Employees who experience distressing incidents at work may develop feelings that prevent them from returning to the scene. Employers can take steps to minimise the post-traumatic impact of such events.
Many employees are at risk of experiencing a traumatic event at work, such as armed robberies, serious assaults and accidents. For those working in security, cash-handling, transport and construction, for example, the risk comes with the role.
Figures from the Health and Safety Executive show that in 2009/10, 152 workers were killed at work and there were 26,061 major injuries. The 2009/10 "British crime survey" estimated that there were 366,000 threats of violence to British workers during the 12 months prior to the interviews, as well as 310,000 physical assaults.
Employers often have great sympathy for those affected by trauma, but over time this can be replaced by helplessness and frustration as sickness absence shows no sign of ending.
Example case study
A scenario is that of John (a fictitious example) who was threatened during an armed robbery in his workplace. He experiences panic at the thought of returning to work and avoids any contact with the organisation. Although John accepted the offer of counselling, he still could not face re-entering the workplace, and six months later he went on unpaid sick leave. The organisation is left with little option but to consider capability and dismissal procedures. This common scenario is a "lose-lose" situation for employer and employee.
To prevent the situation from developing and to help John make a successful return to work, it is important to understand the psychology of traumatic stress reactions. This provides us with the rationale behind rehabilitation strategies.
The brain's response during a traumatic incident
During the robbery, John becomes aware that he is in danger through his senses. They are on high alert, taking in detailed, vivid input of the threat. Images could include the robbers, weapons, a sudden blur of movement, bystanders or colleagues who may be in danger and exit routes - any of these images, along with their colours, shapes and tones, will be noted by his brain, even if it is only at a subconscious level.
His brain will also be aware of sounds - these could be smashing glass, screams or shouting from the perpetrators. Again, his brain could have an awareness of tones, volumes and accents, as well as the actual words. The criminals may have been sitting waiting to strike, high on adrenalin, so body odour, the smell of alcohol, cigarettes or aftershave may be present. His brain will be taking in tastes - perhaps his dry mouth, the taste of bile, or even the metallic tang of blood if he is hit in the mouth. Physical sensations may also be present - the feel of a weapon, pain, or the cold or smooth surface as he falls.
John is not consciously aware of all these things. In fact, he would have to really stop and concentrate to notice them all in his conscious mind, but at a primitive level his senses are aware. All of these sensory fragments are important as they can become "triggers" at a later stage.
Employers often have great sympathy for those affected by trauma, but over time this can be replaced by helplessness and frustration as sickness absence shows no sign of ending."
Triggers can be anything that reminds John of the sensory input from that time. When he encounters a trigger, his internal "alarm system" goes off as it perceives the original threat is present. John then becomes anxious and ready to fight or run.
Unfortunately, with this traumatic incident taking place at work, his triggers also include his colleagues, his place of work or work clothes.
Therefore, the workplace and everything associated with it is now perceived as dangerous by John.
Humans are hard-wired to avoid triggers, which is a survival strategy that evolved in primitive man after learning that the avoidance of triggers was useful for survival. If primitive man went to a part of his environment where he met a dangerous predator, he would probably be reluctant to repeat the encounter. His triggers may include smells, sights or sounds of the predator and its habitat. These triggers would raise his anxiety, putting him on red alert for danger.
That works equally for modern man. If John was bitten by a dog, he would probably avoid dogs. If he was mugged in a rough part of town, he would think twice about returning to the area. This avoidance behaviour keeps us safe and is a very common post-traumatic stress symptom.
However, John needs to work to survive. Yet work feels very unsafe so he wants to avoid going there and repeating the exposure to potential danger.
Worse still, every time he thinks about work or talks to colleagues or managers, he is reminded of the trauma and this triggers his anxiety and nightmares. Therefore, he may feel it is best to just avoid his colleagues and managers.
Very quickly, John can become isolated and estranged from others just at a time when his social support network is needed. By behaving in this way, he can quickly find that his confidence reduces and he is fearful of life in general.
The problem is that if we run away from the trigger, we feel better for a while, so this starts to feel like a good strategy. But the next time we encounter the trigger, we run away again as we previously "learned" that this works. We then become even more anxious about the triggers and go to great lengths to avoid them. This is how phobias can develop.
