Exporting vulnerability

Counsellors and trauma experts are queuing up to offer assistance to the Russian town of Beslan. UNICEF, the World Health Organisation (WHO) and the Red Cross are offering help for post-trauma counselling and treatment. The government of the Republic of Ireland has pledged financial assistance towards trauma counselling (1).

There are predictions of a ‘trauma epidemic’ if it isn’t tackled immediately. UNICEF spokesman Damien Personnaz said: ‘What will happen to the children and their families who are most likely in a state of shock and are traumatised? The key issue is to identify these children and to identify to what extent they will be traumatised or not. It has to be done right away.’ (2) Some authorities warn that the need for therapeutic intervention may extend well beyond the region of Ossetia. National television news in the Republic of Ireland, for example, warned that people could be traumatised from watching the images of the attack on TV (3).

The events at Middle School Number One are beyond anything that most people could ever conceivably experience. As one report outlined: ‘For outsiders, what the children in the hospital have been through is almost unimaginable. Held by armed militants for three days without water and food, they were barely able to breathe in the crowded, stuffy school gymnasium that was their prison. But the manner of their escape was even more traumatic. Rushing out of the collapsed building into a storm of gunfire, they witnessed the bloody horror of severed limbs, exposed innards and mothers screaming for their children.’ (4)

Moreover, in the general confusion it is difficult for parents and other adults to reassure children by providing them with factual information. One report quoted a young man who was looking for his wife: ‘I’ve been searching for her all day and I can’t find her. Where are our people? No one tells us anything. No one is protecting us.’ (5) Many of the children are suffering from gunshot wounds, have been deafened by the explosions, or have parts of their bodies covered in severe burns. A doctor in one of the local hospitals says: ‘Many children will be invalids. Some do not have eyes.’ (6) A local paediatric psychologist points out that ‘so many of these children have lost their mother. This will make their recovery longer and more difficult’ (7).

But should we assume that Beslan’s children need trauma counselling? Behind this assumption is a model of the human agent as vulnerable, and always in need of professional support. Those who are arguing for extensive therapeutic intervention to help those exposed to traumatic events present children as being more vulnerable than has previously been recognised.

There is an alternative view, which points out that people’s frameworks of meaning and social networks can help them to overcome traumatic experiences. Some of the key critics of trauma counselling, such as Vanessa Pupavac and Derek Summerfield (8), have pointed out that Western humanitarian organisations, especially those dealing with disasters and promoting post-conflict peace-building programmes, have promoted the kind of worldview which has been described by British sociologist Frank Furedi as ‘therapy culture’, which holds that people need professional support to deal with every trial and tribulation (9). They also point out that psychological responses to war, disasters and other humanitarian emergencies are culturally mediated and that the frameworks of meaning which people employ shapes their responses to exposure.

This is alluded to by one reporter who tells us about Zuma, an 11-year-old boy who had to be moved from Beslan to a hospital 700 miles away in order to receive treatment for severe burns. ‘On his way from the Beslan hospital… [Zuma] – from a fiercely masculine culture – gave ambulance workers the thumbs-up and said he would not cry because it would not be fitting.’ (10)

Evidence from the conflict in Northern Ireland suggests that children are not necessarily traumatised by violent experiences. In the early 1970s, during the most intense phase of violent conflict, the child psychiatrist Morris Fraser wrote Children in Conflict, based on his experiences of living and working in Belfast. Fraser distinguishes between three phases in the response to a traumatic event (the periods of impact, recoil and the post-traumatic phase); he notes differences in the symptoms displayed and coping mechanisms employed by different age groups; and he provides some practical suggestions for dealing with children’s responses (11).

Fraser cites eyewitness accounts that during or after a period of rioting children in the locality ‘seemed to be possessed of intense and ill-directed nervous energy, shouting, singing, dancing about, giggling inanely’. This activity, he suggests, is directed at ‘concealing a good deal of anxiety about their own and their parents’ safety’. He judged that the best response is for a parent to reassure the child, provide them with physical closeness and factual information. In the period of recoil children often relive the experience, ‘sometimes in a repetitive, compulsive way’, through play, storytelling, drawing or other expressive activities. Fraser suggests that this is an attempt to re-experience the event in order to gain mastery over it.

According to his research, most children recover from their ordeal and are able to function normally after several weeks or months. Some, however, experience a post-traumatic phase that is characterised by fears about a recurrence of the traumatic event and a heightened awareness of reminders of the event. The most effective treatment in this phase, Fraser suggests, is to allow the child ‘to relive and integrate the stressful experience, this time in a calm and supportive setting’.

Fraser suggests that young children below the age of eight have a limited understanding of the events that they witness, and as a result can be more easily reassured. The reactions of significant adults, such as parents, are crucial to the response of very young children. By contrast, adolescents have a more active relationship with their external environment and consequently are able to employ ‘fight or flight’ responses. Fraser was most concerned about children aged eight to 12, who are at a stage where they have a greater capacity for understanding the threats, but are less able to act on their experiences – and most of the referrals to his clinic were in this age group. But he notes that in most of these cases parents had projected their own anxieties on to the child, and in this way retarded their child’s recovery – and it is also worth pointing out that the majority of children in this age range didn’t develop chronic or pathological responses to the traumatic events they witnessed.

