- Email: [email protected]
Mental first aid
Soc. Sci. Med. Vol. 38, No. 3, pp. 479-482, 1994 PrintedimGreat Britain.All rights reserved
0277-9536/94$6.00+ 0.00 Copyright © 1994PergamonPress Ltd
MENTAL FIRST AID 0. T. Foss* Norwegian Directorate of Health, Department of Preventive Services, P.O. Box 8128 Dep., N-0032 Oslo, Norway Al~traet--This paper reports a survey of staff of Oslo Sporveierwho had been involved in serious incidents such as accidents resulting in severe personal injuries and death, suicide, robbery and assault. The survey was carried out to evaluate the efficacy of Mental First Aid in a retrospective study. The introduction of Mental First Aid was based on the beneficialeffects from early intervention reported from follow-up studies after previous disasters, so for ethical reasons there was no control group. When help was given within the first few days without the use of any external specialists, and with strong support from colleagues during the first days back at work, there was little absenteeism. The beneficialeffects of early intervention are stressed as is the use of non-professionals in forming a social network around employees who have been involved in traumatic incidents. Safety ombudsmen who have been given brief instruction are brought to the site of the incident to apply the principles of Mental First Aid. These secondary preventive measures are very effective and could be implemented by other medium-sized transport companies whose staff are exposed to the risk of suicide attempts. Key words--suicide, preventive measures, effects on staff
INTRODUCTION
During the last 15 yr the development of Disaster Psychiatry has been extensive in Norway. Experience from industrial disasters (e.g. Jotun, Sandefjord, 1976), disasters at sea (oil rig Alexander Kielland, North Sea, 1980), natural disasters (Vassdalen, 16 soldiers killed by avalanche, 1986) and transport disasters (Scandinavian Star, 1990) has led to an increasing awareness of post-traumatic stress reactions and the benefits of early intervention. However, for every front-page disaster there are hundreds of events at work, in public places and in the private sphere that have disastrous consequences for one or just a few people at a time. Only a minority of such persons come into contact with specialist disaster psychiatrists. The results from the survey presented here suggest that this absence of specialist intervention can be an advantage for the persons involved if the simple principles of early intervention (e.g. Mental First Aid) are implemented. Mental First Aid (MFA) was established as a service to the staff of Oslo Sporveier in 1984. The term 'psychiatric' was deliberately avoided in order to emphasise that many of the reactions commonly experienced following severe emotional traumas are normal. To many people, however, the suggestion of a referral to a psychiatrist implies their having a mental illness. When a driver is told that it is normal to re-experience a suicide situation during the day and/or during the night as a nightmare, and that it is not a sign of him becoming insane, this enables him to cope better. The result is further improved if the *The author was Occupational Health Physician in Oslo Sporveier 1983-1992. SSM 38/3---G
479
person who tells him that this is a normal reaction is a colleague who has previous experience of the same type of event. Oslo Sporveier is the main public transport company in the Norwegian capital. Of a total of 2800 employees there are 1800 who operate the tram-, busand metrolines, mostly drivers. The rates for severe work-related incidences such as suicides, robberies and assaults are low compared with other major cities in Europe, and has enabled the company to intervene on most of the incidents. During the period 1984-87, 50 incidents occurred which involved employees of Oslo Sporveier in severe personal injuries or death (including suicides), robberies or assaults. This led to the implementation of M F A given by the Occupational Health Physician. A questionnaire survey was carried out in 1987. With the experience gained from this survey the focus has shifted from routinely referring the involved person to the Occupational Health Physician to the use of safety ombudsmen as first line helpers at the site of the event. The most recent improvement was the establishment of a self-support group for those drivers who have had fatal incidents (mostly suicides).
MATERIALS AND METHODS
A questionnaire was sent to the employee's private address with an explanatory letter from the Occupational Health Physician. The questionnaires were given an identification number so that only the Occupational Health Physician knew who had answered, and could fill in information from the medical records for those who did not return it. 50 events were registered for 50 different employees.
