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Work-related
Psychological Trauma

The Australasian Journal of Disaster
and Trauma Studies
Volume : 1998-1


Work-related psychological trauma:
A social psychological and organisational
approach to understanding response and recovery


Douglas Paton, School of Psychology, Massey University, Palmerston North, New Zealand. Phone +64 6 350-4118 Fax +64 6 350-5673 Email: D.Paton@massey.ac.nz
Leigh M. Smith, School of Psychology, Curtin University, Perth, Western Australia. Email: L.Smith@psychology.curtin.edu.au
Christine Stephens, School of Psychology, Massey University, Palmerston North, New Zealand. Phone +64 6 350-4118 Fax +64 6 350-5673 Email: C.V.Stephens@massey.ac.nz

Keywords: Debriefing, organisational environment, social psychology, cognitive theory

Douglas Paton 1
Leigh M. Smith2
Christine Stephens1

1. School of Psychology, Massey University, Palmerston North, New Zealand
2. School of Psychology, Curtin University, Perth, Western Australia


Abstract

The question of the effectiveness of psychological debriefing has stimulated considerable debate. Evidence is contradictory. While evidence for its effectiveness is apparent when evaluation is conducted shortly after intervention takes place, it becomes less likely as the time interval between debriefing and intervention increases. This paper adopts an organisational psychological approach to ask what might happen during this interval to influence effectiveness. It explores the theoretical nature of work-related traumatic stress reactivity and the context within which reactions occur and recovery takes place. Cognitive, social and organisational influences on response are identified and used to tentatively offer explanations for the differential effectiveness of debriefing observed in evaluation studies. General conclusions regarding the implications for intervention effectiveness and design are discussed.


Work-related psychological trauma:
A social psychological and organisational
approach to understanding response and recovery


Introduction

Widespread acknowledgement within several professions of the risk of exposure to traumatic occupational demands faced by their membership has stimulated the development of interventions designed to assist the recovery of those affected. Psychological debriefing is the most commonly provided resource in this context (Raphael, Meldrum & McFarlane, 1995). Although in common use, the term 'debriefing' covers a range of interventions (McCammon & Allison, 1995; Shalev, 1994). The implications of this diversity, and particularly the need for evaluation studies, is discussed elsewhere (Bisson & Deahl, 1994; Kenardy & Carr, 1996; Raphael et al., 1995; Robinson & Mitchell, 1995; Shalev, 1994). This paper will contribute to the evaluation debate by exploring the conceptual and theoretical underpinnings of traumatic stress reactivity and its implications for the development and administration of interventions designed to assist recovery in populations affected by work-related traumatic stress. We will start by briefly reviewing the evidence for the effectiveness of psychological debriefing as a means of reducing psychological morbidity following traumatic exposure.


Debriefing as a recovery resource

Support for the effectiveness of debriefing has been cited in several studies (Busuttil, et al., 1995; McFarlane, 1988; Robinson & Mitchell, 1993, 1995; Shalev, 1994). However, some studies have concluded that psychological debriefing had no effect on subsequent psychological morbidity (Deahl, Gillham, Thomas, Searle, & Srinivasan, 1994; Hytten & Hasle, 1989; Kenardy et al., 1996; Stephens, 1996). Others conclude that debriefing may exacerbate psychological morbidity over time (Bisson, Jenkins, Alexander & Bannister, 1997; Carlier, Lamberts, Van Uchelen, & Gersons, in press; Hobbs, Mayou, Harrison & Worlock, 1996; Griffiths & Watts, 1992; McFarlane, 1988). Concerns about effectiveness are not restricted to the academic community. Orner (1997) reports that one Emergency Services group in the United Kingdom has questioned the efficacy of CISD. Similar questions are being raised by other consumers (Dunn, 1997; MacKenzie, 1996). Such contradictory findings indicate a need for additional research. The methodological issues that should be pursued to clarify intervention effectiveness are discussed elsewhere (Kenardy & Carr, 1996; Robinson & Mitchell, 1995).

This study will explore the implications of the post-event social and organisational environment for recovery. In the above evaluation studies, evidence for the effectiveness of debriefing was often forthcoming when evaluation was conducted shortly after the intervention was provided, but less likely as the time interval between the precipitating event and the evaluation increased. This paper raises questions about what might happen during this interval to influence recovery. It will do so by exploring the theoretical nature of work-related traumatic stress reactions and the context within which reactions occur and recovery takes place.


