervention _ safety and security, ventilation and validation, and prediction and preparation _ are critical in death notification, but other issues also rise to the surface. Among them are the timeliness of the notification, the accuracy of the information, whether the notification was made in person or through telephone or electronic communication, and the ability of the notifier to provide immediate assistance with practical concerns such as the notification of other loved ones, identification of the deceased's body, explanation of autopsy requirements, or funeral or memorial arrangements, if necessary.

III. Elements of Crisis Intervention

A. "Safety and Security"

1. Safety

Safety is an issue for victims who survive. Until it is addressed, other issues or concerns will be tangential. Providing for the safety of victim-survivors involves the following services.

a. Assisting with and showing concern for the victim's or survivor's physical safety and medical needs. Issues to be addressed include:

• Is the victim in need of medical care?

• Is the victim in immediate danger?

• Are the victim's family, friends or neighbors in immediate danger?

• Are the victim's home or belongings in immediate danger?

• Is there a safe place to which victims and their loved ones can be taken while waiting for immediate danger to pass?

• Are there belongings significant to the victim that need to be rescued, if possible?

b. Taking care of witnesses' and family members' safety and medical needs. The following questions should be asked:

• Are any people in immediate danger?

• Do any people need immediate medical care?

• Is there a safe place where these people can be taken while waiting for further word of loved ones or for further questions from investigators?

c. Ensuring that victims or survivors have warmth, food, clothing and are able to sleep.

• Is there a source of power for heating?

• Are there sufficient blankets for maintaining warmth?

• Do they have a change of clothing?

• Is there a quiet place where they can rest and feel secure?

d. Giving victims and survivors a sense of connection with other people in a secure setting.

• Are telephones or others forms of communication available so that victims and survivors can get in touch with friends or relatives?

• Is there someone the caregiver can contact for the survivors so that they feel more secure?

• Can groups of survivors meet and talk in order to get a sense of the range and the extent of the disaster?

• Is there a respected authority who can talk to survivors?

• What information do survivors want and need to feel more secure?

2. Security

Survivors who know they are physically safe may still feel insecure. Individuals who have survived the death of a loved one are not often concerned about their own safety. But they do need to be given a sense of security.

a. Help survivors find privacy for the expression of emotions.

• Most survivors are uncomfortable with intrusive or sensational media scrutiny.

• Many survivors do not want family, friends or members of their own culture to witness their loss, pain or grief.

• Some survivors feel more secure if they talk to only one or two caregivers at a time.

b. Ensure confidentiality of communication.

• Confidentiality of communication can be assured when survivors talk with professionals who are legally bound by confidentiality laws, at least within the limits of those laws.

• Confidentiality of communication may be assured when survivors talk with crisis responders who are ethically bound to keep information private.

• Assurances of confidentiality should be expressly limited if a crisis responder cannot guarantee for legal or policy reasons that what is said will not be repeated.

• Assurances of confidentiality should be expressly limited if other people are present during the course of communication and the crisis responder cannot guarantee their trustworthiness.

c. Reassure survivors that their reactions are acceptable and not uncommon.

• The reason for knowing the range of crisis reactions and their various manifestations is so that caregivers can let survivors know that they are not "going crazy" and that such patterns of response are not unusual.

• Telling survivors of common grief reactions, and assuring them of the validity of such reactions, is also important.

• Immediate family members should be reassured that family members, friends, and others may react differently to the notification of death, but that grief reactions and crisis reactions of many different types are not unusual.

d. Help survivors begin to take control of the events going on around them.

• Ask survivors where they would like to sit and talk so they can make initial decisions over their environment.

• Ask them if they would like a glass of water or a beverage while they talk.

• Offer them a cigarette or refreshments, if available.

• Ask them what their names are and what they would like to be called while you talk with them.

• These are all simple questions that have no "correct" answer but help survivors make small decisions in gaining control over certain parts of their lives.

e. Support survivors in their efforts to achieve a sense of emotional safety.

