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Road victim trauma: an investigationof the impact on the injured andbereavedNoreen Tehrani Dr, Managing Directora Assessment and Rehabilitation Consultants , Twickenham, UKPublished online: 22 Oct 2010.

To cite this article: Noreen Tehrani Dr, Managing Director (2004) Road victim trauma: aninvestigation of the impact on the injured and bereaved , Counselling Psychology Quarterly, 17:4,361-373, DOI: 10.1080/09515070412331331255

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RESEARCH REPORT

Road Victim Trauma: aninvestigation of the impacton the injured and bereaved*

NOREEN TEHRANIAssessment and Rehabilitation Consultants, Twickenham, UK

abstract Every day in the United Kingdom ten people are killed and between 900 and

1,000 injured on the roads and, consequently, the health of large numbers of the victims, relatives

and friends are adversely affected. Yet despite the magnitude of the problem little has been done to

assess the full impact of road crashes on those involved, or to identify the best ways to provide help

and support. This paper describes the impact of road traffic incidents on a large group of injured

and bereaved victims, who approached Road Peace (a national charity for road traffic victims)

for support. The research that examined data collected over an eight-year period was able to

identify the nature of the impact of the traumatic exposure of these victims. The paper goes on to

examine the needs of the road crash victims and suggests ways that timely support and advice

could help to reduce the levels of distress.

Introduction

Until very recently little had been written about the psychological consequences of road

traffic crashes. Even today, the literature on the subject is small (Mayou, 1998). This lack

of systematic research and investigation into the subject is surprising given the numbers

of people affected by road crashes every day. Dealing with the psychosocial problems

related to the trauma of a road crash is a complex process which involves large numbers

and types of professional and other stakeholders. It is not surprising that injured

victims and distressed family members find it difficult to identify and access the best

information and support. Much of the post-crash distress is caused by failures in the

system to recognise the basic needs of the primary and secondary road crash victims

(Figley, 1995). This problem is compounded by failures in the delivery of the support in a

form that can be understood and accessed by anxious and distressed people. In many

*A study undertaken in co-operation with RoadPeace.

Correspondence to: Dr Noreen Tehrani, Managing Director, Assessment and Rehabilitation

Consultants, 12 Barensfield Road, Twickenham TW12QU, UK; e-mail: ntehrani@btinternet.com

Counselling Psychology Quarterly,

Vol. 17, No. 4, 2004, pp. 361–373

Counselling Psychology Quarterly ISSN 0951–5070 print/ISSN 1469–3674 online # 2004 Taylor & Francis Ltd

http://www.tandf.co.uk/journals

DOI: 10.1080/09515070412331331255

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ways, the victims of road crashes respond to trauma in the same way as victims of other

disasters. However, there is one major difference. Where an untimely or traumatic death

or injury occurs in a factory, ship, or mine the event is carefully investigated, causal

factors are identified and, where appropriate, action taken to reduce the likelihood of

similar incidents occurring again. In the case of death or injury on the road, post-incident

investigations are often minimal and occur in an atmosphere where road death is regarded

as an unavoidable outcome of a minor road traffic offence. The death or injury of the

victims is sometimes not seen as significant enough to warrant a mention in court. This

attitude of society has a profound impact on road crash victims and their

families who often feel let down and marginalised in their distress. A frequent cry

from victims of road crashes is for justice and an appropriate recognition of the pain

and suffering they have experienced.

Reactions to road traffic injury

It is important to recognise that while most people are resilient and cope well with the

physical pain and disability caused by a road crash, many road crash victims suffer

distressing psychological symptoms (Alexander, 1997). Post-trauma psychological symp-

toms vary in their type and magnitude and may continue to affect the victim long after the

physical scars have healed. Whilst it is difficult to predict who will suffer the most

following a road crash, the victims with pre-existing psychological (Blanchard et al., 1997)or social problems (Mayou, Tyndel & Bryant, 1997) have been shown to have more

difficulty in dealing with the stress and shock of bereavement. Supporting a disabled

family member, or becoming disabled oneself can be the cause of additional strain.

Unfortunately, the needs of families are frequently overlooked, with the result that the full

extent and cost of road crashes are significantly underestimated in terms of physical,

psychological and social disruption caused.

