Not long after escaping the explosion in his carriage on the Edgware Road tube, Thomas L, a 38-year old computer scientist from Germany, began to notice that he had acquired a puzzling psychological tic. It wasn’t the worst of his symptoms, only the most tantalisingly specific. It happened whenever he laughed. Admittedly, in the weeks following the London bombings of July 7th, Thomas didn’t have much to joke about, but when he did find something funny his reflexive laughter would be replaced, an instant later, by an overwhelming rush of sadness. Referred to a counsellor by his London GP, he had been told to write down his thoughts when this occurred. But there was nothing to write. He didn’t have any particular thoughts; just a jolting switch of feelings. When it was explained to him that the laughter must be a trigger for a suppressed memory, Thomas asked how he should un-suppress it. The counsellor replied, frankly, “I don’t know.”
It wasn’t until he managed to find his way into mainstream cognitive therapy at an NHS psychotrauma clinic in November that Thomas got his explanation. Suffering from nightmares and flashbacks, he had only fragments of recall, and his feelings about what had happened to him on the day were either weirdly incongruous or numb. The partial amnesia seemed to be paralysing him. When he tried to concentrate or work, a kind of pressure would build up, as if he could feel it physically in his brain—“like I’m a missile locked onto a target,” he explains, “going faster and faster, and I can’t get out.” So his therapist started to help him re-live his experience of July 7th in order to regain his memory and, in the argot of cognitive therapy, to “re-process” it.
While piecing together events before the bomb went off, Thomas told his therapist how he had been sitting on the circle line train, reading a book by one his favourite German authors—Wladmir Kaminer, a Russian émigré who writes about absurd and improbable events in a world gone mad. In his “re-live,” Thomas recalled being in a good mood and finding the book, called Militarmusik, very funny. It was then that the penny dropped. At the moment the suicide bomber Mohammad Sidique Khan blew himself up a few feet away, killing 7 people in the train and injuring 163, Thomas had very likely been laughing.
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The idea that the human mind can get locked into an exact replay of a past event, repeatedly performing the same short-circuit of experience, can seem overly neat, like detective-fiction psychology. But Thomas’s automatic flip from laughter to horror—replicating his responses during the event—is a highly precise example of what many others caught up in the London bombings have since been experiencing in varying ways and to varying degrees. The notion that memory contains triggering and blocking mechanisms is one of the most basic premises of current, cognitive psychology. What remains controversial is the extent to which, once those mechanisms begin to malfunction, people may be plunged into a state which can be given a clear medical diagnosis—Post Traumatic Stress Disorder.
Almost every single one of the approximately 4,000 people directly caught up in the London bombings qualifies for what is known as “criterion A” of a PTSD diagnosis. Which is to say, they have gone through a calamity that involved actual or threatened death, and experienced intense fear, helplessness or horror. But the degree to which they can be said to be clinically ill as a result depends on whether they also fulfill criteria B to F, which include flashbacks and nightmares, avoidance, hyper-vigilance, exaggerated emotional reactions, and an inability to function socially. If a survivor displays enough of these symptoms he or she will be eligible for Cognitive Behaviour Therapy (CBT). If not, then a GP may be able to offer a more general counsellor. But therapy on the NHS is not easy to get without a diagnosis—even if you were sitting on a tube train when a bomb went off.
There is a kind of fantasy that at some point we adopted a lifestyle therapy culture, indulging our neuroses in private practices. If so, it’s an indulgence with is strangely absent at the front line of psychological crisis. The standard estimate is that between 25-30% people involved in a Criterion A event can go on to develop full PTSD. Which means that, at the very least, 1,000 people directly affected by the London bombings should by now be displaying full-blown PTSD symptoms. To date, the NHS trauma response team tasked with the job of diagnosing them has been able to screen only 516 survivors, of whom 178 (a bit above average at 34%) have been offered clinical psychological help.
What has happened to the 800 or more other probable PTSD sufferers out there? And what about other survivors who may be labouring through psychological crises without qualifying for a diagnosis? The London Assembly’s recent report into the response to the bombings makes it clear that the emergency plan, which focused primarily on the physically injured, left a large group of traumatised victims to fend for themselves, with little information about what they might expect to suffer as a consequence of their experiences. Over 3,000 people wandered away from the four bomb-sites without being identified.
