Life Mental Health

Sunday 21 September 2014

Most people exposed to trauma do not develop mental health problems

Professor Patricia Casey

Published 30/06/2014 | 02:30

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A child places a flower outside an Oslo cathedral on July 22, 2012. Thousands of Norwegians gathered at memorials to the 77 people killed a year earlier by Anders Breivik. REUTERS/Lise Aserud

IN HARDER times, decades ago, we were told to "pull ourselves together" and get on with life when bad things befell us. Then, sometime in the 1970s, all of that changed and it became de rigeur to claim, because of our suffering, professional help when unpleasant and distressing events overtook us.

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This led to a mushrooming of counselling and therapies. Even those who did not have mental health problems sought professional help for the normal and understandable reactions to life's woes – those who were bereaved received solace from counselling as did those who were anxious.

But after the 9/11 attacks and the London bombings, it became clear that the received wisdom was being turned on its head since people did not develop significant mental health problems in the overwhelming numbers expected. For example, 7.5 per cent of Manhattan residents exposed to the events on 9/11 showed symptoms of post-traumatic stress disorder (PTSD) one month after, but that dropped to 0.6 per cent six months later.

Another terrorist incident involving a fanatic, Anders Breivik, occurred in 2011 on Utoya Island, off the coast of Norway. In that shooting, 564 young people were exposed to a protracted attack, in the course of which 69 fatalities occurred and 56 sustained serious injuries. Most heard the voice of Breivik and a substantial number also saw him, as they ran for cover.

A study of the survivors by Grete Dyb from Oslo University and published in this month's issue of the British Journal of Psychiatry shows that when interviewed 4-5 months after the event, PTSD was six times higher than in the general population of Norway, with 11 per cent describing full PTSD and 36 per cent describing some symptoms. Having good social support was a protective factor.

Another study in the same issue of the British Journal of Psychiatry, carried out by Eva Alisc of Monash University and the University Medical Centre, Utrecht, examined the prevalence of PTSD in children and adolescents exposed to various traumas by combining data from 72 peer reviewed studies. It found that overall 15.9 per cent of the sample had developed PTSD. This was higher in females than males and was higher for traumas inflicted by others than for non-interpersonal traumas.

What do these findings tell us about vulnerability and resilience? In a carefully written editorial, Jonathan Bisson of Cardiff University, an opinion leader in Ireland in the field of PTSD, points out that not everybody exposed to terrible trauma develops major psychiatric problems. In fact, it seems that the majority do not.

This then raises the question as to how we should respond when an individual or a group is exposed to horrific events and how we should treat those who exhibit mental health problems afterwards. There is now clear evidence that single session post-event debriefing is not helpful and may be harmful. Attempts to develop multiple session debriefing have likewise proved unsuccessful in preventing harm. Bisson argues that for the majority, the reaction to such events should not be medicalised.

Instead, he advocates psychological first aid. In the early stages after the event, a sense of safety and calm should be encouraged and the emphasis should be on hope and personal empowerment. Important also is providing the opportunity to talk, while also respecting the desire of some not to. Linking people to support through family and friends, encouraging normal daily routines and identifying those who need further help and arranging referral are all considered important.

This perspective on coping with deeply disturbing events shows that, for the most part, human beings are resilient and unless there are specific risk factors most address their emotions through friends and family.

This also has implications for how we should respond to non-traumatic events such as loss through death, breakdown of relationships and so on. Since most of us are resilient we can deal with such events with the support of those who care about us, without medicalising life's ups and downs. It is time to rethink our therapy culture and reserve it for the minority who need it. The flagrant use of therapy to deal with life's ups and downs is ill advised.

Resilience researchers are interested in two core questions: "Why do most people cope when bad things happen to them" and "What is the source of human resilience"? A number of attributes have been identified as associated with resilience and these include the commitment to finding meaning in life, the belief that one can influence one's surroundings and that one can grow from negative as well as positive experiences.

High self-esteem and being able to feel positive emotions in the face of trauma (gratitude, interest, love, happy memories) have also being linked to resilience. Finally, what has become known as "repressive coping" or the tendency to avoid unpleasant memories, thoughts or emotions has been shown to be helpful.The notion that ordinary individuals are strong and able to cope turns on its head both professional and popular ideas about how people respond to adversity – the evidence is that we do very well and we should not tamper with that.

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