Post Traumatic Stress Disorder: Implications for Seasonal Lifeguards.

It was a pleasant summer day. The outdoor pool, a fairly large facility with 6-8 guard stations, was open. In the middle of open swim, a situation develops which causes lifeguards to jump from their stations into the water, submerge themselves on the bottom of the pool, stay on the bottom as long as possible, come up and check the situation, and then return to the bottom of the pool. What the lifeguards were responding to were gun shots. The standard procedure for gunshots heard is for lifeguards to jump, enter the water, submerge and stay there until they know the situation on the top of the water is safe -- theory being, a dead lifeguard is of no use to anyone. The safest place to be when you are out in the open in a swimming pool during gun[ire is on the bottom, not up on top or on deck. So, indeed, a young lifeguard submerged, stayed there, and came up when the shots had finished. The actual shooting occurred in a locker room area. Lifeguards had to clear the pool, deal with the shooter until police arrived, and do an evaluation after the event.

This is only one of many different life threatening situations lifeguards face. Probably the most familiar life threatening situations are patron generated -- water related incidents that are drownings or near drownings, as well as non-water related incidents such as a heart attach on deck or in the locker room. But lifeguards face other life threatening situations. A second type of life threatening situation is the non-water related life threatening situation; gun shots, assaults, and stabbings. A third category of life threatening situations which can happen to lifeguards are natural disasters, like tornadoes, which happen when the facility is open.

All of these life threatening situations have several common factors--

* They threaten the very life existence of someone

* They involve the presence of the lifeguard (or could)

* They are all psychologically distressing

* They are outside the range of usual human experiences (including bereavement, chronic illness, business loss, and marital conflict -- normal trauma in life)

* They all have the potential to result in post traumatic stress disorder (PTSD) for the persons involved.

PTSD Defined

Post traumatic stress disorder is development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member of other close associate. (APA, 1996).

PTSD gets it's definition from the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association -- more commonly known at DSM -- at this point in time, DSM IV.

Diagnosis in an individual is by characteristic symptoms which include --

* exposure to a traumatic event that is life or serious-injury threatening, during which the individual experiences a response of helplessness, extreme fear and/or horror

* re-experiencing a traumatic event through dreams, intrusive thoughts, reliving the experience, psychological distress upon exposure to event cues, and/or psychological distress upon exposure to symbols of the event

* persistent avoidance of stimuli associated with the trauma, or a numbing of general responsiveness that was not present before the trauma

* persistent feelings of increased arousal not present before the trauma, including sleep disturbances, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response 

* intensified symptoms when exposed to situations or activities that resemble or symbolize the original trauma

* a full symptom picture present for more than one month

* a disturbance causing clinically significant distress or impairment in social, occupational, or other important areas of functioning

PTSD can be--

* Acute -- duration of symptoms of less than 3 months

* Chronic -- when symptoms last 3 months or longer

* Delayed Onset -- at least 6 months have passed between the traumatic event and the onset of symptoms

Focus here is on PTSD, it's causes and occurrence specifically related to the job of the lifeguard and, more particularly, the job of seasonal lifeguard. This will include discussion of lifeguard related causes of PTSD, as well as recognition, treatment, and prevention of PTSD.

Lifeguard Related Causes of PTSD

We know what lifeguards do that contributes to stress build-up. They--

* sit or stand in the same place for long periods of time

* repeatedly visually scan the same area

* experience the potential for boredom while having to remain highly alert

* respond immediately through extremely physical tasks with little time for thought and analysis

* repeat and repeat their emergency response pattern

* endanger their own lives

* may have to watch or assist other rescue workers

* may observe death

* may have to apply emergency rescue techniques, including techniques which could result in contraction of fatal disease, and

* may have to invest an intense amount of physical and emotional energy in trying to save a life and be unsuccessful in that attempt.

Lifeguards have described (Nealy, 1993) the extreme impact of their experiences--

* Seeing a dead person -- pupils fixed, eyes rolled back, blue skin, flaccid skin, lack of muscle tone, no movement, wet, slippery -- are characteristics remembered by all.

* Watching other guards in initial rescue attempts and then assisting in completing the rescue when initial efforts are not successful is remembered.

* The crowd cheering when the guard is successful, bystanders saying the guard was incompetent when the victim dies are both remembered.