Theoretical issues

Intervention effectiveness will be driven, at a basic level, by the consistency between intervention process and content and current theoretical understanding of the psychological basis of traumatic stress reactivity. In a recent article Robinson and Mitchell (1995) reiterate the point that the most popular approach, Critical Incident Stress Debriefing (CISD) is based on crisis intervention theory. However, Belkin (1988) points out that crisis intervention theory describes practical intervention principles rather than theoretical or a priori constructs. While consistency with crisis intervention principles provides procedural justification for the use of CISD, crisis intervention theory does not provide a comprehensive theoretical basis for defining the factors that influence traumatic stress reactivity and which should be catered within recovery intervention processes. The need for a wider framework has been acknowledged by several authors (Dunning, 1994; Robinson & Mitchell, 1995). The latter authors discuss this issue under the term Critical Incident Stress Management (CISM). The recognition of a broader base is important for both researchers and practitioners. This is consistent with the goal of this paper which is to draw upon pertinent theoretical bases to define the factors that could influence work-related trauma reactivity and recovery.

The starting point for the present review is some recent work exploring the nature of the traumatic stress construct (Smith, Paton, Ramsay, & Akande, in prep). Instruments used to assess traumatic stress, as is true for any psychological construct, are used on the assumption that there is a degree of stability in the psychological constructs they seek to assess. In the present context it is assumed that the underlying construct 'traumatic stress' is robust and homogenous and manifests itself in the same way in all those affected. This assumption provides a consistent platform for intervention planning, design, administration and evaluation (Paton & Smith, 1996). Smith et al., (in prep), reporting the results of a structural re-assessment of Impact of Event Scale (IES) data obtained from over 1600 subjects drawn from several populations who had experienced traumatic incidents while performing their professional duties, suggest that this assumption may not be justified.

Their structural re-analysis revealed that, at least with respect to the core diagnostic indicators of traumatic stress reactions, intrusion and avoidance, professional status, organisational membership and nationality influence the nature of work-related traumatic stress reactions. The extent to which the responses of each group were structurally different is evident in figure 1. Smith et al's. ( in prep) study reveals that work-related traumatic stress reactions cannot be attributed solely to exposure to a specific traumatic incident. Rather traumatic stress reactions reflect causal influences emanating from the interaction between a traumatic event and factors that reflect national origin, and organisational and professional membership. This conclusion supports the argument that the physical, interpersonal and performance context of work interact with the demands of the traumatic experience to alter the character and intensity of the traumatic experience (Dunning, 1994). A prominent role for organisational factors in stimulating the nature of traumatic stress reactivity suggests that intervention procedures should be designed to manage the consequences of a specific traumatic incident and the organisational and professional context within which it occurs. This observation also implies that evaluation should take place over time and against a backdrop defined by the work environment.

A more prominent aetiological role for organisational factors in the development of post-trauma reactions raises an issue that relates less to the question of debriefing effectiveness and more to the manner in which a focus on a given intervention can preclude or hinder the exploration of traumatic stress from other perspectives. Psychological debriefing is often described as a preventative intervention. The term 'prevention', as used in this context, refers to the goal of minimising reactivity after an individual has been exposed to a traumatic event. This approach tends to encourage the view that traumatic stress reactions are an inevitable consequence of exposure to particular kinds of events (Dunning, 1995). A focus on the post-event management of individual reactivity has diverted attention from exploring personal, group and organisational factors that could serve to promote adaptation and minimise impact. Acknowledging that professional and organisational status influences the nature of traumatic stress reactivity and recovery makes it easier to appreciate the potential for strategies that can be used to prevent or minimise reactions prior to exposure as well as managing reactions following involvement. This issue will be particularly pertinent for professions whose members face exposure to traumatic incidents repeatedly throughout their careers (Dunning, 1990; Lundin & Bodegard, 1993; Paton, 1994). It suggests that appropriate interventions such as organisational change, job re-design, training, and managerial development have a role to play in the management of work-related traumatic stress.

Figure 1
Figure 1: Differences between groups defined by their location in a two dimensional space by derived subject weights. Adapted from Smith et al (in prep).


Issues for further investigation

Social and organisational conventions, roles, norms and work practices influence occupational well-being under normal circumstances. Since their influence is unlikely to be suspended in the aftermath of a traumatic event, there exist good reasons for anticipating that these will influence the nature of work-related psychological trauma and affect the recovery process. This points to a need for a more expansive conceptualisation of work-trauma reactivity and recovery processes than has existed in the past.

