Road Trauma and Trauma Counselling for Road Crash Victims

Introduction

More than 14,000 people died on the roads of South Africa in 2017. These are only the official road fatality numbers and do not refer to the tens of thousands who are mutilated, injured physically or left traumatized!

Even though we find included on the Arrive Alive website information on trauma counselling and post-traumatic stress, we believe it is important to share some additional information by way of a Q&A with some industry experts.

We approached our experts from EMS as well as some prominent psychologists to gain insights pertaining to the trauma experienced on the scene of a road crash as well as some important information on how to deal with such trauma! We also would like to focus on our most vulnerable road crash victims as well as those who are exposed regularly to incidents of trauma not only as a result of road crashes but also due to incidents such as crime, drowning etc.

How would we define the difference between Shock, Anxiety, Emotional Trauma and Post Traumatic Stress after a road crash or traumatic incident?

Stress and trauma reactions is a natural reaction to a crisis. Persons could react with horror, total shock, fear, panic, helplessness and anxiety. Prolonged states of stress reactions can developmental and physical health complications or psychiatric diagnosis.

Normal reactions to trauma occur in phases namely the first phase of shock (denial, numbness and anxiety). The second phase is anger (blaming, outbursts) and the third phase a phase of a depressive state and the fourth phase being acceptance and healing.

We decided to approach our experts for a better understanding of these concepts:

Shock

Shock is a normal reaction to traumatic incidents, bereavement, any minor or major life crisis and receiving unexpected bad news. Shock can be understood in terms of the individual’s immediate response after experiencing emotional distress or a traumatic event.

Shock comprises of both psychological responses which include a stunned emotional response and psychological detachment from the psychological event; and physiological responses which include changes in physiological functions such as breathing patterns, changes in heart rate and alleviated blood pressure. This is also known as acute stress reaction - having an intense reaction to stress or trauma.

Shock is seen as suppression of a variety of physiological processes due to an accident, critical incident or intense emotional experience. This may manifest as a sense of derealization (the environment seems surreal) or depersonalization (one experiences one’s own self as surreal).

Critical to any major incident we need to identify true physiological shock from emotional trauma, as physiological shock and major trauma should take preference over managing emotional trauma, because early intervention may save a life.

In physiological shock, we see changes to vital signs such as low blood pressure and a fast heart rate as well as potential causes for the shock for example bleeding. Emotional type shock is not a clinical diagnosis and may occur in a patient without serious injuries. Medically this would present as anxiety or stress. All emotional trauma should be managed with the initial debriefing, as if it’s not dealt with early it could eventually lead to post-traumatic stress, sometimes years later.

Anxiety

Anxiety forms part of the process of trauma and is also experienced as an emotional reaction to trauma. Anxiety may become pathological due to the exposure to trauma or present as a part of personality and temperament.

Anxiety is a more chronic condition of acute tension, distress and physiological symptoms such as hyperventilation, increased heartbeat and excessive perspiration. It is distinguished from fear in terms of its time duration and that it is not associated with a specific object or stimuli.

Anxiety is the body’s natural response to stress. It is a feeling of anticipation for something to happen or be done - to this end anxiety is a natural driving force of behaviour.

Anxiety can be “positive” or “negative” for example, it can be a feeling of fear or apprehension or excitement or anticipation about something that is due to happen.

It has been proven that experiencing anxiety in controlled intensities can act as a motivational force to evoke positive behaviours. Normal anxiety comes and goes for example when you start a new job, or when you move or when you just started driving a car.

When feelings of anxiety (worry, fear, concern etc) are extreme it interferes with daily functioning and becomes problematic. When focusing on anxiety in terms of a traumatic response, it can be understood in terms of the anticipation of the trauma reoccurring when exposed to triggers associated with the trauma. Additionally, anxiety can trigger additional psychological effects such as a flight or fight response and hyperarousal.

Emotional Trauma

Trauma is a natural reaction to abnormal circumstances, crisis and life events on which the person was not prepared for; as whole beings, we react to these, sometimes, unbearable experiences. Trauma responses are viewed as the human ability to protect itself through self-protective stress responses by the brain and body to enhance our survival.

