Post-Traumatic Stress Disorder is a term that gets bandied around a lot, explains Christine Husbands. But what does it mean precisely, how does it present, and what role can occupational health play in terms of supporting employees dealing with the aftermath of a traumatic event or incident?
We frequently hear the term Post-Traumatic Stress Disorder (PTSD) but what exactly is it and what are the consequences? What measures can employers take to help reduce the risk of employees who have been affected by trauma developing PTSD? And how can they ensure that those who have experienced a traumatic event are supported during their recovery?
Post-Traumatic Stress (PTS) is a normal emotional response to some form of trauma, the severity and impact of which can be a very personal thing. Some people may cope with an event but others may have a significant adverse reaction to it. Multiple traumas, particularly those relating back to childhood can exacerbate the effect, and a new trauma may cause a tipping point and lead to a situation of not coping. In addition, those with previous mental health problems and problematic family relationships may be more vulnerable to developing the disorder.
About the author
Christine Husbands is managing director of RedArc Nurses
There is considerable overlap in symptoms between PTS and PTSD. However, there are significant differences in symptom intensity, duration, and treatment.
After a traumatic event, it is common for people to feel shocked or numb and be unable to accept what has happened. A person may behave as though the trauma hasn’t happened when in denial. People react differently and take different amounts of time to come to terms with what has happened. It is normal to experience a mix of feelings, and these will vary in intensity. Feelings of fear, helplessness, shame, anger, guilt and relief are commonplace. Over a few days these feelings should gradually fade, and other thoughts and feelings take their place.
Good-quality sleep is key to recovering from trauma. Sleep allows the brain to process and store the memories and facilitate a good recovery from the experience. However this is often difficult to achieve due to the individual’s distress. Dependent on the length and intensity of symptoms, individuals may need to access professional support, but the symptoms should have reduced significantly within six weeks.
Causes of Post-Traumatic Stress Disorder (PTSD)
The emotional response to a traumatic event is a very personal thing and, of course, as human beings we all have previous experiences which can affect our ability to process difficult situations. If a person is exposed to prolonged trauma they may develop a complex condition. The interpretation an individual makes of an experience, and the threat to their family and environment is key to how their distress will manifest.
Events such as witnessing a shocking event, serious accident, violence, natural disaster, physical or emotional abuse can lead to the development of PTSD. Often people struggle to come to terms with the fact that they have survived a situation whereas a colleague has not, this is known as survivor guilt.
PTSD does not normally develop following distressing life events, such as divorce. However, people can still experience PTSD-like symptoms. Life-changing events that initiate a distressing emotional reaction may illicit similar symptoms to PTSD. However, some events can be more problematic. For instance, it has more recently been recognised that a miscarriage can trigger PTSD; as many as one in four pregnancies is thought to end in a miscarriage.
The symptoms experienced during the weeks following the trauma, although very difficult at the time, can be relatively short-lived. Nevertheless it is important that post-traumatic stress is recognised as such, and help sought to manage the symptoms. This will enable recovery and help to avoid the disorder developing. Prescription medication can be helpful during this initial phase, particularly in aiding good quality sleep which is so vital to recovery. Although preferable to self-medication with alcohol and illicit substances, prescription medication should be used short term, and closely monitored by a health care professional.
PTSD can be complicated to diagnose but is likely to take into consideration prolonged symptoms such as:
- Persistent remembering or “reliving” the stressor by intrusive flashbacks, vivid memories, recurring dreams, or by experiencing distress when exposed to circumstances resembling or associated with the stressor
- Actual or preferred avoidance of circumstances resembling or associated with the stressor
- Inability to recall, either partially or completely, some important aspects of the period of exposure to the stressor
In addition, persistent symptoms of increased psychological sensitivity and arousal such as:
- Difficulty in falling or staying asleep
- Irritability or outbursts of anger
- Difficulty in concentrating
- Exaggerated startle response
PTSD sufferers can often also abuse alcohol and illegal substances and/or have mood and anxiety disorders. The Post-Traumatic Disorder Checklist – Civilian (PCL-C) is a validated tool providing a self-report rating scale for those who have experienced trauma. As with all assessment tools, however, this should be used in conjunction with assessment by a medical professional. It is worth being aware that two versions of the PCL exist: 1) PCL-M is specific to PTSD caused by military experiences and PCL-C is applied generally to any traumatic event. The PCL can be easily modified to fit specific timeframes or events.
