Introduction
Within all organizations in the UK, including public and private healthcare providers, there are clear policies and protocols in relation to health and safety at work [Health and Safety Executive (HSE), (2011)]. These procedures are aimed at proactive interventions to minimize the risks of injury/trauma in the workplace, ensuring clear pathways of organizational response and reporting should incidents occur, with monitoring mechanisms such as: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) (HSE, 1995), for evaluation of systems and processes.
The Health and Safety at Work Legislation (HSE, 1974, 1992), states that ‘employers have a responsibility to protect the psychological as well as the physical well-being of their employees’; however, response systems, in terms of psychological trauma, do not always appear as integrated within healthcare workplace policy as those that protect physical well-being. When recognized, only certain aspects of potential psychological trauma are written into policy and guidance (i.e. bullying and harassment, single traumatic incidents, violence and aggression), the rationale for this is unclear, but may be due to the often subjective, multi-faceted and contentious nature of what constitutes psychological trauma and how best to intervene (Bar-on, Reference Bar-on1998; Regehr, Reference Regehr2001; Courtois & Gold, Reference Courtois and Gold2009).
Despite this, there is a large body of research concerning the multi-level impact of psychological trauma, post-traumatic stress reactions (NICE, 2005) and the cumulative effect upon professionals (specifically working within a healthcare context) who continually work with physically and psychologically traumatized individuals (Bennet-Levy & Thwaites, Reference Bennet-Levy, Thwaites, Gilbert and Leahy2008; Nelson-Goff et al. Reference Nelson-Goff, Reisbig, Bole, Scheer, Everett Hayes, Archuleta, Henry, Hoheisel, Nye, Osby, Sanders-Hahs, Schwerdtfeger and Smith2009).
The holistic effects of trauma upon physical, psychological, social and occupational functioning have long been of interest in healthcare (Rothschild, Reference Rothschild2000; Kraus & McArthur, Reference Kraus, McArthur and Evans2006). The heterogeneous nature of the term ‘trauma’ is increasingly being recognized within research; however, only certain types of trauma are currently included within diagnostic frameworks [i.e. post-traumatic stress disorder (PTSD), adjustment reaction; WHO, 1992]. Occupational trauma is cited as a phenomena in the literature; however, it is not a recognized diagnostic category.
The categorical separation of psychological and physical trauma are disentangled in terms of proximal and distal aspects of trauma: direct trauma and post-traumatic stress responses (Courtois & Gold, Reference Courtois and Gold2009), secondary traumatization (Robins et al. Reference Robins, Meltzer and Zelikovsky2009), generational trauma (Baranowsky et al. Reference Baranowsky, Young, Johnson-Douglas, Williams-Keeler and McCarrey1998), and vicarious trauma (Collins & Long, Reference Collins and Long2003) are a few examples.
Subsequently, the resulting psychological effects of contact with trauma cases in the workplace are separated within the literature: compassion fatigue (Moeller, Reference Moeller1999), burnout (Ruysschaert, Reference Ruysschaert2009), victimization (Black et al. Reference Black, Newman, Harris-Hendriks and Mezey1997; Wolhuter et al. Reference Wolhuter, Olley and Denham2008), and counter-transferential responses (Shubs, Reference Shubs2008). These effects are generically summarized as ‘traumatoid states’ (Wilson & Thomas, Reference Wilson and Thomas2004). All of these effects are listed as potential consequences to occupational trauma.
Within this literature review, the effects and response to occupational trauma will be explored in specific relation to healthcare and related professions, providing focus upon occupational responses. For the purpose of this review, the term ‘occupational trauma’, is therefore defined as: the psychological effects of trauma directly attributable to occupational activity.
The dual processing of trauma in health and psychological care is detailed as a dynamic process that may influence trauma transmission (Brewin, Reference Brewin2003). The secondary effects of trauma and resulting traumatoid states are listed as occupational hazards for professions who both make contact with and provide care for those who are traumatized (Neumann & Gamble, Reference Neumann and Gamble1995), and also for those who work in environments where there is a risk of traumatic events occurring, where staff bear witness to these events with differing frequency (Robins et al. Reference Robins, Meltzer and Zelikovsky2009).
