Resilience

Only five participants mentioned that they had experienced no reaction after a fatality and things went back to normal very quickly. They also were the ones who felt that going back to work quickly helped them return to normal.

Short term (within hours and days)

The most frequent reactions in the moments and hours following the impact (after the initial reaction at impact) were feelings of guilt, anger/irritability, feeling of detachment, exhaustion, being upset, emotional upheaval, difficulty sleeping and nightmares.
These symptoms were reported to quickly recede within the following days.

Other effects were mentioned, such as intense disbelief or empathy for the victim. These feelings can be associated with longer term impacts.

A very intense short term reaction can be a strong predictor of long term effects of incidents. Those who experienced high levels of stress, intense immediate shock, strong feelings on site and in the following days are at more risk of developing longer term symptoms, diagnosed problems and difficulties.

Stress and non diagnosed effects

All participants in the present study experienced at least one symptom that is indicative of stress after the incident.  This contrasts with Malt et al., who found one third of drivers with stress symptoms in Sweden.  

Previous studies have shown that the impact of suicides and accidents on train crews tend to diminish over time. This reduction in symptoms occurs for both accidents and suicides as people “learn to live with it.” However, we have found that after the initial shock recedes, there are still mid and long-term effects (after 3 months) for 40% of the incidents. The impact usually manifests itself in the form of flashbacks in situations that recall the incident. They can also be observed in dreams, in hyper- vigilant behaviour, and generalized anxiety. None of these effects seem to reach the level where a mental disorder can be diagnosed but they still result in significant suffering and impairment to crew members. The manifestation of symptoms that do not yet meet the criteria for a diagnosis are coined 'sub threshold symptoms'.

Non diagnosed effects can also be observed in symptoms associated with Acute Stress Disorder (ASD).  Most of those interviewed in the present study showed signs of ASD although they might not have displayed enough symptoms to qualify for an ASD diagnosis.  The most frequent responses identified at the time of impact were: rush of adrenaline, horror/shock, feelings of helplessness, feeling upset, a sense of disbelief as well as anger.  Feelings of responsibility are also common at this stage.  These feelings are common immediately after the incident but generally disappear between a week and a month following the event.

Traumatic reactions (PTSD and ASD)

Of the 40 train crews interviewed, 7 (17.5%) reported being diagnosed with PTSD. This is similar to the findings of Farmer et al. who after examinig similar populations found 16% in England however these figures are significantly higher than those found by Theorell who found 4% of PTSD in their driver sample in Sweden.

Cumulative effects

Fatalities rarely occur just once in the life of a conductor or an engineer. The mean number of fatalities experienced by the participants was 4.5, ranging from 1 to 22.

There appeares to be four ways of handling more than one fatality:

1. Some people responded to one incident at a time and did not show signs of a cumulative effect. Once the effect of the first incident had time to recede, the next one was experienced as separate.
2. A majority of respondents, on the other hand, reported a cumulative effect. Fifteen of them said that the more fatalities they were involved in, the harder it was to return to normal.
3. A small number of participants said that the accumulation of incidents had hardened them.
4. Some said that having had previous incidents helped them understand what was happening during an incident. This knowledge and familiarity may have diminished the traumatic effect of the subsequent incidents.

We found that of the 7 persons with PTSD, only 2 developed PTSD after their first fatality. The others developed PTSD after their second to seventh incident. In two cases, the repercussions of the last event lead the person to stop working completely.
Cumulative effects are not always easy to identify. They may appear as long term mood shifts, in changing perceptions about life or work, flashbacks in varied circumstances, general edginess, as well as fatigue and long recovery periods for minor incidents. Another sign of a cumulative effect is loss of commitment to work and hope that they will live to retire.

Cumulative effects have been documented before (Malt et al;., 1993; Karlehagen et al., 1993; Theorell et al., 1992), but they were limited to ASD and PSTD. In this study, we found that the cumulative effect can be subtle for crew members, affecting them in more indirect ways in the long term (for example in changing moods, fatigue, etc.) that do not necessarily appear when Acute Stress Disorder (ASD) and Post Traumatic Stress Disorder (PTSD) are measured.

