FIRST RESPONDER & VICTIM ISSUES WITH TERRORISM

These class notes were composed by Dr. Tom O'Connor for his class on Homeland Security at NORTH CAROLINA WESLEYAN COLLEGE, original documents can be found here

FIRST RESPONDER & VICTIM ISSUES WITH TERRORISM
"The care of human life and happiness is the first and only legitimate object of good government" (Thomas Jefferson)

Future first responders will hopefully never experience anything like the scale of casualties which took place on that disastrous day of Sept. 11, 2001. Events of this magnitude have a tremendous impact. There are many kinds of trauma associated with the impact and aftermath of a terrorist incident. It is the purpose of this lecture to overview those kinds of trauma, and analyze current capabilities and capacities for dealing with it. An attempt will be made to show that some new approaches to disaster trauma management may be called for. The topic of societal impact is focused upon, and as space permits, new directions in a field that can best be called the victimology of terrorism will be pointed out.

Some 37 million Americans experience trauma every year, at least according to hospital emergency room and trauma center statistics. Trauma is usually defined as any physical or psychological shock, wound, or distress which is likely to have long-lasting effects. Most people are familiar with the term PTSD (Post-Traumatic Stress Disorder) which emphasizes the "psychological" and "long-lasting" components of this definition. However, there are many other kinds of trauma, including Crime Victim Trauma which may or may not involve PTSD, and Acute Stress Disorder (ASD) which occurs within the first 30 days of trauma impact and may be predictive of PTSD. PTSD is not, by any means, the most typical reaction to trauma, since PTSD depends in large part on whether a person has any pre-existing traumas, personality disorders, or other chronic conditions in their life history (Hendin 1983; Goodwin 1988). It is not the intent here to dismiss the issues associated with PTSD (for which no good treatment exists, incidentally), but in this lecture, we are concerned mainly with the kinds of trauma experienced by first responders (disaster rescue and response workers) and victims (survivors) of a terrorist attack, and not just any terrorist attack, but a catastrophic or disastrous incident. The terms incident, catastrophe, and disaster were defined and discussed in the lecture on Emergency Management Principles, but it may be helpful to revisit them here. In Alexander's (2002) book, the following entry can be found in the glossary for catastrophe:

Catastrophe: The terms disaster and catastrophe are used synonymously, because definitions of the two terms are not sufficiently well developed, precise or subject to consensus that the terms can rigorously be distinguished from one another. However, some authors regard a catastrophe to be more cataclysmic than a disaster and to affect a larger area. Jurisdictions affected by a catastrophe, or so it is argued, are more thoroughly overwhelmed by it that they would be in the case of a mere disaster. As there are no quantitative measures of the distinction, or even adequate functional ones, I regard it as an unsafe and unwise distinction.

While Prof. Alexander might be right about the difficulties of making quantitative distinctions, the argument in favor of making a distinction between catastrophe and disaster rests primarily upon qualitative grounds. The Diagnostic and Statistical Manual in psychology says that post-traumatic stress disorders are more severe and longer lasting when the stressor is of human design. Terrorism is a stressor of human design, and with terrorism, each person is likely to have an emotional and psychiatric reaction which draws upon not only the personal meaning of the event for them, but also draws upon the societal meaning of the event -- how it impacts their sense of patriotism, their notion of homeland, their beliefs about fairness and justice in the world, and their conceptions of human life, value, and dignity. Terrorism trauma disrupts deeply-held cultural assumptions about social values. Terrorism as catastrophe is inherently an emotional or psychological form of trauma which in many ways is related to the concepts of war trauma and indirect "vicarious" or "secondary" traumatization. Terrorism as catastrophe is indisputably an unique social form of disaster (creeping and continuing) with unique traumatization properties.

War and terrorism both involve accepting repugnant facts, the most important of these facts being that human life is cheap and that murder, misery, and torture can be used in cold, calculating ways for symbolic or political purposes. Military psychiatrists have long debated whether war trauma exposes mental illness or creates it, but the expert consensus at the end of the 20th century is that despite a few expected cases of malingering and the triggering of pre-existing illness, the vast majority of cases are created by the trauma (Shephard 2001). Historically, "shell shock" was the first war trauma discovered, in 1917, by a British physician named Charles Myers. Then, during World War II, American psychiatrists introduced the terms combat stress, war neurosis, and battle fatigue (Weinberg 1946). After the Vietnam War, the diagnosis of PTSD came about. The 1991 Gulf War brought with it the Gulf War Syndrome. The wars in Afghanistan and Iraq have yet to have trauma syndromes named after them. It's not only soldiers, but civilians who suffer from war trauma. Global relief organizations such as TPO report that 50% of the world's mental and behavioral disabilities are related to war trauma. Children who grow up in war-torn or conflict-ridden areas tend to have "fixations" which make them susceptible to later outbursts of hostility and aggression (Rosenblatt 1983). Children of war, for example, almost always want to grow up and become soldiers and nothing else.

