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Individual Differences |
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Individual Differences |
Abstract
In the past, awareness of the nature of emergency worker stress has been constrained by images of individual strength and coping even in the face of extreme events. Today, it is often assumed that certain events are so horrific that virtually everyone will react the same way. The stereotype of the macho stoic has been replaced by that of the vulnerable emergency worker. This paper argues against both stereotypes. Although certain circumstances can be horrific in themselves, emergency workers have a variety of coping styles and not all will be affected by events to the same degree. Moreover, debriefing may sometimes run counter to individual coping and impair rather than help some individuals. Acceptance of individual differences in reactions to traumatic stress may help us better manage emergency workers' training and in-service education, but there is the risk it may be misinterpreted as blaming an individual for reacting to events.
The nature of critical incidents, the environments in which they occur, and the organisational
imperatives of emergency services make it extremely difficult to study the process of critical
incident stress and debriefing under controlled conditions that can be achieved elsewhere, for
example in hospital clinical trials (Kenardy & Carr, 1996; White, 1996). Nevertheless, most
work on CISD has occurred in the framework of evaluating the benefits of interventions. In
emergency organisations, there is considerable support for debriefing and it may seem churlish
to question its value. This paper recognises its perceived value to those exposed to trauma,
but we need to be circumspect when discussing the acceptance of debriefing. Not all
emergency workers attend debriefing, and not all complete research questionnaires on stress.
Individual differences can contribute to the perceived effectiveness of debriefing.
Much has been written on the nature of stress and coping in the last decade, largely
influenced by the work of Lazarus and Folkman (1984) which gives priority to individual
appraisal in determining what is stressful. This view is sometimes referred to as the
transactional model of stress. According to this model, our perceptions and interpretations of
events around us contribute to our experience of stress. The transactional model of stress thus
sees individuals very much as the source of their stress reactions because of the process of
appraisal. In the emergency context, it seems simplistic to adopt this view because it
minimises the extent of trauma encountered during emergency work. That is, there are many
extreme circumstances where the role of appraisal is severely constrained by the nature of the
incident, and it seems insensitive and naive to say a person is reacting a certain way because
of how they are thinking about the incident. It could be argued some incidents are horrific
in themselves. Nevertheless, as researchers we are faced with the fact that not all emergency
workers react to the same incident in the same way. Paton (1994) has preferred to use the
term schemata to explain to individuals' tendencies to perceive and process information in the
environment in habitual ways.
People also differ in their coping style (general tendency to deal with situations in a particular
way) and their coping strategies (specific behaviours they engage to deal with a stressor or
event). There are many typologies of coping, although most reflect to some degree that of
Lazarus and Folkman in which coping is divided into problem focussed and emotion focussed
strategies (Parker & Endler, 1992). Emergency workers may be more prone to use problem
focussed than emotion focussed coping (Moran & Britton, 1994a), but whether this changes
with type of incident has not been established. Coping is a dynamic process which changes
in response to the demands of life and personal appraisal of circumstances (de Ridder, 1997).
People may have stable coping preferences, although as Carver, Scheier and Weintraub (1989)
found, habitual ways of coping do not adequately predict coping strategies used in specific
situations. Coping style also has a poor track record in predicting post-trauma symptoms
(Shalev, 1996) but our current tools for assessing coping may be at fault (de Ridder, 1997).
If we can find out more about what helps some people cope with extreme or traumatic
incidents, such as existing schemata or coping strategies, we may be able to use this
information to enhance selection, training or intervention procedures in emergency work.
There are several forms of formal debriefing, but most appear to have some relationship with
CISD as documented by Mitchell (1983, 1988), although over the years they may have been
modified to be more flexible in the emergency environment or match the requirements of
particular emergency organisations. Debriefing can give an opportunity to ventilate feelings,
provide social support, expedite cognitive reframing and minimise subsequent post-trauma
symptoms. The variability in the aims of debriefing makes it difficult to assess its
effectiveness. For those who believe it provides social support and emotional assistance,
debriefing is seen to work, and this conclusion is generally supported by ratings from
emergency responders indicating they value the intervention (eg Robinson, 1989; Robinson
& Mitchell, 1993, 1995; Temple, 1991). If the aim of debriefing is to reduce post trauma
symptomatology, particularly related to PTSD, the beneficial effects are more debatable. Some
research studies indicate that debriefing can actually lead to poorer adaptation to trauma than
no debriefing (see Raphael et al, 1996; Bryant, 1994). The variability of its aims and putative
processes makes it easy either to overstate or understate the value of debriefing, depending
on what one means by debriefing.
