OH support for mental health problems

OH professionals can support people adversely affected by dealing with traumatised colleagues. Sarah Silcox reviews a new book on the topic.

Occupational health professionals have a key role to play in supporting people exposed to secondary trauma at work, including in their own profession, according to Noreen Tehrani, editor of a new collection of writing on trauma management.

Our understanding of how working in a high-stress environment, such as the emergency services, can lead to burnout and stress is well developed.

Less understood is the impact that this trauma can have on the professionals supporting people exposed to trauma, who often have to listen to or read horrendous stories as part of their job. The teacher dealing with a refugee pupil distressed by genital mutilation, for example, or the insurance claims assessor listening to a claimant’s testimony of sexual abuse by a priest. Even the human resources practitioners helping an employee deal with the terminal illness of a partner are exposed to the risk of secondary trauma.

All those people involved in supporting others are at risk from secondary trauma. That is the subject of a new collection of articles edited by Tehrani, a chartered occupational, counselling and health psychologist with an international reputation for her work dealing with disasters, crises and trauma.

She argues that occupational health professionals (OHPs) can play a vital role in raising awareness of the existence of secondary trauma, both in those employed by their client organisations but also, crucially, among themselves.

Supporting HR

OHPs need to be aware that the people they work with may experience secondary trauma, particularly those whose work involves listening to, or reading, the sometimes distressing, stories of others. Tehrani argues: “You cannot understand text without making it real, and translating it into the familiar, using your own experiences.”

OHPs must recognise that secondary trauma comes through this route. It is not anxiety or depression, and must be treated appropriately.

HR professionals are one group singled out for particular attention in Tehrani’s book, and she argues that they are particularly vulnerable to secondary trauma, often being reluctant to recognise the need to look after their own. The HR role enshrines stresses and strains, which can lead the people performing it to experience compassion fatigue and burn-out. Tehrani calls for organisations to do more to take care of this important group and to recognise the level of expertise required to perform it.

She argues that HR teams are often torn between embracing the business model – employing people in the most effective way for the benefit of the business – and acting as workers’ advocates, particularly if they are experiencing distress. Bearing news of redundancy or maintaining an even hand during worker conflicts are both examples of situations that can lead to secondary trauma. Unlike other professionals dealing with trauma, where practitioners are obliged to achieve a prescribed level of competence and register with a professional body, HR professionals face no such requirement.

A survey of 276 HR professionals, OH nurses and employee counsellors undertaken by Tehrani suggests that people in HR receive very little supervision compared with others in trauma management roles. Only one in five had access to professional or management supervision, compared with 91% of counsellors and 53% of OH nurses. HR professionals tend also to ignore their own physical and spiritual health, and do not use difficult and demanding experiences for personal growth, but rather ignore them. “HR professionals are so busy administering stress audits and introducing healthy living campaigns that they forget to include themselves,” Tehrani suggests.

OHPs can provide much-needed support to the HR team in an organisation, Tehrani believes. Both OHPs and their counterparts in HR are expected to be business-focused, but they should also demonstrate a caring side. Occupational health professionals should be forming alliances with HR to help them deal with secondary trauma arising from their own work.

Supervision and training

The work of OH teams is becoming more psychosocial, and most professionals are now likely to use counselling and coaching skills in their day-to-day activities. However, OHPs, unlike trauma management specialists, are not required to engage in professional supervision, and most employing organisations could not afford to provide it in any case.

Tehrani uses alternative supervision arrangements in her work with the police, and believes this could form a model for OH peer supervision. Her supportive groups involve talking to teams of people involved in trauma management about how their work impacts on them. She adds: “This has proved valuable in reducing the likelihood of stress and burnout.”

She argues that OH training should cover how to conduct these “protected time” sessions, enabling groups of OHPs to talk about case work. “It is about creating a safe place and allowing people to talk about the things that are bothering them,” she adds.

Trauma risk management

Tehrani uses a nine-element trauma management model in her work with people in emotionally demanding jobs where there is a high risk of secondary trauma and burnout. This is based on the HSE risk management model, and incorporates job design, pre-employment screening, induction training, education, resilience building and a staged, post-event intervention starting with demobilisation.

Demobilisation involves a short team-based session to talk about the traumatic event, undertaken immediately afterwards. Evidence from the 7/7 London terrorist attacks suggests that performing demobilisation early means that people are able to return to work quicker. Tehrani argues that demobilisation is an ideal technique for OH nurses to use, as it looks at four aspects of wellbeing in a systematic way. “It is essentially first aid,” she adds.

Defusing is the next step in the trauma management model and allows people more time to examine their stories in detail, but still falls short of a counselling intervention. Defusing typically involves a one-to-one session between an individual and their manager, working with a risk assessment checklist to enable the line manager to identify if a referral to OH for a medical or psychological intervention is appropriate. “Most people do not need a lot more than this, but it is important to monitor them and, if they’re not improving, to get a proper assessment,” Tehrani suggests.

Post-medicalised vision

There has been much debate in recent years about the value of immediate, lengthy post-trauma counselling and, indeed, around the whole medicalisation of trauma itself – people experiencing distress after trauma are being categorised as “ill” and in need of specific interventions.

Such a view takes little account of an individual’s reaction to trauma, which is usually a natural and normal reaction to the extreme situation, the authors of a section of the book on a post-medicalised vision for trauma management argue.

