the use of trauma risk management to support employees exposed to traumatic events professor neil...
TRANSCRIPT
The Use of Trauma Risk Management to Support Employees Exposed to
Traumatic EventsProfessor Neil Greenberg
Who am I?
• Professor of Mental Health at King’s College London
• President-elect of the UK Psychological Trauma Society
• In the Royal Navy for 23 years
• Provide psychological advice and assessments:– BBC / News UK– FCO– PSCs– Military
Plan for my talk
• Background• Trauma • A preventative model• TRiM • Conclusions
Why is mental health (MH) important?
• In 2008 ~ 13.5 million days were lost to work-related stress in the UK
• Presentee-ism (reduced productivity) accounts for 1.5 X as much working time lost as SA
• Presentee-ism especially important• Safety critical roles• Senior decision makers• Team relationships
MH and Incapacity benefit
Mental Health and ‘stress’
What is a Potentially Traumatic Event (PTE)?
• Being exposed to: • Death• Threatened death• Actual or threatened serious injury• Actual or threatened sexual violence
• By • Direct exposure• Witnessing in person• Indirectly learning of a close relative/friend’s trauma• Repeated or extreme indirect exposure to aversive details of
the event(s), usually in the course of professional duties
The PTSD Diagnosis
• Experience a Potentially Traumatic Event(often causing intense helplessness, horror or fear)
• Symptoms (for more than a month)– Re-experiencing– Avoidance– Arousal– Negative alterations in cognitions and mood
• Impairment of function
What is the natural history of PTSD?
0
10
20
30
40
50
60
70
0 10 20 30 40 50 60
Time elapsed since trauma (weeks)
PT
SD
ca
se
ne
ss
(%
)
PTSD ‘caseness’ of patients directly involved in a raid over time. Data from Richards (1997) The Prevention of PTSD after armed robbery: the impact of a training programme within Leeds Permanent Building Society.
Important Caveat
• PTSD is not the only post incident psychological health problem related to trauma
• Depression, Anxiety, adjustment disorders and substance misuse also common
Learning Points
1. Symptoms of distress =PTSD
2. Most people exposed to Potentially Traumatic Events (PTEs) do not become ill
3. PTSD is not the only, or most common, illness to follows PTEs
But….
Most people who suffer with post incident mental health problems don’t seek help!
Stigma
• “an attribute that is deeply discrediting” (Goffman, 1963)
• “the bearer of a mark that defines him or her as deviant, flawed, limited, spoiled or generally undesirable” (Jones,1984)
• Long history of stigma in “robust” organisations
WW1 - Stigma
“It is wholly out of place to show themcompassion. People with shell shock areweaklings who should never been allowed to join the Army or tricksters who
deserved to be punished”
Captain Dunn, Medical officer, RWF
Stigma and Barriers to CareStigma and Barriers to Care
0
510
15
2025
30
3540
45
Don't knowwhere toget help
Difficultygettingtime offwork
Wouldharm my
career
My unitleadershipmight treat
medifferently
Would beseen as
weak
% i
n a
gre
em
en
t
USA
UK
AUS
CAN
Gould et al, 2010, JRSM
“Why might you not seek help after being exposed to a traumatic event?”
0
5
10
15
20
25
30
35
40
45
Perceived asweak by
managers
Adversly affectpromotion
Less chance ofbeing given
responsibility
Not trusted bypeers
Embarrassed abtasking for help
Peers wouldtease
Greenberg et al, JMH, 2009
0%10%20%30%40%50%60%70%80%
No treatment Medication only Counselling ortherapy only
Non Veterans
Military Veterans
Most people with PTSD do not get treatment
Woodhead et al, 2010, Soc Sci Med
Learning Points
4. Distressed people do not usually ask for help
5. Stigma (esp self-stigma) is an important barrier to care
The seduction of Screening
• Screening beforehand for “vulnerability to PTSR” is seductive
• The grandmother test is good…however other tests are very poor
• US Army and WW2
Pre deployment Selection/Screening: PTSD Cases
Main Study (04)Main Study (04)
++ -- TotalTotal
Screening Screening
Study (02)Study (02)
++ 66 2727 3333
-- 4141 15401540 15811581
TotalTotal 4747 15671567 16141614
PPV 18% (5-31%); NPV 97% (96-98%)
Risk Factors for PTSD
0
10
20
30
40
50
Imp
orta
nce
in p
redictio
n
Brewin et al, 2000
Post Incident Screening• Within organisations this can be problematic
• Concerns about stigma/labelling and confidentiality may hinder benefit
• Example: US military Post Deployment Screening– Written and then face to face– Done at “immediate redeployment” and again at 3-6
months– Leads to referral advice if score +ve
US Army Screening research Milliken, et. al., Table 4, JAMA 2007 (N=56,350)
PTSD Screen Positive(PC-PTSD ≥ 3)n=3474 (6.2%)
Number (%) Who Received Mental Health Treatment
and Number of MH Sessions
Number (%) Recovered 6 Months
Post-Iraq(PC-PTSD < 3)
Referred to Mental Health
n=804
None, 349 (43.4) 205 (58.7)
1 Session, 128 (15.9) 69 (53.9)
2 Sessions, 70 (8.7) 36 (51.4)
≥3 Sessions, 257 (32.0) 96 (37.3)
Not Referred to Mental Health
n=2670
None, 1721 (64.5) 1181 (68.6)
1 Session, 419 (15.7) 254 (60.6)
2 Sessions, 129 (4.8) 67 (51.9)
≥3 Sessions, 401 (15.0) 150 (37.4)
Post Incident Counselling??
