The role for coaching in psychological trauma
Noreen Tehrani and David A. Lane
Trauma is everywhere impacting on most people at some point either directly or through secondary impacts from people we know (Breslau, 1989). The concept starts to appear in literature from the time of the Trojan Wars. In Sophocles’ “Ajax”, the play follows the story of a combat veteran who slips into depression and attempts to kill his commanding officer. In John Arden's Serjeant Musgrave’s Dance, toward the end of the play, Serjeant Musgrave exclaims “There used to be my duty: now there’s a disease”. The description of his night tenors maps across to PTSD (see Langley, 2004). Beveridge describes how Charles Dickens was involved in a serious rail accident and reported, a year later, “sudden vague rushes of tenor even when riding in a Hansom Cab”. In the nineteenth century neurologists started to describe post traumatic “railway spine” and there is brief mention of “traumatic neurasthenia” in Tuke’s 1892 Dictionary of Psychological Medicine and early case examples refer to “mental parasites” following road accident. However, controversy about the term and the role of organic and functional elements occur very early in the literature Knapp (1897).
By the time of the First World War the concept of shell shock appeared which implied nervous damage caused by the impact of shellfire. After the Second World War the reference manual DSM coined “battle fatigue” and “gross stress reaction” with the recognition that even the most robust could suffer. It was following the Vietnam war that the concept of post-traumatic stress disorder became established. It entered the psychiatric lexicon in the form of DSM 111 (and ICD classification). This has been regularly updated as understanding increased. This was elaborated upon through to DSM-IV and connected with non-combatant forms of trauma, such as the capsize of the car ferry, The Herald of Free Enterprise.
What has been increasingly understood is that such trauma can emerge from any extreme condition and can become even more difficult to resolve where multiple traumas occur in the form of a complex trauma for example childhood abuse followed by abuse in adulthood or exposure to a life-threatening accident.
The descriptors indicative of psychological trauma are listed in the DSM and ICD guidelines (see DSM V for current descriptors: www.ptsd.va.gov/ professional/treat/essentials/dsm5jptsd.asp). However, it is important to note that the emergence of DSM V was highly contentious (www.nhs.uk/news/ mental-health/news-analysis-controversial-mental-health-guide-dsm-5).
There is a tendency to think: about interventions for trauma as solely an individual therapeutic endeavour. We contend that it is also an organisation level matter and that ways to work with individuals, teams and systems need to be part of the approach (Taylor and Lane, 1991; Tehrani, 2011). This creates a role for coaches. However, coaches need to understand trauma and the way in which cunent events can trigger memories from the long distant past. If coaches work in this area, they have a responsibility to understand the boundaries of their role, when and when not to intervene. This chapter explores the skills that coaches bring, guidance on when to refer on to a trauma therapist and briefly looks at preventing secondary trauma and compassion fatigue. We draw extensively upon ideas presented by Tehrani et al. (2012).
Why coaches and trauma, is that not just for therapists?
There has been much discussion of the boundary between coaching and parallel fields (e.g. psychology, therapy). In particular coaches have been warned to stay away from anything that might be therapy. It is the case that coaches should not attempt to be therapists, yet the complexity of our lives and the contexts in which we work mean that there are ways for coaches to intervene which are outside of therapy bitt nevertheless helpful. The argument that therapeutic areas should be off limits because coaches do not have the training for it and it could be dangerous is correct, but only if a narrow view of distress, disengagement, and trauma are adopted. The boundary discussion has prompted research into the differences between coaching and therapy (Turner, 2008; Bachkirova, 2007; Spinelli, 2008) The debate includes the concepts that other disciplines bring to coaching and the transfer of ideas between disciplines without a research base to support it. (Lane, 2010) The boundary debates exist not only within coaching but rage fiercely within the therapeutic disciplines. (House and Loewenthal, 2008). It is not only the boundaries between coaching and therapy that may be fuzzy but also those within therapy as practices and disputes about what is and is not appropriate are as tense as they appear across the coaching therapy divide.
When we turn to consideration of trauma Taylor and Lane (1991) in a Special Issue of the British Journal of Guidance and Counselling introduced a number of papers that made clear that invention is not just about therapeutic work. They argue that we have to address four stages to generate a comprehensive approach -preparation, response, recovery and mitigation. A similar case was made in a position paper from the British Psychological Society on Psychological Aspects of Disasters (1991). Intervention involves:
Preparation to include design of environments to reduce causes of disaster or stress and burnout and the prevention and management of trauma in the workplace.
Response includes action taken in the immediate aftermath of a crisis or disaster.