480
O.T. Foss
26 employees returned the questionnaire and contributed to the employee's evaluation of the MFA. For these and the remaining 24, the medical records contained information on the traumatic event, time elapsed until contact with the Occupational Health Service (OHS), days off work and whether or not employees returned to their old job. Of the 24 who did not return the questionnaire, 4 had left the company (not directly connected with the event), 1 had died, 2 had retired, 5 probably had difficulties with the language and 1 was involved in a legal action against the company. All of the remaining 11 non-respondents had returned to their old jobs after the event, none being absent for more than 14 days (5 were not absent at all). A plausible explanation for why some of them did not answer is that they did not consider their event being sufficiently dramatic to merit talking about. The questionnaire consisted of 22 multiple choice questions. The questionnaires also allowed for answers to individual questions to be explained in more detail and general comments and suggestions about improving M F A in the company were invited. This invitation resulted in many personal and valuable cries from the heart especially from those who had been given poor support at the site of the event and in the period following the incident. In the total material (n = 50) 14% had been involved in an accident which had led to the death or life-long injury of another person, another 46% in accidents which resulted in less severe injury, but still more than an everyday accident; 12% had been involved in accidents that led to extensive material damage without injuries, and 10% had been robbed or assaulted. The last 18% included work accidents, serious close-to-accident situations and so on. In 12% of incidents, the employee had a physical injury according to our medical records, but none died. RESULTS
The mean age, duration of employment and sex ratio of the sample was similar to the entire group of drivers. The age range was 19 to 57 yr with a mean of 32 yr and a median of 31 yr. Drivers had been emloyed by the company for up to 20 yr, with a mean of 6 yr. 24% had served for less than 2 yr. 36% were females with a mean age of 34 yr and 64% males with a mean age of 31 yr. Several questions evaluated the help employees were given at the site of the incident. Drivers were asked to rank in order of preference 8 categories (or if none of these applied to specify someone else) of persons who they considered to have been most helpful to them at the site of the incident. With a simple scoring of 3 points for first priority, 2 points for second and 1 point for third, the following list emerged: 1. Traffic officer (a company employee who attends all traffic disturbances).
2. 3. 4. 5. 6. 7. 8.
Safety ombudsman. A colleague. Police officer. Someone else; passenger, passing pedestrian etc. Ambulance personnel. Fireman/rescue personnel. Someone from the OHS.
When analysed by sex, the prioritisation was slightly different with females ranking 'someone else', traffic officer and police officer as the first three. The males gave a top three prioritisation of safety ombudsman, a colleague and a traffic officer. To correct for the fact that not all the above-mentioned groups were present at all the sites, an additional question was posed: "Did you miss any of the following groups of personnel who, in your opinion, could have given you better help at the site of the incident?". The following ranking list emerged: 1. None (i.e. did not miss any). 2. Traffic officer. 3. Safety ombudsman and someone from OHS. 50% replied that they did not miss the attendance of any of the listed groups. A police officer was missed by one person, none answered positively for the need of alternatives~disaster psychiatrist, fireman/rescue personnel, plain or physician-manned ambulance, a colleague or 'someone else'. A second group of questions concentrated on time elapsed from the incident until M F A was given, length of work absenteeism, secondary causes of absence and whether the person returned to the same job or temporarily or permanently moved to another job. Where not otherwise indicated, these data were obtained from the medical records for the total material (n = 50). Time elapsed before M F A was split in three categories: 56% had been given M F A by the Occupational Health Physician the same day the incident occurred or the following day, 24% 2-7 days after and 20% more than 1 wk after. 40% were not absent at all (except for the rest of the day of the incident in most of the cases), 24% were absent for 1-3 days; 16% for 4-14 days; 10% for 14 days--3 months and the remaining 10% for more than 3 months or there was insufficient information to classify them. The causes of absenteeism for the 60% that had not returned to work the following day were as follows: in 70% of cases mental trauma, in 10% physical injury and in another 10% a mixture of these two alternatives. 82% returned to the same job they had held at the time of the incident the following day or as soon as they returned to work. An additional 8% had temporarily been in another job, and 10% had permanently been given another job or the situation was unsettled. Long-term effects of the incidents on mental health were identified by the question, "Do you think that
