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The suicidal
bombing of the Doha Players Theatre in
March 2005 had a considerable impact not
only on those present at the time, but
on the whole population of Qatar. The
country has not been exposed to
terrorist attacks of this nature,
certainly not on this scale, before.
Doha Players Theatre was a portacabin
structure located outside a private
British school. On the eve of the second
anniversary of US-led invasion of Iraq,
William Shakespeare's Twelfth Night had
been showing. The audience attending was
of different nationalities, religions,
and age groups. Normally, there would
have been a large number of school
children amongst the audience as the
play covers part of their curriculum. On
that day, there were no school groups.
Subsequently, the audience was less than
expected, reportedly 80-100 people.
Sadly, the director of the play, a
British national, was killed in the
suicidal car bombing, and around 12
members of the cast and audience were
injured. The blast was heard several
kilometers across the city, shattering
windows of cars and houses in the
surrounding area. The attack left all
those present in various stages of
shock. People who attended the play
before, or were due to attend at a later
date, describe anticipatory anxiety, the
feelings of "what if". Foreigners in
particular felt targeted. The population
as a whole was in disbelief as to how
such an attack could occur in this
normally very peaceful country.
As part
of the Disaster Management process, The
Psychiatry Department at Hamad Medical
Corporation established a team of 2
psychiatrists, including one consultant
psychiatrist, and a psychologist. Our
first active role within the disaster
management team came in the aftermaths
of that attack, which occurred on a
Saturday night. By Monday morning, a
debriefing session had been organized.
There were practical difficulties with
contacting victims. In an attempt to
announce the session to the largest
possible number of people, relevant
Embassies of victims were contacted, in
addition to spreading the news by word
of mouth.
About 20 people attended the
debriefing. After introducing ourselves,
and explaining the nature of the session
and our role within it, the victims
introduced themselves in turn, and
whether they were directly or indirectly
affected by the attack. The majority was
actually present in the theatre at the
time; one or two had minor injuries.
There were a couple of people who were
present to support their friend or
partner. At the very beginning, there
was some hesitancy in starting the
discussion. However, as the session
progressed, the intensity of emotional
outpouring escalated. People could be
observed in various stages of grief.
Some were very tearful throughout the
session, especially those who knew the
deceased in person. Feelings of
disbelief were evident. Although the
meeting occurred almost two days post
the trauma, some of those present
described a sense of "unreality",
despite being fully aware of the extent
of the attack. A minority preferred to
remain silent, merely absorbing others'
comments. The prevailing mood was that
of immense anger, directed not only at
the attacker, but, with a few, also at
the care providers after the attack, at
the authorities, and some even expressed
anger at their relevant Embassies for
not providing sufficient warnings, the
attack having occurred around the second
anniversary of the war on Iraq. As would
be expected following any major
incident, what the majority felt they
needed was information. They needed to
know the answers to questions of who,
how, why, and lots of other concerns.
They all shared the concern about future
safety. Although acknowledging that
Qatar is a safe country, where help is
never far when needed, they felt that
sense of safety had been violated. We
observed the victims' interactions; they
actually provided the main support for
each other. Some of them were meeting in
small groups, a form of unofficial group
therapy.
Our role was that of
facilitators of the group session. We
encouraged them initially to talk about
what happened on that day, their
immediate feelings and thoughts, their
response to the traumatic experience.
The discussion then moved on to consider
the progress of the victims' thoughts
and emotions two days later. Generally,
the line of discussion spontaneously
leads to the next stage of the
debriefing. The victims themselves
guiding the talk, they started talking
about how they can move on. Admirably,
they had a strong sense of resistance,
not allowing the attacker to succeed in
achieving his goals, wanting to rebuild
the theatre, and refusing to leave the
country. To most, this theatre was the
core of their social life; it is where
they spent their days after work, and
met with their friends. They were
determined not to let the attacker take
that away from them.
Because of the difficulty in informing all
involved about the debriefing session on
time, and the number of calls received
by people who were traumatized and
needed professional help, another
session was organized. This took place
two days after the first, four days post
attack.
The change in the general mood compared to the
first session was dramatic. At this
stage, there was less anger evident, and
more depression. A couple of people had
attended both sessions. The extent of
anxiety that was evident in them at the
first session had calmed down
significantly. There was more emphasis
on the psychological impact of the
trauma. They were less forthcoming with
the details of what happened, and their
first responses. Their participation was
less spontaneous, needing more
prompting.
This time, it was easier to predict who is more
likely to develop psychiatric sequels
post trauma. The night before, there had
been fireworks as part of the opening
ceremony of the Doha Cultural Festival.
Several members of the group expressed a
panic response to the sound produced by
the fireworks. Some had a startle
response to any loud noise. Some were so
emotionally distraught that they already
fulfilled the criteria for a major
depressive disorder.
At the end of both sessions, we explained to the
victims what symptoms are considered
within the normal response to trauma,
and at what stage should the possibility
of a psychiatric disorder be considered.
The roles of the psychiatry services in
providing help should they need it was
discussed, and the type of help
available. We gave our contact numbers,
and stressed the confidential nature of
our treatment. For a few patients, whom
we thought were at greater risk, we
approached them individually, advising
them to contact us when they are ready
to do so.