Some mental health occupationally linked risk groups in terms of research include; nurses (Clark & Gioro, Reference Clark and Gioro1998), psychotherapists (Ben-Porat & Itzhaky, Reference Ben-Porat and Itzhaky2009), emergency-care workers (Baum, Reference Baum2010), chaplains (Sinclair, Reference Sinclair1993) and social workers (Cunningham, Reference Cunningham1999; Stalker et al. Reference Stalker, Mandell, Frensch, Harvey and Wright2007). The corresponding impact of these issues is often categorized under the broader term of ‘stress-related health effects in human service work’ (Dollard et al. Reference Dollard, LaMontagne, Caulfield, Blewett and Shaw2007).
In the UK, for those who are directly traumatized, there are clear guidelines regarding evidence-based health and social pathways which will benefit the trauma sufferer (NICE, 2005). The evidence-based treatment applications focus upon the use of cognitive behavioural psychotherapy (CBP; Robertson & Humphreys, Reference Robertson and Humphreys2004), eye movement desensitization reprocessing (EMDR; Blore & Holmshaw, Reference Blore, Holmshaw and Luber2009), and in some cases, the use of certain psychotropic medications. However, research is limited concerning transferability of these interventions for those with occupational trauma, which more often consists of indirect rather than direct traumatization (i.e. working with victims of trauma, being exposed to the trauma narrative). Such trauma has added complexity in regards to potential repeated exposure, environmental considerations due to the trauma context and the subjectivity of response to the trauma stimulus which underpins group trauma dynamics.
With individuals whose trauma is due to secondary or tertiary trauma contact, or on-going/resulting from their occupational role, pathways of intervention are less clear (Ploeg et al. Reference Ploeg, Dorresteijn and Kleber2003). Rather than focusing upon the unique trauma experience, occupational responses are often solely aimed at workplace stress support (Murphy, Reference Murphy1996; Saunders et al. Reference Saunders, Driskell, Johnson and Salas1996; Richardson & Rothstein, Reference Richardson and Rothstein2008), without specific interlinked support structures for different professions/professionals (Ellis, Reference Ellis2006).
In the UK, in both NHS and non-NHS mental healthcare employers, there is a lack of consistency in support pathways for traumatized employees (White, Reference White2006), and through initial literature appraisal, there is a lack of uniformity of intervention offered (Phoenix, Reference Phoenix2007), providing a research deficit, prompting the need for a review of the related literature.
This literature review aims to establish occupational trauma as a phenomenon of interest to cognitive behavioural psychotherapists and healthcare providers in terms of proactive and reactive organizational support. A literature review was conducted to investigate the subject area and explore current and recommended pathways/interventions, with specific consideration of CBP support strategies, so that effective assessment and treatment approaches may be developed for future practice.
Research questions, aims and objectives
Research questions
(1) What are the effects of differing levels of occupational trauma on the individual and/or organization?
(2) Are there any current CBP-specific models, or treatment pathways, aimed at supporting those experiencing the effects of occupational trauma?
The objectives are to
• identify CBP interventions relating to occupational trauma;
• examine the context and costs of occupational trauma within the current social and economic climate in relation to mental healthcare;
• utilize findings of the literature review, to enhance the knowledge base relating to the field of CBP and to examine such organizational approaches that use CBP that could form part of a care pathway for occupational trauma.
Scope of the literature
A broad range of literature was reviewed, taken from: research databases, primary and secondary studies and clinical narratives. The following electronic databases were searched: OVID, CINAHL, Psycharticles and the Cochrane library. In order to focus the literature search, consideration was made as to whether to utilize the search words pertaining to the separate traumatoid states (i.e. burnout, compassion fatigue, vicarious traumatization); however, these search terms were not utilized, as they are not considered as pertinent to the research question unless included within literature directly focused upon occupational trauma. Where related conceptual states are raised in the search, these will be discussed in the Results section. The search terms employed for analysis are given in Table 1.
Search terms for the literature review
CBP, Cognitive behavioural psychotherapy; PTSD, post-traumatic stress disorder.
This list is not exhaustive; the author does not discount the possibility of inclusion of other constituent components as the search expands and hermeneutic exploration increases.
Inclusion/exclusion criteria
• Date inclusion: information sources no older than 10 years; however, it is acknowledged that related conceptual information may predate this.
• No restriction was imposed upon research regarding country of publication; however, research from non-UK sources are identified.
• Expert opinion is accepted as valid data, alongside qualitative and quantitative studies.
• Sources are limited to those pertaining to healthcare and related support services only, due to the focused aims of the study.
