Psychological consequences depending on exposure

The psychological impact of terrorist attacks is extremely widespread. In fact, it is one of the goals sought by those who carry them out. However, this impact is strongest on people directly exposed to the events and on those who have had a loved one killed or injured.

Those directly exposed

When confronted with such an event, some people experience stress that can be intense, but which can be considered normal in such a context. Others experience psychological injury, known as psychological trauma. In this case, symptoms are observed within the first few hours or on the first day following the attack. Thoughts and dreams are dominated by certain aspects of the traumatic events (images, sounds, sensations). This recreates the same distress each time as when the event occurred.

During the first month, the course of the condition varies greatly:

• in some people, symptoms will gradually decrease,

• in others, they will persist or even worsen,

• and in others, they may appear even though the person had been doing fairly well up until then.

When symptoms of traumatic stress are present for more than three days but less than a month, it is referred to as acute traumatic stress.
When symptoms last longer than a month, it is referred to as post-traumatic stress disorder. In this case, it is essential to seek professional help, as post-traumatic stress disorder, once established, tends to become chronic in many cases, leading to harmful consequences for health, family and professional well-being, education, and so on. This is even more common when the trauma is “intentional,” that is, deliberately inflicted.

Other disorders may develop, with or without post-traumatic stress disorder:

• major depression,

• anxiety,

• suicidal thoughts,

• alcohol, drug, or medication abuse or dependence.

In such situations, effective treatments are available, and you should not hesitate to seek help, even long after the events have occurred, and even if taking that step may seem difficult—whether because you want to avoid the subject or feel ashamed of feeling this way.
It is also important to note that a young age does not protect against psychological trauma or its consequences, and that children of all ages can be affected (post-traumatic stress disorder in children).

Those in mourning

This applies to people who were at the scene (who witnessed the event and have lost a loved one), and to people who were not at the scene but who lost a loved one in the event.
We speak of grief whenever we lose someone with whom we had an emotional bond. Grief itself is not an illness, even though it causes great sorrow. Grief occurring in a traumatic context causes particularly intense shock and pain, especially since the death is sudden, violent, and unexpected, and often involves young people. Such bereavements, in which trauma compounds the loss of a loved one, are among the most difficult trials one can face. It is always helpful to seek support in such cases.

Those at a Distance

People who did not directly witness the event and who are not in mourning may nevertheless experience negative effects. Many people experience symptoms of anxiety, fear, and sadness. These are generally temporary and have little impact on daily life. In some people, however, adjustment disorders or other mental health issues may develop. People with existing psychiatric conditions may see their symptoms worsen.

Families of those affected

When a person is affected by trauma and/or grief, the entire family is involved and must be able to receive support if necessary. Post-traumatic distress in one family member can affect others, who often struggle to understand it and are reluctant to discuss it. This can then lead to feelings of guilt for everyone involved. The family is the primary support system for traumatized individuals and should often be involved in their care, while maintaining the confidentiality between the patient and their therapist.

What is psychological trauma?

Psychological trauma is the effect on the psyche of certain events that result in psychological “injury.”

What kinds of events can be traumatic?

Only certain events can produce such an effect: those that brutally confront a person with death or a threat of death or injury, as well as sexual violence. Psychological trauma therefore primarily affects people who have directly experienced the event: victims who were directly threatened, but also all direct witnesses to the scene. It is currently recognized that having a very close relative who was injured or killed in such an event, or, for a professional, being repeatedly exposed to difficult details, can also cause trauma.
In other cases, for example for people who did not witness the event, we do not speak of psychological trauma: there may still be psychological consequences (such as adjustment disorders), but not post-traumatic stress disorder. Psychological trauma can occur at any
age, including in children, even very young ones.

How can the traumatic experience be described?

The experience of the traumatic moment varies, but very often people describe a reaction of terror that seized them, something beyond mere fear: “It was like a blank,” “I looked death in the face,” “I saw myself dead.” There are no words to describe this indescribable feeling that bursts into the psyche, and which is often followed by intense emotions (loneliness, abandonment, horror, anxiety, anger, helplessness, guilt…). In some people, dissociation may occur; it then serves as a protective mechanism for the psyche in the face of terror. Other symptoms may appear on the first day or within the first month. This experience of terror lies at the heart of post-traumatic stress disorder, since in this case, it is the experience of the traumatic moment that will keep returning (in thoughts, traumatic nightmares), as if the threat were still present.

What becomes of these “invisible wounds”?

Like all wounds, these “invisible wounds” can have varying outcomes. For many people, they will cause suffering for a few days or weeks before subsiding. For others, they will lead to a state of chronic distress, such as post-traumatic stress disorder, and it is not possible to predict the course of the condition in advance. In the case of a single traumatic event, 10 to 40% of those exposed develop chronic disorders.
Certain factors increase the risk of developing chronic disorders, whether they are event-related (intensity and duration of exposure, captivity, physical injury, exposure to horrific images…) or person-related (history of psychiatric disorders, history of exposure to trauma even if it was overcome, social isolation…). The support received in reality (from family and friends, superiors, the government, etc.) plays a protective role.
People who have experienced psychological trauma retain a trace of the events in their psyche, like a scar, which may reopen later in life, for example due to another painful event or an anniversary. In such cases, it is never too late to seek help, and treatment remains effective.
Finally, some people who have faced severe trauma eventually feel that their experience has led to positive changes in their lives, that they have acquired new strengths, or dared to make positive decisions (resilience, post-traumatic growth).

Reference: Lebigot F. Psychological Trauma. Brussels: Ministry of the Wallonia-Brussels Federation; 2006.

What kinds of reactions might someone experience on the first day after a traumatic event?