* Having the scene of another guard working to resuscitate a victim be so upsetting that they had to leave the scene rather than present themselves to help.

* Doing the very best they could do, doing everything just like during drills, but this time having a real body, having the emergency action plan unfold perfectly but still losing the victim.

Priest (1992), writing on critical incident stress in lifeguarding, reports the ultimate stressor for lifeguards is a life-threatening injury, a near-drowning, or a drowning. The YMCA of the USA (1994) tells lifeguards, "anytime you are involved in a rescue you are subject to great stress as a result of your duty to react to the emergency and the danger you face in doing so." Following a life-threatening emergency, the guard must deal with the regular, on-going stress as well as the memories of the acute traumatic event.

Research on rescue workers cite similar factors contributing to development of PTSD. Lifeguard specific research is not available. Extrapolation from research on other categories of rescue workers is necessary, though remember, most rescue workers are older than the average age for lifeguards and most rescue workers have more hours of training. As early as 1984, the National Institutes for Mental Health cited observing death, whether death of victim or emergency worker, as the event most likely to have emotional impact on emergency workers. Additional stressors on emergency workers cited include work schedules, having to make split second decisions, and having responsibility for others (NIH, 1985).

Referring to work of Maslach, Stanley and Saxon, NIMH further reports working with people in and of itself is stressful and adding responsibility for well being and/or lives of others is implicated as a source of serious stress in health care workers: (1985). Later research done by Foster (Austin, 1992) indicates most critical is evidence those exposed to severe or repetitive traumatic stress may have more stress related sequelae. All of the these descriptions apply to lifeguards as rescue workers.

Current trends in litigation following aquatic accidents increase the stress factor for lifeguards. According to R.J. Smith (1991), writing for Aquatics International, "our present court system is designed to assume fault for traumatic accidents in any swimming pool must be attributed." Closely related to attribution of fault is payment of damages. Insurance companies are noted for having what Smith refers to as "deep pockets". To get to the insurance company and/or pool owner/operator, if the accident is people related {requiring involvement of a lifeguard as opposed to mechanical), the lifeguard may be named in the legal action and/or called to testify. Whether or not the lifeguard was negligent, the guard, as the first responder, can become involved in litigation.

Annie Clement (1989, p. 2), writing on patterns in litigation in swimming and diving advises "professionals must become aware of the magnitude of the problem presented by litigation in the swimming profession.... Accidents ... have reached limits beyond the comprehension of many professionals." This means--

* A lifeguard may be blameless, but their actions may be questioned publicly for years

* Legal investigation and court testimony will involve repeated reliving of the experience.

* There will be on-going questioning regarding actions taken during the emergency.

While some expressive recounting is healthy, repeated scrutiny at the discretion of others is not conducive to the PTSD healing process.

Issues of age and training also affect lifeguards and influence occurrence of PTSD. The typical lifeguard is between the ages of 16 and 24. Training can occur as early as age 15. This is an extremely young age for individuals to be responsible for life and death situations. Lifeguards can be employed at age 16 with as little as 50 hours of training. This training can take place in as little as one week's time (at a high powered aquatic school). Lifeguard work is often seasonal. While some individuals are career lifeguards and/or lifeguard trainers, primary employment is seasonal in most of the country. Summer employment at camps, beaches, and outdoor pools, after school and weekend employment in community programs during the school year, quarterly employment at large resort and vacation areas to allow for rotating around college schedules are typical patterns. Lifeguards come and go. Rescue workers in more traditional careers stay. Lifeguard training programs give little attention to PTSD. Some do, yes. Many don't.

The lifeguard who jumped from his guard stand and submerged to the bottom of the pool knew his life was in danger. He had already been on duty for over a hour, sitting in his chair, scanning the pool, quickly responding when a young child moved into water that was too deep. He had assisted with a first aid emergency and now he was, for all intents and purposes, in the line of gunfire. He was 16 years old. It was his first summer job after a semester of training at his high school. Actually, he had more training than most first year guards as he did Red Cross CPR-Pro and Lifeguarding in his high school training and then another 40 hours of First Responder training at the local technical college and additional water rescue training provided by the county that employed him. He survived the gunfire, and assisted the other lifeguards and pool staff in handling the emergency. They he returned to his lifeguard post. Life went on. Everything appeared line, but was it?

