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7.      STAFF CARE AND CONSULTANCY

 

Annexes following this chapter: click to go direct to the Annex

Annex A7: A Staff Care Strategy

Annex B7 - Post Traumatic Stress: An Outline by Howard Davis

The Need for Staff Care

7.1.      It is recognised that practice and development in this area varies widely across authorities; and that this aspect of departmental function is unlikely to command a higher priority than many other aspects of day-to-day operation.

 

Justification of Staff Care

7.2.      It is in the interests of any organisation undergoing such a period of crisis, to provide mechanisms that will support and attempt to safeguard the welfare and well being of its personnel.  This will protect against low morale and poor service delivery.  It will also protect the individual employee against “burnout”, leading to the loss of that individual to the organisation and to their profession.

There is a good evidence to demonstrate that staff care is cost-effective. The costs of setting up and administering a system is more than off-set by savings in absenteeism, staff turnover and replacement costs and legal actions are a factor now.  It is now standard practice to set up and monitor staff care services on the basis that they demonstrate their cost effectiveness on a year-on-year basis.

 

An Ideal Staff Care Strategy

7.3.      An overall staff care strategy is presented diagrammatically at Annex A/7.  The following should be read in conjunction with the diagram.

 

Individual worker

7.4.     Primary responsibility for staff care and well being lies with the individual.  Individuals have a primary responsibility to themselves, their loved ones and dependants, (as well as their employer and professional colleagues) to look after themselves, so they can discharge their various roles and commitments.

All training is aimed at enhancing role competence.  In preparing to work in major incidents, specific training should familiarise the worker with what to expect, so that they may be better protected.  Stress-management training, including the uses of debriefing, will be appropriate, as well as familiarisation with the staff care resources available. The objective is to encourage appropriate self-care practices throughout the workforce.

 

The Line Manager

7.5.     In addition to the training provided for each individual, line managers in a major incident need to be equipped to play the vital role of promoting and monitoring the well being of their subordinates.  They will require training in the managerial aspects of staff care, in the tasks of personal and task supervision, in violence management, and in monitoring their staff on a personal level, and through monitoring absences.  In preparing for major incidents, particular emphasis needs to be given to specific training, stress-management and monitoring, and to the uses of debriefing and counselling. The objective is to encourage line managers, who are the key players in a comprehensive staff care strategy, to develop and deploy the supervisory and advisory skills.

 

The management team

7.6.     All managers should be familiar with the aspects covered at the lower levels of the organisation. The objective is to secure selection, staffing and deployment policies, which will attempt to build good staff, care practices into these procedures.

 

The organisation

7.7.     A comprehensive staff care strategy will encourage an organisational climate within which staff care policies and practices are emphasised.  The organisation will provide resources to enable staff to work effectively and to enable staff to access staff care resources. The objective is to set an appropriate organisational climate and to support this with adequate resources.

 

Staff Care in a Major Incident

7.8.     The crisis creates conditions of acute stress, and the longer-term work with affected people can induce chronic stress in workers.  The following factors, which are helpful in minimising the risk of psychological harm, are these:

Selection – Staff should be selected against criteria, which seek to ensure that they have the necessary attributes, experience and training to carry out the task without experiencing undue stress.

Experience – Staff who have experienced crises, and come through them without suffering unduly will have acquired skills and strengths, which will help them to cope with future crises.  The converse is also true.  Individuals who react badly to crises should not be selected.

Training – People who know what to expect and what is expected of them, experience less stress than conditions of a crisis.  There is also a protection against Post Traumatic Stress Disorder, in explaining to people the psychological processes they will encounter in themselves and others.

Organisation – A strong management structure and clear role definitions will enable staff to attend to their part in the effort without having to consider whether there are other tasks with which they should be engaging.  Focusing on the job at hand is known to be protective.

Supervision – A strong management structure must also be sensitive to those it manages.  The established tradition of supervision in SSD’s will be invaluable in monitoring the well being of staff.  This requires organisational commitment in order to put the appropriate mechanisms in place.

