In a previous article, we examined how psychological first aid could help OH practitioners ensure the wellbeing of employees in crisis. In this article, Dr John Durkin looks at supporting employees who have experienced a traumatic exposure.
Occupational health practitioners frequently find themselves on the front line dealing with traumatised employees. In contrast to rushing in to manage trauma on behalf of those affected, Rutter (2012) takes Tehrani's (2011) view that empowerment rather than treatment is most likely to increase a worker's resilience. Empowerment is achievable through a structured and supportive conversation designed to reduce distress, where talking through the trauma with others can give the employee support, education and encouragement.
At an organisational level, a comprehensive strategy for dealing with an unforeseen crisis would also include the employment of critical-incident specialists. However, the professionals who might be deployed to meet the acute needs of an organisation's personnel are likely to play a lesser role in the response than the senior staff at the organisation. If managing trauma is to be dealt with through empowerment rather than treatment, what should those senior staff be doing in readiness for a crisis?
In this regard, there are a number of options available, including: psychological first aid (PFA)(Rutter, 2012); crisis intervention techniques such as defusing, debriefing and demobilisation (Everly, Flannery and Mitchell, 1999; Mitchell, 1983; Tehrani, 2004); and traumatic incident reduction (TIR)(Gerbode, 1988), an evidence-based approach amenable to non-mental-health professionals.
PFA relies upon social support of various types - the long-standing literature of evidence for social support in alleviating distress makes PFA commendable. Similarly, crisis intervention techniques enable peers within the workplace to be trained in basic counselling and listening skills to apply social support in a structured and practical way to both individuals and groups at various times in the aftermath of a crisis. The application of TIR is possible any time a one-to-one meeting can be arranged.
Collectively, these techniques provide several options to senior staff responsible for managing a critical incident. However, the pursuit of a strictly evidence-based approach may not be straightforward.
Psychological debriefing
Prior to the publication of a Cochrane Review that reported two critical evaluations of psychological debriefing (Rose, Bisson and Wessely, 2001), organisations with personnel trained in crisis intervention would have relied upon peer support to manage traumatic reactions in staff.
The use of techniques such as defusing and critical incident stress debriefing (CISD), originally designed for firefighters and paramedics (Mitchell, 1983), were efficient and cost-effective ways of rapidly reducing distress and encouraging a supported return to work. But when the Cochrane Review was endorsed in the National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of post-traumatic stress disorder (PTSD) (NICE, 2005), many organisations believed it was no longer appropriate to continue with debriefing, which had until then been a highly valued crisis intervention.
It has now been established that the studies in the Cochrane Review warning against the use of psychological debriefing were fundamentally flawed (Hawker, Durkin and Hawker, 2011). Hawker and her colleagues raised concerns about the methodology used to investigate debriefing and challenged the conclusions of the critical studies. Many health practitioners, including OH practitioners, who are confident of the benefits of debriefing have continued to use crisis interventions including debriefing to manage the aftermath of critical incidents - some have justified their actions by changing the name of their intervention.
Rutter's advice to use critical-incident specialists as a rapid response to a potentially traumatising event shows some OH practitioners' belief in their organisation's staff to move themselves beyond crisis.
Providing PFA or crisis intervention through formal peer support or informal social support presents an opportunity to empower those affected through expertise from specialists that allows them to monitor and verify the positive outcomes that would be anticipated.
Peer support
Some benefits of peer support are implicit in the term, as work colleagues are familiar with the culture, unwritten rules and common fears implicit in the organisation.
Take a firefighter, for example, who has a dread of incidents involving the death of children. This dread is understood best by a colleague who has a common understanding and appreciation of the difficulties when such an incident arises. In any situation involving children, other firefighters doing the same job in the same workplace are likely to be harbouring similar fears and will identify sympathetically with their colleague's situation. This brings a familiarity and intimacy to the aftermath that is unlikely to be achieved by outsiders, regardless of their expertise. An approach that is amenable to peer support provides a great advantage in enabling a trauma sufferer to talk about something they may initially find unspeakable.
