DBA Ltd., York, Manchester and Newcastle

1. Treatment of occupational trauma on the rail network or “Psychiatry owes a lot to British Rail”The European History of Psychotraumatology, Weisæth L., 2002Journal of Traumatic Stress 15:6 443-52 DBA Ltd., York, Manchester and Newcastle David Blore – Consultant Psychotherapist Researcher Birmingham University Visiting Lecturer Teesside University ARIOPS Conference, National Railway Museum, York – 17.10.11

2. Agenda • Railway trauma – a history • Attitudes to psychological healthcare – a history • Accepted interventions for psychological trauma from high voltage to high tech • The 21st century reality of railway trauma • 2005 NICE report recommendations • As applied to the NHS • As applied to TOCs • EMDR • What is it and how does it work? • 2010-11 Audit

3. 19th century railway trauma William Huskisson MP for Liverpool on 15th September 1830… …was the first person to be killed by a train in motion, when, at the opening of the Liverpool and Manchester Railway whilst crossing the tracks to greet the Duke of Wellington, he was hit by Stephenson’s ‘Rocket’ passing in the opposite direction. Huskisson, his left leg crushed, was taken by train, driven by Stephenson himself, to Eccles where Huskisson died a few hours later.

4. 19th century railway trauma The Staplehurst rail crash 9th June 1865… …resulted in 10 passenger deaths and 40 injured. It is remembered particularly for its effects on the author Charles Dickens, who was travelling as a passenger in a front, first class carriage of a ‘boat train’ with his companions Ellen Ternan and her mother.

5. 19th century perspective onrailway trauma • Largest civil engineering project • Railways are dangerous > speed kills • All injuries considered to be due to physical damage • Post mortems confirmed this • Including “Spinal concussion” (whiplash) • Survivors also ‘damaged’ but appeared to have no physical damage > cause? • Almost certain that this is the origin of ‘spineless’ • Early but derogatory description of psychological problems?

6. 19th to 21st century psychological trauma milestones • Pre WWII: • No agreed formulation of psychological trauma • In fact denial and ‘Lacking Moral Fibre’ • Pre 1977: • No Health and Safety at Work Act • Lots of compensation cases though especially 19th century! • Pre 1980 context (apart from a short period in 1950’s early 1960’s): • No recognised diagnosis for psychological ‘damage’ • 1980 Post Traumatic Stress Disorder becomes a diagnosis • 1987 Accidental discovery of EMDR • 1998 Cahill & McGaugh devise the Reconsolidation of Memory theory • 1999 NICE formed - focus on evidence-based practice • 2003 SOVRN reort • 2005 NICE report on PTSD issued

7. Progress in understanding how the brain processes traumatic information and effective interventions to accelerate that process Increase in knowledge stems from two sources: 1 Ongoing neurophysiological research 2 The ‘battle’ to convince/refute EMDR as a legitimate intervention March 2005 NICE ‘truce’ Start of recorded history 1989 2005 2011

8. Accepted pre 1989 interventions for psychological trauma (any causation) • Psychoanalysis • “…brutal forms of electrical therapy…” • ‘Causal will’ therapy • Group psychotherapy • Therapeutic community milieu therapy • Hypnosis • Psychodynamic psychotherapy • Supportive counselling • Client centred counselling • Critical incident debriefing • Psychological debriefing • Nerolinguistic reprogramming (NLP) • Gestalt therapy • Medication Therapies ranged from: “Torture” and ‘totally ineffective’, to ‘vaguely effective’ Which was used was regarded as the domain of: Fashion, politics, personal preference or “sheer guesswork”

9. Accepted 1989 – 2005 interventions for psychological trauma (any causation) • Psychoanalysis • “…brutal forms of electrical therapy…” • ‘Causal will’ therapy • Group psychotherapy • Therapeutic community milieu therapy • Hypnosis • Psychodynamic psychotherapy • Supportive counselling • Client centred counselling • Critical incident debriefing • Psychological debriefing • Nerolinguistic reprogramming (NLP) • Gestalt therapy • Medication • Trauma-focussed Cognitive Behavioural therapy (tfCBT) • Eye Movement Desensitisation & Reprocessing (EMDR Therapies ranged from: ‘Vaguely effective’ to ‘Effective’ Which was used was regarded as the domain of: BR CoCaS directive (mid 1990s) and especially post SOVRN report (2003) which recommended ‘counselling’

10. Accepted post-2005 interventions for psychological trauma (any causation) • Psychoanalysis • “…brutal forms of electrical therapy…” • ‘Causal will’ therapy • Group psychotherapy • Therapeutic community milieu therapy • Hypnosis • Psychodynamic psychotherapy • Supportive counselling • Client centred counselling • Critical incident debriefing • Psychological debriefing • Nerolinguistic reprogramming (NLP) • Gestalt therapy • Medication • Trauma-focussed Cognitive Behavioural therapy (tfCBT) • Eye Movement Desensitisation & Reprocessing (EMDR Therapies now: ‘State of the art effective’ Which was used is regarded as the domain of: Research evidence (March 2005), client tolerance of intervention, long term effectiveness