The quality of help and support provided for the victims and their families are critical

factors in the process of recovery, with social support being consistently found one of

the most important factors in facilitating recovery. It has been found (Perry, Difede,

Musngi & Jacobberg, 1992) that a lack of adequate psychosocial support has a greater

influence on the onset of post traumatic stress disorder (PTSD) than the severity of the

physical injury. A lack of social support has also been shown to increase the likelihood

of ‘late onset PTSD’ (Andersson, Dahlback & Allebeck, 1994). Late onset PTSD can

occur months or even years after the traumatic event in an individual who previously

appeared to be unaffected by the ordeal.

The psychological effect of serious injury or death on the road may be further

compounded by post-crash experiences. These experiences may include the insensitive

attitude of police, hospital personnel, mortuary attendants, coroners or magistrates.

Post-crash trauma (sanctuary trauma) occurs when an individual, having suffered a

traumatic event, encounters a person or situation expecting support or protection but

only experiences a lack of support or a malevolent attitude. The following case studies were

collected as part of the FEVR study (European Federation of Road Traffic Victims, 1997).

Case Study 1 gives an example of sanctuary trauma where the friend of a girl killed

by a car was distressed by the leniency of the courts.

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Case Study 1 (Boyfriend of girl killed in road crash)

I don’t feel justice was done. The driver of the car that caused the death of my

girlfriend, through absolutely no fault of her own was not even banned from

driving for one year. If someone causes the death through dangerous driving

they should be automatically banned for at least a year. The driver was fined

£100. I feel that I am unable to depend on anything anymore.

Traumatic experiences such as a road crashes can shatter the fundamental beliefs on

which people build their lives. Many of our most deeply held beliefs are irrational,

reflecting a wish for how things should be, rather than how they are in reality. Some of the

commonly held beliefs that are shattered for victims of road crashes are illustrated in

Table I.

When, following a road crash, some or all of these beliefs are shattered the victim is

left feeling shocked, angry and abandoned in a world that they once experienced as being

predictable and safe. The failure of society to meet the victim’s expectations challenges

their basic values and can result in complex patterns of psychological symptoms including

post traumatic stress disorder (Janoff–Bulman, 1992). Case study 2 illustrates how a

bereaved mother reacted to the death of her daughter.

Case Study 2 (Mother of child killed by speeding car)

I felt alienated from the people who did not know what to do. Some friends

avoided contact with me, the good ones tried to cope with me. Initially my

family was good but when they thought that I should have got over it, they

stopped giving any support. Now I get no support from my family at all and

I have withdrawn from them. I feel isolated. I have problems sleeping and have

nightmares. I have lost all interest in everyday activities and in my profession.

I am depressed most of the time.

Post trauma symptoms

There is an increasing body of evidence that has identified a significant overlap between

Post Traumatic Stress Disorder (PTSD) and other psychiatric symptoms (Green, Lindy,

Grace & Leonard, 1992). Victims with pre-existing psychological conditions such

as anxiety or depression often find these conditions re-emerge following a road crash.

TABLE I. Common irrational beliefs

If I am careful I will come to no harm

The law always protects the innocent

Life is fair

The future is predictable

I can depend upon professional people to do a good job

The payment of damages will compensate my loss

Road Victim Trauma: an investigation of the impact on the injured and bereaved 363

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Post trauma responses, physiology, personality, family environment and social stressors

interact to bring about a wide range of physical and psychological symptoms. Because the

post trauma symptoms may be delayed or lack any clear causal link to the road crash,

physicians often fail to recognise them as being part of a road crash syndrome (Bloom,

1998). In a study which compared trauma victims with PTSD with patients suffering

from a chronic depressive disorder, it was found that those with PTSD were more likely

to suffer from poor social support, more marital difficulties and occupational problems as

well as more financial problems (Landsman et al., 1990). When compared with patients

with chronic depression people with PTSD were also found to have a higher level of

physical illnesses, substance abuse, major depression, phobia, obsessive compulsive

disorder and depersonalisation (Solomon & Davidson, 1997). In Case Study 3 a father

describes the debilitating impact the death of his son had on his life.

