Coping After Crisis
Originally Published in Employee Assistance, 1993

Many employee assistance programs are being asked to respond to the psychological consequences of work-related traumas, i.e. robberies, sexual assaults and natural disasters. Typically, post-trauma interventions are provided on an emergency basis without careful planning and consideration of the psychological, legal and organizational issues involved. The purpose of this article is to identify problems with emergency post-trauma services, offer options for planning these interventions and suggest strategies for implementing post-trauma programs as part of employee assistance programs.

Often employee assistance programs begin providing post-trauma services after a frantic call from a company representative (external EAP) or a manager (internal). Eager to assist and be involved, counselors are sent to the company or work site to "get things back to normal." Often, brief meetings or "debriefings" are the only intervention and support provided to traumatized employees.

There can be some serious problems associated with these unplanned attempts at emergency post-trauma services. First, when those providing the services are primarily concerned with "pleasing the boss" or "keeping the client happy," the needs of employees may not be of primary concern. Second, post-trauma interventions can force difficult choices for employee assistance professionals when workers' compensation and fitness for work issues arise. For instance, relationships which may have taken months or years to develop may be damaged when providers advocate for organizational changes in response to traumatic events. Third, organizations not previously educated concerning trauma or committed to the psychological recovery of their employees may limit (for financial or other reasons) post-trauma counseling or other follows-up services. Last, employee assistance professionals without proper training may try to do more than they are able endangering employees' recovery efforts. With the litigation for psychological injuries a possibility, interventions provided by those with little training and experience can seriously damage the company and increase settlement costs.

Employee assistance programs also provide services after traumatic events to "gain visibility," as a "loss leader" or to separate their programs from others in the employee assistance marketplace. Our experience is that post-trauma services provided for these reasons tend to emphasize the public relations value of the response and focus on brief interventions with little follow-up with employees or managers.
The most effective employee assistance response to a trauma begins before an incident occurs. There should be careful consideration of organizational and program component issues followed by a process of planning, training, program implementation and maintenance strategies. In this way, the possibility for post-trauma recovery for all employees can be maximized.

Organizational issues refer to:

1. building commitment within an organization for appropriate and thorough post-trauma services
2. the identification of changes necessary within an organization to adequately accommodate survivors of traumatic events and
3. the process of facilitating these changes.

Employee assistance programs should anticipate the kinds of potentially traumatic incidents that might occur and specify the needs of those most impacted. One simple way to do this is to make a list of incidents that have occurred in the last ten years and brainstorm "worst case" scenarios. It is important to insure that your list includes those kinds of events that would clearly be traumatic and fit accepted definitions of trauma (Barnett-Queen and Bergmann, 1988a). Recognizing that the process of change is difficult in most organizations, it is important to identify the individuals and departments which will likely help or hinder your efforts. For example, we have worked extensively with banks and have found that security personnel often assume that post-robbery services will interfere with the identification of losses and investigations. Therefore, when developing post-trauma services in financial institutions, we always target security personnel for education and include them in planning. Other areas to be targeted are marketing, public relations, human resources and medical departments. Unless addressed early in the planning process, these concerns could block the development of post-trauma services. It might be helpful to prepare a brief presentation and explanation of the impact of trauma and the importance of post-trauma services to be delivered to each of these key people and departments. Legal and workers compensation issues should also be addressed as well as the experience of other organizations. The process of building commitment is a difficult but necessary step in developing an effective post-trauma program. The goal is not merely approval to provide the services after a traumatic event but an overall change in the view of psychological injuries by the organization (Dunning, 1988).

Program issues refer to decisions concerning the initiation of the post-trauma response, types of services provided, training and maintenance strategies that will occur.

In most cases, the decision to initiate a post-trauma response to a particular event is obvious. The list of potentially traumatic events described above will cover the majority of situations that arise. However, there may be times when things are not so clear such as the death of a co-worker after an illness or a prolonged period of high chronic stress followed by an incident of moderate traumatic potential, i.e. a hospital with a post-trauma program reported a series of unusual and sudden death on an obstetrics unit followed by an automobile accident during which a nurse's husband was severely injured. In these cases, it is important to have criteria for the characteristics of traumatic events which can serve as a starting place to discuss whether or not to response John Wilson et al (1985) have developed one such list that includes life threat, exposure to death and destruction, degree of loss, suddenness, moral conflict, number of individuals impacted. Understanding this list can assist in the decision to offer post-trauma services. 
The decision to respond should not be made carelessly. When services are provided too frequently to events which do not qualify as traumatic, the credibility of the post-trauma program can suffer. The providers might come to viewed as rescuers who "chase ambulances" looking for work rather than professionals with a legitimate interest in post-trauma recovery.

The field of traumatic stress is quite new and no research-based consensus has emerged concerning the most appropriate post-trauma interventions. It is possible to make some recommendations based on post-trauma services presently provided to a variety of work settings including business and industry, health care, public safety and corrections.

We have written previously concerning a post-trauma "Continuum of Care" which describes an array of services that includes the critical elements of recovery and promotes organizational commitment (Barnett-Queen & Bergmann, 1988b). The components of the program include:

Trauma Preparation Training
Employees who receive information concerning post-trauma consequences and procedures for the organization's post-trauma response will be better able to manage their feelings and participate in post-trauma services. The goals of this training are to: 1) prepare personnel for the normal psychological consequences of exposure to potentially traumatic incidents; 2) teach basic recovery coping skills to be used after an incident; 3) assist in creating a supportive environment throughout the organization; and 4) describe the components, procedures and regulations associated with the post-trauma program. Every at-risk employee should receive trauma preparation training.