Briefing – Well-briefed staff are protected from the elements of surprise and helplessness.  Letting people know exactly what they will be required to do, helps them to cope.

Discipline – In crises, work discipline should be tightened.  It is important in maintaining efficiency, but it also gives people the psychological protection of handing over responsibility for the broad outline of what they do to someone else – especially when to become involved and when to leave the situation.

Support - People need to feel that what they are doing is valued by the organisation they are doing it for.

Debriefing – This is a formalised method of helping people to articulate issues and feeling to do directly with the work they have done and to enable them to continue work effectively.  (See Annex B7)

People under stress - are uniquely vulnerable to addiction and consuming alcohol in a social situation, involving colleagues is NOT a substitute for formal debriefing: it is essentially an attempt at suppression, rather than at understanding.

Exercise and recreation -The quickest way to get rid of toxins produced under stress is to exercise. Some recreational activity, which empties the mind of the stresses of the day – is also beneficial. 

Counselling – There should be access to personal counselling if the symptoms warrant it.  Arrangements should include partners and other family members.

 

Organisation

7.9.      If a staff-care programme is already in place, team leaders and other line managers should access key personnel and ensure that an effective service is delivered. If such a programme is not in place, team leaders and other line managers should procure the help of a consultant (see below), on the first day of the emergency. The consultant should work with the management team to define what is needed, in addition to existing resources and how it will be delivered. The Association of Chief Police Officers (ACPO) provides a Disaster Team consisting of people who have experience of disasters and are able to provide advice. (ACPO can be contacted on: 020 7227 3434 or e.mail: info@acpo.police.uk The use of an independent consultant, or a manager knowledgeable in this area is recommended to protect the organisation’s interests and avoid over provision.

Minimum Provision

In the absence of a staff care strategy, the minimum direct provision required is:

·           a proactive debriefing service;

·           an independent, well publicised, but discreet counselling service.

Termination

It needs to be made clear to Core Crisis Team (CCT) members at selection, during training and at every subsequent opportunity, that they will be engaged for a limited period, after which the Rehabilitation Phase arrangements will be put in place. The reasons for this are as follows: 

a.             the winding down of crisis responses - especially after a disaster -can be problematic for responding organisations and workers due to the urgency of the work’s excitement; the emotional investment (e.g. perceived importance; the relationships developed with victims; a wish to remain engaged in the work) making it difficult for workers readily return to their previous, or similar, posts.

b.             Conflict and resistance can result, where there should be a managed transfer of a response/ tapering between workers and/or organisations. Along with other stresses inherent in the work, this can lead to feelings of depression, disillusion and debility in workers, which can drive them out of their particular profession.

c.             A firm date of termination for their effort will be protective for members of the CCT as it provides a psychological horizon to their work, and allows the organisation to plan.  (See Section 10).  To maintain protective effect, workers must be represented or preferably, fully consulted in all discussions, which could lead to an earlier termination of their part of the response. 

d.             As termination becomes closer, the work should be acknowledged by review days and other events, as appropriate, thus progressing disengagement from the task. Some resistance may be experienced to termination, based on the argument that clients should experience a continuity of relationship, that clients will resent the change and to entering into a new relationship with another worker. But careful planning and introduction of new workers should minimise the extent to which clients refuse to accept change.

e.             It is known that prolonged involvement in crisis and its aftermath is detrimental to worker, so the emphasis should be placed on protecting workers interests.

f.               It is probable that some CCT members will try to stay engaged in the work by seeking employment in any longer term arrangements which may be set up, though not ideal each case should be treated on its merits. There may be difficulty in recruiting sufficient workers to staff a longer-term service, if so some outside involvement from a consultant knowledgeable in the problems posed by longer-term immersion in disaster work would be beneficial.

 

CONSULTANCY

Knowledge  Needed 

7.10.   The presence of an expert outsider can be very beneficial.  It helps greatly if they have substantial knowledge on the following subjects:

·        Crisis management

·        Organisational psychology

·        The effects of crisis at all levels, including victims.