Case Study 3 (Father of boy killed in road crash)

I am unable to put aside the vivid memories of our son lying on the pavement

dying. Nothing seems real or important except Gary. I have been unable to show

love to my other two sons, especially the youngest who was 8 months when Gary

was killed. There are constant reminders in our daily life of Gary. What would

he be doing now? Followed by memories of seeing Gary dead or seeing his

coffin. Not wanting to carry on, to walk away and cop out on life. I feel let down

by the law and society, and a burning desire to obtain justice, human justice!

I feel immediate anger and frustration when I see cars parked on the pavement

or speeding cars. I have flashbacks of how Gary was killed, a lack of sleep,

concentration, and a belief that I have no future, no prospects or hope.

Primary and secondary victims

Much of the research into the impact of road crashes has focussed on primary victims.

Primary victims are those people who were directly involved in the road crash (Blanchard

et al., 1997; Mayou et al., 1997). Where the research has looked at the impact of

road crashes on secondary victims it has focussed on the experiences and symptoms

of emergency workers, counsellors and other supporters (Figley, 1995). However, the

largest groups of secondary road crash victims are the families and friends of the injured

and bereaved. These two groups have had little investigation to assess the impact of

the road crash on their physical, psychological and social well-being. The mother in Case

Study 4 gives a typical response to a road crash bereavement.

Case Study 4 (Mother’s response to a road crash bereavment)

I cannot accept what happened to my Carolyn, although it is a year now.

The pain is as sore now as it was then. I cannot go anywhere in public without

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the tears falling. Seeing mothers with their children. My stomach goes in knots

and I feel physically sick.

European research

An important pioneering study was undertaken in 1997 by the European Federation of

Road Traffic Victims (FEVR). This study looked at the principle causes of the decline in

quality of life and living standards suffered by road crash victims and their families. This

study found that families bereaved through road death suffered a dramatic decline in their

quality of life, standard of living and psychological well-being in much the same way as

the disabled victims and their families. The main findings of the FEVR research are

illustrated in Table II. One of the most concerning findings of the FEVR study was that

even after three years the magnitude of symptoms had only decreased by an average 10%.

When the study separated the groups of victims it was found that there was little

difference in the incidence of symptoms for relatives of dead victims, relatives of disabled

victims and the disabled victims themselves, indeed in many cases the bereaved relatives

appeared to have the most problems.

The FEVR study although providing an indication of the impact of road crashes

on the primary and secondary victims was not designed to provide data that could be

empirically tested.

The study

This study presents the findings of an investigation designed to identify the prevalence of

post-traumatic stress in victims of road crashes. In the study two groups of subjects were

identified, firstly, the primary victims of road crashes where the victim sustained an injury

requiring hospital treatment and secondly the bereaved families of people killed as a result

of a road crash. The study also looks at the relationship between post trauma symptoms

and the level of post trauma support.

TABLE II. Post trauma symptoms in secondary road crash victims

(source FEVR Study)

Symptom Prevalence (%)

Difficulty in sleeping 49

Nightmares 41

Anxiety attacks 37

Phobias 27

Eating disorders 35

Suicidal feelings 37

A loss of interest in everyday activities 72

A lack of drive 70

A loss of self confidence 47

Road Victim Trauma: an investigation of the impact on the injured and bereaved 365

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Method

The subjects for the study had all contacted the RoadPeace helpline following a road

crash. The purpose of the study was explained and the callers were invited to complete

a self-assessment questionnaire.

The questionnaire was made up of seven sections:

1. Demographic information.

2. A description of the crash.

3. The impact of the crash on those involved.

4. Where the subject placed the responsibility for the crash.

5. The IES-E questionnaire which measures post traumatic stress symptoms.

6. A life style questionnaire.

7. Information on the quality of the immediate and ongoing support.

Subjects

One hundred and fourteen subjects took place in the study. The subjects formed five

groups:

1. The families and friends of people killed on the road.

2. People injured in road crashes.

3. People injured and bereaved in a road crash.

4. Carers of the injured.

5. Witnesses to a road crash.

There were 46 subjects who were injured, 57 who had been bereaved, eight injured

and bereaved, two carers and one witness. (Due to the smallness of the numbers of

groups 3, 4 and 5, no further analysis of these data was undertaken.)

