My world irrevocably changed on Tuesday, 11 September 2001, when my brother vanished in the attack on the World Trade Center in New York, alongside nearly 3,000 other people. At the time, I was training to be a psychotherapist, and while this immensely traumatic event impacted every aspect of my life, it also led me to work with collective trauma.
Over the past 16 years, I have worked with people directly affected by a number of terrorist attacks. As a therapist but also an advocate and representative of people affected by terrorism and other major incidents, I grew to value what we as therapists can bring to those whose lives are shattered by disasters. In this article, I look at how we could ensure that timely and competent therapy is made available to those who need it in the aftermath of major incidents.
As we mark the first-year anniversaries of the traumatic events of 2017, it’s a time to both reflect and to ask some questions of our profession and of how our society responds to support its citizens. Between March and September last year, we had no less than five terror attacks as well as the horrific Grenfell Tower fire, affecting hundreds of people directly and thousands indirectly. Many of us who specialise in trauma are still likely to be very involved with those whose lives have been profoundly impacted by these incidents.
Understandably, these anniversaries trigger waves of emotion and unanswered questions. My focus is on where we are now and what would be needed if disaster were to strike again in England, Scotland, Wales or Northern Ireland. Sadly, the current climate indicates that the wave of terrorist activity is unlikely to decrease and so preparation is a vital part of our possible response options. It’s also well acknowledged that our mental health services are struggling with a lack of capacity to meet the need and that access to some services such as CAMHS or specialist trauma services can involve long waiting times. Against this backdrop, it’s reasonable to assume that the provision of timely quality therapy and psychological interventions on a sufficiently large enough scale would not be in place in the event of another major incident to support children, young people or adults.
It’s my opinion that in addition to the existing mental health services, those in charge of psychosocial support after disasters should reach out to appropriately qualified trauma specialists, to meet the needs of those who are traumatised by major incidents, especially when a surge in demand happens. Across the UK, there are qualified and experienced therapists ready to work with trauma, who could meet the demand and provide necessary timely expertise for those who need it. For example, therapists working in organisations providing post-trauma interventions have such skills, as well as those working for specialist charities or as self-employed private practice therapists.
I am convinced that as a therapy community and through our professional bodies (including BACP), we could find a way to mobilise those with the appropriate skills and competences in the case of a major disaster. This stems from my concern that there are too many people across the country who as a result of being caught up in a major incident, need appropriate post-disaster therapy but that this isn’t happening. It does not have to be this way. A mechanism that could connect the people who need help with the people who can help, is the way forward.
It requires transparency with policy makers and the UK Government about the surge in need for psychological services after an event, which could be met by BACP and other professional organisations’ members. As there are no funds clearly earmarked for the provision of trauma support services, we ought to be prepared and to plan for such demands in ‘peace time’, and to make the economic case for provision.
Responses overseas
There are examples of successful networks which have operated in the US, Canada and Australia to help ensure that those with psychological expertise are connected with those who need it after a disaster. The American Psychological Association (APA) set up its own Disaster Resource Network (DRN) 25 years ago, which consists of psychologists from the US and Canada, who have expertise in the psychological impact of disasters. DRN members become Red Cross Disaster Mental Health (DMH) volunteers, and APA partners with the American Red Cross to facilitate this connection. In addition to delivering disaster interventions, members of the network also offer support groups, training sessions, consultations to organisations and media briefings. Similarly, in Australia, the Association of Australian Psychologists has signed an agreement with the Australian Red Cross to provide disaster response.
Towards a new approach
These networks provide useful models for the UK as we think about how we might improve the support we provide. However, it’s important to highlight that the US model is based on volunteering and this is not a model that I think we should follow. Any future arrangements need to propose a structure where trauma services are paid for, not least because so many therapists are self-employed, but also because of the increased potential for burnout involved with trauma work and the particular need for self-care that the work calls for.
We must learn from our responses during 2017, and, as a professional community, create a network of appropriately qualified therapists who could be called upon in various phases of disaster response, across the UK. Creating such a register or a network would be a necessary step, but not the only step.
Planning, training and competence
Disaster response requires collaboration and relationships with other organisations in the field, such as the emergency planners and responders within and across the NHS, emergency services organisations, local authorities, the third sector, the business community and so on. Our professional bodies, BACP, UKCP and BCP, could take a new role to be involved and present in the planning, training, exercising and the revision of emergency plans. This should include being actively engaged in Local Resilience Forums and the professional bodies such as the Emergency Planning Society. A working group could be formed, ideally across different professional bodies, including BACP, UKCP and BCP, to co-ordinate a national register of therapists and supervisors, which could be called the UK Disaster Resource Network.
Counsellors and psychotherapists may be needed when the mainstream services are overwhelmed, but therapists in private practice may be perceived to be lacking in the skills required to deliver evidence-based interventions. For this reason, we need a pre-agreed understanding of who would be considered appropriately trained and qualified, because once the disaster strikes, it’s too late.
Together, we need to define the required competences and expect controversies! A starting point could be for therapists to have a competence in one of the evidence-based therapies for PTSD (according to NICE, currently EMDR or TF-CBT) with an addition of disaster-specific knowledge, focusing on different phases of disaster; as well as an understanding of traumatic bereavement and of other trauma-related difficulties.
Additional standardised training in disaster interventions needs to be designed and could be in the form of a short CPD programme, delivered across the UK. I have been delivering such a programme for several years and have trained a number of therapists, who are now engaging in disaster work, such as facilitating disaster support groups.
How might people access support?
It is important that those directly affected by major incidents can choose their own therapist and that the work is paid for from a pre-agreed fund. The network can be promoted as a register from which individuals affected by disasters can make their own choice and do so in the knowledge that they will be reimbursed. There is precedent for this too. After 9/11, individuals like myself who were directly affected (and there were many bereaved individuals in the UK, given that the country lost 67 citizens), were able to choose their own therapists, as long as they were accredited by a professional body, and were then reimbursed for the sessions. The scheme was administered from the New York State Office for Victims of Crime, and while there were administrative cross-border issues, it allowed individuals to have a flexible number of sessions, which for some people spanned several years.
Similarly, After the Indian Ocean tsunami in 2004, British citizens were encouraged to contract with a therapist of their choice and were later reimbursed, although the sessions were limited to a maximum of 12. Support groups were organised by the British Red Cross through the Tsunami Support Network, and these were very well received by those directly impacted by the disaster. Furthermore, after the Paris attacks in 2015, the bereaved and survivors based in France or abroad, were able to choose their own therapist. As in the case of 9/11, they were reimbursed by the French authorities for their services, from a fund that was specifically set up for victims of terrorism.
Closing thoughts
To ease the suffering of those directly affected by terrorism or other major incidents, we need to be more organised as a community of practitioners so that we can respond promptly and competently to any sudden demand for therapy and psychological support. Having a register of therapists trained and willing to work in the aftermath of major incidents, and involved in emergency planning, would be an important step forward in addressing the needs of those who, just like any one of us, can be affected by a large-scale trauma. I hope this article will be seen as a call for collaboration and community building among all those responding to the psychological needs of those affected by major incidents.
Jelena Watkins is a psychotherapist and disaster mental health consultant. She has helped advise a number of authorities in the aftermath of disasters and is currently advising authorities responding to the Manchester Arena attack.