Mental first aid you have any permanent psychic problems due to the incident, and if yes, what kind of problems?" Of the 26 persons who had returned the questionnaire 65% answered positively to this question, and amongst these 60% reported anxiety as a problem. Less frequently reported were sleeping problems or nightmares. None reported an increased consumption of alcohol or tranquillisers. The sample did not have an over-representation of persons with complex psychiatric problems dating from before the incident. In their own opinion (25 answered this question), 72% had prior to the incident a mental health "approximately at the same level as most of my colleagues", 24% "better than the average of my colleagues" and only 1 person (4%) "worse than the average of my colleagues". None answered positively to the statement that they had "major psychiatric problems or were under treatment with a psychiatrist or psychologist". When asked how their mental health was today compared to the time just after the incident, 52% claimed that they were better, 36% unchanged and 12% worse. To evaluate the attitude of employees towards M F A , the following questions were asked: "How do you evaluate the effect of the M F A to your mental health status after the incident?"--none stated that it was negative, 17% said it was indifferent, 46% that they were better, but not completely back to normal, 17% were back to normal (i.e. the situation before the incident) and 21% did not know. "Do you think that it is essential to give M F A in our company?"-was agreed with by all but one of those who answered. The answers to a final question illustrated our huge information problem: "Had you knowledge of the M F A before the incident?" was answered in the affirmative by only 35% of those who returned the questionnaires. DISCUSSION
The most interesting interpretation of the results is achieved by dividing the material into three groups according to the time elapsed from when they were involved in a serious incident until they were formally given M F A by the Occupational Health Physician: Group 1 - - M F A given the same or next day (n = 28):
- - 8 2 % (23/28) were absent for fewer than 4 days - - 8 9 % (25/28) returned to the same job - - 1 2 responders to questionnaire in group 1: - - 7 0 % (7/10) stated that the M F A had been beneficial for them - - 7 3 % (8/11) had a better mental health today than after the incident - - 0% (0/11) had a worse mental health status - - 5 0 % (6/12) had long-term mental problems
481
Group 2 - - M F A given from day 2 up to 1 wk
(n = 12): - - 5 0 % (6/12) were absent for fewer than 4 days - - 7 5 % (9/12) returned to the same job 6 responders to questionnaire in group 2: - - 5 0 % (3/6) stated that the M F A had been beneficial for them - - 3 3 % (2/6) had a better mental health today than after the incident - - 1 7 % (1/6) had a worse mental health status - - 6 7 % (4/6) had long-term mental problems Group 3---MFA given after more than (n = 10):
1 wk
- - 3 0 % (3/10) were absent for fewer than 4 days - - 7 0 % (7/10) returned to the same job 8 responders to questionnaire in group 3: ---63% (5/8) stated that the M F A had been beneficial for them - - 3 8 % (3/8) had a better mental health today than after the incident - - 2 5 % (2/8) had a worse mental health status - - 8 8 % (7/8) had long-term mental problems Since the material is rather limited, a comparison between the groups with regard to one parameter at the time, would not give any statistically significant differences. But when combining the results, it seems evident that the issue of timing is essential. Hence the term Mental "First" Aid. When analysing the results of the enquiries into who were considered to have been most helpful at the site of the incident and if they missed someone, it was found that the 50% who did not miss any particular personnel group felt that they had been best helped by safety ombudsmen and traffic officers. The other 50% who had missed one of the listed personnel groups, had been given most help from policemen, colleagues, passengers and pedestrians. As a result of the two findings mentioned above, an attempt has been made to improve M F A by stressing that it is essential that help is given as soon as possible, preferably within 3 days. Safety ombudsmen attend a half-day course on the principles of M F A . They are in a position to give excellent help since they regularly go to the site of all serious incidents and have the opportunity to immediately make use of the social network within the workplace. The resources of the OHS are better utilised when contact is made the day after the incident, since the person has by then usually passed the acute phase of the post-traumatic stress reaction, and can more easily assimilate the information and advice given during the consultation. The evaluation of best help at the site left "someone from OHS" in the bottom priority. This can easily be explained, since the OHS was only at the site
482
0. T. Foss
of the event on two occasions, where by coincidence, one of the OHS nurses was a passenger of a tram that had an accident and another time one was passing the site as a pedestrian. Experience from other disasters in Norway has taught us that the number of cases of post-traumatic stress disorders can be reduced significantly if realistic preparatory exercises are held regularly. The Occupational Health Physician and two safety ombudsmen take part in a group within the Metro Division of the company established to revise and improve emergency plans and routines, including the use of regular exercises to prepare drivers, traffic officers, traffic leaders, information staff and directors for the dramatic events that take place from time to time. To improve on the lack of follow-up of employees who have received M F A after serious incidents, a self-help support group was recently established. In the first instance, those who have experienced suicides and other fatal accidents are invited. The intention is to make even greater use of the supportive social network which for a large part is still intact in our company. To conclude therefore, the simple secondary preventive measures of M F A have been very beneficial and could easily be implemented by other mediumsized transport companies where staff are exposed to the risk of suicide attempts.