• Sometimes victims and survivors are not physically safe after a traumatic event. Crisis responders may not feel safe either _ an earthquake may be followed by scary aftershocks; a hurricane may be followed by a flood; an assailant may not have been apprehended. Crisis responders may be called upon to help victims or survivors gain a sense of mental safety (thinking of a place or a time when they did feel safe); safety in the belief that others care (perhaps giving small gifts of pictures, ornaments, soap or shampoo, stuffed animals); or spiritual safety (participating in prayer or meditation).

3. Hints for Helping

a. Make sure the victims/survivors feel safe or secure when you are talking to them.

b. Respond to the need for nurturing — but be wary of becoming a "rescuer" on whom the victims become dependent.

c. Help survivors contact loved ones whom they trust and would be willing to assist them.

d. Help survivors solve immediate problems that have been caused by the tragedy.

e. Help survivors re-establish a sense of control over the small things, then the larger ones, in their lives.

B. "Ventilation and Validation"

1. Ventilation

Ventilation refers to the process of allowing the victims/survivors to "tell their story." Survivors often need to tell the story of the disaster over and over again. Each time it is told it may take a different form. Occasionally the differences will be due to memory problems. Sometimes the differences will reflect what is important to survivors at that particular time. Ventilation involves identifying appropriate words to express experiences, reactions, and responses. Sometimes it helps survivors to read or hear synonyms for words they are using, words which may more accurately express what they are feeling. Survivors may express their reactions through art, dance, music, prayer, or other forms of ventilation. Caregivers may encourage "story-telling" by asking appropriate questions and engaging in active listening. When encouraging survivors to talk about their experiences, caregivers should remember that body language, facial expressions, and tone of voice are as important as the words used in conversation.

a. Compassionate presence

• Caregivers and survivors should be seated during conversations. Chairs should be arranged at an angle so that the discussions seem less confrontational. Seating is not always available, so when standing, caregivers should allow the victim or survivor to set the standard for a comfortable distance between the conversants.

• Lean forward in your chair or incline your head to indicate attentiveness.

• Keep facial expressions generally neutral but reflect concern or sadness when appropriate to the content of the victim's story.

• In most cases, it is important to maintain eye contact with survivors. However, in some cultures, it may be more appropriate to only occasionally look a speaker in the eye, particularly when conversations are held between people of the opposite sex.

b. Speaking style

• Speak distinctly and clearly, with modulated tones.

• Convey calm and avoid agitated voice levels.

• Pace your words so that you speak neither too rapidly nor too slowly for the listener.

c. Effective words

• Focus what you say on concrete issues.

• Ask, "How should I address you?

• Ask, "Is there someone you would like me to contact so that they can be with you?

• Ask questions like: "How do you think that happened?" "What do you think were the reasons for that?" Never ask "why" questions.

• Begin conversations with: "When did this happen?" "Where were you when this happened?" "Who were you with?" "What do you remember seeing, hearing, smelling, touching, or tasting at the time?" "What did you do?"

• Follow up questions, if necessary, with questions such as: "How did you react to that?" "Were you afraid?" Were you angry?" "What did you do that makes you think you were at fault?"

d. Effective listening

Listening is an intellectual and emotional process that integrates physical, emotional and intellectual inputs in a search for meaning and understanding. The focus is on the entirety of each person's being, not just on words.

_ "Effective Listening," NOVA Training Guide, 1987.

Ineffective listening styles occur when listeners are affected by the following behaviors and attitudes.

• Assumptions are often made by listeners that they already know what will be heard so they listen carelessly.

• Boredom may occur when listeners do not think that what they will hear is important.

• Concentration is interrupted by distractions with other things.

• Disagreement is perceived with another's thoughts or interpretations of events.

• Ego-involvement by listeners so that they focus on their own words and think it is more important to hear themselves talk or teach rather than listen.

• Failure by the listener to understand what has been said or to interpret what was meant.

