Nothing in his 22 years as a railwayman had prepared Geoff Howell for his gruesome discovery when he was called out one night to secure the scene of a suicide in a railway cutting near the racecourse in Albury’s northern suburbs.
By the light of his torch, the assistant station master picked out a severed hand, then a foot, then other mangled body parts. The woman who had thrown herself onto the tracks in front of the XPT Sydney-Melbourne express that summer night in 1992 had been chopped into 42 pieces.
It didn’t help that a woman had earlier telephoned the Albury station to ask whether the XPT was on time. Nor that before he went to the cutting someone had told him that a garbage bin was needed at the scene, not an ambulance.
Geoff Howell did receive counselling to help him get over the shock – two telephone calls from a psychologist working for the State Rail Authority (SRA). By the time he sought proper care two months later he was suffering from what one psychologist later described as the worst case of post-traumatic stress disorder (PTSD) he had seen.
Howell displayed the classic symptoms. He became insecure, socially isolated, aggressive and angry; his relationship with his de facto wife broke up, and he became estranged from friends and family; he began drinking heavily; he lost his job and became unemployable; and then, on several occasions, he was admitted to hospital after attempting suicide. Three years later, in spite of the drugs he was taking and the psychologists he is still seeing almost weekly, a doctor who examined him said he was “the epitome of misery”.
Last month that horrific night had a second sequel, in the Supreme Court in Albury, when Howell, now aged 43, was awarded $750,000 damages for the psychological damage he suffered that night – and the failure of the SRA to provide him with adequate counselling to try to prevent it. His disorder, said a judge, was “materially contributed to by the omission … to properly debrief and counsel [Howell] after the trauma.”
For Howell – whose colleague at the station hanged himself the day his own trial for compensation over the same tragedy was due to begin – is was a pyrrhic victory because the evidence was he would never recover. “I was dumped,” he said. “No amount of money will make everything rosy, put it all back together.”
The verdict is still sending shock waves through Australia’s corporate and government sectors – and not just for the extraordinary amount of the damages. His lawyer, John Gunson of the Alburn firm Gibney and Gunson, says it was the first case in Australia in which an employer was held liable for failure to effectively debrief after a traumatic incident. Underlining its importance, the SRA poured hundreds of thousands of dollars into the test case, fighting two trials and two appeals, one to the High Court.
Even more dramatically, it has focused a spotlight not just on the ineffectiveness of the treatment offered Howell, but on the validity of the therapy itself. Overwhelmingly, the evidence from studies around the world is that debriefing is at best worthless, and at worst may actually increase the likelihood of people developing PTSD. ……. “IT is the RSI of the 1990s,” says an eminent Sydney silk, who for obvious reasons did not want to be identified. “It is getting right over the top, it is costing tens of millions, and it lends itself to total fraud: no other way to describe it.”
RSI, that other awkward acronym, is repetitive stress injury, a painful condition affecting the fingers, hands or arms mainly of people who work at keyboards all day. It swept Australia like an epidemic in the 1980s, resulting in thousands of victims lodging compensation claims before it disappeared as mysteriously as it arrived. No other country has seen anything like it.
PTSD, on the other hand, is a worldwide phenomenon. Its grandfather is the “shell shock” suffered by troops in World War I. It first emerged in substantial numbers among United States troops returning from the horrors of the Vietnam War, and in 1980 it officially became a disease when it was defined in “DSM-III,” the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, which is the practitioners’ Bible.
Since then, it has been cutting swathes through Australia’s defence forces – most sensationally among survivors of the collision between HMAS Melbourne and HMAS Voyager while on naval exercises off NSW in 1964, in which 82 lives were lost. So far 220 of the 232 survivors from Voyager – the ship that sank – have received compensation, totalling $45 million, for the physical and mental disorders they claim they suffered as a result, according to lawyers associated with the cases.
Now, with the award last year of damages believed to exceed $1 million to William McLean, the first man from HMAS Melbourne to win a case – he successfully argued that PTSD caused him to drink heavily, gamble and smoke, shortening his life – lawyers are advertising for clients, and the Government is alarmed that up to 800 more claims from Melbourne survivors are about to come flooding in.