Individual reactions as an immediate response to an exceptional event revolve around the central concept of stress, a term borrowed from the English-speaking world that encompasses physical, behavioral, and emotional aspects. Coined by the Canadian physiologist H. Selye in the 1945–1950 period, the term “stress” refers to the “biological, physiological, and psychological reaction of alarm, mobilization, and defense in an individual facing an attack or threat.” The term generally applies to exceptional aggressions or threats that endanger the individual’s life or physical integrity: physical assault, rape, torture, war, accidents, natural disasters, or acts of terrorism.

Normal, adaptive stress response

Following alarm and preceding defense, the essential effect of stress is the mobilization of the individual’s resources. The normal stress response mobilizes well-known biological and physiological processes centered on the release of endorphins, the enhancement of immune defenses, and, more broadly, a cascade of information involving the sensory organs, the cerebral cortex, the adrenal glands, and the autonomic nervous system. These mobilizing processes put the body into a physiological state of alertness and defense. The individual then experiences a range of symptoms and physical manifestations. While the four cardinal symptoms are increased heart rate, trembling, sweating, or shortness of breath, we frequently encounter chest pain, a feeling of a tight throat, a heaviness in the chest, or a sensation of muscle tension. Less specific signs are not uncommon: headaches or digestive symptoms such as nausea, vomiting, or abdominal pain. Despite the presence of these bothersome symptoms, it is important to remember that stress is first and foremost a useful and adaptive reaction that enables the individual to make decisions and take actions conducive to removing themselves from danger or helping others to do so. The stress response is generally short-lived, but can be prolonged as long as the individual has not managed to reach safety. Demanding in terms of mental energy, this stress response leads to an ambiguous state combining euphoric relief with a sense of physical and mental exhaustion. Sometimes, all the emotional tension accumulated during the event is released once the individual is safe, leading to dramatic emotional and autonomic outbursts: crying, screaming, agitation, aggressive outbursts, uncontrollable tremors, or even urinary or bowel incontinence.

Excessive, maladaptive stress reactions

When stress is too intense, repeated at short intervals, or prolonged excessively, it depletes the subject’s energy reserves and emotional control capabilities, leading to archaic, stereotyped, and often maladaptive forms of stress overload. Four reactions to stress overload can be distinguished. The first is the reaction of shock, affecting the motor, cognitive, and affective components. Thus, we encounter victims who remain motionless, frozen in place, completely unable even to remove themselves from danger. More boisterous, the agitation reaction occurs in individuals who, struck by stupor, gesticulate in a disorderly manner, unable to formulate an appropriate decision. Derived from the previous one, the panic-stricken flight reaction—generally very sudden and sometimes mimetic—can propel the subject, with no regard for their surroundings, into even greater danger. More difficult to detect, automatic action, meanwhile, leads a person in a state of shock to repeat automatic gestures that escape conscious control.

Dissociation

Peritraumatic dissociation is a more recent cluster of symptoms that has taken on significant importance in the field of psychotraumatology. It leads to a genuine loss of contact with reality.
To learn more about dissociation, click here

References:
Brunet A, Birmes P. (2002). Psychopathology of early reactions following a traumatic event. Ann Med Psychol, 160, 461-463.
Crocq L. (1999). Psychological trauma of war. Paris: Odile Jacob.
Crocq L, Doutheau C, Louville P. (1998). Disaster psychiatry. Immediate and delayed reactions, sequelae. Panic and collective psychopathology. Encyl. Med. Chir. (Elsevier Paris), Psychiatry, 37-113-D-10, 8 p.

What is dissociation?

Dissociative Disorders: Overview

Dissociative disorders are common.
Generally speaking, dissociative disorders are characterized by a partial or complete loss of memory integration, control over bodily movements, and awareness of identity. This term encompasses a variety of presentations, including possible episodes of amnesia, motor disturbances, and even symptoms resembling seizures…
Historically, some of these disorders were referred to as “hysteria” or “conversion disorders.” Today, we speak of dissociative disorders, and more specifically of functional disorders in some cases—medical terms that are less stigmatizing for the patient.
These disorders must be distinguished from feigning on the part of the individual. They are not voluntary.

Peritraumatic dissociation

Generally speaking, a dissociative episode involves a separation of mental elements (emotions, thoughts, behaviors…), which are usually well-integrated within the individual.
The individual may experience various forms of dissociative symptoms: for example, a distortion of the perception of time and space (a sense of blurriness; feeling as if in a movie), disorientation (loss of temporal and spatial bearings); this can extend to a sense of depersonalization (perceiving oneself as strange or unfamiliar) or derealization (the feeling that the world around one has become strange and unfamiliar). One may also experience a sense of unreality, motor behaviors not controlled by the individual, or even transient alterations in consciousness.

Within dissociative disorders, peritraumatic dissociation holds a special place in the context of a traumatic event. During this episode, which caregivers may also refer to as “overwhelming stress,” four types of reactions are observed, alongside inappropriate and unusual interpersonal contact on the part of the individual:

• psychological shock: frozen, “frozen,” the individual is stuck,

• agitation: the individual “fumbles” aimlessly and chaotically,

• panic flight, without planning,

• automatic behavior: the individual repeats a habitual behavior or one performed at the time of the event.

Dissociative mechanisms

The mechanisms underlying these disorders are now partially understood thanks to functional neuroimaging. Key regions involved in motor, emotional, and cognitive activity are implicated in specific and reciprocal ways, but to date, there is no comprehensive explanatory model for dissociative disorders.