 

To Facilitate Effective Consultancy

7.11.   Choose consultants who are expert and objective.  A formal knowledge base is valuable.  Direct experience of previous crisis can also be valuable, but direct involvement in the same may be a disadvantage, undermining the person’s capacity to be objective.  Following from the above where expertise exists it is vital to accord the consultant the status of expert.

Retain consultants long enough to complete their tasks (for instance the initial response recommended may be elaborate, but would be wound down by them within weeks if they were given the time, thus matching effectively demand to supply.)

As the consultant has no effective knowledge of how the Department has currently been functioning or has previously functioned, the most effective technique will be for the consultant to work closely with the Major Incident Management Team.  This will enable the Team to take care of their own emotional needs through the support and advice offered and thus ensure a more effective level of functioning.

 

Principal Activities of Consultant

7.12.   Educational – informing the organisation of what the consequences or events, actions or omissions are likely to be and why.

Validation – checking that what has been put in motion makes sense and that there have been no significant oversights.

Monitoring – encouraging monitoring of the situation as it unfolds, to spot any new needs or redundant provision.

Conceptualising – those caught up in a crisis may often find it difficult to think analytically and thus unravel problems.  A consultant’s knowledge of relevant texts and documents may prove invaluable.

Presenting the problem – enabling a succinct and coherent presentation of the problems, scale and implications to be made to officials and politicians.

Problem solving – coming up  with solutions to problems that seem insoluble or are being avoided.

Tapering – supporting the de-commissioning of the effort, using theory and analysis to support and augment common sense.

 

Judging Effectiveness  

7.13.   Reviews of the effectiveness of consultancy must be based on organisational debriefing, if they are to have any real validity.  North West or adjacent SSD’s (for instance Liverpool) have used consultants and they may have useful insights to offer regarding their own experiences.

 

Post Traumatic Stress Disorder (PSTD)

7.14.   The Concept of PSTD originated from Freud, First World War shell shock and Vietnam. There is a legal and medical definition of PSTD (see Annex 7b), which links the range of symptoms to a specific time of stress. This formal definition does not capture the complexity and potential impact of on survivors or agency workers.

Two hallmark symptoms are: trauma related intrusions into consciousness and a numbing of response. Both these factors can be present in an individual.

The trauma incident will influence the survivor according to their belief system and how much that incident calls the belief system into question. “I can handle anything” or “God is benevolent” would be two examples. It is usual for the survivors and bereaved to react emotionally (albeit in quite different ways to extreme events, their initial responses are therefore not necessarily indicative of PSTD).

 

Implications for SSD Response

7.15.   There is no need to start support work from an assumption that the traumatised or bereaved person should be counselled in the usual sense that implies a need for a counselling qualified practitioner. What is essential for any helper responding to a major incident is that the helper should be sufficiently prepared to and psychologically robust to act with total sensitivity (respect for the individual /family/culture uniqueness) in terms of the following psychological first aid:

Comforting, protecting from undue disorientation, meeting practical and physical need, helping survivors form new goals, providing support in ‘reality tasks’, re-establishing security, forming or re-connecting to support networks, bringing together information on the survivors/ for future helpers, potential referral to psychiatric help.

The overall function of the SSD helper is not concerned with ‘treatment ‘ or ‘cure’ (there is no cure for life changing events) but with orientation – mapping out the issues and help sources for those affected. Listening to the survivors’ story is an aid to sanity – but the larger objective is helping the individual towards building up their social and psychological defences so as to minimise the onset of PSTD. All disaster work should assume that all SSD helpers are potentially at risk from PSTD themselves and monitor and support accordingly.

 

De- Briefing – Survivors and SSD and Related Staff.

