institute for employment studies
publications by IES authors
free Acrobat Reader for PDF files
From Accidents to Assaults
How organisational responses to traumatic incidents can prevent Post-traumatic Stress Disorder (PTSD) in the workplace
Rick J, Young K, Guppy A
Contract Research Report 195/98, Health and Safety Executive, November 1998
Since the beginning of the century there has been a growing awareness of the psychiatric impact of certain severe stressors on an individual’s ability to function effectively, in both their personal and professional lives. In more recent years, attention has been focused on the psychological consequences for those exposed directly to, or working in the aftermath of, extremely traumatic incidents.
The pattern of harm which follows traumatic events has to some extent been charted, and in 1980 the term ‘post traumatic stress disorder’ (PTSD) was adopted to describe the pattern of symptoms.
Attention quickly turned to developing responses to minimise further psychological harm, post-trauma. However, different research approaches in different settings have produced varying findings on just how effective certain types of response are. As a result, there is little persuasive evidence about which responses work best.
|
Primary research objectives:
|
With this in mind, the Health and Safety Executive commissioned a research project to help clarify these issues and to determine whether sufficient is now known to offer employers guidance on best practice.
What is PTSD?
PTSD is the term commonly used to refer to the reactions that some people experience in the aftermath of an extreme incident.
Normal reactions to extreme events
It is to be expected that people who have been exposed to a traumatic event will show some reaction in the immediate aftermath. Extreme reactions in most people during the first two days following an event are normal. Some may go on to experience traumatic symptoms for several weeks after an incident, but by four to six weeks following an incident, most people will recover.
Research suggests that between 10 and 30 per cent of people exposed to a traumatic event will go on to experience a range of traumatic symptoms in the longer term.
PTSD and traumatic symptoms
A diagnosis of PTSD is complex and only a very few are likely to fulfil all the criteria for diagnosis. Many more of those affected in the longer term are likely to experience some (though not all) of the symptoms associated with traumatic experiences.
There are two sets of criteria currently available for making a diagnosis of PTSD. There are differences between these, but they both describe the following clusters of symptoms:
- persistent re-experiencing of the traumatic event (flashbacks)
- avoidance of any reminders of the event, feelings of emotional detachment or numbness
- increased arousal (eg an exaggerated ‘startle’ response, or hyper vigilance)
Normally a diagnosis of PTSD is only considered if an individual has experienced symptoms from all three categories for at least a month following a traumatic event.
|
In understanding the impact of a traumatic event, it is important to consider all those who may experience traumatic symptoms, not only the few cases that result in a diagnosis of PTSD. |
What causes PTSD?
Although it took the Vietnam War to generate a large volume of research into post traumatic stress reactions, the impact of death and disaster upon human beings had been noted throughout history.
We normally think of PTSD as only occurring after highly traumatic or distressing incidents, such as the Hillsborough disaster, the Lockerbie plane crash or the Omagh bombing. Early research in the area tended to support this view by focusing on people whose jobs were more likely to put them at risk, eg emergency service personnel and soldiers with combat experience or by studying the reactions of people who had experienced extreme disasters.
However, more recent research clearly shows that people can experience traumatic symptoms in relation to far more everyday occurrences (eg assaults, car crashes or accidents). Although these reactions do not always lead to a diagnosis of PTSD, the trauma symptoms that individuals experience can be severe enough to affect people’s day to day lives and their ability to work.
|
This emphasises the need for employers to give careful consideration to the threats that exist within their workplace and to undertake thorough risk assessment in relation to psychological as well as physical factors. |
Why does it matter to organisations?
Two reasons of major importance should prompt organisations to be concerned about trauma. The first (and by far and away the most important amongst our case study organisations) was concern about the ability of staff to function on both a personal and a professional level following an incident. A secondary concern was that of the legal implications for an organisation following a traumatic incident.
In fact all industries have employees at risk. For example, experiencing an injury/accident at work can occur in any job, as can witnessing such an event to a colleague, which could in turn lead to the experience of PTSD or traumatic symptoms. Hence, although it is possible to identify several occupational groups within the research literature where some form of data on post-incident reactions is available, this by no means represents the sectors more at risk, simply those where research has been done in the past.
There is wide variation in the probability and severity of traumatic incidents across different occupational groups. This makes comparison virtually impossible. Certain jobs have known and repeated traumatic events (for example, in the financial sector where the majority of incidents are bank raids or across-the- pavement attacks). Other jobs may regularly involve exposure to a wide range of extreme events (for example, those in the emergency services) and many jobs will involve contact with the public (for example, the public sector and the health sector). In occupations such as these, staff may accept frequent threats, or even violence as part of the job and not report incidents at their true frequency. However, research suggests that the majority of assaulted employees will display typical trauma reactions.
Other types of experience that can give rise to trauma symptoms apply to a wide range of different jobs. For example, road traffic accidents (RTAs) are likely to affect a large number of employers, although the effects are distributed over a wide range of occupations. The UK, despite dramatic reductions in annual fatalities over the last ten years, still records around one-quarter of a million injurious road accidents per year, with around 4,000 fatalities. With a prevalence such as this, it is no surprise that a substantial number of PTSD cases have been identified in association with such incidents and that RTAs represent large potential for incident-related trauma for both general and working populations.
How do organisations manage trauma?
