Running head IMMIGRANT WOMEN AND HEALTHCARE CHALLENGES1IMMI.docx

Running head: IMMIGRANT WOMEN AND HEALTHCARE
CHALLENGES
1
IMMIGRANT WOMEN AND HEALTHCARE
2
Immigrant Women and Healthcare Challenges
Bruce Norcise
Introduction
Traditionally, humankind migrate from one geographical region
to the other for various reasons such as the need to seek better
employment opportunities in preferred nations of choice
(Arcury et al., 2007). Many people across the globe perceive
America as land of opportunity, which makes it a preferred
migration destination. In the recent past, women migrant
population has drastically shot up from various parts of the
globe such as Africa, Asia, Mexico, and the wider Latin
America among others. On arrival, majority tend to settle in
Hawaii, California, Nevada, and Washington. By 2013, 21.2
million female immigrants lived in the U.S and this translates to
approximately 13% of the total female population in the
country. In an attempt to seek better employment opportunities
and earn a decent livelihood, quite a number of migrants face
various healthcare related challenges, which significantly
endanger their lives. That is why this paper focuses more on
women migrants and healthcare related challenges that bedevil
them from time to time.
Challenges facing women immigrants
Female migrants in an attempt to migrate and improve their
standards of living, face myriad challenges. Several female
immigrants across the country face numerous healthcare related

challenges, which hinder wellness and wellbeing. These
challenges mainly stem from structural and social-cultural
perspectives (Williams, 2002). A number of factors
considerably contribute towards inefficacy of healthcare
provision to these vulnerable groups. Some of these factors
include lack of enough money and income disparity,
stigmatization, and lack of formal education among others.
Quite a number of women migrants find it rather hard to secure
meaningful employment opportunities in America compared to
natives (Hacker et al., 2017). It therefore follows that many
remain without employment for quite a long period. The lucky
few who secure employment opportunities face severe income
disparities, which disadvantage them even more. In fact, female
immigrants earn far less salaries or wages compared to natives
and male counterparts in the U.S. This puts them in an awkward
financial position concerning healthcare service accessibility
and provision. They lack finances needed to access standardized
healthcare services in various quality healthcare facilities
across the country.
Aside from lack of employment opportunities, lack of formal
education also contributes significantly to poor healthcare
provision among many migrant women. Majority lack adequate
formal education needed to secure better employment
opportunities to earn rewards that can both sustain those
concerning nutritional needs and healthcare services (Williams,
2002). This makes them reside in substandard living conditions
in suburban areas such as Hawaii, Miami, and Michigan mostly
under poor diet, which further exacerbate already bad situation.
Additionally, the low level of education denies them sufficient
basic knowledge needed concerning healthcare related issues
affecting them. They stand exposed more too various infections
or ailments that may reach chronic levels before seeking
appropriate medical attention.
On top of inadequate formal education, stereotype or
stigmatization is another significant factor that considerably
contributes to substandard healthcare service provision to

minority migrant women population. Being minority groups,
they suffer various stereotypical practices from the majority
population. Stigmatization leads to stress, depression and other
mental related ailments, which greatly toll on them (Arcury et
al., 2007). Because of their low socioeconomic status, some
resort to extra ordinary means of getting income for survival
like prostitution. This may further complicate health conditions.
The practice may expose them to severe infections, some of
which remain incurable such as HIV/AIDS. This further deepens
the challenges of quality healthcare accessibility.
Migrant women face several forms of abuse from their partners
including physical and sexual abuse, which further exacerbates
the degree of stigmatization. Those who happen to find some
money that can provide healthcare services, end up being
discriminated by some healthcare providers. This actually bars
them from accessing quality healthcare services from experts
(Thomson et al., 2015). Moreover, lack of knowledge
particularly concerning the exact health care issue contributes
to the worsening of their healthcare service provision. Language
and communication barriers between them and healthcare
experts lead to improper communication, which makes
expression of healthcare issues to medical experts a problem for
appropriate diagnosis and subsequent treatment.
Personal Concerns about Migrant Healthcare Needs
It raises a lot of concern that these immigrant women contribute
a lot towards building and developing the economy of the host
nation and yet cannot access medical healthcare as required.
They engage in either paid employment or self-employment
through starting and running small businesses, which contribute
to socioeconomic growth and development of a country. In
contrast, they face several challenges including healthcare
provision disparities. For example, discrimination and
stigmatization regarding healthcare provision is quite prevalent
(Williams, 2002). In many occasions, they fail to get the
necessary attention from relevant authorities particularly
regarding quality healthcare provision and this affects health.

The unmet healthcare needs contribute to high morbidity and
mortality rates witnessed among this minority group.
This situation requires quick remedy to restore dignity and
respect among these groups of people. Their contribution
towards economic growth and development requires ultimate
recognition from the society (Thomson et al., 2015). In fact,
putting in place appropriate reforms such as modern immigrant
rights movement sponsored by the civil society, may be helpful
under such circumstances to help address unmet healthcare
needs. This group offers counselling and educational services to
victims alongside agitating for their healthcare rights.
Efforts of this program have actually borne some commendable
fruits in enhancing wellbeing of this social group. Empowering
it may help enhance healthcare service delivery to this social
group. Moreover, a proposed healthcare insurance program
tailored for such groups may help address their healthcare needs
and bring some meaningful improvement (Hacker et al., 2017).
Additionally, granting citizenship status for this social group
may help concerning employment and healthcare service
accessibility. This would enhance their chances of securing job
opportunities as well as getting standardized healthcare
services.
Conclusion
Migrant women prefer settling in America hoping to secure
better employment opportunities to enhance their livelihood. In
contrast, this is not always the case since many meet various
challenges relating to social and economic challenges that
require redress. Particularly, quality healthcare service presents
one of the greatest challenges to female migrants. Since their
overall contribution helps improve economic growth and
development, healthcare issues need consideration. Many
members of this group I interacted with suffer in silence
because of discrimination and communication barriers that
demand immediate attention. Lack of finances remains their
greatest undoing coupled with stereotypical practices they face

from dominant communities. In fact, they cited high levels of
discrimination as a major hindrance to acquisition of improved
healthcare services.
References
Arcury, T. A., & Quandt, S. A. (2007). Delivery of health
services to migrant and seasonal farmworkers. Annu. Rev.
Public Health, 28, 345-363.T
Hacker, K., Anies, M., Folb, B. L., & Zallman, L. (2017).
Barriers to health care for undocumented immigrants: a
literature review. Risk management and healthcare policy, 8,
175.
Thomson, M. S., Chaze, F., George, U., & Guruge, S. (2015).
Improving immigrant populations’ access to mental health
services in Canada: a review of barriers and recommendations.
Journal of immigrant and minority health, 17(6), 1895-1905.
Williams, D. R. (2002). Racial/ethnic variations in women's
health: the social embeddedness of health. American journal of
public health, 92(4), 588-597.
A R T I C L E
WHAT IS AN EMPOWERMENT
APPROACH TO WORKING WITH
SEXUAL ASSAULT SURVIVORS?
Sarah E. Ullman
Department of Criminal Justice, University of Illinois at
Chicago
Stephanie M. Townsend
Department of Psychology, Dominican University

This exploratory study sought to better understand what
constitutes the
empowerment approach used by rape crisis advocates working
with sexual
assault survivors. A grounded theory, qualitative,
semistructured inter-
view study was conducted of rape victim advocates (N 5 25)
working in
rape crisis centers in a large metropolitan area. Several
characteristics
were described as reflecting an empowerment orientation or
approach to
work with survivors, some of which were specifically described
as a
‘‘feminist’’ empowerment approach. Implications for research
and
practice are drawn. & 2008 Wiley Periodicals, Inc.
Rape crisis center advocates provide a variety of services to
victims of sexual assault,
including crisis counseling, medical and legal advocacy, and
24-hour support on
hotlines (Campbell & Martin, 2001). The importance of these
services is underscored
by research that suggests that survivors who worked with a rape
crisis center advocate
experienced significantly less distress than those who did not
(Campbell et al., 1999).
Additionally, in community studies when victims have been
asked to rate the
helpfulness of a variety of support sources, rape crisis centers
are rated as most
helpful after an assault (Filipas & Ullman, 2001; Golding,
Siegel, Sorenson, Burnam,
& Stein, 1989), even though only about one in five victims

report seeking such services
following sexual assault.
This article is based on research conducted while the first
author was a faculty scholar at the University of
Illinois at Chicago Great Cities Institute.
Correspondence to: Sarah E. Ullman Department of Criminal
Justice, 1007 West Harrison Street, University
of Illinois at Chicago, Chicago, IL 60607-7140. E-mail:
[email protected]
JOURNAL OF COMMUNITY PSYCHOLOGY, Vol. 36, No. 3,
299–312 (2008)
Published online in Wiley InterScience
(www.interscience.wiley.com).
& 2008 Wiley Periodicals, Inc. DOI: 10.1002/jcop.20198
Reports from victims are an important source of information
about what type of
support they need and feel is helpful. However, it is also
important to seek the
perspectives of advocates whose role it is to provide direct
support and help victims to
access resources from other systems. According to the Illinois
Coalition Against Sexual
Assault (2002), sexual assault services provided by rape crisis
centers are unique
community services due to the following reasons:
* The primary goal is to create an environment in which the
client feels safe and
empowered.