Recognition of PTSD

It is normal to have emotional reactions to traumatic events. Some people quickly regain emotional health and go on with their lives with no undue side effects. Some people will not recover quickly, experiencing significant emotional upset for one to three months after the trauma. Other individuals may appear to recover and, in fact, lead emotionally healthy lives until some point in the future. At that point they may be involved in another trauma, see representations of a trauma, or experience a triggering event that recalls their trauma thus compromising their emotional stability.

Children and adults experience PTSD differently. Peterson, Prout and Schwartz (1991) discuss the work of several researchers and list several differences between child and adult PTSD.

* Children do not become amnesiac or employ denial of reality or massive repression as adults do. Children report images just pop into their mind.

* Adults experience physic numbing. Children do not; they appear hyper-alert and agitated.

* Children do not experience sudden flashbacks; they consciously choose to remember the trauma or to avoid actively thinking about it.

* Children's school work generally suffers for only a few months after the trauma, in contrast to the long term work problems of many adults.

* Post-traumatic play and re-enactment of the trauma happens more frequently with children.

* Time skew is more common and more dramatically expressed in children.

* Children express a sharp foreshortening of their view of the future.

When do children become adults? We do not have a precise benchmark for that happening. Yes, there are differences between childhood and adult PTSD. These differences put adolescents at particular risk for misinterpreted behavior. Childhood symptoms may include--

* sleep disturbances continuing for more than several days (with or without dreams of the trauma)

* separation anxiety or clinging behavior, including reluctance to return to school

* phobias about stimuli that remind the child of the traumatic event

* behavior disturbances, including problems at home or school that serve as responses to anxiety or frustration, and/or

* doubts about self, including comments about body confusion, self-worth, and desire for withdrawal

Adult symptoms may include--

* recurrent, distressing thoughts about the traumatic event

* recurrent, distressing dreams/nightmares

* recurrent memories of the event, illusions, hallucinations, flashbacks

* diminished interest in significant activities

* restricted range of affect

* psychogenic amnesia 

* avoidance behaviors 

* sleep disturbances

* irritability and outbursts of anger or rage

A lifeguard may be an adult. A lifeguard, depending on his level of psychological maturity, may be a child. Many lifeguards fall somewhere in between.

Following his summer of lifeguarding employment our lifeguard returned to his high school for his senior year. Early in the semester he was observed in the hall giving a very animated explanation of something to a group of students. His voice was loud, his gestures grandiose, his body leaping several feet into the air as his reenacted situation. His speech pattern was rapid. One had to listen closely to keep up. Sentence after sentence after sentence. The narration appeared unending. Eventually, he did wind down and everyone then went on with other things. A week later, a very similar situation took place -- another reenactment. Many of the same students were present. Again high agitation, rapid speech, large, unusual movement patterns took place. While this type of discourse was, the first time it occurred, viewed as different from his normal interaction with others, this time it was even stranger as it was a repeat to pretty much the same audience {and it was not a repeat for it's entertainment value}. Recognizing something unusual was going on here, it was now time to talk privately with the student. Subsequent conversation revealed--

* He was describing a shooting incident at the pool where he had worked that summer (now roughly 2 months ago).

* He did think his life was in danger at the time of the incident.

* He had to assist other guards in handling the incident.

* He was thinking about that incident a lot.

* He was having problems sleeping and not getting a lot of sleep.

* He had left his lifeguard job before the end of the season (he left, he was not tired).

* There were some problems on the job, after the trauma and before he left.

Treatment of PTSD

PTSD is a recognized psychiatric disorder. It is more than the normal emotional upset individuals experience following a crisis. In PTSD individuals usually are not able to recover on their own. Effects are more lasting, for example, than with a grief process.

Diagnosis is complex and requires assessment by specialists trained in PTSD evaluation and treatment. While employers, teachers, family members and/or friends may suspect PTSD, based on the presence of a traumatic event and the individual's subsequent behavior, they are not in a position to diagnosis or treat the condition. When PTSD is suspected employers should make a psychological referral, supplying as much information as possible about the traumatic event, including--

* when and where it occurred

* how the person was involved

* any injuries or deaths

* what the person may have seen or experienced

* anecdotal information on what behaviors the person is exhibiting and under what circumstances.

