A discussion of the advances of Post Traumatic Stress Disorder (PTSD) management

Health and Safety in the workplace has become more prolific over the past 25 years.

The strength of the unions and increased public awareness of corporate responsibility have demanded that organisations accept a greater responsibility for the health and safety of their employees. Whilst progress is being made, the wealth of compensation claims and massive corporate fines for negligence, however, suggests that health and safety has yet to reach the top of the priority list for some organisations.In fact, a 2001 Canadian Human Resource (HR) Reporter's survey of HR professionals indicated that only 30% ranked health and safety and 16% ranked wellness as being 'very important'. More recently, the Institute of Occupational Safety and Health (IOSH) published their Value of Health and Safety Report (2005) highlighting that most health and safety professionals spend less than a quarter of their time tackling occupational health issues; one of which is occupational stress.

These reports not only indicate the low commitment from HR practitioners towards health and safety, it also identifies a more worrying position for occupational health. Organisations with a poor occupational health record face problems associated with absenteeism and the threat of compensation related legal action. The Chartered Institute of Personnel Development Absence Management Survey (2005), indicates sickness absence accounts for 4% of working time, equivalent to 8. 4 working days or $1200 per employee per year. In addition, the courts are awarding employees significant damages for work related stress.

With both impacting on the 'bottom line', it is therefore not surprising that absence management and workplace wellness is becoming one of 'HR professionals' top three agenda items' (Human Resources Canada, 2002). According to the Health and Safety Executive, this progress is crucial as 'stress is likely to become the most dangerous risk to business in the early part of the 21st Century'. There is currently no statute specifically covering the issue of stress in the workplace and the law governing stress has evolved mainly from case law rather than legislation.Under existing health and safety legislation, employers have a duty to undertake risk assessments and manage activities to reduce the incidence of stress at work. Examples include the European Union Framework Directive 89/391 and the United Kingdom Health and Safety Executives 'Management Standards for Work-Related Stress' (2004). Although these standards are still voluntary, the Health and Safety Executive has indicated that they will be used as evidence against employers that continue to ignore their responsibilities in managing stress under the Health and Safety at Work Act 1974.

In response to the above as well as the knowledge that both employees and employers have become more cognisant of the effects of work-related stress, HR departments of organisations have begun to implement measures to address occupational health issues. At the strategic level, some organisations have implemented a 'Stress or Well Being Policy'. This requires organisations to undertake an audit of their policies, procedures and systems to ensure that they provide a working environment that protects the well being of their workforce whilst also being able to identify troubled employees and provide them with the appropriate level of support.At a more tactical level, HR practitioners and supervisors are using approaches that look to identify the occupational health related problem through the risk assessments discussed above whilst also examining sickness absence levels, claims for compensation and performance deficits.

Operational level approaches include those that take a more proactive stance and look towards identifying ways of creating a healthy workforce through education, employee counselling and stress management training.Falling under the occupational health umbrella is the form of occupational stress described as Post Traumatic Stress Disorder (PTSD). Being hailed as 'a phenomenon of the 21st Century' (Meighen, 2005), the term PTSD was introduced in 1980 to describe a pattern of symptoms associated with the reaction to the aftermath of a traumatic event. Whilst it is considered normal for people to show some reaction in the immediate to short term, Hoge et al (2004) suggests that between 10-30% of people exposed to a traumatic event will go on to experience a range of traumatic symptoms in the longer term.

Symptoms include persistent flashbacks of the event, avoidance of any of the reminders of the event, feelings of emotional detachment and numbness and an exaggerated 'startle' response or hyper vigilance. Although concerns about the psychological effects of trauma were initially raised in the aftermath of the Vietnam War, it is only in the last decade that governments and military institutions have begun to take any action.Initial research into PTSD focused n employees whose jobs were more likely to put them at risk such as emergency service personnel and members of the armed forces with combat experience. More recent studies have shown that any occupation can be susceptible to traumatic events as a result of workplace accidents and injuries. Since organisations are already adhering to forms of health and safety legislation that seek to reduce workplace accidents, there are two reasons why they should also consider the need for a trauma management strategy.

