As the country reels from the Sydney siege and its unhappy end, many will be wondering what can be done for the hostages stuck for hours with the gunman in the Lindt café. The answer may be surprising little – especially if we want people to recover to a healthy psychological state.
Growing social awareness of psychological trauma’s impact may lead people to conclude that providing psychological support and counselling to those exposed to life-threatening events is an essential first-line response. But we need to temper the desire to offer well-intentioned care by abiding to the guiding principle of not causing harm.
To understand why psychological aid is not a suitable first response for all people, we have to go back to the fundamentals of human health.
Body and mind
In life-threatening situations, the human body enters into a state of extreme hyper-alertness and threat reaction referred to as the freeze, fight, flight response. This reaction is designed to promote survival by orientating the person to sources of threat (freeze), and then preparing the body for immediate escape from danger (flight) or for taking whatever direct action is necessary to remove the threat (fight). Everyone has this reaction when faced with danger that threatens their physical or mental well being.
People being held hostage face the extraordinarily difficult challenge of having to contain this survival response and wait for rescue, a chance for escape, or the threat to be over in some other way. And their survival response doesn’t necessarily shut down once the siege is over.
Many survivors experience ongoing hyper-arousal and extreme alertness after exposure to a life threat, and this warrants treatment when it continues to a degree or for a length of time that interferes with their day-to-day functioning.
Along with survivors, family members and friends, who faced the possible loss of their loved ones, may also experience intrusive memories, nightmares, and flashbacks following incidents such as the one that occurred in Sydney’s Martin Place. They may feel a strong desire to avoid places associated with the trauma and other reminders.
In extreme situations where every decision may mean the difference between life and death, it’s also not uncommon for people to second guess themselves after the fact, and wonder if they could have behaved differently. There’s no easy answer to knowing how to behave in such situations – and indeed their aftermath – but questioning your reaction under duress can be a source of great distress. That some people go on to develop longer-term psychological problems is no more surprising than the fact that most people will resolve their response, particularly with the support of friends and family.
Dangerous good intentions
In the past, mental health professionals were of the view that early intervention was critical for helping prevent early symptoms progressing into debilitating conditions, such as post-traumatic stress disorder. But three decades of research has demonstrated that indiscriminant psychological intervention carried out in the immediate aftermath of a critical incident may well do harm.
Until the mid-1990s, the most common response to traumatic events was the provision of a one-session “debriefing” intervention – the most common brand of which was called Critical Incident Stress Debriefing (CISD). Growing concern about its outcome led to multiple studies evaluating the efficacy of such an intervention.
Every randomised controlled trial showed only one of two results: either CISD had no effect, or led to worsening symptoms. Our guiding principle of primum non nocere (first do no harm) called for mental health professionals to stop this practice.
One possible explanation for this counter-intuitive finding is that the symptoms of hyper-arousal and hyper-alertness that follow a critical incident tend to naturally fade for many people as time passes. This natural process of recovery and redeveloping a sense of safety may be disrupted by ill-timed psychological interventions.
The critical time for psychological review and support often comes not in the immediate aftermath of trauma but across the medium to long term when distressing symptoms may persist, or when they may emerge for the first time, causing increasing distress and difficulty in daily functioning.
In fact, there’s little evidence to suggest the presence of symptoms in the immediate aftermath of a traumatic event will be enough to identify those who may go on to develop debilitating mental ill health. It’s long been noted that some people may even have a delayed onset to post-traumatic stress disorder with minimal symptoms present soon after the trauma-causing episode.
The right time
This is not to suggest that survivors of critical incidents who experience distressing symptoms shouldn’t have access to psychological services during the acute phase, if that’s what they want. What’s critical is that psychological interventions are carefully tailored to the needs of those who seek care, and that they’re not provided with a one-size-fits-all approach.
For some people, the best approach may be to return straight back to the normal routines of their life. For others, it will be to spend time with family and friends until they feel the time is right to return to their roles and responsibilities. Others still may find the acute distress following the events lead them to seek professional support.
But in nearly all cases, the first helping response to trauma is not psychological – it is practical, instrumental assistance. This may include answering questions and providing information about the incident, ensuring safety and addressing the practical difficulties survivors are facing, such as assistance reconnecting with their social supports. Providing specialist psychological intervention may actually be the last rather than first item on the list.
What we know is that in the months, and sometimes years, following a traumatic incident, when the attention of the world has moved on to other issues, some survivors and their family and friends may start to experience difficulties. So what the survivors of the Sydney siege need is mental health support in the longer term, when the media spotlight has moved on.
Zachary Steel receives funding from NHMRC & ARC for research into traumatic stress.
Grant Devilly was involved in developing the Australian & New Zealand Guidelines for the Treatment of Acute Stress Disorder and Post-Traumatic Stress Disorder.