Stress in Front Line Workers during
Role Stress in Front Line Workers during
the 2001 Foot and Mouth Disease Epidemic:
The Value of Therapeutic Spaces
Dr Ian Convery
Faculty of Science & Natural Resources
Dr Maggie Mort, Dr Cathy Bailey
The 2001 Foot and Mouth Disease (FMD) (See footnote 1) crisis represents one of the greatest social upheavals in the United Kingdom since the Second World War, as well as one of the worlds largest ever epidemics of the virus. In order to deal with an epidemic of this magnitude, The Department of Environment Farming & Rural Affairs (DEFRA) needed to second and reassign staff (many from other government organisations such as the Environment Agency) to work on the front line of the crisis, often in dangerous and highly stressful environments. These workers typically received little training to prepare them for their roles, and what limited preparation they did receive often contrasted strongly with practical experiences, they thus found themselves working in unpredictable and chaotic situations. Based on a longitudinal ethnographic study of the health and social consequences of the 2001 FMD epidemic, our research (See footnote 2) indicates that repeated exposure to distress and suffering led some of these front-line workers to experience what we term post traumatic experience. The study raises a number of issues relevant to the evolving concept of occupational health in increasingly fractured and ambiguous domains of work and particularly in disaster and post-disaster situations.
We all had to go, us 'dirty' people, to a training day up in Carlisle, where we'd be get told what our duties were it was a complete and utter waste of time it wasnt like that at all, I was off work with depression afterwards, I still havent really fitted back into workDEFRA Field Officer, interview, April 2002
Role Stress in Front Line Workers during
the 2001 Foot and Mouth Disease Epidemic:
The Value of Therapeutic Spaces
The 2001 FMD epidemic was the worlds largest ever outbreak of the virus in a country previously free of the disease, with 2030 confirmed cases nationally, though such numbers alone give only a limited idea of the true scale of disruption and chaos. There are estimates of between 6 to 10 million animals slaughtered as a result of FMD, and much of this slaughter occurred out of place and time (i.e. on farm, in large numbers at the wrong time in the farming year) and represented a huge logistical problem. The events of 2001 have thus been described as a traumatic and devastating experience for all those who were affected by it. It was a national crisis and was probably one of the greatest social upheavals since the war (Anderson Inquiry, 2002). The effects of the crisis were felt locally and remotely; directly and indirectly; immediately and in the longer term. Rural communities in particular were hit hard, socially and economically, by the 2001 Foot & Mouth Disease crisis and elsewhere we have detailed the health and social consequences of the epidemic within Cumbria (See footnote 3)(Bailey et al, 2004; Convery et al, 2005; Mort et al, 2005).
The main agency responsible for managing the crisis was the Ministry of Agriculture, Food and Fisheries (MAFF), later to become the Department of Environment Farming & Rural Affairs (DEFRA). High numbers of additional staff were required to deal with an epidemic of this magnitude, and DEFRA responded by seconding and reassigning staff (many from other government organisations such as the Environment Agency) to work on the front line of the crisis. This paper is concerned with the experiences of these workers. During FMD, frontline workers often had to operate in dangerous and highly stressful environments, to the extent that a number of respondents have likened this to war-work. More specifically, we address three main aims: first, to highlight the issue of occupational stress and relate this to disaster situations using evidence from our study of FMD frontline workers. Second, to examine briefly the response of disaster workers to trauma, focusing on what we term post-traumatic experience. Third, to consider what helps and what doesnt. Drawing on both academic literature and the narratives of study respondents, we develop an argument for the creation of therapeutic spaces and peer-support networks for disaster workers.
A detailed account of the study design is given by Mort et al., (2005). In short, our study was a longitudinal qualitative ethnographic account of the health and social consequences of the 2001 FMD epidemic (See footnote 4). A standing panel of 54 citizens, who were involved in different ways during the epidemic, was recruited independently. Selection criteria were framed by a demographic profile that was designed by the project steering group (comprising representatives from DEFRA, Cumbria County Council, the Environment Agency, North West Development Agency, the NFU, Business Link Cumbria, Voluntary Action Cumbria, Primary Care Trusts, local veterinary practices and health professionals (e.g. GPs and community nurses)). The resulting panel included farmers and their families, frontline workers, workers in related agricultural occupations, those in small businesses including tourism, rural accommodation and rural business, health professionals, veterinary practitioners, voluntary organizations and residents living near disposal sites. The project began with a meeting to explain the project, which was followed by individual, in-depth interviews with all panel members. Respondents were asked to write weekly diaries for a period of 18 months and regular contact was maintained through monthly visits by the research team to collect diaries, for which a small monthly payment was made.
