Immediate Trauma Counselling:
A roadblock on the path to healing?
Paper presented by Michael Tunnecliffe to the Annual Conference of the Australasian Critical Incident Stress Association, Sydney, April, 1997

The greatest fear of any community is the disaster or emergency which takes an enormous physical and mental toll on all affected. Recovery from such events becomes an all-important focus, involving the use of many organisations to assist those directly affected and the community in general. Since the early 1980's, especially, the psychological needs of people have become a significant aspect of crisis recovery, yet there appears to have been only moderate consideration, and even less agreement, on who should give this support and how it should be applied.

Given the public attention focussed on major emergencies in Australia, the influence of the media, and the extent of assistance which may be required, it's often suggested that major agencies, government departments, or welfare groups should be directly involved, if not responsible for, emotional support and counselling for major incidents affecting large segments of the community. This theme is frequently reinforced at emergency exercises Australia-wide, accompanied by assumptions of professional competence, knowledge and understanding of what is required, and an expectation of automatic and effective liaison with other agencies involved.

Industry, institutions, hospitals, schools and private organisations often arrange their general "Disaster Plan" or "Major Emergency Procedures", so as to meet the 'duty of care' responsibility which organisations have. A perusal of such plans shows that, in the majority of cases, meeting the emotional needs of those affected is assumed to be automatically achieved once the "counsellors" have arrived and those involved are "counselled", regardless of what is indicated in the situation. It's not uncommon to hear senior personnel make statements about mandatory counselling. This is highlighted by the statement made to a staff member by her manager following a very stressful incident in the workplace. When the distressed staff member asked could she have her husband pick her up and take her home, the manager replied... "No, you have to be counselled whether you like it or not. The company policy is to avoid the situation of someone saying later on that we didn't help you following the incident". Given there is a genuine role for counsellors in the aftermath of traumatic events, a continual problem for mental health professionals is the idea that mental health is identical to physical health. If someone has a headache, they take a pill and it goes away. The extension of this approach to psychological problems explains the popularity of medications such as valium and prozac.

Over the last decade, many people appear to have factored counselling into the "quick-fix" equation. It's not all that uncommon to hear managers and supervisors make comments like, "I don't know what's going on with Fred. He went to counselling and he's still having problems." Such comments raise the question of just what is meant when we use the term counselling.

Some organisations use the term to describe a problem-solving process for employees having difficulties, while in others it describes a disciplinary procedure. When it comes to traumatic events, the media talk about counselling as a mandatory treatment given to anyone in need (like Red Cross blankets), yet few people take the time to describe what they actually mean when this generic term, counselling, is used.

One of the reasons we have confusion and misunderstanding is because it's difficult to say there's a single procedure called counselling. Someone once said... "Counselling is what a counsellor does", and this is probably very close to the reality of the situation. While we can discuss communication skills, active listening, problem solving, developing options and implementing strategies, no two counsellors are likely to work in the same way. This tends to be even more so when a psychological treatment or intervention is given the label of counselling.

In trying to provide assistance for what is often a genuine need, there appears to be three potential problems of assumption, which frequently arise in the planning of emotional assistance for people affected by trauma. Firstly, the assumptions we have about counselling which are based on our individual experiences, secondly, the assumption that the counsellor knows what he or she is doing and thirdly, that counselling needs to be provided immediately. The issue is... we may be wrong in all three cases.

In the light of these comments, some of the lessons learned following the crash of TWA Flight 800, back in July 1996, are worth considering. Emergency response expert in the USA, Dr Richard Gist, reported that in the immediate aftermath of this tragedy, the American Red Cross announced they had mobilised almost 500 volunteers, "the majority, mental health counsellors" to assist families, while another welfare organisation advised they had also sent their grief counselling teams to JFK Airport. These two press releases alone indicate that counsellors would outnumber victims, and doesn't take into account the other providers and would-be providers converging on the area. Following emergencies of any form, there seems to be ever increasing numbers of people who feel obligated to help those affected, regardless of who holds responsibility for the situation. Notions held in many emergency plans of simply calling in government counsellors, chaplains, welfare agencies and volunteers, who may or may not be capable of genuinely assisting and who are not really going to be accountable for any actions they take, are both unrealistic, naive and often counter-productive.

