The Grenfell Tower fire and the latest terror attacks in London, Manchester and Barcelona have focused media and public attention on how people react to traumatic incidents. They have also led to increased scrutiny of how organisations and society can best protect those affected from long-term psychological damage.
Though terrorist action has become more widespread in the west, the chances of any individual being directly exposed remain rare, but workers in some organisations, such as the police, military, emergency services or the media, routinely deal with traumatic incidents as an integral part of their jobs. And even those employed in businesses that may not immediately spring to mind as trauma-exposed can experience one-off incidents -- such as workplace fatalities, threats of violence and road traffic accidents.
Most people do not suffer long-term psychological effects after a serious incident, but some inevitably experience temporary distress and a smaller proportion develop mental health disorders (including post-traumatic stress disorder -- see "post-traumatic stress disorder" box below). However, organisations can adopt procedures for staff who may be at risk as well as support should there be an incident.
"For any organisation, whether staff are exposed to trauma predictably or not, the best advice is to try to foster an environment in which there is good support available and good trauma-informed leadership," says Neil Greenberg, professor of defence mental health at King's College London and past president of the UK Psychological Trauma Society (UKPTS). "It's actually the same things that work for good mental health generally."
The guidelines on post-traumatic stress disorder (PTSD) from the National Institute for Health and Care Excellence (NICE) are a good starting point and quick reference guide for what works and what doesn't (www.nice.org.uk/guidance/cg26).
"[The guidelines] highlight that we have historically over-medicated people who have suffered trauma," says Andrew Kinder, professional head of mental health services at Optima Health. They give tips on how to recognise PTSD, warn about the lack of evidence for drug-based treatments and recommend psychological therapies.
There might be a big contract coming in the next day but, if something traumatic happens, you may need to delay that
Kinder adds: "The guidelines are also clear that single-session mandatory debriefing, where you re-expose people to trauma and what they were thinking, feeling or doing, is not advisable. Instead, they recommend 'watchful waiting' and monitoring people over four weeks to see if through natural processes -- social support, exercise, being with family and work colleagues -- the effects gradually dissipate. If someone doesn't settle down during that time -- even after a week or two -- that's when you need to look for further specialist help."
A common mistake organisations make, usually with the best intentions, is to draft in a team of outside counsellors, often at great expense, immediately after a traumatic event, to provide every member of staff with counselling.
"Phoning the employee assistance programme (EAP) provider and asking it to bring in counselling for everybody is not just a waste of money, it actually has the potential to make things worse," says Greenberg. "Instead of doing that, the role of the psychological health expert, from your EAP or elsewhere, is to come in and help your management team and your supervisors create an atmosphere where everyone is going to support each other, and to get people talking and keep an eye on how people are doing."
Post-traumatic stress disorder
According to the National Institute for Health and Care Excellence, post-traumatic stress disorder (PTSD) develops after "a stressful event or situation of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone".
Statistics suggest that around 25-30% of people experiencing such a traumatic event may go on to develop PTSD. Symptoms often develop immediately after the event but in some sufferers (less than 15%) the onset of symptoms may be delayed. The most characteristic symptoms of the disorder are:
re-experiencing aspects of the traumatic event, including flashbacks, nightmares, repetitive and distressing intrusive images or other sensory impressions
avoidance of reminders of the trauma, including people, situations or circumstances resembling or associated with the incident -- people with PTSD often try to push memories of the event out of their mind; others may think excessively about why something happened to them or how it could have been prevented
hyperarousal, including hypervigilance for threat, exaggerated responses, irritability, difficulty concentrating and sleep problems
emotional numbing, including lack of ability to experience feelings, giving up activities previously enjoyed, and amnesia for significant parts of the traumatic event.
Kinder says people who are experiencing trauma for the first time and are unaware of the effects may need particular care: "If someone has had a trauma and never had any psychological issues in the past, or experienced anything similar, they might be having flashbacks, vivid nightmares, night sweats, mood swings, blaming themselves, and asking 'what if' questions. But those symptoms are in a way a normal response to an abnormal situation, so educating people about that actually gives some reassurance."