Peritraumatic dissociation can be viewed as a neurological “survival” mechanism that allows the brain to protect itself, in the moment, from the destructive impact of a traumatic event. This “short-circuit,” however, increases the risk of subsequent Post-Traumatic Stress Disorder (see fact sheet). This episode and the resulting reactions are transient; the individual returns to normal functioning after a few seconds, minutes, or hours. This is, however, considered a significant predictor of subsequent Post-Traumatic Stress Disorder (see fact sheet).

When experienced repeatedly, dissociation becomes an maladaptive reaction to new events or various emotional stresses. It then often persists alongside Post-Traumatic Stress Disorder, particularly with episodes of derealization and depersonalization.
Impaired motor, sensory, or memory function may emerge, along with disturbances in self-representation or heightened emotional reactivity, although no specific anatomical lesions have been clearly identified to date.
Numerous studies have found a particularly high frequency of prior traumatic events (history of physical violence or sexual abuse, etc.) among individuals experiencing dissociative disorders. There appears to be an interaction between past and recent traumas. This suggests that early-life traumas influence the response to new traumatic events, even years later.

What treatments are available for dissociative episodes?

Peritraumatic dissociation most often resolves spontaneously. However, during the episode, the individual requires monitoring to ensure their basic needs are met (drinking, eating, staying warm, using the restroom, etc.) and to ensure they are not at risk while they return to their previous, adaptive functioning. In the face of significant behavioral manifestations or a particular risk, a doctor may prescribe short-term treatment to reduce the emotional burden.
In cases of repeated dissociative episodes, a medical evaluation is necessary to determine the cause of the disorder (and to avoid overlooking another medical condition, even if it coexists with a mental disorder!). Subsequently, if the cause is psychological or even psychotraumatic, psychotherapy is recommended as the first-line treatment.

Reference: Hubschmid M, Aybek S, Vingerhoets F, Berney A. Dissociative disorders: neurologists and psychiatrists working together. Rev Med Suisse. 2008 Feb 13;4(144):412-4, 416. Review in French.

What is post-traumatic stress disorder (PTSD)?

Post-Traumatic Stress Disorder (PTSD) (formerly known as Post-Traumatic Stress Syndrome or traumatic neurosis) is a mental health disorder. It can occur in a child or an adult following exposure to a potentially traumatic event, in which the person has been confronted with death or the risk of physical or psychological harm—whether to themselves or to others—as a result of, for example, an assault, sexual violence, an accident (traffic, workplace, etc.), abuse, an attack, a disaster…
It should be noted that the loved ones of victims may also be affected by psychological trauma linked to the news of a sudden violent event suffered by their loved one. Similarly, emergency responders or professionals who regularly interact with victims may, in some cases, be indirectly impacted.

In all cases, the psychological distress is significant and has debilitating effects on physical, psychological, relational, and socio-professional levels.

How does Post-Traumatic Stress Disorder (PTSD) manifest itself?

Symptoms may begin immediately, a few days after the event, or much later. In the month following the event, Acute Stress Disorder is possible. The symptoms are generally similar to those of PTSD but appear earlier and are easier to treat.
By definition, PTSD symptoms persist beyond one month and can last for months or years, significantly impacting daily life.

Reactions following a traumatic event vary, but warning signs include:

• severe distress, or dark/suicidal thoughts,

• symptoms (particularly sleep disturbances) that show no improvement for more than a month,

• significant disruption to professional and/or personal life.

Four typical symptom patterns of PTSD are observed:

1. Flashbacks: the feeling of reliving the scene or a “part” of the event (the entire scene or a detail, an image, a sound, a smell, a sensation). One then feels the same emotion as during the event, even if it happened long ago. These thoughts “intrude” regularly; one cannot control them. They may be triggered by something (a noise, an image…) or not, and can occur during the day, often at bedtime or at night in the form of nightmares.

2. Targeted avoidance of anything that might remind the person of the event: situations, places, people, thoughts... The person may isolate themselves in a place that feels safe (home...), withdraw into themselves, and limit contact with the outside world.

3. A state of heightened alertness, hyperarousal of the body and mind, hypervigilance day and night. The person is on guard, despite themselves. The energy cost is very high.

4. Negative changes in thoughts and emotions: mood fluctuates, emotions shift rapidly from one moment to the next, accompanied by negative feelings (anger, sadness, fear, shame, guilt…), and difficulties with memory and concentration. It may be difficult to express or even feel emotions that are otherwise familiar. Individuals feel that the world and other people have become dangerous. They are suspicious of everything and everyone, may become agitated, and exhibit a certain degree of aggression, while finding this mistrust unusual in themselves.

Other disorders may be associated:

• “instinctual” disturbances: eating disorders (including anorexia, obesity, etc.), libido, sleep issues…,

• physical complaints: pain (migraines), etc.,

• somatoform disorders: presenting as a physical illness (digestive, neurological disorders, etc.); psychosomatic illnesses involving a combination of anatomical factors (e.g., bacteria) and stress (e.g., ulcers),

• various mental disorders:

  • depression, anxiety attacks, dark or suicidal thoughts, substance use (alcohol, cannabis, anxiolytics, etc.),

  • dissociative syndrome: transient episodes (isolated or recurring) involving a sense of being disconnected from oneself, a feeling of unreality, or a sense of strangeness regarding oneself or the world,

• changes in one’s sense of purpose or personality.

What are the consequences of PTSD?

The suffering can be severe. The consequences are significant in daily life, for the individual and those around them: relationships become complicated, whether with a partner, family, friends, or at work. It can be difficult to go to work, attend family gatherings, or participate in celebrations. The victim and their loved ones struggle to understand PTSD and its consequences.

What are the possible treatments for PTSD?