Some survivors who have begun to vent their frustration at the lack of information or support they received, and almost all who gave evidence to the London Assembly expressed a sense of isolation. Not many were even invited to November’s memorial service in St Paul’s. A gulf seems to have opened up between those who were maimed or bereaved, and the rest—the majority—of the survivors. “Those who were severely injured were brought into the system and treated impeccably—physically and psychologically,” says Kirsty, a member of King’s Cross United, a self-formed group of Piccadilly line survivors. “The big downfall of the whole thing was the people who weren’t physically injured, but were mentally injured. Obviously, on the day, when there are people with limbs missing, that’s the priority. But there should also have been a long term priority to let people know what can happen to you, and to make an effort to get in touch.”
Part of the explanation for this, interestingly, comes from within the trauma profession itself. During the King’s Cross fire of 1987, groups of counsellors went into to attend to victims, but this kind approach has now been discredited. Much of the research into “psychological debriefing” shows that it may not be helpful—indeed, it may be actively harmful—to talk individuals through their experiences immediately after a disaster, and may disrupt their natural defence systems. Blocking, far from a being a bad and “repressive” mechanism, is now commonly seen to be healthy, so long as it doesn’t become chronic. Ideas of how to treat PTSD emphasise that the condition should be picked up only after symptoms have been shown to persist.
Professor Simon Wessely, a leading PTSD specialist at the Institute of Psychiatry dismisses the popularisation of trauma culture. “What we’ve lost in the PTSD argument is what they knew in the second world, par excellence,” he says, “which is that people’s reactions to trauma, adversity, war and terror are determined by the group psychology and not individual psychology. Now we’re beginning to remind ourselves that normal people are pretty resilient. They have their own resources; they can maximise their social support. You don’t immediately need to involve pointy-headed people like me with our white coats and couches. People are usually the best judges of what they need and when they need it.”
Notoriously, in New York, during the immediate aftermath of 9/11, psychotherapists outnumbered victims, and even began haggling for patients. In Britain, by contrast, trauma culture seems to have moved in the opposite direction, towards a kind of puritanism. There is a powerful scientific and ideological move within the NHS to ensure that trauma treatment should come from a centrally researched and managed programme of CBT, leaving counsellors and other kinds of psychotherapists to pick up the other, “softer” problems.
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Yet a PTSD diagnosis only describes particular symptoms; it cannot quantify a person’s suffering and it may not be the best index of how much someone may need help, or what form that help should take. While Thomas L had specific problems which he needed to address—and for which cognitive therapy was well suited—others have needed something else. George, a 62-year old property inspector from north London, echoes something of Simon Wessely’s emphasis on the importance of group psychology. George describes how his journey on the front carriage of the Piccadilly line train out of King’s Cross “was obscenely cut short.” Nobody on the train would ever get to where they were heading through “that bloody tunnell.” But what began to happen afterwards was that some survivors—people who would never normally have spoken to, or even noticed each other on the impersonal underground—began to get together in order to complete a different journey.
The resulting group called itself King’s Cross United and, with its website and pub meetings, acts as an information service for its 100 or so members, a source of emotional support and, on occasion, a political voice for survivors. George describes King’s Cross United as being “as important as a counsellor” for him. He had been just four or five feet away from Jermaine Lindsay when the suicide bomber blew himself up, killing 26 surrounding passengers. George would later come to understand that he had been shielded from the blast by the thickly packed group of passengers standing between him and the bomb. He was left, the only person still standing in that section of the carriage, dumbfounded by a surreal sense of loneliness in the choking dark.
It would be a while before he found his way to King’s Cross United, but what George, like many others, got from it, was release from that isolation. As he stood in the middle of that carriage, amid the screaming and the praying, his first thought had been that the driver must have been killed which meant that he, too, was about to die. In November, thanks to information provided by King’s Cross United, George managed to get himself an invite to the St Paul’s memorial service, and it was there that he actually met the driver—who, on the day, had spent hours underground tending to the wounded and dying. By pure coincidence, they had been sitting next to each other in the cathedral. “I thought you were dead,” George told the driver. In turn, the driver told George that he was the first person on the train he had spoken to since 7/7. So George invited him to one of the King’s Cross United meetings. “We got the driver there,” George exclaims. “And he’s a lovely guy!”
Much of what happens at these informal gatherings is that people piece together the details of that broken journey—where they were in the carriage, who was next to them, who they helped, or who helped them. This kind of reconstruction is not so different from the “reliving and reprocessing” of traumatic memories which takes place in cognitive therapy. Nevertheless, George found out that the group wasn’t, in itself, enough. There were darker and more personal ordeals for which he eventually needed personal treatment. He discovered that he too had triggers that would bring him back into that carriage all over again.
