and Adjustment Strategies
Coping and Adjustment Strategies used by
Emergency Services Staff after Traumatic Incidents:
Implications for Psychological Debriefing,
Reconstructed Early Intervention and Psychological First Aid.
This survey reports few points of convergence between post incident coping and adjustment strategies used by 217 experienced emergency services and the principles that inform delivery of debriefing services. Officers prefer immediate access to colleagues and those with whom they feel close. Most wish to talk freely and flexibly about events and prefer to be consulted about a possible need for early intervention. Cluster analysis identified five core components of deliberate coping strategies; wait and see, rest and relaxation, finding relief from somatosensory sequelae, re-establish routines and a sense of control, and graded confrontation with distressing reminders.
Coping and Adjustment Strategies used by
Emergency Services Staff after Traumatic Incidents:
Implications for Psychological Debriefing,
Reconstructed Early Intervention and Psychological First Aid.
Devastation wrought by wars, natural disasters, violent assault, accidents and a broad range of other significant life events bring into sharp focus the physical, social and psychological reactions evoked by trauma. Every such event presents modern psychotraumatology with a challenge to demonstrate and document its relevance to all those touched by what has happened. A central platform for improved understanding of psychological reactions manifested in the intermediate and longer term is an evidence base detailing the nature and course of immediate and early reactions to trauma (Schnyder and Moergeli 2003). Drawing upon this emergent knowledge base it is possible to conduct further research and enter into informed discussions about the impact of early psychosocial interventions on personal or group adjustment over time.
Of the latter psychological debriefing have been championed for their prophesied capacity to alter the course and development of traumatic stress reactions as well as smoothing delivery of other critical incident stress management services (e.g. identifying individuals at particular risk). Popular intervention protocols include critical incident stress debriefing (Mitchell, 1983), psychological debriefing (Dyregrov, 1989) and a number of related derivatives (Armstrong, O'Callahan & Marmar, 1991). Calls for systematic evaluation of the effectiveness of such intervention protocols were first made by Raphael, Meldrum and McFarlane (1995) and subsequent systematic reviews of outcome studies have failed to demonstrate a consistent relationship between early intervention and outcome (Rose et al. 2002). Based on the evidence engendered by one such study the authors caution against uncritical reliance as one off intervention protocols for police officers mobilised for disaster response (Carlier et al. 1998).
In recognition of the seemingly self perpetuating controversies engendered by outcome based studies, some commentators have promoted an alternative and complementary approach to collating evidence about which forms of early intervention are both acceptable and effective for various survivor groups (Ørner and King 1999). The recommended strategy initially involves retrospective surveys of survivors' views and experiences of personal and group benefits accruing from their preferred post trauma coping or adjustment strategies. 'User' focused studies should furnish a new evidential baseline for sensible practice against which the acceptability of professionally advocated provision can be tested. This approach might also be particularly informative when used with established professional groups, such as emergency services staff and military personnel, because it may help identify a range of post trauma adjustment routines that are deliberately used to modulate psychological and somatic reactions to trauma. If successful in this regard, the evidence can be incorporated into basic staff training, preventative initiatives within employee assistance programmes and be offered as guidance to accidental survivor groups or in public education initiatives.
This paper reports findings from a survey carried out amongst 217 mostly middle ranked emergency services officers in Lincolnshire, England. Officers from the local police, ambulance, firebrigade (grouped as front line services), health and social services (grouped as second line services) completed two questionnaires as an initial exercise when attending awareness raising courses on trauma in the workplace. The first questionnaire asked respondents to think back to a specific incident at work that had been exceptionally distressing. Then they gave four point Likert-scale answers to questions about early intervention strategies that might have or did mitigate the psychological impact of the event. The second questionnaire asked about deliberate coping strategies routinely used by each participant to minimise the emotional sequelae of critical events at work. All course participants agreed to complete the questionnaires. When grouped by employing emergency service the five occupational cohorts were comparable on all demographic variables except that males were over-represented in front line services (police, ambulance, firebrigade) as were females in second line services (national health service, social services) (df=1, p<0.001).
