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Occupational Medicine 2019;69:559–565
Advance Access publication 3 August 2019 doi:10.1093/occmed/kqz111
© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: journals.permissions@oup.com
Evaluation of a trauma therapy programme within
emergency service organizations
N. Tehrani
Noreen Tehrani Associates Limited, Twickenham TW1 2QU, UK.
Correspondence to: N.Tehrani, Noreen Tehrani Associates Limited, 12 Baronseld Road, Twickenham TW1 2QU, UK. E-mail:
noreen.tehrani@noreentehrani.com
Background Occupational health practitioners working in emergency services, where employees are exposed to
a higher level of physical or psychological trauma, need to be able to access trauma therapy pro-
grammes which are economically viable and effective in reducing post-traumatic stress disorder and
associated symptoms of anxiety and depression.
Aims The aim of this review is to provide evidence on benets of a short-term organizational programme
of trauma therapy using NICE (2018) [1] recommended interventions.
Methods The review examined the pre- and post-therapy clinical scores from 429 emergency service profes-
sionals (ESPs) who were employed in ve police forces, two re and two ambulance services. The
ESPs in higher risk roles were in a psychological surveillance programme, with those found to be
experiencing clinically signicant levels of trauma-related symptoms being referred to a psychologist
for an assessment which identied the ESPs requiring trauma therapy. At the end of the therapy, the
symptoms of theESPs were re-assessed, and the scores before and after the therapy were compared.
Results The results showed a signicant improvement in the level of symptoms, with 81% of ESPs no longer
exhibiting clinically signicant trauma symptoms and 6% showing an increase in symptoms. In add-
ition, the clinical results also showed improvements in ESPs’ perceived work capacity and quality of
social relationships.
Conclusions The ndings indicate that there are clinical and personal benets to using an organizationally based
short-term model of trauma therapy in an emergency ser vice setting.
Key words Emergency services; trauma; trauma therapy.
Introduction
There are many organizations where workers face phys-
ical and psychological danger. The Health and Safety
Executive [2] produce data on the number of workplace
fatalities and serious accidents, with construction, agri-
culture, waste and recycling at the top of the table. Other
groups of workers are exposed to psychological trauma,
including train drivers, social workers, medical staff, re
ghters, police ofcers and ambulance personnel [3].
For occupational health practitioners (OHPs), working
for these industries, it is important to have means of
dealing with the psychological as well as the physical im-
pact of traumatic events.
Generally, workers in emergency services cope, but
occasionally they require a therapeutic intervention to
reduce their psychological symptoms [4]. Several emer-
gency service providers have introduced programmes of
trauma support for their emergency service professionals
(ESPs), and these programmes include early interven-
tions such as debrieng [5,6] and psychological rst aid
[7]. OHPs have also developed training for ESP super-
visors and debriefers to help them recognize and refer
members of their teams to occupational health (OH)
when they are showing signs of distress following a trau-
matic exposure [8].
Despite OH support, some ESPs develop serious clin-
ical conditions including generalized anxiety, major de-
pression and post-traumatic stress disorder (PTSD) [9].
The development of these trauma-related responses may
be delayed and go unrecognized, leading to increased
sickness absence and lower levels of productivity. The
need to maintain a healthy workforce has led to the intro-
duction of psychological screening and surveillance [10]
by some occupational health departments as a way of
identifying ESPs requiring a psychological assessment
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560 OCCUPATIONAL MEDICINE
and referral for trauma therapy. In addition to measuring
clinical symptoms, some screening programmes also
measure resilience factors, with one of the better-known
resilience measures being the Sense of Coherence (SOC)
scale which assesses the extent to which people nd their
lives and work to be meaningful, comprehensible and
manageable [11]; these attitudes have been shown to be
psychologically protective.