Treatments have evolved significantly, and today there are various effective treatments available, provided they are initiated early.
The first-line treatment is targeted psychotherapy with a psychologist or psychiatrist specializing in post-traumatic stress. There are various techniques: Cognitive Behavioral Therapy (CBT), EMDR, psychodynamic therapies, medical hypnosis, and other complementary therapies (mindfulness meditation, stress management, etc.). (see fact sheets).
If improvement is insufficient, if symptoms are too severe, if psychotherapy is not possible, or if another disorder is present, a doctor may prescribe specific medication.

Can seeking treatment for PTSD be difficult?

There are many reasons, but certain factors are specific to psychological trauma:

• the individual is poorly informed about PTSD: they believe it is “normal” to experience these flashbacks or other symptoms. They do not know that it is a medical condition, that specific treatments exist, or that they can get better,

• the avoidance typical of PTSD means the person effectively avoids discussing the trauma, and is therefore afraid to seek help,

• the traumatic experience causes a feeling of isolation, the belief that one cannot be understood by a “non-survivor” or properly express the event experienced,

• there may be feelings of shame and/or guilt: unaware of appropriate mental health care, the victim may not feel justified in asking for help, or may feel that their suffering is trivial compared to others considered more severely affected.

The risk is then becoming trapped in one’s suffering, with existing symptoms worsening or new ones emerging.
As with any therapy, it may happen that the first therapist isn’t a good fit; in that case, one can switch therapists—but above all, don’t stop therapy! In such cases, do not hesitate to seek advice from your primary care physician, a support group, recognized professionals in the field, or a friend who has received treatment... Ten regional psychotrauma centers have recently opened in France to provide optimal care for these psychological traumas.

Reference: https://www.nice.org.uk/guidance/ng116

Major Depression

Depression is a common illness

Depression is one of the most common mental health conditions. In France, about 10% of people aged 18 to 75 experience depression during the course of a year, and about one in five people have experienced or will experience depression at some point in their lives. Between 2010 and 2017, there was a 1.8-point increase in the reported prevalence of depression (EDC) over the past 12 months. Depression affects women about twice as often as men. It can occur at any age (infants, children, adolescents, adults, older adults), with symptoms that vary slightly depending on age.

Depression is a major contributor to suicide risk. More than half of those who die by suicide were suffering from depression, most often undiagnosed or untreated.

Symptoms of Depression

Feeling sad, “depressed,” having dark thoughts, or having trouble sleeping does not necessarily mean you have depression. Moments of feeling down and discouraged are normal human experiences.

To speak of depression—and thus of an illness—there must be a combination of several symptoms that occur (almost) constantly for at least two weeks and cause significant emotional, social, and professional distress, as well as impairing daily functioning. A depressive episode is characterized by two main symptoms:

• unusual sadness, a sense of hopelessness,

• a marked loss of interest and pleasure in most activities that are usually enjoyable.

These two main symptoms are accompanied by several others:

• a feeling of exhaustion, severe fatigue, and lack of energy,

• general psychomotor retardation in both physical and intellectual and emotional activities, with difficulty concentrating and reduced attention,

• a loss of self-confidence, low self-esteem, and feelings of guilt,

• sleep disturbances,

• recurring thoughts of death and suicidal ideation,

• changes in appetite leading to weight fluctuations (loss or gain).

Depending on the number of symptoms and the degree of disruption to daily functioning, a depressive episode is classified as mild, moderate, or severe.

Depression and Trauma

Depression can occur after a traumatic event. For example, 23% of people exposed to the Oklahoma City bombing were depressed six months later, whereas only 13% showed signs of depression before the bombing. Often, depression following a traumatic event is associated with post-traumatic stress disorder. Depression is 3 to 5 times more common in people with post-traumatic stress disorder than in the general population.

Depression and Grief

When grieving, people experience many feelings that resemble the symptoms of clinical depression: sadness and emotional pain, fatigue, sleep disturbances, despair, and a loss of the ability to experience pleasure… These symptoms are part of the inevitable experience of grief. In some cases, however, due to their intensity and persistence, they may be considered a true clinical depression, which then requires the same treatment. Distinguishing between the two can be difficult, and you should not hesitate to seek the advice of a specialist if in doubt.

Evaluation by a healthcare professional is essential

Depression is an illness that should not be taken lightly. It is important to consult your primary care physician, who will know how to take the necessary steps. When depression is properly diagnosed and managed, it is an illness that is easily treated. If left untreated, it can worsen, become chronic, and even lead to suicide. The combination of psychotherapy and antidepressants is undoubtedly the best treatment approach. Hospitalization is generally not necessary during treatment, except for the most severe cases.

Treatments

Psychotherapy

Psychotherapy addresses the psychological, family, and social factors that may be linked to the depressive episode. Several types of psychotherapy are available; two in particular have proven effective for treating depression: cognitive-behavioral therapy and interpersonal therapy.
It can be as effective as antidepressants in cases of mild or moderate depression.

Antidepressants

Antidepressants help regulate neurotransmitters and aid in restoring sleep, appetite, energy, pleasure, and positive thoughts, usually after two or three weeks of continuous treatment.
Antidepressants are not addictive and must be taken for at least six months to minimize the risk of relapse. However, treatment must be extended if depressive symptoms persist.

Follow-up

To limit the risk of relapse into a depressive episode, it is recommended to continue medical follow-up with monthly consultations and full-dose treatment for 4 to 6 months following symptom remission.

