A message of hope and resilience

At 22.31 hours on 22 May 2017, an improvised explosive device was detonated in 'The City Room' Foyer area which links Manchester Arena to Victoria rail station. It was an attack on music fans and their families as they were exiting a music concert, but it quickly felt like more than that too. An attack on all that Greater Manchester represents, its cultural heritage and identity, at a time when more power was being devolved from Whitehall.

Many of us working in mental health were saddened and angered by this attack and felt a strong desire to do something. An extraordinary event demanded an extraordinary response, and so with the inventiveness and ingenuity that Manchester is synonymous with, a specific approach was developed. As we near the second anniversary of the attack, we reflect on the work of the Manchester Resilience Hub (MRH), a new enhanced NHS service to support the mental health of those affected.  

The first days and weeks

Within a few hours of the attack, senior staff from psychological therapy and other mental health services across Greater Manchester (GM) made themselves known to Silver Command on hospital sites, and got on with offering support to frontline staff to enable them to continue their roles. Spaces were provided for people to decompress after a shift, with food, drink and a listening ear on hand. When requested by acute care colleagues, direct support to the injured and their relatives and friends was provided.

Secondary schools were contacted by their local mental health service with an offer of advice and support. Infographics and media messages describing normal responses to trauma, and when and how to seek professional help, were written and disseminated. National charities are commissioned to provide the initial psychosocial response to such incidents, and the Red Cross, Victim Support and Foundation for Peace began providing immediate emotional and practical support to those affected.

Four days after the attack, senior clinicians and managers from the four GM mental health providers sat around a table with colleagues from the Strategic Clinical Network to discuss next steps. Pathway documents were developed for Adults, and Children and Young People, which were shared within two weeks with colleagues in London following a number of significant incidents they suffered. With no funding available and potentially thousands of people affected, the Clinical Commissioning Groups agreed to underwrite an initiative for the first year in the hope of securing national monies. Drawing on other terrorist incident responses, a model was developed, ratified, operationalised and fully staffed and mobilised with seven weeks.

This new NHS service, the 'Manchester Resilience Hub', was set up to support the mental health and emotional wellbeing of all those impacted. It was an innovative model with mental health clinicians from across GM from adult mental health and child and adolescent mental health services being seconded to form a team. The different organisations showed they could rise above the normal day-to-day differences and irritations, pulling together to create this new service, with many staff going above and beyond.

The community response

Attacks on the way of life of communities, such as the targeting of young people enjoying a music concert, often lead to an increase in that activity. Thus the community got behind the 'We Love Manchester' concert, within a fortnight of the attack. Of course this prompted anxiety amongst many parents/carers who saw their children going to a concert so soon after the traumatic events, but the people of Manchester were united in their defiance. This had been an attack on their city, on their heritage, their way of life: but it would not become the dominant narrative.  

The general public showed their solidarity with those directly affected. Hundreds attended the vigil in St Ann's Square a week after the attack, there were queues around the block for bee tattoos (the Manchester symbol of industriousness, hard work and community spirit) and thousands of bee stickers appeared on cars and in shop windows. More than £21M was raised for the bereaved and injured via the We Love Manchester Emergency Fund. This outpouring of support and affection has been really important for the identity of the city and region.  

But we have to hold in mind that recovery can be a long-term process. After the 10,000 items left at memorial sites were archived and the city was returning to normal, families continued to live with the consequences of this horrific attack. Some of those directly affected, whilst feeling supported by the community response, found it difficult to reconcile the early path to recovery for the city with their own understandable continued difficulties. For families not living in Manchester there was the added complexity of having their recovery journey far from the location and community who had been targeted.  

The Manchester Resilience Hub

Within days a dedicated NHS telephone helpline and email address was established, and staffed by the regional Military Veterans' Service on a voluntary basis with the support of other volunteer clinicians. Initially available to professional staff, it quickly became the referral route for partner agencies to direct requests for support for the injured, bereaved, and those on the police witness list.