Our design was also underpinned by action research (AR), a philosophy that is carried out with research respondents rather than on research 'subjects'. Because of the sensitivity of the post FMD situation, it was felt that a style of research which could both generate knowledge of health and social impacts as well as inform policies to help alleviate some of the potential consequences of these, was ethically more appropriate. The participants in this study therefore included the members of the project steering group (See footnote 5) representing a wide range of stakeholders, as well as those who directly contributed the data the 54 members of the citizen panel (respondents). All had regular opportunities to guide the research process and later comment on the emerging themes and findings. As Hart & Bond (1995) describe, there are many modes of action research, from the managerialist to the emancipatory. Our approach was largely practical in that at the early stage the steering group acted as co-designers of the research, while once recruited, the citizens panel members acted as co-researchers (See footnote 6) . To assist with this a number of feedback loops were created:
All interviews and group meetings were transcribed from audiotape; diaries were transcribed from the original (usually hand written) format. In addition to personal reading and initial coding of material, eight all-day 'data clinics' were held to identify emerging themes, using a constant comparative approach. The data were stored in ATLAS Ti software, and once the themes were refined following agreement that 'saturation' had been reached according to the principles of grounded theory, coding was undertaken. This analytical approach is well established in the social sciences (Charmaz 1997) and a methodological literature has developed to accompany its use (Barnes 1996; Glaser 1992; Strauss & Corbin 1994,1998). Constant comparison entails breaking down, examining, comparing, conceptualising and categorising the data so that central, recurrent and robust, analytical themes or categories emerge. The final dataset includes 3071 weekly diaries, 72 semi-structured interviews and 12 group discussions (all taped and transcribed).
Occupational Stress and Disaster Workers
As Perrewé et al. (2002) report, the literature on occupational stress and burnout has grown exponentially over the last twenty years. They attribute this interest largely to the recognition that stress can have detrimental effects on individuals mental and physical health as well as negative effects on factors such as work performance and staff turnover. Put simply, stress is a fundamental element of the workplace that appears to affect adversely the well-being of individual employees (Dobreva-Martinova, et al, 2002).
Much research on occupational stress has focused on role ambiguity and role conflict. Role ambiguity has been described as stress resulting from uncertainty (Furnham, 1997) often resulting from lack of clear job description, goals or specified responsibilities. The stress indicators associated with role ambiguity include depressed mood, lowered self-esteem, life dissatisfaction and low motivation (Arnold et al., 1991; Dobreva-Martinova, et al, 2002). Role conflict refers to stress from conflicting demands, and occurs when an individual is torn by conflicting job demands or by doing things he or she does not really want to do, perceives as being not part of the job or suffers psychologically uncomfortable demands (Arnold et al, 1991, Furnham, 1997; Piko, 2005, Mullins, 1996). Recent work has highlighted the relationship between roles changes, role ambiguity and post-industrial society, where labour markets tend to be associated with flexible production systems typified by adaptable, redeployable labour and high rates of turnover (Storper & Scott, 2002). For example, Hage & Powers (1992) discuss the links between increasing societal complexity in post-industrial society and relate changes in the structure of roles, identifying, amongst other things, the tendency for work teams to be viewed as temporary rather than permanent.