Post-Trauma Debriefings (Educational and Psychological)
A debriefing is a specifically designed group meeting for the purpose of preventing long term post-trauma psychological consequences. There are two types of debriefings. Educational debriefings are normally of limited duration (approximately ninety minutes), accommodate large groups of survivors, are didactic in nature and emphasize coping skills and self-referral for further treatment. Psychological debriefings allow small groups of employees to discuss the traumatic incident in detail, understand the normalcy of post-trauma consequences and create a detailed plan for recovery. During a psychological debriefing, employees are assessed by trained debriefers concerning the need for further services. 

Post-Trauma Counseling
Counseling sessions are extensions of debriefings and include continued discussion of the traumatic event, post-trauma consequences and the further development of coping skills. Post-trauma counseling sessions are different from many other kinds of counseling and psychotherapy in that they are almost exclusively oriented to the "here and now." Few personnel who participate in a psychological debriefing require further services in the form of individual counseling. Those who do generally require three to four sessions of special post-trauma counseling. (Barnett-Queen & Bergmann, 1990)

Among those providing services after work and duty-related trauma, there is general agreement about the importance of these components. Many public safety (law enforcement, fire and emergency medical) and corrections organizations also include a peer support component to their programs (Barnett-Queen and Bergmann, 1988b). Peer supporters can be the "eyes and ears" of the post-trauma program, identifying potential traumatic incidents and assessing the need for post-trauma debriefings and counseling. In addition, peer supporters are taught basic crisis intervention and active listening skills and participate in debriefings facilitated by trained mental health professionals. Employee assistance programs may also consider interventions for family members and formal six month and one year follow-ups for all impacted personnel (Williams, 1988).

Employee assistance professionals are often asked to immediately travel to the site of the traumatic incident to provide initial support and crisis intervention. Others choose to provide extensive services within the first few hours after the incident occurs. There is some disagreement about the utility of these "on-site" services. The moments that immediately follow a traumatic incident are characterized by shock, a sense of disbelief and physical/psychological numbing. Many survivors of traumatic events report that they are very tired, have difficulty concentrating and remembering important information. In addition, survivors often want to leave the site of the incident and make contact with family and friends. Therefore, the psychological response of survivors immediately after the incident may preclude effective post-trauma services.

Organizations are also traumatized and in disarray and are besieged by internal security and law enforcement personnel and the media. Immediate post-trauma services can be very difficult to coordinate and may interfere with investigations and run the risk of worsening the crisis. Finally, employee assistance professionals who respond on-site run the risk of traumatizing themselves. Immediate arrival means possible exposure to rescue efforts, severe injury or triage decisions. Many providers have not developed the skills necessary for managing such exposure. For these reasons, we generally do not recommend immediate interventions.

Those supporting such services argue that the recovery process can begin sooner when personnel respond immediately. From this point of view, survivors with strong, acute responses can be medically treated and information provided concerning immediate coping skills. Further, some organizations insist on immediate responses for their personnel and it may be difficult to refuse these "requests." Each employee assistance program should carefully consider these and other factors when deciding to provide "on-site" responses.
A major program consideration for employee assistance programs is the maintenance of post-trauma services once they are established. There are several factors which hinder the continued existence of these programs.

1. There is a general tendency for people to avoid consideration of exposure to traumatic events at work. Thoughts of the potential dangers in a work setting may trigger uncomfortable anxiety. Information concerning the post-trauma program is often avoided.
2. Post-trauma programs may be idle for long periods of time when potentially traumatic events do not occur. Inactivity works against program maintenance.
3. The post-trauma program depends on relationships between management, employee assistance professionals, and employees. All must communicate effectively for the program to operate and important contacts may diminish over time and hurt the program. Barnett-Queen & Bergmann, 1988c).
   As a result of these factors, the planning process for post-trauma programs should include careful consideration of program maintenance. A number of strategies have been used by other post-trauma programs including regular public relations campaigns, continuing education and the use of post-trauma advisory councils.

Two final program notes:

• Providing post-trauma services is a specialized area. All providers should receive adequate training in post-trauma responses and skills training for all interventions.
• A post-trauma program requires employee assistance professionals who do not suffer from the long term consequences of repeated exposure to traumatic incidents. Therefore, there must be a formal mechanism for psychological debriefing of providers. It is often helpful to locate and contract with providers from other organizations to be on call for "debriefing the debriefers."

Employee assistance programs will be increasingly involved in responding to traumatic events. To avoid the problems associated with unplanned, emergency interventions, employee assistance professionals should carefully consider the organizational and program component issues associated with these services.

References:

Barnett-Queen, T. R. & Bergmann, L. H. (1988a). Post-trauma response programs. Fire Engineering,(141)8, 89-91.

Barnett-Queen, T. R. & Bergmann, L. H. (1988b). Implementing post-trauma programs. Fire Engineering,(141)9, 52-58.

Barnett-Queen, T. R. & Bergmann, L. H. (1988c). Maintaining posttrauma programs. Fire Engineering,(141)10, 73-75.

Barnett-Queen, T.R. & Bergmann, L.H. (1990). Response to traumatic event crucial in preventing lasting consequences. Occupational Health and Safety, July, 53-55.

Dunning, C. (1988). Intervention strategies for emergency workers. In M. Lystad, Mental Health Response in Mass Emergencies: Theory and Practice.New York: Brunner-Mazel.
Williams, T. (1988). Personal Communication.

Wilson, J.P., Smith, W.K., & Johnson, S.K. (1985). A comparative analysis of PTSD among various survivor groups. In C.R. Figley (Ed.),Trauma and Its Wake: The Study of Post-Traumatic Stress Disorder.New York: Brunner/Mazel.

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