Improving the mental health system for trauma victims in France

ABSTRACT

France has a rich history of exposure to large-scale traumas such as wars, disasters and terrorist attacks, and psychiatric teams specialized in emergency interventions for mass trauma have been created across the territory. However, no public resources are dedicated for long-term interventions or for individual trauma cases. This letter describes how a government supported model of care has been created and implemented in 2019. A national centre for resources and resilience (CN2R) and 10 regional ambulatory services specializing in psychotraumatology were created with the aim of improving public mental health-care delivery while providing a comprehensive suite of services for trauma victims from the most immediate to longer-term considerations.

HIGHLIGHTS

• France opens a national centre for resources and resilience and 10 regional psychotraumatology centres.• These facilities aim to ensure easy public access to specialized trauma care to all victims regardless of trauma type or individual victims’ characteristics.• The challenge is to achieve universal access to prevention, improve free access to trauma-focused psychotherapies, and ensure coordination of trauma care and social support.

Both mass trauma and individual trauma are prevalent around the globe (Kessler et al., 2017). Trauma care in Europe varies across countries (Jacobs et al., 2019; Schäfer et al., 2018). France has a rich history of exposure to large-scale traumas such as wars, disasters and terrorist attacks. France has participated in major European wars, and the 21st century was marked by several terrorist attacks resulting in more than 264 dead and 935 injured individuals, such as the 2015 Paris terrorist attacks and most recently the tragic shooting in Strasbourg in December 2018. Since the Saint-Michel terrorist attacks in 1995, psychiatric teams specialized in emergency interventions for mass trauma have been created across the territory. To date, no dedicated competence public centres that specialize in providing therapy for trauma cases or long-term interventions exist throughout the country. Two French clinicians – Jean-Martin Charcot and his student Pierre Janet – pioneered our understanding of the concept of trauma and research on traumatic hysteria and hypnosis. This inspired, among others, Freud who developed his ’talking cure,’ an approach that was largely embraced in France. This historical psychodynamic approach was gradually but slowly replaced by structured trauma-focused psychotherapies.

In the more recent context of the terrorist threat in France and in response to pressure from public opinion and victims’ associations against domestic cruelty and sexual violence (polls suggested that it was the French public’s top concern), President Macron stated that the issue of violence against women was a priority for his presidency. The government decided to support dedicated public trauma centres for all victims regardless of the type of trauma or individual victims’ characteristics (age, sex, nationality, etc.). Subsequently, in 2018, the French government financed a national centre for resources and resilience (CN2R) and 10 regional ambulatory services specializing in psychotraumatology (Figure 1). Their aim is to ensure long-term high-quality trauma care to all victims in need across the country. The focus of this letter is to describe the new care system for trauma survivors in France.

Figure 1.

Mapping of French Psychotraumatology centres.

The CN2R was created in 2019 by a government initiative to strengthen the resilience of the French society. To meet this objective, a competitive governmental process appointed Guillaume Vaiva (Lille) and Thierry Baubet (Paris) to lead a team of multidisciplinary researchers and civil society members to drive the deployment of the CN2R in Lille. The CN2R will be managed by an administrative structure, including six ministries (solidarity and health, education, research and innovation, armed forces, justice, and national security). The roadmap of the CN2R is to develop a research centre and training of excellence to better understand and treat psychotrauma. The CN2R will thus coordinate the action of the regional centres by defining the state-of-the-art of interventions, a shared method for clinical evaluation, and by providing efficient information and training programmes. It will also address the current challenges in caring for trauma survivors, and the topics that need to be most urgently addressed by conducting research programmes. The CN2R will have many challenges including the prevention of traumas and the promotion of trauma-informed practices and standards of care in the whole health-care system and standards of care.

The missions of the CN2R, which aims to respond to the needs of all age groups and all types of trauma, focuses on five areas:

1/Carry out continuous monitoring of the medical and scientific literature, and disseminate such information.

2/Provide the means and structure for excellence in research on psychotrauma and resilience, and share the data with the international community. The CN2R has three research objectives, namely, to better understand, detect and repair the psychotraumas. To achieve achieve these objectives, new tools will be developed, such as a national mapping of health-care facilities and health-care professionals in psychotrauma, a project to recontact victims, a record of care that is common to all sites responsible for psychotrauma consultation, and a digital tool to automatically transfer care.

3/Develop training modules adapted to good clinical practice that will be accessible at all regional sites for the public (E-learning, MOOC modules).

4/Inform the general population and specialized audiences through the creation of a French web media on psychotrauma.

5/Create a national coordination tool for regional care centres: design, construct and animate a digital platform ‘e-script’ that will allow for the establishment of regular teleconferences between the CN2R and regional care centres.

Ten regional psychotraumatology centres opened in 2019 with the aim to improve public mental health services delivery while providing a comprehensive suite of services for trauma victims from the most immediate to longer-term considerations (Frewen et al., 2017; Akiki, Averill, & Abdallah, 2018; Magruder, McLaughlin, & Elmore Borbon, 2017). These centres are aimed at providing easy access to specialized medical, addiction and psychological care to both minors and adults who experienced any traumatic event during their lifetime, to provide training programmes for health-care workers, and to disseminate information designed for institutions and the general population. Each patient should be offered a structured and personalized evaluation of his/her symptoms and provided access to specialized care. However, the funding for these centres is somewhat limited and thus the resources that are necessary to satisfy all the health-care demands are lacking. To solve this problem, the centres will develop regional networks of caregivers with three different support levels. i/The first level is the provision of a directory of specialized caregivers, for the benefit of the family physicians and associations of victims. ii/The second level is to develop a regional coverage building on public and private institutional resources to offer dedicated specialized consultations in psychotraumatology at various locations. These consultations should offer integrated multidisciplinary expertise (e.g., services to victims and trained caregivers, physical assessments, and facilitated access to legal aid and social assistance). iii/The third level is the access to mental health care in each regional centre working closely with a university hospital, with a dedicated team of trained therapists that can provide personalized assessments and structured evidence-based trauma-focused psychotherapies.

The regional centres will provide a comprehensive training in psychotraumatology for professionals in different settings in trauma-related practices in accordance with national curricula. Each centre will also implement telemedicine solutions and provide resources at its territorial level in order to improve patients’ long-term treatment protocols and to prevent trauma-related problems from becoming chronic (Bourla, Mouchabac, El-Hage, & Ferreri, 2018; Bui et al., 2010).

Challenges for the future

The perspectives above show that the first steps towards a better provision of specialized care for trauma victims have been taken in France. However, the provision and access to treatment remain limited by the fact that there are only a small number of trained trauma therapists and the limited number of regional centres are not globally distributed across the country. The challenges to achieve universal access to prevention, improve free access to trauma-focused psychotherapies, and ensure coordination of specialized care and social support are many. The CN2R will have to coordinate and organize trauma care actions in the country, to establish a single French umbrella organization of the French societies for traumatic stress, help creating a qualifying training curricula, and to set up a French certification committee connected to the ESTSS accreditation committee, in order to meet modern European and international standards (Schäfer et al., 2018). Assessing this new facility for trauma survivors needs to occur in the coming years in order to assess its overall efficiency before making recommendations to other countries.

Disclosure statement

No potential conflict of interest was reported by the authors related to this manuscript.