PTSD in the
* - Preliminary versions of this paper have been presented at the International Society for Stress and Trauma Studies Annual Conference, San Francisco, November, 1996 and at the British Psychological Society, Scottish Branch, Annual Conference, Crieff, November, 1996.
Organisations whose workers risk traumatic exposure, are increasingly interested in preventing sequelae such as posttraumatic stress disorder (PTSD). A common intervention is the provision of psychological debriefing following trauma. In accordance with recent criticisms of this approach, Harvey (1996) has proposed a multidimensional model of trauma recovery. The present study tested some of the person, event and environmental variables in the model with 527 New Zealand police officers who responded to a questionnaire survey of trauma and social support at work. The results showed no differences in PTSD symptoms between officers who had and those who had not been debriefed. However, greater social support and opportunities to talk about traumatic experiences and their emotional impact, with others in the work place, were shown to be related to fewer PTSD symptoms. The findings support current suggestions that organisational post-trauma interventions should be developed take into account social environmental factors and recovery needs over time.
Although psychological debriefing has theoretical rationale and strong support from many
practitioners, much of this support is anecdotal and there is a need for further empirical study
to examine the immediate and long-term effects of such interventions (Shalev, 1994). Bisson
and Deahl (1994) also call for more rigorous evaluative research before debriefing is
provided routinely. The results of the evaluation of debriefing to date are mixed. Bisson
& Deahl cite examples of studies that support the effectiveness of early psychological
intervention, but have been flawed for at least one of several reasons: they assessed only the
subjective, immediate reactions of participants and no long term outcomes; there were no
control groups; or their results were thrown into doubt by other contradictory findings.
There are some more recent studies that have employed comparison groups of people who
have experienced the same event and have not attended a debriefing. These studies have not
found any differences in psychological stress symptoms for those who were debriefed, at two
weeks (Hytten & Hasle, 1989), six months (Brom, Kleber & Hofman, 1993), nine months
(Deahl, Gillham, Thomas, Searle & Srinivasan, 1994), or up to two years (Kenardy et al.,
1996) after the traumatic event. Griffiths & Watts (1992) found that emergency workers who
had been debriefed following bus crashes had significantly higher symptom scores one year
later, than those who were not debriefed. These findings, in combination with findings of
psychological sequelae in emergency service personnel, six months following debriefing
(Sloan et al., 1994), suggest that debriefing alone, is not effective in preventing adverse
outcomes. Other aspects of prevention are suggested by Thompson & Solomon (1991), who
found that a body recovery team had lower symptom scores compared to other similar teams.
They attributed this to careful selection, training, and ongoing managerial support as well as
critical incident debriefing sessions, which were managed as part of the group routine. Such
findings support recent suggestions (e.g. Raphael, Meldrum & McFarlane, 1995) that,
whatever the contribution of psychological debriefing to the reduction of posttraumatic stress
symptoms, there are other variables in the environment which also contribute to recovery and
must be considered by responsible organisations and health professionals.
In accordance with these suggestions, Harvey (1996) has proposed a multidimensional
definition of trauma recovery. She suggests that the efficacy of an intervention depends upon
its fit with the recovery environment and accordingly, provides an ecological model of
trauma recovery that includes person, event and environmental factors. The present study
is an initial test of some aspects of Harvey's model (see Figure 1) in the context of the
recovery environment of officers in the New Zealand Police. It examines the main effects
of some person, event and environment characteristics on PTSD symptom outcomes, taking
into account whether the officers have ever attended a debriefing or not. The personal
characteristics suggested by previous research (Smith & Ward, 1986) to have impact on
behaviour in stressful situations in police officers are gender, length of service, membership
of a branch of the service, and educational qualifications. The event characteristics are the
number of traumatic events experienced (Vrana & Lauterbach, 1995). The environment
characteristics are, the ease of talking about trauma at work, the attitudes to expressing
emotion in the work place, social support from peers and from supervisors. These have been
proposed in a related report (Stephens & Long, 1996) to be important recovery environment
characteristics in an organisational context. These aspects of the model to be tested are
shown in Figure 2 and according to this model it is predicted that the event, person and
environment characteristics will show important effects on PTSD symptoms, and these effects
will be moderated by the experience of debriefing.
1. Demographic variables. The variables included because of their demonstrated importance in relation to police stress and health outcomes were: age, length of service (in years), educational qualifications (none, secondary school or tertiary), gender, and the branch of the service (general duties or traffic and CIB).