Emotional trauma can be described as an acute stress reaction to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about the unexpected or violent death, serious harm, or threat of death experienced by a family member or other close associate.

The person’s response to the event involves intense fear, helplessness, or horror. The characteristic symptoms resulting from the exposure to the extreme trauma include persistent re-experiencing of the traumatic event, persistent avoidance of stimuli associated with the traumatic event, and numbing of general responsiveness, and persistent symptoms of increased arousal.

The reactions to trauma are categorised into four sub-categories namely physical reactions, emotional reactions, cognitive reactions and behavioural reactions. Emotional trauma is then one of the sub-categories. These symptoms may last 6 - 8 weeks.

Trauma and stress response engages the activation of parts of the nervous system that is responsible for survival, the person would respond on cognitive, behavioural and biological levels. As a reaction to trauma and crisis, continuous stress affects the thinking, emotions, reasoning as well as physical and psychological aspects of the person. These reactions can affect the capacity to cope with other forms of stress and general everyday difficulties.

Post Traumatic Stress

Post-traumatic stress occurs when anxiety and the fear response (psychological effects) experienced after a traumatic event persists for more than a month [6-8weeks]. This includes characteristics such as anxiety, fear, hyperarousal, re-experiencing the traumatic event through flashbacks or nightmares, startled response, hypervigilance, disassociation etc.

Receiving trauma counselling from a trained professional may assist the survivor in taking control once again of their life and assist in the recovery process.

Does trauma manifest immediately or could there be a delayed response from the victim?

A traumatic event can affect individuals differently and can manifest at different times, depending on how the victim processes the initial shock both physically and psychologically.

Trauma may manifest immediately or there may be a delayed response of even days, weeks or months after the traumatic incident.

The onset of the trauma is affected by the severity of the trauma, the premorbid psychological vulnerability of the person involved, as well as the personality functioning of the person. It can manifest immediately or there can be a delayed onset that is not time specific.

In many instances such survivors will not seek counselling as the phase of denial is extended. Their subsequent experiences and reactions are then not always related back to the traumatic incident and may seek medical advice for the symptoms experienced.

Diagnosis in the form of Acute stress disorder and Post-traumatic stress disorder needs to be consulted if the trauma has a delayed response. It is important to consult the diagnostic criteria regarding how long symptoms associated with trauma responses persist in order to distinguish between the two above mentioned disorders.

When symptoms persist for a month or shorter it can be regarded as Acute Stress Disorder, while symptoms that persist for longer than a month can be regarded as Post-traumatic Stress Disorder. It is important to note that these disorders (and characteristics thereof) can manifest immediately or have a delayed response.

Following a horrific event; anxiety, fear and stress might also be experienced, and these responses are biological attempts to handle, cope and adapt to the experience. Drawn out exhaustion stages and continuous presence of stress hormones can result in psychological agony and health implications. As people are biological, social and psychological beings, a combination of medical treatment, professional psychosocial intervention, family and community support would address the wholeness of the person.

What are the signs for a first responder that someone at the scene of a crash is suffering from trauma and in need of assistance?

The reactions to trauma are as universal as the exposure to it. Some individuals may flee the scene, others may become very aggressive or seem completely numb (zombie-like), crying or physical symptoms such as shivering, shaking, sweating etc.; even inappropriate behaviour may be present such as laughter or making jokes.

Any first responder may assess the accident scene in terms of severity and conclude that the individuals involved in the accident are experiencing trauma in a more or lesser manner.

Because vehicle accidents are sudden and unexpected, the impact of such incident will also be higher. We also consider the current life status of the individual (of which there is no time on a scene to do) regarding other stressors such as financial, relationship, illness or major changes which will make the impact of any trauma higher.

A first responder can look at their distress levels, how they speak and how disorientated they are. People suffering from emotional trauma is usually disorientated, their bodies might begin to shake and excessive crying accompanied by anxiety. This may be a normal way of somebody coping with the incident.

It is recommended that first responders receive training in psychological first aid to handle survivors correctly without causing more undue stress.

What are the Steps to be taken by paramedics to limit the person from incurring or suffering from further shock?

