Vulnerability to Trauma in the Workplace - Who Suffers and Why?
Definition of trauma
The terms “stress” and “trauma” have become ubiquitous in the workplace. Many medical certificates describe a patient’s problem as a “stress” reaction or a “post-traumatic” reaction, yet such terms carry no significance in legal frameworks. The working definition of “stress” is of the overwhelming of an individual by an environmental challenge. Life is full of such challenges and so all of us can legitimately claim to be “stressed.”
The definition of “trauma” is more complicated. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and the International Classification of Diseases Tenth Edition (ICD-10) both define the term “trauma” as involving threatened or actual “harm” to an individual. However; while conducting research for my PhD, I asked many experts in the field the question “what can be legitimately considered traumatic?” The invariable answer was “that which the patient experiences as traumatic.”
Which answer is correct?
Possible disorders following trauma
Post Traumatic Stress Disorder (PTSD) is the classic diagnosis following exposure to traumatic events. Despite this, the most common psychiatric disorders to emerge after traumatic events are either Depression or Anxiety. Most people exposed to trauma have non-specific responses such as mild anxiety, some psychological numbing or brief phobias.
Case managers working in the workers’ compensation field encounter a variety of diagnostic labels. Undoubtedly, the most common of these is Adjustment Disorder. An Adjustment Disorder conveys the meaning that a person’s reaction to an event is disproportionate or beyond what would be reasonably expected of someone of normal fortitude. Putting aside the value judgments involved in this view, what is implied by this diagnosis is that there is some sort of individual vulnerability in the face of a particular event.
What are the vulnerabilities and how do these help in evaluating or managing claims? People who have liability to mental illness or suffer from an established mental illness are clearly vulnerable to develop psychiatric disorders after exposure to traumatic stressors. The other broad grouping of vulnerable people is those with personal histories of trauma, neglect or illness, particularly in the early parts of their lives.
Salience of events
One of the most important considerations in the impact of events on people is the salience of the event. Salience is best defined as an outstanding or striking quality of something. When an event has salience for a person, this accords it more significance to the person than other events. There is probably a neurological explanation for this, in that the hippocampus (part of the brain which mediates emotion and new learning) processes new experience using past memories to filter new incoming stimuli. In this way, salient events are encoded in long term memory. The other model to explain this phenomenon is that arising from neural networks.
In essence, the brain comprises billions of neurons which form trillions of elaborate network connections. The brain functions by different networks of connections firing, or “activating”, in a particular pattern. The experience of remembering your first family holiday or day of school is mediated by a particular pattern of activation of a neural network. Each time you have that memory, the network activates in a similar way. If an event is traumatic, then the pattern of activation will involve the limbic system – the part of the brain (including the hippocampus) which mediates emotion.
In this way, experiences that may not have an obvious significance to other important events in one’s life may be highly emotionally challenging. We know that anniversaries or commemorations of tragedies are apt to cause severe distress in survivors of catastrophic events like wars or natural disasters. Even innocuous experiences like music or sounds can have a profound effect on a traumatised person.
By way of example, let’s consider the case of a worker who suffered emotional and physical abuse at the hands of a step-father. That person may have been able to endure this experience and still have completed school and entered the workforce.
Such a worker may have been able to participate in the workforce for many years without incident. The situation changes when a new manager arrives in the workplace and raises his voice or is excessively critical. Such an experience may be salient to the worker in that they may be “hardwired” to experience such events in a different way from other events. The theoretical explanation of the experience is that the criticism of the manager activates a neural network in a pattern that is similar to that of the experience of abuse – presumably involving the limbic system. The experience of criticism is as traumatic as the abuse in childhood, leading to psychological distress and either unmasking or exacerbating underlying mental illness.
What does this mean for managing psychiatric claims?
While my explanation of this process involves some complicated neuroscience, there is an important implication for how stressful events in the workplace are managed. A good IME report should provide the reader with a clear sense of the worker’s background. If a worker’s history indicates the experience of neglect or trauma in childhood, or a work history characterised by multiple job changes due to harassment or bullying, this should be considered in planning their rehabilitation. Workers who are vulnerable to such stressors should benefit from psychological therapy which enables them to cope better with the kind of challenges in the workplace that lead to psychological distress and psychiatric disorder.
Treating psychologists should be able to provide information as to how they are helping the worker cope with salient events – such as cognitive or behavioural therapies aimed at challenging assumptions and behavioural patterns leading to psychological distress. In considering modification of duties, the restrictions placed upon a worker’s environment needs to integrate salient events, such as exposure to aggressive customers or environments that have some significance for the worker. Such information should form part of a good independent medical assessment.
Associate Professor Michael Robertson - Consultant Psychiatrist
MBBS (Hons) FRANZCP PhD
SIRA DRS Assessor, NSW WCC Approved Medical Specialist, Comcare Assessor