2. PTSD. The Civilian Mississippi, a version of the Mississippi-PTSD (M-PTSD; Keane, Caddell & Taylor, 1986) was used to measure PTSD symptom scores during the past month across a 5 point Likert scale. Lower values indicate no evidence of PTSD symptoms and higher values indicate the presence of symptoms. A total score is obtained by summing across the scores on all items with a possible range of 35 to 175. The coefficient alpha estimate of reliability was .90. To identify respondents as PTSD cases, for use as discriminant groups, the least conservative cut-off score of 94 on the Military M-PTSD (Watson, 1990) was used. There has been little published work to date employing the Civilian version of the Mississippi Scale and less use of cut-off points to identify respondents with high scores as PTSD cases. A recent study resolved the problem, of the differences between the Military and Civilian versions of the Mississippi Scale. Eustace (1994) calculated the number of standard deviations from the mean, for the cut-off score of 94, on M-PTSD data from a New Zealand sample of Vietnam Veterans (Long, Chamberlain & Vincent, 1992). This number of standard deviations was applied to a community sample of respondents to the Civilian Mississippi. This was done with the approval of the author of the scale (T. M. Keane, personal communication, December, 1993). When this method was applied to the present sample, the resulting cut-off score was 96 (z = 1.07); the same cut-off score which Eustace had calculated using her 1994 sample. At the cut-off score of 96, 69 respondents were classified as PTSD cases (13.6%, N = 508). The least conservative score for classificatory purposes was chosen as being more conservative for the purpose of making statistical comparisons between groups on related variables.
3. Traumatic stressors. The traumatic stress schedule (Norris, 1990) was used as a basis for the collection of data on past events likely to be traumatic. The 9 items in this instrument were supplemented with 6 items relating specifically to police duties. The sum of the Events experienced while on duty as a police officer (range from 0-9) was used as the measure of traumatic stress.
4. Social support from peers and supervisors. Two scales of 4 items each from Caplan, Cobb, French, Van Harrison & Pinneau (1975) were used to measure perceived emotional social support. Each item was measured on a 5-point Likert scale and each set of 4 items was summed into an index of support from that source. The possible range of scores was from 1 to 5 with higher scores indicating stronger perceptions of support. The coefficient alpha estimates of reliability were .80 (peers) and .88 (supervisor).
5. The ease of talking about trauma at work. Two items in which respondents rated, on a 3 point scale, how easy it is to talk about traumatic experiences - details or feelings - at their work place. The items were combined into one measure named `Talk' with a coefficient alpha of .81. Possible scores ranged from 0 to 4, with a higher score indicating greater ease of talk.
6. Attitudes to expressing emotion at work. This scale (`Attitude') comprises four items that describe incidents related specifically to police work. The three possible responses to each item ranged from acceptance of the expression of personal emotions (score = 2), through avoidance techniques such as humour and more acceptable emotions such as generalised anger (score = 1), to physical avoidance and suppression of feelings (score = 0). Scores on each item were summed to provide an expression of emotion index for each individual. Higher scores indicate greater acceptance of the expression of personal emotions at work. The coefficient alpha estimate is .52.
7. Psychological support. Officers were asked whether they had attended a trauma policy debriefing or not.
The statistical package, SPSS/PC (Norusis, 1992) was used to run the following analyses:
A factorial ANOVA was used to examine the effects of trauma and debriefing on PTSD symptoms. The N varies for each analysis owing to missing data on some variables.
Direct discriminant analyses were run to test the model by determining which set of variables would contribute the most to the variance in PTSD symptoms for those who had and those who had not experienced debriefing. To minimise loss of information in this multivariate analysis, missing data on each variable, except for the Debriefing and PTSD scores, was replaced with the sample mean for that variable (N = 507). Dummy dichotomous variables (Education1 and Education2) were created to test the level of Educational Qualifications.