• Generalizations made by the listener that the survivors of one crisis are equated with the survivors of another.

• Hearing only what the listener wants to hear.

• Interruptions by the listener to complete the speaker's sentences or thoughts.

• Judgments of the speaker's behaviors or actions.

• Kindnesses that can kill when listeners respond to stories with their own emotions.

• Listening to words only __ not the intent, meaning or physical reactions of the speaker.

Effective listening is a skill developed with training and patience. It is based on the following principles.

• Ask questions only to facilitate the flow of story-telling.

• Believe the speaker's impressions and reactions are the most important concern.

• Clarify what is being said.

• Discern unspoken messages from speakers in their body language, voice tone, and facial expressions.

• Echo words or phrases that survivors use to indicate that you are paying attention and following their stories.

• Find new or alternative words that repeat or enhance the meaning of speakers in order to respond affirmatively to their reactions.

• Give information that might help survivors understand the situation more clearly, if it might dispel specific concerns, without arguing with them or answering unasked questions.

• Help survivors remember what happened by asking them about the chronology of time during which the event took place and a chronology of what has happened since the event, or asking them to describe the contextual nature of the event, such as colors, sounds, sensations, or impressions.

• Instill peace through silence by waiting for survivors to decide when they may want to continue their stories.

• Journey with survivors through their narratives. If parts of the story are confusing, ask survivors if they can repeat those parts or remember other things that might help you understand what they are saying.

• Keep your personal values, beliefs, biases, and judgments to yourself, and avoid imposing them on others.

• Listen, summarize, and remember you are helping survivors develop a narrative for the event and to create words to describe their emotional reactions.

2. Validation

Crisis intervenors try to help survivors understand that most reactions to horrific events are not abnormal. Validation should be content-specific. A caregiver should refer to the actual tragedy that has taken place.

a. Validation is based on effective hearing by caregivers.

In order to validate and affirm survivors' reactions, caregivers should not only learn how to listen but also be aware of the skill of hearing what is said. Hearing has four different registers: decoding ordinary meanings; resonating these meanings for another's lives; awakening to the meanings for the survivor who lives and speaks; and communing with that survivor through dialogue. (Egendorf, A., "Hearing People Through Their Pain," Journal of Traumatic Stress, January, 1995).

i. Decoding ordinary meanings involves an effort to understand a survivor's story in terms of our own. It means listening carefully and identifying the story and the sur-vivor's reaction with his or her past experiences and identity. Hearing requires someone willing to listen, and who brings at least some experience to the listening process.

I was in bed with the flu, totally unable to function. The phone rang and the voice on the other end told me my son had been injured in an automobile accident. I knew I needed to go the hospital but I couldn't drive. I was so angry. I called a taxi and went to help him. He is doing okay, but I can't get over the anger.

_ A mother whose son was in a drunk driving crash, NOVA Case Notes, 1991.

Hearing ordinary meaning in this case may entail listening to the anger and the reason for the anger. The mother was not angry at the son; she was angry at the fact that she could not respond as she would have liked.

ii. Hearing resonance refers to a musical metaphor that incorporates harmonies, dissonance and counterpoints.

In resonating with another we hear the immediate sense that extends from what someone says to his or her wider ecology. This sense is given more directly than associations, conceptual schemes or interpretive linkages and develops as we appreciate more deeply what is being said.

_ Egendorf, A., "Hearing People Through Their Pain," Journal of Traumatic Stress. New York, NY. Plenum Publishing, Vol. 8 No. 1, 1995.

iii. Awakening to what has been heard means trying to understand the context of the trauma and what it means now for the person who survived it. It is a recognition of life and hope.

Hearing people through their pain therefore means, in this respect, that we draw them out in the midst of what obscures them from themselves, and use talk creatively ourselves to show, rather than tell them, that they, not their hurt, are foremost.

