Trauma Within The Workplace

When I first wrote this article it was the week before the terrorist activities we have suffered in Manchester and London. As those involved in workplace counselling, we will be facing the ripple effects of these tragic events in many forms for many months and possibly years to come. This may come very sadly as direct experience of bereavement, long term health effects of the incidents by being at the concert or in London and more widely by relationships with others directly involved in their family, friend and colleague groups including people we know of through others in our wider network. For those practitioners who are involved in the healthcare and statutory sectors it will also involve dealing with first responders and the impact on their psychological well-being and sense of safety. Many clients we see are likely to come in the form of increased ‘what if’ thinking, general anxiety and hyper-vigilance about day to day life including travel into work and attendance at larger events particularly for those employed in our larger cities. Individuals who suffered the impact of past events such as 7/7 or much earlier tragedies such as Hillsborough may also find their trauma is reactivated. A challenge perhaps to EAP services will be that many of those employees will be troubled by the impact of these events on their families particularly children. Research shows that when parents see their children are receiving appropriate support and recovering, their anxiety lessens and their own recovery improves. As many contracts are focussed only on the employee, it may be that our role is about signposting our clients on how best to support their loved ones, useful practical information and who to refer into within the NHS.

The prevalence rate of post traumatic stress disorder in the adult population is shown to be 3.6% for men and 9.7% for women. Whilst an employee can experience trauma this may never develop into a formal diagnosis of post traumatic stress disorder as defined within DSM-V but that doesn’t mean they are not struggling with distressing symptoms every day. Certain groups of workers are more likely to experience trauma such as those working in the emergency services, first responders and health care which are often linked with compassion fatigue. Other occupational groups are also a high risk such as train drivers, cashier clerks, war correspondents. Basically anyone can experience trauma. Sustained bullying or sexual harassment can be experienced as trauma if the individual felt severely threatened. It is vital that we understand how to recognise the various symptoms of trauma, how they can present themselves at work and what we can do to quickly to support that employee (or group of employees).

Traumatic events come in many forms but usually involve an incident that was extremely threatening to someone or to others the person is close to eg colleagues or loved ones. It usually involves feelings of fear, helplessness or horror. Often it involves feeling as though their very survival or that of someone else was threatened either in reality or in their perception.

Trauma experienced in the workplace itself can take many forms and those situations we normally think of would be things like being involved in an accident, a robbery, life threatening health event or assault. Obviously there is a high risk of trauma from the tragedies of the last few weeks although fortunately these events are rare. However employees outside of immediate events themselves may also be experience negative reactions – thoughts such as “that could have been me on that shift or walking down that street or at that concert” and feeling relief then guilt it wasn’t them (often called survivor’s guilt); “I should have helped more”, “why didn’t I see that could happen”, “why couldn’t I stop it” are very common and are often grouped into negative beliefs around levels of responsibility for others. These often cause guilt and self-blame. The employee themselves does not even need to have been present at the time of the event – just hearing about it can cause a reaction called ‘vicarious trauma’.

We as workers helping others with these types of events can also suffer from ‘vicarious trauma’ and compassion fatigue so need to keep careful watch on our own self-care. Being aware if we are thinking about a particular client and their experience to excess, dreaming about the client or the event, feeling disconnected from our activities are just a few symptoms. Managing our caseload carefully and not having a high proportion of complex traumatic material is important, ensuring adequate space to release any emotions or material after each client, accessing regular clinical supervision and keeping our own self-care as a focus are all essential.

People who have been exposed to such things are often haunted by memories of it. This reaction is very understandable given what was experienced. What happened would be markedly distressing to almost anyone. It’s really a normal reaction to an abnormal event and that is how I describe it to clients. When things happen that are so outside our experience then it really is natural to feel markedly distressed about it for a while. One could call it an ‘aftershock’. The mind and the feelings need some time to heal and this time varies according to each individual and what they experienced. Sometimes a recent event taps into a previous traumatic situation that happened a long time ago. We need to be mindful of employees’ lives – how previous experiences that may have been non-work related, even before work began for them can be triggered by current events. How much is what we see causing difficulty within work but is completely non-work related? The context is all important. I recently worked with a client who had suffered the traumatic death of a relative. Her relative was treated within her workplace. Returning to the workplace caused overwhelming flashbacks and work was not currently a safe, supportive place to be. She needed therapy outside of the occupational health department in a neutral environment.

Trauma reactions can be terrifying and cause people to feel they are ‘loosing their minds’. People often end up worrying about their reactions and struggling to understand what is happening to them. One of our first tasks as workplace counsellors is to normalise the reactions as the body-mind’s way of dealing with something way beyond normal life experience that are just a way of trying to cope with the event. Sitting with someone, listening and explaining the normal symptoms of being anxious or irritable, feeling ‘switched off or blank’, being ‘on guard’ or highly vigilant, having memory gaps, suffering with flashbacks and not being able to control a stream of thoughts that overtake the mind about the event, avoiding people and going out, struggling to trust are all highly common reactions. Ultimately our view of our world, where we are in that world and how safe our place is have been called into question.

We need to remember the mind-body’s capacity to self-heal with the right conditions. Over 60% of people who experience a traumatic event will recover within 3-6 months with no ongoing symptoms and without any formal therapeutic intervention at all. What they need is to be understood, be encouraged to use their healthy ways of coping or perhaps develop new ways, and to keep accessing support from those in their lives. This is what I call the ‘first aid for trauma’. In the initial phase, we don’t need the employee(s) to fully recount their experience in detail and that should be explained to them. Some may want to and that’s fine but for others that is unhelpful. Offering to sit with someone for say 2-3 sessions of one to one, working with our core toolkit of empathy, non-judgemental listening and looking at a psycho-educational model of support is what is proven by research to be most helpful particularly in the initial weeks post-trauma. As counsellors within organisational and EAP settings, we are often working in short term brief models. As formal trauma therapy is recommended by NICE guidelines to be around 20-24 sessions this is beyond our remit often and it would be our role to identify employees with longer term difficulty for onward referral.