The distribution statistics for both dichotomous and continuous variables are shown in Tables
1 and 2.
|No School Qualifications||54||10 .3|
|Secondary Qualifications||356||67 .7|
|Tertiary Qualifications||116||22 .0|
|General Duties||365||69 .5|
|CIB and Traffic Safety||160||30 .5|
|Civilian Mississippi||508||78 .99||15 .77||45-161|
|Nos. of Events||527||2 .60||1 .70||0-9|
|SS from Supervisor||518||3 .28||1 .00||1-5|
|SS from Peers||517||3 .16||.75||1-5|
|Attitude||506||4 .90||1 .46||0-8|
|Talk||515||1 .85||1 .22||0-4|
A factorial ANOVA (2 X 10) showed that there were significant differences on Civilian Mississippi mean scores between groups who had experienced different numbers of events, F (9, 497) = 5.94, p=<.001. There were no differences in Civilian Mississippi mean scores for those who had attended a debriefing, or for an interaction between Events and Debriefing. Table 3 provides the mean scores for the groups (No. of Events is compressed into 3 groups) and shows that Civilian Mississippi scores are higher as the number of events experienced while on duty increases. Although the means for those who had experienced a debriefing are slightly higher than for those who had no debriefing, these differences were not significant.
|Nos of Events||N||Debriefing||No Debriefing|
First Analysis. As an initial test of all predictor variables, a direct discriminant function analysis was performed using five demographic variables (Gender, Age, Service, Education and Branch), five recovery environment variables (Attitude, Talk, Social Support from peers and supervisors, and Debriefing), and Events as predictors of membership in two groups. Groups were those classified as PTSD cases (Civilian Mississippi score equal to or greater than 96; N = 69) and non-PTSD cases (Civilian Mississippi less than 96; N = 436). The discriminant function showed a significant association between the groups and predictors, X2(12) = 70.13, p<.001. The predictors together accounted for 13% of the variance (Canonical R = .36). The loading matrix of correlations between the predictors and the discriminant function (see Table 4) shows that the best predictors for distinguishing between the PTSD and non-PTSD cases were Talk, Events, Social Support from peers and supervisors, Attitude and Education1 (which compares no educational qualifications with secondary and tertiary qualifications). As the ANOVA analysis has shown, Debriefing adds nothing to the prediction. A Box's M test of homogeneity of variance-covariance matrices was significant at p<.001, which indicates that, with numerous DVs and discrepancy in cell sample sizes, the significance test may not be robust (Tabachnick & Fidell, 1989). Accordingly, a second test was performed to test the model using only the most important predictors.
Second and Third Analyses. As a test of the model (see Figures 1 & 2), two direct
discriminant function analyses were performed, using six variables (Talk, Events, Social
Support from peers and supervisors, Attitude and Education1) as predictors of PTSD and
non-PTSD cases. To include the possible moderating effect of debriefing that is described
in the model, separate analyses were performed for those who had been debriefed (N = 117)
and those who had not been debriefed (N = 390). The results were similar for both groups
and are reported together, with those for the non-debriefed group in brackets. The
discriminant function was again significant, X2(6) = 14.13, p<.05, (X2(6) = 58.09,
p<.001). A Box's M test was non-significant at p<.05, indicating homogeneity of
variance-covariance matrices, for both sets of variables. The predictors accounted for 12%
(14%) of the variance (Canonical R = .34 (.37)). Table 4 shows the correlations between
the predictors and the discriminant function for each of the three analyses. The contribution
of Events to the discriminating function is notably reduced for those who have been
debriefed. However the results of the ANOVA reported above show that there was no
significant interaction between the effects of Events and Debriefing on Civilian Mississippi
scores. Table 5 shows the differences between the mean Civilian Mississippi scores for each
continuous variable in the discriminant functions and the results of a univariate F-test. The
mean score for Attitudes, Talk and Social Support from peers and supervisors is significantly
higher for those classified as non-PTSD cases. Those officers who had any educational
qualifications were more likely to be classified as non-PTSD cases than those who had none,
but this difference was not significant.
|SS from Peers||.47||.63||.43|
|SS from Supervisor||.44||.27||.49|
|2. Debriefing (N=117)||3. No Debriefing (N=390)|
|Variables||No PTSD||PTSD||F||No PTSD||PTSD||F|
|SS from Peers||3.18||2.70||6.15*||3.24||2.86||11.56*|
|SS from Supervisor||3.22||2.94||1.11||3.39||2.83||15.19*|
As predicted, the environment characteristics (but only education among the person
characteristics) were related to PTSD symptoms, but these effects were not moderated by
the experience of debriefing. The effects of the environmental variables were the same for
the debriefed and non-debriefed groups. There were no main effects on PTSD symptoms of
debriefing although the number of potentially traumatic events did have a significant effect
on PTSD symptoms. The more events that an officer had experienced, the more likely they
were to have higher symptom scores. When the effects of the number of events on
symptoms was taken into account, along with a number of other demographic and
environmental variables, debriefing did not predict whether an officer would be classified as
a PTSD case or not. The best predictors of PTSD, as shown in Figure 3, were: the ease
of talking about traumatic
experiences at work; attitudes to expressing emotion in the work place; social support from
peers; social support from supervisors; and whether officers had educational qualifications
or not. The differences between those classified as PTSD cases or non-cases were such that,
those with higher PTSD symptoms reported less social support from peers or supervisors,
less positive attitudes to expressing emotion and less ease in talking about trauma at work.