Recovery is concerned with both assisting individuals and organisations through from initial victimhood, stuvival and then learning to thrive. Therapy has a role but so do coaching and organizational change processes.
Mitigation takes the longer-tenn view and looks at how organizations and individuals can generate new approaches to mitigate problems occurring in the future based on learning from past incidents or future scenarios.
This leads us to think about issues such as the influence of workplace culture, business continuity, mental health, organizational structures, the role of toxic organizational process, resilience, compassion fatigue and bumout and building organisations fit for a complex world. These are areas in which coaches have contribution to make. We explore in this chapter some of these issues.
Trauma and the workplace
When we think of the workplace, we have to recognise the wide range of factors affected by personal traumas (Tehrani et al., 2012):
Some workplaces have a higher exposure to traumatic events; indeed they are almost routine. This can be direct exposure in the case of fire-fighters, paramedics and police officers or indirect when dealing with victims of rape or child abuse. Organisational effectiveness is impacted. In a scoping review for Public Health England, The British Psychological Society and College of Policing, Richens et al. (2019) reviewed fifty studies on early intervention. They found that such interventions help emergency responders to manage post incident trauma with the proviso that they are delivered in a way that respects organisational culture, have the support of the organisation and senior management, and incorporate existing social cohesion and peer support within teams. This detailed report is required reading for anyone working in this field or considering setting up an organisational response. It carefully evaluates various studies and provides guidance on approaches.
Some of these would be within the capability of properly trained coaches. Coaches work with clients, as a result of events such as a redundancy, bullying, conflict or relationship breakdown. It can happen that the current issue triggers an underpinning issue which is trauma related. This makes it important for all coaches to have some understanding of traumatic stress - the similarities and differences from everyday stresses and strains of life.
Understanding psychological trauma?
It is important to understand that trauma can happen to anyone - it arises from our evolutionary past - it is not a sign of weakness. The key to how our brain responds is through a primitive part called the amygdala which is highly sensitive to danger, (see Diagram 1 from Tehrani et al., 2012) Because the amygdala is unable to discriminate the dangerous from signals associated with danger a past event can trigger it to react. In a project (known as the Raid Trauma Network) working with staff who were subjected to bank raids, it was found that long after tire event someone, entering the bank, who shared features to tire raider could generate a fearful response. It was necessary for the employer to recognise that recovery could be a long process.
Tire evolutionary' benefit that the amygdala generates is the speed with which it can respond to danger signals. Essentially over time we develop templates of real and associated danger signals to which the amygdala reacts potentially causing anxiety, distress or fear. The hippocampus is the site of ways of coming to terms with these events, essentially th ough the creation of narratives. New memories are constructed which can be reconstructed to form more helpful stories that enable progress from a fearful state to an adjustment. Lying between the amygdala is a connection that metaphorically acts like a fuse which blows between the amygdala and the hippocampus, protecting the brain fr om being overwhelmed. Coaches need to understand the role of the amygdala its relationship to the hippocampus and the way traumatic events are processed. Useful theories for coaches to explore include the Dual Representation Theory' of Brewin (Brewin et al., 1996). This proposes that traumas experienced after early childhood create two types of memory: (1) verbally accessible, e.g., narr ative memories and (2) automatically accessible, e.g., situational
Figure 6.1 The Brain’s response to trauma or sensory images. The ways these interact give rise to different ways of processing trauma. Kleim and associates (2009) explore a number of theories and experimental studies on memory processing after trauma. Their findings are compatible with the dual representation theory but also offer support to other approaches. The different approaches certainly should inform any intervention by a coach.
It is important to recognise that given the opportunity to reflect and make sense of the experience (creating a meaningflfl narrative that can be constructed and reconstructed) most people will recover from a traumatic exposure. They may still experience flashbacks but can leam to recognise that this is the amygdala reacting to related sensoiy features of the trauma experience (see Brewin et al., 2017 for an account of developing thinking about diagnosis of PTSD).
As a coach working with a client who has experienced a traumatic event the emphasis is on issues raised by the client - listening to their stoiy so that they feel heard. For example, Tehrani (Tehrani et al., 2012) provides a case to illustrate this:
If a client was involved in a car crash it is important to focus on the features of the crash and not explore other times when the client may have feared for his or her life or felt out of control. Whilst in therapy it may be appropriate to explore the significance of the date, people involved or meaning of the crash or early life experiences and attachments, this is not helpful to a traumatised person, who needs to deal with the trauma in a more straight-forward way.
Tehrani makes the points that:
When might coaches help?