_ Egendorf, A., "Hearing People Through Their Pain," Plenum Publishing, 1995.

iv. Communicating our abilities to hear and learn from survivors provides them with support in their process of learning to live from their pain. Caregivers can be very effective in this if they hear well since their hearing is dependent upon their ability to live from and through their own pain.

Then, ever the poet of transformation, Rilke announces the promise "But as soon as we acknowledge its dreadfulness … with a confidence that this very dreadfulness may be something completely ours, though something that is just now too great, too vast, too incomprehensible for our learning hearts —: as soon as we accept life's most terrifying dreadfulness, at the risk of perishing from it … then an intuition of blessedness will open up for us and, at this cost, will be ours."…Giving "joyous consent" to the dreadful is not to be confused with acquiescence to or collusion with evil. Nor will any other one-sided formula dictate the way therapy, which, in the beginning, middle, and end, is a matter of cultivating and balancing timeless virtues: autonomy and affinity, fierce honesty and kindness, courage and compassion, commitment and care, and a good deal more.

_ Egendorf, A., "Hearing People Through Their Pain," Plenum Publishing, 1995.

b. Words should be used carefully in validation.

• Let survivors find their own words and use their words in response.

Victim: "I get so frustrated when I read about this airplane "crash." This was no crash! The airplane exploded because of a terrorist bomb."

Intervenor: "An airplane crash is certainly different from an airplane explosion."

• Allow survivors to name their own reactions, but when repeating their descriptions, provide them with synonyms for their responses.

Victim: "I am so angry, I could kill him."

Intervenor: "You say that you are angry, perhaps even outraged or furious. It is not uncommon for people who are hurt so badly to think about killing the person who hurt them."

• Apologize if you use words that upset survivors or words that they indicate are inaccurate for their situation.

Intervenor: "You seem to be very angry about what happened."

Survivor: "I am not angry. I am just very confused and frightened."

Intervenor: "I am sorry I misinterpreted what you said, I was trying to understand what happened. Could you tell me more about your confusion and fright?"

• Avoid careless phrases.

Intervenor: "I am sorry to hear that this tragedy happened to you." This sentence may convey the idea that you were sorry to listen to the victim, not that you were sorry that the tragedy took place.

"Thank you for sharing that feeling." "Sharing" involves both persons experiencing the same feeling. Survivors often resent caregivers who assume that they can share feelings or stories. Some survivors also dislike discussing feelings while they may be willing to talk about reactions and responses.

"I would have done exactly the same thing as you did." No one knows what they will do throughout a traumatic event or its aftermath. It may be better to say, "I don't know what I would have done, but what you did doesn't seem unreasonable."

c. At times, repeating key elements of the survivors' stories back to them may be useful validation. It also confirms what the caregivers thought they heard said.

Survivor: "I was in bed asleep when I was awakened by a noise. I was disoriented and confused but went back to sleep for a moment because I heard nothing more. The next thing I knew was that a large man was on top of me and I could not breathe. He told me not to scream or he would kill me. I did what he said without thinking. I was just thinking about staying alive. He tied me to the bed post before he left. I was able to free myself fairly quickly but I waited for the sun to come up before I called the police. Then, I didn't know what to say because I couldn't explain why I didn't call sooner."

Intervenor: "Let me see if I heard you correctly. You were awakened suddenly. You went back to sleep. And then you awakened again while this man was attacking you. You were so terrorized that he would kill you so you followed his instructions and when you were able to call the police, you did."

d. The emphasis in the validation should be on the fact that most types of reactions such as fear, anger, frustration, guilt, shame and grief are not unusual and that each survivor's situation is unique.

Survivor: "I have always tried to do what was expected of me and what I expected of myself. No one ever taught me about what to do if someone broke into my house and stole everything. When I got home that night, I could not believe my eyes. Everything was gone. I was so angry. It was so unfair. Why did someone feel they had a right to my stuff? But then I became scared because whoever took my things might come back and kill me. I didn't cry because I was so frustrated and worried. I called my sister and stayed the night with her. It was when I returned home the next day and I realized that not only were most of my things gone but that the burglar had stolen my mother's wedding picture that I cried."

