Beyond Debriefings: The Process of Trauma Response
Originally published in Employee Assistance Professional Association's Exchange
September, 1993

As violence in the workplace increases, employee assistance professionals are increasingly asked to coordinate, direct and implement the organizational and psychological response to these traumatic events. The provision of clinical services including debriefings is only one aspect of a complete response to workplace violence. This article reviews the significant dynamics and services critical for reducing the impact of psychological trauma following violence in the workplace.

Violence in the Workplace

Workplace violence is a special type of traumatic event with its own dynamics. Intense exposure to death and destruction in the form of wounded or murdered colleagues is often a major cause of later psychological distress. Loss is also a primary issue in workplace violence. Not only is there the potential loss of body function and/or loss of the relationship with the deceased/survivors, there may also be the loss of the relationship with the perpetrator, loss of control as well as the loss of belief in safety at home or at work, Issues of anger and blame are inevitable as employees search for the cause of violence in their workplace. Even when there is no clear reason for blame, lax security measures or other organizational problems are often cited as the cause of the incident. When an unusual and traumatic event occurs, there is always a concern about the possibility of a reoccurrence. The more meaningless and arbitrary the incident, the more vulnerable and unsafe employees seem to feel. It is these and other characteristics of workplace violence that are the major causes of psychological symptoms after exposure. Such post trauma symptoms or consequences typically include a component of reexperiencing of the event (intrusive thoughts, flashbacks, exacerbation of symptoms after triggers), avoidance (avoidance of feeling, thoughts, activities, withdrawal from relationships, numbing). Other symptoms such as anger, hypervigilence, concentration difficulties and sleep disorders are also to be expected. The goal of the post trauma response is to reduce the likelihood of the development of long term psychological difficulties by providing immediate services or referral to more intensive services.

EAP Response to Workplace Violence

The EAP and trauma literature now commonly report efforts to reduce the impact of violence and other traumatic events in the workplace (Friedman et al, 1988; Gwaltney, 1987). However, there has been a tendency to view various models of structured group meetings (post trauma or critical incident stress debriefings) as the only appropriate response to trauma (Yandrick,1991). Yet, there are no reliable outcome data to support reliance on one intervention tool and the disaster, crime victim and other trauma literature point to the effectiveness of an eclectic approach toward trauma management. It has been our experience that multiple interventions including ventilation, information concerning the incident, a high level of organization support and coping skill training are most likely to reduce the level of long term damage and identify those in need of post trauma psychotherapy (Barnett-Queen & Bergmann,1993). ). Thus, the use of post trauma debriefings is considered part of an overall approach of individual and organizational strategies. (Note: Whenever possible, post trauma responses that are developed and planned before the incident are most effective (Barnett-Queen & Bergmann, 1988, 1991). They reduce the difficulties associated with locating trained post trauma assistance, providing timely service and raise organizational commitment increasing the probability of recovery.)

Initial Contact

A post trauma intervention begins when the EAP or other post trauma responder is notified of the traumatic event. The content and process of this initial consultation (usually via telephone) is critical. A calm and controlled manner by the provider communicates immediately that a response to a traumatic event occurs in a deliberate and organized manner and that the providers are not going to race in like "white knights". During this initial conversation, it is important to discuss the general philosophy of a post trauma response and follow-up, assess the severity of the event, the extent of organizational support for post trauma response and the expectations for the outcome of the services. The primary decision-makers in an organization should also be identified. Often, the person who initially calls is not the person who will be making scheduling, financial and other decisions. The effectiveness of consultation can be reduced if access to the appropriate decision-makers is limited.

During other contacts before service provision (typically 24 to 48 hours after the incident), conversations continue to identify natural groups of survivors, most likely schedule for interventions, appropriate debriefing types and assess the organizational culture within which the post trauma response will occur. These contacts also provide a glimpse of the receptivity of the organizational culture for the post trauma efforts. The purpose of this up front contact is to prepare the client and service providers for what will and will not occur upon arrival. 

There is some disagreement concerning the utility of immediate crisis intervention or "defusing". In most cases, we have found that their primary benefit is the presence of a support system where one is not already available. Where post trauma programs are already in place, managers and other on-site personnel are likely to be as effective as immediate services by post trauma responders. Our present approach is not to provide defusings unless specifically requested by the organization.
 

Onsite Consultation with Managers

Meetings with managers before the provision of services increase the overall effectiveness of the post trauma response Setting accurate expectations for the outcome of interventions is a primary goal of this meeting. When an organization has a planned program, expectations concerning the outcome of interventions is much more likely to be accurate. However, it is important not to assume that all parts of an organization have been equally prepared. Expectations are set by explaining the probable psychological results of trauma, services to be provided and their possible outcome. It is important not to oversell the effectiveness of debriefings. When this happens, gaining support for further group meetings, post trauma counseling, transfers or other worksite adjustments is much more difficult. 