At the individual level the role of the coach is primarily to create a safe container for the client to tell their story. This can happen without the need to challenge or explore the emotional responses. It is about the opportunity to begin to create a
Table 6.1 Difference between trauma support coaching and counselling
narrative that is open to reconstruction. As clients work with their narrative they can envisage movement from a victim status to someone who can learn from the experience and begin to thrive (Joseph, 2012, see Corrie and Lane, 2010 for an exploration of approaches to exploring narrative). However, coaches often bring other capabilities such as organisational development experience giving them the opportunity to contribute at the team and systems level. Table 6.1 shows the different skills and activities involved in dealing with an individual traumatised client (Tehrani et al., 2012).
According to Hawker, (Hawker et al., 2011) dealing with a traumatised client in an effective way requires a clear structure and an exploration, in a safe environment, of what happened. The focus should be on factual and sensory information, not the processing of thoughts and emotional responses. The process of acting as a psychological first aider is now widely established (see bulleted suggestions from the National Child Traumatic Stress Network and the World Health Organisation). PFA provides an opportunity to acknowledge and gain closure to traumatic experiences. A trauma supporter will accept the story and impressions of their client rather than challenging their recollection and provide the client with opportunities to dictate the speed and content of what they wish to describe. Unlike counselling which generally will not include providing information or advice, trauma support requires the supporter to provide information, education and exercises to help reduce the trauma symptoms. While some coaching psychologists reject an advice-giving role for others, it makes sense when appropriate to the client. This is one of those occasions. Suggestions from the National Child Traumatic Stress Network cover eight PFA Core Actions:
The essence of Psychological First Aid according to the WHO is:
These provide a number of ways in which the experiences of coaches can be useful. However, coaches need to recognise:
How can coaches help provide support?
Much of the discussion in the trauma field has been on the negative impact. However, there is an increasing body of evidence to demonstrate that trauma can lead to personal growth (Joseph, 2009, 2012). Helping clients to grow is a key part of the capability of the coach. In addition, many coaches have experience of undertaking skill assessments. (Linley and Minlias, 2011). The aim of such assessment in trauma is to help clients remember their inherent abilities and strengths which may be applied to the current situation. There are several toolkits available which contain material which will be familiar to coaches who have worked to develop skills or journeys towards growth. Of particular value is the roads to resilience project from the American Psychological Association (see The Road to Resilience, www.apa.org/helpcentei7road-resilience). This provides a ten-step guide.
There are also many resources available from the National Center for PTSD (www.ptsd.va.gov/professional/assessment/screens/tsq.asp). These include screening questionnaires and practical tools for assisting clients. These tools help to create new learning and as a result increase capacity to make sense of distressing experiences. The practical use of such tools to build capacity fits well with a coaching approach.
Of particular value to coaches are a number of approaches to looking at trauma in the workplace (Tehrani, 2011) provides a wealth of information and practical ideas for understanding the contexts within which trauma impacts and ways to deal with it.
Coaching can be a process for supporting clients to achieve a valued goal or objective. Coaches therefore employ a range of skills all of which are useful when dealing with a traumatised client or supporting an organisation. Table 6.2 (Tehrani et al., 2012) highlights some of the skills.
Table 6.2 Coaching skills and post trauma support at individual and organisational level
A case example of combining approaches from coaching and therapy within an organisational process
On 11 September 2001,1 (DL) received a call from one of my clients. She asked if I was watching the television, which I was. In her organisation, a trading company, the screens were permanently switched on. Staff members in London saw, as it happened, the attacks on the World Trade Centre in New York in one tower of which, their colleagues were based. She asked if I could get to London immediately to discuss how we might set up a support system in what was a very chaotic situation.
It was also a mass attack that was witnessed as it happened across the world with messages from inside the Towers emerging in real time and colleagues, friends and relatives seeing the destmction of their loved ones played over and over again. While I had experience of other disaster situations and had written on the matter as well as provided trauma counselling services, this was the first time I had seen and heard the unfolding story alongside those I would be helping. On arriving in London, it was clear that many individuals had been deeply affected as they personally knew many working in the Twin Towers. They had both to deal with their emotions and fears and make decisions which had significant business and market consequences.
The organisation was clear that it wanted to do whatever was the most appropriate for their staff, and looked to me to assess the situation, and to devise and implement a planned response. However, there was no agreed collective framework for such a service. We were all on an individual journey from the unknown.
How might you have developed the intervention in this situation? Consider this before reading further.
Here is what actually occurred.
Initially, it seemed that an objective might be quickly foimd. The organisation stated that it wanted to do what was best for the staff and I certainly wanted to devise a worthwhile response. What was most appropriate was unclear, given the circumstances and how much of the situation was unknown. Dealing with personal reactions while still needing to make business decisions represented the first potential conflict. Where do you look for answers in known evidence-bases in order to create a structured decision model?