It is highly recommended that first responders receive training in psychological first aid to deal with their own and the survivors trauma more effectively. The basic premise in order not to increase the impact of the trauma is not to be judgemental or be critical and furthermore to treat everyone with dignity and respect. Skilled paramedics will be trained to deal with empathy and compassion at all times. Calming and reassuring the patient is vitally important.

Allowing a person to express their fears or concerns, and providing honest answers is important when dealing with emotional trauma. The emergency medical team are being trusted immediately by the people involved emotionally in the incident and everything they say and does has an effect.

To help limit the shock, we try to provide great care and compassion (unless somebody’s safety or life is in danger, as we may need to be very assertive in these situations).

Furthermore, information is vital as the people in shock have no idea what is happening or what is going to happen, and this information helps them to know what to expect and what to do.

Then a further important step is that paramedics should get support for the people in shock as soon as possible in the form of family or friends.

First responders sometimes work very closely with a team of trauma debriefs to render assistance with a debriefing on scenes.

Are there specific minimum requirements/qualifications that the counsellor must have - Can further damage be escalated if the counsellor is incompetent to provide the treatment?

Counselling and debriefing fall within the scope of practice of registered healthcare and mental health professionals. With reference to the Mental Health Care Act 17 of 2002 (Mental Health Care Amendment Act 12 of 2014) the following professions are defined as mental health care practitioners: (xvii) “mental health care practitioner” means a psychiatrist or registered medical practitioner or a nurse, occupational therapist, psychologist or social worker who has been trained to provide prescribed mental health care, treatment and rehabilitation services.

The rendering of healthcare and mental health care services is strictly regulated by law, the regulations of government and statutory bodies. All practices should be accountable and responsible for the benefit of society. Practitioners are further regulated by statuary bodies, practitioners should be duly registered at one of the following professional councils:

South African Council for Social Service Professions (SACSSP)
Health Professions Council of South Africa (HPCSA).
South African Nursing Council (SANC).

The above-mentioned councils function under the guidance and supervision of the Minister of Health (HPCSA & SANC) and the Minister of Social Development (SACSSP). Only these councils are responsible for the regulation of healthcare and mental health care professionals.

Yes, it has been recorded that an individual that does not have knowledge and experience in handling victims of trauma may cause survivors to experience secondary trauma and delayed recovery.

In a collision where parents are killed or severely injured in a road crash and young children are found in their car seats - what would be the specific signs of trauma and what care should be taken with young children?

It is important to carefully assess each scene, the mechanism of injury, damage to a vehicle etc. Trauma is not always the obvious blood and gore, but more often than not the person who is the quietest on the scene is the one suffering from an underlying issue and needs attention.

A quiet baby is always a concern. Children suffer and deal with trauma differently to adults. Children should always be dealt with the utmost empathy and care always. Close attention is always paid to ensuring that exposure to graphic scenes is limited always.

Communication to kids is also important, reassure and comfort.

Young children often do not display shock whilst on the scene as they may take longer to comprehend what happened. Children will be traumatised by the nature of the incident; however, their reaction and wellness depend on the first responders and parents to minimise further traumatisation.

Children require the basic need for safety and a sense of security. One responder may be allocated to comfort the children (if this can be done), kept warm and away from noise and visuals that can be traumatic.

If the children can communicate and understand, no false hope and promises should be made. Communication such as “we came to help, and everything is being done to get you away from here as soon as possible”. The SAPS should also be called in for taking guardianship of the children until they can be reunited with their family.

It is crucial that family or friends of the family in the accident be notified and asked to assist. The most important thing the children need is a familiar face to help them and help contain the trauma.

Contact numbers from the cellular phones of the parents should have details referring to words like “mom” “Dad”. Even the last dialled number can be utilised to obtain information on next of kin. First responders should also look in the vehicle for the nappy bag and baby food/feeding to hand to the SAPS in the instance of an infant/baby.

All children under 18 fall under the obligations of the Children’s Act where the “best interest of the child” is emphasised. The thorough examination, assessment and guidance by a healthcare and mental health professional such as a social worker should be provided.

Attention should be given to some of the following signs:

Re-experiencing the trauma through intrusive distressing recollections of the event, flashbacks, and nightmares (including bed wetting)
Avoidance of places, people, and activities that are reminders of the trauma, and emotional numbness.
Increased arousal such as difficulty sleeping and concentrating, feeling jumpy, and being easily irritated and angered.
Changes in temperament - “difficult” children or children with problematic behaviours.

