,

Maintaining Routines after Trauma

Should military and emergency services workers maintain work routines after exposure to

trauma?

 

As a police manager I’ve thought about this question because I’ve seen officers who take time

off after witnessing trauma, and I’ve seen others that stick to their normal work schedule.  I’m

not talking about just taking a day or two off, since that wouldn’t throw your work routines out

of whack, however some officers get a doctor’s note giving them a few weeks, sometimes over

a month off of work.  That would definitely throw their routines off.

 

I recently read an article from Journal of Adolescent Health (2006) Maintaining Routine despite

Ongoing Exposure to Terrorism: a Healthy Strategy for Adolescents?  The researchers (Pat-

Horenczyk, Schiff, Doppelt) studied high-school age youth in Jerusalem during the Al Aqsa

uprising of 2002-2003.  During that time there were 26 suicide bomb attacks in Jerusalem.  They

happened in buses, coffee shops, fast-food restaurants, shopping centers, and in the downtown

area.  Those are all areas that teens would typically go to hang out with their friends.

 

Of the 1336 Israeli adolescents examined, the majority (approximately 70%) continued with

their routines and did not avoid buses, malls and restaurants.  Even adolescents who reported

exposure to terrorist attacks were as likely as teens reporting no exposure to maintain their

level of routine activities.  Thirty percent of the teens avoided taking buses and going to those

locations, either because of their own choice or due to parents not allowing it.

The study found that a reduced level of routine was a significant predictor for higher post-

traumatic stress (PTS) and functional impairment.  Interestingly, it didn’t matter why the

subjects avoided going out, whether it was their own choice to avoid danger, or whether it was

due to their parents limiting them, the outcome was the same – significantly higher rates of PTS

and functional impairment. Maintaining routine was associated with less PTS, and parental

encouragement for maintaining routine was associated with less PTS.

 

The article also mentions that it is consistent with other coping theories suggesting that

“avoidance” coping strategies, including avoiding routines are associated with greater PTS than

“approach” or active coping strategies.

 

The study doesn’t go as far as to determine why, but I’ll give some of my thoughts on it.  It may

be because teens stuck at home without their friends are more isolated and don’t have their

normal support system of peers.  It may be due to the avoidance behavior increasing their fear,

instead of facing their fear which would likely reduce it.

 

It may be that the adolescents who continued their routines felt more confidence and self-

efficacy and felt more in control of their environment.  Despite the fact that they placed

themselves in more physical danger, it was psychologically protective.

 

Does this apply to military and emergency services personnel? In my opinion it does.  I think

depending on the level of exposure to trauma, in most cases the members should be

encouraged to return to duty and re-establish routines sooner than later.  I wouldn’t question

the recommendation of a clinician, but often the subject is also getting advice from peer

support teams or CISM members.  Even after minimal exposure, sometimes their advice to the

member is to take time off work.  This is done with sensitivity and caring for the member, but

may actually increase the chance of PTS and functional impairment.

 

I had one member who was involved in a traumatic incident.  He told me that the peer support

member told him he could take a month off work if he needed it, but he told me that his father

used to say “When you fall off a horse you get back on”.  He was back at work the next day.

That was healthy for him.

 

Should EAP counselors, CISM teams, and peer supporters encourage members to get back to

work as soon as possible?  It may be counter-intuitive, but I think in most cases maintaining

routine helps bolster resiliency.

/by

Trauma does not equal PTSD

I have read articles where the author said that PTSD is a normal reaction to trauma, or a normal reaction to an abnormal event. But it’s not true. Usually the people that say that are people that have suffered with PTSD. However science doesn’t support that view.

George Bonnano a leading resilience researcher from Columbia University wrote in 2011 that the single most common outcome after a traumatic event is recovery without intervention. Research shows that most people recover after trauma without any kind of treatment. In other words, most people are naturally resilient.

It is normal to have some type of stress reaction after trauma, but those reactions in the vast majority of cases are temporary. Most people will experience some type of physiological or emotional reaction after severe stress, at the very least due to the adrenaline dump. You may have feelings of shock, horror or disbelief and may experience hyperarousal, emotional numbing or have trouble sleeping. These various reactions are reasonable to expect and usually subside within a few weeks, and do not turn into full blown PTSD. Most research shows that PTSD rates are in the neighbourhood of 15 percent after a traumatic event. That means that 85 percent of people do not develop PTSD after experiencing trauma. That is good news.

The other positive news is that PTSD is preventable in many cases. Prevention can be accomplished through resiliency training pre-incident, and also through post-incident support. In a study (Brewin et al, 2000) researchers found that the severity of the trauma had less to do with the outcome than the support the victim received after the event. A lack of support after trauma will be a major factor in increasing the chances of PTSD, but the reverse is also true. A strong support system can prevent PTSD onset.

Sometimes people diagnosed with PTSD, and people that work with victims balk at the idea that PTSD is not a normal reaction and that it is preventable. They feel it is insensitive to the victims. Like saying they are weak, or mentally inferior in some way. That’s not what the scientific research is saying though. It’s research, it’s not a personal attack. And of course the purpose of the research is to help people in the future.

Let’s compare it to cancer research. If there was a study that found a method of preventing cancer that was effective 50 percent of the time, it would be celebrated and promoted. No one would assume that it’s being insensitive to people that already have cancer. It would just be great to know that much of the suffering could be prevented.

Those victim’s advocates or critical incident stress responders who, because of their sensitivity to victims, don’t want to discuss the fact that PTSD is not the normal response and preventable, really don’t help future victims.

I know that PTSD can’t be prevented in all cases, but that should not stop us from working towards that goal. There should be a greater focus on resiliency training, not just treatment for those with trouble coping. Is it not better to prevent somebody from falling, instead of afterwards trying to put all the pieces back together again?

We will all face some significant trauma in our life and will have stress reactions to that event. It is good to seek treatment and a have a support system. And it is good to know that those reactions are usually temporary and that over the next weeks we will regain a sense of normalcy. It’s good to know that odds are strongly in our favour that we won’t develop PTSD. This positive assumption will help us.

If people assume they will develop PTSD because they experienced trauma, because they believe that is the most common reaction, it can create a self-fulfilling prophesy. The placebo effect is well documented, and it shows that beliefs can help or hinder healing.

We need to have a healthy perspective about the natural resiliency of the human mind and our ability to effectively cope with trauma and bounce back.

/by