* Services are client-centered and trauma-based. The client
leads the process
and discloses information she feels is pertinent. This may be
different from the
traditional medical model, in which the purpose is to complete a
diagnostic
assessment or direct the victim’s decisions.
* The client and sexual assault crisis worker work in a
partnership to assess
strengths and areas of concern as well as to develop and
evaluate services goals
in order to empower the client. This may be different from the
traditional
medical model in which the provider may be considered the
expert who will
direct, treat, or cure the client.
One of the unique features of rape crisis centers and their
workers may be their
approach to working with survivors, which is often labeled as a
‘‘feminist’’ or
sometimes simply an ‘‘empowerment’’ approach. Riger (1984)
examined feminist
organizations, including those addressing violence against
women, and described how
grassroots organizations that enable people to obtain access to
resources and develop
skills and self-esteem can be important vehicles for
empowerment. In other words,
empowerment can occur at multiple levels as reflected in
Rappaport’s (1984)
definition: ‘‘Empowerment is viewed as a process: the
mechanism by which people,
organizations, and communities gain mastery over their lives (p.
3).’’

Rappaport’s definition introduced the idea that empowerment
can occur at
multiple levels. This idea is explained in more detail in
Zimmerman’s (1995)
theorizing that psychological empowerment can occur at
intrapersonal, interactional,
and behavioral levels. This conceptualization of empowerment
at the individual level is
described by Mechanic (1991) who stated, ‘‘Empowerment may
be seen as a process by
which individuals begin to see a closer correspondence between
their goals and a sense
of how to achieve them, and a relationship between their efforts
and life outcomes
(p. 800).’’ This definition may reflect how survivors of sexual
assault navigate their
recovery individually and in relationship to supportive others
such as advocates and
counselors who may help to facilitate adaptive behavioral
coping strategies. In fact,
some research suggests that women in particular experience
empowerment when they
can control their thoughts, feelings, and behaviors (Yoder &
Kahn, 1992).
However, in a now classic paper, Riger (1993) critiqued
empowerment theory’s
individualistic, cognitive focus on autonomy, separateness, and
control over one’s own
behavior and circumstances. She argued that this notion of
empowerment ignores
actual power and the social structural and situational factors
that limit individual
empowerment, as well as community connection and
relationship-based forms of

empowerment. Researchers and theorists have shown how
community, organizational,
and societal contexts can constrain or facilitate individual
behavior and thus the degree
300 � Journal of Community Psychology, April 2008
Journal of Community Psychology DOI: 10.1002/jcop
of their empowerment (Martin, 2005; Zimmerman, 2000),
whether they are sexual
assault survivors or persons attempting to assist survivors in
their recovery.
Despite these theoretical discussions of empowerment, in the
past 20 years there
has been almost no empirical research examining how advocates
actually empower
victims of sexual assault or looking at whether survivors do end
up empowered from
seeking rape crisis services. Although much has been written
about empowerment and
its importance for working with female victims (Campbell et al.,
2004), little research
has identified what defines this approach from the perspective
of victim advocates. In
summary, although some research has documented the
importance of an empower-
ment approach to working with victims (Campbell et al., 2004),
further work is needed
to understand service providers’ perspectives on what this
approach looks like and
how those endorsing this approach differ from other advocates.
Therefore, a

qualitative interview study was conducted of victim advocates
from various rape crisis
centers in a large urban area. This was a grounded theory,
exploratory study that
aimed to (a) identify what constitutes an empowerment
approach of advocates and (b)
elucidate any unique characteristics of those endorsing a
‘‘feminist’’ approach. This
study is important because it may yield insights into best
practices for helping sexual
assault survivors for both informal and formal support
providers, including mental
health professionals, who frequently encounter this population.
This study may also
help to clarify whether advocates who self-label as feminists are
unique in how they
describe their use of an empowerment approach when working
with survivors.
METHOD
Sample
The sample was comprised of 25 women who were current or
former rape victim
advocates, working at rape crisis centers in a large Midwestern
metropolitan area. This
sample is part of a larger study of both clinicians and advocates
working at a variety of
social service agencies, including rape crisis centers (see
Ullman, 2005, for a
description of the first author’s experience doing these
interviews). Participants were
recruited using multiple methods. Letters were sent to 60 people
working in agencies
in the metropolitan area who were listed as participants at the

most recent national
conference on sexual violence prevention. All persons who
called the researcher or
responded to the researcher’s phone calls did participate in the
study. In response to
these letters, 14 interviews were conducted (a 23% response
rate). Although the sexual
violence conference is a selective source to sample, many
eligible participants could be
easily identified from that list, including contact information
for many metropolitan
area rape crisis workers who attended the conference. It should
be noted that the first
author, who made all the contact with participants and
conducted all interviews, did
not know any of the advocates interviewed and did not attend
the conference.
Additionally, 10 interviewees were identified by participants
referring the interviewer
to other people who have worked in the rape crisis field in the
area, and one person
was located by a chance meeting at a professional function.
This sampling strategy resulted in a total sample of 25
advocates, representing 10
distinct agency locations, with an average of 2.80 persons
interviewed per location.
Nineteen participants were currently working as advocates
doing advocacy, referral, or
crisis counseling at rape crisis centers. Six were former
advocates who had worked at
rape crisis centers, generally, within the past year. Most
advocates had done medical
Empowerment Approach to Working with Survivors � 301

advocacy or crisis counseling. Two had done primarily legal
advocacy, one had done
health education, and six had also done administrative work
(e.g., volunteer
coordinator, director, supervisor etc.) in addition to advocacy.
All women had
experience working with sexual assault survivors ranging from
1.5 to 16 years of
experience with an average of 5.14 years of experience (s 5
3.83). Eleven workers also
had mental health experience doing crisis counseling or other
types of therapy with
sexual assault survivors with an average of 3.64 years of
experience (s 5 6.00).
Participants were asked to indicate if they had any or all of four
types of training
(sexual assault, domestic violence, child abuse, violence against
women). Thirteen had
all four types of training and 12 had from one to three types of
training. All had
training on sexual assault. No further detail was specifically
asked about the nature
and extent of participants’ training. In terms of practice
location, 4 worked in
suburban locations, 19 worked in the city, and 2 worked in both
city and suburban
settings. Women were asked to check off all applicable items in
a checklist that
characterized their treatment orientation. Seventeen endorsed a
feminist orientation
in their approach to working with survivors, whereas 12
endorsed various other

treatment orientations such as client-centered and cognitive
behavioral. All partici-
pants were women. In terms of education, one had a PhD, seven
had master’s degrees,
14 had bachelor’s degrees, and three had some college or an
associate’s degree. Most
women were White (n 5 12), followed by Hispanic (n 5 6),
Black (n 5 5), Asian (n 5 1),
and multiracial (n 5 1). Women’s average age was 33.04 years
(s 5 9.20 years). Most
women (n 5 12) were in their 20 s with a range of 25 to 58
years. Two had incomes of
$10–20,000, 11 had incomes from $20–30,000 per year, eight
earned $30–40,000 per
year, three had incomes of $60,000 or more, and one refused to
provide her income.
Agencies
Eight rape crisis centers were freestanding organizations, two
programs were housed
within a larger social service agency or community mental
health center, and one
participant worked both on a rape crisis hotline and in a
university counseling/
advocacy setting. Services for rape victims in the area from
which participants were
sampled include a 24-hour hotline for the entire metropolitan
area that is run out of
the largest rape crisis center in the city. The hotline is
coordinated by full-time
employees and staffed by trained volunteers 24 hours a day.
Other services provided
by the area’s rape crisis centers include medical and legal
advocacy, crisis counseling
and referral to other social and mental health services,

prevention education, and
training for other agencies including the police and the State’s
Attorney’s office.
Agencies where workers were employed included two large rape
crisis centers, one of
which had satellite offices in both city and suburban locations.
Both of these rape crisis
centers had administrative/supervisory staff, advocates, and
counselors, with a smaller
core of paid full-time staff and a larger core of volunteer victim
advocates, who
typically went on emergency room calls when rape victims were
taken there by police
following an assault (see Wasco et al., 2004 for more
information about services in this
region).
Some workers mainly did crisis counseling and gave referrals to
survivors of sexual
assault, while others did longer term therapy with survivors or
administrative work
and supervision of other employees in their agencies. Most
advocates did crisis
counseling and medical advocacy, with two advocates primarily
doing legal advocacy
and prevention education to area schools and colleges.
Typically those doing mostly
counseling also worked on advocacy needs with clients, some of
whom were also

receiving therapy from mental health professionals outside of
the rape crisis center.
Smaller agencies were typically more mental health focused and
were often a part of
community mental health centers, although they still identified
as rape crisis centers.
They provided the same advocacy and counseling services, but
the larger organizations
where they were housed also served other populations, such as
child victims or clients
with general mental health needs. Agencies varied in geographic
location and both
provider and client demographic characteristics, partially
reflecting the agency, its
philosophy, and the client population of the specific agency
location. For example,
agencies in predominantly Black or Hispanic neighborhoods had
more staff with
similar ethnic backgrounds, whereas agencies located in the
downtown central city had
a greater proportion of White staff.
Procedure
Participants completed in-person interviews at a time and
location convenient for
them. Most interviews were conducted at their work offices (20)
at a convenient time
for the women, but five preferred to be interviewed at other
locations. Interviews were
conducted from November 2002 through May 2003 by the first
author. Interviews
ranged from 45 minutes to 1 hour 20 minutes, with the average
interview length of
65.36 minutes (s 5 13.36 minutes), and a modal interview of 1
hour. Semistructured

interviews asked about women’s training and work experience
with survivors of sexual
assault as well as other relevant work experience, how
disclosures of sexual assault
tended to occur, how interviewees typically respond to
disclosures, difficult and
rewarding aspects of working with survivors, barriers to
working with survivors and to
survivors’ obtaining services, and solutions that might improve
services to this
population. Participants were also asked about their views about
the role of mental
health professionals in working with sexual assault survivors.
Only the data on the
advocates’ treatment orientation or role were analyzed in the
current study. In the
section of the interview about treatment orientation, participants
were asked to
indicate which approach from a list of treatment approaches
characterized their
approach to working with survivors, with multiple responses
possible.
Analysis Strategy
A grounded theory approach was used for data analysis. Four
stages of analysis were
used. The first stage consisted of open and axial coding (Strauss
& Corbin, 1998).
Open codes emerged from the text to break the data into
discrete parts. Axial coding
extended the analysis from the textual level to the conceptual
level. The second stage
of analysis involved construction of a meta-matrix, which is a
master chart that
compiles descriptive data from each case into a standard format

