BARRY ENTERED MY office in a whirl of fluorescence, hyperventilation and dirt. His workplace referred him to me under the banner of ‘veteran affairs’ due to his past army service. After a verbal altercation with a fellow worker, he had been placed on his final warning. Wearing blue jeans and a bright vest over a thick long sleeve shirt, he was the embodiment of Australia’s mining economy, as he scattered red dirt around my office. He worked as a driver of an excavator for a mining site involved in aluminium extraction. He had managed to keep his job for almost eight years, but informed me early that he was known as someone to steer clear of.

‘They say I should have a “Handle With Care” sign on my forehead,’ he said.

His face and cheeks had a puffy, red tinge. My eyes drifted towards his hands to assess if there was a tremor typical of alcohol withdrawal – there was not. This was his fourth altercation at work in the past two years and management were considering termination. They had taken all possible measures, from allowing him a repetitive, low stimulation job, giving him extra leeway for breaks and minimising his interaction with others.

In the late 1990s, Barry had served in Rwanda for almost eighteen months as a private on a peacekeeping mission, during what has been widely reported as one of the worst genocides of the twentieth century. After his return, he struggled to function in any of the five different roles he was assigned to in the defence forces, from paperwork to answering phone calls to assisting with maintenance.

‘I just couldn’t do it. It was like I was demented or something,’ he said, shaking his head, when asked why he stopped working for the army. But it wasn’t a medical discharge, just a voluntary one.

JAI WAS A thin, young man born in the South Indian city of Madras. He entered my western Sydney rooms grabbing at his neck brace in one hand and carrying a pile of documents with the other. His wife walked beside him, opening doors and organising the seating. Jai looked forlorn. He was barely audible when he began his story, shuffling through his documents and fiddling with his phone as he spoke.

‘I was bullied, you know, terribly,’ he said, reaching once more towards his neck. ‘It was racial abuse.’

Jai lifted his smartphone on to the desk separating us, scrolled through his text messages before turning the phone towards me.

‘You smell a bit like curry today. I bet your wife’s a good cook.’

‘You’ve got a pretty good job, don’t ya…all the Indians I know are cleaners or in servos.’

‘I love that new flat top you got. Ha. It’s a shocker mate. You gotta get some fashion advice.’

Rather than detailing the story, Jai then drew out several business cards from his selection of documents. One stated that he was the Team Leader at a data processing section of a New Zealand energy company.

‘I was very senior there,’ said Jai.

Next he showed me a picture of him receiving an award for community contribution, also during his time in New Zealand.

‘They told me that Australians were a bit rough, but I have never been treated so badly,’ said Jai, turning to his wife who was holding back tears. ‘He has taken my life.’

Jai had migrated from New Zealand where he, his wife and two children had lived for five years. He worked in an office role and had trained in accounting back in India. His first job in Australia was for an insurance call centre. He had not worked for several months and was filing a legal suit for workplace bullying.

‘Tell me about the neck?’ I asked, confused about the brace.

‘Car accident. Whiplash,’ Jai informed me, pulling out a letter from a hospital in Bangalore. He was the passenger in a car accident, which left him with neck stiffness. When nothing is revealed from imaging tests such as X-rays and CT scans, ongoing neck pain is classified as whiplash. Jai suffered the injury in the weeks after taking sick leave from his job, during which he visited relatives in India.

He continued to wear a neck brace months later and described tightness and pain emanating from the back of his shoulders to the back of his head. I immediately considered the pain to be more likely an expression of anxiety, but did not press him so early in our interactions. Like all psychological symptoms, his pain had a meaning and not acknowledging it was a recipe for disaster.

Jai described regular nightmares where he walked alone in an empty office unable to find his desk. He didn’t have flashbacks of his alleged assailant, the man who sat in the adjacent booth, but noted his headaches worsened whenever he would read the text messages on his phone.

LIKE MANY INFLUENTIAL ideas during the twentieth century, from management consulting to the internet, knowledge surrounding psychological breakdown arose through the army and the experience of soldiers in combat. War provides an exaggerated version of the entire range of the human experience. It gives us unique insights into the borders of our humanity.

