Trauma out of a crisis

Nicola and Keith Guy are experienced social workers and
counsellors.  Together they developed a special interest in trauma
work and co-founded the Red Poppy Company.  Their organisation is
dedicated to increasing the awareness of psychological trauma, its
impact on sufferers and its treatment.

Sarah is a 15-year-old girl who was violent, involved in drugs
and prostitution, and prone to self-harming. She had received
counselling and medication as well as help from social workers and
youth workers. But no one identified that she was suffering from
post-traumatic stress disorder (PTSD) as a result of seeing her
mother raped and beaten by her alcoholic father.

After she received the correct diagnosis and treatment, the
self-harm and addiction subsided and Sarah was able to engage
constructively in counselling.

Sarah’s story is not an isolated one. PTSD and psychological
trauma are routinely missed by health professionals. Instead,
sufferers are likely to be diagnosed with depression, anxiety or
personality disorders and prescribed medication, or they may fall
into the criminal justice system. Sufferers of PTSD may also
include many social care staff and their clients. But it is a
psychological condition which, when diagnosed, can be treated
effectively.

• PTSD and psychological trauma injury are caused by events that
  are termed critical incidents. A critical incident is any sudden,
  shocking event that involves a threat to life, limb or
  psychological well-being.
• The greatest risk of PTSD is from violent attacks, including
  domestic violence. For example, half of all rape victims develop
  the condition. Also death threats and bullying can also cause
  PTSD.
•  Sudden death or suicide of a relative or friend.
• Verbal, physical, emotional and sexual abuse and also stalking
  and harassment.
• Combat experience.
• Accidents, life-threatening illness or surgery.
• Miscarriage, stillbirth and suicide.

Children are likely to be affected by:

• Sexual abuse. Research suggests that up to half of all children
  who are sexually or physically abused have PTSD.
• Bullying.
• Being taken into care.
• Domestic violence: In most domestic violence incidents children
  are in the same or next room.

But it is not just the victims of traumatic events who are
affected. Witnesses or those who hear third-hand accounts about an
incident are also at risk of developing this condition. This
includes social workers and counsellors, who may become traumatised
from hearing their clients’ stories. Simply working in social care
for a long time can put workers at risk.
The traumatic event can happen a few days back or years ago in
childhood – and, unless the symptoms are treated, they can last a
lifetime. Key symptoms of PTSD include:

• Intrusion: the sufferer may relive the event in some way, often
  through flashbacks, nightmares or hallucinations. The memory will
  be triggered by smells, sights and situations – anything that
  serves as a reminder of the original traumatic event.
• Avoidance: individuals may close down socially and emotionally
  to try to cut themselves off from situations or feelings that might
  remind them of the traumatic event.
• Emotional and behavioural difficulties: these may include a
  short temper, anger, aggression, violence, antisocial behaviour,
  depression, suicidal feelings, phobias, self-harm, disturbed sleep,
  or anxiety attacks.
• Addiction: in an attempt to cope with the disturbing symptoms
  victims frequently resort to alcohol and drugs.

Social care workers often face situations that pose a risk to
their psychological health as the sector is one of the most violent
environments in which to work.(1)

Problems can sometimes be triggered by apparently “routine”
cases. For example, two female social workers were intimidated each
time they visited the house of a violent local family from whom
they had taken a child into care. They were reluctant to involve
the police as they did not want to make things worse. But the
harassment escalated until death threats were made to the district
office. Rather than tackling the family, managers moved the social
workers to another office, but expected them to carry on with the
care proceedings. Both social workers developed panic attacks and
ended up taking long-term sick leave. Neither was able to return to
work because of posttrauma symptoms.

Employers need to take PTSD seriously as it is now accepted as
grounds for compensation. They need a clear set of policies and
procedures safeguarding psychological well-being in the workforce,
covering issues such as stress, bullying, harassment and
violence.

Legal responsibilities include health and safety law that
applies to risks from violence, stress and any other event that
poses a risk to psychological health, just as it does to other
risks from work.

Under the Health and Safety at Work Act 1974 employers have a
legal duty to ensure the health, safety and welfare at work of
their employees so far as it is reasonably practicable. Under the
Management of Health and Safety at Work Regulations 1999, employers
must consider the risks to employees, including the risk of
reasonably foreseeable violence; decide how significant these risks
are; decide what to do to prevent or control the risks; and develop
a clear management plan to achieve this.

The Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995 (Riddor) require employers to notify their
enforcing authority of an accident at work to any employee that
results in death, major injury or incapacity for normal work for
three or more days. This includes any act of violence towards a
person at work. Also, organisations should have a plan for
psychological health and safety issues. A confidential
psychological service should be offered to whoever completes a
Riddor form.

Carrying out psychological risk assessments is an integral part
of managing stress in the workplace. Job descriptions need to be
assessed for stress and, under health and safety legislation,
preventive procedures should be put in place.(2)

But if an individual experiences a traumatic incident, early
intervention and support should be available with an expert in
psychological trauma.

Also, managers need to recognise that just because a worker
remains at work it does not necessarily mean that they are all
right or have recovered. Managers need to know where to find help
and should be given psychological training so that they know how to
respond to workplace incidents. They should be taught how to defuse
situations and how to recognise the signs of psychological trauma
injury and PTSD.

Good councils will have a qualified psychological service to
help employees. A general occupational health service will be
unable to provide this because doctors and nurses are not trained
to deal with psychological issues. As a result, the employer will
not fulfil its duty of care.
PTSD is an occupational hazard in social care and social work. But,
with the right monitoring and support, organisations can help their
staff deal with psychological trauma and maintain their mental
well-being.

Case studies – before and after treatment.

One client who was sexually abused as a six-year-old, 21 years
earlier, says: “Before treatment the smell of alcohol made me want
to be sick as I did if anyone touched my arms – the abuser used to
grab my arms.  I suffered flashbacks and dreams of what happened. 
I didn’t like going out and was called a hermit.  I was not a nice
person to look at – this is how I felt inside.

“Now (following treatment) I don’t have any more flashbacks and
the smell of alcohol doesn’t bother me any more.  I feel like a
different person, more confident and outgoing – whereas I used to
be petrified.  I don’t feel like a six year old any more.”

Another client had been issued with death threats two years
before he started treatment for PTSD.  He says: “I didn’t feel safe
at home or outside.  I wouldn’t take my four-year-old son into town
and I detached myself from my wife and family.  I regularly had
flashbacks of the incident – sheer panic and anxiety.  Having the
problem diagnosed and treated has made me much more confident and I
can go out to the pub again.  I can communicate better with my
wife.  And I have gone back to work.”

A treatment example: The rewind technique.

The rewind technique should be learned and practised under the
guidance of an experienced practitioner.  It is carried out in a
state of deep relaxation.

Once relaxed, clients are asked to recall or imagine a place
where they feel totally safe and at ease.  Their relaxed state is
then deepened.  They are then asked to imagine that they have a TV
set and a video player with a remote control facility.  Next, they
are asked to imagine watching themselves watching the screen,
without actually seeing the picture, to create emotional
distance.

Clients then watch themselves watching a “film” of the traumatic
event.  The film begins at a point before the trauma occurred and
ends at a point at which the trauma is over and they feel safe
again.  They then imagine pressing the video rewind button, so that
they see themselves quickly going backwards through the trauma,
from safe point to safe point.  Then they watch the same images,
but going forward quickly, as if pressing the fast forward
button.

This is repeated back and forth as many times as needed, at a
speed dictated by the individual, until the scenes evoke no
emotion.

If it is necessary to build up confidence so that they can face
the fear in the future, for instance, driving a car or using a
lift, the person is asked to imagine a scenario in which they are
doing so, and feeling confident and relaxed.  Once accomplished,
clients are brought out of trance, and the work of the rewind
technique is complete.

Abstract

This article looks at the impact of post-traumatic stress
disorder on clients and the lives of social care staff and how it
is routinely missed or misdiagnosed.  Significant numbers of
clients have undiagnosed PTSD, which impairs functioning and leads
to dependence on the social care sector.  PTSD is caused by
violence, abuse and life traumas.  Once diagnosed PTSD can be
treated effectively and will free up clients to engage
constructively with caring professionals.

References

(1) The British Crime Survey report, Violence at Work – Findings
from the British Crime Survey, Health and Safety Executive and Home
Office 1999.

(2)  Regulation three, Health and Safety at Work Regulations,
1999.

Further Details

• Diagnostic and Statistical Manual of Mental Disorders 4th
  Edition, American Psychiatric Association, 1994, www.psych.org
• The HSE Management Standards for Tackling Work-related Stress,
  2004, www.hse.gov.uk/stres/standards/index.htm

Contact the Authors

Nicola and Keith Guy can be contacted at the Red Poppy Company
on 0845 2011334, or go to the Red Poppy website at www.theredpoppycompany.co.uk