Intervenor: "Most people don't expect someone to break into their homes and steal their possessions. It is unfair and you have a right to be angry. And, it is very frightening to think that someone can come into your home, at will, to steal or perhaps to hurt you. You survived, and I cannot imagine how painful it must have been to lose everything, most particularly to lose your mother's picture. Anger, fear, frustration and grief are a part of a pattern of many reactions that victims often have to such a violation of their lives."

e. Although most people manage their reactions well, some may become violent or dangerous to themselves or others. Intervenors should be alert to any signs of potentially harmful responses. Of particular concern are statements of intent to harm when linked to a well-thought-out plan of action in which the victim also identifies the means to carry out the plan.

Victim: "I have decided that I will have to kill my neighbor. He raped me. I identified him. The police have done nothing. He sees me every day and acts like everything is all right. I know how I will kill him. I have my father's gun. I have ammunition. I think I will invite him over to my house for dinner. If the gun accidentally discharges when I show it to him, it won't be my fault."

f. Do not validate the survivors' experiences by telling them of your own experiences. Previous experience with similar tragedies may be mentioned to help build credibility and create a sense of commonality, but everyone's experience is different. Caregivers should stay focused on the survivors and not use intervention to validate their personal reactions.

Survivor: "I don't know why I'm talking to you. You can't possibly understand what it is like to have a child murdered. It has been hell every day. I think I see Joe coming home from school even though I know that he will never come home from school. I hear him getting ready for bed even though I know that he won't be in the bedroom when I look. I feel like I'm going crazy. I try to continue working and looking after my daughter but it seems impossible now that Joe is gone. Sometimes I put Jane to sleep reading a story and then wake her up with my own tears."

Intervenor: "I can't imagine what anguish you face each day. I do know how I felt when my daughter died, but the circumstances of Joe's death seem overwhelming. I don't think you are going crazy, but I would like to hear more about the problems you are facing. Can you tell me about some of your times with your daughter this last week?"

3. Hints for Helping

a. Open discussions with words such as "I am sorry that this tragedy happened to you."

b. Ask survivors to describe the event.

c. Ask them to describe where they were at the time they heard of the event or saw it happen.

d. Ask survivors to describe their reactions and responses.

e. Ask survivors to describe reactions and responses in the aftermath of the disaster — the time period between the disaster and the point in time at which you are talking with them.

f. Let survivors talk for as long as they want, but when there is a pause, validate what was talked about. (If you have a reason to limit the time of the discussion, indicate what those limits are at the beginning of the talk.)

g. Don't assume anything. Survivors will tell you what happened and how they reacted.

C. "Prediction and Preparation"

1. Prediction

Assist survivors in predicting the practical issues that will face them in the aftermath of the tragedy. One of the most important concerns of survivors is "what is going to happen next?" Ask them about the problems they think they will have over the next few days or months. If there are some that you can predict, and that they don't realize will occur, give them as much concrete information about such issues as you can.

a. Practical predictions

• Some survivors will have to relocate after a catastrophe. The relocation may be temporary or permanent. They may have concerns about what to take in the relocation, how to contact relatives or friends, or what type of transportation will be provided.

• It is not unusual for financial issues to be of paramount concern. If an employment site has been disrupted, employees may be out of a job. Serious physical injury may result in hospital or medical bills that are not reimbursed by insurance.

• If a crime has been the cause of the disaster, victims may become involved in the criminal justice system as witnesses. Many catastrophes also result in civil litigation. In either case, the survivors may be involved in the legal system for years.

• Any medical prognosis should be made as clear as possible to survivors.

• Often survivors are not aware that they must identify loved ones who have died or they are not prepared to deal with funeral arrangements or notification of relatives. These issues should be explained as quickly as possible.

• Survivors should be warned about the possibility that the media will want to do interviews or may broadcast stories about the disaster. Sometimes the treatment of the disaster story by the media can cause a great deal of anger and distress for victims and survivors.

b. Possible emotional reactions should also be predicted.

