Sousse beach massacre: Are we getting trauma treatment for victims right?

Experts have urged the Cabinet Office to implement a comprehensive screening procedure for post-traumatic stress disorder, as Oscar Quine reports

Oscar Quine
Friday 14 August 2015 18:56
Tourists begin their journey home from Sousse in June
Tourists begin their journey home from Sousse in June

On the afternoon of 26 June – the day that Seifeddine Rezgui massacred 38 people, including 30 British citizens, on a Tunisian beach – Chris Beck received an email. A 60-year-old former intensive care nurse, she was sitting at her desk in the Red Cross office in Reading where she is an operations manager. Now she headed to her home just outside the town to pack.

"When I'm on call, I'll always have the basics ready to go and add to them," she explains. By midnight, she was at Stansted Airport waiting for an early-morning flight to Sousse.

For the past decade, the Red Cross's Psychosocial Team (PST) has been an important part of the Foreign and Commonwealth Office's rapid deployment unit – a crack team of health and social-care professionals with experience of people in the throes of shock and trauma. PST members have been first-responders at some of the most harrowing events in recent history. From the Westgate mall massacre in Kenya to the earthquake in Nepal, if a catastrophic event has involved British citizens, the PST is deployed.

With a contractual agreement to be at the airport within six hours of a call, Beck and her three colleagues were at the Riu Imperial Marhaba hotel less than 24 hours after the killings. British consulate staff had arrived from Tunis the night before and identified people they felt most in need of psychological care – the bereaved and those who had seen others killed.

"We spent time just listening to them," says Beck. "Their main concern was how overwhelming their emotions were. How they felt they were almost out of control with anguish, with fear, with general upset. Listening to that and trying to really reassure them that they weren't abnormal, that this was very much the reaction that any person would have to something that was so sudden, unexpected and devastating.

"There were some people who had been awake since it happened. They didn't want to shut their eyes because of the pictures that would flash before them. They would start reliving seeing the gunman, seeing people being shot, seeing people injured, so they were keeping themselves awake, which meant they were sleep-deprived as well as emotionally distressed."

The PST's first deployment was to another beachside struck by tragedy. Dr Sarah Davidson was one of two staff members flown to Bangkok to provide support to British embassy staff in the wake of the 2004 Boxing Day tsunami. She has since headed up the programme and says she has lost count of the number of deployments she has been part of, though it's "at least 10".

"The thing about trauma is that people often feel that their ideas of the world have been challenged," says Dr Davidson. "Tunisia, unfortunately, has similarities to Thailand in that people were on the beach, holidaying, escaping from the rigmaroles of normal life. The last thing you expect is for there to be a critical event when you're on your sun lounger.

"Every single deployment is different. The contexts are different. I was out in Haiti after the earthquake, and that was different from the tsunami, which was different from Algeria after the gas plant attack in 2013. There's always learning about how the team could function better."

Chris Beck, a member of the Red Cross's Psychosocial Team, was at the Riu Imperial Marhaba hotel less than 24 hours after the killings

While the 2009 evacuation from Zimbabwe, the 2010 Haiti earthquake and the 2013 Fukushima tsunami and nuclear disaster all provided formative lessons for Davidson and her team, it was that first deployment to Thailand from which they learned the most. As the numbers caught up in the catastrophe climbed, she says the situation became "utterly, utterly overwhelming". Some 20 additional staff were drafted in over the next eight weeks.

"We had four people in Bangkok and four people based in Phuket. In Bangkok they were visiting four or five different hospitals and the same in Phuket. On top of that there were three mortuary sites where we were providing support."

While one might expect probing questions, cathartic tears and the occasional heartfelt embrace, trauma counselling is a relatively hands-off process. A year after the Asian tsunami, the National Institute for Health and Care Excellence (Nice) issued new guidelines on the practice. The guidelines stated that in the immediate aftermath of a tragedy, people should be given practical support. In a minority of cases – mostly involving people suffering from pre-existing mental conditions – early intervention counselling may be beneficial. Otherwise, it should be avoided.

Up to that point, practitioners tended towards a more proactive approach. The recounting of events and the tackling of feelings head-on were encouraged. The approach had been developed in the US in the 1980s by a fireman and paramedic named Jeffrey Mitchell. He had seen colleagues struggling to cope with what they had witnessed on duty and believed their apparent symptoms should be treated. This came to a head in the days following 9/11, when 9,000 counsellors reportedly descended on New York to provide their services. At the same time, extensive research was leading many to question whether this approach breached the first rule of medical care: "Do no harm".

"This is something I feel very passionately about," says Professor Neil Greenberg, president of the UK Psychological Trauma Society, who has 23 years' experience serving as a naval doctor. "In the early stages – we're talking in the first month – the vast majority of people do not need trauma counselling. In fact, they are more likely to be damaged by it than they are to be helped."

On the whole, research found, people are perfectly well-equipped to deal with emotional trauma themselves. "Most people need access to good social support, which comes from all the sources you and I would normally use and trust – our friends, our colleagues, our work mates, maybe our GP, maybe a priest. But having outsiders come in, particularly if they were 'forced upon you' – people suggesting counselling rather than you going to get it – is a really bad idea."

Davidson is quick to stress that the PST adheres strictly to Nice guidelines. "We do not do trauma counselling. We're helping people to cope," she says, adding adds that the team instead offers a kind of triage service "to make assessments of people's responses and provide them with additional information if required".

But it seems these guidelines are not being adhered to in the case of all returnees from Tunisia. "The problem," says Greenberg, "is that there's an industry out there which provides counselling. There seems to be this almost intuitive need to have counsellors attend traumatic events."