Firstly, workplace trauma may have an effect on the ability of employees to function on both a personal and a professional level and, secondly, the significant legal implications associated, not just with the nature of a workplace accident but also the organisations response and after care, can be financially costly. Since, however, the majority of information and media speculation regarding PTSD focuses primarily on the armed forces, the remainder of this essay will concentrate specifically on this occupational group.For the United States (US) Military the wars in Iraq and Afghanistan have been the most sustained combat operations since Vietnam, while it is possible that they may be as prolonged. It took the Vietnam War for the military community to understand and accept the effects of traumatic experiences on psychological well being; since war veterans began legal proceedings against governments for failing to recognise or treat their stress, PTSD has become a household term.With increasing numbers of western military personnel currently engaged in combat operations there is a fear that cases of PTSD will intensify.

The numbers of those affected is already concerning. The most recent public study to evaluate active duty soldier's reports of various war zone experiences and rates of mental health problems estimates that levels of PTSD in the US military was around 18% for Iraq and 11% for Afghanistan (Hoge et al 2004).The United Kingdom government is more guarded of its combat and non-combat casualty statistics, but a study published by the British Journal of Psychiatry estimates that 10% of troops airlifted out of Iraq between January and October 2003 suffered from psychological symptoms. Statistics from 2002 indicate a level of only 2. 8% within the Canadian military, probably attributable to Canada not arriving in Afghanistan until 2003 and their non-participation in the Iraq conflict.

In all cases there was a positive relationship between the number of combat deployments and incidences of PTSD. This is concerning as the above conflicts are likely to persist, implying the same soldiers will be required to return on second or subsequent deployments. This is reflected in Hoge et al's (2004) statistics that predict that the cases of PTSD in soldiers returning from Iraq are likely to increase to 20%. The overall situation is even worse as the accuracy of the figures is suspect due to under reporting.

Paton, (2004) suggests that half of the servicemen who suffer psychiatric illness as a result of traumatic events do not seek medical help, or do so up to 15 years later when the damage to marriages, careers and mental well being is irreparable. Some under reporting has been attributed to a purely British 'stiff upper lip' phenomenon where servicemen and women refuse to accept that they have a problem and are reluctant to discuss emotional issues for fears of being considered 'sick' or 'weak' in a demanding mental and physical occupational environment.Furthermore, PTSD is still viewed in the United Kingdom with a great deal of suspicion; especially amongst serving soldiers and a generation that lived through the horrors of the Second World War, the Korean War and the daily struggle against terrorism in Northern Ireland. "Psychological stress is a symptom of political correctness in the 21st Century where everyone has to be stressed or depressed" (Bremer, 2005) According to Elliott (2005), 'the stigma attached to mental health problems puts many soldiers off asking for help'.In a culture of mental and physical toughness soldiers remain concerned that admitting to psychological problems will have a negative impact on their career. "PTSD is seen as a career stopper in the Army" (Skelton, 2005) Although the research to illustrate the effects of PTSD on a soldier's performance at work is limited, there has been an increase in the litigation against government bodies for negligence.

Soldiers in Northern Ireland involved in Bloody Friday, the Omagh bombing and Enniskillen bombing are suing the Ulster Defence Regiment for failure to diagnose and treat their PTSD (BBC News Online).Similarly, in Canada, a former solider who served in Cyprus, Somalia, Bosnia and Haiti has initiated legal proceedings against the federal government seeking $88 million in compensation (Vaidynanath, 2005), while in the United Kingdom, a former soldier was awarded ?? 620,000 damages from the Ministry of Defence for stress suffered while on duty (Greene, 2005). With such high financial consequences for failing to recognise the impact and management of PTSD, it is not surprising that governments and armed forces have begun to implement trauma management strategies that better cater for the needs of their employees.Even though the military do not have HR managers per se, their HR is done through various branches of the service as well as through the chain of command; it is traditionally the responsibility of the officer in charge to manage their subordinates in terms of both their career and welfare. Although the measures implemented by civilian organisations on occupational stress can be assimilated with those used by the military for PTSD, the latter have a more grand strategic and government level commitment.

Within the North Atlantic Treaty Organisation (NATO), an exploratory team of psychologists and psychiatrists have been tasked to investigate issues of stress and psychological support within the military institutions of its member countries. This grand strategic policy is still in its infancy and has yet to be released but will address areas of psychological stress, the psychological preparation of military personnel, screening, psychological support during and after deployment and methods of support for families.It is anticipated that this policy will provide more formal, regulatory direction for NATO countries on the management of PTSD in their armed forces. At a more strategic level, Veterans Affairs Canada and the Department for National Defence opened the Saint Anne's National Occupational Stress Injuries Centre in 2002. This joint venture gives the centre sole responsibility for advances in mental health clinical care through program development, research, education and outreach activities.