Coexistence of other events

Personal life events, such as bereavement or a divorce, occurring around the time of the incident will add to the difficulty crew members experience. These events and their emotional impact get intertwined with the fatalities. The emotions experienced and memory of both events tend to be linked together. Remembering one brings up the other, increasing the extent of emotional turmoil. This co-occurrence of events were not frequent in our sample, but those who experienced both work related and personal events in the same period took longer to recover.

Delayed onset

Although it is documented in the trauma literature, none of the interviewees reported delayed development of PTSD after fatalities. In our sample, the strongest predictor of long term symptoms was the presence of an intense immediate reaction after the event. However, several interviewees described very strong subsequent reactions to lesser events. Close calls or non fatal incidents, which previously had little impact, induced a traumatic reaction after the traumatic event. This could account for delayed symptoms, where a later stimulus triggers the traumatic symptoms that did not develop at the time of the main event.

Accidents versus suicides

Generally, we found that suicides induced more short-term reactions (partly due to the anger we discussed before). We also noted differences in the long term effects. Of the 7 individuals who were diagnosed with PTSD, 6 were involved in suicides (15% of the 40 crew members, 10.9% of suicides).  
Participants were asked to reflect upon the difference it made to be involved in a suicide versus an accident.  Whatever the type of incident, the initial reactions were of shock and pain.  However, after these initial, almost physiological reactions, crew members developed different attitudes, sometimes quite contradictory.  

The intent of the person
Knowing that the person chose to put himself in front of their train seemed to make it easier for some crew members to come to terms with the incident. This knowledge alleviated their sense of responsibility because they felt there was nothing they could have done differently. They tended to get angry, which is an emotion they found easier to deal with.

The avoidability of the incident
When the crew member thought that the incident could have been avoided it was more difficult to deal with.  Crew members tended to get upset with those who could have prevented it, whether it was a reckless driver or a psychiatrist who let a patient out of hospital. They tended to see accidents as more avoidable than suicides, in part because of the notion of intent, but also in part because of the timing of the events. They tended to think in terms of “what if...” and some crew members obsessively wondered how an accident could have been avoided. They might also feel more responsible for the incident, even if they were operating according to regulations at the time of impact.

The ability to make sense of what happened
Being able to understand why things happened seemed to play a part in lessening the trauma.  When drivers were faced with a suicide that they were able to understand, it made it easier to deal with.  Making sense of things helped them come to terms with the event.

Costs

Costs involved in railway prevention strategies are an important issue. Although it is impossible to put a price on a human life, the high costs of some prevention strategies make them difficult to justify and implement on a large scale.

Patterns

Railway suicides do not have similar patterns in all countries. Therefore a prevention strategy that is effective to prevention platform and railway station suicide will not be useful in a country where most suicides take place away from stations on open tracks, such is the case in most of Canada.   An in-depth analysis of the local patterns of railway suicides is needed before any strategy can be devised to fit the local context.

Hotspots

Hotspots are a common phenomenon that renders the implementation of a railway suicide prevention strategy easier because there are a large number of suicides in a small area. Thus, local actions at and near hotspots may save lives with relatively limited investments. However in some places there are no hotspots and even when there are hotspots, they only account for a limited number of suicides. Therefore, prevention measures that focus on hotspots, although they may be effective in saving lives, only address part of the problem.

Evaluation of Effectiveness

For many railways, suicide remains a rare phenomenon with a small number of suicides per mile or kilometre of track therefore evaluating the effectiveness of a suicide prevention strategy may be difficult. Natural variations in small frequency behaviours may make it difficult to isolate the effect of the prevention strategy and provide statistically significant proof of the effectiveness of prevention strategies, unless the research continues for many years.

Costs

Costs involved in railway prevention strategies are an important issue. Although it is impossible to put a price on a human life, the high costs of some prevention strategies make them difficult to justify and implement on a large scale.

Patterns

Railway suicides do not have similar patterns in all countries. Therefore, a prevention strategy that is effective in preventing suicide on platforms and in station will not be useful in a country where most suicides take place away from stations and on open tracks, as is the case in most of Canada. An in-depth analysis of the local patterns of railway suicides is needed before any strategy can be devised to fit the local context.

Hotspots

Hotspots are a common phenomenon that renders the implementation of a railway suicide prevention strategy easier because there are a large number of suicides in a small area. Thus, local actions at and near hotspots may save lives with relatively limited investments. However in some places there are no hotspots and even when there are hotspots, they only account for a limited number of suicides. Therefore, prevention measures that focus on hotspots, although effective in saving lives, only address part of the problem.