Early Intervention Protocol Prescriptions
Protocol prescriptions for Critical Incident Stress Debriefing (CISD) (Mitchell 1983) and Psychological Debriefing (PD) (Dyregrov 1989) offer the following guidance. These interventions, suitable for both groups and individuals, should ideally be carried out between 48 and 72 hours after a critical event. Mandatory participation is recommended with mental health care professionals acting as co-ordinators and facilitators in the delivery of these services. Listed objectives for CISD and PD are to undertake a detailed review of facts, thoughts, impressions and feelings engendered by what has happened with a view to normalising these reactions. Getting as accurate a picture of the incident as is reasonable under given circumstances is also deemed important. Group meetings also offer opportunities to advise participants about coping strategies to limit the personal impact of precipitating events and identify individuals thought to require more intensive post incident support.
Neither protocol offers advice about the circumstances under which these early interventions are indicated or contraindicated. Nor is it made clear if they are equally suitable for all trauma survivor groups (adults, children, military personnel, rescue staff) irrespective of their level of post incident psychophysiologial arousal or the nature of the precipitating event (disasters, road traffic accidents, sexual assault, torture). Some of these key elements of CISD and PD intervention protocols are listed in Table 1, column 1.
Protocol Prescriptions and Officers' Preferred Practices
Table 1, column 2 lists officers' generally low levels of endorsement of key protocol prescriptions for CISD and PD. In contrast, these same respondents indicate that their preferred practices for modulating the psychological and physical effects of work related trauma comprise of elements featured in column 3. Officers' actual levels of endorsement of these strategies are given in column 4.
It is clear from Table 1 that only in few and a very limited respects does consensus exist between early intervention protocol prescriptions and preferred practises resorted to by experienced emergency services officers. For instance, a policy of routinely calling mandatory meetings after work related critical events was endorsed by only 2.3% (n=5) of respondents. There was significant agreement amongst 79.7% (n=173) of respondents about the value of making a point of talking about the incident but marked differences exist in respect of the actual methods, contexts and processes for doing so.
Table 1. Levels of Endorsement for Protocol Prescriptions compared with Officers' Preferred Practices
|CISD AND PD PROTOCOL PRESCRIPTIONS
|Routine Prescription of Mandatory Meetings Following Critical Events
|Prefer to Make Independent Decision or Consult With Colleagues About Accessing Services
|Talking About Events Is Helpful
|Prefer Not to Talk About Events
|Routine Mental Health Professional Involvement Is Indicated
Prefer Involvement From :
|Early Intervention Indicated Between Two and Three Days After Incident
|Most Helpful To Talk To Colleagues Immediately After An Event.
|Early Reactions Manifested After Two Days
|Early Reactions Manifested Within One Day
|Advisable For Group Meetings To Follow Set Protocol
|Flexible Peer Support Meetings Preferred
In contrast to the prescriptive practice that early intervention should involve trained mental health professionals, members of high risk occupational groups who participated in this survey stated a clear preference for having access to colleagues (71.4%, n=155)) and those they feel close to (72.4%, n=157) rather than independent professionals (9.2%, n=20). Peer and friend contacts were assessed as having been most helpful immediately after the index event (51.2%, n=111), but the value of continued contact over a period of several days post incident was also recognised by 37.8% (n=82) of respondents. Contrary to assumptions that have been made about a need to await the emergence of trauma related reactions 84.8% (n=184) of the emergency services officers believe they can recognise the likely impact an event within 24 hours of its occurrence. Only 7.8% (n=17) state this tends to become clear only after a delay of several days. In these respects therefore scant justification exists for focusing the delivery of early intervention services on reactions that persist for some days after an event which may have emerged during its aftermath.
When officers talk about what has happened and their reactions to it, 85.7% (n=186) prefer doing so in a free and flexible manner. Linked to the same, 40.6% (n=88) of respondents wish to make their own independent decisions about whether or not to access early intervention services as well as the appropriate timing for doing so.
