Transcript Treatment of occupational trauma on the rail network

Treatment of occupational
trauma on the rail network
or
“Psychiatry owes a lot to British Rail”
The European History of Psychotraumatology, Weisæth L., 2002
Journal of Traumatic Stress 15:6 443-52
DBA Ltd., York, Manchester and Newcastle
David Blore – Consultant Psychotherapist
Researcher Birmingham University
Visiting Lecturer Teesside University
ARIOPS Conference, National Railway Museum, York – 17.10.11
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Agenda
Railway trauma – a history
Attitudes to psychological healthcare – a history
Accepted interventions for psychological trauma from
high voltage to high tech
The 21st century reality of railway trauma
2005 NICE report recommendations
As applied to the NHS
As applied to TOCs
EMDR
What is it and how does it work?
2010-11 Audit
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19th century railway trauma
William Huskisson MP for Liverpool
on 15th September 1830…
…was the first person to be killed by a train in
motion, when, at the opening of the Liverpool
and Manchester Railway whilst crossing the
tracks to greet the Duke of Wellington, he was hit
by Stephenson’s ‘Rocket’ passing in the
opposite direction. Huskisson, his left leg
crushed, was taken by train, driven by
Stephenson himself, to Eccles where Huskisson
died a few hours later.
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19th century railway trauma
The Staplehurst rail crash
9th June 1865…
…resulted in 10 passenger deaths and 40
injured. It is remembered particularly for its
effects on the author Charles Dickens, who
was travelling as a passenger in a front, first
class carriage of a ‘boat train’ with his
companions Ellen Ternan and her mother.
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19th century perspective on
railway trauma
Largest civil engineering project
Railways are dangerous > speed kills
All injuries considered to be due to physical damage
Post mortems confirmed this
Including “Spinal concussion” (whiplash)
Survivors also ‘damaged’ but appeared to have no
physical damage > cause?
Almost certain that this is the origin of ‘spineless’
Early but derogatory description of psychological
problems?
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19th to 21st century psychological
trauma milestones
Pre WWII:
No agreed formulation of psychological trauma
In fact denial and ‘Lacking Moral Fibre’
Pre 1977:
No Health and Safety at Work Act
Lots of compensation cases though especially 19th century!
Pre 1980 context (apart from a short period in 1950’s early 1960’s):
No recognised diagnosis for psychological ‘damage’
1980 Post Traumatic Stress Disorder becomes a diagnosis
1987 Accidental discovery of EMDR
1998 Cahill & McGaugh devise the Reconsolidation of Memory theory
1999 NICE formed - focus on evidence-based practice
2003 SOVRN reort
2005 NICE report on PTSD issued
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Progress in understanding how the brain processes
traumatic information and effective interventions to
accelerate that process
Increase in knowledge stems from two sources:
1 Ongoing neurophysiological research
2 The ‘battle’ to convince/refute EMDR as a
legitimate intervention
March 2005 NICE
‘truce’
Start of
recorded
history
1989
2005
2011
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Accepted pre 1989 interventions
for psychological trauma (any causation)
Psychoanalysis
“…brutal forms of electrical therapy…”
‘Causal will’ therapy
Group psychotherapy
Therapeutic community milieu therapy
Hypnosis
Psychodynamic psychotherapy
Supportive counselling
Client centred counselling
Critical incident debriefing
Psychological debriefing
Nerolinguistic reprogramming (NLP)
Gestalt therapy
Medication
Therapies ranged from:
“Torture” and ‘totally ineffective’, to ‘vaguely effective’
Which was used was regarded as the domain of:
Fashion, politics, personal preference or “sheer guesswork”
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Accepted 1989 – 2005 interventions
for psychological trauma (any causation)
Psychoanalysis
“…brutal forms of electrical therapy…”
‘Causal will’ therapy
Group psychotherapy
Therapeutic community milieu therapy
Hypnosis
Psychodynamic psychotherapy
Therapies ranged from:
Supportive counselling
Client centred counselling
Critical incident debriefing
Psychological debriefing
Nerolinguistic reprogramming (NLP)
Gestalt therapy
Medication
Trauma-focussed Cognitive
Behavioural therapy (tfCBT)
Eye Movement Desensitisation &
Reprocessing (EMDR
‘Vaguely effective’ to ‘Effective’
Which was used was regarded as the domain of:
BR CoCaS directive (mid 1990s) and especially
post SOVRN report (2003) which recommended ‘counselling’
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Accepted post-2005 interventions
for psychological trauma (any causation)
Psychoanalysis
“…brutal forms of electrical therapy…”
‘Causal will’ therapy
Group psychotherapy
Therapeutic community milieu therapy
Hypnosis
Psychodynamic psychotherapy
Therapies now:
Supportive counselling
Client centred counselling
Critical incident debriefing
Psychological debriefing
Nerolinguistic reprogramming (NLP)
Gestalt therapy
Medication
Trauma-focussed Cognitive
Behavioural therapy (tfCBT)
Eye Movement Desensitisation &
Reprocessing (EMDR
‘State of the art effective’
Which was used is regarded as the domain of:
Research evidence (March 2005), client tolerance of intervention,
long term effectiveness
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The 21st century reality
(based on 2010-11 audit of incoming referrals to DBA Ltd.)