The data extraction and analysis tool (Benton & Cormack, Reference Benton, Cormack and Cormack2004) provides a framework for consistent thematic exploration. The above criteria demonstrate data collection methods; however, the author recognizes that subjectivity may affect repeatability of results by other researchers (Bowling, Reference Bowling and Bowling1997).
Methodology and method
The researcher approached the topic from a constructivist perspective. An inductive approach was used, and the methodology followed was a hermeneutical approach to systematic literature review, utilizing a qualitative method of enquiry. The researcher declared an interest in the use of CBP in trauma intervention, while accepting the influence of different psychotherapeutic and allied health professional disciplines.
Ethical issues
Ethical implications of research studies must be explicitly stated in terms of any research presented (Kaslow et al. Reference Kaslow, Rubin, Forrest, Elman, Van Horne, Jacobs, Huprich, Benton, Pantesco, Dollinger, Grus, Behnke, Shen Miller, Shealy, Mintz, Schwartz-Mette, Van Sickle and Thorn2007; Watt, Reference Watt2008). This research concerns a non-participant study and non-clinical data study, therefore ethical approval was not required via NHS (National Patient Safety Agency, 2008). However, consideration was given to how ethical considerations remain important, specifically in terms of rule-deontology (Seedhouse, Reference Seedhouse and Seedhouse1988). Therefore, ethical considerations for the critical literature review included:
• Specification of the author's philosophical standpoint when reading literature (Girden, Reference Girden2001).
• A diverse range of literature included, not research selected to comply with the researcher's expectations (Barker et al. Reference Barker, Pistrang, Elliot, Barker, Pistrang and Elliot1994).
• A respectful approach to literature analysed (Long, Reference Long, McSherry, Simmons and Abbott2002).
• Methodological fidelity regarding data extraction and analysis, aimed at bias reduction (McLeod, Reference McLeod2001).
• Acceptance and inclusion of results, whether positive or negative, demonstrating psychological flexibility of the researcher (Barker et al. Reference Barker, Pistrang, Elliot, Barker, Pistrang and Elliot1994).
Study selection process
A search was conducted as described above. Through the search, when applying the inclusion/exclusion criteria, the literature sources were focussed, as outlined below in Figure 1 (a full breakdown of sources reviewed, for study repeatability, is available upon request from the author).
Study selection process.
Details of studies included
Details of the studies included (excluding books and grey literature) are given in Table 2.
Details of studies in the review
Results and Discussion
Critical literature review results and discussion are presented jointly under the two headings of the research questions:
(1) What are the effects of differing levels of occupational trauma on the individual and/or organization?
Initial difficulties posed within the review are the interchangeable nature of terms used to describe occupational trauma, specifically with the homogenous term of ‘work stress’ (Whinghter et al. Reference Whinghter, Cunningham, Wang and Burnfield2008). On inspection, researchers who have used such terms, collaboratively combined trauma aspects with other occupational stress-related issues, i.e. workplace bullying (Ferris, Reference Ferris2009), and work-based violence (McKinnon & Cross, Reference McKinnon and Cross2008), which may or may not be considered as contributing factors to occupational trauma.
This factor means that the specific efficacy of interventions advocated may not be applicable directly to occupational trauma experiences, and therefore may need further research to prove their generalizability. Despite this limitation, findings are still provided, with indications where there are questions in terms of the type of stress referenced in the papers. Ploeg et al. (Reference Ploeg, Dorresteijn and Kleber2003), advocate splitting of specific occupational stressors rather than ‘lumping together’.
Personal effects
Whinghter et al. (Reference Whinghter, Cunningham, Wang and Burnfield2008) suggest several effects connected with occupational trauma: negative affect reactions, decreased job satisfaction and decreased job performance, alongside increased staff turnover, increased absenteeism, organizational aggression and interpersonal aggression. Blutstein (2008) expands, stating that in some cases occupational trauma can result in ceasing employment, which has been consistently linked with: self-esteem issues, relationship difficulties, substance misuse and differing degrees of mental ill-health.
