What kinds of medical and psychological support are available after a terrorist attack?
Doctors, psychiatrists, and psychologists discuss the key measures that can be implemented immediately or in the aftermath of such events, for both the affected civilian population and the professionals who respond to these types of incidents.
Medical-Psychological Emergency Units (CUMP)
Medical-Psychological Emergency Units (CUMP) are part of the emergency medical response system and are responsible for managing medical-psychological emergencies.
History of the CUMP: a system established in France in 1995
For over 25 years, a system has been in place to address the psychological trauma of victims of violence and terrorism. The first formalized intervention took place in December 1994, following the special forces assault required to free the hostages on a plane returning from Algeria that had been hijacked by a terrorist group, which had killed several hostages. This intervention, a first of its kind in the civilian sector in France, was distinguished by the involvement of a psychiatric team specializing in the emerging field of psychotraumatology, working alongside the Emergency Medical Assistance Service (SAMU).
At that time, teams of psychiatrists working with the SAMU proposed to intervene and treat psychological distress as soon as the event occurred and the victims were accessible.
Indeed, during sudden, brutal, and extremely violent exceptional events, stress reactions can trigger acute distress, leading to individual and collective behaviors that may be severely disrupted and even endanger people’s safety or disrupt rescue efforts. Furthermore, these so-called immediate reactions can be complicated by chronic psychotraumatological disorders.
It was in this context that France, beginning in 1995 following several terrorist attacks, established a relief system linked to the SAMU and dedicated to the psychological needs of victims of disasters, attacks, and mass accidents. In the aftermath of the July 25, 1995, terrorist attack at the Saint-Michel station in Paris, President Jacques Chirac instructed the Secretary of State for Emergency Humanitarian Action, Xavier Emmanuelli, to establish an appropriate body to care for “psychologically injured” individuals. The “medical-psychological emergency units for victims of terrorist attacks, disasters, and mass accidents” were created.
On August 17, 1995, the unit carried out its first mission following another attack in Paris. Beginning in 2012, the government decided to strengthen the legitimacy of these CUMPs and to integrate them more firmly into the medical emergency response framework by converting administrative orders and circulars into a decree. The year 2013 thus saw the introduction of new administrative texts governing the CUMPs, regulated by a decree on preparedness and response to exceptional health situations and several orders defining, in particular, zonal, regional, and reinforced CUMPs. The general decree on preparedness and response to exceptional health situations No. 2013-15 was published in the Official Journal on January 7, 2013, and the orders were published on February 24, 2014.
The 2015 terrorist attacks marked a turning point in the organization and operation of the CUMPs, notably with the creation of the positions of National Referring Psychiatrist and Deputy National Referring Psychiatrist in 2016.
The initial directive of February 24, 2014, regarding the organization of medical-psychological emergency care was therefore replaced by the directive of January 6, 2017.
In June 2018, two innovative tools were formalized:
The national Medical-Psychological Emergency Hotline (PUMP), designed to strengthen the medical-psychological support system in the event of an Exceptional Health Situation (SSE) within the country and to provide medical-psychological care to French citizens abroad facing a traumatic event.
The Medical-Psychological Task Force (TFMP), which enables the deployment of a CUMP team abroad to provide medical and psychological care to French nationals involved.
The missions of the CUMPs
The primary mission of CUMPs is to provide urgent medical and psychological care to victims of disasters or events involving a large number of victims and likely to cause significant psychological repercussions. This mission is structured around several key areas:
Establishing one or more PUMPs, located as close as possible to the Advanced Medical Post (PMA) or at any appropriate location;
Ensuring the traceability of victims treated in the PUMP(s);
Provide immediate medical and psychological care to victims and all persons involved in the event, including healthcare professionals and rescuers, and, following coordination by the SAMU, evacuate victims requiring hospitalization to healthcare facilities;
Issue a medical certificate describing the medical and psychological symptoms to victims treated at the PUMP and provide them with the information sheet in accordance with national templates;
Organize, as needed and in coordination with the SAMU, a telephone-based medical and psychological response (telephone PUMP) to provide an appropriate response to victims;
Provide post-acute care to patients who require it and, where appropriate, refer them to an appropriate follow-up program.
