The school environment is, like the rest of society, regularly confronted with violence and serious events with a strong traumatic impact . Brutally exposed to a threat to their physical or psychological integrity, to a mortal risk for themselves or for others, or even the spectacle of a horrible death, the subjects involved may experience a feeling of total insecurity or loss of control.
In this unexpected, disorganizing and destructive experience of the “real of death”, victims and witnesses find themselves helpless, as in the Saint-Thomas-d’Aquin high school in Saint-Jean-de-Luz (Pyrénées-Atlantiques), where, the February 22, 2023, Agnès Lassalle, Spanish teacher died after being stabbed in class by a student.
The second classes present that day were taken care of by a psychological unit , said the Minister of Education immediately after the tragedy.
Often acclaimed by the media and politicians in the context of potentially traumatic events with a collective dimension, systems of this type are put in place to detect, support and prevent the occurrence of psychological sequelae. Who are the personnel who make them up? How do these cells work and what are their missions?
Let us first recall that, for each individual, the subjective experience of potentially traumatic events is unique, with variable repercussions depending on the degree of exposure to the event, its severity, the personal history of each (traumatic history, violence , deficiencies, anxiety), the internal resources at our disposal and the social support that we perceive. Those involved may feel intense fear, bewilderment, horror and helplessness.
During the event, or just after, most of the subjects are in a state of adapted stress, that is to say with effective behavior in the face of danger. Other people develop a state of outdated stress, that is to say a state of stupefaction, excessive agitation, panic flight, or automated behaviors not adapted to the context.
In the days following the event, it is common to experience difficulty sleeping, with nightmares and intrusive thoughts or images of the traumatic scene. These early acute stress reactions are physiological and can be considered normal. Nevertheless, nearly a quarter of those involved, children or adults, may see these symptoms persist and significantly alter their daily lives. We then speak of acute stress disorder in the first month and post-traumatic stress disorder (PTSD) beyond.
PTSD is characterized by symptoms of repetition of event-focused thoughts, images, and dreams, avoidance behaviors with the adoption of strategies and significant efforts to avoid what may be reminiscent of the event ( place, thoughts, activities, people, etc.), an affective state marked by predominant negative emotions, and symptoms of hypervigilance in a state of permanent alert with concentration disorders and irritability.
This post-traumatic picture can be complicated by anxiety disorders (generalization of fear, phobia, etc.) in 60% of cases, depression in 40% of cases, increased risk of suicide multiplied by four, addictions or even manifestations somatics of psychogenic origin.
Psychic first aid
Created after the wave of terrorist attacks in 1995 to offer care adapted to mentally injured victims of collective events with a high traumatic potential, the medico-psychological emergency cells (CUMP) have gradually become structured into a national network.
Established in each departmental SAMU headquarters, they are locally led by a referent psychiatrist and made up of volunteer doctors, nurses and psychologists.
The medico-psychological emergency cells intervene at the exclusive request of the SAMU or the prefecture. They can intervene immediately, within the first 24 hours, or post-immediate up to a month after the event.
The CUMP deploys on site or near the event, for example in the school, in the first hours following the tragedy. It receives additional staff from the reception and listening unit of the national education system (composed of doctors, nurses, psychologists and social workers from the national education system). The objectives of this early intervention are to bring the first psychic aid to the children, teenagers, or adults present. The guiding principles of this type of intervention are proximity, immediacy and the restoration of hope.
The CUMPs deploy a system adapted to each situation, in collaboration with the actors of national education and the emergency services, to restore as quickly as possible a reassuring framework and to fight against the images of harmful chaos for the victims, in particular for the children. .
Promote emotional discharge
A first step, in consultation with the contacts of the establishment, consists in identifying, in the children and adults exposed to the event, the degree of exposure to the traumatic event.
This step is essential for targeting the different sub-groups of people involved and adapting treatment according to the degree of exposure. Indeed, collective care without this distinction would deprive direct witnesses of the floor, for fear of causing additional distress among their peers who did not attend the event. Conversely, indirect witnesses might not feel entitled to verbalize their emotions in front of their peers or colleagues who are direct witnesses, which would trap them in silent suffering.
The immediate care offered aims to soothe the stress and anxiety generated by the event, to reduce the feeling of isolation or helplessness, to recognize the harm suffered and the appalling and exceptional nature of the event, to restore the adaptive functioning and to mobilize personal resources.
The second step consists of identifying people whose emotional control capacities have been overwhelmed, requiring increased vigilance from CUMP professionals, an intensification of calming techniques, and close follow-up in the face of the increased risk of development of PTSD . . Sometimes, a transfer to a hospital can be organized when the clinical condition justifies it.
For all the people involved, the CUMPs use “defusing” techniques , or shock interviews , individually or in groups. The goal is to reduce distress by promoting emotional discharge through the shared factual account of the event, in a safe setting. This makes it possible to initiate the cognitive and emotional integration of the event experienced, to help the subject regain control over what is happening to him, and to rehumanize him in his relationship to others.
This flexible care is non-intrusive, sometimes allows a rapid improvement in the mental state, and is systematically accompanied by information – adapted to the comprehension capacities of the people taken care of – on the possible emergence of “normal or pathological” in the following days. The contact details of specialized health professionals to be consulted if necessary are also communicated.
Work with the educational community
The CUMP may be required to intervene within 3 to 10 days, to carry out Post-Immediate Psychotherapeutic Interventions (IPPI). This directive and relatively intrusive psychotherapeutic technique requires specific training, and can be offered individually or to groups of voluntary people, homogeneous in terms of exposure, and belonging to the same group before the event.
Its purpose is to facilitate the integration of the event experienced, while limiting the potentially traumatic effects, by limiting emotional outbursts, legitimizing the emotions felt and correcting inaccurate information. This intervention promotes the resumption of the activity and functioning of the group that existed before the event. It also allows the identification of people with incipient PTSD, and directs them to care.
Traumatic events are unforgettable. Their occurrence in the school environment can have a lasting impact on the establishment concerned. It involves raising the awareness of all professionals in the educational institution and paying specific attention to the people affected by the event. Health professionals monitor the risk of traumatic reactivation, which can sometimes occur years later, on anniversary dates, or during more personal life events. Their mission is then to accompany the child or the adult towards the appropriate care structures.
Author Bios: Antoine Bray is a Psychiatrist at the Regional Center for Psychotraumatology (CHRU Tours), CUMP 37 and Wissam El-Hage is Professor of Psychiatry, Head of the CVL Regional Psychotraumatology Center both at the University of Tours