If treatment is not undertaken, unresolved emotional issues related to trauma can have lifelong psychological consequences. Evident behavior problems will continue. At any point in the future, even years ahead, flashbacks can occur, having additional negative emotional effect. Similar events and/or circumstances can trigger additional emotional problems as well as emotionality loaded flashback situations. Job performance in a similar job setting can be affected as the individual repeats the situation/circumstances in which the trauma occurred in the first place.

Our lifeguard was exhibiting what might be signs of PTSD. He was still very vividly reliving the scenario of a shooting incident at his pool. He felt his life was in danger. This was certainly outside the realm of normal experience. He was present and saw others in life-threatening danger. The main elements of PTSD were present. A week later [probably now the second month of school and three months after the trauma), he brought a knife to school. It was supposed to be for an art project and in this case the actual bringing of the weapon was legitimate. However, when he proceeded to take the knife out during homeroom and brandish it around while making grandiose statements about life/death, his behavior became out of context. In fact, it became so out of context the was removed from school by security and suspended to the system central administrative offices. Prior to this event, this student had an absolutely clean school record. He was an A/B student, responsible, well liked, "normal". Now he was on his way to not being allowed back into school. Many people spoke on his behalf and he was eventually allowed to return. However, nothing was ever quite the same. He was referred to the school psychologist. A teacher who knew about the summer incident did refer him for possibility of PTSD. After hearing the story, the school psychologist met with the young man and did concur with the possibility. PTSD was explained to the student and he also felt this could be what was happening. By this time he was a most unhappy person and knew he did need some help. The next step was involvement of his parents (as he was not yet 18). His parents did not agree. They felt he had made a mistake (in regards to the knife) and that everything else would just "blow over". No amount of effort would convince them additional help was needed for this young man. That is where this situation ended.

Prevention

There is no way to predict who is likely to get PTSD and who isn't. Assume it is possible for anyone. Know the types of events that can precipitate PTSD--

* exposure to a traumatic event that is life or serious-injury threatening, during which an individual experiences a response of helplessness, extreme fear and/or horror -- a successful rescue or a rescue failed, watched and/or participated in

* re-experiencing a traumatic event through dreams, intrusive thoughts, reliving the experience, psychological distress upon exposure to event cues, and/or psychological distress upon exposure to symbols of the event -- re-experiencing the event itself as the guard makes or observes a similar rescue

* persistent avoidance of stimuli associated with it, or a numbing of general responsiveness that was not present before the trauma. -- a lifeguard who no longer wants to do his job, comes to work late or has frequent absence where before no work related attendance problems existed

* persistent feelings of increased arousal not present before the trauma, including sleep disturbances, irritability, difficulty concentrating, hypervigilance and exaggerated startle response -- behavioral changes noticed when comparing the individuals behavior at the start of the season and the post-trauma present

* intensified symptoms when exposed to situations or activities that resemble or symbolize the original trauma -- symptoms which can be triggered not only months but years after the original trauma

Teach staff and particularly seasonal lifeguards about PTSD--

* it's existence as a legitimate illness

* the fact anyone can experience PTSD, through no fault of their own

* the symptoms of PTSD

* treatment possibilities

* the lifelong effects if treatment is not obtained

Implement a three step process for critical incident management (Grosse, 1994, 19951. Accident reporting itself is the first step in management of critical incident stress. As normal part of safety evaluation for any aquatic facility, it is part of the legal process. In addition, accident reporting begins the healing process following critical incident stress. Accident reports, while factual, concise, unemotional, verifiable, and specific, are the first reliving of the trauma, the first venting of thoughts about the incident.

Staff informational debriefings are step two. The American Red Cross (1994) recommends staff debriefings to examine what happened, how the emergency action plan worked, and how to prevent similar incidents in the future. Informational means factual reporting--

* analyzing life-threatening emergencies

* documenting this analysis

* being proactive in taking measures to assure similar incidents to not recur

Staff debriefings, done as soon as possible, are where lifeguards can now hear additional factors regarding the incident which may help in understanding the final outcome. They should be held in a secure area, away from interruption. All information shared is considered confidential. The content of the meeting is addressed objectively -- no attempt should be made to assign blame. Written records of the debriefing should be kept. The ground rules for the meeting should be clearly explained at the outset and a moderator used to keep the group on task. Asking questions is appropriate as along as objectivity is maintained. All staff should be required to participate -- participation does not mean an individual cannot cope, their information is needed and they can supply information needed by someone else.