(Miles & Huberman,
1994). Column headings identified key variables and each row
represented a program.
This process allowed for the identification of themes that were
common to many
programs and those that were unique to a small number of
programs. The third stage
of analysis was the manipulation of the meta-matrix to create
submatrices that were
ordered conceptually according to key variables (Miles &
Huberman, 1994). This
process allowed for identification of patterns between variables.
The final stage was the
creation of analysis forms that summarized the submatrices. In
completing these
forms, both within-case and cross-case analyses were done in
which the content of
codes within and then across cases were compared. The goal
was to identify and
interpret any themes or patterns that could answer the research
question of what
constitutes an empowerment approach and a feminist
empowerment approach to
working with survivors following a sexual assault. The results
as described in the
following section were based on the final stage of analysis.
RESULTS AND DISCUSSION

Several approaches to working with survivors were described by
advocates most
frequently. These included feminist, empowerment, client-
centered, problem-or-
iented, and crisis intervention. In this sample, 72% of
participants said they had a
‘‘feminist’’ orientation or approach to working with survivors.
Of this 72%, just under
half (44%) mentioned this as the only approach they used to
work with survivors.
Almost one-third (28%) of advocates said they used client-
centered approaches, 16%
used cognitive-behavioral approaches, and 8% mentioned
empowerment approaches
generally to working with survivors. In addition, 36% of
advocates mentioned also
using some ‘‘other’’ form of treatment including:
psychodynamic, crisis counseling,
trauma treatment, systems, and no specific treatment model.
Definitions of Feminist/Empowerment Approaches
All advocates interviewed mentioned ‘‘empowerment’’ at some
point in their
narratives, even if they did not describe this as their treatment
orientation. This
approach was used by a majority (over two-thirds) of advocates
in this sample with or
without other approaches. It was explained and distinguished
from other approaches
as follows.
We use what’s called an empowerment approach; it’s really not
just like what
people would think of as client-centered because we don’t use
the medical

model. We don’t make diagnoses, although we do treatment
plans. We discuss
the case history, do progress notes every week, each time we
see a client or
refer a client. The goal is really to see the person get their
power back or to see
them get some type of control back in their life, where they can
function day to
day. (Advocate 1).
[Agency X] is very strict about using the empowerment model
approach, very
client-centered, meet the person where they are at. Don’t
pressure them into
making any sort of decision. We lay out the options on the table
and we
support their decision. If it’s a decision that may harm them like
suicide or
homicide, we don’t support those. (Advocate 3).
Really the philosophy is very client-centered—follow the
survivor’s agenda is
sort of your mantra. (Advocate 10).
These three advocates all appear to describe a client-centered
approach as actually
constituting the empowerment approach, yet the first advocate
states that empower-
ment is distinct from client-centered approaches in that it does
not rely on the medical
model or on diagnoses. The other two advocates’ descriptions
use the term client-
centered but do not seem to describe an approach that differs
from the first advocate.
Given that the term ‘‘client-centered’’ comes from the
psychological treatment field, it

may be that the first advocate was trying to distinguish rape
crisis center’s
empowerment approach from a traditional, client-centered
approach used in the
mental health field. These quotes also differ in that the first
advocate identifies the
elements that constitute the ‘‘goal or outcome’’ of an
empowerment approach, which is
characterized as one who gets power/control back in their life.
The other two advocates
speak about the ‘‘method(s)’’ used to effect the goal of an
‘‘empowered survivor’’
describing this as ‘‘meeting the survivor where she is’’ and
‘‘following the survivor’s
agenda.’’
Importance of Control
The rationale for the empowerment approach as explained by
one advocate was
typical. She explained the use of an empowerment approach by
advocates as being a
contrast to the ways in which informal network members often
respond to survivors
that may be experienced as having control taken away from
them, just as it was during
the assault:
A lot of times, people want to take over—they look at a sexual

assault victim
and they may even feel helpless themselves. A lot of people
such as significant
others and parents want to take over because they want to make
it better. But
really the survivor has to make it better for themselves is how I
look at it. So
you need to work with them and to let them take control back
into their own
lives. Help them when they ask for it, but let them make the
major decisions,
let them know what their options are, but don’t make those
decisions for them.
I let the survivors control the conversation, so it goes where
they want it to go
and to bring out issues. I might guide them to decide what they
want to focus
on in the conversation, but really it’s their call. (Advocate 7).
A major characteristic of the empowerment approach described
here is who takes
control. Because the act of rape constitutes having someone
take away control from the
victim, it is crucial that survivors regain control in any and all
ways possible to facilitate
their empowerment. Implicit in this idea is that no one can
really make things better
for the survivor or fix the problem, which is likely a common
well-intentioned, yet
ultimately negative reaction of those around the survivor. These
reactions may emerge
from egocentric needs (Ullman, 2000) of support providers
trying to cope with their
feelings of anger, violation, and distress at the perpetrator and
the traumatized
survivor. It may be that support providers really want to help

survivors they care about
from truly altruistic motivations, but they may also have a
personal need to help in
order to empower themselves to cope with the harmful ripple
effect of victimization or
‘‘vicarious trauma’’ affecting those around the victim (Davis,
Taylor, & Bench, 1995;
Salston & Figley, 2003; Schauben & Frazier, 1995).
Techniques for Empowerment
Several specific techniques like mirroring and empathy were
described as part of the
empowerment approach. For instance, one advocate described
what this approach
should help to achieve for survivors:
My explanation particularly to other people who are in training
about what
the role of the advocate is in the process is that we are a kind of
a mirror. That
is, we hold up a mirror and say, ok, this is what you have, these
are the options
you have, this is your situation, this is where you can go, these
are your paths
that you could possibly take. Now you need to look at yourself
and say okay,
what do I want to do with that? (Advocate 8).

Another advocate when discussing her counseling work with
survivors explained
the client-centered approach in more interpersonal terms saying,
I treat them from the heart and I think that’s what I’ve noticed
they respond
to. It’s just about really being there with them, allowing
yourself to feel
someone else’s pain and when you share that, that’s when the
growth seems to
come. (Advocate 14).
She went on to describe this process further and her role in
helping her clients
find their own path to recovery.
I firmly believe that change only comes if the client is the one
who figures it
out. My supervisor at the center said you know we are not the
tour guides. It’s
almost like you are on a path with the client, they got the map,
you’re just
there to make sure they don’t necessarily get off the road.
You’re not leading
them or anything. The way I work is to trust that they are going
to get to the
point that they need to and it’s not going to help if I sit here and
bombard
them with advice. (Advocate 14).
This description sounds very akin to ‘‘non-directive’’
counseling practices that may
also facilitate empowerment of therapy clients, and clearly
highlights the role of
empathy in facilitating empowerment of survivors. Another
advocate described the

lack of taking an active role to empower survivors saying,
Part of empowering survivors is letting them know, I’m not
going to be on
your back and I’m not going to hassle you to get these services,
but if you want
them, they’re there. And it doesn’t matter when you decide that
you want
them. (Advocate 25).
This lack of taking an active role described here contrasts with
the role of many
other professionals and informal social network members’
responses who often taken
control of what happens after assault and thereby disempower
survivors (Campbell
et al., 1999; Martin, 2005; Ullman et al., 2007). Others talked
about skills and
responses to survivors reflected in this approach:
I’ll just support them and be like yeah, that makes sense you’re
pissed
off about it, they shouldn’t have done that to you. So it’s really
about
active listening and giving them back what they’re telling me. I
never doubt
them, I never question them, I’m there to empower them, to
support them.
(Advocate 29).
One advocate expressed the contrast between what she termed
the feminist
empowerment model with more traditional counseling.

You know this approach has been talked about a lot lately.
We’re reviewing all
of our policies and procedures. I think as a feminist and
believer in the
empowerment model, as an advocate I don’t have to be
completely detached,
don’t have to have flat affect. Initially, when you see a
counselor, they’re
practiced in being somewhat detached, not completely, you
know, they’re
engaged with the client, but flat affect, but we’re allowed to
react to what
victims say and to be empathic and reach out to them.
(Advocate 33).
She proceeded to describe her approach to working with
survivors in more detail:
I very clearly explain this to all of my survivors. I say to them
there will be
times when you want me to make a choice for you, but I can’t.
If there’s a way I
could just fix it and wave a wand I would, but I can’t. So we
talk about their
options so they can take back their life and I offer them
nonjudgmental
support and just give them a chance to tell their story. The first
thing I do with
all my clients is just let them sit and tell their story for as long
as they want.
(Advocate 33).