7.16.   (Introduction by Ben Heal Training Officer Sefton Social Services)

The Manual does not prescribe a specific approach to de-briefing – so much depends on the nature of the incident – but it is keen the reader is aware of the potential dangers highlighted in some contemporary research. In broad terms de-briefing refers to the process by which survivors/friends and relatives  or helpers are called together collectively to contribute both factual and emotional responses relating to their involvement in the incident. Such de-briefings have tended to follow a military model. De-briefing which is brief, purely functional and overly directive has been criticised by some researchers as being at the least ineffective and at the worst damaging to those de-briefed. It may raise issues and emotions for the individual, which are not dealt with in the group or are simply not suitable for further work in a group setting. This criticism should not be taken to apply to the use of meetings for the purpose of information gaining to form a more complete picture of the event and the response, or to give information to workers or survivors/friends and relatives. These would be good practice in terms of giving helpers information to inform their decision making and making sense of the event. Such meetings would also be useful for survivors/relatives and friends in that it empowers them with information for which most need to start making meaning of a reality-threatening event. The criticism relates more to de-briefing, which raises emotional issues in individuals and families, which are then not sensitively supported or monitored; without ongoing monitoring such de-briefings are potentially dangerous in mental health terms. The de-briefing may be momentarily cathartic in releasing emotions but it is the longer term responses and support that is important  So there is an ongoing need for monitoring  by those helpers  or professionals who have  an eye to note that  over time, for some individuals  their numbness and disorientation is not fading or other symptoms have emerged.

 

Conclusion:

7.17.   We would recommend any positive responses to survivors, staff and friends and relatives would do well to be guided by Herman’s advice (see appendix) that dis-empowerment and disconnection are likely to be the central problems. If the individuals remain dis-empowered and disconnected these are potential precursors to PSTD. It would seem important therefore that the SSD welfare response follow the psychological first aid model outlined above. In both the short term and the long term, work should constantly be influenced by how it can empower the survivor /friend & relative/ worker. It must ensure they get as much help as possible in reconnecting socially, gaining practical, emotional and social support - the better to build up their psychological defences.  

 

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Two annexes following this chapter: click to go direct to the Annex

Annex A7: A Staff Care Strategy

Annex B7 - Post Traumatic Stress: An Outline by Howard Davis

 

ANNEX 7

A STAFF CARE STRATEGY

ANNEX B7

Post Traumatic Stress: An Outline

by Howard Davis

Modern approaches to psychological trauma have two related antecedents. The first approach is derived in the discovery by Freud (1896), of histories of sexual abuse among his women patients. Freud originally claimed that these experiences caused symptoms of ‘hysteria’, and began to develop a way of working named by one patient as ‘talking cure‘. This could be long term work, out of which facing the reality of the trauma would produce a healing ‘catharsis’. The development of person centred counselling in the latter half of the twentieth century also placed emphasis on long-term exploratory work. This approach differed form psychoanalytic approaches however in that it aimed to be less ‘directive’, viewing  ‘diagnosis,’ with suspicion, and allowing the client to be the author of her or his own ‘growth’.

The second antecedent was grounded in the crisis faced by the military, and by military medicine when ‘shellshock’ began to count for massive numbers of soldiers in the Great War. The responses were varied and included variants of Freudian approaches. However over the course of the twentieth century, military requirements led to san approach, which emphasised treatment that was prompt, brief, directive and aimed at returning the soldier to duty.

It is worth recounting this brief historical account, not least because several of the controversies surrounding trauma during these early years continue to resonate today. These included, for example:

·        Concern that ‘trauma’ might excuse ‘malingering’, ‘cowardice’ or ‘weakness’ continue to be applied today.

·        A potential conflict between what might be ‘best’ for a patient ‘s ‘health’ as against what might be in the organisational (military) or social interest.

·        Dispute over what was the best treatment. Physical treatments, as a well as varying (and sometimes contradictory) ‘ counselling ‘ therapies.

Eighty years after Freud had first  ‘discovered’ the mental distress deriving  in ‘domestic’ terror, its rediscovery by feminist and medical researchers coincided with the return of veterans from another war. This time they were Americans and the returned from was Vietnam. It was directly out of the struggles of these veterans and the mental health professionals who worked with them, that the current diagnostic category of PTSD was born.