ADDENDUM
The basic MFA-principles that the safety ombudsmen in Oslo Sporveier are trained to follow, can briefly be summarised as follows: ----early intervention is essential, try to reach the site of the incident while the driver still is there --since the driver will always feel at least some guilt for the accident, the only thing you are not supposed to do is to enhance this feeling of guilt - - i f you use common sense, offer a hand to hold, a shoulder to lean on, someone to talk to, a companion through the formalities; you are the best help the driver can get just after the incident (the results from the survey presented here are used in the education) - - i f you cannot stay with the driver until family, friends or other colleagues take over, contact the OHS or the psychiatric outdoor clinic for assistance if necessary
- - i f the driver does not express a wish to see a physician or other professionals you should accept it, but always make a personal appointment for follow-up the next day --offer your help to establish contact with the OHS, preferably within the first 3 days, and it is an advantage if you can accompany the driver to the OHS - - t r y to explain what a normal acute stress reaction is like, since a driver who has been told beforehand that he might experience this, is likely to cope better: Fear, fight and flight--reaction immediately or delayed sleep disturbances might occur re-experiencing the incident is common and is probably necessary for a successful outcome of the stress reaction ----crying is acceptable and for many, beneficial, if you can provide a safe shelter --protect the driver from media representives etc. No statements should be given in the acute phase because of the tendency for the driver to be self-critical. He will usually be busy with his own mental inquiry with all kind of questions in the line of "If I just had done this instead of that, this wouldn't have happened" and "Why didn't I do . . . " - - t r y to give objective answers if such questions are posed to you. After all, most of the suicide accidents are unavoidable from the drivers' point of view, and the driver involved is picked by coincidence more than by poor driving abilities or unattendance --prepare the driver for going back to work as soon as possible, offer your assistance and support the first few days if necessary; if the driver knows there is someone to replace him if he gets problems while driving, he is not likely to have problems --inform the driver that tranquillisers or alcohol do not solve any problems with re-experiencing the incidence, sleep disturbances or other thoughts, they only postpone them and sometimes make them worse to deal with later on - - y o u are no more a psychiatrist when you give M F A than you are a surgeon when you give first aid to a person with a bone fracture, but in both cases your initial measures can limit the damage and enhance the possibility of complete cure.
0277-9536/94$6.00+ 0.00 Copyright © 1994PergamonPress Ltd
MENTAL FIRST AID 0. T. Foss* Norwegian Directorate of Health, Department of Preventive Services, P.O. Box 8128 Dep., N-0032 Oslo, Norway Al~traet--This paper reports a survey of staff of Oslo Sporveierwho had been involved in serious incidents such as accidents resulting in severe personal injuries and death, suicide, robbery and assault. The survey was carried out to evaluate the efficacy of Mental First Aid in a retrospective study. The introduction of Mental First Aid was based on the beneficialeffects from early intervention reported from follow-up studies after previous disasters, so for ethical reasons there was no control group. When help was given within the first few days without the use of any external specialists, and with strong support from colleagues during the first days back at work, there was little absenteeism. The beneficialeffects of early intervention are stressed as is the use of non-professionals in forming a social network around employees who have been involved in traumatic incidents. Safety ombudsmen who have been given brief instruction are brought to the site of the incident to apply the principles of Mental First Aid. These secondary preventive measures are very effective and could be implemented by other medium-sized transport companies whose staff are exposed to the risk of suicide attempts. Key words--suicide, preventive measures, effects on staff
INTRODUCTION
During the last 15 yr the development of Disaster Psychiatry has been extensive in Norway. Experience from industrial disasters (e.g. Jotun, Sandefjord, 1976), disasters at sea (oil rig Alexander Kielland, North Sea, 1980), natural disasters (Vassdalen, 16 soldiers killed by avalanche, 1986) and transport disasters (Scandinavian Star, 1990) has led to an increasing awareness of post-traumatic stress reactions and the benefits of early intervention. However, for every front-page disaster there are hundreds of events at work, in public places and in the private sphere that have disastrous consequences for one or just a few people at a time. Only a minority of such persons come into contact with specialist disaster psychiatrists. The results from the survey presented here suggest that this absence of specialist intervention can be an advantage for the persons involved if the simple principles of early intervention (e.g. Mental First Aid) are implemented. Mental First Aid (MFA) was established as a service to the staff of Oslo Sporveier in 1984. The term 'psychiatric' was deliberately avoided in order to emphasise that many of the reactions commonly experienced following severe emotional traumas are normal. To many people, however, the suggestion of a referral to a psychiatrist implies their having a mental illness. When a driver is told that it is normal to re-experience a suicide situation during the day and/or during the night as a nightmare, and that it is not a sign of him becoming insane, this enables him to cope better. The result is further improved if the *The author was Occupational Health Physician in Oslo Sporveier 1983-1992. SSM 38/3---G