The current organization and operation of CUMPs
The organization and operation of the CUMPs are precisely described in Instruction No. DGS/VSS2/2017/7 of January 6, 2017. It incorporates the founding legal texts of the CUMPs, specifies the organization of the medical-psychological system—including its territorial scope and evaluation—and describes, for the first time, the national network for medical-psychological emergency care.
In its current structure, the regional network plays a particularly important role. The Regional Health Agency (ARS) is responsible for ensuring, within the framework of emergency medical care, that the medical-psychological emergency system is organized at the departmental, regional, and zonal levels when it also serves as the Zonal Regional Health Agency (ARSZ).
The ARS ensures that every SAMU-affiliated healthcare facility includes a CUMP known as a “departmental CUMP,” which constitutes a functional unit attached to the SAMU, and ensures that this system formed by the departmental CUMPs covers the entire regional territory. All departmental CUMPs are coordinated by the designated regional CUMP, which is itself coordinated by the designated zonal CUMP. This entire system is integrated into the organization of the national CUMP network.
The CUMP is coordinated by a lead psychiatrist, who is responsible for the CUMP functional unit and is appointed by the ARS. In the absence of a psychiatrist willing to serve as the lead, the CUMP may be coordinated by a lead psychologist or a lead nurse appointed by the ARS.
Note the existence of so-called “reinforced” departmental CUMPs, identified by the ARS as departments “at risk” or with a high volume of medical-psychological emergency cases.
Reinforced departmental, regional, and zonal CUMPs carry out a mission of public interest. As such, they are staffed by permanent personnel whose positions are funded.
As part of the SSE initiative, and following the strengthening of the regulatory framework for medical-psychological emergencies, a medical-psychological component of the health system’s response plan (the “ORSAN” mechanism) has been established and organized by the ARS. This ORSAN medical-psychological component organizes and coordinates the scaling up of the medical-psychological response within a defense and security zone in collaboration with local healthcare facilities.
More recently, the interministerial directive of November 15, 2017, aims to strengthen the coordination of interventions by the CUMPs and Victim Assistance Associations (AAVs). Its objectives are to “present best practices that can enable better coordination of interventions by the CUMPs and AAVs.”
The operation of CUMPs relies on volunteer healthcare personnel and professionals (psychiatrists, psychologists, nurses) who are specialists or experts in mental health, have received specific initial and continuing training in psychotraumatology, and have volunteered for this work. Personnel from categories other than those comprising the CUMP (social workers, administrative assistants, secretaries, paramedics, etc.) may assist CUMP members as needed and within the limits of their expertise, particularly during interventions.
These volunteers are listed on a roster approved by the Director General of the ARS, identifying the teams capable of responding. They may work in a healthcare facility or in private practice and must be able to make themselves available quickly to respond whenever immediate care for victims is necessary. The CUMP’s response is triggered by the SAMU following an assessment of the situation and a call for intervention issued by the CUMP coordinator during disasters or events involving a large number of victims.
References
AFORCUMP website (Association for Training and Research in Medical-Psychological Emergency Units - French Society of Psychotraumatology)
Text written by Dr. Gaëlle ABGRALL, lead psychiatrist for the CUMP in Paris and the Île-de-France region, and Dr. Elise NEFF, associate lead psychiatrist for the CUMP in Paris.
Organization of Medical and Psychological Care for First Responders and Other Personnel Involved in Post-Attack Situations: The Case of the National Police
The serious events we have faced—whether terrorist attacks, natural disasters, or technological accidents—have required medical and psychological care for first responders. In our case, this refers to police personnel.
The need to establish a framework for this care has gradually become apparent. Indeed, medical and psychological interventions must be organized and coordinated because they are multidisciplinary, complementary, and sometimes concurrent.
Preventive medicine is an integral part of this approach, with the goal of preventing the development of mental health conditions and maintaining the operational capabilities and performance of affected personnel. Keeping the preventive medicine network informed—specifically its national and regional coordinating physicians—is a critical component of this system, as it facilitates the medical monitoring of officers and enables the mobilization of local support resources.
Immediate medical-psychological care, which consists of a clinical assessment, triage, and referral, generally falls under the purview of emergency services rather than preventive medicine. It is during this initial phase that a defusing or psychological debriefing is offered, ideally within 48 to 72 hours following the event. This initial intervention is carried out by the CUMPs or internally by operational psychological support structures (SSPO for the National Police). However, these services cannot be imposed on police officers who do not wish to participate.