The organisations which formed our case studies were involved in a range of activities aimed at both assessing risks and minimising the likelihood of an incident, as well as providing support and aftercare.
Pre-incident activities
Many case study organisations are minimising risk and empowering staff in a number of ways. Activities fell into four broad categories:
- security measures
- training to prevent incidents
- training to manage incidents
- education of the possible consequences of incidents.
On the whole, the case study organisations in this research recognised the importance of educating and preparing staff as much as possible, in terms of what to expect if an incident occurs at work. This was seen to have positive outcomes in terms of lessening the impact of an incident should it occur, and enhancing individual coping skills which could help to protect the employee from further psychological damage.
The clear message here was rehearsal of procedures and that ‘good practice is to practice’.
Managing after the incident
Two forms of response were widespread amongst the case study organisations participating in this research:
- diffusing (or defusing)
- debriefing
1. Diffusing after trauma
‘Diffusing’ is the term generically used to describe employees getting together after an incident to discuss and make sense of what has happened. In many instances this is a naturally occurring phenomenon, although in some cases diffusing has been formalised and managers trained in running diffusing sessions.
Whatever the nature of the incident, however long the duration, ‘diffusing’ is almost uniformly the first line of response. In many cases there was no formal diffusion training. Several interviewees said that they had always done this — before they had ever heard of diffusion.
Where diffusing was a more formalised process, the aims tended to vary slightly from organisation to organisation, but could be broadly summed up as follows:
- to help staff come to terms with what has happened
- to offer reassurance and support
- to explain the subsequent help that is available should it be required.
In many situations, diffusing happens informally, without the benefit of any training, but appears to play a critical role in the process of allowing staff to discuss and review, or make sense of what has happened.
|
Diffusing From the perspective of the case study organisations, we can conclude that the importance of diffusing should not be underestimated. |
2. Debriefing after trauma
By far the most commonly used form of post-incident intervention found amongst our case study organisations was that of psychological debriefing. Debriefing was first developed as a response to trauma in the early eighties. It was originally developed for use with teams of emergency personnel and is now applied in a wide range of UK organisations. ‘Debriefing’ describes a structured group process for reviewing traumatic events. Although the original protocols for debriefing were quite strict in identifying, for example, the timing of a debriefing sessions and who should attend, many different approaches to debriefing had been developed within the case study organisations. For example:
- debriefing was used both in groups and with individuals
- the models used were often adapted to the needs of the individual organisations
- there was much variation in the timing of a debrief after an incident had occurred
- in some organisations, attending debriefing is mandatory, in others it is on a voluntary basis
- in some organisations debriefing is open only to those directly involved in an incident, in others it is open to (or mandatory for) all staff in an affected office.
In fact, there were only two similarities that were consistent in the way that all organisations undertook debriefing:
- the belief that in some way debriefing would lessen the likelihood of subsequent traumatic symptoms
- that the debriefing process itself involved at some stage intense re-exposure to the incident.
In fact, whether debriefing meets its stated objectives of reducing traumatic symptoms can be difficult to evaluate and only a very few studies have been completed to date. Findings from these studies have been mixed, with some studies suggesting that at best debriefing has no benefit (in reducing traumatic symptoms) and in some circumstances could possibly be harmful.
|
Debriefing The jury is still out on the subject of debriefing and more research will be needed to establish whether or not it works in different settings and whether or not it is suitable for all people. |
Although debriefing has not been proven to reduce traumatic symptoms, there were found to be many other benefits associated with its use. Possibly the most important amongst these were the management systems for dealing with incidents and allowing staff the opportunity to talk to each other about their experiences and make sense of what had happened.
This raises the issue of whether organisations are trying to manage or treat trauma symptoms. It highlights the need for organisations to have clear and realistic aims set down for any intervention that they propose to use, and for them to constantly monitor or evaluate the outcomes against the stated objectives.
The case study organisations visited had in place many exemplary practices and procedures for managing trauma in the workplace. A key aspect of this good practice is that it was rare to find one initiative working alone. In virtually all organisations visited, there were a package of measures in place, including risk assessment, selection and recruitment measures, training and education, rehearsal of critical incident procedures, clearly defined practices and policies for managing incidents wherever possible, clear guidance on dealing with the immediate aftermath of an incident, as well as longer term support for employees. All of these approaches, adapted to differing organisational needs, serve to reduce the likelihood of incidents occurring and to minimise the harm when they do.
Also available:
Workplace Trauma and its Management: a review of the literature, Rick J, Perryman S, Young K, Guppy A, Hillage J. HSE Contract Research Report 170/98. May 1998. ISBN 0 7176 1552 9. £44.00
Both reports may be purchased from HSE Books, PO Box 1999, Sudbury, Suffolk CO10 6FS. Telephone: 01787 881165. Fax: 01787 313995.
Health & safety enquiries:
HSE InfoLine, tel. +44 (0)845 345 0055, or write to:
HSE InfoLine, Caerphilly Business Park, Caerphilly, CF83 3GG, UK
HSE Contacts Page
From Accidents to Assaults: How organisational responses to traumatic incidents can prevent Post-traumatic Stress Disorder (PTSD) in the workplace, Rick J, Young K, Guppy A. Contract Research Report 195/98, Health and Safety Executive, 1998.
ISBN: 978-0-71761-631-2. £32.50
1998 © institute for employment studies About this site