Many people working or volunteering in trauma-exposed roles feel ambivalent about accessing support, and so it helps if they feel you know something about the job they do and the challenges they face.

This doesn’t need to be a comprehensive understanding of the organisational structure, role and type of incidents they attend. However, it is a sign of respect, and will help with making a supportive relationship, if to try to understand their work role and context. Use this site to familiarise yourself with their role, be curious, ask questions (especially if you don’t understand the jargon they use) and be aware of the other support services available to staff and their families.

In return, you’ll find they value your professional expertise and are usually motivated to engage in psychological treatment which makes working with them very rewarding.  

The language we use matters. It is a way of reducing stigma by normalising the fact that some occupational roles involve exposure to psychological hazards while retaining hope for recovery. As we say in the Lifelines 10 Essentials, there is a risk of psychological injury, but it isn't inevitable, and, when it happens, these psychological injuries can heal.

Providing psychoeducation is super important, both about mental health and wellbeing and about the things that usually protect them at work. People are often bewildered and ashamed of how they’re feeling, so a key task is to help them understand why they’re feeling as they are.

If you understand how their Protective Armour works, then you can help them make sense of what it is about this incident, or this time, that is has made it hard for them to bounce back. And you can help them regain their resilience.

Most people show remarkable resilience in the face of adversity and exposure to potentially traumatic events, whether this happens in their work or personal lives. When someone does get injured, our task as helpers is to do what we can to restore and enhance resilience.

This is even more important when that injury happens in the work context. Familiarise yourself and encourage them to look at the information on the Why I’m OK most of the time? section, so that together you can understand what normally protects and keeps them well.

Perhaps the thing that has made the difference to their ability to cope comes from a change in their circumstances outside work or volunteering, e.g. not being able to exercise as much, because of an injury or caring responsibilities.

Always make sure they’ve got more tools than exercise in their self-care box

Stigma, and in particular self-stigma, is still a big problem for people who work or volunteering role is to protect and help others. Being strong, a fixer or coper, is often a big part of how they see themselves, and how they’re viewed by others.

When they get psychologically injured and become unwell, the shame and confusion they feel about this happening is often as big an issue as the injury itself. For some it is the main issue, and they can experience a collapse in their sense of identity.  

Remind them that we all have mental health and that no-one is invincible. Show them the films on this site of others  talking about how self-stigma affected them. Encourage them to talk to colleagues if, and when they can.

Use (and persist with!) self-compassion strategies to challenge self-criticism, asking them how they would treat their best mate if they were struggling. How they would talk to them, encourage them, support them.

The same people who found it difficult to ask for help can become passionate about helping others once they’ve benefitted from support. Finding ways to act on this desire to give something back can be an important part of their recovery. However, if the person you're supporting takes on this role, remind them to take care of themselves. It can be hard once they've become a mental health champion to ask for further help if they need it.

For several reasons your client may play down the difficulties they’re having. They often worry that they’re wasting your time or that other people need, or are more deserving, of help. They may feel ashamed or afraid that their career or volunteering role is over.

This means that you may not get the full story of how much they’re struggling. Consider using questionnaires (not least because they give the message that they’re not the only person to feel like this) and ask direct questions about symptoms, especially suicidal thoughts.

The avoidance behaviour which characterises PTSD may not be obvious with clients who seem to continue to “run towards danger” in their role. Watch out and ask about safety behaviours, emotional and cognitive avoidance and numbing, including through alcohol and other substances.

Although PTSD is a common injury following trauma, it is not the only post traumatic injury your client may sustain. They may have post traumatic depression, a traumatic grief reaction, or difficulties unrelated to trauma exposure.

Organisational stress is a common problem and may be what's causing their mental health difficulties. Or perhaps they're under stress in their personal lives and this is why they're unwell. As well as affecting their mental health, these things may reduce their resilience as they face potentially traumatic events at work, making chinks in their protective armour.  

Like any of us, some clients will have experiences of trauma and adversity in their personal rather than their work or volunteering lives, and this may be what they need your help with.

Volunteer responders tell us that the thing that causes them most stress is how their role can impact on their family and work lives. They can feel guilty at leaving a child's football match to respond to an incident or for not responding with their team because of family or work commitments. Remember many volunteer responders are juggling a 3 way balance between work, family and responding, plus they're still dealing with all the everyday challenges of life.

So, don't assume that because your client works or volunteers in a trauma-exposed role then they must have PTSD. Do your assessment carefully and match your intervention to this.

When someone does have PTSD, lots of things can get in the way of doing trauma-focused work. You may need to address depressive symptoms or feelings of shame first. Or you may find your client tends to minimise their difficulties and/or disengages when they’re feeling a bit better, before you've done the trauma work.

‍It can be hard to focus on trauma work when your client is feeling angry, misunderstood, or let down by the service, and wants to focus on this. While these organisational stressors are important and should be addressed, don’t let them distract you from doing trauma-focused treatment when it’s needed. Untreated PTSD is likely to be aggravating these stressors, and the person’s ability to cope with them.  

It may be difficult to treat and resolve PTSD in the context of a return to operational duties. The prospect of a return to work and further trauma exposure can maintain and compound PTSD symptoms for some. This needs to be assessed carefully and discussed with the client and occupational health colleagues (see below).

If trauma work is put on hold because someone is going through the ill health retirement process then it is important to revisit the trauma processing work once a decision is reached to address and treat the residual symptoms of PTSD.

Volunteers
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‍For those who volunteer, PTSD symptoms may be hidden behind feelings of shame or depressive symptoms and things can be complicated by the impact of an injury in their volunteer role on their paid employment. They may decide that the best solution is to stop being a volunteer responder.

Watch out for when this decision to stop is driven by avoidance of exposure to trauma reminders. Encourage them to engage in trauma-focused treatment when it’s needed, because we know that untreated PTSD will have a negative impact on life beyond their volunteering role.

If you are providing a service under a contract, then you should be clear about how and what you communicate with the organisation.

If you are working independently from the organisation, there may be times when you’re asked by your client to contact it, for example, to request an adjustment to their duties. Your client may give consent for you to talk directly with their manager, but you should be cautious about this. It is usually best to share information through the clinical staff working in the occupational health department. Their expertise is in providing medical advice to the service and managers, based on discussions with GPs and other professionals.

If your client is unable to return to work, they may be referred for consideration of ill health retirement. Your letters/reports will be shared with the Doctor (Independently Qualified Medical Practitioner) who makes this assessment.

Often, yes although they may take a break from their role while they are receiving support/treatment. Continuing in their paid or unpaid role and being with colleagues may be what sustains them through a period of psychological ill health or the thing that completes their recovery.

People are likely to feel a range of emotions if they are unable to continue in their role because of ill health. Especially if the injury is psychological. Any relief is likely to be tempered with sadness, disappointment or perhaps shame. Acknowledge the loss of leaving through injury and where possible encourage them to think about how they can celebrate their service with colleagues and family. Help them think about what else they can do to get the sense of civic service and camaraderie that is so important to many responders.
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The ill health retirement process
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If your client is unable to return to work, they may be referred for consideration of ill health retirement and assessed by a Doctor (Independently Qualified Medical Practitioner). Part of the IQMP’s role is to establish whether:

Bear this in mind when you are providing reports and, where appropriate, address these issues directly.

The ill health retirement process can take several months and is often the source of considerable stress and distress for the individual, especially when it is part of an absence management procedure. Try to help them understand that however personal it feels, the reason the process is so rigorous is to prevent and protect people against unfair dismissal on the grounds of ill health.