On the evening of July 7th he had eventually got home, miraculously intact except for glass cuts in his neck and head, having been told by his wife that his five-year old grandson Callum knew he had been on the train and was deeply upset. As a result, George described to no-one in his family the sounds he had heard in the darkness of his carriage, or the mutilated bodies he saw at Russell Sqaure when he came out. “I was very careful about what I said, because I didn’t want to upset Callum any more. If I had let it go, I think I’d have let it go completely.” So he clammed up. The following Tuesday, sweating and palpitating on a Victoria line escalator, he forced himself back down onto the tube and into work.
When George finally broke down in February, the trigger for his collapse was the sound of Callum crying. It was the crying he had wanted to quieten when he came home on July 7th, but this had fused with the crying he had heard in his carriage that day. He was never screened for PTSD, despite giving his details to a plain clothes security, and had found his way to a counsellor by contacting the 7th July Assistance Centre, which provides advice for survivors. What the counselling gave him was the ability to identify and live with the psychological triggers that had begun to set off his intermittent breakdowns. There were three of these, forming a sort of triangle around the day’s events. Firstly, there was Callum’s crying, then there was the thought of the driver’s death (which presaged his own), and finally there was the guilt that came to him with the recurrent thought that, at the age of 62, he should not have walked out unscathed while, around him, younger people were maimed and killed.
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Guilt is one of the strangest responses to catastrophe survival. It rarely bears much relationship to what actually happened. Survivors can feel guilty if they panicked, or if they remained eerily calm; they can feel guilty if they were too bewildered to help, and even when they performed like heroes. Even if they do not feel guilt, they will often find this puzzling, as if they should have done. It is likely that guilt is a social interpretation of the primitive fear responses which are triggered during moments of extreme stress. When a small, almond-shaped part of the brain called the amygdala regulates a “fight or flight” reaction, the area next to it—the hippocampus—works to provide the context through which memory can process the emotive rush, thus allowing rational operations up ahead in the pre-frontal cortex to explain to a confused conscious mind what the hell just happened. If this process breaks down, events cease making sense.
While George was standing bewildered in his devastated carriage, back at King’s Cross station, Steve, a 47 year old inspector with the British Transport Police was rushing down the escalator, barking orders to a junior colleague and preparing—contrary to protocol—to head alone down the tunnel into the smoke. It is fair to say that Steve was already carrying a significant backload of psychological baggage. In his 28 years of service, he has been beaten up, run over by a hit and run car, confronted a gunman, and been on hand at several major disasters, including the Hatfield and Selby train crashes, and the 1987 King’s Cross fire. He had even been in counselling three years before, but this was for management-related stress rather than for any specific trauma.
But July 7th would very nearly break him. The first down the line to the train, Steve began helping people off at the back, including some who he would later meet again at the King’s Cross United pub sessions. Then he made his way up to towards the front of the train where the bomb had gone off, and forced open the door into the first carriage, where the bomb had gone off. “I’m holding the seek and search lamp and I realise that the people inside can’t see what I can see,” he explains, “and, Dear God, I do a quick head count of people who are still alive. There are a number of people I can see who I know are not going to survive. And I explain that I can’t move them for fear of exacerbating their injuries. And I say I’m going to get help. And the hardest thing I have to do is to turn around and leave them. There were people in that front carriage that I just could not believe were still alive. And those people so desperately just needed someone to hold their hand while they died, to exit this world with a kind word. Imagine being the only person to go into that. Then imagine the people in there watching as you walk away. Now imagine the emotional baggage I have to deal with.”
Having alerted paramedics and other transport police, Steve went outside to deal with his smoke inhalation, and then he went back down into the tunnel again. There he worked with paramedics who were “making decisions that only a god should make: choosing which person should get help first.” His actions that day saved lives and earned him an MBE. But he still feels guilt. He knows that he did the right thing, but he cannot get over walking away from the dying.
What makes Steve unusual, aside from the fact that he was the first to see what had happened in that carriage, is that he also had a very clear sense in advance of how the pattern of his traumatic reactions would play out. Experience had taught him pretty much what to expect of himself psychologically. “When 7/7 happened, I knew what form my trauma would take. I reckoned I’d be ok for 4-8 weeks, and then I would need to offload it. And at about week 6 I realised, yes, now I’m going to need counselling. And my counsellor basically saved my sanity.”