Finally, an advocate described ‘‘feminist’’ counseling as:
Strengths-based counseling where I try to figure out what
resources exist,
what they have a handle on already and find ways to expand that
as opposed
to trying to introduce totally new strategies. I also try to really
think about the
situation they are in, because there may be things that would be
great for them
to do, but they’re not realistic. Financial constraints can be
problematic and for
underage girls it’s hard, because you can tell a woman to get
away from her
abusive partner, but you can’t tell a child to get away from an
abusive parent.
You really have to think about that, when you’re thinking about
how to
structure counseling—what is available to them. (Advocate 35).
Advocate Versus Agency Orientations
In considering experiences survivors have when seeking
services from rape crisis
agencies and the impact of those agencies on survivors’
recovery, it is important to
consider not only the individual advocate with whom the
survivor may interact but also
the agency as a whole. While the hope is that all interactions the
survivor has with the
agency are empowering, this may not be true. Survivors may
interact with multiple
agency staff (e.g., advocates, hotline volunteers, receptionists,
etc.). Additionally, their
experiences may be affected by the climate in the agency when
they are seeking

services onsite, the information and tone of literature the
agency distributes, etc.
Therefore, it is important to examine the consistencies and
inconsistencies in
orientation throughout the agency. Because this study relied
only on data from
advocates, findings about inconsistencies is limited. However,
comments by advocates
do provide evidence that the consistency or fit between
advocates and the larger
agency should be considered.
One ex-advocate who had burnt out and left her job after feeling
mistreated
by her agency said that although a feminist empowerment
approach was her
approach, it was not that of her agency, even though they
claimed to have
this philosophy.
I can’t buy that RCC’s have an empowerment model, because
that’s not how
the infrastructure of the agency works and that’s not how the
staff are. I agree
that’s what is said and that’s what is encouraged with clients,
but it’s definitely
not how the agency works. (Advocate 30).
After hearing this, I sought elaboration, and in future

interviews, I asked advocates
how supportive the agency was of survivors and got the
following responses from an
ex-advocate and from a current supervisor, respectively,
regarding the same agency.
The agency is not overall supportive, I mean I kind of had to
think about it
and decide whether I thought it was supportive or not (laughs).
So I mean yes,
but I mean with this huge disregard for the staff going on also.
So yes, but
indirectly no, kind of, does that make sense? I just feel like how
much can they
care about survivors when the staff is being, the staff who’s
working directly,
the frontline people working directly with survivors, it’s like
this blatant
disregard for their well-being so, it just kind of makes me
wonder how, I don’t
know, I mean that’s sort of my cynical perspective at this point.
(Advocate 30).
I would say here, it’s really extraordinarily supportive. We all
have our bad
days but I think that overall this agency strives to really try and
support and
acknowledge the difficulty in doing this work. I think our
agency does that on
some level, whether or not they’re able to achieve it is a
different story
(Advocate 8).
These advocates describe the dilemma of an organization whose
goal is to
empower victims that in fact may disempower female workers,

by tapping into
traditional female gender-role socialization of advocates that
leads to female workers’
sacrificing of their own needs and self-care in order to take care
and advocate for the
needs of survivors (Wasco & Campbell, 2002). In fact, barriers
to the empowerment of
survivors may occur at societal, organizational, and individual
levels (Ullman &
Townsend, 2007).
Data from advocates interviewed in this study suggest that
although empower-
ment can occur at the interpersonal level (e.g., between
advocate and client), it also
may or may not characterize organizations, which fits
Zimmerman’s (2000) theory of
levels of empowerment. From a sociological perspective, it is
hard to imagine that
advocates’ ability to empower survivors would not be facilitated
or constrained by how
empowering their organizations’ practices are, as suggested by
this advocate. In fact,
advocates argue that rescuing does not really help clients, as
they need to make their
own choices and be supported in that process. Zimmerman
(2000) states that
‘‘organizations that provide opportunities for people to gain
control over their lives are
empowering organizations’’ (p. 51). Of course, rape crisis
centers should be
empowering and have that as a goal for survivors, but it is
important that they do
the same for their workers as lack of support/empowerment for
advocates may harm
them and limit their ability to empower clients. Empowerment

should be viewed as
being not only a dynamic between advocate and client but also a
guiding principle that
should permeate the functioning of the entire agency.
Safety Planning as Empowerment
Several advocates talked about discussing ideas about safety as
empowering survivors.
For example:
I talk about futuristic type goals. If you go out with your friends
to a party or
bar, what steps will you take for safety? We advise them to pair
up with a
friend, make sure you have a ride home, don’t go with a friend
you don’t
knowythings like that, so they can feel they have a strategy for
the next time
and are better equipped, so that they can try to be social again.
(Advocate 1).
We support their decisions, but we also make sure to give them
as many safety
options and opportunities as possible as well as resources and
referrals.
(Advocate 3).
The link that advocates are making between safety planning and
empowerment is

an example of Zimmerman’s (1995) concept of behavioral
empowerment, which
occurs when actions are taken to regain a sense of control over
life. Actions associated
with behavioral empowerment vary with the goals and
opportunities available but
could include problem-focused coping, stress-management
activities, and resource
utilization. Other forms of behavioral empowerment include
active responses aimed at
averting or dealing with potential violence such as taking self-
defense classes or
engaging in safety planning. However, it should be noted that
the idea of safety
planning as empowerment is not universally accepted out of
concern that it is
dangerously close to victim blaming. The importance of not
blaming victims is a
recurring theme in the training of advocates (c.f. Bay Area
Women Against Rape
[BAWAR], 1993; Brighter Tomorrows, 1996; Sexual Assault
Prevention and Awareness
Center [SAPAC], 1991 for examples). It is debatable whether
safety planning as
empowerment is an example of Ryan’s (1976) definition of
victim blaming as a process
in which a social problem is identified (sexual violence), those
who are affected (female
victims) are studied to discover how they differ from the rest of
the population, the
differences (vulnerability to sexual violence, including
behaviors) are defined as the
cause of the problem itself, and a bureaucrat (agency) invents a
program to correct the
differences. Because safety planning was not specifically raised
as a question for all

advocates, it is not clear if the idea of safety planning as
empowerment was uniformly
endorsed in this sample. Given the emphasis in the field on not
blaming victims, this is
an important question for future inquiry.
Social Support as Empowerment
Finally, several advocates described empowerment as
encouraging support seeking
and/or community involvement in their work with survivors.
It’s important to go back to society and connect with people, to
not fear
socializing and engaging in a dialogue or having a good time
with people. I
think that’s important for normalization. (Advocate 1).
When we talk about support systems, we talk to survivors about
who is going
to support you, how are you going to find support after this? A
lot of times
people will say, I’m gonna talk to my cat or my dog, because
that’s somebody
that’s not going to be judgmental of me. I hear that so often that
I try to
normalize that feeling. (Advocate 8).
We find it interesting that the need for both safety and social

support were raised
by advocates as issues that they had also faced personally in
their organizations and
that compromised their work as advocates on behalf of
survivors (Ullman &
Townsend, 2007).
Summary
In summary, the empowerment approach taken by advocates was
client-centered and
emphasized survivors making their own choices and taking
control by taking a lead in
the therapeutic process, which allowed for a personal level of
engagement between
advocate and client and included connecting the client with
outside resources.
Descriptions of how this approach was enacted did not actually
appear different
whether labeled as feminist specifically or not. As reported
elsewhere, however,
self-labeled ‘‘feminist’’ advocates did differ from those not
endorsing the feminist label
in some of their personal characteristics, perceptions of their
agencies and difficulties
in doing their work, and perceptions of barriers survivors face
in getting help
(see Ullman & Townsend, in press).
CONCLUSIONS AND STUDY IMPLICATIONS
This study explored what constitutes an empowerment approach
to working with rape
survivors as described by advocates and counselors in rape
crisis centers. Obviously
our study is limited by a small sample from a subset of centers

in one metropolitan
area, some of whom were former advocates with negative
experiences that may have
motivated them to participate. No rural advocates were included
in this study, which is
a limitation because rape crisis services are much more limited
in rural areas (Martin,
2005) and both advocates’ and victims’ experiences may differ
in rural areas (Logan,
Evans, Stevenson, & Jordan, 2005). Clearly the small
convenience sample of advocates
studied presents biases that may not reflect what a random
sampling of rape crisis
center employees and former employees might report. Although
some participants
were drawn from a sexual violence conference list because this
was a conference in the
same metropolitan area as this study it was heavily attended by
rape crisis center
personnel from the region’s rape crisis centers, actually making
it a fairly dense local
source of advocates from which to draw a sample.
Because only the first author conducted these interviews, age
and race matching
with advocates was not possible. The first author is a White,
middle-aged female, which
may have led to fewer or poorer quality data from advocates
with different age/ethnic
characteristics. (See Ullman, 2005 for a discussion of her
perceptions of how this may
have affected interviews with older, ethnic minority women in
particular.)
One issue we did not ask about was what participants believed
the meaning was of

the treatment orientation terms used to identify their strategy of
working with
survivors. For example, some advocates described client-
centered and empowerment
approaches as quite similar, whereas others felt they were
distinct. Research must
examine not only philosophy and training practices employed by
organizations but
also what these labels mean to workers who use them as part of
their identities and how
those labels actually relate to their work with survivors.
Clearly, the self-labeled
treatment orientation did mean something to those interviewed
in this study, but it is
not clear that these labels relate to differences in how advocates
work with survivors,
perhaps due to relative homogeneity in the rape crisis
organizations’ philosophies and
training of advocates.
On the other hand, assessing empowerment at the level of the
organization and
the individual advocate is important as well as assessing
organizational practices and
advocates’ behaviors with their clients. Such data are needed to
clarify how these labels
relate to actual practices at organizational and individual levels,
and more importantly
how organizations varying in the degree of empowering

practices they employ affect
the ability of their advocates to empower survivors. Martin
(2005) has argued that
organizational constraints and goals often result in secondary
victimization of rape
victims because workers follow rules required to do their jobs,
which entails practices
that often conflict with the needs of rape victims. The term
‘‘empowerment’’ is widely
used but not clearly defined in terms of how it translates into
practice, which highlights
the need for more research to understand what rape crisis
centers mean by
empowerment and how they enact it. Enacting empowerment
needs to be examined
in terms of interpersonal relationships between advocates and
survivors, intervention
strategies when working with survivors, other work done by the
agencies, and the
climate within the agencies for both survivors and staff.
REFERENCES
Bay Area Women Against Rape. (1993). Advocate training
manual. Oakland, CA: Bay Area
Women Against Rape.
Brighter Tomorrows. (1996). Advocate training manual. Grand
Prairie, TX: Brighter
Tomorrows.
Campbell, R., Dorey, H., Naegeli, M., Grubstein, L.K., Bennett,
K.K., Bonter, F., et al. (2004). An
empowerment evaluation model for sexual assault programs:
Empirical evidence of
effectiveness. American Journal of Community Psychology, 34,