The literature on disaster management had developed rapidly over the previous few years from a low base in the 1980s to significant research by this time. During the late 1980s and early 1990s a model of practice had grown up which combined counselling, coaching and critical incident debriefing initially, with longer tenu work to alleviate PTSD where necessary However, by the late 1990s this research was being challenged and elements of it were seen by some as unhelpful or harmful while still being championed by others. As a result, the literature did not lend itself well to a structured decision-making model and in fact, added to the confusion. In terms of the organisation the response was highly varied some seemingly minimally affected and others significantly so. The organisation had to function, closure was not a considered option and the work for staff during that period was intense. After multiple coaching conversations condrrcted over two days with staff at several levels a shared sense emerged which could form the basis for a Mission statement.
The elements included:
In terms of the disaster literature a decision model for the response, recovery and mitigation phases was established (Taylor and Lane 1991). This included structured decision models where the literature supported it (for example debriefing sheets were provided and counselling services established). It also included emergent decision-making models to respond to rapidly changing circumstances; a short decision chain was set up so that different modifications to service could be introduced as needed. A senior manager was assigned to liaise with the support team daily with authority to assess and decide.
When do coaches need to pass cases to a trauma therapist/GP?
We have to recognise that not all who have been impacted by trauma are suitable for coaching. Some will require a much more in-depth approach, for example, trauma informed cognitive behavioural therapy, to help them deal with their experience (Bisson et al., 2013). Steps that a coach should consider are:
Table 6.3 (Tehrani et al., 2012) provides an indication of the help that can be provided by coaches, trauma psychologists and psychiatrists.
Importance of supervision when coaching traumatised clients
While it is recognised that supervision is important for coaches (Canoil, 2006,2007; Cavanagh, et al., 2016) many coaches report that they do not use it or see the benefit (Lane, 2011 ; Grant, 2012). Working with trauma requires the coach to be supervised by someone with the appropriate background to be aware of the dangers in undertaking this kind of work (McNabb, 2011). The role of supervision in trauma-based work has been explored explicitly by Tehrani and Levers (2016). This makes clear that coaches need to be cognisant of the potential impact of hearing trauma stories on their own w’ell-being. In particular empathetic listening, essential to the w'ork, can also create thoughts and feeling in the coach similar to those experienced by the client (Figley, 2002; Morrissette, 2004). The development of secondary trauma, compassion fatigue and burnout are clear signs of the coach becoming vicariously affected by their work with trauma (Taylor and Lane, 1991). Tehrani and Levers (2016) make the point that before starting this work the coach should have supervision in place and take personal responsibility for themselves and their need to build then emotional resilience and emotional resotuces. This includes the areas that all coaches should consider in their work such as recognising any personal unresolved or ongoing traumas and that they have a wide range of social support.
Tehrani (Tehrani et al., 2012) suggests that when selecting a supervisor coaches need to ensure that the supervisor is prepared to:
There are a number of interesting areas of development in trauma supervision. These include the role of culturally informed trauma supervision, (Bledsoe, 2012; Levers, 2012) integrative and systemic approaches, (Levers, 2012) and the use of relational transactional concepts (Etherington, 2009). Gray et al. (2016) refers to developmental and social role models. Lane et al. (2016) argue that it is important to build a personally effective model of supervision and provide a framew'ork to do so. They present a framework that considers the purpose of supervision, the perspectives that inform it and the process for providing it all based on specific professional contexts. In the same book psychologists and others from a range of clinical, health, forensic, educational, sport, counselling, coaching and work and organisational contexts outline how they interpret the purpose, perspectives and process they use to undertake supervision. In the specific coaching context Gray et al. (2016) provide an account of supervision in coaching and explores the idea of stages of development for supervisors.
There is an important and emerging conversation to be had about the role for coaches and coaching psychologists to facilitate the creation of resilient organisations and provide support to individuals and teams following traumatic events. They are not acting as therapists (and should not attempt to do so) but they can provide a structured process of support. The skills that coaches bring, in terms of understanding organisational process, building teams and enhancing individual and organisational resilience offer real value to understanding response to trauma. The skills that individuals develop within a coaching process assist clients seeking to come to terms with such events and build the sense that they can move from being a victim, to surviving the current dilemmas to a future in which they can thrive. There are boundary issues which we have to respect. Nevertheless, the benefits of a coaching offer are clear. Trauma is an area to which coaching and coaching psychology can make a contribution. The conversations need to happen.
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