Twelve years of trauma
Counselling at Work, January 2018: Issue 95

From the 7/7 bombings (2005) to the Grenfell Tower fire (2017), Fiona Dunkley explains why organisations need a trauma management programme.

In the last twelve years, working as a trauma specialist psychotherapist, I have seen an increase in the demand for trauma therapy. The most poignant incidents where I have supported organisations and individuals include the London 7/7 bombings (UK, July 2005); Syrian civil war (Syria, ongoing since 2011); Ebola outbreak (West Africa, from 2014); Search and Rescue refugee crisis (Mediterranean, from 2015); Nepalese earthquake (Nepal, July 2015); Westminster terrorist attack (London UK, March 2017); London Bridge terrorist attack (UK, June 2017); Brussels bombing (Belgium, March 2016); anti-government protests, Istanbul (Turkey, July 2016); Juba attacks on aid workers (South Sudan, July 2016); and the Grenfell Tower fire (London UK, June 2017).

This is not an exhaustive list of major incidents, but as I composed it with a heavy heart, it reminded me just how much trauma has become part of our daily lives. As well as these high-profile cases, I support individuals with other traumas, including sexual violence, childhood abuse, bullying, transport accidents, domestic violence and medical health issues, which also impact individuals and families, with devastating effect. We are exposed to trauma continuously in the media, as images become more graphic and stories more personal, and we are all vulnerable to vicarious trauma (sometimes named ‘secondary trauma’ or ‘compassion fatigue’). Vicarious trauma is the cumulative impact of indirectly witnessing trauma or hearing stories of traumatic content. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), for post-traumatic stress disorder (PTSD), recognises that individuals can be impacted by trauma symptoms whether they experience a traumatic event indirectly, directly, or as a witness.¹

Background

My passion is caring for the carer, and a great deal of my work is supporting emergency first responders, including the police, fire brigade, medical staff, and humanitarian aid organisations internationally. A previous article I wrote for Counselling at Work, ‘Caring for the Carers’,² highlighted the psychological risks of working with trauma and explored coping strategies for the carers of our world. It’s an area I know well, having worked in the NHS offering crisis support in The Havens’ forensic sexual violence units. I went on to join the counselling and trauma service, as the lead counsellor, at Transport for London (TfL), after the London 7/7 bombings. Later, I moved into the field of humanitarian aid work, offering psychosocial support to organisations including the Red Cross, Save the Children, Oxfam, Plan International, and Voluntary Services Overseas (VSO). I currently have a private practice, work internationally and undertake consultancy work, supporting individuals and organisations at risk of being exposed to trauma.

Responding in a crisis

It is essential that organisations have a thorough and well-rehearsed critical incident plan, which needs to incorporate a trauma management programme. This should clarify what psychosocial support is available for staff throughout every stage of a critical incident, including early intervention, specific treatments for trauma, follow-up and recovery. A well thought-through critical incident plan saves lives and helps people recover quicker. Staff need training, guidance, knowledge and clear policies. The reality is that major incidents almost always catch us unaware; therefore, forward planning is essential.

As the lead on InterHealth Worldwide’s Responding in a Crisis (RIC) service between April 2014–April 2017, I gathered a significant amount of crisis response data. During that time, InterHealth managed one hundred and eighty-eight critical incidents for eighty-nine client organisations. The prevalence of each type of incident is shown in percentages, and the findings are below:

Ill mental health (twenty-one per cent). This refers to an individual suffering from the severe end of the spectrum of mental ill health, such as psychotic episodes or suicidal attempts or ideation.
Civil unrest and terrorism (sixteen per cent). The data show that civil unrest and terrorism have increased by thirty-seven per cent over the last two years. Many more countries have become targets of terrorist attacks over the last few years.
Sexual violence (nine per cent). The data record that sexually violent crime has increased by twenty-five per cent over the last two years.
Death of a member of staff due to accident/illness or murder (eight and a half per cent).
Kidnapping and hostage-taking (five per cent), with an increase of thirty-three per cent over the last three years.
Other incidents recorded: robbery, mugging, assault, vehicle accidents, carjacking, natural disasters, accidents and illnesses (non-fatal) and disease epidemic.

It is noticeable that incidents of both sexual violence, kidnapping and hostage-taking have increased over the last three years. These figures could be impacted by increased numbers of individuals reporting incidences, and more organisations having systems in place to encourage reporting. However, unfortunately, the research is demonstrating that the overall risk to aid workers of being involved in a traumatic event has increased.³

Organisations need to give careful consideration to how they will implement the stages of a trauma management programme; and to illustrate this, I turn now to two high-profile cases. Both Peter Moore, who was held hostage for just under three years in Iraq, and Megan Nobert, who was raped while working in South Sudan, agreed to speak to me in detail about their experiences. They both hope that some of the learning points that came out of their own horrific experiences will be taken forward and implemented into organisations’ critical incident policies.