Rubino et al. (Reference Rubino, Luksyte, Jansen and Volpone2009), explain that alongside the variety of trauma experiences, there is a corresponding variety of negative responses which can be observed with occupational trauma. Some workplace trauma is consistent with diagnostic criteria for PTSD, although this is restricted to primary trauma experience, the range of secondary and tertiary trauma effects are more varied. Themed effects include:
• Psychological effects. Distress (Krieger et al. Reference Krieger, Kaddour, Koenen, Kosheleva, Chen, Waterman and Barbeau2011), emotional exhaustion (Cronin, Reference Cronin2001), reduced self-esteem (Riggs & Adams, Reference Riggs and Adams2008), burnout (De Vente et al. Reference de Vente, Kamphuis and Emmelkamp2008), shame in regards to the trauma experience (Wenzel, Reference Wenzel2002), depression due to the cognitive evaluation of the potential for loss and harm in trauma witnesses (Wang, Reference Wang2005; Lang et al. Reference Lang, Bliese, Lang and Adler2011) and avoidant tendencies (Katz et al. Reference Katz, Snetter, Robinson, Hewitt and Cojucar2008). Schematic change is listed as an outcome, although this is narrowly focused upon in research concerning psychotherapy practitioners (Harrison & Westwood, Reference Harrison and Westwood2009).
• Physical effects. Much research linked occupational trauma with ‘work-related accidents’ and/or physical trauma and on occasions, fatal injuries, sustained during work (Alexandrescu et al. Reference Alexandrescu, O'Brien, Lynons and Lecky2008). In terms of psychological trauma, consequential physical implications found were: fatigue (Ploeg et al. Reference Ploeg, Dorresteijn and Kleber2003), insomnia (Eidelson et al. Reference Eidelson, D'Alessio and Eidelson2003), nausea (Pyevich et al. Reference Pyevich, Newman and Daleiden2003), poor general health with occupational stress and related occupational trauma exposure (McFarlane & Bryant, Reference McFarlane and Bryant2007).
• Social effects. Social withdrawal (Langman, Reference Langman2006), specific difficulties regarding interpersonal relationships and disruption in family life, although this is applied to workplace stress generically, rather than trauma-specifically (Rantanen et al. Reference Rantanen, Mauno, Kinnunen and Rantanen2011) and an increased likelihood of substance misuse issues (Al-Humaid et al. Reference Al-Humaid, el-Guebaly and Lussier2007).
Within the literature searched, several occupational and organizational costs were found:
• Increased absenteeism (Parks & Steelman, Reference Parks and Steelman2008).
• Increased malpractice due to the effects of occupational trauma. Examples are provided, including medication errors (Dollard et al. Reference Dollard, LaMontagne, Caulfield, Blewett and Shaw2007). Hecht & Boies (Reference Hecht and Boies2009) suggest the ‘knock-on’ effect of occupational trauma is a reduced ability to manage other work stressors, which cyclically affects performance if not supported to process trauma adaptively.
• Financial cost due to of loss of productivity (Kaminski, Reference Kaminski2001)
• Financial implications for organizations in terms of compensatory claims for work-related ‘mental stress’, which may include occupational trauma (Searle, Reference Searle2008). Job dissatisfaction (Parks & Steelman, Reference Parks and Steelman2008), and related/targeted organizational aggression and blame (Whinghter et al. Reference Whinghter, Cunningham, Wang and Burnfield2008). This has both a direct and indirect effect upon organizations in terms of recruitment and retention, employer reputation and liability in terms of lawsuits (Dollard et al. Reference Dollard, LaMontagne, Caulfield, Blewett and Shaw2007).
Finally, Dollard et al. (Reference Dollard, LaMontagne, Caulfield, Blewett and Shaw2007) researched the potential cyclic effects of occupational trauma upon both worker and client(s), suggesting that: ‘customer satisfaction with service quality is likely to deteriorate as providers experience emotional exhaustion, depersonalize clients as objects, and distance themselves emotionally from clients, as levels of stress increase’.
A further criticism of the studies reviewed is that many studies appear to gauge the effects of occupational trauma upon self-report measures, the dichotomy being that many individuals may be unable or unwilling to disclose experiences (Rubino et al. Reference Rubino, Luksyte, Jansen and Volpone2009), or lack insight into their condition. Issues such as the roles of: shame (Shubs, Reference Shubs2008), stigma (Linton, Reference Linton1995), secrecy (Harrison & Westwood, Reference Harrison and Westwood2009, Anon. 2007), empathy (Eidelson et al. Reference Eidelson, D'Alessio and Eidelson2003), cultural views of trauma (Steinberg, Reference Steinberg2002; Jacob & Veach, Reference Jacob and Veach2005), and professional implications (Miller, Reference Miller1998), are recognized as key roles within the lack of reporting/recognition of occupational trauma.