References:
Léon C, Chan-Chee C, du Roscoät E, et al. Depression in France among 18- to 75-year-olds: results of the 2017 Health Barometer. Bull Epidemiol Hebd. 2018,32-33:637-44. http://invs.santepubliquefrance.fr/beh/2018/32-33/pdf/2018_32-33_1.pdf
The Santé Publique France report on depression: http://www.info-depression.fr/ France
Dépression website (patient association): http://www.france-depression.org/sample-page/ National Institute of Health and
Medical Research (Inserm) page on depression: http://www.inserm.fr/thematiques/neurosciences-sciences-cognitives-neurologie-psychiatrie/dossiers-d-information/depression

When suffering becomes so unbearable that it leads to thoughts of suicide

When negative events pile up in life and suffering becomes so overwhelming that it blocks out the horizon, thoughts of suicide can arise. This happens to 4% of French people each year, according to Santé publique France.
At this stage, don’t isolate yourself—reach out to others to fight the urge to withdraw. Always remember that being strong means asking for help.

Depression or post-traumatic stress increases distress and makes it easier for suicidal thoughts to take hold. In such cases, people begin to have negative thoughts about themselves and imagine that the future holds nothing good. These negative expectations are triggered by post-traumatic stress and depression. They disappear with treatment. Medical follow-up is therefore essential. Loved ones must be informed of the level of distress to help them respond appropriately. Suicidal crises can progress through varying stages: thoughts, intention, planning, and, much more rarely, action. It is this level of suicidal urgency that will determine the timing and nature of the protection needed.

If you are having suicidal thoughts: do not stay alone; talk to loved ones, a victim support group, or a crisis hotline.
See a doctor immediately; if necessary, go to the emergency room at the nearest hospital, or call 911 (15), which can respond to your needs 24 hours a day.

Support hotlines

The SOS Suicide Phénix France Federation

Founded in 1978, it welcomes and organizes meetings for those who have attempted suicide or who have, at some point, contemplated it. Its volunteers, who receive ongoing training, listen and hear without judging or offering advice. Individual counseling and participation in group activities help restore social connections and give meaning back to speech. Some meetings are reserved for the families of those who have attempted or committed suicide, while others are specifically dedicated to those under 25. SOS Suicide Phénix also works with students, as well as education and health officials, to provide information and promote prevention. It operates a national hotline and offers in-person support at its offices, located in six major cities across France.

National Hotline: 01 40 44 46 45 (available from 1:00 PM to 11:00 PM, 7 days a week)
Website: https://www.sos-suicide-phenix.org/
Email: accueil@sos–suicide–phenix.org
Facebook: @federation.sos.suicide.phenix
Twitter: @SosSuicideFr
Instagram: sossuicidefr

The SOS Amitié Federation

A non-profit organization under the 1901 law, recognized as a public utility and founded in 1960. It offers a 24-hour emergency hotline whose primary—though not exclusive—goal is suicide prevention. A chat service and messaging system also complement the tools available to counselors. Anonymous, non-judgmental, and non-advising support is provided by 1,600 volunteers, rigorously trained by psychologists and continuously supported, who answer more than 600,000 calls per year.
SOS Amitié also contributes to discussions on psychological and social issues within the UNPS (National Union for Suicide Prevention) and IFOTES (International Federation of Telephone Emergency Services)

National Hotline: 09 72 39 40 50 (available 24/7) Paris –
Île-de-France Hotline: 01 42 96 26 26
International SOSHelp Hotline: 01 46 21 46 46
Website: https://www.sos-amitie.com/
Messaging and Chat on the website (chat from 1:00 PM to 3:00 AM, 7 days a week)
Facebook: @federationsosamitie

Suicide Ecoute

Suicide Ecoute’s mission is to provide anonymous telephone support to those at risk of suicide and those attempting suicide, while respecting everyone’s beliefs. Its services are designed to be compassionate, supportive, selfless, and non-judgmental. Suicide Ecoute does not pass moral judgment on suicide. Its goal is to ensure that people considering taking their own lives do not face their suffering alone.
Suicide Ecoute receives an average of 20,000 calls per year. The organization also works with schools and other organizations upon request to organize conferences and awareness-raising discussions on the issue of suicide. Suicide Ecoute is a member and founder of the UNPS (National Union for Suicide Prevention).

National hotline: 01 45 39 40 00 (available 24/7)
Website: https://suicideecoute.pads.fr/

Reference: National Suicide Observatory. Suicide. Understanding to Prevent: National, Local, and Community Dimensions. 2nd Report/February 2016. Available at: https://drees.solidarites-sante.gouv.fr/IMG/pdf/ons2016_mel_220216.pdf

The grieving process in adults and how it differs in this context

We will distinguish between normal grief and grief related to trauma.

1. Definition of Grief: Grief is the loss of a loved one through death. It is not the loss of material possessions or something abstract. It is important to clarify the concept of the duration of grief. We can distinguish between a “social” duration and a “psychological” duration. The social duration varies from a few months to a year, or even two years. Grief may manifest itself in a particular way of dressing, behaving within the family and at work, and choosing whether or not to visit certain places. After a while, the bereaved person may change their behavior, often at the urging of those around them to “move on” or “get back to life as before.” The psychological duration is different. Grief is a state that lasts a lifetime. However, the behavior of those grieving varies throughout the grieving process. This process differs from one person to another, and especially depending on the circumstances of the loss. It is best to avoid speaking of “stages” because the progression is variable and complex.

2. Traumatic Grief This is a type of grief that can be described as complicated. It is characterized by the circumstances of the loved one’s death, which are experienced as brutal, unexpected, absurd, unjust, and sometimes traumatic—especially if the bereaved person witnessed the death of their loved one, or if they are repeatedly told the story of their death.The grieving process can then be more complex, involving: - daytime and/or nighttime flashbacks of the traumatic scene that was witnessed or imagined; these are then intrusive memories;- hyperarousal or despondency;- a mental block that can, at the beginning of the grieving process, lead to a state of stupor;- sometimes, an absence of outward grief at the start of the grieving process;- the bereaved person may be frozen, if there is, at the beginning, denial of the loved one’s death; - sleep disturbances; - eating disorders; - an overwhelming sense of despair that may manifest as a depressive state, with or without suicidal thoughts; - multiple physical symptoms; - risky behaviors, with or without substance abuse.