That is pretty much the way a cognitive therapist would expect things to play out before diagnosing PTSD. But Steve did not want a PTSD diagnosis; what he wanted was the counsellor he had seen before, someone he could trust. As for the “cognitive stuff,” he knew as much as he needed to know. The aspect of it that involves reliving is not dissimilar to the advanced interviewing techniques police use with witnesses to help them recall specific details of a crime scene. Steve describes the process of working a witness slowly, like a video camera, setting the scene and slowing consciousness, then rewinding and fast forwarding. “I used to get partial or whole registration numbers from people and they’d go, ‘wow, that’s magic.’ It’s not magic. It’s just unlocking a part of the brain. If you do it properly, going backwards and forwards—it’s called episodic memory—it’s amazing how much detail you can remember.”
Steve is still on anti-depressants, and still gets the nightmares, but he is ready to part company with his counsellor once next month’s anniversary is over. He knows that what he calls his “career bucket” is spilling over, but he also knows what his triggers are (chiefly a smell of burning), and he knows how to cope with symptoms that the trauma people would call “hyper-arousal” and “hypervigilance.” He has, almost certainly, seen through the worst events of his career, and he knows now where he can go to get help if he needs it again.
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This wasn’t the case for Kirsty, a 38 year old designer who was in the last carriage on the Piccadilly line when Steve came through. After the event, like a lot of survivors, she resisted any suggestion that she try to find help. “There a big thing for a lot of people in my carriage,” she says, “which is the feeling that ‘I’m not worthy to be traumatised, because I wasn’t in the first carriage, I didn’t hear the screaming, really I should be fine. For a long time I thought the thing that happened to me wasn’t that bad.” Until, one night, she cracked. And then she found it incredibly hard to find help.
The kind of counselling being offered at the 7th July Assistance Centre, which George had found so useful, didn’t tackle her specific needs, and she wasn’t screened for PTSD until later. To start with, she had been a classic “avoider,” staying out and ensuring she wasn’t alone. The onslaught of her nightmares occurred after she began trying to get back on the tube, a process which she describes as being like mini-repeats of the event all over again. But her biggest trigger was being late, just as she had been on the day. When she eventually lost control last September, it came as a kind of dark revelation. “I got this sudden respect for my mind, and a feeling of being kind of separate from it. I’ve always been an in-control type of person. If you have a bad experience, my response has always been just to get through it. And that’s what I tried to do this time, but something came from deep inside that made me wake up screaming one night and wiped me out for two months. And that wasn’t in my consciousness. That was way down, totally out of my control, out of my knowledge, like it was another being.
Unable to get a referral, it was through a friend that Kirsty eventually found a psychiatrist specialising in trauma, who she pays for herself. By the time she did get a formal offer from one of the five main trauma clinics operating in London, she didn’t want to risk changing therapists mid-flow. “The biggest thing he’s done is to make me feel normal, and to tell me that what I’m going through is normal,” she says. “He explained how the brain works, and how it gets stuck in a kind of whirring mechanism, like the way the hard drive on your computer can get stuck. I still felt crap, but at least I knew why.” But Kirsty was also looking for her own explanations. While cognitive therapy can provide views of how the mind’s mechanisms work, and the individual meanings that people ascribe to experience, what it isn’t equipped to do is explain things at an existential level—the wider human meaning of an event.
For Kirsty, this proved crucial. Like many other survivors she has since become obsessed by a need to understand what happened on July 7th and, most particularly, “what on earth it was that motivated four young men, born and bred in this country to go and kill themselves with the specific intent of killing innocent people.”
If there is a general psychology to all the survivors, the meaning (or lack of meaning) of the bombers is one of the issues that unites them. None of them appear to feel any anger towards the perpetrators, and few even think of them as murderers; in fact many survivors will talk about the bombers as if they too were victims, brainwashed by non-specific forces. The power of suicide terrorism is, of course, that in the process of killing and maiming, the perpetrator is simultaneously removed from the scene, leaving no target for anger. It is even more extraordinary to think that the suicide bomber may, in this process, even be able to elicit sympathy from some of his victims.