This medical-psychological support system is developed in collaboration with internal and, where applicable, external partners in medical-psychosocial support.
The relationships developed with emergency services, particularly the CUMPs (medical-psychological emergency units), provide an overview of how those involved are feeling, as well as the personnel being supported, to ensure follow-up care.
Post-incident intervention is organized in a second phase by distributing lists of the personnel involved to support networks. The occupational health service can then arrange emergency medical consultations, refer personnel to specialized services (hospital consultations, psychiatrists, the National Police’s operational psychological support service, etc.) or to additional examinations based on clinical findings and the circumstances of the interventions (gunfire noise, exposure to blood, respiratory pollutants, infection risks, etc.). The initial medical certificate is often issued during this period if it has not been issued previously.
However, the symptoms typically identified in the immediate post-traumatic phase are nonspecific regarding their progression. Their initial nature and intensity do not predict a potential subsequent progression toward a traumatic disorder.
In this regard, preventive medicine, which is responsible for the mandatory medical follow-up of active personnel, plays a crucial role in the delayed response. Indeed, the systematic scheduling of consultations allows for individual assessments of all responders and the conduct of a comprehensive clinical evaluation, taking into account possible co-exposures. Screening for post-traumatic stress disorder as well as other conditions is essential, and the persistence of psychological symptoms beyond one month must lead to a specialized medical evaluation. To this end, two self-administered questionnaires are used: the PCLS (Post-Traumatic Stress Disorder Checklist Scale) and the TSQ (Trauma Screening Questionnaire). The test results, which are strictly confidential, are provided exclusively to the individual concerned and kept in the occupational health medical records.
Recording exposure to the traumatic event, medical consultations, and the various results of additional tests or questionnaires is essential in the occupational health medical record. This fulfills the requirement for traceability of exposures, as with all other occupational risks, and is important for recognition and potential compensation. Indeed, the recognition of a psychological injury sustained in the line of duty following a traumatic event, if not systematic, may be subject to the opinion of the Reform Commission. It will rely in particular on the mandatory report from the occupational health physician.
A brochure explaining post-traumatic symptoms will be provided to police officers; it emphasizes the need to consult a healthcare professional promptly and highlights the role of each support network.
Beyond the individual care of personnel, occupational health participates in debriefing processes following events and plays a proactive role in assessing the appropriateness of various protective or emergency equipment.
In conclusion, medical and psychological care for personnel is essential. Efforts must be coordinated through preparatory work involving periodic meetings with other stakeholders and the formalization of a support system. Regular communication between various professionals and management is essential for effective long-term follow-up. Occupational health fits perfectly into this framework and provides specific expertise.
Quick Reference Guide – Occurrence of a Major Incident
Department heads should contact support networks as soon as possible and provide them with key information:- the National Police Psychological Support Service (SSPO) via the sector psychologist or the service’s operational hotline to arrange psychological support for responders, - the regional prevention coordinator to receive guidance on how to address risks and on existing support structures for the most exposed personnel, based on the clinical situation and the circumstances of the interventions, - the social services department to support the families of the injured and deceased.
Department heads send the following to the support networks: - the list of personnel involved and the locations of the incidents, - the names of the injured or deceased victims and the contact information of their relatives so that the Ministry’s social services can arrange for their care.
Department heads involve the occupational health physician and the SSPO in the crisis management structure to specify the response procedures:- to receive initial prevention guidelines from the occupational health physician in the event of exposure to certain risks (chemical or radiological, for example), - to adapt support measures and anticipate needs.
These measures ensure immediate post-incident care for all responders: 4.1 - In the immediate aftermath: - all responders should be referred to the SSPO (even if an employee may subsequently refuse care), - for the most severely affected employees, prompt medical care must be arranged through the employee’s primary care physician or a specialized medical service. The occupational health physician may also be consulted to refer the officer to an appropriate facility.4.2 - In the short and medium term, the following must be done:- identify the onset of significant psychological distress in any officer,- refer personnel seeking psychological support to the SSPO,- ensure that all responding officers are referred to the occupational health physician within a maximum of six months.
The statutory physician must be consulted, particularly in the event of a work stoppage, so that so-called “invisible” injuries can be recognized, where applicable, as work-related injuries and trigger entitlements.