479
person who tells him that this is a normal reaction is a colleague who has previous experience of the same type of event. Oslo Sporveier is the main public transport company in the Norwegian capital. Of a total of 2800 employees there are 1800 who operate the tram-, busand metrolines, mostly drivers. The rates for severe work-related incidences such as suicides, robberies and assaults are low compared with other major cities in Europe, and has enabled the company to intervene on most of the incidents. During the period 1984-87, 50 incidents occurred which involved employees of Oslo Sporveier in severe personal injuries or death (including suicides), robberies or assaults. This led to the implementation of M F A given by the Occupational Health Physician. A questionnaire survey was carried out in 1987. With the experience gained from this survey the focus has shifted from routinely referring the involved person to the Occupational Health Physician to the use of safety ombudsmen as first line helpers at the site of the event. The most recent improvement was the establishment of a self-support group for those drivers who have had fatal incidents (mostly suicides).
MATERIALS AND METHODS
A questionnaire was sent to the employee's private address with an explanatory letter from the Occupational Health Physician. The questionnaires were given an identification number so that only the Occupational Health Physician knew who had answered, and could fill in information from the medical records for those who did not return it. 50 events were registered for 50 different employees.
480
O.T. Foss
26 employees returned the questionnaire and contributed to the employee's evaluation of the MFA. For these and the remaining 24, the medical records contained information on the traumatic event, time elapsed until contact with the Occupational Health Service (OHS), days off work and whether or not employees returned to their old job. Of the 24 who did not return the questionnaire, 4 had left the company (not directly connected with the event), 1 had died, 2 had retired, 5 probably had difficulties with the language and 1 was involved in a legal action against the company. All of the remaining 11 non-respondents had returned to their old jobs after the event, none being absent for more than 14 days (5 were not absent at all). A plausible explanation for why some of them did not answer is that they did not consider their event being sufficiently dramatic to merit talking about. The questionnaire consisted of 22 multiple choice questions. The questionnaires also allowed for answers to individual questions to be explained in more detail and general comments and suggestions about improving M F A in the company were invited. This invitation resulted in many personal and valuable cries from the heart especially from those who had been given poor support at the site of the event and in the period following the incident. In the total material (n = 50) 14% had been involved in an accident which had led to the death or life-long injury of another person, another 46% in accidents which resulted in less severe injury, but still more than an everyday accident; 12% had been involved in accidents that led to extensive material damage without injuries, and 10% had been robbed or assaulted. The last 18% included work accidents, serious close-to-accident situations and so on. In 12% of incidents, the employee had a physical injury according to our medical records, but none died. RESULTS
The mean age, duration of employment and sex ratio of the sample was similar to the entire group of drivers. The age range was 19 to 57 yr with a mean of 32 yr and a median of 31 yr. Drivers had been emloyed by the company for up to 20 yr, with a mean of 6 yr. 24% had served for less than 2 yr. 36% were females with a mean age of 34 yr and 64% males with a mean age of 31 yr. Several questions evaluated the help employees were given at the site of the incident. Drivers were asked to rank in order of preference 8 categories (or if none of these applied to specify someone else) of persons who they considered to have been most helpful to them at the site of the incident. With a simple scoring of 3 points for first priority, 2 points for second and 1 point for third, the following list emerged: 1. Traffic officer (a company employee who attends all traffic disturbances).
2. 3. 4. 5. 6. 7. 8.
Safety ombudsman. A colleague. Police officer. Someone else; passenger, passing pedestrian etc. Ambulance personnel. Fireman/rescue personnel. Someone from the OHS.