Table 2 lists these same stated preferences of emergency services officers and compares the extent to which these views are held to different degrees within front line and second line responder groups. In most respects the two groups share a consensus view as to what constitutes informed practice. However, significant group differences exist with regards to rated helpfulness of talking (df=1, p<0.01) and the extent of valuing support from colleagues (df=1, p<0.001). In both respects most frequent endorsements are given by second line emergency services staff. Providers and planners of early intervention services should therefore note that, as a consequence of observed statistically significant differences, it is unwise to presume one pattern of provision will be equally acceptable or effective amongst members of front and second line services.
Table 2. Front and Second Line Emergency Services Preferences
|Prefer to Make Independent Decision About When to Access Early Intervention Services
|Talking About Events Is Helpful
Prefer Involvement From
|Prefer to Talk To Colleagues Immediately After An Event
|Early Reactions Manifested Within One Day
|Prefer Flexible Peer Support Meetings
Other results of this survey give substance to the view that coping and competence, rather than psychopathology and dependency typically prevail amongst emergency services staff in the early aftermath of exceptional incidents. Respondents indicated they deliberately make use of specific adjustment strategies to reduce the psychological impact of such events. Although idiosyncratic preferences appear to evolve over time for each officer and some of its constituent subgroups (front and second line services) statistical analysis identified general strategies for the whole survey sample.
Survey respondents indicated on a four point scale (0=never, 3= always) the extent to which they make deliberate use of the listed coping and adjustment strategy to modulate reactions evoked by work related critical events. When their responses were subjected to a five factor principal component analysis the emergent factors could be labelled as 'Wait And Self-Monitor Changes in Evoked Reactions', 'Rest And Relaxation', 'Find Relief From Somatosensory Sequelae', 'Re-establish Personal Routines and Sense of Control' and 'Graded Confrontation of Memories of Critical Event'. Together these factors account for 41.9% of the total variance of scores observed within the survey sample.
These five deliberate coping and adjustment strategies are listed in Table 3, column 1.
Table 3. Deliberate Adjustment Strategies used to Modulate Reactions Evoked by Critical Events
|Level of Endorsement
|Guiding Principles For Coping and Competence
|Strategies for Deliberate Coping and Adjustment
|Prescription For CISD and PD Interventions
|Wait and Self- Monitor Changes in Evoked Reactions
|Deliberately Let Time Pass
|Intervene Within 48 - 72 hrs
|Rest and Relaxation
|Deliberately Go Somewhere
|Convene Group Meeting and Commit Officers to Attend
|Comfortable Deliberately Relax
|Find Relief From Somatosensory Sequelae
|Deliberately Use Humour
|Only Talk Based Interventions Considered
|Deliberately Release Feelings
|Re-establish Personal Routines and Sense of Subjective Control
|Deliberately Take Charge of My Life
|Mental Health Professionals Unilaterally Recommend Mandatory Attendance
|Deliberately Re-establish Routines
|Graded Confrontation of Memories of Critical Event
|Deliberately Talk About Events In General Terms
|Adhere To Prescribed Agenda of Successive Protocol Stages.
|Deliberately Avoid Some Reminders of Events
Some of the constituent coping and adjustment strategies are given operationalised descriptions in Table 3, column 2. The levels of endorsement given to each questionnaire item using a three-point scale can be seen in Table 3, columns 3, 4 and 5. As can be appreciated by comparing column 6 with all the ones that precede it, striking contrasts exist between conventional protocol prescriptions for early intervention and the preferred adjustment strategies typically used by the large sample of emergency services officers who participated in this survey.
For instance, contrary to prescriptions for early intervention this group of high risk professionals state a preference for not convening mandatory meetings to review non-routine incidents and talk about thoughts and impressions evoked by it. Instead, at this crucial time, a broad consensus exists that personal and group interests are better served by an initial period of waiting and self-monitoring of changes that may occur in the initial reactions that follow in the wake of trauma. Such a strategy has the added advantage of also affording opportunities to rest and relax after what may have been exacting experiences both physically and psychologically. It also creates the necessary time gap for officers to once again re-establish personal routines and re-building a sense of safety and return to normality.