Research reviewed also appears to suggest that the level of personal pathology is complex, with the following variables to be considered; the level of training in dealing with occupational stress/strain and trauma (Searle, Reference Searle2008), the level of unprocessed personal trauma vulnerability (Rubino et al. Reference Rubino, Luksyte, Jansen and Volpone2009), intrapersonal rather than interpersonal/external resilience factors (Friborg et al. Reference Friborg, Hjemdal, Martinussen and Rosenvinge2009) and secondary alexithymia (de Vente et al. Reference de Vente, Kamphuis and Emmelkamp2006). Additionally, a counter-argument is presented in terms of the degree of corporate responsibility regarding occupational trauma. This issue revolves around the effects of the person's pre-existing vulnerability to trauma, including the ‘kindling’ effects of trauma (Harkness et al. Reference Harkness, Bruce and Lumley2006) and the worker's obligation to manage and/or identify their own increasing stress levels (Tomczyk et al. Reference Tomczyk, Alvarez, Borgman, Cartier, Caulum, Galloway, Groves and Faust2008). These are acknowledged as affecting the questions posed within this review, but not explored further due to review focus.
Last, some positive effects of occupational trauma exposure were found, including: finding work with traumatized individuals personally rewarding and satisfying (Kinzel & Nanson, Reference Kinzel and Nanson2000) and the experience of ‘stress-related growth’ (Slattery & Park, Reference Slattery and Park2007), although these positive experiences were limited to literature regarding psychotherapeutic disciplines, and therefore transferability of results to other healthcare professionals may be questionable.
(2) Are there any current CBT-specific models, or treatment pathways, aimed at supporting occupational trauma?
Within the results, research was found regarding CBT provision for occupational PTSD only (Pagani et al. Reference Pagani, Hogberg, Salmaso, Nardo, Sundin, Jonsson, Soares, Aberg-Wistedt, Jacobsson, Larsson and Hallstrom2007). Much evidence supports group or individual use of CBT with post-trauma sufferers (Bolton et al. Reference Bolton, Lambert, Wolf, Raja, Varra and Fisher2004); however, the main focus is on PTSD sufferers with direct trauma experience, rather than the range of traumatoid states, in particular secondary traumatic stress or occupational trauma within caring professions.
Various CBT models for PTSD are acknowledged (Brewin, 1996; Elhers & Clark Reference Elhers and Clark2000; Dalgleish, Reference Dalgleish2004); however, the research base for these models is based on persons who meet the diagnostic criteria for PTSD. Although these models could form an evidence-based component of an occupational trauma pathway, no papers were sourced that focused upon occupational trauma only, and as there are other influences upon trauma processing within occupational trauma (as detailed in the response to question 1 above), further research would be required to verify whether or not these models would be equally applicable to occupational trauma.
Multi-level conceptualizations may be considered as appropriate for encompassing occupational trauma [i.e. schematic, propositional, analogical and associative representation systems (SPAARS): Power & Dalgleish, Reference Power and Dalgleish2003, and interactive cognitive subsystems (ICS): Barnard & Teasdale, Reference Barnard and Teasdale1991], although as above, no papers were sourced that focused upon occupational trauma only, and therefore applicability of these models for occupational trauma would have to be tested prior to recommendations being made.
Accepting the areas of ‘traumatoid states’ that can potentially result from exposure to occupational trauma, defined within the Introduction (i.e. compassion fatigue, burnout, victimization, counter-transferential responses), the literature search generated results concerning the related concepts:
• Wilson & Thomas (Reference Wilson and Thomas2004), present two related models, one concerning the role of ‘empathetic rupture: countertransference effects in the treatment of trauma and PTSD’ (Wilson & Thomas, Reference Wilson and Thomas2004, p. 110) and another concerning ‘a model of affect dysregulation, anxiety states, coping and defence in post-traumatic therapy’ (Wilson & Thomas, Reference Wilson and Thomas2004, p. 140). However, the models only focus upon the occupational trauma responses of psychotherapists and psychologists, providing specific PTSD interventions. Therefore although these models may have a place in a trauma pathway, they may not be generalizable to all mental health staff.