The mean age of the injured subjects was 37 years; there were 33 females and 13

males. The mean age of the bereaved subjects was 43 years; 48 were female and nine

male. The average time since the crash for the injured subjects was 5.5 years and for the

bereaved subjects 4.5 years. All subjects were aware that the information they provided

would be used for research purposes and that no personally identifiable information

would be revealed without their written permission.

Measures

The extended impact of events scale (IES-E) (Tehrani, Cox & Cox, 2002) was used to

measure the post trauma symptoms. This post traumatic stress instrument has been used

for measuring the level of post traumatic stress in a number of occupational groups

including a large study in the emergency services (Tyler, 1999) The IES-E measures the

three post trauma symptoms of avoidance, arousal and re-experience. The questionnaire

also examines a further 11 associated psychological symptoms. These symptoms were the

most commonly occurring symptoms taken from the written accounts of more than 200

road crash victims. The social impact of the road crash looked at financial, relationships,

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social life, status and ability to work. The physical impact looked at the severity of the

injuries together with the pain, disability, disfigurement and length of hospital treatment.

The quality of support assessed the subjects perception of the quality of support provided

by the emergency services together with the follow up support in the areas of legal,

insurance, health and general well-being. The subjects were also given an opportunity to

provide further comments, which provide additional qualitative feedback.

Results

Results were calculated for each section of the questionnaire.

Responsibility for the crash

The other driver was almost entirely attributed with the blame for the crash with 94.6%

of the injured and 88.7% of bereaved subjects believing that the other driver had caused

the road crash. A total of 3.9% of subjects indicated that the road conditions were the

likely cause of the crash and a further 3.9% believed that there was some shared

responsibility for causing the crash.

Trauma symptoms (IES-E)

The Extended Impact of Events Scale (IES-E) was used to measure the post traumatic

stress symptoms (Tehrani et al., 2002). This scale measures the three trauma symptoms

of arousal, avoidance and re-experience. The results showed that 76% of the injured and

70% of the bereaved were suffering from ‘caseness’ levels of arousal. That 59% of injured

and 47% of the bereaved had caseness levels of avoidance and 59% of injured and 75% of

bereaved were experiencing caseness levels of re-experience. Based on these scores 73.9%

of the injured and 66.7% of the bereaved subjects were found to be experiencing levels of

Post-Traumatic Stress which required psychiatric or psychological investigation.

The levels of symptoms found in this study was rather different than had been found

in victims of violent attacks and armed raids (Tehrani et al., in press). In both the injured

and bereaved groups, the levels of avoidance symptoms were found to be lower than

would have been predicted.

TABLE III. Percentage of injured and bereaved subjects suffering from Post Traumatic Stress Symptoms

Arousal Avoidance Re-experience PTSD

Injured 76.1 58.7 58.7 73.9

Bereaved 70.2 47.4 75.4 66.7

Road Victim Trauma: an investigation of the impact on the injured and bereaved 367

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Associated psychological features

Table IV summarises findings related to the levels of associated psychological features

and the percentage of injured and bereaved subjects exhibiting these symptoms.

In addition, the levels of correlation between the associated psychological features

and the symptoms of PTSD as measured by the IES-E were also calculated. Using

Odds Ratio (OR) the increased risk of having PTSD was estimated for each of the

associated psychological findings. The results showed differences between the post-crash

symptoms of the injured and bereaved with the injured having more panic attacks,

phobias, depression, anger and resentment than the bereaved. The bereaved

subjects were more likely to experience higher level of suicidal thoughts and feelings

of and guilt.

When the correlations were checked it was found that all the associated symptoms

were strongly correlated with the PTSD symptoms. The Odds Ratio indicated that all

of the symptoms were associated with a higher risk of PTSD. However, irrational shame

or guilt was found to be particularly powerful in that the risk of developing PTSD was

TABLE IV. Percentage of victims with high levels of associated psychological symptoms and

the increased risk of PTSD

Symptom Injured (%) Bereaved (%)

Correlations

with PTSD

Increased Risk

(OR) of PTSD

Panic attack 72 46 p<0.000 1.0

Phobia 76 56 p<0.001 1.3

Anxiety 79 76 p<0.000 1.4

Depression 86 78 p<0.000 1.3

Suicide 37 55 p<0.005 1.5

Shame/Guilt 27 44 p<0.006 2.9

Anger 79 69 p<0.000 1.6

Resentment 85 70 p<0.000 1.4

Enjoy life 62 75 p<0.008 1.5

Loss of drive 80 79 p<0.000 1.4

Sense of future 73 80 p<0.002 1.3

TABLE V. The negative social impact of a road crash indicated as % of subjects suffering extreme of

severe difficulties

Area of impact % Injured Anx. Dep. % Bereaved Anx. Dep.

