Diving is not always easy and sometimes things go wrong. The physical impacts of diving-related trauma are the realm of dive medicine, where we are making developments all the time in treating decompression illness and barotrauma. But what about the psychological aspects? Are we talking enough about trauma in diving, and developing support for those who need it? In the UK (for example) our healthcare guidelines give clear directions for healthcare professionals to support people who’ve experienced various forms of traumatic incidents. For example: road traffic accidents, violent assaults, falls, accidents at work, etc. Theoretically, these guidelines apply to an accident in scuba diving, as they would to a car crash. Is this the case in reality? Are divers getting support when needed?
TRIGGER WARNING: THIS ARTICLE BRIEFLY MENTIONS SOME DISTRESSING ISSUES AND THE TYPE OF EVENTS THAT DIVERS MAY FIND TRAUMATIC.
Support for diving trauma
In fact, we do not know. There is not much research on this topic. Until recently, the concept was often dismissed. How we acknowledge psychological trauma is subject to cultural beliefs and biases. There is stigma around admitting difficulty coping following an incident. This is a shame, because there are highly effective ways to address stress injuries psychological trauma. So much so, that people who experience and address trauma will often end up more resilient. Rather than”battling through” or “toughing out” trauma (making it worse, btw) divers could receive support. There are approaches that can help a diver through PTS more safely, and in a way that leaves them stronger than before.
“Psychologists can play an important role in the prevention of risk and in the management of behaviour affecting diving security. They can help divers solve psychological problems following traumas, including those connected to underwater accidents.”Divers Alert Network – Psychological reactions and scuba diving, description of a treatment
Techniques such as EMDR support the nervous system to process trauma memories. This therapy helps people to make sense of what happened and let go of the distress. After trauma memories are processed the person can still remember the event and is better able to learn from what happened. Healing from psychological trauma is not only helpful for the individual, but to everyone around them.
Trauma in organisations and workplaces
Diving activities can often involve teams within organisations, and incidents do occur in workplaces. We sometimes forget that recreational/technical instruction and guiding is work for the professionals involved. Then there are commercial diving operations, saturation diving, scientific and media diving. These are workplaces, subject to employment law and with specific duties with regard to health and safety.
There are useful models for thinking about safety processes and how we respond to incidents. For example, at the Human Factors in Diving Conference (October 2021) I was intrigued by “the Bowtie model”. We often focus on the left side of the bowtie: preventing factors that cause incidents. But the right side of the bowtie is just as important. It covers controls to reduce the impact of incidents/accidents; how we recover and build resilience. Vallorie Hodges, University Diving Officer and Safety & Wellbeing Advisor at the University of Tasmania, presented an adaption of the model. The bow tie must be spun to keep a balance between prevention and response that “propels” safety forwards. She argued that: Regardless of how much effort we make to prevent diving incidents, they will still occur, so we must also be able to respond when things go badly.
More focus on stopping incidents and less on building effective responses is an unbalanced system. On the surface, it seems to make sense. Imagine the fire brigade putting all of their resources into preventing fires. Preventing fires is clearly better than waiting for a fire to fight, right? Certainly. But if it meant that no resources were directed to training and equipment for putting out fires? When there is a fire, would the response be as good?
The talk mentioned response, recovery and resilience in terms of processes and training. I could not help but think of psychological trauma in diving. Stress injury or post-traumatic stress is a potential outcome of a critical incident in diving. But it is not as obvious as a physical trauma. Where medical issues will be assessed and treated, psychological trauma can go under the radar. This is particularly likely across diving workplaces where there may be social or financial implications to seeking help. Responding to an event effectively would include processes for recovery from psychological trauma.