Critical incident stress debriefings are step three. They are conducted by mental health professionals for benefit of potentially vulnerable individuals. This may include, but not be limited to--

* lifeguard making a rescue

* lifeguard assisting a rescue

* lifeguard on duty when a rescue is made

* bystander observing a rescue

* supervisor/pool manager providing administrative review of a rescue

It may be a threat to their own life, as in a gang violence incident, or threat to the life of someone else, as in a drowning. Involved individuals are, by virtue of the life-threatening nature of the event, vulnerable to post traumatic stress. Whether or not they actually develop post traumatic stress disorder depends, according to Roy-Brisebois (1981), on a variety of factors including the --

* number of crisis events the person experiences

* time span between events (quickly repeating events can lead to "violence overload")

* nature of the incident itself (proximity of the individual, contact with victim, degree of violence)

* quality of work climate (is the work environment already generally stressful due to long hours, boredom of task, endangerment, etc.)

* degree of self-help/positive feelings among employees

* kindness and warmth in home environment

* major events in the individuals personal life (concurrent, outside of work stressors)

Eaton of the Royal Lifesaving Service, U.K.(1990) reminds us "many people suffer a delayed reaction to the events they have witnessed or experienced. Often they may appear outwardly calm during an emergency, yet may later experience a variety of emotions from euphoria to depression and shock." Stress management debriefing is based on the "conception that ventilation or a cathartic experience precipitates the healing process" (Dunning, 1988).

It is done to minimize emotional impact (Wilson, 1993). Debriefing also sets the stage for crisis resolution and successful management of future crises. How well an individual handles a present crisis depends in part upon successful resolution of previous similar crisis situation. If a prior crisis is resolved, successfully learned coping skills are available for the newest trauma (stein, 1988). This is particularly important for lifeguards as they repeatedly face life threatening situations and must at all times respond with peak efficiency

Stress management debriefing is than accident reporting and informational debriefing. While accident reporting and informational debriefing begin the process of stress management they are just that, a beginning. Dunning (1988) documents stress debriefing as having two parts, ventilation of feelings and discussion of signs and symptoms of stress response. Stein (1988) details a five step process--

* introductory explanation of the purposes, steps, and expectations of the

* ventilation of feelings

* information sharing about the disaster, steps being taken to recover, and expected behavior and stress-reaction symptoms

* establishment of feelings of normalcy of emotional reactions and feelings of support and community in the group

* Integration of feelings and information from the meeting

Priest (1992), synthesizing work of several researchers, outlines a seven step process--

* Introduction -- discussing confidentiality, setting the stage that this is not an operations critique, and expressing one purpose being to restore routine.

* Fact phase -- describing what happened.

* Thought phase -- describing what individuals think about what happened.

* Reaction phase -- describing what the worst of the situation was.

* Symptom phase -- describing stress symptoms individuals might experience during and after the incident.

* Teaching phase -- providing stress reduction information

* Re-entry phase -- question asking by the group.

According to Dunning (1988), one or two session group debriefings have been widely described as a formal way of reviewing events and understanding them, as well as a way of educating individuals about possible psychological consequences of traumatic stress. A follow-up debriefing session is recommended for several weeks after the critical incident to address any lingering concerns or problems voiced by the group or by individuals (Dunning, 1988).

Stress debriefings validate emotions. Helping people recognize and deal with their emotions facilitates healing. Stress debriefings also educate individuals in recognition of post traumatic stress disorder potentials and symptomology. Debriefings are not an end in or of themselves. Stress debriefings are not judgmental. They are not involved with fault finding, nor are they investigatory. No participant should feel threatened or evaluated. While participation should be voluntary, the very existence of stress debriefings should be a regular part of every aquatic facility's emergency action plan.