As a starting point, one approach involves drawing upon existing theoretical and practical literatures that illuminate the relationship between people, organisations and psychological well-being. The organisational aspects are particularly relevant when dealing with work-related psychological trauma because the work environment defines the context within which the traumatic experience occurred and within which recovery will take place. Robinson and Mitchell (1995) argue that one of the primary goals of debriefing is to restore people to normal functioning within their routine environment as soon as possible. For work-related populations, the therapeutic implications of returning to work have been acknowledged (Dunning, 1994; Paton, 1997). Achieving this goal requires that interventions are designed to facilitate a survivors' ability to manage subsequent environmental demands. Determining whether this goal is met can only be accomplished by evaluating the effectiveness of an intervention after people have returned to the workplace. While Robinson and Mitchell (1995) were correct in arguing that exposure to intervening events and demands complicates the process of evaluating the effectiveness of a debriefing per se, following individuals over time provides valuable insights into the nature of the interaction between recovery resources and the recovery (work) environment. It is thus important that evaluation be conducted at several points during the post-event period. The need for normative and pre-event data, and appropriate methodological approaches, is also indicated by this shift to a more longitudinal approach (Paton & Smith, 1996; Robinson & Mitchell, 1995).

In addition to developing an understanding of how the environment affects recovery per se, we also need to explore the manner in which support or recovery interventions interact with environmental variables to determine the nature and rate of recovery. Insights into why debriefing may work in some cases but not others, and why it may exacerbate psychological morbidity in some, may be gained in the process.

An appropriate starting point is to examine the personal, cognitive, social psychological and organisational variables that could influence post-trauma reactivity and recovery. A more prominent role for organisational and professional variables in the aetiology of work-related traumatic stress than has previously been acknowledged means intervention can also be conducted at the level of organisational analysis and re-design. Isolating organisational determinants of traumatic stress reactivity will furnish information that can serve as a basis for designing salutogenic working environments. In reality, there will be considerable overlap between these levels of analysis.


Personal and Cognitive Influences

Observed differences in post-trauma reactivity have heightened awareness of the role of individual differences as determinants of reactivity. Demographic, cultural, personality, biological, historical and psychological factors have been implicated as playing a mediating role in this process (Gibbs, 1989; Lyons, 1991, Paton, 1997; Scotti, Beach, Northrop, Rode, and Forsyth, 1995).

From the point of view of preventing or minimising reactivity, several strategies could be envisaged. Alexander and Wells (1991), Deahl, et al. (1994), Friedman, Framer & Shearer (1988), Lyons (1991), McCammon (1996), Paton, Ramsay, and Sinclair (1992) and Tehrani (1995) discuss data suggesting that screening represents a useful means of identifying high risk individuals. Screening could be used to pre- select those at risk (and so prevent their involvement) or, post-event, to identify high risk employees and prioritise them for support and monitoring. The latter is likely to be the most feasible strategy in most circumstances. Indeed, this function has been identified as an alternative to the standard use of debriefing (Orner, 1997). However, additional work is necessary to clarify the potential use of vulnerability data in this context (Green & Solomon, 1995; Lyons, 1991; Paton & Smith, 1996; Scotti, et al., 1995).

Individual differences in vulnerability have other implications for intervention design and administration. As yet there is no clear understanding of how vulnerability status influences reactivity nor how it might affect response to support interventions. Certainly cultural/ethnic factors will be influential in this context and may render group interventions less appropriate for the members of some cultures (e.g., because it is inconsistent with cultural grieving traditions and practices). The increasingly multi-cultural nature of those in employment makes this an important issue for future investigation. Dispositional factors may also affect utilisation of formal and informal sources of social support (Scotti et al., 1995), rendering debriefing less effective for individuals whose dispositional attributes limit support usage. Risk status can be influenced in other ways. For example, although involved in the same event, the unique nature of individual experience can expose participants in a group process to diverse additional insights, some of which may be helpful and some of which may not. Considerable care must be exercised to ensure that exposure to the traumatic recollections of others does not trigger secondary traumatisation.

Exploring individual differences in vulnerability to traumatic reactivity can provide insights into why debriefing may work for some individuals but not for others. It is pertinent to ask whether a group intervention, conducted over a period of a few hours, affords sufficient opportunity to explore differences in vulnerability and accommodate it within the group process. Assuming similarity on the grounds of shared involvement in a given event may be inappropriate until the relationship between vulnerability and reactivity and between vulnerability and intervention effectiveness has been established. Considerable personal knowledge of those involved would be required and this information would be difficult, if not impossible to obtain, in the time frame prior to a debriefing being conducted or during the process itself. Nor, in general, would it be available from organisational sources.