Says the barrister quoted earlier: “In the last eight or nine years claims have been pouring in from personnel up to the rank of lieutenant-commander – these are peacetime psychological casualties on a scale that we have never seen before in Australian military history, including on the western front in World War I.
“I am afraid to say that what we are really seeing is a compensation syndrome. As soon as word got around that there was $150,000 or $200,000 in it, suddenly people discovered that they had it [PTSD] and started lodging claims.”
And the military casualties are only the tip of the iceberg. In NSW “mental disorder” – of which a large part is PTSD – is the fastest-growing category of complaint for which workers’ compensation is claimed. According to WorkCover NSW, “major claims” (involving more than five days off work) quadrupled in the five years 1991-1996: the total compensation payout last year was a staggering $64 million.
Extrapolating these figures nationally, “stress-related illness”, which includes PTSD, is claiming at least 15,000 victims a year. As well as the obvious human tragedy, this is costing private and public-sector employers somewhere between $150 million and $200 million a year – on top of court awards such as Geoff Howell’s, for which no statistics are compiled.
Curiously enough, according to WorkCover data, it is not just the obviously dangerous occupations like the emergency services, road and rail transport and working in prisons that carry the highest risk of psychological trauma. A typical victim profile is a female aged 40 to 44, working as a welfare officer, social, child-care or refuge worker, teacher, TAFE lecturer – or librarian.
And another inexplicable oddity. Trauma counselling is offered to ambulancemen attending road accidents, but usually not the victims; police involved in shootings are counselled, but not the people they shoot; bank employees in armed robberies, but not customers. It is workplace medicine.
In response to this personal and financial toll, post-trauma counselling has boomed in Australia in the past decade. Hundreds of practitioners – from qualified clinical psychologists to self-styled “counsellors” who may have paid as little as $140 for a certificate – are involved in an industry that aims to prevent casualties by early psychological intervention. Trauma counselling costs Australia a rapidly rising $35 million a year, on top of that compensation bill.
One of the most reputable firms involved is the Sydney-based Davidson Trehare, which in 12 years has grown to be probably the largest trauma counselling group in Australia. In NSW alone it has 50 psychologists on its books, and has contracts with the big banks, with large retailers like Coles Myer, and with government employers including Australia Post and the NSW Education Department.
The group aims at having a trained clinical psychologist on the job within 60 minutes of receiving a call – for instance, after a bank robbery, an industrial accident, or an assault on a schoolteacher. The “debriefing” may take from 30 to 90 minutes, says spokesperson Dr Louise Morrow, and costs the employer something under $148 an hour, the recommended fee for a psychological consultation.
The range of experiences that require counselling raises the vexed issue of what exactly constitutes trauma, which varies according to the individual. There was much mockery last year, for instance, when it was reported that British Broadcasting Corporation employees covering the funeral of Princess Diana were given post-traumatic stress debriefing.
One of the strangest examples I came across researching this story was that of a Sydney high school acting principal who received a written directive a week after the Jakarta riots to counsel students of Indonesian background who may have been upset by the TV coverage. What puzzled her was that she was told to counsel only the fee-paying students; those kids who didn’t pay could presumably get better on their own.
Psychologists talk of employers so concerned about claims they call in trauma counsellors if “someone falls down a couple of stairs”. Schools may shut down for the day for mass debriefings if a student dies, and banks may close for a day’s “stress leave” after a robbery. An Australian authority on trauma, Dr Richard Bryant, says he refereed out of existence a paper submitted for publication in a psychological journal urging trauma debriefing for every woman who has a baby.
“Having sat through two of my own wife’s births I have no doubt it is highly stressful,” says Bryant, senior lecturer in psychology at the University of NSW and a leading critic of debriefing, “but to say that it leads to psychological illness is absurd. It’s an example of debriefing gone crazy.” ….. THE method mainly used goes by another acronym, CISD, which stands for critical incident stress debriefing. It was developed in the United States by a former volunteer fire-fighter and paramedic named Jeffrey Mitchell, who now travels the world proselytising on the benefits of “debriefing” people who witness or experience life-threatening situations like fires, accidents and natural disasters.
