Post-traumatic stress disorder: overview
c/o School of Applied Psychosocial Studies, Faculty of Health and Social Work, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK
Correspondence to: Carole Adamson, c/o School of Applied Psychosocial Studies, Faculty of Health and Social Work, University of Plymouth, Drake Circus, Plymouth PL4 8AA, UK. Tel: +44 1752 233842; fax: +44 1752 233258; e-mail: ceadamson{at}hotmail.com
The impact of traumatic events and the experience of psychological trauma have been depicted in myth, legend, art and literature throughout human history (for instance [1,2]). They have, for the last generation, been psychiatrically classified as post-traumatic stress disorder (PTSD) and as acute stress disorder (ASD). The papers in this In-Depth Review serve both to describe the status of current thinking in regard to the scientific conceptualization of psychological trauma and to raise questions in regard to our understanding of the contextualization of traumatic experience within occupational settings. For many years, occupational medicine and health and safety legislation has focused upon observable injury and illness caused by single events. These articles play a timely role in reminding us that many health and welfare concerns with far-reaching effects within organizational environments may be psychological, social and complex in nature and have enduring effects over a considerable span of time.
In the first paper, Bisson [3] introduces the diagnostic categories of PTSD and ASD and presents an overview of the characteristics of the Diagnostic and Statistical Manual of Mental Disorders and International Statistical Classification of Diseases and Related Health Problems [4,5], describing prevalence and risk factors in the development of traumatic symptoms. The variation in diagnostic features between these two classification systems serves to illustrate the ongoing development and refinement of our contemporary understanding of traumatic experience. Bisson signals our increasing awareness of resilience as opposed to the pathology of trauma. The concept of a resilience trajectory may challenge the reader to query whether employee resilience can be strengthened through processes of selection, screening and organizationally based support systems. These issues are addressed and developed in the following papers.
While the first article focuses upon individual outcomes of treatment, Bisson suggests that individual prediction of risk is indeed a poor predictive tool and stresses that the degrees of support, connection and affirmation within the organizational context will contribute to recovery. Using the National Collaborating Centre for Mental Health Guidelines for intervention (the development of which he played a significant part), Bisson briefly considers the viability of particular interventions. He signals the issues concerning early intervention in the workplace that the following articles then address. In particular, he stresses that the emotional component of single-session interventions termed as psychological debriefing (PD) should be avoided, suggesting that in many situations practical and pragmatic support provided by an informed peer group is both necessary and sufficient an intervention.
Utilizing their extensive experience in Australia, McFarlane and Bryant [6] then focus specifically upon the impact of trauma in occupational settings acknowledging that individuals and groups within some occupations and workplaces experience higher risk factors than others. They introduce notions of cumulative risk and secondary stressors and suggest preventive or minimization strategies for the management of trauma within the workplace. Management strategies such as systematic assessment, reduction of exposure and rotation of duties are noted alongside the repetition of Bisson's caution that there is inherent difficulty in providing accurate and ethical prediction of risk on an individual basis. They suggest that employers and supervisors nevertheless have a duty of care to identify and support those individuals adversely affected by traumatic events. The authors raise issues of legal and employer liability and financial compensation, a key factor in the ongoing debate about effective support for workers. Such risks are balanced against acknowledgement of the financial costs of providing support systems and the necessary cost-benefit analysis evaluation of any intervention adopted by an organization. They argue that early intervention or treatment to prevent further injury is crucial. The need for an evidence-based choice of intervention is stressed, an issue of particular importance in evaluation of PD and other structured interventions. Their acknowledgement of cumulative effects and potential sensitization to recurrent occupational stressors signals a need for occupational health practitioners to remain aware of the latest research in regard to complex PTSD and to constructivist interpretations of the relationship between cumulative stress and traumatic events.