When analysed by sex, the prioritisation was slightly different with females ranking 'someone else', traffic officer and police officer as the first three. The males gave a top three prioritisation of safety ombudsman, a colleague and a traffic officer. To correct for the fact that not all the above-mentioned groups were present at all the sites, an additional question was posed: "Did you miss any of the following groups of personnel who, in your opinion, could have given you better help at the site of the incident?". The following ranking list emerged: 1. None (i.e. did not miss any). 2. Traffic officer. 3. Safety ombudsman and someone from OHS. 50% replied that they did not miss the attendance of any of the listed groups. A police officer was missed by one person, none answered positively for the need of alternatives~disaster psychiatrist, fireman/rescue personnel, plain or physician-manned ambulance, a colleague or 'someone else'. A second group of questions concentrated on time elapsed from the incident until M F A was given, length of work absenteeism, secondary causes of absence and whether the person returned to the same job or temporarily or permanently moved to another job. Where not otherwise indicated, these data were obtained from the medical records for the total material (n = 50). Time elapsed before M F A was split in three categories: 56% had been given M F A by the Occupational Health Physician the same day the incident occurred or the following day, 24% 2-7 days after and 20% more than 1 wk after. 40% were not absent at all (except for the rest of the day of the incident in most of the cases), 24% were absent for 1-3 days; 16% for 4-14 days; 10% for 14 days--3 months and the remaining 10% for more than 3 months or there was insufficient information to classify them. The causes of absenteeism for the 60% that had not returned to work the following day were as follows: in 70% of cases mental trauma, in 10% physical injury and in another 10% a mixture of these two alternatives. 82% returned to the same job they had held at the time of the incident the following day or as soon as they returned to work. An additional 8% had temporarily been in another job, and 10% had permanently been given another job or the situation was unsettled. Long-term effects of the incidents on mental health were identified by the question, "Do you think that
Mental first aid you have any permanent psychic problems due to the incident, and if yes, what kind of problems?" Of the 26 persons who had returned the questionnaire 65% answered positively to this question, and amongst these 60% reported anxiety as a problem. Less frequently reported were sleeping problems or nightmares. None reported an increased consumption of alcohol or tranquillisers. The sample did not have an over-representation of persons with complex psychiatric problems dating from before the incident. In their own opinion (25 answered this question), 72% had prior to the incident a mental health "approximately at the same level as most of my colleagues", 24% "better than the average of my colleagues" and only 1 person (4%) "worse than the average of my colleagues". None answered positively to the statement that they had "major psychiatric problems or were under treatment with a psychiatrist or psychologist". When asked how their mental health was today compared to the time just after the incident, 52% claimed that they were better, 36% unchanged and 12% worse. To evaluate the attitude of employees towards M F A , the following questions were asked: "How do you evaluate the effect of the M F A to your mental health status after the incident?"--none stated that it was negative, 17% said it was indifferent, 46% that they were better, but not completely back to normal, 17% were back to normal (i.e. the situation before the incident) and 21% did not know. "Do you think that it is essential to give M F A in our company?"-was agreed with by all but one of those who answered. The answers to a final question illustrated our huge information problem: "Had you knowledge of the M F A before the incident?" was answered in the affirmative by only 35% of those who returned the questionnaires. DISCUSSION
The most interesting interpretation of the results is achieved by dividing the material into three groups according to the time elapsed from when they were involved in a serious incident until they were formally given M F A by the Occupational Health Physician: Group 1 - - M F A given the same or next day (n = 28):
- - 8 2 % (23/28) were absent for fewer than 4 days - - 8 9 % (25/28) returned to the same job - - 1 2 responders to questionnaire in group 1: - - 7 0 % (7/10) stated that the M F A had been beneficial for them - - 7 3 % (8/11) had a better mental health today than after the incident - - 0% (0/11) had a worse mental health status - - 5 0 % (6/12) had long-term mental problems
481
Group 2 - - M F A given from day 2 up to 1 wk
(n = 12): - - 5 0 % (6/12) were absent for fewer than 4 days - - 7 5 % (9/12) returned to the same job 6 responders to questionnaire in group 2: - - 5 0 % (3/6) stated that the M F A had been beneficial for them - - 3 3 % (2/6) had a better mental health today than after the incident - - 1 7 % (1/6) had a worse mental health status - - 6 7 % (4/6) had long-term mental problems Group 3---MFA given after more than (n = 10):
1 wk