• It is important to describe the immediate physical and mental responses that characterize the crisis reaction and grief reactions.

• Long-term stress reactions should be explained.

• Stress reactions that might occur in family members or friends should be described. It is particularly useful to describe possible reactions of children. It is not uncommon for parents to underestimate the effect of a disaster on children.

• Certain things can trigger physical and emotional reactions after a disaster. For instance, holidays or birthdays may trigger grief over the loss of a loved one. Sights or sounds that are similar to those experienced during the disaster may trigger responses of fear or horror that were prevalent at the time of the catastrophe.

• Reassure survivors that long-term stress reactions are not unusual but that not all people will suffer all of them and many may not face them at all.

2. Preparation

In addition to predicting what might happen in the aftermath of a disaster, it is helpful for caregivers to assist survivors to prepare and plan for such events.

a. Provide survivors with as much information as they want and need concerning financial aid, insurance, and compensation to meet financial concerns. Help them fill out eligibility forms, if needed.

b. Help survivors with developing plans for future protection of themselves and their families. Assist them in rehearsing the implementation of such plans.

c. Provide survivors with referrals to additional resources for counseling, advocacy, or assistance.

d. Provide survivors with information on prevention of possible similar events in the future or the mitigation of the consequences of such events.

e. Give survivors accurate and truthful information about the length of time you will be able to assist them and what they might do when you are no longer available.

f. Help survivors decide what things they can do to deal with specific problems and if there are any that they do not have the capacity to deal with, provide them with assistance once they have decided upon a particular plan of action.

g. Tell victims and survivors what their rights are in the criminal justice system. Let them know how they might enforce these rights. Let them know what is happening in your state and in the United States concerning victim rights.

h. Do not make promises that you cannot keep.

3. Hints for helping

a. Remind survivors to focus on living one day at a time.

b. Help them explore options and use problem-solving techniques with everyday concerns.

c. Encourage survivors to talk and write about the event.

d. Suggest that survivors establish a daily routine that they can easily follow.

e. Help survivors plan time for memories and memorials.

f. For some survivors, finding a "buddy" who can support them during times when they confront practical problems is helpful.

g. Promote healthy eating, sleeping and exercise habits that can increase the ability to cope.

D. Useful phrases for crisis intervenors

1. "You are safe now" (if the survivor is safe).

2. "I'm glad you're here with me now."

3. "I'm glad you're talking with me now."

4. "I am sorry this (tragedy) happened to you."

5. "This wasn't your fault" (if the survivor has done nothing to contribute to the tragedy and its consequences).

6. "Your reaction is not an uncommon response to such a disaster."

7. "It's understandable that you feel that way."

8. "It must have been upsetting to see (hear, feel, smell) that."

9. "I can't imagine how terrible this must be for you."

10. "You are not going crazy."

11. "Things may never be the same, but they can get better, and you can get better."

12. "If you can't tell me what happened to you, try to tell me what has been happening to your family."

Give Sorrow words; the grief that does not speak knits up the o'er wrought heart and bids it break —

_ Shakespeare's Macbeth.

IV. Death Notification and Identification

A. Death notification

For survivors, the beginning of their reactions to the death of loved ones is the death notification process. It is important that death notification be handled as well as possible because it is the critical point of trauma for most survivors. Properly done, it can begin a healing process. When it is done improperly or without insight into the survivor's possible reactions, it may delay the process of reconstructing the survivor's life for years.

You never know when you are making a death notification. Many people think of death notification in terms of the notification of next of kin. But the "next of kin" may be a parent, sibling, or spouse. Clearly there are many additional family members who need notification and who might react with strong emotions. In addition, there are often close friends, colleagues, and even longtime acquaintances who may be severely affected by a notification.