11. The 21st century reality(based on 2010-11 audit of incoming referrals to DBA Ltd.) • Fatalities (31.6% of referrals, about 12% of UK total of fatalities) Around 200 people per year commit suicide on the UK railways (this compares with 6000 in Japan) • Assaults (26.3% of referrals) This includes physical and verbal assaults as well as spitting incidents • Non-work traumatic events, impinging on work (14.4% of referrals)

12. Less frequent reasons for referral • SPADs • Cat A • Signal reversions • Wrong possession • Near misses • Derailments • Adhesion problems • Impact with unidentified objects • Level crossing gates left open • Siderodromophobia • Robbery at work • Crushed at work (overcrowded trains) • Trapped at work (accidental lock-in) • Being stalked at work • Giving first aid at work • Post customer complaint trauma

13. NHS application of the 2005 ‘NICE’ guidelines Event (day 0) 10-14 days post event tfCBT or EMDR Discharge 28 day assessment No treatment required

14. TOCs: “Rolls Royce” application of the 2005 NICE guidelines HR & Board > formulation of policy Event Managers mandatory training (TATs) Psych 1st Aid (DARE) 10-14 day assessment Audit ASD: improving or deteriorating/n.c.? EMDR or EMDR/tfCBT Advice on sustaining R2W 28 day (if needed) reassess No treatment required

15. ASD PTSD Acute Chronic Delayed onset Adjustment Disorder DARE Disbelief/Denial Automatic behaviours Reduction in awareness Emotions ASD ASD PTSD Acute Chronic Delayed onset DSM IV TR ‘Extensions’ to DSM IV TR

16. So what is EMDR?Information on EMDR can be obtained from www.davidblore.co.uk click on What is EMDR? • Stems from an accidental discovery that there is a mathematical relationship between presentation of traumatic memories to the conscious awareness AND • Engaging in a visual task that compromises the working memory’s ability to retain the affective component of a visual memory • Demonstration needed to explain? - OK but don’t ‘have a go’ later!

17. So how does EMDR work?Information on EMDR can be obtained from www.davidblore.co.uk click on What is EMDR? • Thought to be similar to REM sleep responsible for the: • Why-do-older-people-recall-the-good-old-days? phenomenon • EMDR certainly mimics a natural process of erasing affect over time – but significantly speeded up, therefore: • No side effects of the treatment process itself • However, speeding anything up comes at a cost, therefore significant emphasis on post treatment safety. Details can also be found online at: • www.davidblore.co.uk click on ‘Advice after EMDR’

18. “I’ll always have that memory” • A very common phrase • Assumed to be correct • Yet can’t be because of long term effects of REM sleep • Now thought that memory permanency is under the executive control of the visiospatial sketchpad portion of the working memory as per…

19. Cahill & McGaugh’s (1998) Reconsolidation of Memory Theory Stimulus/ experience e.g. fatality whilst driving train EMDR thought to compromise the effects of this stage Influences memory storage Interpretation of meaning Long term function Cognitive/ emotional response Autonomic stress hormone response Short term function Influences immediate coping behaviour

20. EMDR treatment notes relating to railway trauma • Treatment always uses a ‘dry run’ - very quick way of covering large range of explanations and experience of treatment • NCs most important “I’m not in control” in over 90% of cases (direct contradiction to training: “You will always be in control of your train”) • Targets worked out beforehand and comprising one of two most common protocols (EMDR treatment modes): • RETP ‘frame by frame’ approach • B2T non disclosure approach • Most common targets: • First sight of problem/ person on tracks/ strange behaviours • Eye contact • Impact/ noise or vibration under train • Seeing body/ immediate aftermath/ disgust (most common in spitting incidents) • Coroner’s Court

21. EMDR treatment notes relating to railway trauma • Assessment will help divide potential treatment application into: ‘brief’; ‘single memory’; ‘full treatment’ – this helps organise different length sessions ranging from one to two hours • IESR/ HADS taken every session • Future templates incorporate a R2W plan. R2W plan incorporated in discharge letter and must be present at BUPA when they assess for SCW – ‘the ‘resumption medical’ • Psychological reasons for not recommending a R2SCW include: even slight problems with concentration; and sleep problems; if sleep is not restful; intrusive imagery • R2W plans aimed at sustaining R2W usually includes R2W on full hours immediately – least reorganisation of working day routine • Dedicated contact system with managers to identify subsequent R2W problems quickly

22. Outcomes: 2010-2011 audit • Average no. EMDR sessions for closed cases (54 out of 76 referrals) attending at least 2 sessions (minimum length of treatment and excluding all assessment only referrals) = 4.95 • Average reduction in IESR 94.7% • Total R2W 96.8% • Subsequent absence? None at all = 64.5% • Subsequent absence? Yes = 24.2% (unrelated to reason for referral) • Subsequent absence? Yes, related to reason for referral = 8.1% • (The above figures do not add up to 100% because of movement of labour and/or missing data)

23. Thank you for listeningAny questions? 24 hour voicemail: 07976 933096 Website: www.davidblore.co.uk Email: help@davidblore.co.uk