Respondent testimonies, from interview, focus group and diary data, indicate issues of role ambiguity and role conflict linked to working on FMD. In particular, those who were assigned the role of field officer reported receiving limited role training and, initially at least, limited logistical support. As one DEFRA Field Officer (See footnote 7) commented:
I was supposed to be at the farm gate handing out licenses, but I was soon helping the vet hold down animals for slaughter, it was like that for the rest of the time [people] didn't give any concern regarding their own health and safety. I think the events just took over and you just did what you could to help at the time. The role didn't really match the briefing at all,
We had a choice to go dirty or stay clean. 'Dirty meant going out to farms and help with slaughter, 'clean' didn't. I decided to go dirty, basically because I've worked on a farm, worked with stock, seen dead animals before so I knew it wasn't going to throw me. We all had to go, us 'dirty' people, to a training day up in Carlisle, where we'd be get told what our duties were it was a complete and utter waste of time it wasnt like that at all, I was off work with depression afterwards, I still havent really fitted back into work
The literature on role conflict suggests an association with reduced job satisfaction, higher anxiety levels, psychological strain and physical health problems such as heart disease. It is also strongly linked with burnout (Perrewé et al., 2002; Chang & Hancock, 2003), which is typically defined as a syndrome of emotional exhaustion and depersonalisation (Chang & Hancock, 2003) as well as an inability to cope with stressful situations. The result may be a sense of hopelessness, fatigue, and range of psychological and physical health problems and deterioration of family and social relationships (Perrewé et al., 2002; Karatepe & Sokmen, 2005; Chang & Hancock, 2003). Here a DEFRA field officer describes withdrawing from social contact at home:
I was coming home (very late at night) and I didnt want to talk to anybody [ ] I was just ignoring [my boyfriend] I wouldnt talk to him. I wouldnt phone my parents, I wouldnt phone any of my friends. [ ] I just wanted nothing to do with anybody.
DEFRA Field Officer, Interview February, 2002
A study of the Piper Alpha disaster (See footnote 8) highlighted that the factors which appeared the most powerful causes of stress, were principally organisational and managerial. For example, paperwork, lack of personal recognition, obstacles at work, lack of opportunity to display initiative (Alexander and Wells, 1991). Correspondingly, respondents in the FMD study reported frustration at not being able to carry out their roles because of perceived excessive bureaucracy:
'It was like trying to dress an octopus in a set of bagpipes'. They [ DEFRA headquarters] wanted to work in traditional ways (regulations), we were working like farmers do, making deals and negotiating an abyss into which things go and never come out.
Group interview with DEFRA workers at Portakabin City' (See footnote 9), Carlisle, 2002
The main event of the week regarding FMD was the DEFRA meeting on Friday morning. Each department spoke on its role in FMD and more or less congratulated itself on how 'wonderful' it performed. It was almost amusing hearing some departments [some] presentations I thought were a bit misleading.
Studies have indicated that the risk of role stress and trauma in disaster workers may be reduced by pre-event training and preparation (Meichenbaum and Jaremko, 1983; Alexander, 1993; Dyregrov et al, 1996; Alexander and Klein, 2001). Other work has highlighted how the notion of victim is rarely used in relation to rescue, medical and support workers (Alexander & Wells, 1991; Shepherd & Hodgkinson, 1990). Disaster workers are instead considered to be infinitely resourceful and impervious to traumatic experience. Yet Deaville & Jones (2001:7), commenting on the sustained mass killing experienced by many frontline workers during FMD, question if training or experience could provide adequate preparation for such work.
Here a livestock valuer, DEFRA Field Officers and a farmer respectively, emphasise the scale and nature of the mass culls and the incongruity of the work:
A lot of farm animals get slaughtered every year normally anyway - but not on that scale
It was the scale of the slaughter and the quality of stock being killed that saddened me I did manage to lamb a few sheep while on a slaughter job, everyone thought I had gone mad when I told them, as they were all going to be killed later that day, but why should their last few hours have to be in pain? They were all killed later and the young lambs were injected straight into the heart
..the pregnant ewes were worst, I think, that was dreadful. There were 2000 sheep on one of the places we were and a lot of the ewes were pregnant and as they were being slaughtered they were having premature births and I wasnt physically sick or anything but you felt you were going to be
[It] was just like a conveyor belt really there were about thirty cows due to calve in the next month, and they were all in two calving sheds, and they were just done where they stood, and dragged out. And there was a calf, and the slaughtermen had to draw straws on who shot the calf and they were absolutely devastated
For other categories of frontline workers, daily conditions of work changed substantially. Respondents speak of long hours, sporadic meal breaks, keeping going on adrenalin, exhaustion. Wagon drivers faced new imperatives when collecting milk or delivering feed and were under constant scrutiny regarding bio-security. In particular, the bio-security measures, of microscopic disinfecting and washing out of infected premises for weeks following a cull, were described by some respondents as punitive:
You started thinking of all sorts of strange things in your mind washing out. I said prisoners wouldn't have done it.