PTSD cases were more likely to have no educational qualifications in this sample.
Harvey (1996) suggests that the efficacy of post-trauma interventions depends on the degree
to which they enhance person-community relationships and achieve ecological fit. Although
debriefing aims to enhance social support and to encourage talk about trauma and the
expression of emotions, it is possible that the provision of debriefing by health professionals
from outside the organisation does not fit with the ongoing recovery needs of police officers
who have experienced trauma. Police officers, who participated in the present study,
expressed appreciation of the provision of support by the organisation and they also spoke
of the value of talking about traumatic experiences. However, they also expressed a
preference to talk with others who had shared their experiences in their own time and a
resentment of compulsory group debriefings, as in the following example:
Officer: Well, the guys might not feel like talking about it by then ...She got very
upset during it, she was crying and that sort of thing, and I just dont - she was very
um annoyed with the guy, she didnt feel like talking about it at the time and she felt
like she was compelled to and he was sort of pressuring her into it.
Interviewer: So you think it was more upsetting for her to actually have the debriefing.
Officer: Yeah, from what I understand, people, they told me, is that they had to go
round the room and talk about specific sorts of things and it wasnt sort of voluntary,
they sort of felt they had to actually say something, and as far as I was concerned if
I was there and I didn't feel like doing it I wouldn't do that, I'd tell him to get
This type of reaction is not uncommon in emergency service workers. Mitchell and
Dyregrov (1993) warn that mental health professionals who are unknown to emergency
workers may be treated with mistrust, resistance and anger. Burns and Harm (1993) speak
of the reluctance of emergency nurses to participate in debriefings. Deahl, et al. (1994)
suggest that the effectiveness of debriefing is enhanced if delivered by members of the
organisation involved in the work, and others (e.g. Paton, 1994) recommend peer support
This study tests only part of Harvey's model and supports recent calls for more rigorous
evaluation of debriefing methods, rather than providing definitive results. There are several
other recovery environment and demographic variables that could be included in future tests
of the model. For example, other variables suggested by Harvey (1996) are initial distress
level of the victim, intelligence and personality. Raphael et al., (1995) include personal
coping resources, cognitive impairments, past psychological morbidity and other life stresses.
Additionally, recent research has shown that organisational factors, such as shift work or
unfair work practices, have the most important impact on psychological outcomes for police
officers and may interact with traumatic experiences (Sloan et al., 1994; Stephens, 1996).
One notable limitation, in terms of the variables that may contribute to PTSD symptoms, is
the measurement of trauma used here. The number of events, although it has been shown
to have some impact on subsequent symptoms, does not include any indication of the severity
or salience of the event to the person. This aspect along with others such as the frequency,
severity and duration of the events, should be included in future studies and must be taken
into account in the provision of debriefing or other forms of intervention (Busuttil, 1995).
Furthermore, this study does not explore in any depth the interactions between event and
person characteristics which the model proposes as mediators between the trauma and the
response. Others (e.g. Atchison, 1995) would view these interactions as constituting the
trauma itself. Finally, the use of PTSD symptoms as an index of recovery is seen by Harvey
as useful but very limited. She proposes a multidimensional definition of recovery which the
present study does not take into account at all. Another type of limitation to this study is the
problems caused by comparing groups of unequal size. The use of the large scale survey,
in an organisation in which events are similar in type and many officers for a variety of
reasons are not included in debriefings, seems a useful approach to evaluation. In this
situation, the selection of the participants for study could be made with specific attention to
the two groups. Future explorations of this model must also take into account the
development of symptoms across time.
Although limited, this use of Harvey's (1996) model has proved fruitful in demonstrating the
importance of a number of aspects, other than debriefing, of the post-trauma environment.
Social support and opportunities to talk about traumatic experiences and their emotional
impact with others in the work place, have been shown to be related to PTSD symptoms.
These findings support current suggestions (e.g. Busuttil, 1995; Gillham, 1995; Jones, 1995)
that post-trauma interventions at work should be developed to fit with local requirements,
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