A rare point of convergence between recommendations made by putative experts within mental health professions and expressed preferences of emergency services staff is found in their common recognition of the importance of confronting what has happened. Talking about events and the reactions they evoke is one of the cornerstones in sensible coping and adjustment strategies. But as revealed by the fifth item in column 1 of Table 3, marked differences exist in respect of prescribed methods as opposed to the officers' preferred ways of doing so. Talking clearly serves adaptive purposes for most staff but to assume all will wish to do so is not supported by the evidence of this survey. 19.2% (n=43) state they regularly prefer not to talk about an event soon after its occurrence. Instead the officers in question rely on other deliberate non-verbal adjustment and coping strategies. So, if a particularly traumatic incident has involved some one hundred staff approximately twenty may have objections or strong reservations about attending group meetings to discuss unfolding events and reactions. This is a sizeable sub-population whose preferences differ from that of most of their colleagues. Special account should therefore be taken of how to offer help and support by means other than those that primarily require participants to develop narratives about critical events.
This finding is amplified by another result featured in this same section of Table 3. As many as 58.6% (n=127) of responder acknowledge having to some degree deliberately avoided reminders of what has happened. This may be functional for several reasons. It may help reduce early levels of psychophysiological hyperarousal (Gersons 2003) while also enhancing officers' sense of regaining a control over themselves, their situation and the habitual routines that give order to everyday life. Fixed, agenda driven protocols for early intervention that rely on participants disclosing their subjective reactions and memories of recent events may therefore be inappropriate. Most especially so if the procedure compromises participants need to regain control and ensure graded re-exposure to distressing reminders of what happened. In this respect early intervention should be provided specifically so as not to evoke inappropriate cathartic processes. At best such reactions may be helpful for patients in longer-term psychotherapy. It should also be noted that talking in a group might involve having to listen to descriptions the nature of which some members may wish not to be reminded, may be unaware or do not need to know. Vicarious re-exposure under such circumstances may intensify memory-based ruminations about particular aspects of the event and the associated levels of psychophysiological over arousal. Neither is likely to assist or complement the participants' in their aims of coping and adjusting during the immediate post incident phase.
A further element of deliberate coping is to effect relief from somatosensory sequelae of trauma. This can be effected by humour as well as tried and tested forms of keeping busy. Working hard and taking exercise may, for some, be more adaptive than talking in public. A period of 'self talking and reflection' may be functional in formulating an open narrative to be expressed at a later stage. Of such coping strategies intervention protocols have been relatively silent.
It is noteworthy that in Table 3, column 1, which lists officers' own preferences for coping and adjustment strategies to use in the early aftermath of traumatic incidents, only two of five clusters rely primarily on verbal communication. Comprehensive early intervention strategies should therefore encompass a broad range of provision flexibly delivered so as to be consistent with what is now known about the adaptive nature of initial human reactions to trauma (Shalev and Ursano 2003) as well as service users' explicitly stated preferences for phased help and support. On any one occasion service providers should be receptive to the possibility survivors do not wish to access any of a range of active intervention services on offer.
As revealed by Table 1, the move towards professionalisation of trauma care, that has been achieved largely by championing prescriptive intervention protocols, has occurred without broad based consultations with actual trauma survivors or likely service users within emergency and uniformed services. The has to be considered an oversight by professionals in the field and is all the more remarkable since staff within high risk occupations such as police, firebrigades and ambulance services typically report high occupational satisfaction rates (Brown et al. 1996). Presumptions of inevitable traumatisation following exposure to life threatening or horrific events are ill advised, but their occurrence warrants considered organisational recognition with systematic strategies for informed, evidence based staff care in place.