Discussing and evaluating debriefing have also been complicated as a result of the higher
profile that debriefing has in the 1990s. Debriefing occurs in a wider context than in the last
decade, with more informed emergency services and more frequent media mention of
debriefing in their coverage of emergencies. During television coverage of the 1997 Thredbo
landslide and the NSW 1994 bushfires (wildfires), media commentators several times reported
emergency personnel were highly stressed by their work and were being debriefed as they
came off their shifts. This media discussion of debriefing raises concerns. In traditional
debriefing sessions confidentiality is highlighted, yet we have recent evidence of individuals
talking on television about what the workers are experiencing, and this seems to be
information revealed during early stage defusing or debriefing. Those being interviewed may
intend to provide other people at risk with information about potential symptoms. Media
presentations are highly edited, usually very brief and selective, and only the more graphic
aspects of reactions are presented to the general public, some of whom will be the emergency
workers who may question why disclosures are so publicly discussed. In addition, individual
differences in reactions to traumatic incidents is given little coverage.
Most emergency organisations now have special debriefing procedures and teams in place.
Despite this, mental health workers sometimes converge on disaster sites (Moran, 1995), and
researchers may do the same (Raphael & Meldrum, 1993). The marketing of debriefing by
independent psychological services may inhibit a critical evaluation of its effects. The increase
in litigation and workers' compensation for job stress have increased the organisational
imperative to provide debriefing and stress counselling services, but this may not be
accompanied by any similar pressure to evaluate their impact.
The context of debriefing has thus changed over time, the aims and procedures vary, and the
expectations for debriefing to be provided are much more public than when it was first
introduced. In this wide context it is easy for individual differences in reactions to stress and
debriefing to become lost. Studying individual differences is further complicated by two rather
different stereotypes of the emergency worker, the macho stoic and the vulnerable tertiary
victim.
Expectations about emergency workers' vulnerability have tended to be discussed in terms
of extremes. For many years there was the stereotype of the stoical worker who was
impervious to stress (Alexander & Wells, 1991). We no longer expect emergency workers to
be a homogenous group (Paton & Smith, 1996), but there are consistent expectations about
recruits and procedures are geared to select those who will be able to cope in stressful
circumstances of emergency work. These characteristics are not necessarily selected using
formal questionnaires or tests. As Flin (1996) argues, psychological tests do not offer
sufficient predictive validity to be useful in selection procedures for emergency work. She
concludes those doing the recruiting at the level of commander, for example, find it easier to
select out the wrong stuff (eg anxiety, personality disorder) than select in the right stuff.
Evaluation of emergency workers' characteristics frequently relies on studies performed on
workers with some years experience. Several of these studies have come to the conclusion
that there is no such thing as `the right stuff'. Moran and colleagues, for example, noted
emergency workers are not necessarily hardier than most (Moran, Britton & Corey, 1992;
Moran & Britton, 1994b) although some individuals in their samples scored very high on this
dimension.
One characteristic of emergency workers that is related to stress and coping is optimism
(Moran & Colless, 1995a) or hopefulness (Carr et al 1996). They rate their chances of
being impaired following stressors as lower than average (Moran & Colless, 1995a). This is
related to the phenomenon of benign illusions discussed by Taylor (1989), who argued such
thoughts enhance wellbeing. It is not clear whether such optimism is stress inoculating to
those in emergency work, but studies are suggesting this could be the case. Carr and
colleagues found hopefulness was associated with fewer trauma symptoms in emergency
workers dealing with the Newcastle (Australia) earthquake (Carr et al, 1996). Even if
optimism mitigates the effects of exposure to traumatic incidents, we cannot be confident it
will always do so. Furthermore, an optimistic outlook with few other coping strategies may
actually make the emergency worker more vulnerable to particularly traumatic incidents.
Other coping strategies noted in emergency workers include humour, suppression and
focussing on the task at hand (Moran, 1990).
Cultural background may influence coping and reactions to incidents, but in Australia the
majority of emergency workers are either of Anglo-Celtic origin or second generation
Australians (eg Moran et al, 1992). This bias is not due to any formal policy, but is perhaps
a consequence of cultural expectations and opportunities. It would be interesting to evaluate
the impact of ethnicity on emergency workers' trauma where there are sufficient numbers for
comparison. To date there do not seem to be any major differences reported (McCammon,
1996).