Financial 82 0.381* 0.327* 46 0.07 �0.136

Relationships 66 0.263 0.253 61 0.470** 0.457**

Sports/Social life 88 0.461** 0.479** 57 0.383** 0.365**

Status 78 0.086 �0.202 52 0.114 0.121

Job 79 0.189 0.202 57 0.285* 0.245

Notes: **p<0.01; *p<0.05.

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almost three times greater in people experiencing irrational shame and guilt than for

subjects who did not have these thoughts.

Social impact

Involvement in a road crash has a large impact on the life of the victims. Table V shows

the percentage of injured and bereaved subjects that experienced social difficulties.

These social difficulties were correlated with levels of anxiety and depression. These

results showed some similarities and differences between the injured and bereaved

groups. The injured experienced more anxiety and depression regarding financial

problems than the bereaved. The bereaved experienced high levels of anxiety and

depression related to relationship problems. In addition, the bereaved subjects were

more anxious when they had difficulties with their work. Both groups experienced higher

levels of anxiety and depression associated with a lack of sports and social life.

Life style

A healthy lifestyle can help to protect against further physical and psychological problems.

The results in Table VI indicated that the injured were having difficulty in maintaining

their health through exercise, getting a good nights sleep, which may be explained by the

nature of their disability. The bereaved subjects ate less well and drank too much coffee.

Both groups had problems in their social lives and outside hobbies and interests.

When the quality of lifestyle was correlated with the PTSD score, it was found that

there was a strong correlation between social life and PTSD for both injured and

bereaved subjects. Exercise and sleep were also related to high PTSD scores for both

groups. In the injured group, there was also a correlation between smoking and PTSD.

Quality of support

The quality of support was assessed in the immediate aftermath of the crash and

during the follow up. The results are in Table VII. In the perception of the bereaved,

TABLE VI. Life style of injured and bereaved road-crash victims: the percentage of

subjects with poor life styles and correlations with PTSD

Lifestyle Area Injured (%) Bereaved (%)

Meals 23.9 33.3

Caffeine 28.0 37.0

Alcohol 13.0 14.0

Exercise 30.4** 24.6*

Interests 32.6** 33.3

Sleep 30.4** 22.8*

Social life 39.1** 40.4**

Tobacco 6.5* 3.5

Notes: **p<0.01; *p<0.05.

Road Victim Trauma: an investigation of the impact on the injured and bereaved 369

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the supportive groups were RoadPeace, the counsellor, hospital, and the church. There

was no significant correlation between the immediate support and IES-E scores.

The injured perceived the courts, The Crown Prosecution and the insurance

companies as least supportive. The most helpful organisations were RoadPeace,

the Church, the GP and counsellors. For the bereaved, the least help was provided

by the psychiatrist, ambulance service, courts and The Crown Prosecution. Most help

was provided to the bereaved by RoadPeace, the church, the mortuary attendant,

the counsellor and the accident and emergency department.

Discussion

The data obtained from the study supports the findings of the FEVR study by

demonstrating that the bereaved and the injured groups of subjects are both vulnerable

to experience post traumatic stress, anxiety and depression. This finding suggests

that there is a need to give some attention to the psychological needs of both groups

following a road crash. The data also showed that around three-quarters of the subjects

experience traumatic stress symptoms which are indicative of the presence of Post

Traumatic Stress Disorder (PTSD). In addition to the post traumatic stress symptoms,

both groups suffered high levels of associated psychological problems including anger,

resentment, an inability to enjoy life and a loss of drive. Of particular importance was

TABLE VII. Satisfaction with the quality of support. Percentage of

subjects that rated the service as excellent or good

Satisfaction levels (%)