Davidson recalls coming across a tent outside Phuket town hall following the tsunami. On display in front of it was a handwritten sign reading: "Trauma counselling: all welcome." Davidson guesses the tent was occupied by one of the thousands who pitched up to help with the devastating scenes they had seen on television. In most cases, these untrained do-gooders were more of a hinderance than a help.

Tourist walk through the debris in Thailand in the aftermath of the 2004 tsunami

"In the first five weeks after an event the responses people have that could be associated with post-traumatic stress disorder (PTSD) – nightmares, flashbacks, avoidance of situations – they're normal reactions, thought to be useful in processing the experience," Davidson says.

"What you don't want is people coming and aggravating that response by insisting you talk in a lot of detail about what happened; that you go through things that are painful."

In the case of Tunisia, one problem it seems has been third-party assistance packages taken out by tour providers. Experts have raised concerns that some providers might be over-zealous in offering prescriptions of treatment while having an inadequate understanding of psychological diagnostics. Counsellors, introducing themselves as representatives of the tour providers, have reportedly contacted holidaymakers since they returned from Tunisia.

John Yeoman, 46, from Kettering, was staying in the Bellevue Hotel next door to the Riu Imperial Marhaba. On hearing shots, he and his wife Mandy barricaded themselves in their hotel room. "We're the fastest cowards in Kettering," he says. "The moment the shootings started we ran."

Yeoman is enthusiastic in his praise of Thomson, their tour provider. The company flew them home that night and issued a full refund for their holiday. "There was a bit of a time lag between when it started until the additional reps arrived. But obviously the hotel next door was the priority and I can understand that – that's where people died. We had reps as soon as they were available: they were with us by 8pm that evening. Some people were a bit unhappy about that but considering what had happened I think they did OK." A few days after returning home, Mr Yeoman received the first of what have been three calls from Thomson's third-party counselling service. He says they announced they were calling "to discuss our needs and to remind us that the service was available to us".

"My wife struggled a bit when we got home," Mr Yeoman says. "I mentioned that to the counselling people and they said they could phone and speak to her directly if required." However, counselling was not necessary. "When they had the minute's silence she made a point of sticking to it and that helped a lot. It was a personal line she was able to draw underneath it. She's felt a lot more comfortable about things since."

A spokesman for Thomson said that "as a tour operator, our customers expect support from us when a traumatic incident occurs, and we work with an independent expert – CCP – to extend an offer of assistance to all of our customers. In this instance, CCP was offering proactive support to those that requested it in the form of a psychological response and advisory service on our behalf. This was to help us ensure that our customers who were on holiday with us felt supported straight after the incident and in the following weeks."

Someone else caught up in the Sousse atrocity was Zoe Pearce, who was holidaying in Tunisia with a friend. Staying at the nearby El Mouradi Palm Marina hotel, they were on the beach when the attack happened. Locking themselves in their room, they called Ms Pearce's partner in the UK. By 8pm, nobody had come to their room to check that they were all right. Ms Pearce then headed down to the lobby. It was deserted. "We'd gone from a hotel that had thousands of guests in and over 500 staff the day before to looking out from our balcony and seeing that all the lights were off. There was just nobody around."

Ms Pearce emailed her holiday provider. She says they replied that evening telling her to arrange her own return travel. Her partner called easyJet and they put her on a flight the next morning free of charge. She and her friend spent the night locked in their room

Both Ms Pearce's partner and her sister-in-law called the Home Office on the day of the attack and were told they would receive a call when there was news. Neither heard anything back. "When I handed back the keys at the hotel, they didn't even ask who I was," says Ms Pearce. "I just feel that we could still be missing people." It didn't help that when Ms Pearce got back to the UK, the car parking service at Stansted Airport charged her £20 for collecting her car early.

Ms Pearce visited her GP two days after returning to the UK. Her doctor signed her up to 12 counselling sessions. Meanwhile, Ms Hayward has been receiving weekly private counselling through an assistance programme provided by her employer.

Sarah Davidson: 'What you don't want is to insist that people talk in detail about what happened'

Sir Simon Wessely, president of the Royal College of Psychiatrists, has expressed concern about the treatment being given to those returning from Tunisia. "The best advice is for people to do what comes naturally," he says. "To talk to someone when it comes naturally: who they want, at the time they want.

"Stretching right back to the Second World War, there has been a tendency for people in authority to underestimate the people's essential resilience. Doctors, politicians, the media, you name it, underestimate the strength of the public. They believe they will panic in situations when they don't, and forget that most people have good coping mechanisms in the form of social networks."

If symptoms persist six to eight weeks after the event, treatment for PTSD should then be considered. Greenberg points to the response to the 7/7 bombings as exemplary. A "screen and treat" programme was set up whereby six to eight weeks after the event, a team of psychiatric professionals contacted people known to have been caught up in the bombings to ask if they would like to be assessed. In the case of those who had been close to the explosion, 10 to 20 per cent were found to display symptoms of psychological trauma. "At that point, people who were seen to be ill were given evidence-based treatment," says Greenberg. "And lots of people got better".

Six to eight weeks is where we are now with British returnees from Tunisia, and both Greenberg and Wessely fear we have not learned the lessons of the King's Cross fire, the 7/7 bombings, and the 50-plus deployments of the Red Cross PST. "This will happen again and again and again," says Sir Wessely. "It makes sense that we have a more thought-out, comprehensive procedure that first recognises the essential resilience of normal people in stressful situations. But second, the need for monitoring and providing subsequent intervention for the minority when needed."

Along with other experts in the field, Wessely and Greenberg have urged the Cabinet Office to implement a comprehensive screening procedure. Fears grow that some of those on the beach in Sousse on that fateful June day will disappear into the general population to join the 70 per cent of PTSD sufferers who bear their affliction undiagnosed, untreated, and largely in silence.

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