And if survivors have few reactions to the bombers, the opposite is true when it comes to government, with whom they are routinely furious. Regardless of the validity, or otherwise, of such a view, it may also belong to a group psychological phenomenon. “I’ve found that the majority of survivors are not angry with the bombers, and are angry with the government, and I definitely feel that myself,” Kirsty says. “I don’t know why, but I can’t feel anger towards them. And maybe it’s easier to feel anger against the government. We’ve voted for them, and they haven’t protected us, plus they’ve lied. So maybe it’s easy to say it’s Blair’s fault. But for the bombers, is it actually possible to put yourself in their shoes, to imagine—which I’ve thought a million times—can I see myself ever being driven to do what they did? You just can’t, and maybe because you can’t it’s too ungraspable to feel angry about.”
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Even Nader Mozakka, who fled Iran as a political activist during the Khomeini regime, still feels fury about the reactionary forces of Islam which gave the bombers their motive, but finds it hard to have any particular feelings towards the man who killed his wife. Nader, a 50 year old software manager with two children, is like many of those at the King’s Cross United Group in this respect—but in no other. Nader is one of the bereaved. He met his wife, Behnaz (or “Nazy” as the family called her), while they were at university in Tehran together, and together they slipped the net of Iran and moved to London, started a new life, raised children and made a success of themselves—she as both a forceful charity worker and a respected research scientist at the Great Ormond Street Hospital. “Nazy was more than a wife to me,” he says, “if you can understand what I mean.”
It would be impossible to give a full picture of Nader’s grief. Nearly a year down the line, he remains unable to speak about her without weeping, though he is—he says—much better than he was. Where some other survivors have two or three triggers that set them off, Nader has hundreds, from seeing a black boy who looks like Jermaine Lindsay to domestic details. The only place he can go that doesn’t remind him of his wife is an Arsenal game—watching football is the only thing Nader did alone—and even there the crowds make him anxious. But what makes Nader’s grief unusual is his full-blown PTSD. Although he wasn’t anywhere near one of the bombs, he still got flashbacks. Traumatologists call this “imaginal” or “vicarious” exposure to the event. Nader was, he says, “tracing” his wife out of the door that morning, into the underground and onto the first carriage of the Piccadilly line.
Nader got a PTSD diagnosis not long after 7/7, and was processed fast. But what CBT can do for him is little more than adjust the more repetitive symptoms, and get him to rethink his beliefs about whether his life is still worth living and the actual nature of the way his wife died (unlike in Nader’s flashbacks, it was almost certainly instant). His CBT sessions have gone on much longer than the normal 8-16 used to treat a trauma. He is also beginning to do something which cognitive therapists (unlike Freudians) try to resist—he is becoming emotionally dependent don his therapist. He can’t imagine how else he would cope with home-life, kids and work.
While he was still in Iran, several of his friends were killed by the regime, but that. he says, was to be expected. He doesn’t quite buy his therapists explanation that these deaths may form an underlying pattern, onto which the great grief about his wife has been grafted. There may, he thinks, be some way in which this has made him fearful that others will die continue to die and leave him. He still sees the therapists once a week, but he says, “she doesn’t have the answer. How could she?”
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Thomas L is perhaps the clearest example of what happens to a person as a result of the impact of a traumatic event. He found the process of his cognitive therapy interesting even as it was daunting. He had not known about PTSD before July 7th, and says that during his therapy he discovered a new respect for what his mind could do, even as it was breaking down. He would experience time slowing down during a reliving session, or notice how his whole sense of mathematical probability (a subject he understands very well), had changed as a result of what happened on the Edware Road tube. Gradually, his emotional responses began to make sense again.
But there was one thing that happened to Thomas which seems to make no sense to him. During one session in which his therapist tried a bit of hypnosis, he realised he was enjoying the sensation of emotion coming back to him, even if that emotion was terrible. And he thought, “How can I enjoy being sad?” And the perversity of this seemed to push him over the edge, into a new region of his consciousness altogether, and a sinister sort of vision suddelnly overwhelmed him. “In that moment, I had an understanding of how it is possible that you could kill someone and actually enjoy doing that, and enjoy seeing someone suffer—and also feel pity at the same time. And, for me, these were evil thoughts to be having. I don’t think it’s about the bombers, but before I used to think I was the good guy over here, and the evil people were over there. But suddenly I realised that we were not that different, because I could understand the same thoughts.”
That was enough for Thomas; neither he nor his therapist considered it wise to pursue visions of evil. That isn’t not really part of the cognitive remit. “I think that thought may be hidden in everyone,” Thomas says, “but I don’t see the benefit of un-hiding it. If I continued, I would probably uncover more things about myself that I don’t want to know.”
An edited version of this article was published in the Guardian Weekend magazine, Saturday June 17, 2006