This spins over to prevention too. Active symptoms of PTS can be a risk factor for further incidents. For example, high anxiety or flashbacks can make it hard to focus and impair concentration. Nightmares can mean chronic sleep disturbance. Mistakes may be more likely. Unresolved trauma can feel like being stuck. Worrying about abilities and struggling to cope adds more pressure. Defensiveness or mood issues can get in the way of communication, raising more risk. When psychological trauma is resolved, the distress subsides and perspective opens. There is often an opportunity for learning, as well as sharing of lessons from the trauma. Occasionally, the person finds themselves with better psychological wellbeing than before the trauma: “post-traumatic growth”.
What is traumatic in diving?
“a deeply distressing or disturbing experience.”OED
Psychological trauma is highly individual. The same horrific order can leave one person with years of symptoms and another unscathed. Similarly, an event that may seem relatively minor to some will have a significant impact on others. Multiple factors have a role. For example: a person’s background, previous wellbeing, experience, role, proximity to the event, ability to respond at the time, individual perception of what was happening … (more on that later in the year). This all means that what events are traumatic in diving is highly subjective. A novice diver could have difficulties after thinking they “almost drowned” while learning to clear their mask in the swimming pool. The instructor with them will have had a very different perception of risk. The student’s reaction may seem disproportionate when the instructor believes the person was always safe.
Dive accidents and rescues
There are more extreme examples of course. Being at the scene, or helping, when a diver dies can be highly distressing. Even more so when the victim is a buddy or family. Experiencing an accident in diving, with or without physical injury can be traumatic for the victims, rescuers and bystanders. Dive boat skippers, depending on local conditions, can be at risk of witnessing multiple injuries and fatalities in a season. Where the event may be a one-off for the visiting dive club, the boat crew are bringing groups to the same site week after week, and may see similar incidents more than once. Multiple trauma can be more of a risk factor.
There are also some less talked about issues relating to the power gradients in diving. (Hopefully, these are rare events.) For example, instructors or guides actions that put less experienced divers in uncomfortable positions. This can range from removing the diver’s equipment, perhaps as a joke or intended as an informal stress test to physical or sexual assault. The novice, having limited skill and (quite literally) out of their depth, is vulnerable. They may even be dependent on the perpetrator for their survival. Scared for their life, they may have no choice but to comply, and continue to follow instructions until safely out of the water. This power imbalance and vulnerability is a predictive factor in whether the person goes on to develop PTS or not. Again, for some these actions would be mild annoyances and lead to nothing more than an unfavorable TripAdvisor review.
One field of diving where workplace trauma is a risk is public safety diving. These divers could be searching for and retrieving bodies in conditions no recreational diver would ever consider going. Stress injury in this area is an odd one, as it may not happen when you might expect. It depends so much on perception. Low visibility, human remains and grieving families, the jobs can easily be considered traumatic. But, most of the time, the divers are not traumatise just doing their job, and are fine. Factors like using experience and skills, routine procedures, working with a trusted team and doing a job that (while not pleasant) is meaningful can be positive. However, there will be times where trauma is more likely to have a psychological impact: jobs gone wrong, accidents at work and the cumulative effect. Team dynamics, working conditions and wider life events also have a role.
There is little research on workplace risks to mental health in diving-specfic roles. The risks may be comparable to emergency services, (emergency responders, police and fire crew). In the UK, the Health and Safety Executive have a new campaign to raise awareness of mental health risks in the workplace. The Working Minds campaign supports the view that psychological health is as important as physical health. HSE regulations cover diving operations.
Going by conversations I’ve been having recently, social media discussions and dive training agency attention (EFR MHA; BSAC Mental Health Blogs; Adaptive diving) divers are increasingly open to talking about mental health and trauma in diving. In the past, I’ve (mistakenly) thought the need for support was rare, but as more and more people share their experiences, it is seeming like there is a significant need. Therefore, in 2022, I’ll be focusing more on psychological trauma in diving. Although there is no funding currently of this research, I hope to carry out at least a small pilot study on diver’s experiences of trauma. I intend to study the existing research literature in more detail and write about the topic, leading up to an informative course for divers to improve understanding of trauma. Finally, I will continue to offer private, online therapy for (UK) divers.
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