Victimhood and Resilience
http://www.100md.com
《新英格兰医药杂志》
At least until the failed attacks of July 21, the gut-wrenching shock of the July 7 suicide bombings in London had been starting to dissipate, and the nonstop news coverage was slowing. Gradually, Londoners were beginning to get on with their lives. Three days after the bombings, I joined the crowds celebrating the 60th anniversary of the end of the Second World War. The sun shone, and the Mall was full of old, proud men, wearing polished medals and fading berets. A military band gave a surprisingly good impersonation of the Glenn Miller Orchestra, and a Lancaster bomber accompanied by two Spitfires flew overhead, dropping poppies on us. The following day, England played Australia at cricket, and all seemed normal — including the resounding English defeat. True, there were more police than usual and we now had to enter the grounds by way of metal detectors, but the rituals of a London summer had returned.
But what about those for whom life as usual is not going to go on? Those whose lives have been shattered by bereavement and those whose bodies were shattered by the blasts of terrorist bombs? As one emergency worker told the BBC after leaving the scene of the bombing at King's Cross station, "I don't know what heaven looks like, but I now have a good idea of hell." Many of the survivors and the bereaved are suffering intense mental anguish, an anguish that is painful for the rest of us even to witness.
What can we do to help these people cope with the unimaginable? The conventional wisdom has been that those affected by such disasters need immediate psychological help to assist them in "ventilating" their feelings, to warn them of the emotional symptoms they may face in the coming days and weeks, and to prevent a subsequent breakdown. But though this belief may have been conventional, it was not wisdom.
There have now been more than a dozen controlled trials in which people who have been involved in accidents and other traumatic events have been randomly assigned to receive or not to receive such counseling. The results have shown conclusively that such immediate psychological debriefing does not work. Those who received it were no better off emotionally than those who did not. Worse, the better studies with the longer follow-up periods showed that receiving such counseling actually increased the likelihood of later psychological problems. In fact, the people who seemed to be harmed by this intervention were those who had been especially upset at the time — precisely those who one might think ought to be treated.1 So whereas immediate post-trauma counseling may reassure the rest of us that something is being done, it does not actually help those who receive it.
Why doesn't it work? For some, such counseling is just too painful and comes too soon. It is also possible that warning people about potential symptoms makes them more likely to experience them. For some people, not talking is the most appropriate immediate response. Talking to a professional whom one has never met before and might not meet again may even get in the way of doing what comes naturally — talking with family members, friends, colleagues, religious advisors, or the family doctor. The people who know us best are likely to know what support we need and when we need it.
Asking people to talk about their feelings when they are still raw with pain is not always a good idea. The day after the bombing, all the television news bulletins showed footage of the father and the grandfather of 20-year-old Shahara Islam, who had gone to work on July 7 and hadn't been seen since. There we saw intense distress — the grandfather unable to articulate a coherent word, the father so distraught that it was uncomfortable to watch him. We didn't need to ask them how they were feeling. Five days later, it was announced that Shahara Islam had been killed in the bus explosion at Tavistock Square. Immediate counseling is not going to heal her family's grief.
Instead, what people need during the first few days is the support of their family and friends and assistance with information, finances, travel, and the planning of funerals. The most appropriate immediate mental health interventions are practical, not emotional.2
Many people who are now in distress and despair will heal with time. Others will not, and serious psychological illnesses such as depression and post-traumatic stress disorder will develop in some. Prevention of these disorders would have required avoidance of the doomed trains. But the illnesses can be treated, and there are already plans to provide treatment.
Shortly after the blasts occurred, the National Health Service's mental health trusts covering the four hospitals that collectively treated 700 casualties from the bombings came together to coordinate their response. The Camden and Islington Mental Health Trust, which covers the area including University College and the Royal Free Hospitals, is taking the lead in organizing mental health services for those in need. About six weeks after the bombings, they will initiate a "treat-and-screen" program for people who were directly affected and are known to be at the highest risk for psychological sequelae. The delay is deliberate; some people will not be ready for interventions before then, and others will by then not need them.