251–262.
Campbell, R., & Martin, P.Y. (2001). Services for sexual
assault survivors: The role of rape crisis
centers. In C.M. Renzetti, J.L. Edelson, & Bergen, R.K.
Sourcebook on Violence Against
Women. (pp. 227–241). Thousand Oaks, CA: Sage.
Campbell, R., Sefl, T., Barnes, H.E., Ahrens, C.E., Wasco,
S.M., & Zaragoza-Diesfeld, Y. (1999).
Community services for rape survivors: Enhancing
psychological well-being or increasing
trauma? Journal of Consulting and Clinical Psychology, 67,
847–858.
Davis, R., Taylor, B., & Bench, S. (1995). Impact of sexual and
nonsexual assault on secondary
victims. Violence and Victims, 10, 73–84.
Filipas, H.H., & Ullman, S.E. (2001). Social reactions to sexual
assault victims from various
support sources. Violence & Victims, 16, 673–692.
Golding, J.M., Siegel, J.M., Sorenson, S.B., Burnam, M.A., &
Stein, J.A. (1989). Social support
sources following sexual assault. Journal of Community
Psychology, 17, 92–107.
Illinois Coalition Against Sexual Assault (2002, October).
Service standards. ICASA Policies and
Procedures Manual. Springfield, IL.
Logan, T.K., Evans, L., Stevenson, E., & Jordan, C. (2005).
Barriers to services for rural and
urban rape survivors. Journal of Interpersonal Violence 20,
591–616.

Martin, P.Y. (2005). Rape work: Victims, gender, and emotions
in organization and community
context. New York: Routledge.
Mechanic, D. (1991). Strategies for integrating public mental
health services. Hospital and
Community Psychiatry, 42, 797–801.
Miles, M.B., & Huberman, A.M. (1994). Qualitative data
analysis (2nd ed.). Thousand Oaks, CA:
Sage Publications.
Rappaport, J. (1984). Studies in empowerment: Introduction to
the issue. Prevention in Human
Services, 3, 1–7.
Riger, S. (1984). Vehicles for empowerment: The case of
feminist organizations. Prevention in
human services, 3, 99–117.
Riger, S. (1993). What’s wrong with empowerment? American
Journal of Community
Psychology, 21, 279–292.
Ryan, W. (1976). Blaming the victim. New York: Vintage
Books.
Salston, M., & Figley, C.R. (2003). Secondary traumatic stress
effects of working with survivors of

criminal victimization. Journal of Traumatic Stress, 16, 167–
174.
Sexual Assault Prevention and Awareness Center. (1991).
Hotline training manual. Ann Arbor,
MI: Author.
Schauben, L. J., & Frazier, P. A. (1995). Vicarious trauma: The
effects on female counselors of
working with sexual violence survivors. Psychology of Women
Quarterly, 19, 49–64.
Strauss, A.L., & Corbin, J.M. (1998). Basics of qualitative
research: Techniques and procedures
for developing grounded theory. Newbury Park, CA: Sage.
Ullman, S.E. (2000). Psychometric characteristics of the social
reactions questionnaire: A
measure of reactions to sexual assault victims. Psychology of
Women Quarterly, 24,
257–271.
Ullman, S.E. (2005). Interviewing clinicians and advocates who
work with sexual assault
survivors: A personal perspective on moving from quantitative
to qualitative methods.
Violence Against Women, 11, 1–27.
Ullman, S.E., Filipas, H.H., Townsend, S.M., & Starzynski,
L.L. (2007). Psychosocial correlates of
PTSD symptom severity in sexual assault survivors. Journal of
Traumatic Stress, 20,
821–831.
Ullman, S.E., & Townsend, S.M. (2007). Barriers to working
with sexual assault survivors: A

qualitative study of rape crisis center workers. Violence Against
Women, 13, 412–443.
Wasco, S.M., Campbell, R., Howard, A., Mason, G., Staggs, S.,
Schewe, P., et al. (2004). A
statewide evaluation of services provided to rape survivors.
Journal of Interpersonal
Violence, 19, 252–263.
Wasco, S.M., & Campbell, R. (2002). Emotional reactions of
rape victim advocates: A multiple
case study of anger and fear. Psychology of Women Quarterly,
26, 120–130.
Yoder, J., & Kahn, A. (1992). Toward a feminist understanding
of women and power. Psychology
Women Quarterly, 16, 381–388.
Zimmerman, M.A. (2000). Empowerment theory: Psychological,
organizational, and community
levels of analysis. In J. Rappaport & E. Seidman (Eds.).
Handbook of community
psychology. (pp. 43–63). New York: Plenum.
Zimmerman, M.A. (1995). Psychological empowerment: Issues
and illustrations. American
Journal of Community Psychology, 73, 581–599.

Comparative Analysis of Three Crisis
Intervention Models Applied to Law
Enforcement First Responders During 9/11
and Hurricane Katrina
Cherie Castellano, MA, CSW, LPC, AAETS
Elizabeth Plionis, PhD
Two distinct fields, crisis intervention (which targets civilian
populations) and disaster
mental health services (which targets first responders), have
emerged in response to
natural and man-made disasters. As a consequence of 9/11 and
Hurricane Katrina,
questions have been raised whether the occupational ecology of
first responders has
significantly changed. Two new concepts, the ‘‘high-risk
rescuer’’ and the ‘‘rescuer–
victim,’’ are identified. Using three field cases, this paper
describes and analyzes the
application of three different crisis intervention models for law
enforcement first responders
during 9/11 and Hurricane Katrina: (a) psychological first aid,
(b) critical incident stress

management, and (c) the Federal Emergency Management
Association/Substance Abuse
Crisis Counseling Program. Implications for meeting the mental
health needs of first
responders post-9/11 and -Hurricane Katrina are discussed.
[Brief Treatment and Crisis
Intervention 6:326–336 (2006)]
KEY WORDS: disaster mental health, law enforcement, first
responders, occupational ecology,
high-risk rescuers, rescuer–victim.
The Issue
Two distinct fields, crisis intervention (which
targets civilian populations) and disaster mental
health services (which targets first responders),
have emerged in response to natural and man-
made disasters. The degree to which concepts
developedinonefieldcanbeappliedtotheother
field, thoughcontroversial,hasledto anarrayof
training programs and a ‘‘tool kit’’ of inter-
ventions and crisis phase-specific responses.
However, unlike civilian populations, first re-
sponders are affected by the dynamics of their
organizational culture as well as the ecology
of their occupation. Organizational dynamics
have always influenced how mental health
services are delivered and received.
Since 9/11 and Hurricane Katrina, mental

health professionals have become aware of
two unique subgroups: (a) those first respond-
ers who are at higher than normal risk due to
terrorist activities and (b) those first responders
From the Cop-to-Cop Crisis Intervention Hotline, University
Behavioral Health Care University of Medicine and Dentistry
of New Jersey, Piscataway, NJ (Castellano) and the Catholic
University of America, Washington, DC (Plionis).
Contact author: Cherie Castellano, Director, Cop-to-Cop
Crisis Intervention Hotline, University of Medicine and
Dentistry of New Jersey. E-mail: [email protected]
doi:10.1093/brief-treatment/mhl008
Advance Access publication September 25, 2006
ª The Author 2006. Published by Oxford University Press. All
rights reserved. For permissions, please e-mail:
[email protected]
326
who are simultaneously rescuer–victim as in
Hurricane Katrina. First responders incur
a higher risk of death and catastrophic injury
when responding to terrorist incidents. During
Hurricane Katrina, first responders faced ethi-
cal dilemmas and personal, family-related cri-
ses. Implications for meeting the mental
health needs of these unique responder sub-

groups are explored by examining the three cri-
sis intervention models identified in the study.
Historical Perspective
The field of psychological crisis intervention
has existed since the early 1900s. It has devel-
oped concepts and practices that target civilian
populations and those placed in harms way (the
military). The development of disaster mental
health (which targets first responders) as a field
of practice developed in the early 1990s. Its pri-
mary target population is first responders. The
development of this second field of practice was
largely due to four factors: (a) the recognition of
the occupational risk incurred by first respond-
ers, (b) the development of critical incident
stress management (CISM) teams targeting
emergency services personnel, (c) the expan-
sion of the Salvation Army’s disaster services
to include disaster mental health personnel,
and (d) the rise in global terrorism.
First Responder Culture
Historically, first responder personnel have
been resistant to seeking mental/behavioral
health services. Tensions have always existed
between administrative and rank and file per-
sonnel. The public safety culture has been
typified as one wherein seeking mental health
services may be interpreted as a sign of ‘‘weak-
ness.’’ Furthermore, the culture attracts individ-
ualswhoexhibita‘‘takecharge,control-oriented
style.’’ Firstresponders arecommonly more com-