For some groups (e.g., emergency services and law enforcement) differences in the expectations they have about their work and the meaning systems underlying occupational choice will influence reactivity (Carlier, in press). The relevance of this issue is highlighted by the finding that responding to 'traumatic' events can, under certain circumstances, be perceived as professionally rewarding (Alexander & Wells, 1991; Andersen, Christensen, & Petersen, 1991; Hartsough & Myers, 1985; Moran & Colless, 1995; Raphael, 1986). More objective appraisal of individual outcome, and researching the factors contributing to positive outcomes, could inform selection and training processes, contribute to the development of organisational response strategies, and facilitate the evolution of more representative models of traumatic reactivity. Moreover, failure to accommodate this possibility within intervention processes may counter the beneficial effects of their experience, increasing their risk status over time (Dunning, 1995; McKenzie, 1996).

Several cognitive factors can be implicated as determinants of traumatic stress reactivity. Schema theory has recently been used as a means of conceptualising the dynamics of trauma impact (Janoff-Bulman, 1989, 1992; Paton, 1994). For example, differences between individuals with respect to their ability to accommodate the atypical physical and emotional demands associated with traumatic experiences will affect vulnerability and the effectiveness of recovery or support interventions (Alexander & Wells, 1991; Paton, 1994).

A further issue that is pertinent to high risk groups, but which may not be readily accommodated by recovery interventions, concerns the implications of repeat exposure to potentially traumatic incidents. Within high risk groups (e.g., law enforcement, emergency services) multiple traumatic or high risk experiences can result in behavioural addiction (Gilmartin, 1986; Grigsby, 1991; Solursh, 1988, 1989; Paton & Violanti, 1997). Wilson (1980) coined the term "action junkies" to describe how some officers become addicted to the experience of violence, excitement and trauma and cannot function effectively without it. When this mind- set is established, difficulty in rationally accepting and reviewing traumatic experiences may make it more difficult for those affected in this way to engage in appropriate recovery behaviours (Kolb, 1993). While participation in debriefing could assist recovery under these circumstances, it is possible that the difficulty that trauma addicted individuals have in reviewing their experiences (Kolb, 1993) may lessen its usefulness. Additionally, hypersensitivity, an increased likelihood of their perceiving environmental stimuli as threatening (Gilmartin, 1986), and a tendency to focus on the traumatic and physiologically arousing aspects of the experience (van der Kolk, 1997) may increase risk status within a group setting. More research is needed into the implications of chronic traumatic exposure and its implications for well-being and intervention design.


Social Psychological Influences

It is widely acknowledged that recovery from trauma is facilitated by emotional disclosure within a socially supportive environment (Pennebaker, 1992). Debriefing is designed to facilitate this outcome (Robinson & Mitchell, 1995). However, this relationship will be complicated by the operation of several social psychological factors which may hinder disclosure and, therefore, contribute to the persistence of traumatic stress symptoms. Amongst high risk groups, the existence of a cohesive culture which advocates, and sustains, the suppression of emotional disclosure (Evans, Coman, & Stanley, 1992; Coman, 1993; Pogrebin & Poole, 1991) may constrain disclosure. Even if disclosure is facilitated within a debriefing, and this cannot be assumed (Deahl et al. , 1994; Everstine & Everstine, 1993), the operation of this cultural norm may make it difficult to sustain as recovery continues within the workplace.

Another facet of this culture that is relevant here involves the perceived need for control (Short, 1979). Control beliefs may be undermined by involvement in any help-seeking process (Eränen & Liebkind, 1993; Everstine & Everstine, 1993) and threaten self-esteem (Coyne, Ellard & Smith, 1990; Gilbert & Silvera, 1996). Similarly, attributions about event causality and blame can influence the utilisation of support resources (Joseph, Yule, Williams & Andrews, 1993). Attributional processes also influence perceptions of professional self-worth (Duckworth, 1986; MacLeod & Paton, in press; Paton, 1994) which may, in turn, affect reactivity and the effectiveness of recovery processes.

The impact of traumatic experiences on social identity processes may also complicate the recovery process. Shalev (1994) argued that participating in debriefing can result in the formation of a collective identity, increasing problems with respect to relationships with colleagues and making it more difficult for individuals to process their personal losses. Patterns of reactivity and recovery can also be affected by the manner in which response outcomes interact with professional identity (Hartsough & Myers, 1985; Shalev, 1994).

Recovery is also complicated by differences in the salience of support needs and providers over time. For example, informational support may be viewed as intrusive if provided by significant others but not if offered by professionals, while the opposite holds for emotional support (Shin, Lehmann, & Wong, 1984; Thoits, 1986). Over time, recovery may be more effectively facilitated by providing understanding during the early stages and assistance with reintegration in routine activities at a later stage (Shin et al., 1984). Effective recovery management will thus require the integration of formal (e.g., debriefing) activities with those of colleagues, managers and organisational systems if the potential of formal event- related intervention is to be fully realised. The potential influence of organisational variables (staff and systems) described in these studies reiterates the need to consider the organisational environment in a discussion of work-related trauma.