• Tyrrell (Reference Tyrrell2010), presents a CBT model relating to the maintenance of ‘burnout’ within healthcare workers. Although this model may be applicable as part of a pathway, what must be considered is that burnout can be one result of occupational trauma; however, is not always the case (Townsend & Campbell, Reference Townsend and Campbell2009), and burnout is a concept applied to all different vocational arenas, not solely in mental healthcare due to trauma exposure (Glouberman, Reference Glouberman2007).
• Bamber (Reference Bamber2007) published CBT for Occupational Stress in Healthcare Professionals. The book encompasses trauma as a part of ‘generic stress’ and also conceptualizes burnout. It proposes a schema-focused approach to occupational stress, which maybe applicable to an occupational trauma pathway; however, this is not specified and would require further research.
Each of the above sources have elements to contribute to a potential CBT occupational trauma pathway; however, each would appear insufficient in isolation, to address the range of experiences encompassed within the definition of occupational trauma due to their specific focus.
Other issues were raised regarding CBT interventions:
• Computerized CBT is recommended for certain occupational stress support packages. However, the reviewed research focused upon treatment of depression and anxiety as an outcome of stress, but no research or specific computerized CBT package was found relating to occupational trauma (Grime, Reference Grime2004).
• Devilly et al. (Reference Devilly, Gist and Cotton2006) and Regel (2007), advocate CBT-based psychological debriefing as a proactive intervention in occupational trauma, which may negate later manifestation of PTSD symptomatology. They clearly separate debriefing from therapy, as it is educational in terms of the stress management basis and focuses upon normalization of trauma response. Research debates the potential detrimental effects of this type of intervention regarding: parallel processing issues (Warren et al. Reference Warren, Lee and Saunders2003), disrupting the natural psychological healing process (Courtois & Gold, Reference Courtois and Gold2009) and the potential for re-traumatization or intensification of trauma response (Regehr, Reference Regehr2001).
Therapeutic interventions from modalities related to CBT
In terms of related psychotherapeutic disciplines, evidence exists for their use in treating PTSD; i.e. hypnosis (Ruysschaert, Reference Ruysschaert2009), EMDR (Largo-Marsh & Spates, Reference Largo-Marsh and Spates2002), mindfulness-based techniques (Berceli & Napoli, Reference Berceli and Napoli2006), and psychodynamically orientated psychotherapies (Pearlman & Saakvitne, Reference Pearlman and Saakvitne1995). However, there are few studies which discuss the support of these interventions for the full range of occupational trauma experiences, or that suggest that these interventions are more clinically effective than CBT for addressing this issue.
Stress management interventions
Rubino et al. (Reference Rubino, Luksyte, Jansen and Volpone2009), advocate use of the ‘stress-strain’ model in occupational health interventions, also suggesting that ‘job-demands-resource’ considerations be made within any assessment or intervention in occupational stress situations, including those linked with trauma. Searle (Reference Searle2008) expands, focusing upon use of these models in providing stress management interventions, suggesting that ‘third-wave’ CBT methods such as Acceptance and Commitment Therapy be used as a framework for delivery of such packages. This may be taken into consideration if developing a CBT occupational trauma pathway.
These approaches, as a part of a larger supportive pathway, are advocated by other authors in the management of both occupational stress and occupational trauma (Murphy, Reference Murphy1996; Saunders et al. Reference Saunders, Driskell, Johnson and Salas1996; Richardson & Rothstein, Reference Richardson and Rothstein2008; Flaxman & Bond, Reference Flaxman and Bond2010); however, it must again be acknowledged that conceptual delineation between occupational stress and occupational trauma was not made by the authors.
In a meta-analyses, Richardson & Rothstein (Reference Richardson and Rothstein2008) suggested solely CBT-based stress management packages as most effective compared to other interventions such as relaxation training. Efficacy was measured organizationally in sickness reduction and increased organizational productivity, as well as improvement in subjective well-being. Finally, this occupational health resource is also supported by Plotnikoff & Karunamuni (Reference Plotnikoff and Karunamuni2011) and Parks & Steelman (Reference Parks and Steelman2008), who make the addition of including physical fitness activities and nutritional advice within such programmes; these may form a central component of a CBT pathway for occupational trauma.
Three self-care interventions/strategies were found as beneficial in terms of occupational trauma: (i) access to effective clinical supervision or supervisory support structures (de Zulueta, Reference de Zulueta2006), (ii) ensuring a balanced caseload or contact with themed trauma (Kearney et al. Reference Kearney, Weininger, Vachon, Harrison and Mount2009); and (iii) access to personal therapy or counselling following trauma exposure (Barnett et al. Reference Barnett, Wise, Johnson-Greene and Bucky2007a–Reference Baumc).