What is PTSD? Traumatisation and Diagnostic Criteria

During Trauma:

“… one’s guiding “paradigms” – one’s fundamental assumption – are seriously challenged and an intense psychological crisis is induced…  The assault on fundamental assumptions is massive… Core assumptions are shattered by traumatic experience “(Janoff-Bulman 1992:51-52)

It is perhaps easiest to think of traumatic reactions as a combination of two and opposite dynamics.  The extreme experience is so intense and threatening, emotionally and cognitively, that aspects ‘intrude’, unwanted, into the consciousness.  They may take the form of nightmares, physical reactions, flashbacks or other symptoms.  Working against this ‘intrusive dynamic is a second dynamic of ‘avoidance’ or ‘numbing’.  This may be thought of as a defence against the overwhelming potential of the first.

Experiencing symptoms that manifest these two dynamics is not in itself unhealthy.  On the contrary, in the short term at least, it is generally felt that a healthy human being will and maybe even should experience some reaction to extreme events.  The dynamics are thus believed to be part of a process in which the survivor tries to come to terms with, and make sense of, what has happened.  This might be a long process as very fundamental beliefs, assumptions and values may be overthrown by traumatic events.  ‘Dominant myths’ about ‘fairness’, safety or security may be challenged by traumatic experience.  Being overwhelmed by emotions is in itself a serious challenge for people who consider themselves to be ‘rational’, ‘copers’, or emotionally ‘in control’.  The actions taken by ‘Survivor guilt’ may in part derive in such desperate actions, or simply in the fact of survival itself.

Whilst short-term post-traumatic reactions are not necessarily considered abnormal, PTSD is a psychiatrically defined disorder.  Although the criteria for PTSD have changed somewhat since 1980, its essential feature remains the linking of a range of symptoms, to the existence of a psychologically traumatic ‘recognisable stressor’.  In the DSM-IV (American Psychiatric Association 1994; 427-428) the concept of the stressor is defined as when:

1.  the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (and)

2.      the person’s response involved intense fear, helplessness, or horror.  Note: In children, this may be expressed instead by disorganised or agitated behaviour.

The traumatic experience needs to be followed by a minimum number of symptoms from each of three categories: one (or more) symptoms of the event being re-experienced, three (or more) symptoms of avoidance or general numbing, and two (or more) symptoms of increased arousal (see figure 1, below). The first and third of these categories in combination can be thought of as representing the first of our two ‘intrusive’ dynamics.  The second category can be thought of as representing the second.

Figure1 Diagnostic Symptoms of PTSD (DSM-IV)

Diagnostic Symptoms of PTSD (DSM-IV)

These symptoms must persist beyond one month and cause clinically significant distress or impairment in functioning (media comments –sometimes within hours - that people are suffering PTSD are therefore inaccurate).  Although symptoms generally improve over two or three years this does not apply evenly to all symptoms or survivors.

PTSD has not been without its critics. Criticisms of the definition and its application include:

·        The definition is arbitrary –what if for example a person suffers many symptoms in one category but not ‘enough’ in another?

·        The cut off between ‘normal’ reaction and ‘disorder’ set arbitrarily at one month, makes no allowance for differences in the severity, duration or repetition of the stressor.

·        PTSD criteria lack the necessary depth and complexity to fully describe post- traumatic reactions. Anxiety and depression for example, whilst common reactions to trauma, are not presented as PTSD criteria. (Borderline Personality Disorders, Multiple Personality Disorder and Schizophrenia, each controversial diagnostic category in themselves have been linked with traumatic experience) 

·        Symptoms of avoidance are easily missed:

They lack drama, their significance lies in what is missing…(Yet with the passage of time, as these negative symptoms become the most prominent feature of the post-traumatic disorder, the diagnosis becomes increasingly easy to overlook. Because post-traumatic symptoms are so persistent and wide ranging, they may be mistaken for enduring characteristics of the victim’s personality. (Herman 1992)

Responding to Psychological Trauma

i.          Psychological First Aid and sensitive ‘Processing’

Contrary to media impressions, it is misleading to suggest that relatives of the bereaved and survivors should be ‘counselled’ immediately after a major disaster.