3. Possible SupportLanguage plays a crucial role: words allow us to share, to provide insight into what the bereaved may be experiencing, to offer companionship on the path of grief, and, in this way, to offer some comfort. This helps them regain a foothold in the world of the living.The grieving process is “impeded” due to the traumatic violence that breaks into the psyche.It is advisable to reestablish interpersonal communication after an event described as “inhuman.” If we cannot find meaning in the senseless, we must find meaning in the bereaved’s reaction. To this end, there are loved ones, but also certain organizations (see below) that offer information, support, a listening ear, and gatherings for the bereaved. Finally, when the pain is too intense, or if there is depression or suicidal thoughts, it is essential to seek professional help.

Organizations:

Vivre son deuil: Inter-organizational network providing support and assistance to those in mourning
http://vivresondeuil.asso.fr/associations.html
tel: 06 15 14 28 31
email: fede.vivresondeuil@gmail.com

Coping with Loss: Support groups for bereaved parents – Meetings for bereaved siblings
http://www.apprivoiserlabsence.com/
1 branch in the Paris region
, 4 branches in the provinces. Phone and email
contact information available on the website

References:
Bacqué MF. Coping with Grief. Paris: Odile Jacob; 2000.
Cornillot P, Hanus M. Let’s Talk About Death and Grief. Paris: Frison Roche; 2000.
Gril J. Living After the Death of a Child: Parents Share Their Stories. Paris: Albin Michel; 2007.
Hanus M. The Death of a Parent, Children’s Grief. Paris: Vuibert; 2008.
Joan Didion. The Year of Magical Thinking. Paris: Grasset; 1997.
Joyce Carol Oates. I Managed to Stay Alive. Paris: Folio.

The grieving process in children and how it differs

Differences in Grief Between Adults and Children

For adults, grief is a process. Periods of emotional breakdown alternate with moments of relief from the pain. Slowly but surely, the grieving adult will move from suffering that is sometimes unbearable to a deep sadness stemming from the realization that the loss is irreversible. Little by little, the grieving adult will confront all the memories with the deceased, then the plans and even the dreams they shared. The distress of the early stages of grief will eventually fade, giving way to nostalgia, and the adult will—sometimes later—recognize the journey taken without the loved one and a new perspective on their own life.
For adults, grief is linked to the ability to process the absence and tolerate the void both personally and socially. Funeral rites are very helpful at the time because they provide reassurance regarding society’s acceptance of death. But although a child may also find comfort in participating in the funeral or visiting the cemetery, the solemnity of these events does not have the expected emotional impact.

In very young children

For children, grief is more complex. First of all, the ability to grieve depends on the child’s age. A baby can lose a parent and feel their absence very deeply. However, since the baby cannot verbalize the loss, the grief will manifest as behavioral changes and sometimes physical signs: the baby is sad, sullen, cries a lot, stops eating, or, conversely, throws themselves at food automatically. The baby may also become very anxious, as if waiting for their parent to return. The therapeutic approach will often involve bringing the surviving or substitute parents together with the baby and discussing the events as a group. Indeed, a young child’s perceptions are shaped by the reactions of their caregiver.
A lack of discussion about the grief often disrupts communication with the baby. Reopening the conversation about the deceased will reassure the remaining parents and reconnect them with the child. As the child grows, however, the story of the parent’s death will need to be revisited using new terms, in line with the child’s development. At each stage of the child’s psychological development, the death of their parent must be revisited by a responsible caregiver using words the child can now understand and process. This conversation will be based primarily on the child’s questions, leaving room for multiple possible answers. For example, an important question from the child does not necessarily have an answer: “Are my parents in heaven? Will I see them again someday?”

As they grow up, children learn about the irreversibility and universality of death

As they grow older, children will gradually come to understand that all living beings are mortal and that death is irreversible. We adults take this for granted, and yet, when faced with grief, how many of us would wish to turn back the clock, to pretend that death were merely a bad movie that could simply be rewound to the beginning? Children only acquire the concept of irreversibility with the development of self-awareness, around the age of seven. As for universality, this depends on their experience. Many children encounter dead animals in the countryside, but in cities and elsewhere, it is mainly the news or video games that teach them to live with death. But this death is most often virtual. The universality of death is therefore often repressed, although children who have access to scientific knowledge are fascinated by all the particularities of death across animal species. Unfortunately, what children have learned in school does not help them cope with the death of a loved one. Death is not, in fact, a matter of “knowledge,” but rather an emotional upheaval that children are often very reluctant to express.

The Specifics of Grief Following a Terrorist Attack

Following the attacks of November 13, some children did not see one of their parents or a loved one come home (though the loss of a parent is considered the most difficult). Here, death was negatively amplified by the brutality and violence of this mass attack. What mattered most to the children this time, regardless of their age, was the way the death was announced to them and how the adults who subsequently cared for them dealt with their own grief. The words used are important. Thus, metaphorical expressions such as “he’s gone,” “he’s in heaven now” often betray the understandable desire not to cause the child even more pain. These expressions can, however, lead to misunderstandings. For example, “gone” implies the possibility of returning, while “in heaven” may lead the child to believe that the parent is stuck up there or watching from afar and no longer wishes to be reunited with them. Fortunately, we can always correct what we said in the heat of the moment. But the best way to put things is to use the word “death” in a sentence where the child can feel the sorrow. Understanding—and above all, being present with the child to share this moment—is far more comforting to the child than a prepared, soulless speech. There is no “right” thing to say, but what matters most is an attitude of “presence” toward the other person, with an honest gaze and warm support.
Even for very young children—though we think the word “death” is understood around age four—death does not necessarily imply the end: “I’m still waiting for Mommy to, well, come back,” says six-year-old Jasmine. Similarly, it seemed that everything had been explained to the child, and yet, a few months later, it appears that he is waiting for his dad, as if he were due to arrive from a long journey. This is not pathological; it stems from the child’s inability to make sense of their parent’s absence. Things need to be revisited together regularly: talking on certain occasions (and especially not all the time) about what we used to do with Dad or Mom, and working with the child to figure out what will happen now and over the coming year.