Group trauma de-brief (often called crisis intervention) is something that was very fashionable at one time but as a one off intervention is something I would caution against. Getting small groups of employees together to normalise how they feel now, talking through what they struggle with, sharing what is helping them and what they need help with now is healthy. Asking people to run through frame by frame what they experienced or witnessed can actually cause more trauma as one person’s part in any event will be unique and our memory of an event is also unique to us. An employee who is initially coping by blocking out part of the event may be flooded by memories and become unstable due to what others share.

One of the most important features of first aid for trauma is helping employees understand our five reactions to threat as a human being. We often hear more about our survival reactions of fight, flight and freeze. There are actually two more, ‘flop’ and ‘befriend’. When we are trapped and unable to run away, we are perhaps overpowered or not capable of fighting, we can ‘flop’ (literally drop down, becoming limp). In other situations like this, we might perceive it is safer for our overall survival to try and ‘be-friend’ the threat or become compliant. This is particularly common in childhood or sexual assault situations. Where we were unable to fight or run, we can be left feeling guilt, embarrassment or shame, as if we failed ourselves in some way. The most important thing to remember is that we did what was necessary for our survival at that time. We often look back on events and reflect, saying to ourselves “I wish I had done this or that”, that is called hindsight bias and is a memory distortion. It is important to emphasise at the time they reacted to that so they could survive the threat. They only knew the information presented at that time which is often very limited and in a chaotic, frightening situation difficult for our brain to interpret and understand. On reflection (often months or years later) with all the benefit of our frontal lobes which access our rational brain this may seem wrong. At the time it was not.

What I encourage employees to do when faced with the aftermath of traumatic events is very basic. Ask them to think about themselves and others in the situation in a kind and compassionate way; consider how they might respond to a friend who had been through a similar event. Switch off their internal critical voice, developing a kind, understanding friend inside their mind. Making time to do what they know helps rather than punishing themselves with harsh criticism or unrealistic demands. Being open with those around them not ‘putting on a brave face’.

Sadly though there will be a proportion of employees who experience more extreme symptoms of trauma such as suicidality; symptoms such as lack of concentration, focus and aspects of dissociation may cause danger when driving or operating machinery; an increasing use of alcohol, substances or over-taking prescription medications can cause serious risk to themselves or others. Employees who have perhaps been managing an addiction well may have a lapse and start to re-use. A vital part of our role is to regularly assess our employees’ behaviours and openly ask questions around these areas as part of an ongoing risk assessment. If we have concern around these areas, we need to understand how our organisation manages onward referral routes to other mental health services and seek consent for joint working with an employee’s GP and sometimes their family. It could be that their line manager is aware of certain behaviours at work that are unusual for that person, extreme lateness, frequent absence, perhaps work performance is suffering. These can also be indicators of trauma residue even months or years later that can also surface as physical health ie musculoskeletal problems, chronic pain, ME, high blood pressure to name just a few. The anniversary of traumatic events or talk in the media about similar situations can also trigger flashbacks and other distressing symptoms – perhaps bringing up things employees felt they had let go of years ago. This is a theme I have seen with ongoing investigation into historic sexual abuse; the Hillsborough inquiry and work of Operation Resolve within the NHS setting I work in.

A question clients often ask me is “why have I got PTSD but x hasn’t?”. This can often lead to feelings of being weak or sub-standard in some way. The answer is a complex one. Negative self-beliefs about ourselves from childhood are often present, sometimes they may have experienced sustained abuse whether that is psychological, physical or sexual. Research shows that individuals are more likely to recover from a life-threatening one-off traumatic event than multiple and sustained events such as domestic violence. Often clients have experienced attachment trauma in early years or the client just hasn’t had a model of good, healthy coping methods in their life. Neuroscience can now show us how high levels of stress hormones affect our brain structure and other aspects of bio-chemistry often causing our emotional resilience to be lessened. In a workplace setting what I see is often a cumulative effect of numerous incidents of greater and less threat that can’t be contained any more perhaps due to difficulties in their personal life eg a recent bereavement, personal ill health event so there is no space left to process what happened on the last shift even though by their standards that was relatively low level.

As someone who practices Eye Movement Desensitisation Reprocessing Therapy (EMDR), one of the two NICE guideline approved treatments for post traumatic stress disorder), within an acute mental health trust and in private practice, I can confirm how important a timely referral is. Someone who hasn’t become stuck in unhealthy ways of coping and who has had helpful psycho-education helps the client move forward much more quickly. We can feel frustrated as counsellors that perhaps we can’t always move the person towards resolution within our work. However the first aid that we do for trauma will provide a stable foundation to support that person going forward if they do enter longer term therapy and hopefully enable the employee to trust the next counsellor they meet.

In these challenging and uncertain times, please also remember to take good care of yourself.

Rachel Wesley

Trauma Psychotherapist

Email: wellness-consultancy@outlook.com

Website: thewellnessconsultancy.org

For more information:

Work related post traumatic stress disorder – Occupational Medicine Journal – Oxford Academic, Vol 63, Issue 3 – April 2013

https://academic.oup.com/occmed/article/63/3/175/1413569/Work-related-post-traumatic-stress-disorder

NICE Guidelines – Post Traumatic Stress Disorder Management

https://www.nice.org.uk/guidance/cg26

EMDR Association UK and Ireland

http://emdrassociation.org.uk/terry-waite/