fortable dealing with the problems of others
rather than with their own problems. Establish-
ing the trust needed for mental health counseling
within such an environment is essential yet diffi-
cult for those mental health professionals seen as
‘‘outsiders.’’
It is no coincidence, therefore, that psycholog-
ical support programs developed to serve the Se-
cret Service; Fire Department of New York; New
York Police Department; the Bureau of Alcohol,
Tobacco, Firearms, and Explosives; and the Na-
tional Fraternal Order of Police all utilize ‘‘peer
support’’ (the use of line personnel specially
trained in crisis intervention) models (Sheehan,
Everly,&Langlieb,2004).Nonpeermentalhealth
professionals often play an indirect or liaison
role, with peer personnel taking the interven-
tion lead. In the three field cases to be described
below, the peer-to-peer counseling model was
overwhelmed by the magnitude and unique
characteristics of 9/11 and Hurricane Katrina.
A Changing Occupational Ecology
In recent years, first responders have been
called upon to intervene in such disasters as
the Oklahoma City bombing, the terrorist attack
on the USS Cole, and the attacks of September
11, 2001. These disasters have added ‘‘terrorist
attacks’’ to the typology of events to which law
enforcement personnel respond. This has led to
the realization that those who respond to terror-
ist attacks may themselves be targets of terrorist
activities and are themselves at high risk for
death or catastrophic injury.

In addition, several recent natural events,
such as hurricanes Andrew, Katrina, and Rita,
have led to the recognition that some respond-
ers fall into a category of rescuer–victim. Some
first responders face ethical and personal crises
when they and their families are themselves
victims of a natural disaster. These recent
events have led to increased awareness among
Comparative Analysis of Crisis Intervention Models
Brief Treatment and Crisis Intervention / 6:4 November 2006
327
mental health professionals of the changing oc-
cupational mental health risks encountered by
first responders.
Risk and Resources for First Responders
Risk
It is well documented that public safety profes-
sions are at greater risk for the development of
posttraumatic distress and alcohol abuse. Some
personnel may present with depression/suicide
or domestic violence. Whereas the general pop-
ulation suffers from post traumatic stress disor-
der (PTST) at a point prevalence of about 3%,
the law enforcement profession has a prevalence
of around 10% and firefighters a prevalence be-
tween 10% and 30%. Those exposed directly
to a mass disaster are reported to have a PTSD

prevalence of about 34% (North et al., 1999).
Although studies vary in their prevalence sta-
tistics, they seem to agree that there is a relation-
ship between an individual’s duration of
exposure to traumatic imagery and the devel-
opment of posttraumatic distress (Everly &
Mitchell, 1999).
Several studies (Bacharach & Zelco, 2004; In-
stitute of Medicine, 2003) have documented the
mental health status of first responders follow-
ing the terrorist attack of 9/11. These studies
suggest that public safety and emergency re-
sponse professionals constitute a ‘‘high-risk’’
group with an increased probability of psychi-
atric morbidity, domestic violence, divorce,
and shortened careers due to their occupational
professional roles. In addition to their ‘‘normal’’
daily exposure to traumatic events, some res-
ponders are at heightened risk when they re-
spond to terrorist events.
Resources and Training Options
Law enforcement personnel have access to
mental health services sponsored by Employee
Assistance Programs (EAP), by departmental
psychological services, by chaplain services,
and by their unions. They also have access to
traditional social services. However, because
of the cultural dynamics of their occupation,
law enforcement personnel tend to prefer mod-
els of mental health counseling that utilize peer-
to-peer counseling such as the Cop-to-Cop
program.

Evidence: Do Mental Health Services for
First Responders Work?
Little well-controlled disaster mental health
outcome research for first responders exists (In-
stitute of Medicine, 2003; National Institute for
Mental Health [NIMH], 2002). Furthermore,
law enforcement officers have several options
to choose from when selecting to participate
in mental health training. There are three major
models of disaster mental health training target-
ing first responders: (a) Psychological First Aid
(PFA), (b) CISM, and (c) the FEMA/SAMSHA
Crisis Counseling Program (CCP). Is one model
more effective than another?
Comparison of Three Crisis Intervention
Models Post-9/11 and -Hurricane
Katrina
Psychological First Aid
Description of the Model. Both the pre-
existing organizational culture of emergency
response personnel and the changing occupa-
tional ecology of first responders must be taken
into account when designing services that will
meet the mental health needs of this population.
As a model of practice, PFA has been endorsed
by the Institute of Medicine (2003). The goals
of this model are to provide (a) information
and education, (b) comfort and peer support,

(c) acceleration of recovery, (d) promotion of
CASTELLANO AND PLIONIS
328 Brief Treatment and Crisis Intervention / 6:4 November
2006
resiliency and mental health, and (e) access to
continued care. This model of crisis interven-
tion may be thought of as a form of ‘‘emotional
first aid.’’
The New Jersey State Police (NJSP) EAP was
developed in 1981 to provide the enlisted per-
sonnel of the State Police a confidential place to
discuss any personal or work-related issues
with a trained professional. Over the years,
the office has become increasingly involved
in CISM consultation and organizational train-
ing. A variety of adaptations to an early crit-
ical incident response model developed by
Everly and Mitchell (1999) were necessary
and were implemented in a model PFA response
for first responders within the New Jersey Task
Force One (NJTF-1)–Urban Search and Rescue
Team.
Field Application of the PFA Model: World
Trade Center. NJTF-1 is a volunteer Urban
Search and Rescue Team comprising approxi-
mately 180 members, authorized and funded
by the NJSP, Office of Emergency Manage-
ment. On September 11, 2001, the NJTF-1

responded to the World Trade Center site
and provided rescue and recovery efforts 24 hr
a day in 12-hr shifts for a 10-day period before
returning ‘‘home’’ to Lakehurst naval base.
At the time of deployment, NJTF-1 was pre-
pared with excellent rescue and recovery train-
ing, comprehensive equipment, and the
capacity to live at the staging area. NJTF-1
was a self-contained unit. Team members had
all the food, clothing, protective equipment,
communications equipment, and shelter they
would need for their 10-day stay. Team mem-
bers were briefed to anticipate any and all
needs created by the intense exposure related
to the rescue and recovery mission. They
erected tents and utilized decontamination
trailers for showers when they returned from
their 12-hr shift on ‘‘the pile.’’ During every
shift change, each team member was medically
examined and cleared for further deployment if
appropriate. What had not been anticipated,
however, was the dramatic emotional impact
this 10-day period would have on members
of this unit.
Intervention Phases of the PFA. Fortunately
fortheNJTF-1teammembers,theNJSPEAPuti-
lized the basic tenants of PFA (developed for
civilians) to respond to the psychological needs
of this responder group. Developed by Everly
and Flynn (2005), this model consists of five
steps: (a) assessment phase, (b) stabilization
phase,(c)triagephase,(d)communicationphase,
and (e) the follow-up or connection phase.

The PFA Assessment Phase. The first task of
this phase is to provide immediate access to
mental health assessment for those perceived
as at high mental health risk because of the na-
ture of the crisis event. To facilitate this phase,
a mental health tent was placed at the rescue
and recovery staging area to allow responders
immediate access to care. The tent was staffed
24–7 with peers and clinical staff specifically
trained to work with first responders dealing
with critical incidents. The use of peer coun-
selors fit the culture of law enforcement
emergency personnel and lent credibility and
familiarity to the counseling effort. Unlike
civilians, law enforcement emergency person-
nel must continue to work professionally
within the crisis environment to complete their
mission.
The PFA Stabilization Phase. Ground zero was
one of the most devastating rescue and recov-
ery missions in the history of the United States.
Itself volatile, the situation proved frustrating
to the newly trained NJTF-1 team members.
Three interventions proved beneficial during
this phase. First, routine psychological check-
ups were initiated to follow medical checkups
every 12 hr. Supportive and nonintrusive
329

interventions were administered as warranted.
Second, ongoing spiritual leadership, present
from day one, sustained morale and proved
to be a stabilizing force. A third stabilizing
force came from the information provided by
the media. Televisions were rigged up outside
the tents and were watched regularly by NJTF-
1 team members.
The PFA Triage Phase. During this phase, job
performance was assessed hourly. The NJSP
EAP leaders communicated with the incident
command structure, NJTF-1 team leaders, and
peers regarding each member’s ability to pro-
vide his/her special skill. Opportunities for
‘‘regrouping’’ a team were available should a
NJTF-1 team member appear distressed and be
in need of further evaluation and/or treatment.
Group cohesion fostered a supportive environ-
ment and promoted individual resiliency. An
unanticipated experience was the appearance
of a barrage of volunteers and crisis counselors
from all over the country eager to engage these
workers in dialogue about their experiences.
The PFA Interactive Communication Phase. Dur-
ing this phase, members of NJSP EAP ‘‘joined’’
the responders by living in a tent in the staging
area, wearing team fatigues, dining with the
team members, and creating a daily religious
service. Normalization was achieved by provid-
ing materials about critical incident stress. A na-
tionally renowned speaker on law enforcement
psychology spoke at a farewell ceremony as the
team departed ground zero. The ‘‘farewell cer-