The above-mentioned characteristics can manifest due to children not having proper coping mechanisms in place to deal with the traumatic event.

What would the first responder do after the basic emergency medical response to ensure such a person is assisted? Is there a reporting duty or an obligation to refer to someone?

The first responders may utilise a network of qualified and trained trauma counsellors that are able to deliver a standardised service nationally with one contact number that they can provide to the survivors. On the scene is a basic psychological first aid and no counselling happens during the crisis as it is counter-productive.

Where first responders feel the patient or the patient’s family are in need of debriefing they may relay to their trauma debriefing team via the emergency contact centre and arrange for a lay counsellor to attend.

Get support in place in the form of family or friends to assist the person in shock and help them plan for the effect of the emergency. They may need their vehicle towed or help with belongings.

If we can’t find family, there are many people such as the Emergency Medical service staff, or even tow trucks that will help the patient. The physical injury should always take preference over fear/ emotion, if in doubt rather have a patient involved in a motor vehicle accident go for a medical check at the hospital, especially if the damage to their vehicle is severe, as the emotional concerns may be masking an injury.

How does trauma differ from the emotional trauma experienced after the loss of a loved one as compared to something you witness or experience yourself?

The process of bereavement in the instance of natural death is completely different from that of a traumatic incident and is a much longer process than that of trauma. Where death occurred within a traumatic incident it becomes complex bereavement and trauma. Bereavement is not trauma but described as a life crisis and stressor which evolves into a grieving process.

Trauma phases on the other hand by witnessing (vicarious trauma) or experiencing it oneself is described in question one. It is usually the exposure and experience to an event outside the range of normal human experience and evokes strong emotions for the self or others such as:

Serious or gruesome motor vehicle accidents
Armed robbery
Shooting incidents
Rape
Natural/man-made disasters
Provocation over an extended period
A threat to life, body or health
Suicides

The severity thereof is determined by the person who witnessed or experienced the event. All people are uniquely different and would react totally different to the same event. The person him/herself forms a perception and interpretation of the event on which the body and mind will react in various ways.

Trauma is an experience (which is subjective) or a perception by an individual that their life, bodily integrity or sanity (psychological integrity) is threatened. Thus, when a person experiences a death of a loved one as compromising their psychological integrity the trauma experienced can be the same as a person who is physically in a crash or who witnesses a crash. Trauma is a subjective experience.

Also, the reaction to an emotionally traumatic experience manifested after the loss of a loved one is dependent on how the loss occurred (natural causes such as sickness or old age; or unnatural event such as a car crash). It is important to differentiate between grief and emotional trauma. Grief is a natural process people go through after the loss of a loved one. It consists of five stages namely, denial, anger, bargaining, depression and acceptance. As previously mentioned, this is a normal process everybody goes through after the loss of a loved one, however, the stages can progress at different paces.

The trauma of loss is perceived to be worse because it is someone you have lost and cannot get back. When witnessing and experience a person also struggles but not in the same depth of trauma than someone who has lost a loved one. With an experience, a person has to deal with the gruesome images, whereby with a loss you deal with all the personal emotions and feelings.

We can’t predict how an individual will perceive their personal loss, and our counselling teams are there to help prepare somebody for the steps towards coping with a tragic life circumstance. It is our perception that emotional trauma may be worse if there are negative thoughts of blame/ the incident could have been avoided and someone caused the death, but every person walks their own journey in coping with a trauma. Loved ones may have had more time to prepare themselves and cope with death due to natural causes, and thus be more accepting, as there is nothing they could do about it and they have still time to prepare themselves as much as they can for the death. Whereby an accident there is no preparation time.

How does trauma and shock/loss differ when experienced after death through natural causes [i.e. heart-attack] as compared to unnatural causes such as a road crash?

When family and friends have been exposed to the motor accident scene it will be described as a traumatic experience combined with the shock of the loss. As mentioned the grieving process becomes complex. However, when they have not been exposed to the traumatic scene, the shock of the loss is similar in that it is sudden and unexpected.