(Farm worker, interview, Jan 2002)
Severe movement restrictions affected a wide range of rural workers. Community nurses report having to take medical histories and make assessments over a gate.
there was a siege mentality in all aspects of life my job changed significantly during the foot and mouth epidemic the guidance from the practice changed all the time, I found myself discussing bowel problems with a farmer and having to shout over the farm gate. I got very angry
In a crisis situation the first thing that you would normally do, as clergy, is go, to be alongside people in their pain and it was the one thing that you couldn't do
Vicar, diary, March 2002
McGraths (1976: 1352) often-cited definition of stress highlights
the significance of perceptual factors in the individual as a significant
factor, stating how the potential for stress exists when an environmental
situation is perceived as presenting a demand which threatens to exceed
the persons capabilities and resources for meeting it. The following
contributions from a
Field Officer seconded to the crisis from the Environment Agency underline this reaction:
I kind of switched off I just thought this is absolute chaos, this is madness
He felt morally compromised:
I resented myself and I resented, the Government and the fact that the only way I could comfortably resolve the situation was to er, leave my job
And extreme anger:
I vividly remember, the last farm I was on, [ ] I was penning up cattle and, I would have been quite happy to have seen (politicians) getting penned up and getting popped in the head [ ] which I dont think was a very healthy state of mind to be in, but...thats how I felt at that time....
He speaks of flashbacks and suicidal thoughts and recurring traumatic images:
Ill never be able to look at a cow or a sheep again without seeing blood pouring out of the hole in its head, [ ] maybe I will in time I walked, walking along the pier one night [ ] I did actually think about jumping in I felt so bad about myself.
While many front line workers were local people whose livelihood had been severely curtailed by the FMD control strategies and who had practical knowledge of handling livestock, others were seconded from government agencies or unrelated branches of the Civil Service:
They were literally taking anybody on but some people had no knowledge of livestock whatsoever . . .because, as far as they were concerned, we would be standing, in full waterproofs with a clipboard, at a gate directing traffic basically, licensing folk in and out, err, making sure they were disinfected properly, err, basically getting in the bloody road!
But being a Field Officer involved much more than directing traffic and paperwork:
I mean, in between all this [culling of cattle] I was keeping an eye on the sheep and I was lambing some of the sheep! I know it sounds completely silly, but I just couldnt walk past and, and leave them.
A Field Officer with milking experience recounts a slaughter team arriving at a farm for a large cull at 3.30pm:
. and they had to be back up in Edinburgh for ten oclock so they were going to stop at half past seven [. . .] I mean, we were going to shoot the little milkers first because Id seen them suffering with not being milked and what have you
I've counted over the last 6 months how many cattle and animals I killed I can only relate to it as like being in the forces, like going to war
Group interview with DEFRA workers, Portakabin City, Carlisle, 2002
Here a slaughter-man (See footnote 10)comments on the role of the Field Officer and the trauma they experienced during FMD:
Well, you used to make a joke when we were going round eh, about Field Officers. I says are you going to give us a look at your Field Officer bible then eh? What you can say and what you cant say? And what you can do and what you cant do? And er, that was the big joke with the Field Officer eh? What do you think? Oh well I cant say nowt eh. They always used to say, Cant comment.
I says Oh youve likely got Field Officer bible read then eh? Aye they couldnt say owt out of turn or anything that would incriminate them these are farmers boys, right and all they were trying to do was make some money because theyd been out of work for so long. Richard is actually a farmers son, and he found killing, that the killing, the disposing of the animals, very hard. Hes been brought up since he was tiny to look after animals, and people were saying, the town people were saying things like Well these farmers lads can cope with it. But these farmers lads have been brought up looking after animals not destroying them and chopping them up so that they can be buried and burned, you know. Erm, I think the ones who managed to keep on going, erm, were the men who hadnt looked after animals, mebbe country born and bred but not having roots directly with farmers. They managed it but the lads like Richard . they couldnt hack it, and theres an awful lot of them. I think theres a lot more going to happen, mental problems for a long time. Oh yes, I mean Richard doesnt like to talk about it.