Once the Hub was fully operational it began proactively reaching out to all online ticket purchasers for the concert. People were invited to complete online screening questionnaires on trauma, anxiety, low mood and functioning, via a customised web portal. This has been repeated at three monthly intervals for the first year, and then six monthly intervals. We work hard to provide equitable access to support by using telephone or email contact. On the phone we typically undertake clinical triage and psychoeducational support. For those who need it, we facilitate local evidence-based psychological and mental health treatment services.

By the end of year one, 3281 individuals were 'open' to the Hub, able to access support when needed. There is no symptom threshold or exclusion criteria. We know that the journey to recovery can be changeable, so our service users are able to access us when it suits them, and we can check in with them as clinically appropriate. It's a psychologically-driven, community model. Building relationships with families allows us to check in with them regularly; strengthening families' day-to-day support structures is crucial.

Promoting psychological health

As Lord Kerslake's report into the incident said, 'The journey to recovery after psychological trauma varies and those affected need flexible offers of support'. Towards the first anniversary the Hub began to provide additional support to our service users.

The Hub facilitated supported return visits to the Arena. There were also 'virtual visits', using immersive 360 degree virtual reality headsets. Home visits supported families to formulate their difficulties and make care plans. Parents and carers described the anxieties they had supporting their child. Greater Manchester Police, who were holding briefings to witnesses on the criminal investigations, were hearing the same. Together, we developed, organised and delivered a one day workshop on overcoming trauma for families: a safe environment for children and young people to meet, share their experiences and learn more about reactions to single incidence trauma. The combination of psychoeducation and space to reflect on personal experience and issues, facilitated by clinically qualified staff, gave us the best possible chance of going beyond support to real therapeutic shift. The feedback was so positive, and charitable donations allowed us to plan more workshops. 80 per cent of those open to the Hub were not from GM, so delivering workshops around the UK was important. During the second year of the Hub we have taken our staff, GMP and our colleagues in VCSE to Scotland and the North of England, delivering workshops on overcoming trauma to families, young people and adults.

In addition to supporting individuals – both concert goers and those affected in a work capacity – we have also provided psychologically informed advice and consultation to other organisations. This attack was also unprecedented from a Local Authority and Police perspective, so we worked closely with them. We advised the We Love Manchester Emergency Fund so they could get to a position where they made financial gifts to those psychologically injured, as well as the bereaved families and physically injured. It's the first time a fund has made gifts like this.

The first anniversary required detailed planning by the local authority, and again the MRH was able to contribute by bringing a clinical perspective to this emotive and important occasion. We provided direct support to families before, during, and following the event at Manchester Cathedral. This included a discreet support function within the venue, arranging advertising of support services throughout Manchester and assisting with protecting families from any media intrusion. Hub staff also remained in contact with many other families who had chosen to stay away from the official marking of the anniversary, and offered follow up support to all.

Next steps

Manchester suffered a deadly terrorist attack on children, young people and their families out enjoying themselves at a concert. It demanded that services stepped up to try and do the right thing. We feel it has been of value, and families tell us they welcome us reaching out to support them. More formal evaluation is underway.

The MRH is now actively contributing to the local Emergency Preparedness and Resilience and Response (EPRR) planning, as well as at a national and international level. As we move into the third year we continue to offer screening at regular intervals, allowing families to track their progress as they continue their recovery journey. There are particular groups, such as professionals, who we persist in assertively reaching out to. And we remain aware that individuals needs and wants vary: we continue to learn and develop, to meet the changing psychological needs of those affected.

Find out more www.penninecare.nhs.uk/your-services/manchester-resilience-hub

- Clare Jones is a Consultant Clinical Psychologist and Clinical Lead for Children and Young People. [email protected]

- Alan Barrett is a Consultant Clinical Psychologist and Clinical Lead, and Honorary Professor at the University of Salford. [email protected]