In many instances where family and friends have had time to prepare for death and loss, the shock is equally the same as to that of a sudden death occurrence. This will mainly also depend on surrounding factors such as extended illness and palliative care, family dynamics and stressors/conflict that occurred before the death.

Are there different symptoms experienced or treatment required when witnessing or being the victim of violence and crime [i.e. hijacking, smash-and-grab, assault]?

Trauma can be divided in three main categories namely primary trauma (being directly exposed to the traumatic incident); vicarious trauma (witnessing the trauma of others) and secondary trauma (the experience of negative procedures and processes after a traumatic incident such as the investigation, court cases, dealing with administration).

The symptoms will be similar however the intensity will differ to that of a person directly involved as well as the duration of the recovery process will differ. This also depends on the relationship between the victim/survivor and the witness, for instance, a mother and child or husband and wife.

In the instance of first responders to scenes, the experience of the traumatic incident may be intensified by various factors such as: weather, the internalisation of the scene to their own family, the reactions of the victims/survivors, long duration of attending to similar incidents, the time of day and, personal stressors such as financial problems, relationship problems and recovery from illness.

There is no difference in symptoms caused by shock and trauma, it is only the length that differs. People who have been victims of crime also suffer from shock and feelings, but it usually takes them a few weeks to work through the trauma. Whereby with a death you also have feelings and shock, but it takes a few months or years to work through. Counselling and understanding the grieving process is critical to coping with both situations. You also don’t have to visualise a crime to experience the emotional trauma associated with it. Sometimes hearing about an emotional trauma may be enough to spark emotional distress.

As per the stress-diathesis model, each person has a different threshold for the amount of stress they are able to endure. Thus, every person’s reaction will be different to traumatic experiences. What will need to happen is trauma debriefing and the follow-up care in the first four weeks following the traumatic event so that the acute stress resolves and it does not become PTSD

How would the trauma experienced differ between those who are the victims of a road crash or other violence as compared to those who respond to the incident?

First responders experience vicarious trauma - which is a transformation in the self of a person that results from the empathic interaction with people who are traumatized and their traumatic experiences. The intensity of the symptoms of the trauma such as fear etc will not necessarily be as intense for the person responding - however as the person continues to respond these experiences will build up and if the responder does not deal with it, it will lead to burn out.

An additional factor that plays an important role for first responders is that of emotional labour. That is the term used for individuals within an organisation that cannot display their emotions within the working environment as they would normally do outside of the workplace. This is the suppression of their own negative emotions and absorption of the emotions of others.

This suppression of emotions leads to physical and psychological illness. To use an example, a paramedic is exposed to a gruesome vehicle accident where small children are involved. He/she must deal with their own emotions regarding the small children and that of the parents and maintain a professional demeanour.

The trauma for the victims is personal and their lives are affected. For the responders, it is also a form of trauma but it is not personal and they develop their own coping mechanisms when processing the incident. This may take the form of talking to colleagues, a formal debriefing, or very often the opportunity to help somebody or save a life is the only trigger they need to cope with the tragedy.

The crisis presents through a variety of experiences; every individual’s perception of the event would differ and would further react in a unique way to the experience. The uniqueness of each individual should thus be respected throughout the process of making sense of the event.

The intensity of the crisis is determined by the person experiencing the event, the person determines whether the experience falls outside the range of coping abilities or not. It might further be experienced that the person does not have the resources or vitality to deal with the crisis and is totally overwhelmed by the event. Person-centred, professional, holistic, preventative and proactive care should be provided to persons presenting with chronic stress-related conditions.

We are aware of the trauma experienced by first responders and police and other enforcement officials to scenes of trauma- is there anything in training that can reduce the impact of the trauma they witness or experience?

Yes, we should consider stress inoculation training- which will need to be conducted by a mental health professional. This means that the first responder will be trained in how to best deal with traumatic experiences- by self-care, seeking immediate debriefing and forming support groups for each other. The training will also boost their resilience.

Training in trauma management is always useful for individual trauma processing, however, it is recommended that a long-term trauma intervention is implemented for first responders who get exposed to traumatic incidents regularly.

