victims require tailored support

Talking is not always the right solution for attack victims, says psychiatrist

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Mental health support for the young survivors of the Manchester Arena attack must be tailored to individual needs, according to a psychiatrist with experience of mass casualty events.

Although some of the people who witnessed the devastation caused by Salman Abedi’s bomb, which left 22 dead, would benefit from talking about what they saw, others would need help finding other coping strategies, said Dr Cristina Carreño, mental health adviser at medical health charity MSF.

MSF has provided mental health support for people who have experienced traumatic events in conflict zones across the world, including Syria, Yemen, South Sudan and Mexico, where students were kidnapped in Guerrero in 2014 and are feared to have been killed.

Carreño warned against generalisations about the impact of traumatic events on young people as much depends on the context. In conflict zones attacks are often expected. In more stable countries, the response can be different.

“One of the most severe psychological reactions is the loss of trust in human beings and the loss of trust in the world as a safe place,” she said. That belief was unconscious but nevertheless important because it was the foundation on which young people built their lives, from day-to-day decision making to planning for the future.

“This will affect their personal relationships, their social relationships and the way they relate to the world,” said Carreño. “It’s difficult for some people and takes time to recover.”

Symptoms experienced could range from anxiety and sleeping problems to avoidance of places, conversations and people that remind the survivor of the attack. Psychosomatic symptoms could include headache, backache and stomach pain. In fewer cases psychiatric disorders might be diagnosed.

Carreño said studies showed that in the case of traumatic events – not restricted to terrorism – only up to 4 per cent might require specialist mental health treatment. Around 20 per cent would need psychosocial support, which could be provided by nurses, counsellors and social workers.

She said: “One of the main premises is that each person will have different reactions and different ways of coping with the situation.

“If this happens to 10 people there will be 10 different ways of coping with the situation – the same as in daily life.”

“Some years ago there was this belief that it was good to talk about everything that happened to you in life and the more traumatic the event is the more you are supposed to talk about it. This is not true anymore.

“If this happens to 10 people there will be 10 different ways of coping with the situation – the same as in daily life. For some people the first thing they will do in a situation is to go and talk to someone and express their problems. Others go and ride or run, or do some artistic work, and they reflect alone for a while until they find a solution. If not, that is the time to assist.

“Ask them what they did the last time they had a problem. There you will find clues. And not everyone will need to go to a specialist.”

Carreño stressed the importance of returning to some sort of routine for survivors whose feelings of certainty in the world had been shaken. “Going to bed and getting up at the same time, having food at more or less the same time, resuming sport or activity, without overwhelming them – this helps to recover some sense of control.”

She said it was to be expected that some survivors would experience emotional numbness in the immediate aftermath of the attack but warned that it was a cause for concern if it persisted, as it might be a sign of detachment from reality. Those involved in the care of young people after the attack should also be on the lookout for survivor’s guilt.

“You can see it in survivors of almost all dramatic events – car crashes, war, terrorist attacks,” said Carreño. “They can be asking themselves: why not me? Why am I only injured? It is an existential question without proper answers and it can be very powerful and painful.”

“Age is a key factor but it’s not always negative.”

Individuals’ responses to the attack depend on a number of factors including education, culture and the importance that had been attached to the event. For many attending the Ariana Grande performance at Manchester Arena it was one of their first big pop concerts, traditionally very significant events in young people’s lives.

“Age is a key factor but it’s not always negative,” added Carreño. “There is a factor in age that makes people more vulnerable because many of them may not have been exposed to very difficult situations before.

“On the other hand children – it’s different for teenagers – have an amazing capacity for resilience. And what is essential for them is the adults around them. Because children live their lives a lot through their carers, if the adults surrounding them can support them this will make a big difference. So they need to understand, they need to be provided with information and very easy access to support for themselves because they will face a lot of challenges and have a lot of pressure.

“There are different risks in teenagers. They are in transition in life. Peer support is a methodology that works very well for them because when you are a teenager the most important people in your life usually are your peers. This is part of that stage in their development. It’s very important to use that for their benefit.”

Mark Rowley, the country’s top counter-terrorism office, said police had “got hold of a large part” of the network they believe Abedi was part of

With raids on houses in Moss Side and Cheetham Hill on Saturday and further arrests, the threat of terrorism in the UK was downgraded from critical to severe. Eleven people remain detained and Assistant Commissioner Mark Rowley, the country’s top counter-terrorism office, said police had “got hold of a large part” of the network they believe Abedi was part of.

For the wider community Craig Harris, Manchester Health and Care Commissioning’s executive nurse and director of safeguarding, said: “I’d like to point out how much help is already out there via helplines and our voluntary and community sector, covering all elements of our diverse society.”

He urged parents to be honest when explaining the attack to their children. “How you broach the subject depends very much on the age of a child,” he said. “Children are naturally inquisitive and there has to be a balance of how much information you can give based on what you know your child can process.

“Always be honest – and don’t pretend something didn’t happen – especially when they will hear about it from friends, school and the news. We all need to be vigilant at the moment – and that includes our children – so we need to give them the tools to help them.”

Speaking following the news that the terrorist threat level has been reduced from severe, the mayor of Greater Manchester, Andy Burnham, said: “This is the result of the outstanding work of the Greater Manchester Police, the North West Counter Terrorism Unit and the security services since Monday’s attack.

“They have made excellent progress with this investigation and, on behalf of the people of Greater Manchester, I would like to thank them for the incredible service they have given. We will all continue to support them in whatever way we can as the investigation continues.

“I hope that the people of Greater Manchester will gain reassurance from this change. However, the threat level remains severe and there will still be significant numbers of armed police on our streets. I would ask people to remain vigilant and to co-operate fully with police and security staff as they carry out the necessary extra checks at events over the Bank Holiday weekend.

Details of the services available for anyone affected by the Manchester Arena attack are at

Photo: memorial to the victims, St Ann’s Square

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