emony’’ was intended to prepare the NJTF-1
team members with education, awareness, and
spiritual grounding. The ceremony also pre-
pared members to meet and greet their families
at the naval base later that day.
The PFA Hotline Phase. Initiating instant con-
tact between team members, peer counselors,
and nonpeer mental health professionals was
a key component of this phase. The hotline also
was a means of maintaining contact as part of
the follow-up after termination. Within the
first few days of deployment, a crisis helpline
was created. Its goal was to ensure a rapid re-
sponse following contact. Callers received fur-
ther assessment and treatment as needed. This
crisis helpline for the NJTF-1 team members
remained active for several years post-9/11.
Many rescuers utilized the line for resources
and services for themselves and their families
long after the PFA had been completed.
Summary. PFA is an acute mental health inter-
vention with five phases. Its application to law
enforcement emergency personnel deployed to
ground zero for a 10-day mission is regarded as
successful by those involved with it.
CISM Model
Description of the Model. The core elements
of CISM are most frequently attributed to
Everly and Mitchell (1997, 1999). However, it
is important to note that the Salvation Army,
Episcopal Church, American Red Cross, and

the National Organization for Victim Assistance
have utilized, with significant success, varia-
tions on the theme of multicomponent crisis
intervention.
The model is consistent with Millon’s three
concepts of potentiating pairings, catalytic
sequences, and the polythetic nature of a crisis
(Millon, Grossman, Meagher, Millon, & Everly,
1999). Potentiating pairings refer to the use of
interacting combinations of interventions to
achieve an enhanced clinical effect. Catalytic
sequences refer to the sequential combination
of tactical interventions to maximize their
clinical effectiveness. The polythetic nature
of the approach refers to the selection of tactical
interventions as determined by the specific
needs of each crisis situation. In other words,
specific crisis interventions within the CISM
2006
model are to be combined and sequenced in
such a manner so as to yield the most efficient
and effective crisis intervention possible. The
various combinations and permutations that
are actually utilized within such an approach
will be determined by the specific needs of each
critical incident or traumatic event as they
uniquely arise (Castellano, Everly, & Langlieb,
2005).

Field Application. One of the many challenges
faced by mental health personnel is to provide
crisis mental health intervention to first res-
ponders in a chaotic and unpredictable event.
Rescue and Recovery Teams from The New Jer-
sey Port Authority Police Department (PAPD)
were deployed to ground zero. Compared to
previous crisis events, first responders suffered
the largest loss of life in a single critical incident
(9/11) in the history of this country.
The number of first responders from the New
Jersey PAPD who themselves died (37) on 9/11
as a consequence of responding to the crisis was
unique. In addition, the duration of the rescue
and recovery tours of teams exceeded normal
tours of duty; most served in excess of 8 months.
The duration of the rescue and recovery efforts
provided a surreal world for first responders,
sustained and punctuated with color-coded
high alerts and threats of reoccurrence.
Intervention Model: CISM. On September 11,
2001, the cop-to-cop program (a mental health
program established by the New Jersey state
legislature for law enforcement personnel) ex-
perienced a 300% increase in calls; many from
the New Jersey PAPD. In everyday crisis or crit-
ical incidents, peer support is often sufficient to
meet first responders’ trauma and stress manage-
ment needs. The unprecedented events of 9/11
overwhelmed the peer-to-peer program, neces-
sitating a collaborative approach between non-
peer professionals and peer counselors. As
a consequence, the multicomponent CISM model

was utilized to augment existing peer-to-peer
counseling. Its six components are described
below.
Component One: Acute Crisis Counseling Pro-
vided by Peer Counselors. Peer counselors (law
enforcement officers who had received special-
ized training in psychological crisis interven-
tion) were deployed from several locations to
support first responders at ground zero. Non-
peer mental health counselors were initially
used as ‘‘mental health backup’’ by the peer
group leading the psychological crisis inter-
vention initiative. During this 3-month phase,
standard psychological crisis intervention tech-
niques were used; individuals were assessed to
determine their needs, and acute, one-on-one
psychological crisis interventions were offered
as needed (Everly & Mitchell, 1999). Strategic
planning, a collaborative effort between pro-
fessional mental health counselors and peer-
trained crisis counselors, led to the development
of other model components.
Component Two: Executive Leadership Pro-
gram. Management and senior staff at PAPD
requested additional assistance in providing
crisis intervention for their officers with a
specialized postimpact law enforcement pro-
gram. A task force was convened to establish
and deliver a program designed to educate
and orient the participants on how to provide
additional service. The leadership program rec-
ognized the importance of addressing the supe-
rior officers as a means of having them perceive

behavioral health care services separate and
distinct from their organizational structure.
Attendees included medical personnel, mental
health practitioners, public safety leaders,
and administrators.
This leadership program consisted of a 2-hr
lecture. Staff were given the opportunity to
engage the participants. The question that
had the greatest heuristic value in designing
331
subsequent interventions was ‘‘what do you
think you need and what will help you?’’
The perceived success of this leadership train-
ing prompted a continuation of services as
part of a ‘‘trickle down’’ effect. Over 100 Acute
Traumatic Stress Management Training ses-
sions were provided in multiple commands.
The success of such trainings depended on
whether the recipient group perceived the
training as accessible and accommodating
rather than cumbersome and interfering.
Component Three: The Multidisciplinary Team. A
multidisciplinaryteam worked 24–7to assess the
status of those working at ground zero. Members
of the team provided customized training ses-
sions to meet the unique needs of first
responders as they were identified. Because

members of law enforcement tend to avoid
anything individually focused or considered
‘‘psychiatric,’’ or even ‘‘therapeutic,’’ group cri-
sis interventions were utilized and were concep-
tualized as ‘‘training.’’ Interventions were more
likely to be well received and utilized if pre-
sented and perceived as training.
Component Four: Acute Traumatic Stress Group
Training Sessions. These sessions consisted of
a 2-day psychoeducational group format. The
group format (rather than a focus on individual
interventions) was seen as an important addi-
tion. The group was seen as both logistically ef-
ficient and better able to normalize reactions,
build informal support networks, and teach
practical coping skills. The group format also
proved to be a valuable triage tool. Most impor-
tantly, the group countered the sense of social
alienation that often accompanies posttraumatic
distress. Outside experts spoke on law enforce-
ment personality traits, the signs and symptoms
of stress and distress, and common effective
coping mechanisms. One special challenge was
the difficult task in processing survivor guilt
and grief among those deployed to 9/11.
Although the intent of the group sessions was
education and training, feedback from the facil-
itators indicated that most groups manifested
a therapeutic quality. Officers described our
sessions as the first supportive group experi-
ence they had where they could discuss
the traumatic events associated with the 9/11
disaster.

Component Five: Hotline. Prior to September
11, 2001, the law enforcement hotline was cre-
ated. Subsequent to September 11, the hotline
served as an invaluable tool for passive out-
reach and for active feedback from field person-
nel. The line operated 24–7. Data collected from
initial calls were used to create the hotline man-
ual and develop resources.
Component Six: Reentry Program. A reentry
program was initiated to meet the needs of
high-risk rescuers. The mental health literature
recognizes that prolonged exposure to danger,
death, and devastation creates difficulties as
members return to routine tasks on the job
and family life. The intent of the reentry pro-
gram was to prepare participants for a return to
routine job functions and normal family life.
Summary of the CISM Model. The CISM
model described above utilized a combined
large group, small group, family, and indi-
vidual intervention approach to engage par-
ticipants who historically are viewed as
intervention resistant. Each intervention for-
mat offered unique advantages that collectively
served as a form of continuum of care, lacking
when only one intervention format is used. The
components in this application of CISM were
formulated only after listening to the needs
of the officers and carefully reviewing relevant
literature within the fields of counterterrorism,
law enforcement stress, psychological trauma,
peer support, CISM, ‘‘debriefing,’’ and suicide
prevention.

2006
The FEMA/SAMSHA CCP Model
Description of the CCP Model. This model
has been frequently used for natural disaster re-
sponse. The CCP model assesses strengths,
seeks to restore predisaster functioning, accepts
content at face value, validates common reac-
tions, and has a psychoeducational focus.
Field Application. The CCP model was adapted
for first responders on the Gulf coast in response
to Hurricane Katrina. A unique aspect of this cri-
sis event was that law enforcement professionals
became simultaneously rescuer and victim. Un-
like most other disasters, the families of these
first responders were themselves endangered
by the disaster.
Three critical incidents resulted from Hurri-
cane Katrina. The first was the actual natural
disaster. The storm and the subsequent breach
of the levees caused massive flooding over 80%
of the city. The second involved the breakdown
of local, regional, state, and national (FEMA)
emergency response organizations. The third
critical incident involved the unprecedented
personal and ethical crises faced by law en-
forcement personnel during the hurricane.