(At least in terms of exploratory counselling. The term counselling is itself problematic as it now describes so many different and often contradictory approaches) This is an important example of the general point that psychological defences should be acknowledged and respected as they can provide necessary protection from apparently unendurable pain. (Hodgkinson and Stewart 1991).

The inappropriateness of exploratory counselling in the immediate aftermath does not minimise the significance of a sensitive response. Initial, acute distress often coincides with the period during which support workers first become involved. Critical is the incorporation of sensitivity throughout the overall initial response:

Because the roles involved in psychological first aid are so linked to many other essential tasks in the immediate aftermath, they should, wherever possible, be carried out in association with these tasks and with the recognition of and collaboration with other emergency workers  (Raphael 1986:260).

(Those affected by disaster inevitably become engulfed by a maelstrom of events and processes of which they have little if any prior knowledge. Such processes can increase emotional vulnerability while denying those suffering any control over events. Their particular form depends on the nature of the disaster.  Some official interventions involve the meeting of survivors ‘ physical needs, but even these can have negative psychological consequences.  For example Brook (1990) argues that mental health problems after the Buffalo Creek flood disaster were largely attributable to re-housing policies that divided communities and damaged pre-existing networks of support)

In the immediate aftermath of disaster the helper may be faced with the temporary cognitive and emotional disorganisation of those affected. The worker needs to consider how this can be addressed to mobilise and increase personal competence and skills. Raphael (1986) provides tasks for “psychological first aid’. These include:

·        Comforting and consoling

·        Protecting the disorientated

·        Meeting physical needs

·        Goal orientation

·        Support in the ‘reality tasks’ that are necessary (including searching for loved ones and the identification of the dead)

·        The re-establishment of some sense of security in the real world.

·        Utilisation and promotion of networks.

·        Assessment of those who may need psychiatric care.

·        Collection of data to enable follow-up.

According to Scott and Stradling (1992:appendix D) the role of “crisis counselling” at times of emergency:

“….is more one of orientating than of treating, mapping out for the client the sort of difficulties that might be encountered and the directions from which means to resolve the problems might be found.  The goal crisis counselling is to help the client get their bearings”.

Raphael (1986:259) concurs, stating that:

“Some ventilation of feelings may occur spontaneously and should be accepted, but always with the idea of helping the victim to reconstitute his (sic) defences and regain control until he is in a more secure emotional situation with support for more in-depth working through of the experience”.

While it may be desirable for the bereaved to re-establish some measure of cognitive and emotional organisation, however, it is important in each situation that practitioners are clear about whose interests are served in ‘promoting’ the re-establishment of ‘control’.  It should not lead to the control of grief by highly pressurised and mechanistic agencies.  Individual workers, unable to face the intensity of survivors’ distress, may unconsciously promote ‘control’ to protect themselves.  While for some individuals ‘professionalism’ masks an inability to bear the distress of another human being (Gibson 1991:64) so the institutionalisation of such responses in policy and practice, controlling and managing the distress of survivors and bereaved, must be prevented.

The development of functional, directive approaches to trauma was originally grounded in the relations of military authority.  Today they remain directive, short in duration, and symptom focused.  They include some of the approaches to ‘psychological debriefing’, which have become characteristic features of the immediate response to trauma.  Used originally with combat personnel they have been the focus of recent criticisms in the psychiatric journals that at best they make no difference to symptoms, and that at worst they may even make matters worse.  There are, it should be emphasised, models of debriefing which are rooted in less directive traditions and to which the recent criticisms cannot automatically be extended.  It is also true that groups and networks of survivors will spontaneously emerge following disaster.  They will naturally want to talk and to share.  This should be facilitated but with a view to ongoing support, rather than as a ‘cure’ in itself.

ii. Helping in the Long Term

The core experiences of psychological trauma are disempowerment and disconnection from others.  Recovery, therefore, is based upon the empowerment of the survivor and the creation of new connections.  (Herman 1992:133)

It follows, on this view that:

The first principle of recovery is the empowerment of the survivor…  Others may offer advice, support, assistance, affection, and care, but no cure.  Many benevolent and well-intentioned attempts to assist the survivor.