A child, regardless of age, needs to feel secure. They also need to do “normal” things: go to school, have hobbies, and be alone from time to time.

When things go wrong

We often become aware of a child’s grief indirectly. Daycare staff call because the baby is “grumpy, maybe still sick,” the school reports restlessness or, conversely, indifference—“he broke another window while roughhousing,” “now she’s often daydreaming, she doesn’t listen anymore,” the grandparents do what they can but feel overwhelmed by their own grief…
And yet, the child says nothing about their deceased parent. Several months after the death, a child may experience “delayed grief,” meaning that the expected emotions did not appear immediately after the bad news, but much later. Here too, we must revisit the situation and even revisit the announcement of the death. We have seen that with babies, a family member, the doctor, or the psychologist can gently revisit the events: “Since the death of … we’ve been doing what we can at home, the grandparents have stepped in, the family’s balance is still fragile, but we’ve found help with so-and-so … .” Intense emotions can be expressed and lead to a greater sense of solidarity among family members. With older children, before the adults speak, a fundamental step must not be overlooked: listening to what the child has to say. Many children have trouble speaking, but by asking them what’s going on right now, how things are going at school, the child might talk about how they feel. The privacy of their emotions must, however, be respected. A child who doesn’t speak can draw; they can also express through play what they might say but… they can’t find the words…

The Value of a Therapeutic Session

Faced with this lack of expression of grief, a session with a psychotherapist can be suggested to the child, but they may refuse in many cases because their privacy has been violated. We cannot force them, but simply make a bet with them: “I suggest we go together to talk to a psychologist; let’s give it a try anyway. If you don’t want to go back, I’ll respect your decision.” Going through an organization is a good idea, but it should be one that isn’t too far from home. So we often go through the family doctor, who knows the right places. After an initial meeting with the family, the organization may suggest joining a group for grieving children. Six months or more after the events, a follow-up assessment may be suggested, or at least a meeting with the organization, to prevent unusual behaviors from taking root in the child, such as withdrawal, isolating themselves from the group, or suppressing their emotions. Although these behaviors signal deep sadness, they can also indicate a sense of guilt or low self-esteem in the child. The child may, in fact, feel strangely guilty about their parent’s death: “We had argued… I was angry with them that day… I’d gotten a bad grade.” This guilt can be discussed with the therapist or in a group setting. On the other hand, the death of a parent can lead to the feeling that the child wasn’t “good enough” or “worthy enough” to keep their parents, like all the other children. These thoughts are typical of grief and deserve to be explored, but be careful: this is only possible if the child has the words to do so. Establishing contact with a therapist is undoubtedly a first step because it will instill the idea that there is a possible way forward and that someone stable and emotionally consistent is potentially there to listen.

References:
Bacqué MF. Hanus, M. Grief. Que sais-je, Paris, PUF (2000, 6th edition, 2016)
Romano H. (Ed.) Supporting Grief in Traumatic Situations. Paris, Dunod (2015)
Romano H, Baubet T. “Tell me, what’s it like when you’re dead?” Accompanying the Child on the Path of Grief. Grenoble: La Pensée sauvage; 2006
Glorion F. Accompanying the Child in Grief. Revue Laënnec 2003; 51(1): 21-33 “7 Useful Resources for Supporting
a Child in Grief.” Website “Les mots du deuil.”

Talking to Children About Recent Events

The goal here is to talk as a family about what happened on November 13, 2015. After the initial shock, children may have exhibited certain difficulties, such as separation anxiety or an increased need for security. They may have asked their parents questions, but sometimes they kept these concerns to themselves, which caused them distress at school or in their usual environment. What can be done to help them process these events?

The November 2015 attacks caused significant distress, even among those who were not direct witnesses. At home, young parents who might have been at the Bataclan, in the restaurants, or at the Saint-Denis stadium imagined themselves in the place of those who were attending the concert or celebrating a birthday with friends. They were initially stunned by the events. On the very evening of November 13, many stayed up late watching TV. Everyone was somber; some were screaming or crying. Sadness was evident in everyone’s eyes. Their children and teenagers not only learned that a deadly attack had claimed many lives, but they also saw that their parents were deeply affected, even though they were safe and sound.

At first, the parents said nothing, stunned. Then they began to speak. Overcome by emotion, they conveyed a great deal of fear and anxiety.

Before putting words to what had happened, emotions came through raw and unfiltered. They were passed on to the children in their raw, unprocessed form. Then, through discussions and reading, the parents tried to make sense of what had happened: “Madmen, terrorists, murderers…” All these words were all the more terrifying because the children sensed the danger that could now affect anyone. On TV, we saw processions and spontaneous demonstrations, but this did not reassure the parents. The children felt increasingly alone. The moment of silence at school was followed by some explanations, but it was still difficult to express themselves at that point.

When a serious, national trauma occurs, children are often the ones left behind. Their parents, after a period of shock, find their voices again. Even if they are saddened for a while, they return to their routines. Children are rarely asked to share how they feel, yet they, too, are deeply shaken, especially by the changes they see in their parents.