Critical incident management begins with training aquatic staff to recognize and respond to emergency situations. It concludes with accurate accident reporting, insightful informational debriefing and meaningful stress debriefing. Educating aquatic personnel to all aspects of critical incident management before a life-threatening emergency occurs helps ensure prompt and appropriate response in time of crisis. It also facilitates resolution of job related stress and supports on-going mental health of each and every member of a facilities aquatic staff.

Characteristics of the seasonal staffing situation work against mental health. Employment is only for a few months. Seasonal staff may not be legally adults. Staff may not even remain in the community after employment. Symptoms may not occur until after the individual leaves the job. Seasonal staff may be supervised by other seasonal staff. Variable hours make it difficult gathering everyone for debriefings. There is no formal support system for comparison of behavior.

Societal attitudes about mental health work against prevention and treatment. We are supposed to be able to handle stress. Seeing mental health professionals is a stigma. Obtaining treatment for a minor required parental consent. Employers of seasonal staff may not be equipped to handle PTSD.

Implications for the Aquatic Industry

It is imperative employers include information on PTSD in preseason and in-service training for lifeguards. The attention and emphasis given this topic during initial lifeguard training is not enough. Most lifeguards in training think a critical incident will not happen to THEM. Discussion of PTSD is a very minor part of training and rarely remembered.

Employers must include PTSD training and critical information stress management training in requirements/training for aquatic managers. These people are in a position of directing lifeguard activities after a critical incident. These management individuals also are charged with monitoring job performance and in doing that monitoring, they may be the first to see signs of incident stress.

Each facility should have a file of both printed and personnel resources to call upon following a trauma. This might include personnel in university programs in PTSD, municipality programs for other types of rescue workers, or the local Red Cross.

Employers must make the three steps of critical incident stress management mandatory for all employees following a traumatic event. Staff should not be expected to volunteer or request PTSD management. It should be there, in place for them, ready to implement.

Every aquatic facility owner/operator must develop a treatment referral system model for use by employers of seasonal lifeguards, including procedures for getting assistance after leaving the geographic area. Responsibility does not end at the conclusion of the season. A person's mental health is forever!

Within the aquatic workplace, employers must encourage a supportive and rehabilitative atmosphere. The traumatized guard often must return to work immediately. It may be useful to include vigorous physical activity at the outset. It may be helpful to have additional emergency response drills to review mastery of skills, increase individual control over circumstances, and to reduce fear of incompetence. Employers must also support everyone's participation in the debriefing process.

The aquatic industry must reevaluate age criteria for lifeguard training and employment. Adolescence is a particularly vulnerable time relative to PTSD. Symptom differences between childhood PTSD and adult PTSD make diagnosis difficult. Necessary parental involvement makes treatment harder. All of these factors indicate against the large responsibility places on the 16 year old lifeguard.

The industry must also support ongoing professional treatment for individuals seeking counseling referral for PTSD symptoms. This includes research into lifeguard PTSD. Much is needed. We cannot continue to rely on extrapolation from research on other populations of rescue personnel. We should be taking care of our own!

Our young lifeguard, following the shooting event, did participate in the initial accident reporting and staff debriefing at the pool where the incident occurred. Then he left employment. After his incidents at school, contact was made with his seasonal employer who documented events had occurred pretty much as the guard had reported. The employer was very understanding and offered additional critical incident stress counseling. The guard declined the offered indicating he would be more comfortable continuing with the mental health referral offered through the school system. Everything was in place -- but the parents did not agree. At that time, and for the rest of the school year, the lifeguard received no further help. Following school graduation, the lifeguard left the jurisdiction of the school and like many seasonal lifeguards, has not been heard of since.

Resources

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American Red Cross (1994). Lifeguarding today. St. Louis, MO: Mosby-Lifeline.

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Brunstein, S. & Kilpatrick, M. (1988). Counseling survivors of workplace accidents & disasters, in Gould, G. & Smith, M. eds. Social Work in the Workplace. New York, NY: Springer.

Clement, A. (1989). Patterns of litigation in swimming and diving. National Aquatic Journal, 5:1.2-5; Winter.

Eaton, D. ed. (1990). Lifesaving. Studley, Warwickshire, England: Royal Lifesaving Society.

Ellis & Associates. (1994). National Pool and Waterpark Lifeguard/CPR Training. Boston, MA: Jones & Bartlett.