The final paper in the review is Regel's [7] assessment of the current evidence for and against PD. This has been viewed within the last 20 years as being the prime but very contentious response to potentially traumatic events occurring in occupational settings. This paper shifts the focus from the consideration of the effects upon the individual, and intervention for that individual, to a wider group focus that reflects the nature of many of the organizational contexts in which traumatic events occur. Regel's argument addresses some of the core issues in the debate over provision of PD (or critical incident stress debriefing) and suggests that much of the scientific and evidence-based interpretation of this intervention should be re-assessed. He encourages an evaluation focused upon PD as an early intervention and crisis intervention tool rather than as a trauma intervention or treatment for individuals. Such a strategy has the opportunity of highlighting debriefing (and other components of what is often termed critical incident stress management, a package of organizational support spanning pre-incident preparation through to follow-up) as a community support and cohesion strategy rather than as a trauma intervention. Regel addresses the concerns of critics of PD in regard to the emotional ventilation or imaginal exposure within some published research critiques. This, he argues, should not be a part of a debriefing and is not emphasized in current occupational models as taught and practised within and outside the UK.
Regel's paper is likely to be viewed with greater contention than its preceding companions because it plunges into the debate that has raged concerning workplace support for those at risk of developing traumatic symptomatology as a result of exposure to critical incidents and traumatic events in the workplace. The In-Depth Review highlights ongoing tensions between an intervention focus on the individual employee experiencing symptoms to be treated, using psychological or pharmacological treatments that are not contextually specific and those workplace-wide responses to incidents that may be experienced by several employees, the design of which reflects the ecology of the organization and its workforce. They highlight the ongoing developments in trauma research concerning the locus of resilience and strengths, so that as readers, we can then ask the following: Does resilience lie within the individual? Can it be sustained and developed through environmental supports? Do organizations have a responsibility to manage environments that serve to mitigate the cumulative effect of stressors? How do the roles of occupational health practitioners and physicians dovetail with organizational responsibilities under health and safety jurisdictions, and what is the evidence base for effective intervention? Where do individual organizations and workplaces lie on the continuum from preventive to reactive responses to the occurrence of trauma? Indications of a paradigm shift in the manner in which jurisdictions address legislative issues of cumulative stress within the workplace (in New Zealand, for instance, cumulative stress is now recognized as an issue for which an employer has a duty of care) suggest that we need to develop a strong understanding of the relationship between cumulative stress, resilience and the impact of traumatic events.
As a researcher, and guest editor of this journal, my perspective in New Zealand affords the opportunity to ask further questions of significance to the impact of trauma in occupational settings. Practitioners in the field of occupational medicine need to grapple with issues of culture that, as a social phenomenon that affiliates us with others, can be both ethnic and linguistic but also professionally and occupationally constructed. The writers of these articles have all, in particular ways, suggested that the management of trauma within the workplace will have a relationship with the social supports and practical responses existing within the occupational setting. Interventions, treatment or support that focus upon the individual devoid of their contextual location, may do so perhaps at the peril of failure or of less than optimum success in the recovery trajectory. Evaluation of trauma-focused supports, likewise, may stumble in their authenticity if the cultural or occupational affiliations, and their own processes, are not incorporated in the assessment of outcome. The ecology of trauma response will likewise have gender and other power relationships that may colour and flavour the individual's propensity for traumatic reaction, their perception of assistance and their likely recovery from traumatic experience.
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None declared.
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- Micale MS, Lerner P, eds. Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870 –1930 (2007) Cambridge: Cambridge University Press.
- Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character (1994) New York: Simon & Schuster.
- Bisson JI. Post-traumatic stress disorder. Occup Med (Lond) (2007) 57:399–403.
- American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders (2000) 4th edn. Washington DC: American Psychiatric Association. [text revision].
- World Health Organisation (WHO). ICD-10: International Statistical Classification of Diseases and Related Health Problems, (10th revision) (1992) Geneva: World Health Organisation.
- McFarlane AC, Bryant RA. Post-traumatic stress disorder in occupational settings: anticipating and managing the risk. Occup Med (Lond) (2007) 57:404–410.
- Regel S. Post-trauma support in the workplace: the current status and practice of critical incident stress management (CISM) and psychological debriefing (PD) within organizations in the UK. Occup Med (Lond) (2007) 57:411–416.
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