Fatalities (31.6% of referrals, about 12% of UK total of fatalities)
Around 200 people per year commit suicide on the UK railways (this compares with
6000 in Japan)
Assaults (26.3% of referrals)
This includes physical and verbal assaults as well as spitting incidents
Non-work traumatic events, impinging on work
(14.4% of referrals)
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Less frequent reasons for referral
SPADs
Cat A
Signal reversions
Wrong possession
Near misses
Derailments
Adhesion problems
Impact with unidentified objects
Level crossing gates left open
Siderodromophobia
Robbery at work
Crushed at work (overcrowded trains)
Trapped at work (accidental lock-in)
Being stalked at work
Giving first aid at work
Post customer complaint trauma
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NHS application of the 2005 ‘NICE’
guidelines
Event (day 0)
10-14 days post event
tfCBT or EMDR
Discharge
28 day assessment
No treatment required
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TOCs: “Rolls Royce” application of the 2005
NICE guidelines
Event
Psych 1st Aid (DARE)
Managers mandatory
training (TATs)
HR & Board
> formulation
of policy
10-14 day assessment
ASD: improving or
deteriorating/n.c.?
Audit
EMDR or EMDR/tfCBT
28 day (if needed)
reassess
No treatment required
Advice on
sustaining
R2W
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DSM IV TR
ASD
PTSD
Acute
Chronic
Delayed onset
Adjustment Disorder
‘Extensions’ to
DSM IV TR
DARE
Disbelief/Denial
Automatic behaviours
Reduction in awareness
Emotions
ASD
ASD
PTSD
Acute
Chronic
Delayed onset
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So what is EMDR?
Information on EMDR can be obtained from www.davidblore.co.uk click on What is EMDR?
Stems from an accidental discovery that there is a
mathematical relationship between presentation of
traumatic memories to the conscious awareness AND
Engaging in a visual task that compromises the
working memory’s ability to retain the affective
component of a visual memory
Demonstration needed to explain? - OK but don’t
‘have a go’ later!
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So how does EMDR work?
Information on EMDR can be obtained from www.davidblore.co.uk click on What is EMDR?
Thought to be similar to REM sleep responsible for the:
Why-do-older-people-recall-the-good-old-days?
phenomenon
EMDR certainly mimics a natural process of erasing affect over
time – but significantly speeded up, therefore:
No side effects of the treatment process itself
However, speeding anything up comes at a cost, therefore
significant emphasis on post treatment safety. Details can also
be found online at:
www.davidblore.co.uk click on ‘Advice after EMDR’
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“I’ll always have that memory”
A very common phrase
Assumed to be correct
Yet can’t be because of long term effects of REM
sleep
Now thought that memory permanency is under the
executive control of the visiospatial sketchpad portion
of the working memory as per…
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Cahill & McGaugh’s (1998)
Reconsolidation of Memory Theory
Stimulus/ experience
e.g. fatality whilst
driving train
EMDR thought to
compromise the
effects of this stage
Influences
Interpretation of
meaning
memory storage
Long term
function
Cognitive/ emotional
response
Autonomic stress
hormone response
Short term
function
Influences
immediate coping
behaviour
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EMDR treatment notes
relating to railway trauma
Treatment always uses a ‘dry run’ - very quick way of covering large
range of explanations and experience of treatment
NCs most important “I’m not in control” in over 90% of cases (direct
contradiction to training: “You will always be in control of your train”)
Targets worked out beforehand and comprising one of two most
common protocols (EMDR treatment modes):
RETP ‘frame by frame’ approach
B2T non disclosure approach
Most common targets:
First sight of problem/ person on tracks/ strange behaviours
Eye contact
Impact/ noise or vibration under train
Seeing body/ immediate aftermath/ disgust (most common in spitting
incidents)
Coroner’s Court
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EMDR treatment notes
relating to railway trauma
Assessment will help divide potential treatment application into: ‘brief’;
‘single memory’; ‘full treatment’ – this helps organise different length
sessions ranging from one to two hours
IESR/ HADS taken every session
Future templates incorporate a R2W plan. R2W plan incorporated in
discharge letter and must be present at BUPA when they assess for
SCW – ‘the ‘resumption medical’
Psychological reasons for not recommending a R2SCW include: even
slight problems with concentration; and sleep problems; if sleep is not
restful; intrusive imagery
R2W plans aimed at sustaining R2W usually includes R2W on full
hours immediately – least reorganisation of working day routine
Dedicated contact system with managers to identify subsequent R2W
problems quickly
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Outcomes: 2010-2011 audit
Average no. EMDR sessions for closed cases (54 out of 76
referrals) attending at least 2 sessions (minimum length of
treatment and excluding all assessment only referrals) = 4.95
Average reduction in IESR 94.7%
Total R2W 96.8%
Subsequent absence? None at all = 64.5%
Subsequent absence? Yes = 24.2% (unrelated to reason for
referral)
Subsequent absence? Yes, related to reason for referral = 8.1%
(The above figures do not add up to 100% because of
movement of labour and/or missing data)
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Thank you for listening
Any questions?
24 hour voicemail: 07976 933096
Website: www.davidblore.co.uk
Email: [email protected]
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