Children will therefore “keep inside” their fear and their sorrow at seeing their parents so upset. This lack of expression can lead to anxiety (yes, even in a young child), an anxiety that isn’t expressed in words but manifests as nighttime rumination and a fear of being separated from loved ones (also known as “separation anxiety,” which is sometimes followed by school phobia, where the child no longer wants to go to school).

To prevent these difficulties from dragging on, it is necessary to consult your family doctor or a psychologist. During this consultation, parents are present with their child(ren) and discuss what happened with the professional. The children say: “Mom turned pale,” “Dad yelled, I was scared…,” they reflect their parents’ distress.

Yes, the adults could no longer control themselves; they created a sense of great insecurity.

Seeing their family doctor or a psychologist allows parents to reclaim their role as adults who reassure and protect. That is what children need. However, parents can revisit these difficult moments and express how deeply shocked they were by what happened. They can emphasize the emotions they experienced: empathy for the victims, helplessness, a desire to help, and a sense of outrage. It is through open communication and the return to normal routines that children will be reassured by the protection provided by their parents, while gradually becoming aware of the dangers around them. During ceremonies commemorating the attacks, parents and children can reflect together on the difficulties they faced and see that family stability has been restored, strengthened by the experience they have now gained.

References:
Bacqué MF. Hanus, M. Grief. Que sais-je, Paris, PUF (2000, 6th edition, 2016).
Bacqué MF. How Death Comes to Children. Journal des psychologues 2004;219, 46-50.
Le P’tit Libé No. 3: The Paris Attacks (November 2015)
Le P’tit Libé No. 5: Safety: Life After the Attacks (January 2016)

Victims and the media

In recent years, violent events and/or those involving numerous victims have had a significant media impact, particularly because news reports can be broadcast repeatedly for days or even weeks. Viewers are thus exposed to a flood of visual and auditory information—along with the emotional impact of the event.
Meanwhile, victims of the incident are interviewed by journalists, either immediately after the event or at a later date. In all cases, they are asked very direct questions about their experience of the event or its consequences (such as deaths).

This raises the question of what impact media exposure has on these victims, and more broadly on viewers, particularly those who have previously experienced psychological trauma?

Media exposure, behind the screens

Today, the media allow each of us, wherever we are and at any time, to be plunged in a matter of seconds into the “heart” of current events. Often spectacular and captured right at the scene, these “shocking” images are shared very quickly. They depict pain, violence, and physical or psychological injuries without always being accompanied by words or commentary. It can then be difficult to maintain emotional distance, as the information conveyed is primarily designed to grab the viewer’s attention, at the risk of impacting or re-exposing them. Journalists, who are sometimes caught up in the violence of the event themselves, can also be affected by these images.
However, current diagnostic classifications in mental health only account for this type of traumatic media exposure in certain professional contexts (intelligence services, etc.).

Laboratory experiments have, however, shown that exposure to traumatic images can induce symptoms of flashbacks (see PTSD fact sheet). Contrary to what was previously thought, the screen does not “protect” the subject from the violence of the information. Such information, particularly visual content, triggers the activation of brain structures involved in fear and psychological trauma and can trigger painful memories, sensations, and emotions in the individual. Post-Traumatic Stress Disorder (PTSD) may, under certain conditions, result from this (see PTSD fact sheet).

Generally speaking, positive associations have been identified between repeated exposure to media (television, social media, etc.) and the presence of psychological disorders, particularly symptoms of post-traumatic stress disorder, several months or even years after the event. Children are also affected.
Studies conducted in the U.S. since September 11 also show that the duration of media exposure is a factor that increases the potential risk of trauma: the more one watches the media, the greater the potential impact. Individuals who have already experienced trauma are particularly sensitive to this repetition, which can reinforce certain beliefs (such as fear or helplessness) and thus increase the risk of psychological trauma.

Despite these findings, a causal link has not yet been clearly established. The studies are primarily retrospective and require further research. High media exposure may also be linked to individual coping and stress management strategies, though these strategies are generally ineffective.

Media exposure of victims

In the immediate aftermath of the event

In the first few hours after the traumatic event, victims are often approached “on the spot” by journalists and/or photographers for an interview. It is then very difficult for the individual to assess the situation and make an informed decision regarding these requests, at a time of intense vulnerability and without the ability to step back and reflect. In the moments following the event, victims may thus be filmed looking haggard, dazed, unable to speak, or even confused, agitated, and unable to control themselves. There is a significant risk that these images will remain frozen in time, despite any subsequent improvement in their condition.

Later

Certain key moments related to the traumatic event, such as anniversaries, can sometimes prompt the victim to want to speak out about their own experience. Before speaking to the media, however, it is essential that they ask themselves a few questions, for their own safety and that of those around them: How do they want the media to portray them? What message do they want to convey? What should remain private? How can children be protected? What are the potential reactions or risks of a media appearance?
By allowing sufficient time between the event and any potential testimony, the individual will be better able to exercise their free will and utilize their capacity for reflection and perspective.

In hindsight, those affected by the event or their loved ones may feel that their pain is being exploited for ratings. Regardless of the timing, the images captured freeze the moment and the subject’s state.
Thus, in all cases, everyone has the right to choose whether or not to speak out, to set their own boundaries, and to refuse questions. Agreeing to be filmed, recorded, or photographed is never an obligation or a duty.

Reference: http://www.info-risques.be/fr/agissez-efficacement/victimes-et-medias.
Enguerrand du Roscoät et al. The November 2015 attacks in Paris: media exposure to images and symptoms of post-traumatic stress. BEH 38-39, November 13, 2018