Research into the aftermath of major disasters demonstrates how poor dissemination of information and denial, restriction or insensitive administration of the viewing of bodies for example cause extreme distress (Coleman et al 1990: Davis and Scraton 1997)

There are several models of debriefing and Shalev (1994:214) identifies their common elements:

“Debriefing is usually done shortly after a traumatic event.  It is usually practised at the site of the action or within the same organisational setting in which the exposure took place.  Debriefing is conducted in groups, with individuals who have been exposed to trauma.  It involves a degree of cognitive review of the event and has a factual basis.  It includes verbal and emotional exchanges within the group, and results in the sharing of various levels of information and most often in reframing previous views and learning new information”.

Founder because this fundamental principal is not observed…. (Herman 1992:133)

It is important that the ascription of a medical ‘label’ should not lead workers to recoil from trauma survivors through anxiety that only ‘experts’ can really help.  Certain basis human qualities and professional skills are fundamental in helping relationships.  Empathy, genuineness and non-possessive warmth, for example are frequently cited.  The skill of real listening derives in them.  ‘Experts’ have no monopoly on such qualities.  On the other hand it should be recognised that although they are sometimes cited as ‘basic skills’ they are ‘basic’ in the sense of ‘fundamental’ rather than ‘simple’ or ‘easy’.

More directive approaches emphasise the application of specific techniques rather than the character of the therapeutic relationship.  In cognitive approaches ‘dysfunctional’ ways of thinking must be challenged and changed.  The extent to which the cause of events during the Herald of Free Enterprise Disaster were believed to originate internally, and to be controllable, was related to ‘poorer’ psychological outcomes (Joseph et al 1991).  Duckworth (1991:20) criticises ‘non-directive’ approaches as likely to sustain rather than reduce feelings of guilt:

When a person’s way of interpreting and evaluating the traumatic events amounts to building a psychological trap, and is thus pathogenic, merely helping to clarify and understand can amount to reinforcing the structure of the trap when really it needs to be dismantled.

Others are more circumspect.  Herman (1992:67) cautions that:

“…..simple pronouncements, even favourable ones, represent a refusal to engage with the survivor in the lacerating moral complexities of the extreme situation.  From those who bear witness, the survivor seeks not absolution but fairness, compassion, and the willingness to share the guilty knowledge of what happens to people with extremity”.

Herman (1992) and Janoff-Bulman (1992) suggest that ‘recovery’ may actually be facilitated by some acceptance of responsibility for what happened during the traumatic event.  Believing a traumatic event to have been totally beyond one’s control, it is argued, leaves the survivor feeling totally vulnerable to the same thing happening again.

There are clearly difficult moral, as well as medical questions here.  ‘Dysfunctional’ or ‘pathogenic’ thinking is not always irrational any more than thinking 'rationally' is always ‘healthy’.  Janoff-Bulman (1992) argues that trauma does not so much cause people to think ‘irrationally’, as shatter previously held over-optimistic generalisations about the world and self.  From this perspective, post-trauma fears, anger at injustice, even lowered self-esteem might be understood as more ‘rational’ more realistic than previous beliefs.  This does not mean that they would promote ‘health’ or functioning, indeed they may be very uncomfortable indeed distressing realities.  As Janoff-Bulman (1992:171) states:

“Trauma survivors do not simply get over their experience.  It is permanently encoded in their assumption world; the legacy of traumatic life events is some degree of disillusionment”.

Social reaction can be profoundly negative toward survivors of trauma.  Those who survive trauma, are reminders of uncomfortable questions.  In western society ‘ …our primary myths emphasise justice and control, optimism and a positive outlook…..There is little place for losers’ (Janoff-Bulman 1992:154.  Workers do not stand outside of this culture.  Their own intensive exposure to traumatic experience ‘by proxy’ creates its own difficulties.  Danieli (1984) details the powerful problems of counter-transference encountered by psychotherapists working with survivors of the Holocaust and outlines the negative ways this impacted upon their practice.  Dasberg (1992:49) concludes that professionals do not stand apart from the social shunning of survivors.  Rather, they may:

“Behave towards the re-entering victims with exactly the same attitudes as the societies they belong to.  In other words, they turn away”.