Slaughter-man, interview 2002
Additional evidence regarding the health problems experienced by DEFRA frontline staff was provided by a questionnaire survey completed by (the then) DEFRA Occupational Health Department in 2002 (See footnote 11), after the crisis was over. The questionnaire was sent out to all staff that had worked on FMD, with 399 completed questionnaires returned (response rate unknown). Questions included location, length of time staff worked on FMD-related activities, and type of activity (diagnosis, slaughter, burning and burial). Staff were also asked if they had experienced health problems (the questionnaire included questions related to respiratory problems, vomiting and diarrhoea, blisters and stress or mental health problems, as well as a other option). In total, 28% of respondents reported work related illness. The most frequently reported health issue was stress or mental health problems (14.5% of workers), followed by respiratory symptoms (8.7%) and vomiting and diarrhoea (7.3%). In addition, more than 14.5% of workers reported an accident whilst working on FMD, but only 9.5% actually reported accidents at work during this time. For the other category, self reported conditions ranged from sore throats and fatigue through to post traumatic stress.
Whilst useful, we argue that in-house surveys of this kind should be treated with caution, not least because staff were asked to give personal information on the questionnaire, which would have made them easily identifiable within the organisation. Nevertheless, the fact that 14.5% of DEFRA staff felt able to disclose to their own occupational health department that they had experienced stress or mental health problems is telling, and gives some indication of the highly stressful conditions workers endured during FMD. This raises the issue of ongoing trauma as a result of these experiences, which we discuss in the following section.
Post Traumatic Experience
A central assumption behind psychiatric diagnoses is that a disease has an objective existence in the world, whether discovered or not, and exists independently of the gaze of psychiatrists or anyone else .However, the story of posttraumatic stress disorder is a telling example of the role of society and politics in the process of invention rather than discovery.
Our study of FMD has led us to reconsider understandings of trauma, and in particular, the relationship between trauma and Post Traumatic Stress Disorder (PTSD). Jones (1995:509) argues the concept of PTSD fails to embrace the complexity of the experiences of suffering and loss in [disaster] situations. We would broadly support this perspective (and the work of others such as Bracken et al., 1995; Summerfield, 2001) and argue for a more nuanced, situated understanding of trauma, which may share characteristics of clinically defined trauma (e.g. DSM III (See footnote 12)), but crucially does not attempt to systematise and pathologise traumatic experiences (with related dangers of disempowerment and victimhood). As Summerfield (2001:95) indicates, distress or suffering is not psychopathology.
Traumatic stress is often represented as the normal reactions of those people exposed to an abnormal disaster event (Yehuda et al. 1998; Alexander & Wells, 1991). Our frequent interactions with respondents have led us to develop a definition of trauma within the context of this particular disaster. Trauma was widespread and both acute and chronic, and respondents have reported feelings of shock, depression, including thoughts of suicide; loss of concentration and interest and recurrent thoughts and flashbacks. While such symptoms might accord with more clinically based definitions of PTSD; we maintain that the experience of trauma in this context (exacerbated by the long duration of the epidemic), should not be seen primarily as a disorder.
Bonanno (2004) argues that most people are exposed to at least one violent or life-threatening situation during the course of their lives, and whilst people cope with these potentially disturbing events in different ways, most people are able to endure potentially traumatic events. Indeed, resilience in the face of traumatic events is not rare but relatively common, and represents healthy adjustment rather than pathology. Significantly, Bonanno, (2004:20) differentiates between resilience (the ability to maintain a stable equilibrium) and recovery (where normal functioning gives way to threshold or sub-threshold psychopathology, usually for a period of at least several months, and then gradually returns to pre-event levels), arguing that resilience represents a distinct trajectory and is more common than has been understood.