Having worked in CISD teams with police officers in New York following the 9/11 attacks, I can recall witnessing sudden enlightenment and resolution to painful memories in trauma-affected police officers. While debriefing and other interventions are in common use in other countries (Lopez Levers and Buck, 2012), the UK is left not quite knowing how to support its traumatised workers.
Traumatic incident reduction
One of the alternative approaches available to OH practitioners is TIR, a person-centred approach to addressing psychological trauma without the need for practitioners to possess any clinical or academic qualifications.
It can be adopted by practitioners who are familiar with critical-incident stress management, psychological debriefing and psychological first aid.
Despite the seemingly low level of expertise required to become competent, TIR has already met the criteria for being "evidence based" with the mental health authority in the US, where in May 2012 the Substance Abuse and Mental Health Services Administration (SAMHSA) listed TIR as the latest approach to dealing with psychological trauma. SAMHSA is the US Government's health department that publishes evidence-based approaches to mental health conditions, a similar role to NICE in the UK.
There are benefits to adopting TIR beyond the economic and social advantages that come from using an approach that can be delivered by a OH practitioner rather than a clinical psychologist or psychiatrist. It has been shown to be effective in helping people recover from a number of conditions, including PTSD, anxiety and depression (Valentine and Smith, 2001). Significant improvements were also reported in perceptions of future personal success with this approach. If empowerment is facilitated by TIR, the anticipation of a positive personal future would be no surprise.
It is clear that TIR does not merely suppress symptoms, but instead resolves the underlying issues causing the symptoms to arise. This is achieved by the persistent and self-motivated retelling of the trauma story until emotional processing is achieved.
Each TIR session is devoted to a single trauma or series of traumas, and no time limit is placed on the length of the session - although any given session is unlikely to last more than three hours.
Practitioners can be trained in TIR in days and supervised over months, which allows a busy OH professional the opportunity to become trained themselves so that skills are at hand whenever needed.
Those already competent in the use of crisis intervention techniques are well suited to using TIR as an adjunct to other techniques. Importantly, however, where psychological first aid, crisis intervention or a simple interview is used to screen for signs that assessment and treatment may be required, TIR requires no more than an individual's interest in their own reaction to be of use.
Conclusion
The use of crisis intervention techniques in the workplace began with firefighters and paramedics in the US after the introduction of CISD (Mitchell, 1983).
Since then, its popularity and the wisdom of its widespread use have been challenged through randomised controlled trials (RCTs) undertaken by psychiatrists and psychologists testing their own form of debriefing on hospital patients. But advocates of crisis intervention and my own experience of using CISD among police officers post-9/11 in New York show that when using these techniques, crisis resolution within hours is possible where protocols are followed and the sessions allowed to conclude at their optimal time.
Implicit in accounts of success is empowerment, the preferred objective that Rutter advocates and a familiar state for those competent in CISD and other crisis intervention tactics. There are several crisis intervention options that lack RCT evidence that are nevertheless soundly based in theory and successfully applied in practice.
It is for the OH practitioner to weigh experts' evidence against personal experience in deciding which option to take. The arrival of TIR on the crisis intervention scene brings an exciting alternative to clinical treatment, as it carries RCT evidence acknowledged by SAMHSA.
It seems inevitable that NICE will follow suit and include TIR alongside cognitive behavioural therapy, eye movement desensitisation and reprocessing, and drugs for treating PTSD. However, unlike the therapies currently accepted by NICE, TIR is not restricted to symptom management - it seeks trauma resolution.
How much more empowering could it be for an individual expressing their feelings of being disabled by catastrophe to dry their eyes, smile and know that it is "all behind them"? How much more empowering is it for the OH practitioner or TIR-trained peer to facilitate that? And how much more empowering is it for the organisation to know that it can handle its own crises without expensive referrals, extensive treatment and potential litigation regarding neglect? If Rutter's call for seeking empowerment over treatment is to be heeded, TIR represents an evidence-based way of achieving it.
Dr John Durkin is a psychologist specialising in post-traumatic growth. He delivers training in traumatic incident reduction and is an academic board member of the Faculty of Applied Trauma Psychology
References
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