Culture does not only refer to ethnicity of course. The culture (ethos) of the emergency
organisation can influence reactions to trauma and stressful incidents. Humour, for example,
is a coping strategy often found in extreme environments (Moran, 1990), but one which
frequently depends on the acceptance of coworkers. Rosenberg (1991) found humour was
passed on from experienced to inexperienced emergency paramedics through observational
learning. A novice worker may also learn from observation not to joke under certain
circumstances. Other coping strategies may also develop in this way. Perhaps one of the more
influential sources of observational learning is the informal debriefing sessions which occur
during clean up at the station or depot after an incident. Anecdotally, many workers report
these informal sessions are as valuable as formal ones. However, Moran and Colless (1995a)
found formal debriefing sessions were more likely to be rated as useful when respondents had
past experience with traumatic incidents. Formal debriefing sessions expose workers to
information and opportunities for referral they might not otherwise encounter during informal
sessions.
Many workers mention they learn how to deal with stressful incidents and traumatic
exposures through working with more experienced workers. For example, station officers may
show new emergency workers their first dead body in a deliberate but controlled fashion,
rather than let the new emergency worker face this alone. They actively model coping styles,
as well as gradually expose the new worker to trauma. Of course, this is not always possible
and recruits just out of training can find themselves in the midst of trauma within hours of
starting their first shift.
Personal vulnerability
The negative impact of trauma on emergency workers has been widely discussed in recent
years, putting paid to the macho stereotype. Discussion in the past was often limited to the
effects of combat and not widely disseminated. Providing this information to a wider forum
was long overdue, but unfortunately in some circles it was adopted so enthusiastically that
a new stereotype emerged, that of the highly vulnerable emergency worker. There is
variability in emergency workers' personalities, stress coping strategies and resources which
interact with the specific nature of incidents. In other words, not everyone matches the new
stereotype. This is not to say severe reactions do not occur after severe incidents, or that we
can predict who is at risk.
Moran and Colless (1995b) factor analysed the responses of over 700 firefighters and reported negative reactions could be summarised by five factors:
In another sample of emergency responders, Moran also noted that severity and length of
reaction to a previous traumatic incident was associated with length of emergency service. In
this case, experience with previous stressful incidents was more important than individual
differences in predicting negative reactions (Moran & Britton, 1994b). These data were
obtained by questionnaire and do not necessarily indicate clinical levels of reactions.
The current diagnostic criteria of PTSD recognises the role of individual differences and the
contribution of factors such as social support, childhood experiences and personality variables
to the development PTSD (American Psychiatric Association, 1994, p426). This is not to say
the nature of the incident is irrelevant. Emergency workers frequently mention certain incidents
are especially traumatic, such as those which involve children, multiple deaths, threat to one's
own life (Dyregrov & Mitchell, 1992; McCammon et al, 1988; Moran & Colless, 1995a). The
point to be made is that diagnostic criteria remind us that we cannot expect each victim to
be affected to the same degree by a traumatic incident. In the absence of data that emergency
workers are a particularly homogenous group, some variation of reactions in emergency
workers is to be expected also.
There are humane considerations which affect discussion of this variation. Informing
emergency workers that `most people' would react the same way under the circumstances
may help them acknowledge their feelings and enhance recovery, regardless of whether this
view is accurate. We need to be careful before removing self-enhancing beliefs in the interests
of emphasising individual differences.
The trauma membrane and coping
Lindy (1985) and others have used the term `trauma membrane' to summarise the way
emergency workers shield themselves from the horrors around them and continue with
activities as though they are unaffected. In some cases this is seen as a psychic defence which
is useful at the scene but which should be shed soon afterwards. Many researchers and
clinicians have encountered workers who have denied feelings and reactions after the incident,
only to have them emerge later as more severe symptoms. We cannot make the general
assumption that denial is always bad, however. As studies in areas such as coronary heart
disease indicate denial may be a health enhancing strategy in some circumstances or at some
point (eg see Taylor, 1991, p370).
It would also be simplistic to say workers deny their reactions because of the machismo ethos
of emergency organisations. This may be the case for some, but others may deny feelings
because of other personal characteristics such as religious or cultural background, or they have
successfully coped using this strategy in the past. Working within the organisation may help
change those with an unrealistic macho image of themselves or an unhealthy reliance on
denial, and exposure to group discussion in formal organisational debriefing sessions may be
the best way to achieve this change. Whether this will also help those whose reasons for
defensive denial are more idiosyncratic is not yet known because research on critical incidents
has not addressed this level of individual responsiveness.
Of course, if emergency workers are not focussing on the horror of a situation this does not
mean they are using denial. There are many ways to put information out of mind, and these
may involve either conscious or unconscious processes. The defensive style of repression has
a long history of being regarded as a poor coping strategy. Suppression, on the other hand,
is considered a healthy and conscious defensive style (Andrews et al, 1989). In popular
folklore there is the understanding that memory is kind - in other words, forgetting sometimes
helps us. Forgetting may help a person cope by reducing arousal and avoidance (Raphael et
al, 1996).