According to the renowned British military psychiatrist, Professor Simon Wessley, knowledge surrounding the symptoms of psychological breakdown in combat has been well known for over a century and perfected even more so through the World Wars. It had different names such as ‘shell shock’ or ‘war neurosis’. In the mid twentieth century Western asylums were full of ex-servicemen with such syndromes. In a 2005 paper for the British Journal of Psychiatry Wessley writes:

For the first half of the 20th century it was assumed that if you broke down in battle, and the cause was indeed the stress of war, then your illness would be short-lived – and if it was not, then the cause of your ill health was not really the war at all, but events before you went to war…your cards were marked, and well marked, long before you joined the Services. In war eventually every man had his breaking point, but if you broke down and never recovered, then the real cause was not the war, but either your genetic inheritance or your upbringing. The war was merely the trigger.(1)

So what was new about PTSD? That war might result in large numbers of mentally ill soldiers was not news; established doctrine taught that if you developed long-term psychological complications then the war was only the trigger, not the real cause. However, amidst the climate of public outrage at an insane, unpopular and unjust conflict, the formulators of PTSD did not accept that. They believed, for honourable reasons, that the war was unquestionably to blame.

What changed was that the cause of PTSD was the ‘T’ – the trauma. Both the attraction and the danger of this concept lay in its simplicity – here was a psychiatric problem with a simple origin: adult trauma. The messy business of dissecting heredity and upbringing could be replaced with the purity of the experience of war. As best outlined by war historian James Mcpherson’s book Shook Over Hell, there was no new physiology or science to support the claim, only the new politics.

BARRY TELLS ME about the first few weeks of returning home to his regional town. One day he walked with his daughter to the main street with the aim of getting a haircut. He remembered feeling exposed, having been used to colleagues covering him as he scoured the streets for threats and monitored roofs and windows for snipers. While he knew rationally that it was not Rwanda, the primitive recesses of his mind did not differentiate so easily.

‘I ran out of the barber with shaving cream all over me,’ he said, breaking down in tears. ‘I just thought it would get better.’ A combination of noises from outside, from a dog’s bark to an acceleration of a sporty vehicle, had triggered an upsurge of adrenalin in Barry, which completely overwhelmed him.

The symptoms of a traumatic syndrome are classed in three categories. One is the re-experiencing phenomenon in the form of either nightmares or flashbacks. The other is avoidance behaviours of anything that might remind the patient of the traumatic event. For example, survivors of serious car accidents may not be able to drive or even sit in a car for months or even years. The final element is what is known as hypervigilance, where the mind is in a constant state of awareness, scanning the environment for potential threats creating a physiological charge, often making the person appear on edge or highly irritable.

Jai suffered the same symptoms, even though his exposure could not be considered life threatening. His dreams were not true flashbacks, but rather symbolic of his loss of identity and psychic disruption. The images of the text messages from his colleague would play over and over in his mind. He would stare at the business cards from his previous managerial roles to help remind him of better days. He was not faking it, but his work identity was so central to his self image, any disruption to it was intolerable. My focus for Jai was to help him see that his physical pain may have been a more acceptable, face-saving way to cope with his sense of humiliation. I wanted to help him realise the pain was a psychological expression rather than something that could be treated with more and more painkillers.

Barry self-medicated his symptoms away for years, drinking up to fifteen beers a day after coming home from work. His wife suspected there was a serious problem, but did not know what to do and so focused her life on their young daughters.

‘Our marriage was just going through the motions,’ said Barry, reflecting on his lost years. Barry’s ability to manage in his routine, a social mining job, for all its benefits, probably delayed him receiving treatment.

I called Dr Lavinia Schmidtman, the medical director of St John of God Hospital in Richmond (Vic) and head of one of the largest trauma programs in Australia. She said that despite the changes in thinking within the medical fraternity, the ADF and Police, accelerated by the Dunt Review into mental health and the Defence Forces in 2009, have only started taking PTSD seriously in recent years.

She estimates only in the last six or seven years have there been major transformations in how the disorder is treated and monitored within both the police and army. She mentions the deployments of psychologists in the field, regular monitoring of personnel after exposure to combat or traumatic events and involvement of rehabilitation co-ordinators to help affected workers return.

Spokespersons from the NSW police and Australia Defence Forces state that regular, structured programs had been in place since 2000 for the police and 2002 for Defence, in response to comprehensive reviews into the mental health management of their personnel. The focus is on psychological wellbeing in general and neither organisation took responsibility for specialised treatment.

Professor Maureen Dollard is one of the foremost experts in Australia about stress and the workplace. In an interview with me she said that psychological risks were not taken seriously in the workplace up until about ten years ago. The focus used to be on mitigating the types of personalities that might make complaints about colleagues or managers, whereas there was now a greater shift in recognising workplaces as a possible contributor to psycho-social risk.

‘There is now more of an accepted belief that anybody could be worn down within difficult environments,’ she said, noting that it reflected similar changes in thinking about psychological trauma.

She also cited the greater tensions between productivity and profit versus the welfare of the workers. Professor Dollard said that work had become the pre-eminent marker of identity and social status, for both women and men, and this exacerbated psychological risks. Furthermore, a service economy depended more heavily on the human resources, especially the highly skilled variety, making the management of workplaces stress and conflict a managerial imperative of the highest order.