This review examines the outcomes of ESPs assessed
as requiring trauma therapy through a trauma surveil-
lance programme and referred to a therapist trained
in one or both NICE-recommended trauma therapy
programmes (trauma-focussed cognitive behavioural
therapy [TF-CBT] [12] or eye movement desensitiza-
tion and reprocessing [EMDR] [13]). At the end of the
therapy, the ESP is re-screened and the changes in their
clinical symptoms, coping capacity and resilience were
recorded.
This review is designed to assess the effectiveness of
the trauma therapy programme in reducing the symp-
toms of anxiety, depression and traumatic stress among
ESPs exposed to trauma, and to assess the impact of the
trauma therapy on productivity, satisfaction and lifestyle
of theESPs.
This review used data gathered as part of the regular
monitoring and evaluation of a trauma screening and
therapy programme for ESPs. The review is on the sur-
veillance results rather than research [14]. The screening
and surveillance programme is undertaken under
Health and Safety legislation and therefore does not re-
quire ethics approval; however, the review met the eth-
ical standards of the British Psychological Society [15].
Methods
The trauma screening and therapy programme was em-
bedded within the ESP OH service, with the services
reporting into the emergency service’s heads of OH. In
January 2019, the programme had been running 6years;
429 ESPs had completed the trauma therapy programme.
Afurther 66 ESPs were engaged in the therapeutic pro-
cess, with slightly more female (55%) than male (45%)
referrals. Most ESPs involved in the review were from po-
lice services (86%), but it also included 12% ambulance
and 2% re and rescue service personnel. Each ESP had
completed an online screening questionnaire [16], which
had identied clinically signicant levels of psychological
trauma, anxiety and depression. ESPs with clinically sig-
nicant scores were referred for a structured psychological
assessment [17] with the Health and Care Professions
Council (HCPC)-registered counselling psychologist.
The psychologist reviewed physical, psychological and
social well-being, and took a personal history, including
educational achievements, employment and an account
of the traumatic exposure. At the end of the assessment,
the psychologist shared the screening results with the
ESP. The psychologist’s assessment was used to formu-
late clinical opinions on the ESP’s psychological state,
reasons for the state and whether trauma therapy or other
intervention was appropriate. The psychologist provided
recommendations to the responsible OH practitioner on
how the ESP should be supported by OH and line man-
agement during and following the trauma therapy. The
trauma therapy programme was for work-related trauma
and, if the traumatic exposure was not work-related, the
ESP was referred for support from the NHS or to the
organization’s employee assistance programme.
Key learning points
What is already known about this subject:
• It is widely recognized [1] that trauma-focused cognitive behavioural therapy and eye movement desensitization
and reprocessing are effective forms of therapy for treating the post-trauma responses of anxiety, depression and
traumatic stress.
• Employees of emergency services are frequently exposed to traumatic events in the course of their work and
seek support from their occupational health department.
What this studyadds:
• The study has shown that the use of short-term trauma therapy provided within an occupational health frame-
work is associated with signicantly reduced levels of traumatic stress, anxiety and depression on completion of
therapy.
• The study supports the development of a practitioner-led business case for a trauma intervention involving ob-
jective and perceptual factors in support of the Society of Occupational Medicine’s value proposition [30].
What impact this may have on practice or policy:
• Organizationally focused short-term trauma therapy can be effective in reducing symptoms of anxiety, depres-
sion and traumatic stress in emergency service professionals.
• The role of occupational health is central to the management of emergency service professional trauma
programmes.
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N. TEHRANI: EVALUATION OF A TRAUMA THERAPY PROGRAMME 561
To assess the effectiveness of the programme, pre-
and post-therpay measures were taken, which included
three clinical questionnaires: the Goldberg Anxiety/
Depression Scale [18], which measures anxiety and de-
pression using a simple yes/no endorsement of symp-
toms with a score range of 0–9; the Impact of Events
Scale-E (IES-E) [19], which measures arousal, avoid-
ance and re-experience using a ve-point scale ranging
from never to most of the time, with a range of 0–92;
and resilience was measured using the SOC scale [20]
using a seven-point scale ranging from never to all the
time (score range 13–91). On completion of the therapy,
the ESPs completed the Goldberg Anxiety/Depression
Scale, IES-E and SOC questionnaires a second time
and the results were compared. The ESPs also provided
satisfaction feedback on the trauma therapy programme
and on any changes they observed in their capacity to
work, understanding of their symptoms, ability to cope
with their job, relationship with colleagues and man-
ager, satisfaction with personal life and ability to deal
with problems.
