1. The Use of Trauma Risk Management to Support Employees Exposed to Traumatic Events Professor Neil Greenberg

2. 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

3. Plan for my talk Background Trauma A preventative model TRiM Conclusions

5. 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

6. MH and Incapacity benefit

7. Mental Health and ‘stress’ Mental Health Work Related Stress Home front Related Stress Ability to function Trauma Related Stress

11. 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

12. 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

13. What is the natural history of PTSD? 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.

14. Important Caveat PTSD is not the only post incident psychological health problem related to trauma Depression, Anxiety, adjustment disorders and substance misuse also common

15. 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

16. But…. Most people who suffer with post incident mental health problems don’t seek help!

17. 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

18. WW1 - Stigma “It is wholly out of place to show them compassion. People with shell shock are weaklings who should never been allowed to join the Army or tricksters who deserved to be punished” Captain Dunn, Medical officer, RWF

19. Stigma and Barriers to Care Gould et al, 2010, JRSM

20. “Why might you not seek help after being exposed to a traumatic event?” Greenberg et al, JMH, 2009

21. Most people with PTSD do not get treatment Woodhead et al, 2010, Soc Sci Med

22. Learning Points 4.Distressed people do not usually ask for help 5.Stigma (esp self-stigma) is an important barrier to care

24. 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

26. Pre deployment Selection/Screening: PTSD Cases Main Study (04) Main Study (04) +-Total Screening Study (02) +62733 -4115401581 Total4715671614 PPV 18% (5-31%); NPV 97% (96-98%)

27. Risk Factors for PTSD Importance in prediction Brewin et al, 2000

28. 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

29. 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)

31. Post Incident Counselling?? ?

33. 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

34. Learning Points 6. Screening (pre and post) is not effective 7.Post incident counselling does not work and may make people worse

36. 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

37. People prefer colleagues to medics? Greenberg et al, JMH, 2003

38. The way your manager treats you matters Jones et al, Psychiatry, 2011

39. 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

40. 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)

41. TRiM – Trauma Risk Management

42. 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?

43. What Peer Practitioners are not! – Counsellors – Therapists – Pseudo-psychologists – Group Huggers – Scented Candle users

46. Filtering the event Target Groups A.Directly involved B.Rescuers & helpers C.Involved at a distance D.Could have been there but were not E.Vulnerable people F.Those at the scene out of curiosity A C F B C D E A

47. TRiM interview checklist 1The person thinks that they had little or no control over their behaviour/reactions during the event 2The person thought they faced serious injury or death during the event 3The person blames or is angry towards others about aspect(s) of the event 4The person expresses shame or guilt about their behaviour relating to the event 5*The person experienced acute stress following the event 6The person has experienced substantial life stressors (e.g. problems with work, home or health) since the event 7The person is having problems with day to day activities 8The person has had difficulties dealing with previous traumatic events 9The person reports problems accessing social support 10The person has been drinking alcohol excessively or using prescription drugs to cope with their distress

48. TRiM publications

49. 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…

50. The Cumbria ‘Bird’ shootings Incident

51. 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

52. 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

53. Results – TRiM Receipt Sample n=640 Briefing Only n=44 (7%) Briefing & 1:1 n=44 (7%) 1:1 Only n=166 (26%) No Intervention n=386 (60%) Low Exposure n=8 (18%) High Exposure n=36 (82%) Low Exposure n=0 (0%) High Exposure n=42 (100%) Low Exposure n=8 (17%) High Exposure n=38 (83%) Low Exposure n=144 (71%) High Exposure n=59 (29%)

54. Results – Exposure, Interventions & Sickness Absence Exposure (n) Shorter sickness length n (%) Longer sickness length n (%) ORAOR*AOR**AOR*** Lower (160) 126 (79)34 (21%)1111 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.

55. Learning Points 10.TRiM meets the NICE guidance on Trauma and Stress and appears to help with sickness absence after traumatic events

56. 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

58. Any Questions?- Fire Away! Neil: neil@marchonstress.com www.kcl.ac.uk/kcmhr