1. General guidelines for notification procedures

a. Before notification

i. Obtain as much information about the deceased as possible: what happened, when did it happen, where did it happen, how did it happen, and what is the source of positive identification _ if it is available.

ii. Get all available information about the person(s) to be notified. Ensure that the appropriate closest adult relative receives notification first. There may be a legal mandate that governs who that person is.

b. Notification should always be performed compassionately, quickly, and with as much accuracy as possible.

2. Parameters of Notification

a. Whenever possible, death notification should be made in person. If it is:

• Make notification in pairs.

• Do not take any personal items of the deceased with you to do the notification.

• If you or your partner have been involved at the scene of the death, try to make sure that your clothes or appearance are not dishevelled or bloody.

• Introduce yourself and your partner, and be prepared to present credible identification, if appropriate.

• Confirm that the person you are talking to is the appropriate person to be notified.

• If you visit the home of a survivor, ask to enter the home before making notification.

• Encourage survivors to sit, and sit down with them when you talk to them.

• The person making the actual notification should take the lead in all of the discussion. The person assisting the notifier should remove objects of danger, monitor the survivors for danger signs to themselves or others, and be prepared to care for any children.

• The notifier should tell the survivors simply and directly. Do not build up to the idea of death. For most people, your appearance, your demeanor, and the ritual involved will give them clues that something horrible has happened. Do not prolong natural anxiety. Do not use euphemisms, even if they are culturally based. Leave no room for doubt or false hope.

"We have come to tell you some terrible news. Your son was killed when a man opened fire on a bus as your son was going to work. I am so sorry."

• Be prepared to present confirming evidence in a convincing fashion in the face of denial. Answer all questions tactfully but directly.

• Focus on immediate needs of survivors. If survivors want, help them to notify others. Help them to explore options over the next few days as they deal with the practical aspects of death. Do not be judgmental about their reactions or thoughts.

• Do not leave survivors alone. Leave them with someone and with a "safety net" — a point of contact. Respect survivors' needs for privacy but ensure protection.

• Remind survivors of their rights as victims of crime or disaster.

b. Is the notification to be done by telephone? While notifications of immediate family members may be able to be provided through personal visits, most death notifications are conducted over the telephone. A mother whose son has died must call her own mother to tell her; or a parent whose child has died must contact their other children in other states to let them know what has happened; or when a disaster occurs, family members or friends may call survivors to find out whether any of their loved ones have been hurt or killed. Survivors themselves may give death notifications over the telephone, but they may also ask crisis responders to make those notifications. In any case, consider the following guidelines.

• Try to arrange for a trusted colleague or friend to be with the survivor when she or he receives the call, if it is possible to make such arrangements without breaching confidentiality in the notification procedure.

• Introduce and identify yourself and be prepared to offer confirmation of your identity or a known reference, if appropriate.

• Confirm the identity of the person called to try to ensure that you are speaking to the appropriate person in the household or family to be notified.

• Be direct in delivering your message, but take a moment to encourage the survivor to sit down while you talk.

"I am calling to inform you that a medical emergency involving your son has occurred. Do you have a place to sit, while I explain what has happened?"

• If no other adult is present when the notification is done, ask for permission to call a clergy member, neighbor, friend, or law enforcement officer to come to the home to stay with the survivor. That person of comfort may be called by another crisis responder while you stay on the line with survivors, or you may need to make the call. If the latter is the case, be sure to call survivors back immediately to inform them who might be visiting and to continue to talk to them, if possible, until additional assistance is available.

• Follow the general guidelines for personal notification with regard to questions, being non-judgmental, considering immediate problems, and providing essential information.

• If you are notifying a number of family members and friends by telephone who may know each other, let each of them know who else you have notified.

c. Is the notification to a large group of people awaiting notice of the results of the deaths in a disaster? Employ the following guidelines.

• Try to ensure that several different trained notifiers are involved in the notification and that the group can be divided into small clusters of relatives and friends. Assign notifiers to each cluster and have them stay with their group while all wait for final information on missing survivors, injured victims and possible deaths.