- - 3 0 % (3/10) were absent for fewer than 4 days - - 7 0 % (7/10) returned to the same job 8 responders to questionnaire in group 3: ---63% (5/8) stated that the M F A had been beneficial for them - - 3 8 % (3/8) had a better mental health today than after the incident - - 2 5 % (2/8) had a worse mental health status - - 8 8 % (7/8) had long-term mental problems Since the material is rather limited, a comparison between the groups with regard to one parameter at the time, would not give any statistically significant differences. But when combining the results, it seems evident that the issue of timing is essential. Hence the term Mental "First" Aid. When analysing the results of the enquiries into who were considered to have been most helpful at the site of the incident and if they missed someone, it was found that the 50% who did not miss any particular personnel group felt that they had been best helped by safety ombudsmen and traffic officers. The other 50% who had missed one of the listed personnel groups, had been given most help from policemen, colleagues, passengers and pedestrians. As a result of the two findings mentioned above, an attempt has been made to improve M F A by stressing that it is essential that help is given as soon as possible, preferably within 3 days. Safety ombudsmen attend a half-day course on the principles of M F A . They are in a position to give excellent help since they regularly go to the site of all serious incidents and have the opportunity to immediately make use of the social network within the workplace. The resources of the OHS are better utilised when contact is made the day after the incident, since the person has by then usually passed the acute phase of the post-traumatic stress reaction, and can more easily assimilate the information and advice given during the consultation. The evaluation of best help at the site left "someone from OHS" in the bottom priority. This can easily be explained, since the OHS was only at the site
482
0. T. Foss
of the event on two occasions, where by coincidence, one of the OHS nurses was a passenger of a tram that had an accident and another time one was passing the site as a pedestrian. Experience from other disasters in Norway has taught us that the number of cases of post-traumatic stress disorders can be reduced significantly if realistic preparatory exercises are held regularly. The Occupational Health Physician and two safety ombudsmen take part in a group within the Metro Division of the company established to revise and improve emergency plans and routines, including the use of regular exercises to prepare drivers, traffic officers, traffic leaders, information staff and directors for the dramatic events that take place from time to time. To improve on the lack of follow-up of employees who have received M F A after serious incidents, a self-help support group was recently established. In the first instance, those who have experienced suicides and other fatal accidents are invited. The intention is to make even greater use of the supportive social network which for a large part is still intact in our company. To conclude therefore, the simple secondary preventive measures of M F A have been very beneficial and could easily be implemented by other mediumsized transport companies where staff are exposed to the risk of suicide attempts.
ADDENDUM
The basic MFA-principles that the safety ombudsmen in Oslo Sporveier are trained to follow, can briefly be summarised as follows: ----early intervention is essential, try to reach the site of the incident while the driver still is there --since the driver will always feel at least some guilt for the accident, the only thing you are not supposed to do is to enhance this feeling of guilt - - i f you use common sense, offer a hand to hold, a shoulder to lean on, someone to talk to, a companion through the formalities; you are the best help the driver can get just after the incident (the results from the survey presented here are used in the education) - - i f you cannot stay with the driver until family, friends or other colleagues take over, contact the OHS or the psychiatric outdoor clinic for assistance if necessary
- - i f the driver does not express a wish to see a physician or other professionals you should accept it, but always make a personal appointment for follow-up the next day --offer your help to establish contact with the OHS, preferably within the first 3 days, and it is an advantage if you can accompany the driver to the OHS - - t r y to explain what a normal acute stress reaction is like, since a driver who has been told beforehand that he might experience this, is likely to cope better: Fear, fight and flight--reaction immediately or delayed sleep disturbances might occur re-experiencing the incident is common and is probably necessary for a successful outcome of the stress reaction ----crying is acceptable and for many, beneficial, if you can provide a safe shelter --protect the driver from media representives etc. No statements should be given in the acute phase because of the tendency for the driver to be self-critical. He will usually be busy with his own mental inquiry with all kind of questions in the line of "If I just had done this instead of that, this wouldn't have happened" and "Why didn't I do . . . " - - t r y to give objective answers if such questions are posed to you. After all, most of the suicide accidents are unavoidable from the drivers' point of view, and the driver involved is picked by coincidence more than by poor driving abilities or unattendance --prepare the driver for going back to work as soon as possible, offer your assistance and support the first few days if necessary; if the driver knows there is someone to replace him if he gets problems while driving, he is not likely to have problems --inform the driver that tranquillisers or alcohol do not solve any problems with re-experiencing the incidence, sleep disturbances or other thoughts, they only postpone them and sometimes make them worse to deal with later on - - y o u are no more a psychiatrist when you give M F A than you are a surgeon when you give first aid to a person with a bone fracture, but in both cases your initial measures can limit the damage and enhance the possibility of complete cure.