As well as attracting genuine, concerned and capable professionals, crisis and trauma also attracts people excited by the event, rather than motivated by the needs of those affected. Anecdotal accounts indicate that on numerous occasions eager, inexperienced counsellors who come from the outside to assist, simply leave the situation when the novelty wears off, or the task is beyond their level of expertise. This is further evidenced by a report on the Internet of two "counsellors" who managed to get on TV immediately after the TWA Flight 800 incident. They said they had spent many hours assisting families of passengers on TWA Flight 800, when they appeared on midday TV the day after the crash. In their interview, complete with news footage of distressed families, they graphically describe the emotional trauma families were going through and how they were helping them to cope. One might ask... "Just who is this helping?"

The sensationalising of trauma response and the frequently inaccurate media accounts of trauma counsellors being rushed to the scene, tends to give two powerful messages. Firstly, that trauma counselling is exciting work at the "sharp-end" of the action, and secondly, everyone needs counselling after a traumatic event. Both of these conclusions are false.

Effective psychological support and assistance following traumatic events.

The following points are suggestions for providing effective psychological assistance following traumatic events. Although unique situations and circumstances need to be taken into account when planning a response, these points are offered as ways to ensure the benefits to those affected are maximised and the likelihood of an inappropriate response is reduced.

1. Plan who will provide psychological support.
   The most effective and supportive response initiative is the mobilisation of support people who have a prior arranged support role. These people may be internal or external to the organisation. The tendency to call for help after the incident has occurred and a need is evident, often does little to meet the real needs of those affected. Even worse, such ad hoc responses can even attract people who are inappropriate to perform such tasks, regardless of how well intentioned.
2. Use an appropriate response time-frame.
   Calling for professional counsellors to respond immediately to traumatic incidents, with the expectation that this will facilitate a rapid recovery for those affected, is a step which not only ignores the more practical needs people have, it may even inhibit people from moving through a normal crisis recovery process. In general, mental health professionals are trained to treat psychological problems and the very difficult, problematic or prolonged reactions to stressful incidents, which are not universal to all involved. People affected by trauma have problems which are often characterised as 'normal' reactions to an abnormal situation. In many cases, support is the most appropriate response, not counselling or treating people, which unfortunately, is too often done.
3. Avoid relying on qualifications alone as indicators of expertise.
   There is a persistent myth in the community that anyone trained in mental health or counselling can counsel anyone else for any psychological problem which presents itself. Many mental health professionals have concerns about how pervasive this myth is, especially when there is an increasing number of "counsellors" from a variety of backgrounds who believe some communication skills and a bit of knowledge is all you need to assist people who may have experienced extremes in stress and trauma.
4. A professional qualification is no guarantee of suitability.
   People used should have training and competence in the task to be undertaken, and be well briefed on what is expected of them by the emergency managers. Such actions help to play down some of the more sensational aspects of the situation. There is increasing evidence that the use of groups, such as peer supporters, who provide emotional support, practical assistance and referral only, is more appropriate and beneficial in the immediate aftermath of traumatic events, than using professional counsellors. Professional counsellors are more likely to have a role after the immediate impact of an event has passed and people are looking for more assistance than a peer supporter, colleague or family member can provide.
5. Ensure those asked to provide support are included in any practice mobilisations or drills.
   The onus is on emergency managers to ensure people being used in a crisis response role are appropriately selected and adequately briefed, co-ordinated and supervised in the overall emergency response, regardless of where they come from or the role they perceive they have in the situation. The site of a major crisis is not the place to argue about who should be doing what. In some quarters there is growing concern about Employee Assistance Providers who offer a CIR (Critical Incident Response) which is integrated with the organisation's overall program to the extent that the Emergency Plan simply says... "The EAP will look after all counselling".

A failure to effectively integrate all crisis response, so that it's used most appropriately can mean that support personnel, counsellors and chaplains may, in fact, increase the problems of those affected, rather than reduce them.

The path to healing for those whose lives are severely disrupted by crisis and trauma is a rocky one to travel. The last thing they need is people who block the way with good intentions, but bad or at best, inappropriate practices.