A principal function of post-trauma support is to provide clear information which helps normalise people's emotions and reactions. In this context, team support is vital. "The shared experience gives a sense of togetherness and shows that others also share their emotional reactions," says Kinder.
Greenberg adds: "At the heart is the question, 'What does this trauma mean for me?' Many people think they are going mad or they are the only one affected. Yet talking with colleagues has been shown time and again to be the most effective way to make sense of what happened."
The "watchful waiting" approach certainly does not mean doing nothing. It requires keeping a careful eye on individuals who have been exposed to the event, not just those who were "there" but people who might feel responsible or had to help in the aftermath.
"What you need to do is make sure the team is incredibly supportive," says Greenberg. "It might be that there is a big contract coming in the next day but, if something traumatic happens, you may need to delay that and focus on staff, just for a little time, because, if you do that, it will pay huge dividends down the line if people don't become ill. All the evidence is very strong around that. Those immediate actions make a substantial difference."
Camaraderie and cohesion
Evidence from military studies shows the role of supervisors or team leaders is vital.
"If you are looking for a bang-for-buck investment for prevention, the best way is to make sure you select trained supervisors, particularly in those teams where there is a predictable trauma exposure," Greenberg says.
"If you look at the junior supervisor -- that's the sergeant in military terms or the team leader in an organisation -- they are the key. It's not what the colonel or the chief executive thinks, but what the supervisor thinks. You need a supervisor that is savvy about mental health, trauma and the potential impacts, and is seen as a supportive leader. The evidence shows that people who work in a team like that suffer as little as one-tenth the rate of trauma-related mental health problems as those whose supervisor's attitude is, 'We don't get problems in our team'."
Camaraderie and cohesion make a big difference, Greenberg adds: "What we suggest is that, where you have incident exercises or table-top exercises -- even a fire alarm test -- it shouldn't be just about whether you can follow the procedure; it's also an opportunity for people to bond in a trauma environment, so use those sort of exercises as a way to reinforce trauma-related social support." In a fire exercise, for example, it might be useful to talk about what would happen if someone hadn't left the building in time. Talk it through and give it context."
Kinder advocates factoring trauma into wider mental health programmes and strategies. "If you are doing mental health training more broadly, you can talk about reacting to an incident, whether that's a suicide, a workplace accident or a terrorist event," he says.
Trauma risk management (TRiM)
TRiM, which uses a peer support approach to managing trauma, started in the UK Royal Marines and has been developed over more than 20 years in the British armed forces. It is now used in many other trauma-exposed organisations, including fire and ambulance services, the Foreign Office, the police, the BBC, and other workplaces where employees deal with trauma as part of their routine work.
The approach incorporates the "watchful waiting" method as recommended by the National Institute for Heath and Care Excellence (see main text) and is designed to identify people at risk after traumatic incidents -- it is not a therapy or medical intervention but focuses on building resilience and providing support and education.
TRiM practitioners, usually from junior management positions, are trained how to spot signs of distress, such as detachment, that may otherwise go unnoticed. They also carry out TRiM assessments -- up to three 28 days apart -- and signpost people to further support if required. Because practitioners are based at an operational level, TRiM can help destigmatise mental health problems and encourage people to ask for help.
Many trauma-exposed organisations use a peer-support model known as TRiM (see "Trauma risk management" box below), which enables frontline workers, whether they are emergency first responders or train drivers, to have structured conversations about trauma. "It's putting trauma awareness at grass roots level," says Greenberg, "rather than keeping it all in experts' [hands] or maybe in an occupational health professional who has done a course. That professional support is great too but it needs to be at a frontline level as well, particularly in organisations with a highly predictable trauma exposure hazard."