If it requires a person to focus on the horror of an event and describe their reactions to it,
debriefing may weaken an existing coping or defensive style such as suppression and make
the person feel worse. Conversely, some people cope by dwelling on an incident (forming a
coherent narrative, perhaps). Aiming to reduce distress by reducing thoughts about the
incident could make things worse by removing another form of coping. Clearly, to take one
coping strategy in isolation and label it as either good or bad would be inaccurate. Coping
occurs in a context, with both internal and external features that influence the value of a
particular strategy or personal style. Similarly, debriefing contexts and characteristics vary,
and not all require a person to share feelings when quiet reflection or not focussing on the
event may be more appropriate for them.
The value of coping is sometimes assessed by looking at whether it leads to a change in
circumstances or events. As de Ridder (1997) points out, thinking over a problem may be
seen as rumination if the circumstances remain unchanged but as problem-solving if
circumstances are changed for the better. In the emergency context such post-hoc labelling
of coping needs to be carefully scrutinised. The level of negative feelings and the degree to
which they impair functioning may better indicate the impact of trauma and help decide
whether people are coping satisfactorily.
Not surprisingly, these reactions were more likely to occur with task oriented incidents such
as fighting fires and less likely to occur with person oriented incidents such as rescue work,
but they were occasionally associated with the latter (eg 23% with motor vehicle accidents).
Even when stress in emergency workers is high, there still can be some positive outcomes in
terms of finding meaning, in a philosophical sense, or learning from the incident (Shepherd
& Hodgkinson, 1990; Werner et al, 1993). Hyten and Hasle (1989) noted that 66% of workers
reported some positive outcomes after a hotel fire which involved handling dead bodies. The
best debriefing is probably that which allows for discussion of such feelings.
If there is only a focus on distress emergency workers may feel guilty or lose faith in the
wisdom of those attempting to work with them after the incident. This bias can occur with
researchers as well. Moran (1994, p5) quotes one emergency worker after a major incident
in NSW: `I've been filling in forms (since the incident) and I'm amazed that I don't feel the
way they say I should'.
Denying the existence of positive feelings may have the paradoxical effect of diminishing our
appreciation of the depth of suffering of those negatively affected by emergency work. That
is, if we do not allow for individual differences in positive coping and assume everyone feels
the same, we are also not allowing for individual differences in the depths of distress. As
those who work with individuals experiencing post-traumatic stress know, suffering is
sometimes so great that it leads to suicide.
Many writers (Flin, 1996; Paton, 1996, Shalev, 1996, Ursano et al, 1996) are suggesting
emergency services teach recruits techniques to anticipate and deal with stress. These
techniques may resemble those of stress inoculation training (Meichenbaum, 1985). Evaluating
the impact of this training would be easier if we had better predictors of stress reactivity and
coping than we do (de Ridder, 1997, Paton & Smith, 1996) but even with the instruments we
have, measuring stress and coping variables may help determine individuals particularly at
risk. The idea of identifying those at risk may not find favour with emergency workers,
however. The emphasis on critical incident stress probably has been accepted by the
emergency worker because the term and procedures treat the individual as less culpable in the
stress-reaction equation, and to return to the idea of individual differences may be seen as a
step backward providing employers with an opportunity to blame the victim. Also, as Britton
and colleagues note, a large number of emergency workers are volunteers and it would be
uneconomical for authorities to use stress predictors to eliminate those potentially but not
definitely at risk (Britton, Moran & Corey 1994). Stress inoculation training has the likely
benefit of enhancing the wellbeing of emergency workers who have a high probability of
being exposed to traumatic incidents. Whether such training would be extended to volunteers
remains to be seen.
The main aim of most debriefing sessions appears to be to provide workers with the
opportunity to discuss negative reactions, but this should not rule out the opportunity to
discuss positive ones. Even following traumatic disaster work some emergency workers, quite
rightly, feel that they have done a good job. It is important we do not impose the vulnerable
stereotype in the same way the macho stereotype was imposed on emergency workers in the
past. The real emergency worker may occasionally be found at these extremes, but many can
also be found in the middle ground, with both personal strategies for dealing with stress and
vulnerabilities to it that occasionally require external help. Perhaps the best form of debriefing
is that which takes this individual variability into account.
This paper has not addressed the degree to which coping resources influence coping strategies.
Social support is a resource which can buffer the impact of stress (Cohen & Wills, 1985) and
this may be one of the pathways through which debriefing works. That is, the debriefing
process facilitates the emergency group members providing each other with social support. Orner (1995)
has argued trauma recovery in emergency workers is a group phenomenon hence we should
study debriefing in terms of what it does to group processes rather than focus on individuals'
reactions. To take this suggestion too far, however, is to overlook the fact that groups are
made up of individuals.
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