When survivors go for trauma counselling it is because they have been exposed to a singular traumatic incident. For first responders and rescue workers, it is a different scenario where the exposure to trauma is regular and, in most instances, daily. Long-term trauma interventions work on the principle of bi-monthly workgroups with the first responders dealing with ventilation of emotions, learning in a relevant topic such as trauma management, relationship management, cognitive restructuring and within these sessions a relaxation intervention is done.

What would be the signs colleagues can detect that a co-worker is suffering from trauma and in need of assistance?

Due to the consistent exposure to traumatic incidents, first responders have become adept at hiding their emotions and the impact of trauma. They would use defence mechanisms or emotional crutches such as substances or extra-marital affairs.

In the instance of young and inexperienced first responders, their first serious traumatic incident will be hard to process. It is useful to prevent further undue stress in inexperienced first responders, to pair them with experienced first responders.

The trauma is usually dealt with in the team, however, alcohol and substance abuse may be initiated here if there are no proper counselling mechanisms in place.

Additional symptoms may be:

Lack of concentration and focus
Tardiness
Diminished functioning in social and occupational spheres
Aggressive outbursts /Irritability
Withdrawal
Absenteeism
Forgetfulness
Increase in mistakes made
Tiredness/sleepiness
Negativity
Depression

Some of the signs are when people start having personality changes when there are severe anger and irritation flaring up when they start cutting corners with their work duties, when they draw back from everyone and start living a lonely lifestyle and when they do no enjoy the things in life that they used to enjoy. They may also have changes in sleep pattern. Depression and constant negativity/ anxiety can also be signs of long-standing post-traumatic stress.

Persistent avoidance of the stimuli associated with the trauma and numbing of general responsiveness (that was not present before the trauma) as indicated by three of the following:

Efforts to avoid thoughts, feelings or conversations associated with the client’s trauma
Efforts to avoid activities, places or people that arouse recollections of the client’s trauma
Errors in judgement about conceptualization and treating the trauma case
Markedly diminished interest or participation in significant activities
Feelings of detachment or estrangement from others
Restricted range of effect
A sense of foreshortened future (e.g does not expect or want lengthy career)

Persistent symptoms of increased arousal (not present before the trauma) as indicated by two or more of the following:

Difficulty falling or staying asleep
Irritability or outbursts of anger
Difficulty concentrating
Hypervigilance
Exaggerated startle response

The symptoms should continue with 30 days

The important concern is to seek medical and professional consultation as soon as possible

We acknowledge that Trauma experienced may differ from incident to incident and person to person- what is usually the time required for the healing process?

It is difficult to allocate a specific time to any healing because every person differs from other people and every person has their own time.

The usual time for learning to live with the traumatic incident is six to eight weeks but depends from individual to individual and recognising additional stressors in that person’s life. It is, however, the norm to refer a person for in-depth therapy after six to eight weeks with no improvement of symptoms experienced.

Could someone ever be regarded as “Healed” or would he/ she just be better equipped to manage the effects of trauma experienced?

Within the stages of trauma, the last phase is acceptance and healing, however, that does not imply that an individual should be happy about the incident. It simply means that a person has come to accept what happened to them and focus on moving forward and to view the world as positive once again.

We can use the example of a person that got shot and takes time to heal. They will have the scar for the rest of their lives and internal tissue, organ and muscle healing will take a long time, however, they are able to go back to work at some point and become fit once again.

Every now and then they see the scar and is reminded of their injury, however it is not the dominant/overwhelming part of their life anymore. It works the same with psychological trauma. Many individuals who find meaning in the traumatic incident obtain a point of healing and acceptance faster and may also choose to help other survivors of trauma to assist further with their own recovery.

Additional note: In the same manner that our driving should be pre-emptive (thinking what other drivers may do on the road and planning pro-actively what I as a driver will do) road users and first responders should do a similar process of stress-inoculation, this does not mean that we view the world pessimistically and in a negative manner. We simply prepare for incidents on a cognitive and emotional level what we will experience before it happens. To use an example, if first responders are called out to an accident, they should prepare for the worst-case scenario with the information that they do have. Preparing what emotions, they would experience and what thoughts they will have. The mind will create a “worst-case scenario” and prepare the first responder before they arrive on the scene. This lessens the impact of the traumatic incident.