Although the efficacy of mental health screening has not been established, it is a proportionate and reasonable response to initiate screening of those who were directly affected, especially given the known barriers to help-seeking among trauma victims with consequent mental health problems. There is good evidence that persons with ongoing stress disorders can benefit from cognitive–behavioral therapy. The real-life effectiveness of such screening and treatment was proved in the aftermath of the 1998 bombing in Omagh, Northern Ireland.3
But the events of July 7 also demonstrated the sensible way in which ordinary people deal with adversity. We did not panic. We coped. That evening, I watched from my home in central London as an endless stream of people began their long walks home. They looked "inconvenienced rather than heartbroken," as one Web article (www.slate.com) put it. Ordinary people are tougher than we sometimes give them credit for being. And this should have come as no surprise. The people who were in the World Trade Center on September 11, 2001, had to find their own ways of leaving the buildings, and they did so without any signs of panic.
Indeed, people generally don't panic in the face of adversity — unless they are caught in confined spaces without any visible means of escape. One can understand the brief moments of overwhelming fear that some experienced when they were trapped in darkness after a bombing. One of our secretaries was on the train that was blown up under King's Cross. She said there was a moment of silence after the flash, followed by moaning and screams from the injured people in the front carriage. When black smoke began to drift into her carriage, some passengers did start to cry or panic. After a few minutes, however, most people regained their composure, and several got together to try to force open the train doors. During the 20 minutes or so that it took the emergency workers to check for chemical, biologic, and radiologic agents before descending to the train, she saw other passengers comforting the wounded and administering first aid.
One young man, named in media coverage simply as Paul, had lost his leg. The driver of the train tied his own belt around what remained of the leg, probably saving the man's life. While waiting for help, Paul told another passenger that there was a bright side: he could now enter the Paralympics, he said, alluding to the previous day's announcement that London will host the 2012 Olympics — news that had been greeted with collective euphoria.
One reason for the stoicism demonstrated by so many Londoners is that although the atrocities of July 7 may have been the worst acts of terrorism to take place in the capital for many years, they were not the only ones we have seen. I remember the flash and boom of the bomb that was set off by the Irish Republican Army in 1992, destroying the Baltic Exchange. The collective memory of the city goes back even further. When Hasib Hussain detonated his bomb on the upper deck of the Number 30 bus and took 13 lives along with his own, he did so at Tavistock Square. A previous resident of that square was Virginia Woolf, and it was there that she returned one morning in October 1940, when the all-clear siren sounded, to find her house destroyed by German bombs. Her description of the scene foreshadowed those of the same square 65 years later.
Politicians, civic leaders, and the media have been keen on invoking the "Blitz spirit" in recent days, in order to foster resilience and remind us of our cultural scripts of defiance in the face of adversity. And there are resonances. Before the outbreak of the Second World War, politicians, military commentators, and emergency planners believed that aerial bombing would provoke mass destruction, panic, and a catastrophic collapse in morale. Yet these reactions did not occur. The Blitz killed 40,000 Londoners, and although there were short periods of considerable fear and disorganization, such a state was the exception, not the rule.4
But perhaps it would be more appropriate to compare our response to the July 7 bombings with the way we — and Israelis— have coped with living under the threat of terror.5 Like the Israelis' immediate response, ours was to turn to our mobile telephones. Initial anxiety died down when we were able to determine the safety of those close to us, and if and when the current emergency resolves, we should expect our confidence in the transportation system to return as well. Moreover, the oft-rehearsed emergency plans worked: services were not overwhelmed, and people did their jobs well.
There is a danger that our stoicism, professionalism, and pride may become diluted over time. Almost immediately, reporters began carelessly describing London as "a city in trauma." Only 24 hours after the bombings, BBC Breakfast News was asking whether people who had only watched the scenes unfold on television would require counseling, and others demanded that counseling services be offered to all Londoners to enable them to "cope with the trauma." Such voices, however, were muted, and the messages coming from most mental health professionals were consistent, balanced, and less dramatic.
We must be careful to avoid shifting from the language of courage, resilience, and well-earned pride into the language of trauma and victimhood. The bombs made more than enough victims; it is important that we do not inadvertently create more.
Source Information
Dr. Wessely is a professor of psychiatry at the Institute of Psychiatry, King's College London, and director of the King's Centre for Military Health Research, London.
References
van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a meta-analysis. Lancet 2002;360:766-771.
Ritchie C, Leavitt F, Hanish S. The mental health response to the 9/11 attack on the Pentagon. In: Neria Y, Marshall R, Susser E, eds. 9/11: Mental health in the wake of a terrorist attack. New York: Cambridge University Press, 2005.
Gillespie K, Duffy M, Hackmann A, Clark DM. Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Behav Res Ther 2002;40:345-57.
Jones E, Woolven R, Durodie W, Wessely S. Public panic and morale: a reasseement of civilian reactions during the Blitz and World War 2. J Soc Hist 2004;17:463-479.