Minister Guarnieri, the Minister for Veterans Affairs commented that, It is important that Canada's military - whether they are still in uniform or already released - have access to mental health care that is comprehensive, integrated and that delivers services consistently to a standard of excellence" (Guarnieri, 2005) The Department of National Defence also has a Veterans Affairs Centre for the support of injured and retired members and their families. This centre has an operational stress injury social support program that specifically targets those affected by operational stress injuries such as PTSD, and delivers educational and professional development modules for the Canadian Forces.The new Veterans Charter (2005) offers veterans and serving members of the Canadian Forces more access to services like rehabilitation, assistance to overcome economic loss, health services and job placement. At a more operational level, Canada has established five Operational Trauma and Stress Support Centres (OTSSC's) in military bases across the country that assist Canadian Force members and their families in dealing with the effects of operational stress.There is also a Canadian Forces Member Assistance Program which offers a 24/7 confidential referral service for external, short term counselling for those who prefer to seek help outside of the military health services. Canada has also included in its pre-deployment package for servicemen and women, mandatory courses on stress coping skills, unit cohesion and social support as well as awareness of the potential effects of stress.

The US Department of Defence uses a very employee centred approach that aims to improve psychological resilience among troops. This involves developing tools to measure stress in the field, establishing a suicide surveillance system, identifying factors that lead to high rates of mental disorders and developing psychological screening and debriefing. Further down the line, this programme intends to develop ways of identifying vulnerable soldiers within both training and operational environments.The US Army is also working with German and Austrian armies to develop a protocol to assess voice changes under stress, making it easier to separate the physical from psychological when it comes to measuring stress levels. Unlike other countries, the US has also made a concerted effort to integrate their returning reserve soldiers back into the workplace. Andrews (2004) describes how HR practitioners within organisations have worked towards facilitating the reservist's reintegration back into the workplace through options that include flexible work arrangements or gradual re-entry processes.

For example, General Electric Energy have produced individualised reintegration plans for employees that include a full year of extra training if required, whilst The Link Agency have prepared a scrapbook that includes photos of staff and samples of recent work and alerted colleagues so that those who want to can send welcome back cards. The British Ministry of Defence's strategic level Stress Management policy was published in 2001 and, for the first time, recognised stress as a debilitating condition.This policy has been implemented at the tactical and operational level, like Canada, through a series of annual mandatory health, safety and stress management training programmes for all members of the Armed Forces, as well as including more PTSD specific training for those deploying on operations. "The measures now in place to combat PTSD have evolved and have been enhanced over a number of years to reflect our improving knowledge of the condition, its effects and the best methods of remediation.Each service runs active programmes aimed at prevention and treatment. Measures include pre-deployment and post-deployment briefing and, when practicable, availability of counselling in theatre" (Moonie, UK Minister for Veterans Affairs, 2005) Two new defence community psychiatric centres have also been established in England and Scotland and the Army Welfare Service is available to soldier's families.

This essay has described the ongoing progress of health and safety with regard to occupational health and PTSD in particular.The degree of HR uptake in occupational health and safety is improving and HR professionals are beginning to implement a series of occupational stress measures in the workplace. While such improvement is the result of a myriad of factors, the more litigious society we now live in will continue to demand greater efforts by employers or face the inevitable financial penalties issued by the courts. A significant amount of progress has been made in the area of PTSD, some of which sets an excellent example for HR practitioners seeking new ways or methods to cater for occupational stress in their workplace.Although the response of governments has been reactionary, various defence ministries have implemented a number of problem and employee centred initiatives aimed at reducing the impact of PTSD, including policy directives, national centres of PTSD excellence, psychological screening, education, training and support assistance.

Furthermore, as in the case of the United States, HR professionals are introducing re-integration and training methods to assist returning reserve servicemen and women in their transition back to work.PTSD prevention and treatment is set to remain at the very forefront of occupational stress management due to the continued commitment of armed forces in Afghanistan and Iraq and research evidence that identifies a positive link between the frequency of exposures to a traumatic event and PTSD. For national governments success is to be measured by a reduction in the number of successful compensation claims from former service personnel, despite their continued commitment in high-risk areas. Such success may well provide a blue print for HR practitioners of the future as they seek to improve occupational health and reduce costly court cases.