Many respondents in our study found resources which protected them against developing illness as a result of exposure to traumatic experiences in the FMD crisis. As McFarlane (1988, 2000) observes, there does not necessarily appear to be a simple relationship between distress and psychiatric illness; distress need not be translated into psychiatric morbidity (Alexander and Wells, 1991). Thus whilst Ursano et al. (1999) argue that disaster workers are at risk of both acute and chronic posttraumatic stress disorder (where the most difficult aspect is exposure to violent death and dead bodies), other work notes the unexpected resilience of rescue workers and body handlers working in extremely stressful conditions following the Oklahoma City (USA) bombing (See footnote 13) (Tucker et al., 2002; North et al., 2002). A meta-analysis of five separate disaster events carried out by Cardeña et al. (1994, cited in Bonanno, 2004) identified that the numbers of people displaying post disaster PTSD-like symptoms were very similar and were apparent in only a minority of respondents.
Other studies have highlighted how the timescale of the disaster is important, not least because of the risks from continued exposure to stress and trauma. As Robinson (1993) indicates, experiencing cumulative stress is potentially more damaging than stress from a single incident. With FMD, the length of the disaster, combined with factors such as the clean/dirty regime imposed on workers, sense of loss of control, and transience of (some) FMD workers, weakened the ability of teams to 'pull together' (this is important, for reasons to be discussed later in the paper).
Anniversaries can be particularly difficult times for trauma-exposed individuals, and around a third have a likelihood of experiencing or exhibiting significant distress (including symptoms of PTSD) on the anniversary of their traumatic events (Morgan et al., 1999). In 2002, many respondents were forced to revisit the events of the FMD year through anniversaries of culls, of financial disaster or of their reluctant participation in the mass killing. Respondents write of anniversaries rather as a rite of passage. Painful and distressing images and some degree of re-living' the events of the past year may be part of the recovery process. For example, a slaughterman speaks of his feelings one year after being involved in the mass culls:
Its a year since I went away killing. I feel a bit funny with myself today. It was our wedding anniversary on the 10th, but this sticks in my mind more.
A DEFRA worker writes of his relief at signs of renewal:
It was good to see sheep back in the fields and even the first lambs were appearing again. The last lambs I saw last year were being given lethal injections by a vet and we laid them out in rows to spray with disinfectant till they were taken for disposal.
With specific reference to the FMD crisis, we argue that it is important to recognise the levels of distress experienced by frontline workers, highlighting the need for what counts as evidence in health research [to go] beyond the pathological and the statistical (Mort et al., 2005) whilst also recognising that many of the individual accounts of traumatic stress are accompanied by accounts of how individuals found a way to contextualise this, or gain some strength from the knowledge that many others locally were experiencing similar horrors. Our definition of trauma is thus a situated one, within the context of the 2001 FMD disaster (describing something experienced individually and collectively). There are certainly features common to the clinical individualistic (e.g. DSM III) definition, but also features of collective damage and impact such as described by Erikson (1979) in his in-depth exploration of the after effects of the 1972 flood in the mining area of Buffalo Creek in Appalachia .
What Helps and What Doesnt
There is much literature concerning the effects of traumatic work on mental health and emotional well-being and how best to manage it (see for example, Alexander & Klien, 2001; Bisson et al., 2003; Carlier et al., 1997, Duckworth, 1991; Everly et al., 1999; Jonsson & Segesten, 1998). A key issue in the literature is the significance of colleague or peer support. Dryden & Aveline (1988), for example, identify that institutions and groups with strong esprit de corps foster feelings of loyalty and a sense of belonging. Such support can have a positive, healing function, particularly when workers have experienced traumatic events. Conversely however, Paton et al. (2000:177) note that while membership of a cohesive group generally enhances resilience, it can, under certain circumstances, have the opposite effect. For example, cultural characteristics which advocate emotional suppression can increase stress vulnerability.
Group membership may also act as the focus for negative coping mechanisms such as alcohol misuse, smoking and drug use. Davey et al. (2000) highlight the link between occupational stress in the police service and alcohol and drug use, and associate drinking subcultures with good teamwork, resulting in peer pressure to drink (Fillmore, 1990, cited in Davey et al., 2000). They note that the working culture of the police service appears to prevent officers from adopting more appropriate coping mechanisms such as social support, counselling, stress management strategies and exercise. Violanti (1993) also identifies the link between alcohol use and occupational stress in the police service (see also Violanti & Paton, 1999; Violanti & Aron, 1993).
