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Treatment of occupational Treatment of occupational trauma on the rail network trauma on the rail network

or or

““Psychiatry owes a lot to British Rail”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 PsychotherapistResearcher Birmingham University

Visiting Lecturer Teesside University

ARIOPS Conference, National Railway Museum, York – 17.10.11

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AgendaAgenda

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 recommendationsAs applied to the NHS

As applied to TOCs

EMDRWhat is it and how does it work?

2010-11 Audit

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1919thth century railway trauma 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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1919thth century railway trauma century railway trauma

…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.

The Staplehurst rail crash

9th June 1865…

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1919thth century perspective on century perspective onrailway trauma railway trauma

Largest civil engineering projectRailways are dangerous > speed killsAll injuries considered to be due to physical damagePost 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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1919thth to 21 to 21stst century psychological century psychological trauma milestonestrauma milestones

Pre WWII:No agreed formulation of psychological traumaIn fact denial and ‘Lacking Moral Fibre’

Pre 1977:No Health and Safety at Work ActLots 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 diagnosis1987 Accidental discovery of EMDR1998 Cahill & McGaugh devise the Reconsolidation of Memory theory1999 NICE formed - focus on evidence-based practice2003 SOVRN reort2005 NICE report on PTSD issued

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Progress in understanding how the brain processes Progress in understanding how the brain processes traumatic information and effective interventions to traumatic information and effective interventions to

accelerate that processaccelerate that process

Start of recorded history

1989 2005 2011

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’

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Accepted pre 1989 interventions Accepted pre 1989 interventions for psychological trauma (any causation)for psychological trauma (any causation)

Psychoanalysis“…brutal forms of electrical therapy…”‘Causal will’ therapyGroup psychotherapyTherapeutic community milieu therapyHypnosisPsychodynamic psychotherapy

Supportive counsellingClient centred counsellingCritical incident debriefingPsychological debriefingNerolinguistic reprogramming (NLP)Gestalt therapyMedication

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 Accepted 1989 – 2005 interventions for psychological trauma (any causation)for psychological trauma (any causation)

Psychoanalysis“…brutal forms of electrical therapy…”‘Causal will’ therapyGroup psychotherapyTherapeutic community milieu therapyHypnosisPsychodynamic psychotherapy

Supportive counsellingClient centred counsellingCritical incident debriefingPsychological debriefingNerolinguistic reprogramming (NLP)Gestalt therapyMedicationTrauma-focussed Cognitive Behavioural therapy (tfCBT)Eye Movement Desensitisation & Reprocessing (EMDR

Therapies ranged from:

‘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 Accepted post-2005 interventions for psychological trauma (any causation)for psychological trauma (any causation)

Psychoanalysis“…brutal forms of electrical therapy…”‘Causal will’ therapyGroup psychotherapyTherapeutic community milieu therapyHypnosisPsychodynamic psychotherapy

Supportive counsellingClient centred counsellingCritical incident debriefingPsychological debriefingNerolinguistic reprogramming (NLP)Gestalt therapyMedicationTrauma-focussed Cognitive Behavioural therapy (tfCBT)Eye Movement Desensitisation & Reprocessing (EMDR

Therapies now:

‘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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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)

The 21The 21stst century reality century reality(based on 2010-11 audit of incoming referrals to DBA Ltd.)(based on 2010-11 audit of incoming referrals to DBA Ltd.)

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SPADsCat ASignal reversionsWrong possession

Near missesDerailmentsAdhesion problemsImpact with unidentified objectsLevel crossing gates left openSiderodromophobia Robbery at workCrushed at work (overcrowded trains)Trapped at work (accidental lock-in)Being stalked at workGiving first aid at workPost customer complaint trauma

Less frequent reasons for referralLess frequent reasons for referral

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NHS application of the 2005 ‘NICE’ NHS application of the 2005 ‘NICE’ guidelinesguidelines

Event (day 0)

28 day assessment

tfCBT or EMDR

No treatment required

Discharge

10-14 days post event

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TOCs: “Rolls Royce” application of the 2005 TOCs: “Rolls Royce” application of the 2005 NICE guidelinesNICE guidelines

Event

Psych 1st Aid (DARE)

10-14 day assessment

ASD: improving or deteriorating/n.c.?

EMDR or EMDR/tfCBT

28 day (if needed) reassess

No treatment required

Advice on sustaining

R2W

Managers mandatory training (TATs)

Audit

HR & Board > formulation

of policy

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DSM IV TRDSM IV TR ‘Extensions’ to ‘Extensions’ to DSM IV TRDSM IV TR

ASD

PTSD

Acute

Chronic

Delayed onset

Adjustment Disorder

DAREDisbelief/DenialAutomatic behavioursReduction in awarenessEmotions

ASD ASDPTSD

AcuteChronicDelayed onset

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So what is EMDR?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 ANDEngaging 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?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” 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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Stimulus/ experience e.g. fatality whilst

driving train

Interpretation of meaning

Cognitive/ emotional response

Autonomic stress hormone response

Influences

memory storage

Long term function

Short term function

Influences immediate coping

behaviour

Cahill & McGaugh’s (1998) Cahill & McGaugh’s (1998)

Reconsolidation of Memory TheoryReconsolidation of Memory Theory

EMDR thought to compromise the

effects of this stage

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Treatment always uses a ‘dry run’ - very quick way of covering large range of explanations and experience of treatmentNCs 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’ approachB2T non disclosure approach

Most common targets:First sight of problem/ person on tracks/ strange behavioursEye contactImpact/ noise or vibration under trainSeeing body/ immediate aftermath/ disgust (most common in spitting incidents)Coroner’s Court

EMDR treatment notes EMDR treatment notes relating to railway traumarelating to railway trauma

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Assessment will help divide potential treatment application into: ‘brief’; ‘single memory’; ‘full treatment’ – this helps organise different length sessions ranging from one to two hoursIESR/ HADS taken every sessionFuture 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 imageryR2W plans aimed at sustaining R2W usually includes R2W on full hours immediately – least reorganisation of working day routineDedicated contact system with managers to identify subsequent R2W problems quickly

EMDR treatment notes EMDR treatment notes relating to railway traumarelating to railway trauma

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Outcomes: 2010-2011 auditOutcomes: 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 listeningThank you for listeningAny questions?Any questions?

24 hour voicemail: 07976 933096

Website: www.davidblore.co.uk

Email: help@davidblore.co.uk