Iraqi militia held Peter Moore hostage for two years, seven months and one day. Peter worked as an IT consultant, training local staff in Baghdad, Iraq. On 29 May 2007, Peter and four British guards were kidnapped while at work. He describes his first year as ‘pretty rough’, including ‘mock executions, being hung over the door and regular beatings.’ By 2008 Peter describes his conditions as ‘better’. He was ‘blindfolded and handcuffed, kept in a lying down position for six months and separated from the other four guards’. He later found out that all four guards had been shot and killed. At this point Peter was released from his chains, for the first time in two years. Peter felt that at this time he hit his ‘all time low’, and considered using the chains to hang himself. In 2009 he was ‘given a laptop, was able to exercise, and had the use of a toilet.’ This was the year he was released, on 30 December 2009, nine hundred and forty-six days after he was first taken hostage.

When I asked him what psychosocial support he was offered on his return, Peter informed me, ‘My organisation did not have any, but after I was released from being a hostage, the UK Government had a military psychologist appointed to me.’ Peter struggled to get back into a day-to-day routine: ‘my company wanted to send me to Afghanistan within a few months of being released. My only option was to quit the job, so I was not impressed with their lack of flexibility.’

One way that is helping Peter to recover is to share his experience through presentations to humanitarian organisations and the military. He ends one of his talks with the quote from the German philosopher, Friedrich Nietzsche: ‘That which does not kill us makes us stronger’, and, at the same time, he also shares that his recovery has been seven years to date, and is still ongoing.

Megan Nobert (former director of Report the Abuse), a Canadian aid worker, was deployed to South Sudan in 2015, where another humanitarian worker sexually assaulted her. Megan shares some of her story with me below.

‘When I was drugged and raped while working in South Sudan, I expected my organisation to provide medical and psychosocial support. Instead, the opposite happened… When I asked for a week off to return home – to see some friends and tell my family what I had experienced in the field – I was told it would be disruptive to programming and if I wanted to go home, I should quit. So, I quit, to go home and heal. There were many traumatising moments: when I was asked to go from room to room and relive my experience for senior management. When I was told that, if I wanted to be evacuated post-rape, it was my responsibility to make it happen. Beyond all of this though was the moment when I was told by senior management that I wasn’t allowed to speak about my experience. If there had been policies or procedures in place, perhaps things would have been handled better… The wounds from how I was treated by my former organisation run deep, though; in some ways, even deeper than those from the rape itself.’

A clear trauma management programme for managers to refer to in the early stages after a critical incident is essential. How individuals are treated by their organisation directly after a crisis is fundamental to their recovery process; the ‘stuck moments’ in therapy can often be an unsupportive comment made by a manager or colleague. Individuals are highly sensitive and vulnerable to being retraumatised in the early stages after an incident.

A trauma management programme

Having worked with organisations for as long as I have, I appreciate that trying to design an organisational trauma management programme is no easy task. Even as an experienced psychotherapist, I’m aware that the information surrounding early intervention is confusing and controversial. Further research is essential in this crucial early stage of trauma support. Below, I have attempted to decipher the confusion and explain, briefly, some of the controversy. Drawing on my experience, I recommend that an organisation’s trauma management programme should include the following:

Immediate crisis management

The situation is often chaotic in the initial stages of a critical incident, and therefore the immediate stage of any crisis is all about practical support, and de-escalating and defusing the situation.

Screening

Most people will recover from a traumatic event naturally, but having an evidence-based screening process, (and one that is culturally and ethically appropriate), can help to monitor individuals who may need further support. Ideally, trained and professional clinicians would conduct the screening sessions using evidence-based questionnaires, which need to be comprehensive, and explore physical, psychological, and social needs.

Family liaison support

Family liaison officers are necessary when a member of staff has died or if they are unable to speak for themselves, perhaps because of a kidnapping incident or because they are unconscious. Ideally, organisations will have in-house volunteers trained as family liaison officers; alternatively, some organisations may use an external source.

Peer support

Several organisations have implemented a peer support programme into their organisation. These can be a great resource to support staff as they are versatile, cost-effective, and can be accessed by staff who are harder to reach due to the environment or circumstances. Peer supporters are volunteers within the organisation who have been trained in trauma and stress awareness.

Psychological first aid (PFA)

PFA was first developed by the Australian psychiatrist Beverley Raphael⁴ and has become the foundation of psychosocial responses to a major incident. PFA can be delivered to individuals or a group, and encompasses safety, information, emotional support, psycho-education and access to further services.

Psychological debriefing

Psychological debriefing⁵ was developed thirty years ago for use in organisations where employees were exposed to traumatic material. However, after the Cochrane review into psychological debriefing for preventing PTSD, psychological debriefing was labelled ‘harmful’.⁶ Since then, many clinicians have argued that the original research was flawed,⁷ as the research evaluated was conducted on individuals for whom psychological debriefing was not originally designed, by inexperienced clinicians, and was too short, both in length of session and time frame. Today, organisations such as emergency first responders, the fire brigade, the police, employment assistant providers (EAPs), NHS foundation trusts, various non-government organisations (NGOs) and United Nations departments, are all continuing to use various forms of psychological debriefing. It is an intervention that needs to be facilitated by specialist clinicians, in an appropriate time frame, and once a traumatic event is over.