However, if we can manage the anxiety and continue to confront the trigger, the anxiety will eventually peak and then drop. The next time that we encounter the trigger we will feel more confident that we can handle it, meaning it will subsequently become more manageable. This has a cumulative effect until it is no longer a trigger.
Small steps are crucial here. Going back to the example of being bitten by a particular dog, someone will understandably feel anxious next time they come across a similar one. They may be completely overwhelmed at the prospect of meeting that same dog.
However, if they can manage their anxiety and stay in the same vicinity as a smaller, non-threatening dog, after a few uneventful encounters they will be reassured and see the original experience as one badly behaved dog among an overall friendly population of dogs.
Advice and support from properly qualified trauma consultants will ensure that you are meeting your duty of care and doing your best for those that experience traumatic incidents at work."
If, however, next time they meet a dog they are so anxious that they have to leave the vicinity, then that will reinforce the anxiety. To put it very simply, what happens is: they see a dog; they feel anxious; they leave the dog; they feel safe. The conclusion they draw is that dogs equal fear, therefore, to their primitive brain, dogs equal danger.
This could escalate so that any triggers associated with dogs, for example hearing one bark, raise anxiety. Rather than seeing the initial traumatic event as a one-off and learning something helpful from it, the person could instead generalise the experience as a lesson that all dogs are dangerous.
Unsuccessful return to work
When John tried to return to work, his anxiety was constantly triggered by:
- his morning routine of "getting ready for work";
- putting on his uniform;
- the journey to work;
- seeing the workplace;
- crossing the threshold with its familiar sights, sounds and smells; and
- seeing his manager.
These triggers were constantly increasing his anxiety until it became overwhelming and he went home badly shaken. Once home, he felt safer and subconsciously reinforced the fear as being associated with the workplace.
The next time the subject of returning to work was raised, John automatically felt anxious. Instead of just fearing the perpetrators, his anxiety had become generalised so that work became dangerous. These feelings are so intense that it is hard to believe that they do not always make logical sense.
Treatment for post-traumatic stress reactions will focus on gradually and safely exposing the person to triggers and teaching them to manage the resulting anxiety.
The National Institute for Health and Clinical Excellence (NICE) recommends only two treatments for post-traumatic stress disorder and suggests that there is no evidence for supportive counselling being effective. Yet many employers still send their employees for this type of support. NICE goes so far as to suggest that requests for supportive counselling should be discouraged.
However, trauma counsellors argue that this is one time when specialist support is needed and, because this type of therapy is focused and directive, it should not go on for months with no observable progress.
Six key steps to building a sustainable recovery
1. Rebuilding a sense of safety within the workplace can start immediately after the event. Management and peer support is crucial at this time. Focusing on the individual's welfare sounds like common sense, but many managers still focus on operational issues before asking: "Are you okay?" If the employee thinks that the organisation does not care, then they will find it hard to trust in the safety of the workplace.
2. Having a manager who understands their anxieties can reassure them that they are being taken seriously. Taking the time to listen properly is a simple but effective means of support. This may also reveal practical steps that could be taken to increase their sense of security, such as temporarily working with a particular colleague while they rebuild their confidence.
3. Gently encouraging the person to face their fears is helpful, provided feelings of panic are avoided. A perception of being pressured will add to stress levels. Encourage small steps such as driving past the workplace or calling in for a cup of tea and a chat. Sometimes these small steps can seem trivial but, for some, even having contact with a colleague can trigger traumatic memories. Remember: slower is faster.
4. Maintain contact if the employee is on sickness leave. This may feel uncomfortable for them but leaving people alone reinforces their avoidance behaviour. Unless it genuinely provokes panic, it is helpful to check in regularly with their progress.
5. Ensure that the person has a support system (colleagues, family or friends) and access to professional support if required.
6. Offering a phased return to work and/or temporary change of role can be a useful halfway house, but always document phased recoveries with clear goals and timelines. Changing these at short notice, or being vague about duties, can add unnecessary anxiety. Structure provides a sense of safety.
For those who are the affected employee's point of contact, these basic steps can help towards a successful long-term recovery. Advice and support from properly qualified trauma consultants will ensure that you are meeting your duty of care and doing your best for those that experience traumatic incidents at work.
Liz Royle is a trauma consultant at KR Trauma Support, which provides free information on managing psychological trauma.