Ongoing symptoms that interfere with daily functioning create problems, as individuals will be unable to return to their usual routine. Resilience is a factor that may reduce the risk of PTSD developing, For example, those who seek out support from friends and family or attend a support group following an event, and those who have well-established coping strategies to manage their stress may also be at less risk from developing prolonged symptoms. Individuals may also go on to develop post traumatic growth, a positive change experienced as a result of the struggle with a major life-crisis or a traumatic event.
Trauma-focused Cognitive Behavioural Therapy (CBT) or Eye Movement Desensitisation Reprocessing (EMDR) are recommended by the National Institute for Health and Care Excellence (NICE) but other treatment approaches are also available.
Treatment for co-occurring conditions such as depression or substance misuse are usually managed before trauma-focused therapy begins. Medication may be indicated to reduce symptoms, usually an anti-depressant.
It was also revealed over the summer that NICE is consulting on new guidance for the prevention and management of post-traumatic stress disorder. The final guidance is expected to be published in December and will replace the existing 2005 clinical guideline CG26.
The role of employers and occupational health
There are clearly some forms of work that are more likely to present traumatic situations, such as the emergency services and military. As such, employers in these sectors have a significant duty of care to their employees in this regard.
However, employees in low-risk sectors can also be affected by post-traumatic stress arising from events in the workplace or their private lives.
Employers can help and support those affected by a traumatic event by maintaining a stable, flexible working environment, and embracing a supportive accessible management structure to encourage employees to seek help.
As highlighted earlier, sleep is very important for recovery, therefore flexible working patterns and changes to shift patterns to allow the employee to maximise sleep can make a big difference. Flexibility to attend medical appointments and therapy sessions and thinking about the timing of sessions so that the individual can go home afterwards if needed.
The treatment for PTSD sufferers can be quite lengthy and more complex than for other mental health conditions. It is usually very tiring and distressing as the individual needs to work through the traumatic event they have been avoiding, so stability is important.
Although there is no real difference in the type of support required for PTSD sufferers, the complexity, severity and long-term nature of this condition means that support needs to be sustained long-term to be effective.
Trauma Risk Management (TRiM) is an initiative initially developed by the military and is now also used by the emergency services. It can help reduce the stigma of mental health and this is most helpful in organisations that are more at risk of being exposed to traumatic events.
However, there are some elements which could be relevant to other employers such as the training of non-medical staff to carry out specialised risk assessments following a traumatic incident and sign-post individuals most likely to be adversely affected at an early stage. This can reduce the impact on the individual, their colleagues and the organisation as a whole.
Support services available to employers
With the pressures on the NHS mental health services, employers would be wise to ensure they have robust good quality support services in place to help employees who find themselves suffering from PTSD or other forms of mental ill health.
Support may well be available without employers realising it. Many employers have group insurance policies (employer-sponsored income protection, life assurance, critical illness) which often include additional services providing mental health support and some also cover all employees even if the financial aspect of the insurance is limited to specific groups of staff only.
So it is well worth checking what is available and, if necessary, consider switching to another provider at renewal that offers such added-value services. Employers can also provide external support services either by sourcing directly from a supplier or more frequently from an Employee Assistance Programme (EAP).
Having third-party experts to support those with mental health issues is often a good solution for everyone as employees value confidentiality, can get faster access to support, and that support can be delivered by parties that are more qualified than anyone within the organisation – all of which point toward a faster recovery.
However, occupational health, HR and line managers do have a vital role to play in noticing the signs of problems developing in their staff, and providing the long-term supportive culture. Training and resources are available from many organisations including the conciliation service Acas and the mental health charity Mind.
By discussing symptoms with a dedicated mental health nurse, the employee can be reassured that their symptoms are normal, and encouraged to return to their usual routine. Dependent on their employment a short period of sick leave can be helpful. They can be encouraged to speak with their line manager about their experience and symptoms, thereby feeling supported at work.
There is also a lot of information to aid sleep, for example sleep apps, which can be highlighted to patients, along with relaxation techniques to help curb anxiety. Should symptoms persist a practitioner can clinically assess whether some form of additional therapy would be beneficial such as trauma-focused CBT or EMDR.
When selecting support services, employers should take care to ensure the service is of high quality and caters for complex disorders such as PTSD. Services available can vary significantly in quality ranging from a light-touch helpline for a one-off telephone call through to long-term support from a dedicated nurse. Some purely offer counselling and others make a clinical assessment to determine the most appropriate therapy which could be counselling, cognitive behavioural therapy (CBT), psychotherapy or others.
PTSD is a complex area, so employers can’t be expected to understand the intricacies of the illness. But by offering a support service they can best help their employees and fulfil their duty of care, demonstrating to the individual and the wider staff community that they care about employees and want to go the extra mile for them.