Text written by Dr. Florence Foullon, Chief Medical Officer and National Coordinator of the Medical Service for Prevention and Occupational Health, Ministry of the Interior
Psychotherapy
Care for individuals exposed to a traumatic event must be comprehensive, addressing both physical and psychological needs. This care must be provided by professionals trained in the specific nature of psychological trauma. Although there is currently no definitive consensus on the subject, psychiatrists and psychologists outline the main psychotherapies used here.
What is Cognitive Behavioral Therapy (CBT)?
CBT developed in France in the 1970s: it represents the application of experimental psychology to clinical psychotherapy. It is recognized by the World Health Organization. It is intended for both children and adults.
Primarily behavioral in nature, they draw on models derived from learning theories and subsequently incorporate cognitive-emotional approaches. They are based on the verified observation that there is a close link between behaviors, thoughts (cognitions), and emotions.
Example: In Post-Traumatic Stress Disorder (PTSD), there are often emotions of shame, loneliness, humiliation, and guilt, as well as thoughts about one’s behavior during the traumatic event, about the safety and benevolence of the world, about others’ reactions, and about post-traumatic difficulties…This model helps people stop blaming themselves and create some distance from their thoughts and emotions, so instead of saying “I am sad” or “I am worthless,” they say “I am feeling sadness” or “I think I am worthless.” In therapy, through psychoeducation and role-playing, the patient learns that just because we have a thought doesn’t mean it’s true. That not all our thoughts are true, even if we tend to believe everything we think.
Objective
After identifying the patient’s needs and following a diagnostic process (for example, PTSD, according to the DSM-5), a baseline is established through the administration of questionnaires, rating scales, and tests (including the PCL-5 scale to measure PTSD), and then the therapist conducts a functional analysis. This is a collection of information organized in the form of a grid or diagram that highlights:
In each situation that is problematic or uncomfortable for the patient: the observable interaction of behaviors, cognitions, and emotions, rated on a scale of 1 to 10, allowing these situations to be prioritized.
For PTSD: hypotheses regarding predisposing and precipitating factors, reinforcements, maintaining factors, and consequences. Thus, CBT explores the past and highlights the vicious cycle of behavior that is maladaptive to the patient’s well-being.
For therapy: a strategy to change behavior that is maladaptive to the patient’s well-being, in the here and now, as part of a therapeutic contract.
CBT posits that if a person is suffering or has a diagnosis, either they never learned a behavior suited to their well-being, or they unlearned a behavior that was suited to their well-being and replaced it by learning a behavior that is not suited to their well-being.
This maladaptive behavior is maintained over time through repeated similar situations and environmental contingencies, reinforced by short-term rewards and hidden secondary benefits. Behavioral change must therefore be motivated by reasons intrinsic to the patient.
Example: In PTSD, an maladaptive behavior would be the avoidance of anything that might remind the person of the traumatic event (place, object, date, etc.). In the short term, this brings benefits (a reduction in feelings of fear, being listened to or even reassured by a loved one), but in the long term, the person or their loved ones may suffer either from the strategies implemented to accommodate the avoidance (taking a route that is 30 minutes longer each day to avoid passing by the site of the event), or from the failure of these strategies (unplanned and uncontrolled exposure to the event).Some people cope very well with avoidance; it is not a matter of normal or abnormal, but rather a continuum regarding the intensity or duration of the strategies employed, on which the person considers whether or not they wish to change a behavior. The more fear one feels, the more one avoids the place, but the more one avoids the place, the more fear one will feel upon returning.
How It Works
The therapist and the patient apply techniques to increase adaptive behavior or reduce maladaptive behavior. This is done gradually through the prioritization of situations, and with the patient’s consent via the therapeutic contract. Here are some examples of techniques:
Behavioral tools: a graded set of tasks designed to allow for gradual habituation to feared situations, exposure techniques (in imagination and/or in vivo), role-playing, modeling (learning by imitating a model) …
Cognitive tools: establishing alternative thoughts, cognitive restructuring, defocusing, downward arrow, decision-making scale, psychoeducation…
Emotional tools: relaxation, cardiac coherence, meditation (mindfulness)…
Example: In PTSD, there is often an initial psychoeducation phase to inform and explain stress, trauma, and physiological symptoms, followed by an emotional phase to facilitate relaxation and calm (breathing exercises to counter hyperventilation, and relaxation). The therapist and the patient decide what is easiest or least difficult to change next. For some people, this will involve behavioral changes through exposure techniques. For others, it will involve cognitive restructuring.