It is common ground that some people who go through ordeals like these will suffer what Dr Simon Wessely, professor of psychiatry at King’s College, London, and a world authority on post-traumatic stress calls “significant psychological morbidity.” He calculates the risk at 30-40 pc of people involved in a “massive disaster” down to 11 pc of people in a traffic accident.
But, since most of these people will recover by themselves, thanks to the mind’s natural healing mechanisms, the controversy raging in psychological circles is what — if anything — should be offered by way of mass psychological counselling.
The seven-point “Mitchell model” which is the basis for debriefing protocols in Australia and around the world involves getting the victims together, encouraging them to talk about what they have seen and felt, and warning them of the possible after-effects like flashbacks, sleeplessness, anxiety, “emotional numbness” and so on.
Sounds like good old-fashioned common-sense. Says Robyn Robinson, a leading advocate of trauma counselling and clinical director of the Victorian Ambulance Counselling Unit which offers a 24-hour hotline to distressed ambulance-workers: “The days when people used to go down the pub to try and deal with it, or keep it bottled up inside them (are gone). This is a healthier way to deal with (trauma).”
Unfortunately, her opinion is not supported by the evidence. Every rigorous scientific study conducted in recent years — and there are now about a dozen in the international medical literature — shows conclusively that the CISD method does not work in preventing post-traumatic stress disorder, and may in some cases make it worse.
Doubts were first raised in Australia in 1992 with the publication of a hefty 107-page study on the effects of debriefing on emergency personnel involved in Australia’s two most horrific bus crashes, which happened on the Pacific Highway near Kempsey and Grafton in 1989, and which killed 56 people and injured 64.
Researchers tracked down 285 of the police, ambulance, hospital, Salvation Army and other personnel, two thirds of whom had been given post-traumatic stress debriefing, who had been involved in the two operations and assessed them a month, three months, and 12 months after the accidents.
The study found that all the emergency workers had “a high level of distress and psychiatric morbidity,” with many people leaving their jobs, some going on “stress leave,” one committing suicide and one attempting suicide. But the key finding was that one year after the accidents there was a “significantly higher level” of symptoms among those who received debriefing, compared with those who did not.
The researchers reported: “Several of the Grafton Hospital personnel commented that their debriefing was ineffective and inappropriate (particularly with the use of alcohol to “assist” in debriefing) with the event being referred to derogatively as “the do”… one staff member cited the debriefing as being the most distressing aspect of the accident.”
The explanation for this paradox is not fully understood. Prof Wessely believes that reliving the event — which people are encouraged to do during debriefing — may expose people to “secondary trauma.” He also theorises that debriefing may “medicalise” normal stress and “by increasing awareness of psychological distress may paradoxically induce that distress in those who would not otherwise have developed it.”
Whatever the reasoning, the evidence is clear. Emergency workers involved in the 1983 Ash Wednesday bushfires did not do any better if they were given debriefing. Assessing the 1994 NSW bushfires, Dr Bryant says in a forthcoming book that approaches by “well-meaning therapists … resulted in hostile responses from fire-fighters, and placed additional stress upon individuals who were attempting to deal with the acute stages of an intense trauma.”
In 1989, Dr Justin Kenardy was lecturing in psychology at Newcastle University when a major earthquake hit, causing 13 deaths and over $1 billion-worth of damage. He was ideally-placed to put together a team of psychologists to study the effectiveness of debriefing, which was offered to many of the disaster workers.
“We expected to find at least some benefit,” says Dr Kenardy. But after examining 195 of the workers over two years “we were knocked off our feet to find no evidence at all that it helps (in preventing PTSD). Other studies show people may actually get worse — just wait till the lawyers get hold of that.”
Study after study has come to the same conclusion — British Army grave-diggers in the Gulf War, hospitalised victims of road accidents, assault, burns and dog-bites, women who have miscarriages … none of them was less likely to suffer from psychological disturbance if given trauma counselling. Some got worse.
Prof Wessely was so alarmed by these findings when he assessed six major studies late last year that he took the radical step of recommending that debriefing of trauma victims should stop.
Dr Bryant supports this view. He says that mass debriefing is “overkill and overservicing. …if critical incident stress debriefing is being claimed to prevent PTSD then it is a total waste of time and it should cease. It may have an affect on morale, it may make people feel better, but it does not prevent the disorder, and in fact may delay its diagnosis and make it worse.”