So What is Debriefing?
Psychological debriefing (PD), also
termed critical incident stress
debriefing (CISD), was introduced early
in the last century, originally to
minimize psychiatric disturbance in
soldiers after combat. By the 1980's, it
became more widely used for the
surviving population affected by a major
disaster. It typically involves
promoting some form of emotional
processing by encouraging recollection
and ventilation of the traumatic
experiences in a single session soon
after the trauma. Originally described
by Mitchell (1983) as "either an
individual or group meeting between the
rescue worker and the caring individual
(facilitator) who is able to help the
person talk about his feelings and
reactions to the critical incident"(5)
Since that early definition, several
methods have evolved in the provision of
debriefing. An example is the method
introduced by Hodgkinson & Stewart,
1998, which divides the session into
four phases, namely: Introduction,
narrative phase, reaction phase, and
education phase. Currently, debriefing
is primarily a group intervention.
Dyregrov (1989) presented the following
definition: "A psychological debriefing
is a group meeting arranged for the
purpose of integrating profound personal
experiences both on the cognitive,
emotional and group level, and thus
preventing the development of adverse
reaction"(5)
There is a general consensus that
debriefing should occur within 72 hours
of the trauma at the latest.
What Does It Do?
Psychological debriefing in a group setting
aims to decrease the sense of
uniqueness, the victims realizing their
experiences are shared by others. It
encourages the group to mobilize its
resources to overcome the trauma, and
provide support for each other. Victims
often feel overwhelmed by different
thoughts and feelings. As they discuss
these within a group, systematically,
guided by the facilitator, they become
more cognitively organized. The group
leader/facilitator prepares victims for
reactions that may arise, and introduces
them to further avenues of help.
In recent years, there has been heated debate as
to the benefits of debriefing. Several
studies have shown clear effects (6,7).
However, several others have failed to
demonstrate any (6,8), a small number
even claiming it may be harmful(4). Most
Studies, whether in favor of debriefing
or not, have serious flaws in their
methodology that affect their
credibility. Several fail to define
debriefing, describe the protocol used
or the training of the debriefers (2).
The latest Cochrane review, January
2006, concludes that single session
debriefing does not prevent
post-traumatic stress disorder. It even
suggests that compulsory debriefing
should cease, and a "screen and treat"
model may be more appropriate (10).
It remains uncertain whether very early exposure
to traumatic memories through debriefing
interferes with the natural fading of
memory over time. This poses a dilemma
to clinicians. While wanting to offer
help as soon as possible to those
unlikely to recover on their own, they
do not want to interfere with natural
recovery. If given a choice, only 10% of
trauma survivors will seek to discuss
the incident with a mental health
professional (11). Survivors may prefer
to rely on their social support network
to facilitate the healing process
To expect debriefing to prevent the development of
psychiatric morbidity is an
oversimplified, naive expectation. A
single session, of a couple of hours
duration at most, is highly unlikely to
have a preventive role. However, it
plays an important role in bringing to
people's awareness the availability of
help, and how to approach it. That was
clearly apparent to us in our sessions;
people were unaware of the nature of the
psychiatry services until then. The
sessions proved valuable in recognizing
those who need further help, allowing us
to approach them individually.
Ultimately, whether studies prove its effectiveness or not,
organizations will continue to offer
debriefing as part of their response to
untoward incidents. The desire to
provide or receive help at times of need
is in human nature. It is generally
expected by victims as the "politically
correct thing to do". The Critical
Incident Stress Management strategy
formulated by Everly and Mitchell (12)
includes Pre-Incident Preparedness
Training. This is a crucial preventive
step, aimed at educating those in
high-risk occupations about stressors
they may encounter, their effects, and
management skills. Survivors, as
observed in our sample, need
information, an understanding of what
has happened; this helps facilitate
their healing process. It is important
to attempt to activate a social support
network for those who lack it.
Brewin(13) suggested using a validated
screening instrument, and intervening
only if symptoms failed to subside
naturally by 4-6 weeks post trauma.
However, this time scale may miss cases
of delayed onset PTSD.
Future
Prospects
While Qatar continues to be a safe and prosperous
country, and we hope attempts at
de-stabilizing never recur, it is
important to be prepared for the
unexpected. We have done our best on
this occasion, despite it being our
first, to provide support for the
victims. The debriefing has allowed us
to assess who's in need of further help.
Indeed, a couple has contacted us at the
Psychiatry department, presenting with
symptoms of depression, for which they
are receiving help. We are now better
prepared to deal with trauma should it
arise again.
"Psychological debriefing was never intended to
be a stand-alone intervention - rather
it should be but one part of a
comprehensive stress management package
that enables individuals to receive
follow-up, an assessment of individual
need and practical support, as well as
allowing the early detection and prompt
treatment of established PTSD and other
disorders."(6)
Acknowledgements:
Special thanks to Dr. E. Dafeeah, and
Dr. A. Khairi for their dedication and
valued input as members of the
psychiatric disaster management team.
References
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