Support group Injured Bereaved

Police* 33.3 47.8

Ambulance* 30.4 15.8

Fire service* Na 50.0

A&E Dept.* 39.1 61.9

Mortuary* Na 75.0

Follow up police 30.3 29.7

Solicitors 44.1 38.5

Crown prosecution 10.5 25.0

Coroner Na 45.9

Courts 8.3 16.7

Insurance 20.0 28.6

Hospital 45.7 73.7

GP 51.3 56.4

Psychiatrist 33.3 11.1

Community nurse 37.5 57.1

RoadPeace 96.2 97.5

Counsellor 50.0 64.3

Social services 36.4 50.0

Church 54.5 68.4

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the presence of irrational guilt, which was associated with almost three times the level

of post traumatic stress and panic attacks found in subjects who did not have these

irrational thoughts.

Despite these findings, only 45 of the 114 subjects had seen a counsellor and 22

subjects had seen a psychiatrist. The satisfaction with counsellors was higher for the

bereaved subjects than for injured subjects. However, the counselling did not appear to be

associated with a reduced level of traumatic stress symptoms. Injured subjects were less

likely to have seen a counsellor than bereaved subjects, it is possible that this is because of

the mobility problems that are faced by injured victims. There was a low level of

satisfaction with psychiatrists, among the bereaved. An inspection of comments made

on the questionnaires suggested that this dissatisfaction largely related to psychiatrists

being seen as part of the legal system used to assess the level of psychological injury for

insurance claims.

The social problems suffered by the injured victims of road crashes were found to

cause extreme or severe distress to over 75% of subjects. Social problems are strongly

correlated with high levels of anxiety and depression. Social support has repeatedly

been found a critical component of the recovery or lack of recovery of those involved in

a road crash. This finding confirms the work of Andersson et al. (1997) which showed

that poor social support is one of the main risk factors in the development of post

traumatic stress.

Severe financial hardship was reported by 70% of the subjects taking part in this

study. This data gives some indication of the magnitude of the economic problems

faced by many road crash victims. Whilst this may not be a totally representative

sample it is indicative of the problems that are facing a large number of families following

a road crash.

The life style patterns of the injured and bereaved were shown to be rather different

from each other. Overall, the injured road crash victims tended to eat more regularly

and drank less caffeine than the bereaved. On the other hand, the bereaved tended to

take more exercise and have more sleep than the injured. A healthy lifestyle was

associated with lower levels of post traumatic stress. From the data gathered it was

not possible to show whether the poor life style caused in the increased levels of post

traumatic stress or that people with post traumatic stress were more likely to have a poor

life style.

Whilst this study did not identify a direct link between the quality of support and

post traumatic stress this linkage has been demonstrated in many other studies

including that of Landsman et al. (1990). Landsman et al. showed that 3 years after the

traumatic experience the levels of psychological distress were predicted less by injury

severity than by the subsequent financial, employment, family and other social difficulties.

The road crash victims identified a wide difference in the level of care and

support provided. Some groups were seen as significantly more supportive than other

groups. Of particular note were the mortuary attendants where there was a 75% level of

satisfaction. In contrast, there was only a 15.8% level of satisfaction with the support

provided by ambulance staff. The results also showed a low level of satisfaction with the

legal services, particularly the courts and Crown Prosecution. As most road crash victims

Road Victim Trauma: an investigation of the impact on the injured and bereaved 371

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will have some contact with the legal system, it is important that more effort is made to

ensure that these services become more sensitive to the needs of the road crash victims.

Of particular importance is the benefit of a self-help advice and guidance service such

as that provided by RoadPeace, together with support from the church and counsellors

this was seen positively by both groups of subjects. It is vital that the support provided

is long term and meets the personal, social and psychological needs of the road crash

victims. The provision of a single, isolated intervention such as debriefing and other

forms of crisis intervention has been shown to be inadequate (Paton et al., 1998). What

is required is a national programme of support that provides early assistance and

information followed by support resources which facilitate self-help and which sustains

and promotes positive personal growth and recovery.

Acknowledgements

I would like to offer my gratitude to all the victims of road crashes who took part in this

study and to RoadPeace for their support of this research.

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