Risk pathways and occupational trauma
McFarlane & Bryant (Reference McFarlane and Bryant2007) and Jones et al. (Reference Jones, Roberts and Greenberg2003), advocate proactive engagement and individual risk assessment in regards to occupational trauma. They emphasize the appreciation of differing levels of exposure in different professions in healthcare (Baird & Jenkins, Reference Baird and Jenkins2003), incorporating the impact of ‘perceived threat’ and clinician/employee control in a variety of situations (Walsh & Clarke, Reference Walsh and Clarke2003). The research encourages development of clear support pathways regarding occupational trauma (Osofsky, Reference Osofsky2008), with the emphasis upon supervision and reflection (Hartman, Reference Hartman1995). Assessment tools were sourced in regards to clinician's trauma reactions (e.g. Clinicians Trauma Survey; Wilson & Thomas, Reference Wilson and Thomas2004, p. 235–243). Assessment tools must be employed to structure any stepped care CBT pathway, in order to evidence base effectiveness of interventions and change.
Supervision
Although supervision is a theme that was included within many of the sources reviewed, and it is advocated within most healthcare professions, debates surround the varying levels of commitment to actual clinical supervision (NMC, 2008; BPS, 2009; BABCP, 2011; UKCP, 2011; BMA, 2011). No model of supervision was sourced that focused specifically upon the effects of occupational trauma; however, this could be indicated for a future area of research that would support a CBT-based occupational trauma pathway.
No research sourced reviewed the provision of supervision or reflection for non-clinical staff (i.e. administrative staff), therefore it is difficult to gauge whether this raises an issue for these workers as part of teams dealing with trauma.
NHS and private provider interventions
NHS managers are required to provide support and monitoring in terms of workplace stress, including occupational trauma (Cooper, Reference Cooper2003). Monitoring and support are achieved through professional development reviews (DoH, 2004a), supervision (DoH, 2004b, 2006, 2007) and stress interviews, where indicated (HSE, 1974, 2004). Other healthcare providers have individual policies and procedures in line with government regulations (BUPA, 2011; Cygnets, 2011). There are also independent organizations that have developed in the UK, specifically to assist organizations and individuals who have experienced occupational trauma (Blore, Reference Blore2011, Red Poppy Company, 2011), these organizations are privately purchased, subcontracted by larger organizations and also funded following litigation in regards to workplace culpable actions.
Adherence to policy and guidance is monitored through the Care Quality Commission (CQC), who have inspection standards specific to staff health and staff health monitoring (CQC, 2008). Despite safety mechanisms and regulation, due to the nature of healthcare, in 2010, within the NHS Staff survey: ‘8% reported experiencing physical violence from patients, relatives or other members of the public, while 15% said they have been subject to bullying, harassment and abuse’, emphasizing the ongoing need to support staff experiencing trauma on both a ‘one-off’, or ongoing basis, due to repeated exposure working with traumatized clients (CQC, 2011a, b).
Cousins et al. (Reference Cousins, Mackay, Clarke, Kelly, Kelly and Mccaig2004) suggest ‘Research commissioned for the UK's Health & Safety Executive (HSE)’ supports the view that preventative, risk-assessment based approaches would be more effective than case-based methods, in achieving a nationwide reduction in work-related stress, which would include occupational trauma. This must be taken into consideration if developing a CBT occupational trauma pathway.
Recommendations
Within the review, five recommendations are suggested:
(1) Occupational trauma is a term linked closely, and at times used interchangeably with, work-related stress and a range of traumatoid states. This causes difficulty when attempting to define whether it is a separate or umbrella phenomena and if so, what treatments, interventions and support mechanisms may be beneficial. Findings indicate that further research into this area is indicated in order to delineate and define the phenomena in terms of organizational and occupational health response; a concept analysis may be suggested as an appropriate way of defining this.
(2) Although the findings reveal some positive effects of trauma exposure through the work environment, the majority of sources reviewed indicated significant negative personal, psychological, physical, social and occupational problems caused by occupational trauma. This indicates that it is an area still requiring support regarding further research, and also treatment interventions/support pathways.