The view of David Murphy, lecturer in trauma studies at the University of Nottingham, and his colleagues, is that being treated for post-traumatic stress disorder should lead to personal growth, not just recovery.

They suggest that the UK-approved treatment for trauma does not recognise the value of relationship-based approaches to intervention – which they argue is necessary for any post-traumatic personal growth to take place.

Traumatised organisations

Organisations can experience trauma. For example, they can be damaged by the activities of employees, such as rogue traders, or the sudden departure or death of a key individual. Trauma of this type leads to a rapid, negative shift in employees’ perceptions of their organisation, causing feelings of disbelief and shock that are similar to traumatic bereavement.

As a result, the organisation might overreact, overcompensate or engage in distraction activities, rather than acknowledge and deal with the real problems of organisational distress. High-risk organisations, such as emergency services, are serially affected by traumatic exposure, causing secondary trauma in the case of employees with their own unresolved traumas, or a strong empathetic attachment to the people they support.

Tehrani argues that there is little understanding of this organisational trauma, compared with individual trauma, and any corporate failings resulting from trauma are too often viewed as poor management, or a sign that the organisation is itself “failing”. She suggests that poor communications and overbearing management are symptoms of a traumatised organisation.

Yet organisations are well placed to build organisational resilience to trauma, having the power and resources to introduce systems that encourage it, for example, in the selection, training and support of employees. Emotional intelligence and decision-making skills have a vital role to play in fostering resilience. On the latter, Tehrani cites the value of the decision-making capacity and processes displayed by the Captain Sullenberger who safely landed a disabled aircraft on the Hudson River in 2009.

Training is crucial in building a resilient organisation, as most members of a crisis management team will not have direct, real-life experience of the events they are preparing for, Tehrani points out. In particular, specially designed simulations provide opportunities to practise dealing with high-pressure situations in a safe and supportive environment, to review processes and assess employees’ skills.

This training is also part of building trust, which is essential in fostering long-term resilience. Tehrani says: “When workers, teams and organisations work together to improve their technical and interpersonal skills, they treat each other with respect and uphold shared values and principles and the organisation becomes stronger and increasingly resilient.”

OH role in building resilience

The role of OHPs in building resilience should focus on being aware that organisations can be traumatised. Tehrani points out: “If you join an organisation that deals with trauma, it is inevitable that the organisation itself will absorb some of this trauma, it gets into the fabric, and you as professionals will see negative behaviours and trauma symptoms.” For example, the organisation might appear overactive.

If working in an organisation like this, OHPs need to recognise that these behaviours are part of what the organisation does, and not blame it, but rather point out any observations to the management. “But OH advisers will also need to recognise that it is difficult for managers to trust them, and that they must work at winning this trust by providing a model of an alternative way of being, which is all about being a professional,” Tehrani says.

However, she accepts that it is difficult for OHPs to be this “quiet voice” and that it is easy to be swayed by, or trapped in, the culture and drama in which they work. Occupational health teams have a very valuable, but risky, role to play. “They can avoid taking this on, and just do the ‘nursy’ stuff, but to properly engage, they need to tackle the nasty stuff as well,” she concludes.

“Managing trauma in the workplace: supporting workers and organisations”, Edited by Noreen Tehrani, Routledge, 2011. £19.99.

Case study: OH and trauma management at British Transport Police post-7/7

British Transport Police (BTP) officers and staff were among the first at the scenes after suicide bombers struck London on 7 July 2005. Most were involved as rescuers but some experienced the bomb blasts as primary victims.

At the time of the bombings, the BTP was piloting a new organisational approach to trauma management, and 23 officers in supervisory and management roles had been trained in crisis management, demobilisation and defusing (see text for descriptions of these elements of a model trauma management plan). The OH service had also prepared a draft trauma policy.

On the day of the bombing, senior managers decided to activate the organisation’s major incident trauma support programme, coordinated by OH. Over the next 10 days, 321 BTP employees were involved in one or more aspects of dealing with the bombings. The OH team established a number of clinics on different sites across London, where staff involved were given physical checks, and had an opportunity to talk about their experiences.

A trauma support centre was established in a central London hotel, consisting of a reception area and smaller consultation rooms. It became clear over the 14 days following the incidents that far more employees than anticipated had been involved, and 266 employees attended the support centre during an initial assessment period. Just over 100 employees were found to have high levels of symptoms, using two clinical questionnaires and a physical check-up, and were offered the opportunity to have individual debriefing sessions.

During the following six to eight weeks, employees with a high number of initial symptoms completed a trauma screening questionnaire: 26 officers and staff were referred to a trauma stress clinic, and a further six self-referred. Of those attending, five had an adjustment disorder, one a dysthymic disorder, one a major depressive disorder, and 12 were diagnosed with PTSD. The remaining workers were assessed as not having a significant psychiatric condition.

Further follow-up activity with the high-symptom employee group took place six to eight months after the incidents, and after 11 months. This latter exercise encompassed an employee survey, which included questions on the value of the support received. Individuals identified colleagues and family and friends as the most supportive groups, and GPs and counsellors as the least helpful. Opinions were split on the value of the trauma stress clinic. The OH assessments were viewed as “quite” or “very” helpful by 85% of respondents, and 89% found the initial debriefing provided by OH helpful.

Employees were offered support around the one-year anniversary of the incidents.

Source: “Managing trauma in the workplace: supporting workers and organisations”.

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