Shalev A. The Israeli experience of continuous terrorism: 2000-2004. In: Lopez-Ibor JJ, Christodoulou G, Maj M, Sartorius N, Okasha A, eds. Disasters and mental health. Chichester, England: John Wiley, 2005.(Simon Wessely, M.D.)
But what about those for whom life as usual is not going to go on? Those whose lives have been shattered by bereavement and those whose bodies were shattered by the blasts of terrorist bombs? As one emergency worker told the BBC after leaving the scene of the bombing at King's Cross station, "I don't know what heaven looks like, but I now have a good idea of hell." Many of the survivors and the bereaved are suffering intense mental anguish, an anguish that is painful for the rest of us even to witness.
What can we do to help these people cope with the unimaginable? The conventional wisdom has been that those affected by such disasters need immediate psychological help to assist them in "ventilating" their feelings, to warn them of the emotional symptoms they may face in the coming days and weeks, and to prevent a subsequent breakdown. But though this belief may have been conventional, it was not wisdom.
There have now been more than a dozen controlled trials in which people who have been involved in accidents and other traumatic events have been randomly assigned to receive or not to receive such counseling. The results have shown conclusively that such immediate psychological debriefing does not work. Those who received it were no better off emotionally than those who did not. Worse, the better studies with the longer follow-up periods showed that receiving such counseling actually increased the likelihood of later psychological problems. In fact, the people who seemed to be harmed by this intervention were those who had been especially upset at the time — precisely those who one might think ought to be treated.1 So whereas immediate post-trauma counseling may reassure the rest of us that something is being done, it does not actually help those who receive it.
Why doesn't it work? For some, such counseling is just too painful and comes too soon. It is also possible that warning people about potential symptoms makes them more likely to experience them. For some people, not talking is the most appropriate immediate response. Talking to a professional whom one has never met before and might not meet again may even get in the way of doing what comes naturally — talking with family members, friends, colleagues, religious advisors, or the family doctor. The people who know us best are likely to know what support we need and when we need it.
Asking people to talk about their feelings when they are still raw with pain is not always a good idea. The day after the bombing, all the television news bulletins showed footage of the father and the grandfather of 20-year-old Shahara Islam, who had gone to work on July 7 and hadn't been seen since. There we saw intense distress — the grandfather unable to articulate a coherent word, the father so distraught that it was uncomfortable to watch him. We didn't need to ask them how they were feeling. Five days later, it was announced that Shahara Islam had been killed in the bus explosion at Tavistock Square. Immediate counseling is not going to heal her family's grief.
Instead, what people need during the first few days is the support of their family and friends and assistance with information, finances, travel, and the planning of funerals. The most appropriate immediate mental health interventions are practical, not emotional.2
Many people who are now in distress and despair will heal with time. Others will not, and serious psychological illnesses such as depression and post-traumatic stress disorder will develop in some. Prevention of these disorders would have required avoidance of the doomed trains. But the illnesses can be treated, and there are already plans to provide treatment.
Shortly after the blasts occurred, the National Health Service's mental health trusts covering the four hospitals that collectively treated 700 casualties from the bombings came together to coordinate their response. The Camden and Islington Mental Health Trust, which covers the area including University College and the Royal Free Hospitals, is taking the lead in organizing mental health services for those in need. About six weeks after the bombings, they will initiate a "treat-and-screen" program for people who were directly affected and are known to be at the highest risk for psychological sequelae. The delay is deliberate; some people will not be ready for interventions before then, and others will by then not need them.
Although the efficacy of mental health screening has not been established, it is a proportionate and reasonable response to initiate screening of those who were directly affected, especially given the known barriers to help-seeking among trauma victims with consequent mental health problems. There is good evidence that persons with ongoing stress disorders can benefit from cognitive–behavioral therapy. The real-life effectiveness of such screening and treatment was proved in the aftermath of the 1998 bombing in Omagh, Northern Ireland.3
But the events of July 7 also demonstrated the sensible way in which ordinary people deal with adversity. We did not panic. We coped. That evening, I watched from my home in central London as an endless stream of people began their long walks home. They looked "inconvenienced rather than heartbroken," as one Web article (www.slate.com) put it. Ordinary people are tougher than we sometimes give them credit for being. And this should have come as no surprise. The people who were in the World Trade Center on September 11, 2001, had to find their own ways of leaving the buildings, and they did so without any signs of panic.