Ersland, S., Weisaeth, L., & Sund, A. (1989). The stress upon rescuers involved in an oil rig disaster; "Alexander L. Kielland" 1980. Acta Psychiatrica Scandinavica 353:80, 39.

Eth, S. (1992). Clinical response to traumatized children, in Austin, L. Responding to disaster -- a guide for mental health professionals, Washington, D.C.: American Psychiatric Press.

Foster, Pl. (nd). Nature and treatment of acute stress reaction, in Austin, L. (1992). Responding to disaster -- a guide for mental health professionals,. Washington, D.C.: American Psychiatric Press.

Frederick, C. (1985). Selected Foci in the Spectrum of Post-Traumatic Stress Disorders. in Murphy, S. & Laube, J. (eds). Perspectives on disaster recovery. New York, NY: Appleton-Century-Crofts.

Freedy, J., Resnick, H., & Kilpatrick, D. (1992). Conceptual framework for evaluating disaster impact: implications for clinical intervention. in Austin. L. ed. Responding to Disaster: A Guide for Mental Health Professionals. Washington. D.C.: American Psychiatric Press.

Grosse, S. (1995). Incident stress management is critical. Aquatics International, 7:2, 8-9.

Grosse, S. (1994), Lifeguarding and post traumatic stress. National Aquatic Journal 10(1), Winter.

Grosse, S. (1996). PTSD: a primer for teachers. Delta Kappa Gamma Bulletin. 62:3, 33-38.

Hyman, I.A. (n.d.). Post-traumatic stress disorder in children and youth: understanding trauma and grief and what to do about it, patent and teacher handout. Washington, D.C.: National Association of School Psychologists.

Hytten, K. (1989). Accident simulation as a new therapy technique for post traumatic stress disorder. Acta Psychiatrica Scandinavica. 355:80.

James, B. (1989). Treating traumatized children: new insights and creative interventions. Lexington, MA: D.C. Heath.

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National Institutes for Mental Health (1985). Role stressors and supports for emergency workers. Rockville, MD: Center for Mental Health Study of Emergencies, United States Department of Health and Social Services.

Nealy, S. (1993). Making the difference: essentials of effective lifeguarding. (video) Los Angeles, CA: R.J. Ross Productions.

Peterson, K.C. (1991). Post-traumatic stress disorder: a clinician's guide. New York, NY: Plenum Press.

Priest, L, (1992). Critical incident stress: neglected syndrome in aquatics. National Aquatic Journal. Spring, 8(2), 11-13+.

Raphael, B., Seng, B., Bradbury, L. et. al (1983). Who helps the helpers? the effects of disaster in rescue workers. Omega 124:9-24 in Austin, L. (1992). Responding to disasters -- a guide for mental health professionals. Washington, D.C.: American Psychiatric Press.

Roy-Brisebois, U. (1981). Victim assistance: an example of meeting, work-related needs of employees, in Wickstrom. Industrial Social Work Practice. Toronto, Ontario: Family Service Canada.

Smith, R.J. (1991). Don't throw out the baby with the bath water. Aquatic International, 3:2, 4; March/April.

Taylor, A. (1989). Disasters and Disaster Stress. New York, NY: MAS Press.

United States Lifesaving Association (1993). Guidelines for open water lifeguard training and standards. Hunting ton Beach, CA: The Association.

William's, C. (1987). Peacetime combat: treating and preventing delayed stress reactions in police officers, in William's, T. Posttraumatic stress disorders-a handbook for clinicians. Cincinnati, OH:

Disabled American Veterans. Wilson, J. & Rappel. B. (1993). International handbook of trauma stress syndromes. New York, NY: Polonium.

YMCA of the USA. (1994). On the guard. Champaign, IL: Human Kinetics 

Susan J. Grosse, MS, Aquatic Consulting and Education Resource Services, has a certificate in trauma counseling from the University of Wisconsin-Milwaukee. She has been an instructor of lifeguarding for the past 37 years and an American Red Cross Water Safety instructor trainer for 26 years. She has published over 25 aquatic related articles at the national and international levels, with topics ranging from adapted aquatics to waterfront safety. Her work can be found in such publication as Aquatics International, Sport & Dance Journal, and National Aquatic Journal. Her article about Post Traumatic Stress Disorder exemplifies her broad background and can be found on page 60.