At a free post-traumatic stress clinic he heads at Westmead Hospital, he is working on an assessment system which would enable psychologists to identify those people who are genuinely at risk. They would be given, not a one-off debriefing but a programme of “cognitive behaviour therapy” involving five intensive sessions, plus “homework,” which Dr Bryant has shown can prevent post-traumatic stress disorder in 85 pc of patients.
Other Australian critics of debriefing include two of the country’s most eminent psychiatrists: Dr A.C. “Sandy” McFarlane, professor of psychiatry at Adelaide University and president-elect of the International Society for Traumatic Stress Studies ; and Dr Beverley Raphael, former professor of psychiatry at Queensland University, who is the NSW Director of Mental Health.
……. “I’d like to see you get that past the unions,” says trauma counsellor Dr Louise Morrow, when told of the growing movement to abolish her speciality ,”There would be an almighty hoo-hah if any organisation withdrew this service.”
And that, of course, is the problem. An alliance has formed between employees (who now see trauma counselling as a workplace right), employers (who see it as a way to reduce their massive compensation payouts) and counsellors (who make a handsome living from it) to ignore the overwhelming evidence that counselling doesn’t work.
Take Snr Sgt Ian Borland. One night 11 years ago he and his patrol partner were called out to deal with a man who turned out to be a paranoid schitzophrenic — after a high-speed chase near Bathurst, the man produced a .303 rifle and pumped 10 rounds into Borland’s colleague, killing him, and seven rounds into Borland.
Borland was in hospital for three months with massive physical injuries – but the psychological legacy of the shoot-out was to prove even more intractable.
In spite of consulting a “useless” police psychiatrist, Borland’s life was “sheer hell” for two years afterwards — he couldn’t sleep for more than an hour at a time, he lost his appetite, he lost his drive, he was irritable and “became teary at the drop of a hat.” The symptoms lasted, he says, until he met Dr Roger Solomon, the Washington State police psychologist, at a conference, and had two debriefing sessions with him — after which he recovered.
Sgt Borland’s complaint is not that debriefing doesn’t work — but that he wasn’t offered Mitchell model CISD, which he passionately believes does. As a result of a submission put together by Sgt Borland and other Police Association officials, the NSW Police Service has put in place a network of “peer support officers,” of whom Borland is one, and psychologists to debrief officers after traumas such as attending road accidents, suicide and homicide.
The association is now campaigning for the police to hire “outside” psychologists for trauma counselling. “As far as I am concerned, funding for this should be a bottomless pit,” says Borland “In fact it would save the police money because people would not have to exit on medical grounds in the numbers they do now, nor would they have the same compensation claims.”
On the employers’ side of the fence, Dick Perkins, NSW general manager of the Commonwealth Bank, is also unimpressed with the evidence. The Commonwealth has a contract with Davidson Trehare to provide trauma counselling, typically after a hold-up at one of the bank’s 450 branches — although he won’t say how often the counsellors are called in, nor will he point to any evidence that counselling works.
“That’s not my practical experience,” he says, when the scientific studies are pointed out “I am convinced it works … even though, of course, we get some employees who are not able to return to the workplace even after extensive counselling and support.”
As for Dr Morrow, she says the banks have a 60 pc reduction in employee stress-leave if they use counselling.”I don’t feel threatened. I see the benefits our clients receive. They recover more quickly and they are back in the workplace, back to a normal routine (if they are debriefed). If I thought it was doing any harm I would not be in it.”
All of which, of course, is irrelevant to Geoff Howell. His psychiatric illness went undiagnosed and untreated for so long that it is now deemed to be incurable.”I don’t have the answer,” he says ,”But I don’t think State Rail should just dump people like they did me.”
Pub date: Saturday 13 June 1998
Word count: 3391
Classification: Science Social Sciences/Psychology/Counselling Science/Psychology/Counselling
Geographic area: Australia NSW
1. Traumatic tasks…
2. Research found no sign that Newcastle earthquake rescue workers, benefited from debriefing.
3. In addition to disasters such as Thredbo, counselling often follows bank or shop robberies, assaults on teachers and industrial accidents.