Indeed, people generally don't panic in the face of adversity — unless they are caught in confined spaces without any visible means of escape. One can understand the brief moments of overwhelming fear that some experienced when they were trapped in darkness after a bombing. One of our secretaries was on the train that was blown up under King's Cross. She said there was a moment of silence after the flash, followed by moaning and screams from the injured people in the front carriage. When black smoke began to drift into her carriage, some passengers did start to cry or panic. After a few minutes, however, most people regained their composure, and several got together to try to force open the train doors. During the 20 minutes or so that it took the emergency workers to check for chemical, biologic, and radiologic agents before descending to the train, she saw other passengers comforting the wounded and administering first aid.
One young man, named in media coverage simply as Paul, had lost his leg. The driver of the train tied his own belt around what remained of the leg, probably saving the man's life. While waiting for help, Paul told another passenger that there was a bright side: he could now enter the Paralympics, he said, alluding to the previous day's announcement that London will host the 2012 Olympics — news that had been greeted with collective euphoria.
One reason for the stoicism demonstrated by so many Londoners is that although the atrocities of July 7 may have been the worst acts of terrorism to take place in the capital for many years, they were not the only ones we have seen. I remember the flash and boom of the bomb that was set off by the Irish Republican Army in 1992, destroying the Baltic Exchange. The collective memory of the city goes back even further. When Hasib Hussain detonated his bomb on the upper deck of the Number 30 bus and took 13 lives along with his own, he did so at Tavistock Square. A previous resident of that square was Virginia Woolf, and it was there that she returned one morning in October 1940, when the all-clear siren sounded, to find her house destroyed by German bombs. Her description of the scene foreshadowed those of the same square 65 years later.
Politicians, civic leaders, and the media have been keen on invoking the "Blitz spirit" in recent days, in order to foster resilience and remind us of our cultural scripts of defiance in the face of adversity. And there are resonances. Before the outbreak of the Second World War, politicians, military commentators, and emergency planners believed that aerial bombing would provoke mass destruction, panic, and a catastrophic collapse in morale. Yet these reactions did not occur. The Blitz killed 40,000 Londoners, and although there were short periods of considerable fear and disorganization, such a state was the exception, not the rule.4
But perhaps it would be more appropriate to compare our response to the July 7 bombings with the way we — and Israelis— have coped with living under the threat of terror.5 Like the Israelis' immediate response, ours was to turn to our mobile telephones. Initial anxiety died down when we were able to determine the safety of those close to us, and if and when the current emergency resolves, we should expect our confidence in the transportation system to return as well. Moreover, the oft-rehearsed emergency plans worked: services were not overwhelmed, and people did their jobs well.
There is a danger that our stoicism, professionalism, and pride may become diluted over time. Almost immediately, reporters began carelessly describing London as "a city in trauma." Only 24 hours after the bombings, BBC Breakfast News was asking whether people who had only watched the scenes unfold on television would require counseling, and others demanded that counseling services be offered to all Londoners to enable them to "cope with the trauma." Such voices, however, were muted, and the messages coming from most mental health professionals were consistent, balanced, and less dramatic.
We must be careful to avoid shifting from the language of courage, resilience, and well-earned pride into the language of trauma and victimhood. The bombs made more than enough victims; it is important that we do not inadvertently create more.
Source Information
Dr. Wessely is a professor of psychiatry at the Institute of Psychiatry, King's College London, and director of the King's Centre for Military Health Research, London.
References
van Emmerik AA, Kamphuis JH, Hulsbosch AM, Emmelkamp PM. Single session debriefing after psychological trauma: a meta-analysis. Lancet 2002;360:766-771.
Ritchie C, Leavitt F, Hanish S. The mental health response to the 9/11 attack on the Pentagon. In: Neria Y, Marshall R, Susser E, eds. 9/11: Mental health in the wake of a terrorist attack. New York: Cambridge University Press, 2005.
Gillespie K, Duffy M, Hackmann A, Clark DM. Community based cognitive therapy in the treatment of posttraumatic stress disorder following the Omagh bomb. Behav Res Ther 2002;40:345-57.
Jones E, Woolven R, Durodie W, Wessely S. Public panic and morale: a reasseement of civilian reactions during the Blitz and World War 2. J Soc Hist 2004;17:463-479.
Shalev A. The Israeli experience of continuous terrorism: 2000-2004. In: Lopez-Ibor JJ, Christodoulou G, Maj M, Sartorius N, Okasha A, eds. Disasters and mental health. Chichester, England: John Wiley, 2005.(Simon Wessely, M.D.)