Evaluation of Effectiveness

For many railways, suicide remains a rare phenomenon with a small number of suicides per mile or kilometre of track. Therefore, evaluating the effectiveness of a suicide prevention strategy may be difficult. Natural variations in small frequency behaviours may make it difficult to isolate the effect of the prevention strategy and provide statistically significant proof of the effectiveness of prevention strategies, unless the research continues for many years. Differences in recording of railway suicides also make comparisons between countries hazardous. Even within a country, collection instruments for coroners and medical examiners are not always standardised and data are often not directly comparable. Finally, few research has evaluated the combined effect of interventions, despite the evidence that a muti-centred approach to suicide prevention is often more effective.

Improving access to support

• A proactive offer of support and care is likely to have positive effects on the actual use of help by crew members
• We know from interviews and from research on men’s relationships with health services, that when a man tries and fails once to obtain the help he needs, he is less likely to try again. Therefore, improving first time access to services is very important.

Promoting use of resources

• Railway companies (at all levels: top management, Claims Department, Human Resources Department, operation managers, Safety and Police Department, local management, team leaders, employees), as well as the union, the Railway Association of Canada and Operation Lifesaver should promote help seeking, be aware of existing stereotypes and advertise resources (by presenting, describing and explaining them).
• Some authors suggest systematic screening and individualized education after an incident occurs, to improve awareness of symptoms in crew members and increase treatment seeking.

Involvement of peers

• Peers play a key role in changing values and behaviours. Peer support programmes are an important medium to promote existing resources and their use in a time of crisis.
• Peers who successfully used available help become good advocates for help seeking.

Training, support and care protocols

• Accurate and unbiased information is important. The use of resources will depend upon the trust people place in these resources, their usefulness and the absence of negative consequences at work. When people are well informed about the various resources and their impact, they can make the right decisions for themselves.
• In times of intense crisis, reducing uncertainties by clearly describing resources and available support helps people regain a sense of control, feeling supported by their employer and reduces tension.
• When an incident occurs, involving the affected crew member in decisionmaking post incident, including decisions concerning return to work and length of absence, can help them regain some control over the situation and his own well-being.

Fear of lost income

• Some crew members do not “book on trauma” because they fear the 3-month delay it automatically induces before they can return to work (see medical rules). They feel forced off work and feel victimized twice, first with the incident, and again with the loss of income that comes with time off work.

Masculine stereotypes

• Even if it is changing, there is still a strong masculine culture within the railway industry. Men who strongly adhere to strong masculine values and stereotypes tend to “bottle it up”, repress their feelings and deny their difficulties.
• These men tend not to use available resources to help them cope with critical events. Proactive offers of help, support, care and treatment at several key moments after the incident is a key factor in promoting the use of resources in crew members. This proactive offer of interventions should be imbedded in company protocols.
• In a long-term perspective, the railway industry can play a role in promoting help seeking in its values and codes of conduct, encouraging employees’ perspectives to evolve.

Fear of negative consequences at work

• Some people fear that if they take time off work, use medication, consult with a therapist or express emotional difficulties, they will be judged by their peers, by their managers and that this will have a negative impact on their work relationships.
• Protocols that focus on blaming the individual and establishing who is responsible for the incident can have important negative consequences on recovery.

Pre-existing work relations difficulties

• Seeking help implies that people admit to experiencing difficulties. This can only be done in a context of trust. Difficult relations with colleagues or especially lack of trust in managers may prevent crew members from expressing a need for support and care.

Misunderstanding who can help

• People do not always understand the role of the professionals they meet. There are misunderstandings leading to frustrations, unexpected consequences and grievances.
• The role of the company medical officer appears to be particularly ambiguous to employees.
• People do not always understand the difference between a doctor, a psychiatrist, a psychologist, a social worker and a therapist. They do not always contact the right professional and may feel frustrated by the response.
• These misunderstandings may lead to multiple referrals and an increased risk of discontinuing care seeking.

Prior unmet expectations

• The desire to seek support depends largely upon previous experiences. Negative experiences in the past will discourage people to seek help again.
• Past arguments with the employer about a previous sick leave increases pressure when a second incident occurs. This pressure can be enough to discourage affected crew to take time off work.
• Having a poor experience with a mental health professional can lead people to think that these resources are useless.