Somewhere between half and three-quarters of people who have trauma-related mental ill health shun help. "Because of this we have to be absolutely positive about going out and asking people, and that's why a support system like TRiM or another active monitoring process makes the difference," says Greenberg.
"TRiM is not penicillin for trauma; it doesn't stop people becoming unwell but it's a credible way forward. There is good evidence that it makes a difference, helps to mobilise social support and also -- in that 'watchful waiting' way -- for people who four, six, eight weeks on are still having difficulties, helps them get the professional help they need."
Kinder cautions that, though peer supporters are more familiar with colleagues and know the organisation, they could feel overburdened or try to intervene more than required. "With things like TRiM, if you are dealing with a difficult situation, you may absorb some of that and may lack back-up and support yourself," he suggests. Good systems, however, should allow for that risk and ensure they provide the necessary support, perhaps from trauma specialists.
When trauma-exposed organisations are looking at strategies for preventing ill health, the question of pre-employment screening often arises. Greenberg says: "Many organisations think they need to screen people, so we are only taking people into these roles if they can pass some psychological test. Alternatively, they will employ a psychologist at great expense to assess everyone to make sure they won't develop problems. But this doesn't work. There is no evidence that you can screen someone in relation to their propensity to develop a trauma-related mental health problem."
The main reason screening does not work is that the biggest impact on whether someone will become ill after a traumatic event is not their history or background or whether they have been ill before.
"It's not even how nasty the trauma was," says Greenberg. "The biggest factors by a long way are the things that happen after the event: the support that someone gets in the immediate aftermath and how much stress or pressure they're put through as they're trying to recover."
Screening after an incident to try to spot mental health problems is also ineffective, he adds. People will not answer the questions properly "because they are unlikely to speak openly about mental health problems in their organisation".
As well as peer support and keeping an active eye on people, it is important to create an environment in which people feel safe to voice concerns or problems. This can be the hardest part of any mental health strategy but the evidence suggests that cultures can change.
"We've measured that [openness] within the British military since 2008," says Greenburg, "and [reticence] has not gone away but there has definitely been a year-on-year decrease in the level of reported stigma. People say they are more willing to talk about their problems."
Never too late
The two main categories of specialist treatment for those identified as having problems are trauma-focused cognitive behavioural therapy (TF-CBT) and eye-movement desensitisation and reprocessing (EMDR). "These are evidence-based treatments that get around 60-80% of people back to good functioning and can work at any time," says Greenberg.
NICE points out that most patients presenting with PTSD have had the problem for many months, if not years, and the "duration of the disorder does not itself seem an impediment to benefiting from effective treatment". It notes that all PTSD suffers should be offered a course of TF-CBT or EMRD regardless of the time that has elapsed since the trauma.
"We know these work," says Greenberg, who also warns against "fast" interventions, citing one within neuro-linguistic programming. "There is rewind technique -- a fast trauma cure -- but there is no evidence that it works," he says. "It might do, but no one has done the research."
However, the NICE guidance, which was published in 2005, is being reviewed; a report will follow next year. The UKPTS has also issued guidance (bit.ly/2xJkZzs) for organisations with staff working in high-risk environments. This sets out how employers can promote resilience, detect emerging problems and ensure treatment for those whose health has been affected.
Kinder makes a final wider point about how individuals perceive their employers respond to traumatic events. He has worked with people who have been affected in part by an incident but to a greater extent by how their organisation has reacted.
"Some feel they were blamed or did something wrong or that their organisation didn't care about them," he says. "They feel they wouldn't have been in a particular situation if it were not for work. A lot of it is about information, providing facts and communicating. Don't deal with it badly; don't just assume a manager will know what to do; don't ignore the psychological element of any contingency planning; and train and brief managers so they know what to do and when.
"When you're dealing with an incident, it can be chaotic in the aftermath, so if you have a clear set of guidelines you follow and that you've been trained in and good communication and decision making, it all works more smoothly." This also links back to bringing in specialists. The organisation needs to be clear what it is asking providers to do and why rather than having a kneejerk response.