(3) If CBT occupational trauma pathways/models are developed, it is important that research should not only focus upon the individual outcome, but also occupational/organizational outcomes, as reduced occupational costs may offset the cost implications of the pathway developed.
(4) Further research is indicated, to clearly define individual and professional factors in resilience and self-management of trauma exposure. This may aid occupational interventions delivered on both a proactive and reactive basis.
(5) Certain CBT interventions appear to be supported in the literature in terms of interventions for occupational trauma; however, they are diverse in their applicability and style and tend towards symptoms compliant with a full PTSD diagnosis only, or for individuals with a specific outcome following trauma exposure, i.e. burnout. As defined in the Introduction, occupational trauma is not a diagnosis, it may encompass the spectrum of traumatoid states. CBT models are often diagnostic-specific, and although useful to form potential segments of an occupational trauma pathway, with the complexity of the occupational trauma phenomena, a trans-diagnostic or formulation-driven model maybe more appropriate within a pathway of targeted interventions.
As with the ‘Stepped Care Interventions’ proposed within NICE (2004, 2009) guidelines for depression, it may be suggested that such a staged approach may be extended to all traumatoid states, which would include ‘occupational trauma’ and also PTSD. As with the stepped care guidance, staged levels of interventions could be encompassed into a menu of evidence-based interventions, dependent upon need.
With the literature reviewed, encompassing the results obtained, a framework of an occupational support pathway can be proposed (see Fig. 2), with areas identified where additional research is required.
Proposed occupational trauma support pathway.
Limitations of the literature review
Five main limitations are declared concerning the literature review presented:
(1) Although the concept of occupational trauma is used in the literature, it is not clearly delineated from other related topics, therefore when considering recommendations from reviewed literature, findings have been taken from sources that used occupational stress with occupational trauma interchangeably. Where this is the case, this has been highlighted in the body of the review; however, this issue could question the validity of the results generated.
(2) The search criteria had insufficient restrictions, resulting in two difficulties: (a) significant search results being generated, many unrelated to the aimed area of focus, and; (b) difficulty in exploring related topic areas, which may mean that the analysis could be considered as incomplete.
(3) On reflection, due to the high amount of sources generated, focus upon one occupational group (i.e. therapist) may have allowed more specific recommendations to have been made.
(4) The potential effects of subjectivity upon research analysis, due to the methodological approach declared. For bias reduction and repeatability, all result sources are referenced and categorized, lists can be requested from the author if required.
(5) Time limited validity; there may be subsequent literature published that questions or alters the perception of occupational support for secondary trauma, due to the dynamic nature of research (Damasio, Reference Damasio2006).
Conclusions
Occupational trauma is an area attracting increased focus within the current healthcare climate. This appears due to an increased pressure upon productivity with more economical use of resources, an increased recognition concerning how trauma can affect all aspects of an individual's life, including occupational functioning, and an increase seen in terms of workplace litigation related to staff support and retention.
The literature review results raise three main themes: first, that there is a difficulty in delineating occupational trauma from PTSD and occupational stress, posing difficulties in terms of problem conceptualization. Second, the negative consequences of occupational trauma on the worker, client and organization are significant, requiring a range of targeted interventions, tailored to need. Finally, inconsistency in terms of differing levels of support in for occupational trauma, indicates the need for further research and structured intervention, with CBT being one of the main theoretical approaches which could underpin such a strategy.
Without a solid, research-based approach to this subject, individuals who develop occupational trauma will be responded to inappropriately. The above literature review proposes to add to the CBT evidence base on which interventions are planned, and to promote the area of occupational trauma as a target research topic for CBT practitioners. Specialist, targeted treatments will provide long-term solutions with lasting benefits to individuals, support services and the wider society, reducing the stigma and misunderstanding maintaining this phenomena; however, further investment in research regarding this topic will be required to enable this.
Declaration of Interest
None.
Acknowledgements
The author acknowledges the help and support from the CBT Doctoral Programme at the University of Derby, specifically Dr Michael Townend and Jill Schofield.
Learning objectives
(1) To be able to identify Cognitive Behavioural Psychotherapy (CBP) interventions relating to occupational trauma.
(2) To be able to explore the context and costs of occupational trauma within the current social and economic climate in relation to mental health-care.
(3) To be able to utilize findings of the literature review, to enhance the knowledge base relating to the field of CBP and to examine such organizational approaches that use CBP that could form part of a care pathway for occupational trauma.
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