The 24 trauma therapists working on the programme
were all in private practice. This number of therapists
was necessary to ensure that ESPs did not have to travel
a long distance for their therapy and to ensure that there
was a good supply of sessions. The therapists had been
selected for their qualications and skills in undertaking
trauma therapy and their willingness to work within an
organizational setting. The therapists were accredited
by their professional body and all had been trained in
TF-CBT [21] by the author. Some therapists were also
accredited EMDR [22] practitioners. Thirty-nine per
cent of the therapy involved EMDR, 37% TF-CBT and
24% a mixture of TF-CBT and EMDR. ESPs were as-
signed to the nearest available therapist within a week
of their assessment. The programme provided for six
90-min sessions with the opportunity for the therapist
to split sessions into 60-min sessions where this suited
the needs of the therapy or the ESP. At the mid-therapy
point, the therapist provided a report giving information
to the OHP on how the case was progressing, together
with suggestions designed to assist in rehabilitation and
recovery. If in the view of the therapist there was a need
for additional sessions, the therapist could request up
to two additional 90-min sessions. The average number
of sessions provided by the programme was 6.53 (SD
1.25). During the last session of the therapy, the partici-
pants completed the closing questionnaires and provided
feedback on their experience of the therapy. The ther-
apists wrote a closing report providing information on
the lifelong traumatic exposures experienced by the ESP
together with recommendations on any organizational
or OH support that would be helpful in aiding their re-
covery. The data collected were input into and analysed
by GNU PSPP Statistical Analysis Software version
1.2-g0fb4db.
Results
Fifty-two of the ESPs failed to fully complete the
screening questionnaires at the end of the therapy; there-
fore, the analysis involved the results from 377 ESPs. The
analysis of lifelong exposures to trauma showed that ESPs
had experienced a range of traumatic events, including
traumas in childhood, personal life and working life.
The results showed that in childhood, 33% had experi-
enced a childhood trauma, e.g. involved in an accident
or other traumatic incident; 22% had been exposed to
childhood abuse, e.g. physical and sexual abuse; and
17% experienced the loss of a parent through bereave-
ment or separation. In their personal life, 35% experi-
enced at least one traumatic event, e.g. military action
or accidents; 28% had a traumatic relationship, e.g. do-
mestic violence or stalking; and 7% experienced personal
abuse including rape or harassment. In work, 58% had
been exposed to primary trauma as a victim or by being
involved in rescuing or dealing with a primary victim;
51% had experienced secondary trauma relating to their
work, e.g. dealing with child abuse, interviewing victims
or offenders of domestic violence, sexual abuse or other
personal crime; and 18% had been exposed to bullying
or other aversive behaviours at the hands of work col-
leagues or managers (Table 1). The results show that in
most areas women record higher levels of traumatic ex-
posure than men. Asignicantly higher level of primary
traumatic exposures was reported by men but there was
no signicant difference in the level of secondary trauma
by gender. The results showed that women had a higher
number of lifelong traumatic exposures, although this
was at a lower level of signicance.
Table 2 shows the mean clinical scores before and
after the therapy together with the clinical cut-off levels
for those ESPs completing the closing reports. The
average levels of anxiety had fallen by 3.5 points, depres-
sion by 3.1 points and total trauma by 30.6 points. The
improvement in each of these three symptoms was found
to be statistically signicant. When considering clinical
signicance, the results showed, at the beginning of the
therapy, the percentage of people with clinically signi-
cant scores were: 84% trauma, 80% anxiety and 81%
depression; however, by the end of the therapy, it was
found that the number of ESPs with clinically signicant
scores had fallen to 19% trauma, 24% anxiety and 30%
depression. Asmall number of ESPs were found to have
higher clinical scores following the therapy—the percent-
ages of higher scores were 6% trauma, 4% anxiety and
8% depression.