Sustained behavioral change is assessed, compared to the baseline, and considered a major criterion for the therapy’s success. It is therefore a long-term therapy, even though these are brief therapies because they are structured over time. Treatment procedures are described objectively and are therefore reproducible by other therapists for patients with similar difficulties.
References
The Handbook of Cognitive and Behavioral Therapies. Paris, Dunod, 2011. Chapelle F., Monié B., Poinsot R., Rusinek S., Willard M.
Post-Immediate Interventions with Victims. A Guide to Medical-Psychological Emergency Care. Paris, Dunod, 2013. Ponseti-Gaillochon A.
Website of the French Association for Cognitive and Behavioral Therapy (with a directory of CBT therapists)
Text written by Carole Nguyen Rousseau, clinical psychologist
Key points:
EMDR is a recognized therapy for the treatment of post-traumatic stress disorder
In addition to solid skills in psychotherapy, it requires specific training in psychotrauma and EMDR
The desensitization/reprocessing phase of the event through eye movements (SBA) is only one phase of the therapy. It requires preliminary steps: analysis, therapeutic alliance, stabilization tools…
EMDR is not used to “erase” the memory but to treat the emotional distress associated with the memory
An integral part of this therapeutic process, the patient remains fully conscious during sessions
What is EMDR?
In 1987, Francine Shapiro, an American psychologist and researcher, discovered that it was possible to alleviate psychological distress linked to active psychological trauma, even several years after the traumatic event. Subsequent research led to this technique being scientifically recognized for the treatment of Post-Traumatic Stress Disorder (PTSD: see fact sheet). It is based on bilateral alternating sensory stimulation (right-left) (BAS), which activates specific processes in the brain’s emotional system through eye movements (the patient follows the therapist’s fingers in front of their eyes), auditory stimuli, or tactile stimuli (known as tapping: the therapist taps the patient’s knees or the backs of their hands).
It has been recommended for PTSD by the French National Authority for Health since June 2007, and by the World Health Organization since 2013. However, the French Medical Association does not currently recognize the therapy.
How does EMDR therapy work?
EMDR is part of a comprehensive psychotrauma therapy that may include, depending on the situation, medication and/or other psychotherapeutic techniques. In all cases, it requires a preparation phase with steps preceding the actual reprocessing of the event:
analysis of the situation to determine the appropriate indication for EMDR,
establishing a strong therapeutic alliance with the therapist, based on reliability, safety, and trust…,
stabilizing the patient using various tools, before beginning the “treatment” phase of the event itself.
During the reprocessing phase, the identified traumatic memories are revisited (without interpretation at this stage) alongside associated beliefs (negative then positive), emotions, and bodily sensations. The reprocessing is then carried out using Bilateral Alternating Stimulation (BAS) and may require several sessions to treat a single memory. As an active participant in the process, the patient remains conscious throughout the session, and nothing is done without their consent. The stimulation continues until the memory no longer triggers feelings of distress. The patient then feels that the memories are more distant, more vague, and no longer cause the same intensity of emotional suffering.
At the end of the session, fatigue may set in due to the intensive work required of the patient during this desensitization phase. It may be important to arrange for safe transportation—such as being accompanied by a family member—at least for the first few sessions.
A specific, adapted protocol is available for children.
What are the mechanisms of EMDR?
Extensive research has been conducted to scientifically elucidate the mechanisms of this treatment.
It is a neuro-emotional integrative therapy. It combines elements of various psychotherapies (hypnosis, CBT, psychocorporal therapy, etc.) into a protocol that incorporates SBA. It does not aim for forgetting but rather for a restructuring of memory and a distancing from the memory to resolve blocked sensory, emotional, and cognitive elements and to reintegrate negative memories into a broader life context (resilience). EMDR is based on the Adaptive Information Processing (AIP) model. It allows for the “unblocking” of information and the reactivation of the brain’s “natural” memory processing process. This leads to a change in the experience and perception of the event and the present.
Studies have shown that EMDR calms the autonomic nervous system and induces a relaxing effect. Similarities to REM sleep and a reduction in the activity of specific brain structures altered in PTSD (such as the amygdala) have been observed following EMDR sessions.
What are the risks of EMDR?
