twrama 1841_august_2.. - AMA WA

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When no talk is good talk
by Dr Margaret Lumley
Psychiatrist, Royal Perth Hospital
The recent destruction of the Mount Lawley Primary
School by fire represented a tragic loss of historic
buildings and an urgent need for relocation of the 400 pupils
of the school. However, a subsequent plan to provide the
children with ‘trauma counselling’ may prove more harmful
than helpful.
Clearly the aim of the planned counselling will be to help
the children to avoid developing psychological or psychiatric
sequelae to the event. Common sense would dictate that
early intervention should be expected to help the children
adjust to the loss and dislocation involved, and to stave off the
development of subsequent problems such as Post-traumatic
Stress Disorder (PTSD). However, this intention is misplaced.
PTSD is a relatively rare condition, and is a serious
and crippling psychiatric disorder. It includes painful
re-experiencing of the traumatic event, during waking
hours or as repetitive nightmares, withdrawal from the
normal activities of life, and hypervigilance and autonomic
hyperarousal in general.
PTSD in children and adolescents occurs as a result of a
child’s exposure to one or more traumatic events that were life
threatening or perceived to be likely to cause serious injury to
self or others. In addition, the child or adolescent must have
responded with intense fear, helplessness or horror (Lubit
2011(a)). Based on this definition alone, it is clear that, since
no children were at the school at the time of the fire, they are
unlikely to be affected.
However, the situation is now made more complex by the
planned institution of counselling. Contrary to what one might
intuitively think, early trauma counselling has been shown to
at best be of no benefit, but also, in a number of studies, to lead
to positively deleterious outcomes (Radley et al 2011, Cartier et
al 1998, Mayou 2000, Roberts et al 2009).
Pausing for a moment to consider the rich tapestry of
human history, it should be obvious that we are generally
fairly robust in the face of a range of natural and man-made
disasters. The healthy person will react to trauma in his or her
own way, and move on. The initial reaction, and subsequent
course of events, will be determined by a range of factors
including prior experience, personality style, presence of
supports, and the actual nature of the trauma and subsequent
events. Any attempt to get the person to ‘deal with emotions’
or ‘face facts’ or attempt to seek early closure, it seems, may
interfere with a natural process and lead to a poorer outcome.
Iatrogenic pathology may also be introduced by the
very experience of being offered ‘therapy’. We are very
psychologically suggestible, and the act of counselling
itself can plant the seed that we are supposed to be having
problems. Furthermore, group counselling, if employed, is
subject to contagion of distress and maladaptive reactions and
behaviours (Lubit 2011(b)).
Ideally, then, the children of Mount Lawley Primary
School should not be subjected to early ‘intervention’ of a
psychological nature, particularly given that none of them
are expected to have even witnessed the fire. But of course
parents and teachers need to remain sensitive to the needs of
the children, and, if genuine concerns arise with regard to
individual students, seek appropriate help then.
Dr Margaret Lumley is a psychiatrist at RPH working both in the
Emergency Department and the general wards in Consultation
Liaison Psychiatry. She has special interest and expertise in
psychotherapy and for many years ran the highly successful
CHANGES program at RPH, treating people troubled by
Borderline Personality Disorder. Dr Lumley has also participated
for many years on a panel of psychiatrists available to assist fellow
doctors and medical students in distress.
References:
Bisson JI, Brayne M, Ochberg KM, Everley GS (2007), ‘Early
psychosocial intervention following traumatic events’, American Journal of
Psychiatry 164: 1016 – 1019.
Cartier, IVE, Lamberts, RD, van Uchelen AJ, Gersons BPR (1998),
‘Disaster related PTSD in police officers: a field study of the impact of
debriefing’, Stress Medicine 14(3):143-8.
Lubit, RH (2011(a)) ‘Posttraumatic Stress Disorder in Children’ , http://
www.medscape.com/viewarticle/918844.
Lubit, RH (2011(b)) ‘Acute Treatment of Disaster Survivors’, http://www.
medscape.com/viewarticle/295003.
Mayou, RA, Ehlers A, Hobbs M (2000) ‘Psychological debriefing in road
traffic accident victims: Three year follow up of a randomized controlled
trial’, British Journal of Psychiatry 176(6): 589-93.
Radley JJ, Kabbaj m, Jacobsen L, Heydendael W, Yehuda R, Harman
JP (2011), ‘Stress risk factors and stress related pathology: Neuroplasticity,
epigenetics and endophenotypes’, Stress 14(5), 481-97.
Roberts NP, Kitchener NJ, Kenardy J, Bisson JI (2009) ‘Multiple
session early psychological interventions for the treatment of post
traumatic stress disorder’, Cochrane Database of Systematic Reviews
DOI:10.1002/14651858.CD006869.pub2.
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