The feedback of ESPs on their perceptions of the
trauma therapy programme were measured on a ve-point
scale with the range of 1–5. The results showed that the
level of satisfaction was within the range 4–5. The highest
score was for ease of access (4.9) and the lowest score was
for the therapist’s understanding of their problems(4.3).
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562 OCCUPATIONAL MEDICINE
The ESPs also provided feedback on their perceived
capacity before and after the therapy (see Table 3). The
responses were measured on a ve-point scale (range
1–5) apart from the capacity to work which was assessed
as a percentage of their potential working capacity. The
greatest change was seen in the ESPs’ understanding of
their symptoms (2.41) followed by their improved ability
to deal with their problems (2.03). There were small
but signicant improvements in relationships with col-
leagues (0.90) and manager (0.76). The ability to cope
with symptoms (2.41), deal with problems (2.03) and
their satisfaction with life (1.56) had also improved. The
changes in the perceived capacity to work showed the
mean capacity to undertake the work had risen signi-
cantly from 37% to 69% of their potential capacity.
The results from the SOC questionnaire are given
in Table 4—‘before therapy’ scores were taken from
the pre-assessment screening and ‘after therapy’ scores
were taken at the end of the therapy. All the SOC scales
showed a signicant improvement; a correlation be-
tween the trauma scores and the individual SOC scales
showed that there was a signicant relationship between
the changes in trauma symptoms and all the SOC scales
(Table 5).
Discussion
OHPs providing services in emergency services where
there is a higher risk of workers being exposed to
traumatic events, materials or victims need the evi-
dence to show that there is a benet to introducing a
OH-managed trauma therapy programme. This is par-
ticularly important where there are known psychological
trauma hazards leading to the statutory duty to undertake
screening and surveillance to identify employees experi-
encing signs of PTSD [23]. While employee assistance
programmes can offer general counselling, they rarely
have the specialist trauma therapists available to offer
trauma therapy. Trauma therapy in the UK is available
from the NHS via the Improving Access to Psychological
Therapies (IAPT) [24]; however, this often involves long
delays (6–18 weeks) with services that have not been
tailored to the needs of ESPs or their organizations. The
recovery rate standard for IAPT is 50% of referrals.
The trauma therapy programme was therefore de-
veloped to meet the unmet needs of emergency services
where it is important to be able to return emotionally
t ESPs to duty enabling them to carry out their duties
which frequently expose them to challenging relation-
ships and traumatic situations. This review demonstrated
that the trauma therapy programme reduced the symp-
toms of trauma in >90% of those referred and that over
80% of ESPs were no longer experiencing clinical levels
of symptoms at the end of the therapy, signicantly
higher than the aim of a 50% recovery rate identied
by IAPT [24]. As reported, however, a small number of
ESPs were found to have a higher level of symptoms at
the end of the therapy. This result was unsurprising given
Table 1. Percentage of ESPs affected by childhood, adult and work-related trauma
Gender nChildhood Adult Work Mean number
oftraumas
Type Trauma Abuse Loss Trauma Relationship Abuse Primary Secondary Relationship
Male 194 27% 17% 11% 32% 21% 2% 68% 51% 17% 2.86
Female 235 38% 28% 21% 37% 34% 11% 51% 52% 20% 3.57
Total 429 33% 22% 17% 35% 28% 7% 58% 51% 18% 3.24
t score 2.98 2.88 2.93 1.58 3.38 3.06 −2.97 1.34 1.24 3.84
Signicance 0.000 0.000 0.000 0.016 0.000 0.000 0.000 0.859 0.015 0.028
Table 2. ‘Before therapy’ and ‘after therapy’ scores for anxiety, depression and PTSD
Range Mean nSD SE Mean
difference
95%
condence
interval
tSignicance Clinical
cut-off
% < Clinical
cut-off
Lower Upper Before After
Anxiety before therapy 0–9 7.5 377 1.6 0.8 3.5 3.3 3.9 24.6 0.000 5 80 24
Anxiety after therapy 4.0 2.8 0.1
Depression before therapy 0–9 6.2 378 2.0 0.1 3.1 2.8 3.4 21.6 0.000 3 81 30
Depression after therapy 3.1 2.7 0.1
PTSD before therapy 0–92 63.3 377 14.3 0.7 30.8 28.5 32.9 27.0 0.000 50 84 19
PTSD after therapy 32.7 20.7 1.1
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N. TEHRANI: EVALUATION OF A TRAUMA THERAPY PROGRAMME 563
that many of those in the programme returned to work
while they were in therapy and were exposed to trauma
triggers which caused an increase in symptoms; others
with more signicant trauma symptoms had entered the
process of medical retirement which may have affected
their level of engagement in the therapeutic process.