Initial trauma assessments

A trauma assessment needs to include identifying symptoms, normalising of the individual’s responses, and enabling the individual to recognise and develop coping strategies. It creates a space for the individual to talk through their experiences, and can offer a monitoring process and follow-up appointments, if necessary.

Specialist trauma counselling

The National Institute for Health and Care Excellence (NICE), the World Health Organisation (WHO) and the American Psychological Association (APA) recommend two specialist trauma models: trauma-focused cognitive behavioural therapy (TF-CBT) and eye movement desensitisation and reprocessing (EMDR). Both TF-CBT and EMDR have been culturally adapted to be effective globally, although many countries do not have access to therapists who are trained as specialists in these approaches.

Closure/follow-up

It is good practice to offer follow-up appointments, as it is helpful if staff feel that it is acknowledged that they have been through a distressing situation, and important that they feel supported and valued by their organisation. I supported a team of staff who had lost one of their team members in a car crash. They were a close team and were great at supporting one another. They requested that I come back a year later to facilitate a group event for the one-year anniversary of their colleague’s death. Anniversaries and specific dates of events are important to note, and can be triggering for individuals. If it was a high-profile incident, the media may rerun footage of the event and produce documentaries, which can also be triggering. Recognising triggers and enabling events that can create closure to an event, can help healing.

Summary

Working within the field of crisis response, it’s not unusual to receive calls from managers or HR personnel, anxiously demanding that: ‘we need counsellors here, now!’ My role is to contain the anxiety and to manage the situation by grounding and stabilising the individual at the end of the phone, by offering clear support and advice, and explaining the appropriate trauma interventions. Typically, I create a pause moment and give the caller permission to take a deep breath and reflect on the situation, so individuals become informed and responsive, rather than anxious and reactive. This is the challenge of managing a crisis call, as anxiety is highly contagious: ‘Well-intentioned, mental health practitioners should not “parachute” uninvited into a disaster zone, particularly if they have no knowledge of the local culture, language, mores and religious sensitivities.’8 Counsellors or peers trained in trauma awareness, PFA and crisis response can be helpful in these early stages, but general counsellors or counselling are not.

In short, it is essential for all organisations to have a critical incident plan, which includes a trauma management programme that is tested yearly through a simulation training programme. Assessment and triage need to be carried out early on after an incident takes place, and administration processes are important to set up during the immediate response. Psychological first aid can be a useful model to offer as well as providing psycho-education, normalisation and resourcing for staff after an incident. The benefits of PFA are that it can be facilitated by appropriately trained peers, and can be useful even during a long-term crisis incident (such as working and living in war zones). Peer support programmes are also worth considering, so appropriately trained staff are available and at hand immediately during a crisis to support their colleagues. Psychological debriefing should not be activated until the incident has ended, and needs to be facilitated by mental health professionals, and is time sensitive. If individuals are identified as having ongoing psychological difficulties four weeks after an incident, there are excellent trauma specialist therapies available. Support for families needs to be included in the critical incident plan, providing information sheets as required, and family liaison support when necessary. This includes having access to specialist trained family support officers.

Megan and Peter did not receive good quality trauma care, and were often retraumatised by their post-incident experiences. Organisations need to incorporate a clear trauma management programme into their critical incident plan that supports staff through each stage of their recovery process and eventually enables staff, not only to recover, but to experience post-traumatic growth.

Fiona Dunkley is a senior accredited BACP psychotherapist, supervisor and trainer. She manages FD Consultants, offering psychosocial support and trauma specialist services to humanitarian aid organisations. Fiona’s new book, Psychosocial Support for Humanitarian Aid Workers: A Roadmap of Trauma and Critical Incident Support, is published in spring 2018 by Routledge. The case studies in this article are extracts from the book and are republished with permission. For further details, visit www.routledge.co.uk

References

1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5). Arlington, Virginia: APA; 2013.
2 Dunkley F. Caring for the carers. Counselling at Work 2016; 88(spring): 20–25.
3 Aid Worker Security Report. Humanitarian outcomes, US Aid. [Online.] https://aidworkersecurity.org/ (accessed 22 November 2017).
4 Raphael B. When disaster strikes. How individuals and communities cope with catastrophe. New York: Basic Books; 1986.
5 Dryregrov A. Caring for helpers in disaster situations: psychological debriefing. Disaster Management 1989; 2: 25–30.
6 Rose S, Bisson J, Churchill R, Wessely S. Psychological debriefing for preventing post-traumatic stress disorder (PTSD). (Cochrane Review). In: The Cochrane library 2002; Oxford: Update Software.
7 Hawker DM, Durkin J, Hawker DSJ. To debrief or not to debrief our heroes: that is the question. [Online.] Clinical Psychology and Psychotherapy 2010; Wiley Online Library. [DOI: 10.1002/cpp.730]. (accessed 22 November 2017).
8 Alexander D. Early interventions in war and disasters. In: The British Psychological Society: early interventions for trauma: proceedings from symposium held on: 25 November 2014 and 8 January 2015. The British Psychological Society. [Online.] (accessed 22 November 2017).