EMDR allows for the reprocessing of traumatic memories, but this requires exposure to them. It is therefore necessary to be psychologically and physically stable to begin the reprocessing phase. If this is not the case (suicidal crisis, unstable addiction, recent heart condition, etc.), the therapist will address these risk factors through various means (medication, psychotherapy, parallel care with a specialist prior to reprocessing, etc.).
Dissociative episodes (see PTSD fact sheet) may occur following the psychological trauma and/or during the session. This requires appropriate management by the therapist and a discussion of the therapy’s risk-benefit balance.
Various training programs exist, including those leading to EMDR Europe Practitioner certification, a mark of recognized training. Given the sensitivity of patients and the potential impact of the therapy, it is necessary to ensure that the EMDR practitioner has received sufficient initial training in psychiatry or psychology AND has been trained by a recognized organization in the field of EMDR.
Reference: https://www.inserm.fr/sites/default/files/2017-11/Inserm_RapportThematique_EvaluationEfficaciteHypnose_2015.pdf
Text written by Dr. Ludivine Nohales, Auvergne Rhône Alpes Regional Center for Psychotrauma and Medical-Psychological Emergency Unit (CUMP 69), Hospices Civils de Lyon.
Objective
Psychodynamic psychotherapies aim to help the victim cope with and alleviate psychological distress by verbalizing what they experienced during the traumatic event and what they have been experiencing since, while connecting these experiences to their personal history. Therapists use the therapeutic relationship as a working tool.
Like other techniques (CBT in particular), it can be used for psychotraumatic syndrome, grief, an anxiety-depression syndrome, or even a simple emotional shock. However, it is the only technique suitable for treating true traumatic neurosis (hence the importance of the initial diagnosis) because it allows one to work on the subject’s inner psychological structure through transference. The goal is not merely a reduction or disappearance of symptoms (which will be a consequence of the work done) but a genuine psychological reorganization.
How it works
Psychodynamic psychotherapies can begin immediately after the event (i.e., within a few days or weeks) or long after the fact, with no time limit. This type of psychotherapy can be undertaken years after the traumatic event.
A clinical diagnosis is a prerequisite before beginning any form of psychotherapy. It is the clinical assessment that determines the psychotherapeutic technique best suited to each individual.
Initially, psychotherapists focus on creating a safe and supportive space for listening to help the victim verbalize the events, thoughts, and emotions associated with them, while respecting their psychological barriers and defenses. Putting the traumatic scene, shame, fear, helplessness, guilt, hatred, and the anxiety of annihilation into words can only happen once this framework of trust has been established. The content of flashbacks and nightmares receives special attention because they are the “core” of trauma therapy. Attentive listening makes it possible to initiate or reignite the psychodynamic, associative process, at least in those who are ready to engage in this type of work. The psychotherapist’s position of neutrality requires that they do not judge, advise, inform, “exonerate,” or “normalize.”
This technique, in which the psychotherapist does not take a stance or offer advice, can be frustrating; however, the victim benefits from their involvement and the commitment required of them. Through this process of putting things into words, establishing connections, and finding meaning—through this understanding of what is happening within themselves—anxiety subsides, and the repetitions and nightmares become less frequent, transform, or even disappear. The traumatized person gradually comes to understand how they themselves “create” these nightmares and this anxiety. In this way, they can gradually detach from the traumatic scene that overwhelmed them in the early stages. Very often, clinging to the traumatic scene comes at the expense of engagement in social and emotional life; the victim isolates themselves and feels misunderstood without realizing that, at times, they are the ones orchestrating this isolation. Therefore, the psychotherapist also addresses the “loss of desire” (Lebigot, 2011), so that the victim can gradually reinvest in what was previously important to them and regain a vibrant social life, which will compete with the attachment to the trauma. “Healing” involves dissatisfaction with the treatment and a sustained commitment to completely rid oneself of “traumatic fascination” (Lebigot, 2011). The victim can reflect on the traumatic event without being overwhelmed by it. It has certainly become a painful memory, but one that no longer destroys.
The loved ones of direct victims, faced with a sudden and violent loss, can also “benefit” from psychodynamic psychotherapy. The psychotherapy is then structured around the work of mourning, the slow processing of the psychological suffering linked to this loss, and the resulting depressive symptoms.
Reference: Damiani C. & Lebigot F. (2011). The Words of Trauma: A Vocabulary of Psychotraumatology. Savigny-sur-Orge, Editions Philippe Duval.