The Organisational Environment

Prevailing work and organisational practices, including leadership style, managerial attitudes to mental health issues, prevailing levels of social support, and the level of overt organisational concern for staff well-being can influence the intensity and duration of impact and the rate of recovery (Alexander & Wells, 1991; Doepal, 1991; Dunning, 1988; Hart, Wearing & Headey, 1995; Lawson, 1987; Paton, 1994; Thompson, 1993, Violanti, 1996 a, b). The flexibility of the organisational bureaucracy has also been implicated (Powell, 1991). Bureaucratic inflexibility and centralisation intensifies and prolongs reactivity and generates increased costs from higher absenteeism, turnover, performance decline, treatment and compensation costs (Bonifacio, 1991; Doepal, 1991; Powell, 1991; Thompson, 1993).

Those fulfilling managerial or command roles are ideally placed to facilitate adaptation and re-integration in those affected by traumatic events (Alexander & Wells, 1991; Smith, 1985). However, an autocratic management style may limit supervisory willingness or capability to fulfil this aspect of their recovery role (Violanti, 1996 a, b). A lack of supervisory understanding of the reality of traumatic stress reactions increases the likelihood of their responding to subordinates with contempt, blaming them for what happened, or minimising the significance of their reactions and feelings (Dunning, 1994).

Clearly the analysis and development of structural characteristics, policies and procedures, and managerial attitudes and capabilities has a role to play within the trauma management process (Dunning, 1994; Paton, 1997; Powell, 1991). In addition to their more direct role as mediators of reactivity, organisational factors will influence the reintegration process and the monitoring of staff reactions. Organisational systems and practices (e.g., training) affect meaning systems and, as such, represent strategies which can be implemented to moderate traumatic stress reactions, influence recovery rates and the effectiveness of recovery interventions (Alexander & Wells, 1991; Paton, 1994). In the longer term, organisational analyses can contribute to organisational development programmes by providing information that can be used to promote and sustain appropriate management-staff relationships, a supportive organisational climate, and effective response and recovery systems. The organisational environment, and its relationship to reactivity and recovery, thus represents an area where further research is required to identify salient variables and processes and to define the manner of their influence.


Conclusion

While several methodological and conceptual issues make a clear interpretation of the contradictory conclusions reached in studies of debriefing effectiveness more difficult, current conceptualisation of recovery resources and the context within which it occurs may be over simplistic. Recovery should be defined as a process which takes place over time against a backdrop of social and organisational characteristics and demands which will affect the nature and rate of adaptation and recovery.

Resources designed to assist recovery should be made available over a prolonged period. Moreover, support needs may change in a qualitative manner as survivors work through their reactions in the context of a dynamic recovery environment. Intervention development must accommodate the interaction between the survivor, their experience, and the social-organisational context within which recovery takes place. Support resources should thus be capable of ensuring support availability in a contingent manner over the course of the recovery period. The provision of an isolated intervention is likely to be less effective than previously anticipated.

While the issues discussed above have been implicated as determinants of trauma reactivity and as influencing the quality of recovery, more systematic research is required to clarify the nature of these relationships and their implications for the effectiveness of recovery interventions. Because several of these reflect conditions pertaining within an organisation, and which develop over time, a need for organisational level intervention, both with respect to the reduction of problems and the management of reactions, is also indicated.

More research into the nature of the longer term recovery process is required, as is investigation of the relationship between support needs, support providers, and the nature and content of support interventions. A need to develop support resources in a manner that facilitates self-help and that sustains or promotes positive perceptions of the experience is also suggested by the literature.

The important issue here is developing a realistic and comprehensive understanding of work-related trauma reactivity and recovery processes. As this knowledge is accumulated organisations and interventions can evolve in a manner capable of minimising the development of reactions and assisting recovery and adaptation to diverse demands within complex and dynamic operational and recovery environments.


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Douglas Paton, Leigh M. Smith, Christine Stephens © 1998. The authors assign to the Australasian Journal of Disaster and Trauma Studies at Massey University a non-exclusive licence to use this document for personal use and in courses of instruction provided that the article is used in full and this copyright statement is reproduced. The authors also grant a non-exclusive licence to Massey University to publish this document in full on the World Wide Web and for the document to be published on mirrors on the World Wide Web. Any other usage is prohibited without the express permission of the author.


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