• Provide separate facilities for those who are survivors of loved ones who have died — after notification.

• If more than one person has died, information on all deaths should be released as simultaneously as possible. Often such simultaneous notification is not possible because it may take days to determine for sure who was killed in an airplane crash, a bombing explosion, an earthquake or hurricane. In the case of prolonged notifications, all survivors affected by the possible loss of a loved one should be given a "missing notification" and those whose loved ones are immediately identified should be given a death notification.

• While notification should be done individually, confirm after notification with a group announcement to any survivors awaiting news. Group notifications should continue as long as any people remain missing.

d. Are there people who need notification that their loved ones are missing?

• If people are missing after a disaster, loved ones should be given a "missing" notification. This will begin the process of unnatural anticipatory grief (described in Chapter 4), but will also be helpful if the missing are soon determined to be dead. A death notification should be provided as soon as a determination is made.

• If there is doubt as to who was killed and the identity of the deceased needs confirmation, make it clear to the person being notified that, while you have been given evidence that the loved one has been killed, final determination of identity is being investigated. As examples:

"I have come to talk with you about your son. We think he was on the plane that crashed, but we are unsure. Is there any way you can help us?"

"I have come to talk with you about 1your son. We have reason to believe he was killed in a car crash last night. Two people died but we need to confirm their identity. Is there a family member or close friend who might help?"

• If there will be a delay in identification or there is a possibility that there will never be a final identification, remember to keep the survivors informed of what the circumstances are.

B. Guidelines for viewing the body

Upon notification of death, survivors may want to view the body of their loved one; may need to for identification purposes; or may need to be prepared to see pictures of the body in the case of a prosecution. The guidelines for assisting viewing the body or photographs of the body should address the following issues.

1. The decision to see or not to see the body should be made by the loved ones; however, some jurisdictions do not give the survivors that decision.

2. The viewer should be accompanied.

3. If the viewer wants to touch or hold the body, encourage that, and provide privacy and time for the viewer to say farewell.

4. If the body is mutilated or distorted, tell the viewer, prior to viewing, the precise nature of the distortions and, if optional, let the viewer choose whether to see the body. If photographs are used in preparing the viewer, describe them first. Sometimes survivors decide to let a friend, advocate or family member view the body and make recommendations about their own decision whether to view. If pictures will appear in the media, make sure that survivors are given an opportunity to view the pictures prior to their release.

5. Do not be surprised at reactions: crying, laughing, anger. and the like.

6. Some survivors want pictures of the deceased at the moment of death, and may even take photographs for their own use. Crisis intervenors should make no judgments on these decisions.

7. Offer to drive the viewer to and from the viewing; remember that close loved ones may not be physically or emotionally ready to drive an automobile.

8. Be prepared to be an advocate with the coroner, medical examiner, or funeral director. Some of these professionals try to prevent viewers from having contact with the body to shield the survivors from the impact of death. An advocate can be helpful in overcoming such resistance.

I finally decided I wanted to look at the pictures of my Mother who had been murdered. So I asked my best friend to go with me to the Police Department. When I asked to see the pictures, I was refused. However, the officer said that my friend could go into another room and look at them. When she came out she was in tears. Those tears gave me the answer I needed. Her willingness to do that is the most compassionate thing anyone has ever done for me.

_ Daughter whose mother was brutally murdered, Lord, J. H., Beyond Sympathy, Pathfinder Publishing, Ventura, CA, 1988.

V. Conclusion

Crisis intervention and death notification are the two skills most often used by crisis responders. Team after team of crisis responders have reported back from their efforts of planning, training and group crisis intervention that they were called upon to provide intervention to individuals while riding public transportation, waiting in a hotel lobby, or eating lunch at a local restaurant. There was no way to prepare for the community-wide trauma, and no methodical way to respond, except as they were called upon by people in need. Similarly, while community crisis team members are not usually the first responders chosen to provide death notification, they often are the first responders who give death notification due to the necessity of the emergency.

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