The recent terrorist attacks in San Bernadino, California, and Paris, France, have highlighted not just safety concerns but also the devastating health effects of such violence. The victims of terrorist attacks can suffer long-term psychological consequences, including post-traumatic stress disorder (PTSD), depression, and anxiety disorders. A terrorist attack can also bring on or exacerbate addictions to alcohol or drugs.
In the wake of a terrorist attack, people who were wounded or those who were relatives or friends of those injured or killed in the attack are at increased risk for short- and long-term psychological symptoms. Even though terrorist attacks are not common, it’s important for clinicians to be prepared to treat the victims of this unexpected violence with effective psychological interventions.
Terrorism evokes fundamental fears of helplessness because the violent actions are intentional, random, and unprovoked and are often aimed at defenseless citizens, according to the American Psychological Association. The people most affected by the trauma of a terrorist attack are the people who were injured or witnessed the attack, and those who learned of relatives, friends, or acquaintances who were injured, killed, or present during the violence. Among these victims, those who had the greatest exposure to the violence, and people who are also survivors of previous traumas—such as domestic violence, child abuse, or war crimes—are most likely to suffer long-lasting and serious psychological effects. Patients with pre-existing psychological diagnoses are also at increased risk for chronic, long-term psychological health effects after being victimized by a terrorist attack. Early and appropriate evidence-based treatment of these vulnerable populations is important, because once it becomes chronic, PTSD is difficult to resolve– and is often comorbid with other psychiatric conditions.
After the Oklahoma City bombing, 45% of direct survivors had post-disaster psychiatric conditions and 34% were diagnosed with PTSD, according to recent studies. Research indicates that up to 2/3 of those who are directly affected by a terrorist attack, either as a victim or relative of a victim, are psychologically impaired, according to a paper on the psychological consequences of terrorism by the Rand Corp. Even two years after a terrorist attack, 30 to 40% of people who were involved with or nearest the site of the attack are likely to develop a psychiatric disorder, according to scientific studies. Two years after the Pentagon attack on September 11, 2001, for instance, over 20% of employees who were present at the attack and responded to a survey were found to have clinical PTSD, according to a 2007 paper published in the British Journal of Psychiatry.
For clinicians who treat the victims of a terrorist attack—whether in brief clinical interventions or longer-term therapy or counseling—an important first step is to express understanding and sympathy for the unique thoughts and feelings of their patients, according to the American Academy of Experts in Traumatic Stress (AAETS). Empathetic listening and when possible, validating the victim’s thoughts and feelings, can help give the individual a sense of control– and prevent him from withdrawing into isolation.
Victims of terrorist attack may experience and express a cascade of emotions or even a lack of emotional reactivity. No matter the response, clinicians should attempt to normalize the victim’s response as much as possible. Discussing the emotional, cognitive, and physiological aftereffects of traumatic events can help the victim or survivor understand that he is experiencing a normal response to an abnormal event, according to the AAETS.
At the start of clinical interventions, the psychologist or social worker should attempt to assess what symptoms or situational challenges are most distressing to the survivor or victim. Often there’s one element that creates the most intolerable distress in the patient. Recognizing and legitimizing, while smoothly challenging the totality of this emotion or aftereffect can be a useful treatment strategy, according to Arieh Y. Shalev, MD, professor of clinical psychiatry at Hadassah University Hospital in Jerusalem, Israel. Once the most distressing aspects of the victim’s situation is known, the clinician can help identify resources and useful solutions to the life problems that the attack may have caused. For instance, the wife or husband of an individual injured or killed in a terrorist in an attack may find it helpful to focus on caring for the emotional and physical needs of their children, according to Dr. Shalev.
Recent studies have found that cognitive behavioral therapy can be effective for reducing the risk for PTSD in the recently traumatized and in treating long-term PTSD after violence. CBT that involves cognitive restructuring and teaching specific coping skills has been shown to be more effective than relaxation training in preventing PTSD after violence, Dr. Shalev notes in his white paper, Treating Survivors in the Acute Aftermath of Traumatic Events, published online by the National Center for PTSD of the U.S. Department of Veterans Affairs. Antidepressants and anxiolytics can also be used for recent victims of violence to reduce depression and anxiety and enhance sleep. However, anxiolytics—especially benzodiazepines—can have side effects that range from somnolence to problems with balance, especially in elderly populations, and may cause drug dependence. So, there should ideally be a short-term treatment and targeted to specific symptoms, such as panic attacks and sleep problems.
The technique known as psychological debriefing has also been used effectively to treat recent trauma survivors, according to Dr. Shalev. Psychological debriefing occurs in several stages, including a phase in which survivors are prompted to describe the events and one in which they are encouraged to express their emotions after the event. The clinician who leads the intervention will also validate the normal nature of survivors’ symptoms and discuss methods of coping with future emotions and consequences of the violence, according to Dr. Shalev. Although it’s not known how effective this type of debriefing is in preventing stress disorders after recent violent events, most participants report that they find these sessions beneficial and satisfying, Dr. Shalev said.
- Managing traumatic stress: Coping with terrorism. Fact sheet. The American Psychological Association Web site. apa.org
- Terrorist attack: How we can prepare for the hidden trauma. Fact sheet. National Center for Crisis Management. American Academy of Experts in Traumatic Stress. aaets.org.
- Boscarino JA and Adams RE. Overview of findings from the World Trade Center Disaster outcome study: Recommendations for future research after exposure to psychological trauma. Int J Emerg Men Health 2008; 10 (4): 275-290.
- Shalev AY. Treating survivors in the acute aftermath of traumatic events. White paper. National Center for PTSD. U.S. Department of Veterans Affairs.
- Ozbay F, der Heyde TA, Reissman D, et al. The enduring mental health impact of the September 11th terrorist attacks: Challenges and lessons learned. Psychiatr Clin N Am. 2013; 36: 417-29.
- Tanielian TL and Stein BD and the Rand Corp. Understanding and preparing for the psychological consequences of terrorism in the Mc-Graw Hill Homeland Security Handbook (New York NY: McGraw-Hill Companies, Inc.; 2006).
- Whalley MG, Brewin CR. Mental health following terrorist attacks. Br J Psychiatry 2007; 190 (2): 94-96.