The value of more formalised debriefing (See footnote 14) interventions is even less clear-cut. Everly et al. (1999) carried out a meta-analysis of the effectiveness of psychological debriefing following trauma and reported results which supported the effectiveness of group psychological debriefings (though with the caveat that further work was needed in relation to the nature of the intervention programme). Such findings are supported by other studies covering a variety of disaster scenarios, including the Los Angeles riots (See footnote 15) (Hammond & Brooks, 2001) and rescue workers following a major earthquake (Liao et al., 2002). Bisson et al. (2003:145) reviewed the evidence base for psychological intervention following traumatic events and concluded that brief cognitive behavioural early intervention may be beneficial and should be primarily aimed at individuals with acute symptoms, as opposed to everyone involved in a traumatic event. Hammond & Brooks (2001) argue that police officers and fire-fighters receiving as little as 1.5 hour debriefing within 24 hours of an incident exhibited statistically significant less depression, anger and stress-related symptoms at 3 months than did non-debriefed subjects.
There is, however, contrary evidence that psychological debriefing is ineffective and can impede natural recovery processes (Raphael et al., 1995; Mayou et al., 2000; Schouten, et al, 2004). According to Carlier et al, (1998:143) the findings of comparative studies regarding the clinical effectiveness of debriefing were disappointing. Indeed, eighteen months post-disaster, those who had undergone debriefing exhibited significantly more disaster-related hyperarousal symptoms. Critics of debriefing argue that formal debriefing interventions may pathologise normal reactions to abnormal events and thus may undermine natural resilience processes (Bonanno, 2004).
Alexander & Wells (1991) reported (regarding the Piper Alpha disaster) that PT reactions such as intrusive images may be reported without there being raised levels of psychiatric illness or increased sick leave. They found that officers conducted their duties successfully (body retrieval and ID) and emerged relatively unscathed, and that some even seem to have gained from their experiences (Alexander & Wells, 1991: 551). Wilson (1980) also describes how emergency services staff can become addicted to the experience of trauma and may struggle to function effectively without it.
The notion that frontline workers may gain positive benefits from disaster work may appear at face value difficult to understand, but the experience of team work and helping provided strong emotional and psychological support for many frontline workers during FMD. For example, a DEFRA field officer speaks of doing a good job, helping in some way. He liked the adrenaline buzz of working flat out, now he feels flat and dissatisfied with my life.
It's been such a nice place to work, a good team
I think there was actually a real sort of you know, at the end there was a real sort of comradeship about it.
You can only appreciate it through having experienced something similar, and I think for a long time I was looking for that kind of support.
Respondents report that the process of writing a weekly diary (for eighteen months) was helpful in coming to terms with the consequences of FMD. Diaries offered a therapeutic space for reflection and an opportunity to make sense of experiences. In Box 1, respondents comment on their experiences of writing a diary for the project.
Box 1. Diary writing reflections
It has been a tool by which I feel I have been able to mark/measure our (me and my family) progress/recovery from FMD
It has been a chance to reflect on what happened, to look to the future and to recognise the frustration and anger
Yes, this process has been useful in a number of ways and has helped considerably in coming to terms with the effects of the epidemic and its effect both on personal and business level.
It has helped me stop and look at the future, and what I want to be doing in the future, or maybe helped provoke my mid-life crisis!
I wouldnt go as far, to say I have enjoyed writing the diary, but it has certainly been a welcome form of therapy.
I hope this has helped with understanding what people went through and hopefully if it ever happens again people will be more understanding about the pressure that everyone has been under.
Source: Mort et al. (2004)
Drawing on our study we argue that off-the-shelf plans to address all needs are unlikely to be effective given that disaster situations are multiple and dynamic. Rather, what is required is recognition of the sometimes hidden, but extremely important networks that form and coalesce around specific disaster events. Such networks are important not only in terms of managing the disaster, but also exist as ad hoc support structures for those involved in the situation. Despite the doubtless well-intentioned interventions of DEFRA and other agencies to debrief their staff following FMD, what was offered was essentially a formalised, off-the-shelf service, which did not reflect the experiences and needs of frontline workers:
What was DEFRA like in terms of the support they offered? Pretty non-existent nobody can understand what we have been through unless they have been through it with them. The counsellors would probably talk you through divorce, separation, bereavement whatever, but what we went through was way above any of that.