Assess Strengths. The first task of the CCP
model is to assess strengths. Levees separating
Lake Pontchartrain from New Orleans were
breached by the storm surge, ultimately flood-
ing about 80% of the city. According to esti-
mates, Katrina caused damages in excess of
$75 billion. Shortly after the hurricane ended
on August 30, residents who did not or could
not leave New Orleans began looting stores.
Many were in search of food and water, though
some stole nonessential items as well. Reports of
carjackings, murders, thefts, and rapes flooded
the news; many of these reports were later de-
termined to be rumors. Emergency personnel
lacked the ability to secure the scene; geograph-
ically, few areas of high ground existed, and
facilities and equipment were flooded. Individ-
uals who could help other individuals often did
so. Outside resources (material and human)
were needed as the crisis unfolded; however,
requests for such help were delayed. When
available, resources could not readily be
deployed because of the extent of flooding.
Organizational Breakdown. The storm and
subsequent levee breaks disrupted regular po-
lice functions. Members of the police force were
relieved from their shift and told to stand by
within the city. Many of them found rooms
in vacant hotels, with friends or in their homes.
They were told to return at 4:00 p.m. Before
they could do so, they found themselves
flooded and marooned. One officer swam with
her 8-month-old baby to ‘‘headquarters’’ that
was by then an abandoned catering facility,

the highest ground in the district. Water con-
tinued to rise rapidly despite the storm’s end.
The same forces of nature, which prevented
local emergency transportation and communi-
cation, disseminated law enforcement leader-
ship and created an organizational crisis; one
that bubbled up from local to regional to state
and to national emergency response commands.
Communication failed as police radios, cell
phones, and all landlines went out. No central
command existed. What facilities and equip-
ment did exist were improvised. Standard op-
erating procedures became moot.
Restore Predisaster Functioning. Chaos and
Reorganization. Law enforcement attempted
to regroup by forming Krewes (a Mardi Gras
term referring to the custom of a club or group
creating a float). Krewes operated indepen-
dently. Krewes were the only option law en-
forcement personnel had to both function
and survive. Although Krewes generally grew
closer, some fracture lines occurred between
different shifts, between superior officers and
rank and file police members, and between
those officers who had left to take care of their
333
families (even though many ultimately

returned) and those who stayed on the job. It
was impossible to restore predisaster function-
ing while 80% of the city remained flooded.
Unlike other crises, law enforcement was un-
able to secure the scene.
Acceptance and Validation. Law enforcement
personnel themselves lacked basic safety, hous-
ing, a command structure and facility, clean
clothes, food, and water. Rescuers themselves
felt abandoned.
It is estimated that over 80% of the officers
surveyed had lost their homes and all their pos-
sessions. Members of their families became ill,
suffered injuries, and were relocated. Friends
and family members were lost.
In addition, members of the New Orleans po-
lice department faced personal and ethical cri-
ses. Law enforcement members had to decide
whether to stay on the job in a spirit of loyalty
to the brotherhood and their oath to protect the
public or rescue their own family members who
were themselves endangered by Katrina. In ret-
rospect, mental health practitioners recognize
that members of the New Orleans Police Depart-
ment were simultaneously rescuer and victim.
Unlike the media support the first responders
felt at 9/11, media coverage of Katrina further
demoralized the members of law enforcement
by depicting them as malfeasant.
Ethical dilemmas. Unlike other critical incident
events, law enforcement personnel faced a basic
conflict between their sworn oath to protect

and serve the public and their personal commit-
ment to protect and save their families. One
officer described his dilemma as a conflict be-
tween his oath as a police officer and his vows
of marriage and his obligations as a parent to
protect his family. Law enforcement personnel
were not prepared for the ethical dilemma they
faced. Mental health professionals recognize
that recovering from a ‘‘no-win’’ critical inci-
dent is more complicated.
Psychoeducation. Written materials and roll call
presentations informed officers about ‘‘normal
reactions to abnormal events.’’ Law enforce-
ment personnel were connected to available
resources in the outreach phase of the CCP/
FEMA model. Small group meetings were held
at each precinct. Interventions were limited to
recognition of the problems incurred and vali-
dation of the rescuer–victim experience. As was
true at 9/11, some members benefited from
faith-based or spiritual discussions. Topics in-
cluded forgiveness (of self and others).
Summary of the FEMA/SAMSHA CCP
Model. The unusual circumstances of Hurri-
cane Katrina rendered the implementation of
this model difficult. Whenever possible, indi-
vidual officers sought one-on-one peer crisis
counseling. Some diffusings (group format) oc-
curred where and when feasible. Stabilization
was less effective given the unique features
of this crisis. Small gestures such as garbage re-
moval from a temporary command post or the
provision of clean shirts were regarded as

a show of support.
Implications for Practice
Psychological First Aid
Providing mental health support at the staging
area of a crisis (as in 9/11) is a strategy that ben-
efits first responders by making access to sup-
port readily available and more likely to be
used. A spiritual component to crisis interven-
tion is beneficial to many first responders.
The CISM Model
Compared to other models, this model is fluid
and offers a wide range of intervention options
during each phase of a crisis. The Reentry pro-
gram component developed in response to the
Port Authority team assigned to ground zero
2006
proved helpful to those first responders who
are deployed to a crisis site for long periods
of time. In the case example cited, the use
of psychoeducational support groups was
regarded as a more effective intervention than
one-on-one crisis counseling. Customizing in-
tervention content based on input from first
responders on what they need is more effective

than offering predetermined content alone.
Asking ‘‘what do you think you need?’’ or
‘‘what will help you now?’’ is effective in guid-
ing the intervention focus. The multiple phases
of a crisis intervention require specific skills at
different times. When using a multicomponent
CISM model, it is important that one singular
entity controls and integrates the multiphase
plan (Employee Assistance Professionals’ Asso-
ciation, 2002; NIMH, 2002).
The FEMA/SAMSHA CCP Model
Because the geographic and physical facilities
of first responders in New Orleans were demol-
ished, it is important to adapt crisis interven-
tion outreach and follow-up services to the
functional community of first responders. It
is important to redefine a geographic commu-
nity as a functional ‘‘first responder commu-
nity.’’ Primarily a model used to intervene
with civilian populations, the CCP model must
take into account the unique organizational and
occupational features of first responders. Anal-
ysis of its application in Hurricane Katrina led
to increased awareness of the rescuer–victim
and the ethical dilemma faced by first respond-
ers when their own families are themselves en-
dangered by the disaster.
Training Content
Though training programs are intended to be
proactive in preparing counselors to deal with
the mental health needs of first responders, not
all contingencies can be anticipated. Experi-

ence, unfortunately, is the only real educator.
The events reported in this paper have led to
increased awareness of two new first responder
subgroups, the high-risk responder and the res-
cuer–victim.
Other areas to be incorporated in training
content include content on ethical decision
making and ethical dilemmas. First responders
must have a clear understanding of their value
systems. Drills and contingencies must be in-
corporated to handle organizational breakdown
and situations where the rescuers families are
themselves endangered.
Recovery
What facilitates recovery? Some (Reese, 1987)
argue that there is a role for anger in the recov-
ery process. Others argue that denial plays a role
in that it allows individuals to move on. From
these three cases, we learn that recovery also
depends on augmentation of peer-to-peer coun-
seling programs through the use of nonpeer pro-
fessionals in collaboration with peer counselors.
Summary
The field events reported in this paper suggest
that providing disaster mental health services to
first responders requires customized fluid crisis
intervention services based on practical applica-
tion rather than on bounded theory and training
auspice (Castellano et al., 2005, p. 51). Selecting
one model over another may compromise the

practitioner’s ability to offer crisis mental health
intervention for first responders appropriate to
the crisis event they work. Techniques that are
appropriate for one phase may not be sufficient
for subsequent phases of the event. The ability
of a mental health practitioner to engage in best
practice depends in part on his/her familiarity
with a variety of crisis intervention models.
More importantly, it depends on field data
about what is and what is not working at the
moment under different circumstances.
335
Acknowledgments
Conflict of Interest: None declared.
References
Bacharach, S. B., & Zelco, H. (2004). On the frontline:
The work of first responders in a post 9/11 world.
NY: Cornell.
Barkun, M. (April, 2002). September 11th through
Conspiracists’ Eyes. Paper presented to the Critical
Incident Analysis Group (CIAG) conference,
‘‘Terrorism, Intelligence and Democracy,’’
University of Virginia, Charlottesville. http://www.

hsc.virginia.edu/csmhi/ciag/report_barkun.html
Castellano, C., Everly, G. S., & Langlieb, A. (2005).
Psychological counterterrorism and World War IV
(p. 51). Ellicott City, MD: Chevron Publishing
Company.
Dyregrov, A. (1998). Psychological debriefing: An
effective method? Traumatology, 4(2).
EmployeeAssistanceProfessionals’Association.(2002,
November). Employee assistance programs’ critical
incident management: Report of the EAPA Disaster
Preparedness Task Force. Boston, MA: Author.
Everly, G., & Flynn, B. (2005). Principles and
practical procedures for acute psychological first
aid for personnel without mental health. Journal
of Emergency Mental Health, 8(2).
Everly, G. S., Jr., & Mitchell, J. (1997). Critical
incident stress management. Ellicott City, MD:
Chevron.
Everly, G. S., Jr., & Mitchell, J. (1999). Critical
incident stress management (2nd ed.). Ellicott City,
MD: Chevron.
Millon, T., Grossman, S., Meagher, S., Millon, C., &
Everly, G. S., Jr. (1999). Personality-guided

therapy. NY: Wiley.
National Institute for Mental Health. (2002). Mental
health and mass violence. Washington, DC: U.S.
Government Printing Office.
North, C. S., Nixon, S. J., Shariat, S., Mallonee,
S., McMillen, J. C., Spitznagel, E. L., et al.
(1999). Psychiatric disorders among survivors
of the Oklahoma City bombing. Journal of
the American Medical Association, 282,
755–762.
Sheehan, D., Everly, G. S., Jr., & Langlieb, A. (2004,
September). Current best practices responding to
major critical incidents. FBI Law Enforcement
Bulletin, 1–11.
2006
http://www.hsc.virginia.edu/csmhi/ciag/report_barkun.html
http://www.hsc.virginia.edu/csmhi/ciag/report_barkun.html

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