What is crucial here is the nature and standard of supervision available to workers.  In longer-term work with survivors, the practical tasks of ‘normal’ work become less important than the processes within the exploratory and hopefully therapeutic relationship.  This requires supervision resembling a ‘counselling’ model more than a ‘casework’ one.  Workers may require more even than this if their long term daily routine is to listen attentively for the pain and distress of others.  As Rowan (1983:82) writes:

It is impossible really to listen for feelings without having feelings yourself.  Hence this kind of listening (sometimes called empathy) can be hard on the therapist unless the therapist has fully worked through the same level of feelings in themselves.

The construction of ‘disorder’ defined by ‘symptoms’ implies the amelioration of these symptoms in treatment.  But the amelioration of symptoms may not be sufficient. Janoff- Bulman (1992:164) distinguishes between therapies (behavioural, cognitive and pharmacological) which avoid, or minimise the trauma experience, and those (insight, psychodynamic, art and hypnosis) which approach the trauma.

A combination of therapies may be required; in many cases, techniques that minimise anxiety may first be necessary, and more “approach” modalities (e.g. insight therapies) may be effective only after these “avoidance” techniques are successful.

References (see bibliography for full details)

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, pp 427 –428.

Brook R. An Introduction to Disaster Theory for Social Workers, (Social Work Monographs, No. 85.p 7, 1990)   

Coleman S. Jemphrey A. Scraton P & Skidmore P.  Hillsborough and After: The Liverpool Experience. First Report.  – (1990)

Danieli Y. – Psychotherapists Participation in the Conspiracy of Silence about the Holocaust.   Psychoanalytic Psychology (1984)

Dasberg H. – The Unfinished Story of Trauma as a Paradigm for Psychotherapists: A review of some empirical findings and prejudices. (Psychiatry and Related Science  p.49  Vol. 29 No.1 1992)

Davis H & Scraton P. Beyond Disasters: Identifying and Resolving Inter-Agency Conflict in the Immediate Aftermath of Disasters (draft)- 1997 Research commissioned by the Emergency Planning Research Group, , Home Office.

Duckworth DH.  Facilitating Recovery from Disaster – Work Experience. British Journal of Guidance and Counselling. ( p.20 Vol. 19. No1 January 1991) & Everyday Psychological Trauma in the Police Service. Disaster Management (Vol.3  No4, 1991).

Gibson  M. Order From Chaos: Responding to Traumatic Events ( p 64, Chapter 4) – (1991)

Herman J & Harvey MR. The Trauma of Sexual Victimisation Feminist Contributions to Theory, Research and Practice – PTSD Research Quarterly ( p. 67 & 133, Vol.3 No.3 Summer 1992)

Hodgkinson P & Stewart M. Coping with Catastrophe: A Handbook of Disaster Management. p.167, (1991).

Janoff & Bulman R & Morgan HJ - Victims Responses to Traumatic Life Events: An Unjust World or an Uncaring World? (Vol.7 No.1 pp 51-52, 154, 164, 171, 1994)

Joseph SA. Brewin CR. Yule W  & Williams R. – Casual Attributions  and Psychiatric Symptoms in Survivors of the Herald of Free Enterprise Disaster. British Journal of Psychiatry (1991)

Raphael B. When Disaster Strikes: a handbook for the caring professions. p 259-260, (1986)

Rowan J. The Reality Game: a guide to humanistic counselling and therapy. – p. 82  (1983)

Scott MJ  &  Stradling SG. Counselling for Post Traumatic Stress Disorder –Appendix D, (1992 – Counselling in Practice)

Shalev AY. Debriefing Following Traumatic Exposure Chapter 9  – from: Ursano RJ (ed) Individual and Community Responses to Disaster: The Structure of Human Chaos. p. 214, (1994)

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