Future studies should follow up ESPs that have been
through the programme to establish whether the bene-
ts achieved in this review are maintained over time. It
may be possible to look at levels of sickness absence in
the year before trauma therapy and compare them with
the absence levels in the year following the completion
of the rehabilitation of the ESP; this evaluation could
begin to establish some of the nancial benets of the
programme.
One of the surprising ndings from the review was that
ESPs could be working at 37% or less of their capacity
without being identied by their manager as requiring
Table 3. ESPs’ perceptions of their capacities and resilience assessed in the nal therapy session
Mean nSD SE Mean difference 95% condence
interval
tSignicance
Lower Upper
Understanding of symptoms before therapy 2.01 375 0.93 0.05 2.41 2.52 2.31 44.95 0.00
Understanding of symptoms after therapy 4.42 0.64 0.03
Coping with symptoms before therapy 1.90 375 0.98 0.05 1.57 1.69 1.44 25.34 0.00
Coping with symptoms after therapy 3.47 1.14 0.06
Relationship with colleagues before therapy 2.95 375 1.17 0.06 0.90 1.00 0.80 17.35 0.00
Relationship with colleagues after therapy 3.85 1.02 0.06
Relationship with manager before therapy 2.91 375 1.29 0.07 0.76 0.87 0.65 13.66 0.00
Relationship with manager after therapy 3.67 1.15 0.06
Satisfaction with life before therapy 2.23 375 1.01 0.05 1.56 1.67 1.45 27.40 0.00
Satisfaction with life after therapy 3.79 0.92 0.05
Ability to deal with problems before therapy 1.76 375 0.80 0.04 2.03 2.14 1.92 36.19 0.00
Ability to deal with problems after therapy 3.79 0.89 0.05
% of capacity working at before therapy 37% 375 25.5 1.35 31.2% 34.15 28.78 28.05 0.00
% of capacity working at after therapy 69% 28.3 1.50
Table 4. SOC scores measured in screening before and after therapy
Mean nSD SE Mean difference 95% condence
interval
tSignicance
Lower Upper
SOC meaningfulness before therapy 16.77 375 5.41 0.28 2.1 2.71 1.49 6.77 0.00
SOC meaningfulness after therapy 18.87 5.43 0.28
SOC comprehensibility before therapy 17.61 375 6.07 0.31 4.6 5.33 3.94 13.17 0.00
SOC comprehensibility after therapy 22.24 6.38 0.33
SOC manageability before therapy 13.49 375 5.33 0.28 3.2 3.74 2.57 10.63 0.00
SOC manageability after therapy 16.65 5.64 0.29
Table 5. Correlation between the change in scores for trauma and SOC measures before and after trauma therapy
Meaningful
change
Comprehensibility
change
Manageability
change
Changes in trauma scores before and after trauma
therapy Correlation 0.33 0.38 0.41
Signicance
(two-tailed)
0.000 0.000 0.000
n 369 369 369
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564 OCCUPATIONAL MEDICINE
a referral to OH. This nding reinforced the benet of
undertaking regular psychological screening of emer-
gency service workers and others in roles where there is a
high risk of psychological trauma. It would be interesting
to see if introducing a proactive programme of education
and resilience skills training reduced the levels of trauma
found in the psychological surveillance results of these
high-riskteams.