Investigations seeking to develop our knowledge about early intervention have tended to focus on outcomes (Carlier et al. 1998). In part because of difficulties in identifying distinctive therapeutic gains attributable to special initiatives (Rose et al. 2003) entirely different research methodologies have been suggested to progress beyond the impasse of self-perpetuating controversy (Ørner and King 1999). One of these is to empirically document which coping and adjustment strategies are used by those who, in a professional capacity, are exposed to events that most people would consider traumatic. Results of these investigations have intrinsic value and help to furnish an evidence base upon which reconstructed early intervention services can be planned and delivered (Ørner and Schnyder 2003). Psychotraumatology is therefore at a juncture where it is possible to make recommendations about improved strategies and standards for survivor help and support that are rooted in sound theory and empirical findings. In so doing it is effecting a significant shift from assumptions of survivor pathology and dependency to a perspective that recognises, complements and consolidates survivors' personal and group resourcefulness mobilised in support of resilience and eventual mastery.
This paper presents findings that add to the emerging evidence base about how individuals and groups make adaptive adjustments and positive changes in the aftermath of trauma (Tedeschi et al. 1998). Strictly speaking results pertain to front and second line emergency services responders groups only. But the veracity of reported findings can be enhanced by significantly increasing the total number of officers entered into future studies. This will help develop more nuanced perspectives on idiosyncratic adjustment strategies that have evolved within each of the principal emergency services. It will also clarify the extent to which men and women may have different service preferences. The implications of an improved evidence base for early intervention initiatives are that these are likely to be flexibly delivered with less reliance on protocol prescriptions with far more importance being accorded to the needs of survivor populations.
Qualifications pertaining to the results of this study and weaknesses of the existing evidence base about early intervention should not be interpreted as a reason to abandon early intervention altogether. However, it strongly supports a call for radically different conceptual and practical approaches. Just tinkering at the edges of past practices is not a considered option. Most specifically, early intervention should in future incorporate the views, opinions and preferences of trauma survivors. The starting point for professional practice therefore becomes one of being ready to enter into dialogue with possible service users. This should establish if help and support is needed, at what stage the agreed assistance is to be provided (if any at all) within a context of realistic expectations of their likely impact in the short, intermediate and longer term.
If invited to give assistance providers will do well to approach the challenge of delivering quality services with an open minded flexibility that recognises the need to draw upon a broad repertoire of skills to be delivered in a phased manner over time. This is consistent with field reports from practitioners who offered assistance after recent earthquakes in Turkey (Coskun, 2000; Tutkun, 2000; Cetin, 2000; Oguz, 2000). They found survivor groups gave low priority to crisis psychological support in the early aftermath of disaster. Their preoccupations centred on practicalities such as food, safety, security, family care, shelter etc. In consequence 'early psychosocial intervention' remained so only in name.
As summarised in Tables 1,2 and 3 some areas of agreement exist between the principles that informed past prescriptions and those that underpin the emergent evidence base (e.g. the importance of confronting what has happened). However, differences are so substantial, so broad ranging and so marked as to call for a complete rethink and reconstruction of how early intervention should be construed and delivered. As argued above service reviews should bring post-incident provision into line with available evidence on user preferences. It should also be noted that the results of this survey can be incorporated in basic or post qualification training and preparedness exercises for emergency responders. Emergent practices should in their turn be the subject of methodologically rigorous evaluations.
Survey findings also caution providers against claiming expertise through accumulated impressionistic experience. Hindsight indicates that conviction led practice offers no guarantee against misguided interference with survivors whose needs and wishes we are only just now starting to understand. Linked to the improved knowledge of the predicament of trauma survivors has come a realisation of the complexities and vicissitudes of traumatic stress reactions. These extend far beyond those of symptoms chosen for diagnostic purposes in DSM-IV (APA 1994) and ICD10 (WHO 1993). The focus on symptom elimination in service delivery and systematic evaluation of early intervention should therefore be abandoned. In its place assistance should be offered to promote the objective of improving the quality of the recovery environment in support of the aim of helping survivors make phased adaptations and eventual adjustment to what has happened. With the publication of these survey results the evidence is at hand for operationalising these aims and objectives into practical staff care initiatives for emergency responders.
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