Mental health, disasters and what not to do

mental health disasters and what not to do

Photo credit – Transterra Media – Yazan Homsi

Author: Neil Greenberg, The King’s Centre for Military Health Research, King’s College London

Disasters, man-made or natural, may cause considerable ill-health and misery. Since 1980, when post-traumatic stress disorder (PTSD) first appeared in diagnostic textbooks, if not before, there has been a dramatic growth in interventions and approaches claiming to either prevent the mental health consequences of exposure to trauma or to provide rapid effective treatment of established disorders without the need to adhere to established treatment guidelines such as those published by NICE (National Institute for Health and Care Excellence) in the UK.

Such is the high profile nature of the psychological impact of trauma, especially over recent years with the rise in prominence of terrorism-related incidents, that media reporting of such events almost always includes some mention of what is being done to help the ‘survivors’ or ‘victims’. Often, media stories appear to suggest that the provision of ‘trained counsellors’ is a post-trauma necessity and that emergency-responder organisations should screen their personnel to ensure that they are psychologically robust enough to cope with the job.   However, in watching those claims it is clear to ‘those in the know’ that such stories are not informed by contemporary science.

So what should be done?  First, there needs to be a change to the narrative of a panic-prone public and of emergency response organisations failing to acknowledge the impact of working with trauma on their staff. A wealth of evidence shows that most people are far more resilient that the media suggests. In fact, whilst a sizeable proportion may experience short-term distress, developing a psychological illness is the exception rather than the rule.

Second, there is no evidence that short term interventions such as psychological debriefing or ‘trauma counselling’ for all are a good idea. In fact, the now considerable body of evidence into the use of such techniques shows them to have the potential to make things worse and cause harm. On the other hand, social support is highly protective and often freely available within community and organisational settings. In fact, many emergency response organisations have formalised this to some degree with the introduction of peer support programmes which specifically aim to monitor trauma-exposed staff and ensure that collegial support is available. The evidential message is clear, in the aftermath of a trauma people need the support of trusted colleagues, family and friends; they do not need ‘trained counsellors’.

Finally, whilst it would be wonderful if there were effective psychological screening techniques available so that organisations could screen-out vulnerable people and stop them from working in trauma-prone roles, this is not possible. Such techniques are not accurate enough and create many ‘false positive cases’ in which perfectly resilient people are incorrectly labelled as being vulnerable. They also provide false reassurance to the organisations that use them. Neither is it possible to screen people after trauma-exposure to detect if they have mental health disorders in need of treatment. We have recently finished the first randomised trial into post trauma screening and found a complete lack of effectiveness. However, screening within community settings, carried out carefully by a trusted health service, may well be useful.

In summary, supporting the bonds between people within communities and organisations, along with a temporary reduction in exposure to stressful situations as people recover are the best approaches. And, it’s still important, if challenging, to ensure that the relatively small number of people whose short-term distress does not resolve are able to access timely and effective evidence-based care.

Neil Greenberg photo small        Professor Neil Greenberg, The King’s Centre for Military Health Research, King’s College London: Professor Neil Greenberg is a consultant occupational and forensic psychiatrist. Neil served in the United Kingdom Armed Forces for more than 23 years and has deployed, as a psychiatrist and researcher to a number of hostile environments including Afghanistan and Iraq. Neil is an advisor to the Academic Department of Military Mental Health and also runs March on Stress (www.marchonstress.com) which is a psychological health consultancy.

Additional Reading:

Sage CAM, Brooks SK & Greenberg N. Factors associated with Type II trauma in occupational groups working with traumatised children: a systematic review. J Ment Health, Early Online: 1–11 DOI: 10.1080/09638237.2017.1370630

Brooks SK, Dunn R, Amlôt R, Rubin GJ & Greenberg N. Social and occupational factors associated with psychological wellbeing among occupational groups affected by disaster: a systematic review. J Ment Health. 2017 Aug;26(4):373-384

Rona RJ, Burdett H, Khondoker M, Chesnokov M, Green K, Pernet D, Jones N, Greenberg N, Wessely S, Fear NT. Post-deployment screening for mental disorders and tailored advice about help-seeking in the UK military: a cluster randomised controlled trial. The Lancet. 2017 Apr 8;389(10077):1410-1423

Whybrow D, Jones N and Greenberg N. Promoting organizational well-being: a comprehensive review of Trauma Risk Management. Occup Med (Lond) (2015) 65 (4): 331-336.doi: 10.1093/occmed/kqv024

Dunn R, Brooks S, Rubin J and Greenberg N. Psychological impact of traumatic events: Guidance for trauma-exposed organisations. Occupational Health at Work 2015; 12(1): 17–21

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  1. John Durkin

    Paragraph 1. Given 100 years since WWI and dealing with Shellshock, 70 years since WWII and dealing with combat fatigue and 40 years since the Vietnam War and dealing with what was to become PTSD where is the evidence of ‘..dramatic growth…’ since 1980? Even if this is true, where is the cure for PTSD if the growth had so great? They found one for Shellshock.

    There is, and there has never been, a ‘..need to adhere to treatment guidelines…’ – even NICE say so (1.1.2 p.1).

    Paragraph 2. Media reporting is irrelevant, unless I was fooled into thinking that journalism was the lowest form of evidence during my degree.

    Paragraph 3. Given the empty dormitories that surrounded London during WWII to take in the terror-stricken psychological casualties of the bombing this is hardly information. A ‘..wealth of evidence..’ and a ‘sizeable proportion…’ should be quantified if they are to be meaningful to someone trying to grasp the numbers involved.

    Paragraph 4. The ‘straw man’ fallacy should not be allowed in any serious narrative on trauma. Has anyone ever claimed that debriefing or counselling should be ‘for all’? If they did they should be challenged. If they did not, a condition should not be created in order to shoot it down.

    Paragraph 5. The notion of ‘screening out’ is surely discriminatory and elitist. How a privileged psychiatrist/psychologist in a civvy-street profession can determine the suitability of an altruistic, motivated humanitarian to work in a life-threatening disaster-zone overseas on the basis of a pen-and-paper questionnaire and/or interview is a mystery of our times.

    Paragraph 6. A psychiatrist should know better than to simplistically announce social support as the ‘best approach’. Given the predictive quality of social support in just about every psychiatric condition it assumes two things: 1. Social support is possible, available and desirable for that individual, and 2. the term social support is valid; if so the psychiatrist will not simply announce it but define it theoretically (in all its forms) and explain it practically with observation of success and failure from their own experience. Reliance on the findings of studies from a different time, country, culture and population is to stretch credibility in the so-called ‘evidence-base’. When we admit that ‘effective’ can mean no more than ‘better than nothing’ (as it does with NICE-recommended treatments for PTSD) we might recognise failure in the system and mental health professionals calling people into it with such warnings as ‘What not to do’. If more effective options exist than CBT, EMDR and drugs perhaps we should question their absence from the debate. How does the psychiatrist explain an approach that NICE say ‘Do Not Do’ while the US Government’s mental health arm list it as evidence-based? It’s here: https://nrepp.samhsa.gov/ProgramProfile.aspx?id=222

    November 22, 2017