Gaining information about the organization and those impacted also occurs during this initial meeting. What were the strengths and weaknesses in the organization before the traumatic event? Who is being blamed for the incident? How does management understand the task of responding to the incident, i.e.. primarily as a productivity, human resource, or publicity issue. How is management planning to respond? In addition, management or human resource personnel may have specific concerns about certain individuals. Past traumas, performance problems or current stressors alert the post trauma responders to at-risk employees.
 

Provision of Post Trauma Services

Interventions provided after workplace violence are implemented depending on the number of survivors and the severity of the impact. Psychological debriefing is the intervention of choice for those who are most traumatized. This carefully structured group meeting allows each employee to describe the incident and their post trauma response and to learn important information and appropriate coping skills. With each participant given several opportunities to participate, trained facilitators are able to assess the level of the stress reactions and make a decision concerning the need for more services and potential for difficulties associated with return to work. 

Educational or didactic debriefings are most useful for those less impacted or where an effort is made to offer some intervention to all employees. This intervention is in the format of a workshop or seminar and includes information about the traumatic event, likely stress reactions, suggested coping skills and the availability for further assistance. The obvious difficulties with the educational debriefing are the lack of time for each participant to discuss their experience, the absence of close and repeated contact with facilitators and the necessity of self referral for additional mental health services. A typical response to an incident of workplace violence includes several psychological debriefings and at least one educational meeting. 

A difficult problem is "fitness for duty." The providers of post trauma services are ethically bound to identify and protect employees from further danger or injury which might result from the impact of the incident. During the introduction to the psychological debriefing, we review the protections and limitations of confidentiality during the sessions. Clearly stated is an understanding that participants will be protected if they are suicidal, homicidal or present a danger to themselves or others while at work/on duty. Examples of situations where concern might be expressed are the bank teller who might behave in an unsafe manner to another robbery, a machinist with sufficient anxiety to increase the possibility of errors or a hypervigilant law enforcement officer who might not respond appropriately to a motorist.

Post Services Consultation

Before leaving the worksite, a meeting with the management group is held to review the outcome of post trauma services. The providers relate the general condition of the organization and employees and share concerns about individuals (within the limits of confidentiality). In some cases, employees may have requested and given permission to post trauma providers to communicate safety concerns to management. Decisions should also be made about plans for further services either in the form of more debriefings, other group meetings, family group sessions or individual post trauma psychotherapy 

Follow-up and Evaluation Services

There are a number of activities which should follow the initial onsite post trauma response. All debriefings participants are asked to attend a follow-up sessions one to two weeks after the initial meeting. This the an opportunity for the facilitators to reassess employees and the organization. Typically, follow-ups are rather routine because most participants are adequately adjusting. However, post trauma providers may identify employees not previously viewed as needing assistance. During the first weeks after post trauma services, it is important for the post trauma responders to stay in touch with managers and supervisors. The purpose of these contacts is to continue to assess the recovery process and remind managers of the potential difficulty in post trauma recovery. These relationships become critical if transfers or schedule changes are required for certain employees. If possible, follow up should continue for at least one year. Dr. Tom Williams suggests that work records including the use of sick leave and productivity be checked at regular intervals. Post trauma interventions should also include an evaluation process such as a participant evaluation followed by a questionnaire directed at management.

The whole post trauma response process may last days or weeks. The process of consultation, service provision and follow-up continues until management and providers agree that recovery is proceeding smoothly.

EAP's in Post Trauma Intervention

Employee assistance programs should carefully assess their ability to successfully respond to violence in the workplace before committing to this process (Barnett-Queen & Bergmann, 1993a). There are significant resource, organizational and ethical issues in providing these services (Barnett and Bergmann, 1993). Providers should be trained in group debriefing skills and have strong backgrounds in diagnosis, group process and consultation. Not all EAP's should provide every type of post trauma service. It is possible to form relationships with other organizations, EAP's or regional teams of provider of post trauma services (The St. Louis EAPA chapter consisting of internal and external EAP's has formed their own team to address the special issues of workplace trauma). Select the EAP involvement that fits the special needs of the program and organization.

With EAP's being asked to be actively involved in post trauma responses after workplace violence, it is important for potential providers to understand the whole range of task and services required. Thinking in terms of a continuing process of evaluation, consultation, service provision and evaluation will insure that employees exposure to workplace violence are adequate supported.
 

References:

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

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

Barnett-Queen, T.R. & Bergmann, L.H. (1993) Coping after crises. Employee Assistance 5, 8, 6-11.

Barnett-Queen, T.R. & Bergmann, L.H. (1993a) The role of the EAP in post trauma response. Unpublished manuscript.

Friedman, R.J. et al (1988) Early response to posttraumatic stress. EAP Digest, September/October, 45-49.

Gwaltney, H., (1987) Posttraumatic stress and the EAP response. EAP Digest, July/August, 57-60.

Yandrick, R (1991) Critical incident stress debriefing in the workplace. EAPA Exchange (21)8, 38-39.
 

Back to list of articles