I did counselling, counselling for 2500 people who came through my door! There were vets from all over the world, they'd come in and have a cup of tea.
We didn't use the counselling service, we'd counsel each other. I'd sit in the rest room, there would be about 15 of us, and we'd just talk about the days events, some of those farms, it got nasty. It could be violent
Group interview with DEFRA workers, Portakabin City, Carlisle, 2002
North & Hong (2000) highlight how during disasters, people seek support
from trusted members of their own communities rather than mental health professionals,
and advocate training volunteers to support their peers. Importantly, North
& Hong state that distress is universal following a disaster and that
most people are not psychologically ill. Jonsson & Segesten (2004) also
argue that through dialogue with colleagues, it is possible to cope with the
effects of traumatic experiences, highlighting in particular the importance
of making the experiences understandable and meaningful. It is salient also
to emphasis that peer support, rather than supervisor or managerial support,
is important. A study of ambulance workers (Hedlin & Petersson, 1998,
cited in Jonsson & Segesten, 2004) identified that whilst good support
from peers was vital, less than 50% of workers thought that they could talk
to their supervisor or manager. Alexander & Wells (1991) identify the
importance of good relationships amongst police officers involved in body
retrieval work (following the Piper Alpha disaster), and found that humour
and talking with colleagues were the coping strategies police officers found
most helpful in dealing with their work. More recently, Alexander (2005:13)
has highlighted revived interest in psychological first aid, which
includes principles such as protection from further threat and distress,
helping reunion with loved ones, sharing the experience
and links with sources of support. Based on the experiences of
frontline workers during FMD, we would support such perspectives. In disaster
situations, agencies need to create therapeutic spaces for workers
to talk over experiences, opening opportunity for dialogue channelled through
existing trusted peer-support networks.
It is also important to note that for the temporary workforce of frontline workers co-opted or recruited to work for DEFRA at short notice (from all over the UK) and then often disbanded just as quickly, formal counselling services were not available to these staff (or, in all probability, the informal networks we mentioned above). Agencies have a responsibility to all frontline workers in disaster situations, not just permanent members of staff.
In addition, frontline workers amassed huge expertise during FMD. We argue that this is still not being sufficiently recognised or recorded and thus cannot inform future contingency planning (as identified by the Cumbria Inquiry, 2002). For many frontline workers, this formal lack of recognition has compounded a prevailing sense of anger and frustration. We suggest that agencies that employed front-line workers should hold joint meetings to formally record these acquired skills and expertise. Further ensuring ways of accessing such knowledge should be part of contingency planning, this would not only formally recognise the contribution of frontline workers in managing the 2001 FMD epidemic, but also bring together strategic and operational knowledge and experience about FMD. This would be a critical resource for the management of future outbreaks.
The respondents in our study are not emergency or disaster workers in the traditional sense. Nevertheless they had to deal with difficult and highly stressful situations, which they often endured on a daily basis, for weeks if not months. The evidence suggests that during disasters, frontline workers tend to seek support from trusted colleagues, who are able to share like experiences, rather than more formalised support from mental health professionals or counsellors. As a DEFRA Field Officer indicated, you can only appreciate it through having experienced something similar, and I think for a long time I was looking for that kind of support. Our work highlights that in disaster and post-disaster, there is a need for staff to support each other and we would urge organisations to encourage and facilitate such seemingly low-key, yet vital, therapeutic spaces.
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Footnote: 1 Foot and Mouth Disease (FMD) is a highly infectious viral disease that mainly affects cloven-hoofed animals, including cattle, sheep, pigs and goats. Fever is typically followed by the development of blisters - chiefly in the animal's mouth or on the feet. It can spread by direct or indirect contact with infected animals, and whilst the disease is rarely fatal, the effects are serious and debilitating. In dairy cattle these include loss of milk yield, abortion, sterility, chronic mastitis, and chronic lameness. Secondary bacterial infections may also lead to further complications. Advice from the UK Department of Health is that FMD is very rare in humans. There has only been one recorded case of FMD in a human being, in Great Britain in 1966. The general effects of the disease in that case were similar to influenza with some blisters.
Massey University, New Zealand
November 6, 2007