THE EXAMPLE OF Jai illustrates how this greater reliance on work as the primary marker of modern identity, in combination with a loosening of the notions of trauma has precipitated a rapidly burgeoning field of psychological risk in the workplace. The trauma that Jai was exposed to was of a much smaller magnitude than that of Barry, but his coping resources were overwhelmed nevertheless, resulting in similar symptoms. How realistic is it then to attribute the cause to the T, namely the trauma.

THE COSTS ARE astronomical and rising. According to the Workplace Trauma Project Team at Griffith University, the financial cost of trauma and its manifestations to business is between $6 and $13 billion per year and can include decreased productivity, increased absenteeism, staff turnover and poor morale. The average cost of a bullying claim is $41,500.

Within the police there has been a huge blowout in disability claims relating to mental illness, right across the country. NSW taxpayers have paid more than $100 million since 2005 to settle them, according to statistics compiled by the NSW government. There has been a 300 per cent increase in mental health cases.

While the experience of trauma may not always result in PTSD, it was often the trigger to claims involving other diagnoses such as depression or anxiety disorders. Work related psychological claims are the most expensive form of disability and compensation claims as they involve lengthy periods of absence from work.

Barry and Jai are examples of the effects of trauma and their relationship with the workplace, but also of how military concepts of trauma have now taken on new meanings within the civilian sphere.

As further outlined by Professor Wessley, the boundaries of psychiatric injury have since widened. In its initial formulation PTSD could be diagnosed only after situations that had genuinely threatened life and limb. This has been broadened to include situations in which people felt in peril, even if they were not, and finally, to any adverse experience, from viewing a distressing image on television, receiving a medical diagnosis or even normal experiences such as childbirth.

The diagnostic label of PTSD has become shorthand for all distress, and shifted from its initial rigorous formulation in the military context to a much looser one for civilians. The police are a great indicator of societal concepts of trauma for they represent a middle ground between the military and civilians.

Dr Doron Samuell, a forensic psychiatrist and strategic adviser to several major insurance companies, believes, ‘Workers are more entitled now. There is almost an expectation among many that there will be no negative feedback or adversity.’

‘What has changed is that workers attribute the cause to the workplace and their colleagues, rather than their own coping mechanisms.’

Dr Samuell warns that trauma and its association with bullying promises to become an almighty headache for employers since Fair Work changed the law in January of this year whereby there is no longer a requirement for a psychiatric diagnosis after allegations of bullying.

Professor Dollard said employers had to make a greater emphasis on people managers when considering promotion, sometimes ahead of technical abilities. ‘The financial risk of poor people skills is greater than it has ever been.’ But Dollard also noted that applying knowledge about trauma from other sectors was not always successful.

Cait McMahon agrees. She is a former psychologist who runs the DART Center aimed at helping journalists and media organisations better cope with trauma. She said it was not always easy applying models of trauma management inherited from the military in very different workplaces.

‘The models come from more hierarchial, regulated organisations which don’t always apply in the flattened structures and wider varieties of training within the media,’ she said.

She adds that there had been a constriction of the workplace in newsrooms, with greater content demands on a dwindling set of people, placing more at risk but also making managers see it as less of a priority, a trend that disappointed McMahon. ‘A more trauma aware newsroom makes the reporters more trauma literate, which can give them more depth in the work.’

I SAW BARRY once more before he agreed to try a comprehensive trauma program in Sydney. His nightmares of machete-cut bodies returned with a vengeance as soon as he started reducing his alcohol intake. His wife accompanied him to the appointment and broke down into tears in the consultation room, saying she had given up on their marriage long ago. She didn’t think there was any hope.

Jai arrived to his third appointment with a set of forms asking for support with regards to a total and permanent disablement claim, which is defined as having less than a 50 per cent chance of returning to his pre-injury work. I found myself in the awkward but typical position of wanting to maintain rapport and the therapeutic relationship, but not wanting to encourage a victim mentality that would only delay his recovery. He had at least stopped wearing his neck brace. I suggested he postpone his application until he had further engaged with treatment. He was polite through the interview, nodding and grabbing his neck simultaneously. When I asked him about future aspirations, he once again produced his old business cards with titles like ‘Team Leader’ and ‘Assistant Manager’. As he walked out of the session, he gave me a protracted, exaggerated thank you, the meaning of which I was familiar with. Jai had not returned since.

(1) Wessely, Simon (2005). ‘Risk, psychiatry and the military’, British Journal of Psychiatry, 186, pp. 459-466