?
How to deal with PTSD (NICE slide edited)
What isn’t recommended…
•“Psychological Debriefing”•Ineffective psychological treatments•For PTSD, drug treatments NOT a first line treatment (different for depression)
What is recommended…
•“Watchful Waiting”•Checking in after a month•Trauma-focused treatments (CBT and EMDR) for adults and children if unwell
Learning Points
6. Screening (pre and post) is not effective
7.Post incident counselling does not work and may make people worse
Two things that work
• Improving social support– Colleagues– Friends– Family– Boss– Social networking
• Reducing pressure in the short term– Temporary alteration NOT cessation of work– Meaningful, social and short term placement
0102030405060708090
100
military peergroup samedeployment
spouse orpartner
anotherfamily
member
military peergroup not on
samedeployment
civilianfriends/peer
group
chain ofcommand
medicalservices
w elfareservices
People prefer colleagues to medics?
Greenberg et al, JMH, 2003
The way your manager treats you matters
0
1
2
3
4
5
6
7
Prevalence of probable PTSD*
Overall
Good Leadership
Poor Leadership
Jones et al, Psychiatry, 2011
Learning Points
8. Social support is a key element of organisational leadership
9.Never underestimate the effect of leadership on the mental health of those who are being led
So…..
• An ideal post trauma management process would be – Delivered by peers– Supported by leaders/managers– Aim to improve social support– Aim to alter work and social pressures– Evidence based– And NICE compliant (watchful waiting and ‘checking in after a
month)
TRiM – Trauma Risk Management
• Peer group support and risk assessment strategy
• Used by the UK AF since 1996– now Emer Serv, PSCs, Media, Diplomats, Maritime Organisations,
Railway workers
• NOT counselling
• NOT medical
Trauma Risk Management (TRiM)- What is it?
What Peer Practitioners are not!
– Counsellors– Therapists– Pseudo-psychologists– Group Huggers– Scented Candle users
Filtering the eventTarget Groups
A. Directly involvedB. Rescuers & helpersC. Involved at a distanceD. Could have been there
but were notE. Vulnerable peopleF. Those at the scene out
of curiosity
A
CF B
C
D
E
A
TRiM interview checklist1 The person thinks that they had little or no control over their behaviour/reactions during the event 2 The person thought they faced serious injury or death during the event 3 The person blames or is angry towards others about aspect(s) of the event4 The person expresses shame or guilt about their behaviour relating to the event5* The person experienced acute stress following the event6 The person has experienced substantial life stressors (e.g. problems with work, home or health) since the event 7 The person is having problems with day to day activities8 The person has had difficulties dealing with previous traumatic events9 The person reports problems accessing social support10 The person has been drinking alcohol excessively or using prescription drugs to cope with their distress
TRiM
publications
TRiM Research
• No harm• Improve organisational functioning• Supplement rather than replaces other support• Mobilising social support• Measures change in traumatic stress over time• Changes attitudes towards ‘MH’ • And…
The Cumbria ‘Bird’ shootings Incident
Method
• 717 individuals involved• Traumatic exposure was classified and
dichotomised• Socio-demographic information was collated• Receipt of TRiM recorded• Sickness absence recorded• Analyses using SPSS version 19
Results – Sample Characteristics
• ~90% of sample were Police Officers• Exposure information was available for 335
officers • 52% had higher level traumatic exposure• Higher trauma exposure individuals had
higher levels of sickness absence
Results – TRiM Receipt
Sample n=640
Briefing Onlyn=44 (7%)
Briefing & 1:1n=44 (7%)
1:1 Onlyn=166 (26%)
No Interventionn=386 (60%)
Low Exposuren=8 (18%)
High Exposuren=36 (82%)
Low Exposuren=0 (0%)
High Exposuren=42 (100%)
Low Exposuren=8 (17%)
High Exposuren=38 (83%)
Low Exposuren=144 (71%)
High Exposuren=59 (29%)
Results – Exposure, Interventions & Sickness Absence
Exposure (n)
Shorter sickness length n (%)
Longer sickness length n (%)
OR AOR* AOR** AOR***
Lower (160)
126 (79) 34 (21%) 1 1 1 1
Higher (127)
77 (61) 50 (39%) 2.41 (95% CI: 1.43-4.05)
2.33 (1.36-3.99)
1.87 (1.04-3.37)
1.75 (0.94-3.25)
*Adjusted for rank, age, length of service, whether in a relationship, and sex.**Adjusted for attending a TRiM briefing or receiving a TRiM intervention. *** Adjusted for rank, age, length of service, whether in a relationship or not, sex, and attending a TRiM briefing or receiving a TRiM intervention.
Learning Points
10.TRiM meets the NICE guidance on Trauma and Stress and appears to help with sickness absence after traumatic events
Conclusions• A minority of those exposed to PTE will become ill
• Recovery usually over 4-6 weeks (longer for “deployments”)
• Stigma will prevent help seeking
• Good organisational preparation/support helps
• Training of colleagues/managers is important (e.g. TRiM)
• Simple, informal, solutions often the best