Fraser’s insights are echoed by psychiatric experts in Russia. Ekaterina Burmistrova, a psychiatrist with the Moscow City Psychological-Pedagogical Institute, for example, suggests that children generally recover emotionally more quickly than adults because they enjoy outlets, such as playing, drawing and games, which grown-ups avoid (12). Dr Voskresensky, of the Russian State Medical University in Moscow, informed reporters that: ‘Everything depends on the strength of the child’s relations with his family. If they can help the children build a peaceful, quiet and stable life in the next few years, then this event shouldn’t blight their lives forever.’ (13)

Yet in the rush to Beslan, some trauma counsellors argue that individuals’ traditional ways for getting through tough times are not enough. Irina Angel, a child psychiatrist who was born in Grozny, but is now practising in Boston, told reporters: ‘In my experience there will be a much greater emphasis on coming to terms with tragedy through family support, that of the community and through religion. There may still be a reluctance to talk about this with psychiatrists.’

Some supporters of counselling interventions have responded to their critics by calling for more culturally sensitive counselling interventions in order to help overcome this reluctance to talk to mental health professionals. Brandon Hamber, a clincial psychologist who worked with the Truth and Reconciliation Commission in South Africa, suggests that this response from counselling advocates is inadequate. ‘Often – especially from a Western perspective – this [acknowledgement of the social and cultural context] is understood to mean that intervention (for example, counselling) should be tailored or reworked to be culturally relevant. This is, in fact, a wrong approach. Context is not a minor variable whose influence on a programme needs to be considered and accommodated; rather it is the major variable which should be the starting point when developing the healing strategy in the first place’ (14).

Yet there is evidence to suggest that professional counselling could actually make things worse. The most systematic review of counselling has been carried out on critical incident debriefing interventions, the type commonly applied in disasters and other emergencies, and the reviewers concluded that this form of counselling often retarded recovery. The authors suggested that the re-imagining of the incident may produce anxiety rather than help with emotional processing; that promoting awareness of psychological distress may help to consolidate stress reactions; and that counselling may interfere with adaptive defence mechanisms (15).

An independent evaluation of British aid to Kosovo in 1999 found that it was practical aid, such as tracing and message services, which were appreciated by recipients of aid (16). This suggests that the bandages, syringes, bed linen, soap and medicines that UNICEF are sending to Beslan will be of much greater benefit than the trauma counsellors queuing up to provide assistance.

The response to Beslan marks the spread of therapy culture to Russia. Indeed, it appears that diagnosis of post-traumatic stress disorder and counselling are, like Nike sportswear and MacDonald’s, being embraced as indicators of social progress and development in Russia. Boris Voskresensky, a psychiatrist and academic with the Russian State Medical University in Moscow, told the Guardian that: ‘There wasn’t much understanding of the concept of post-traumatic stress a decade ago. It’s no longer the case that people are expected to have Stalinist characteristics of strength and stoicism in the face of crisis. There’s a much greater readiness among doctors now to help people deal psychologically with this kind of catastrophe.’ (17)

No doubt the armies of counsellors and trauma experts believe that they are helping the people of Beslan – but perhaps this is one kind of ‘help’ that they could do without.

Chris Gilligan is a lecturer in sociology at the University of Ulster. Last year he co-edited a special issue of the journal The Global Review of Ethnopolitics on the peace process in Northern Ireland. He is currently working on a research project on referrals of children for conflict-related trauma during the peace process in Northern Ireland.

(1) Messages sent to Russia, with love, The Irish Examiner, 7 September 2004

(2) ‘Siege children need help with mental scars’, Sydney Morning Herald, 8 September 2004

(3) RTE News [Real Player required]

(4) Struggle not over for survivors, The Australian, 6 September 2004

(5) Stunned aftermath of siege bloodbath, Scotland on Sunday, 5 September 2004

(6) Stunned aftermath of siege bloodbath, Scotland on Sunday, 5 September 2004

(7) Struggle not over for survivors, The Australian, 6 September 2004

(8) See e.g.; Bracken, Patrick J., Giller, Joan E., Summerfield, Derek, (1995), ‘Psychological responses to war and atrocity: the limitations of current concepts’, Social Science and Medicine, Vol. 40, No. 8, pp. 1073-1082; Pupavac, Vanessa, (2001), ‘Therapeutic governance: the politics of psychosocial intervention and trauma risk management’, Disasters, Vol. 25, No. 4, pp. 358-372; Summerfield, Derek, (1999), ‘A critique of seven assumptions behind psychological trauma programmes in war-affected areas’, Social Science and Medicine, Vol. 48, pp. 1449-1462.

(9) Therapy Culture, by Frank Furedi, Routledge 2003.

(10) To Speed Healing, Ossetians Cling Together, New York Times, 8 September 2004

(11) Children in Conflict, by Morris Fraser, Penguin Books, 1980

(12) To Speed Healing, Ossetians Cling Together, New York Times, 8 September 2004

(13) Now work begins to help child survivors overcome ordeal – Trauma could have lasting effects, Guardian, 4 September 2004

(14) Hamber, Brandon, (2003), ‘Healing’, in Bloomfield David, (ed), Reconciliation After Violent Conflict: a handbook, IDEA (International Institute for Democracy and Electoral Assistance), Stockholm, Sweden

(15) Rose, S, Bisson, J, Wessely, S, (2002), ‘Psychological debriefing for preventing post traumatic stress disorder (PTSD)’, in The Cochrane Library, Issue 3, Oxford: Update Software

(16) Kosovo and the changing face of humanitarian action, Eldis

(17) Now work begins to help child survivors overcome ordeal – Trauma could have lasting effects, Guardian, 4 September 2004