Website: www.trauma-alfest.com
Text written by: Carole Damiani, Ph.D. in Psychology, Director of Paris Aide aux Victimes
Family therapy was developed in the 1960s in California. It is based on the premise that the symptoms exhibited by one or more family members stem from distorted family communication, which can be restored through mutual understanding during a series of sessions.
Objective
The first session is often devoted to drawing up the family genogram. Everyone participates in creating the family tree, including dates of birth, death, engagement, marriage, and separation.
While psychoanalytic family therapy emphasizes the verbalization of unconscious mechanisms underlying the dysfunction, systemic family therapy seeks to decode the verbal and nonverbal exchanges that lead to paradoxical communication (two contradictory injunctions paralyze a group member who eventually falls ill or becomes the bearer of the family’s symptom).
Support for families affected by terrorist attacks
When a family is affected by an event such as the loss of a family member, it may request a family consultation. Such a consultation can be organized by one or two specialized psychotherapists at a medical-psychological center or in a private practice. The psychotherapist(s) (often two co-facilitators) may be physicians (psychiatrists or general practitioners) or psychologists (with psychoanalytic or systemic training).
How it works
In family therapy, a series of several sessions—typically one or two per month—brings a family together (parents and children, sometimes grandparents) to address a crisis or, conversely, recurring dysfunctional patterns. Everyone is invited to take turns speaking about their place within the group. The past is examined: births, deaths, conflicts, illnesses. The therapists’ role is to listen to each participant, to understand how the group assigns and maintains roles for certain members, and how unspoken truths are kept hidden to preserve bonds (even if harmful to an individual). Sometimes a death is revealed (particularly miscarriages or children who died very young); sometimes a recent death is the cause of the conflict. The therapist(s) will first understand the flow of conversation and interpret it; they will highlight the patterns that have taken root within the family; they will identify the unconscious messages that block communication. On average, about ten sessions will bring about a profound change in family dynamics. After the attacks, the family is still in shock, but most of its members have resumed their activities. The victim’s “psychological defense mechanisms” are fading, and questions arise in the form of reproaches: “Why did you go to that band’s concert? Did you really need to go have a drink at that bar, etc.?” Conflicts emerge; the family struggles to cope with the changes resulting from hospitalizations, disability, and the vulnerability of the person who was a direct victim of the attacks.
The Role of Family Therapy in PTSD Related to Terrorist Attacks
In the case of a violent, particularly unjust death—such as when death was caused by terrorists—memories of an older family conflict may resurface. Furthermore, the role of the deceased is so vital to the family that it collapses in their absence. Finally, the death of a group member reveals difficulties that had been kept hidden, and the group must suddenly confront them. It is all these possibilities that intensify the suffering endured by the family, which can be addressed and treated through family therapy.
In the case of someone with physical and psychological injuries, post-traumatic symptoms take many forms. Flashbacks, nightmares, fear, and physical discomfort are often personal and are not always shared within the family. On the other hand, other nonspecific symptoms have a much greater impact on the family. These include anxiety, depression, changes in personality and behavior, and physical complaints, all of which have repercussions on the family. Indeed, the person who witnessed the attacks or any other violent human assault against people—or who was themselves threatened—sees, within their family, loved ones who alone are capable of bearing such difficulties. However, the family itself has been deeply affected by the events and lacks the capacity to listen and provide support. Thus, the victim of the attacks will place a greater psychological burden on their family than they can usually bear. Their emotional balance will therefore be disrupted. Family therapy will then have the advantage of treating the entire group: the individual who bore the full brunt of the attacks (even if they can benefit from individual psychological support) and the family, which is also heavily affected by the consequences of the tragedy on its normal functioning.
References:
Bacqué-MF. How to Talk to a Grieving Child? Journal of the JALMALV Federation 2009;(97):15-21.
Bacqué MF. Grief and Family Life. Générations. French Journal of Family Therapy 2003;(30):11-15.
Websites to consult: French
Society of Family Therapy: http://www.sftf.net/ French
Society of Psychoanalytic Family Therapy: http://psychanalyse-famille-idf.net/
Text written by Prof. Marie-Frédérique Bacqué, Professor of Clinical Psychopathology at the University of Strasbourg; Director of EA 3071 SULISOM