The SOC questionnaire is recognized as a reliable in-
dicator of psychological resilience to trauma [11]; the re-
sults from this review showed that ESPs receiving trauma
therapy signicantly increased their scores on this
measure, suggesting that the trauma therapy programme
may do more than simply reducing the clinical symp-
toms. It is possible that the SOC provides the framework
for enabling emergency services to work with their ESPs
to create more meaningful work, opportunities to under-
stand how their role ts with the objectives of the organ-
ization and to nd ways to manage role demands which
will not only increase job satisfaction but also reduce the
incidence of traumatic stress.
The lifelong traumatic experiences showed that it
was common for ESPs to have been exposed to mul-
tiple traumas including childhood traumas. This mul-
tiple traumatic exposure suggests that some ESPs may
be experiencing complex PTSD (c-PTSD) [25] rather
than simple PTSD. If this is the case, the results may be
even more interesting as the ESP trauma therapy pro-
gramme is short term rather than the long-term c-PTSD
treatment [26]. The diagnosis of c-PTSD was only for-
mally recognized in the International Classication of
Diseases in 2018 [27] but, with the development of the
International Trauma Questionnaire [25], which meas-
ures both PTSD and c-PTSD, it is possible for future
studies to assess ESPs for c-PTSD.
The trauma programme in this review was embedded
within OH and designed to maximize opportunities for
multidiscipline working [28]. It is likely that some of the
benet came from the close working between the trauma
therapy programme and the OHPs who provided the
vital link between the programme, the manager and the
employees, ensuring that a holistic approach was taken
to well-being. It would be interesting for future studies to
look at the relative contribution of each element of this
collaborative support.
There are several limitations for this review: there
were variations in the therapy offered, some ESPs were
treated with TF-CBT, others with EMDR and a third
group with a combination of TF-CBT and EMDR. It
is not therefore possible to say if one model was more
effective. Twenty-four trauma therapists were engaged
in providing the support, and, while each adhered to
the TF-CBT or EMDR protocols, there are inherent
differences in the personal styles and approaches to the
trauma therapy. However, as has been demonstrated,
the most signicant factor in therapeutic effectiveness
is the nature of the relationship rather than the thera-
peutic model [29]. It is also acknowledged that the
review relied on self-report questionnaires; however,
there was some anchoring, with each of the ESPs re-
ferred being seen by a psychologist qualied to under-
take a trauma assessment to increase the reliability of
the formulation.
Despite its limitations, the programme was valued by
ESPs and their organizations for providing timely sup-
port to ESPs experiencing symptoms of trauma. The
trauma therapists found it rewarding to be involved in
providing trauma therapy, particularly the opportunity
to be able to provide suggestions to assist rehabilitation.
OHPs appreciated the additional information and sup-
port provided by the programme’s psychologists and
therapists which they saw as enhancing the services they
were able to provide.
Competing interests
None declared.
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Medicine, 2017.
SOM annual photo competition
SOM has launched its photo competition again to cele-
brate what OH looks like. We want to use the photos to
visually show what OH is and to bring to life what our
members and wider OH community do across all of our
comms channels including our website, eNews, LinkedIn,
blogs and Twitter prole. Our ambition is that the photos
will give people working in OH a sense of pride when they
look at them and give others a better understanding of
what OH is. The two winning photos will be displayed on
our annual report, on our website and eNews. Enter by
emailing Ann.Caluori@som.org.uk. Judges of senior OH
professionals will agree on a shortlist. Deadline: 30April.
doi:10.1093/occmed/kqaa027
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