With few exceptions, everybody and anybody associated with killing, combat, war, or terrorism will experience certain "hidden injuries" that inevitably result from the attempt to face reality while at the same time attempting to deny any responsibility or role in it. Peter Marin (1995) has called this "moral pain," and the concept adequately captures the uniquely American response to the ethical ambiguities of horror and guilt. Those who are closest to horror have to "numb" themselves emotionally in some way; and those who consider themselves lucky enough to have "survived" are challenged by guilt processes which require either ultra-patriotic "bonding" with "catastrophe buddies" or engaging in ritual ceremonies which offer reassurance that nobody blames them for anything. Counterterrorist operatives who carry out "revenge work" tend to come up with little ways to trivialize the fact that war is war. As Grossman (1996) puts it, the language of war is always full of denial. The enemy is not killed, but knocked over, waxed, greased, taken out, hosed, or zapped, etc. Above it all, there is a collective sense of hate, an obligation to carry on "in the name of the dead," and a felt need to contribute to the common cause any way one can. In many ways, this describes the societal impact of terrorism; but it's also part of the same endless cycle that motivates terrorism in the first place. Hence, the need for community-based treatment, system-wide approaches, and terrorism-specific therapies in the field of preventive medicine among other fields has never been greater. Those who fight the war on terrorism have a desperate need to be told they are doing the right thing, and this is, or should be, a homeland security responsibility.

Henry (2004), Regehr & Bober (2005), and Roberts (2005), among others (such as Ursano et.al. 2003) have looked extensively at the following -- Henry at police trauma and "survival psychology" confrontations with one's own mortality (Henry in fact postulates five "themes" of adaptation - psychic numbing, death guilt, the death imprint, suspicion of counterfeit nurturance, and the struggle to make meaning). Regehr & Bober looked at whether Stress theory, Organizational theory, Crisis theory, or Trauma theory best predict traumatic response. Roberts looked at whether the 7-stage crisis intervention model, the ACT-Assessment model, the Trauma Treatment model, or a Multi-Component Critical Incident Stress Management model works with sudden and unpredictable terrorist attacks. Ursano's group looked primarily at firefighter/rescue worker trauma, but their ideas are probably generic enough to apply to all kinds of first responders. A fact sheet by the National Center for PTSD mentions some of the unique stressors faced in common by rescue workers, police, firefighters, National Guard members, emergency medical technicians, and volunteers. Besides facing the danger of death or physical injury and the potential loss of coworkers and friends, first responders also fall victim to the devastating social effects of a terrorist catastrophe on their sense of community and society. This places them at risk for behavioral and emotional readjustment problems. Rescue workers who directly experience or witness any of the following during or after the disaster are at greatest risk for lasting readjustment problems:

First responders, such as firefighters, police, paramedics, rescue workers, and medical personnel face the rather unusual problem of "anticipation stress" or in common parlance, the "hurry up and wait" syndrome. Extended waiting time, before being deployed to a disaster site, can be quite stressful, especially among those who have never experienced deployment to a mass casualty site before. Anticipation stress is associated with higher levels of fatigue once the work begins. There is also some anticipation stress which occurs at the disaster site, in the form of debris removal and installing safety supports and walkways, which frustrates workers who are anxious about getting to what they see as their main mission -- the rescuing of human lives.

One is likely to encounter dead bodies at a terrorist disaster site, and a number of trauma issues are associated with exposure to dead bodies. Somatic symptoms (burning sensations, suspected infections, gastrointestinal upset, and other imaginary sicknesses) are quite common among those who work with the dead. Many body-handlers also report intrusive imagery (can't get pictures of the crime scene out of their head). The sights and smells of a massive death scene are overwhelming. Burned bodies tend to smell like roast beef, and many first responders find they loose their appetite for meat afterwards. Decapitated bodies tend to produce very vivid memories, although in some ways, decapitation is better than seeing a dead person fully clothed and looking perfectly normal, which tends to produce a sort of "eerie" reaction that "freezes" the worker psychologically. Exposure to the bodies of dead children produces some specific anxiety effects, and exposure to the bodies of dead women tends to result in male rescue workers loosing interest in sex for awhile (seeing dead pregnant women is especially traumatic). Studies have shown that the causes of most reactions are due to "identification" with the victims, and, in general, there are three kinds of identification:

None of these identification processes between first responders and dead victims are healthy. Identification can occur over a number of things other than what the victim looks like or is imagined to have looked like. It can occur because of some personal belonging of the victim -- a piece of clothing or jewelry, for example. Personal articles belonging to the victim tend to humanize the victim, and in many ways, identification and emotional attachment occur (no matter how much the worker is trained to avoid them) because of a strong need to humanize the situation. There is an obvious need to treat the dead in a respectful manner during search and rescue operations, but some workers go to fantastic extremes -- taking extreme care with each and every body part while expressing an extreme form of overattachment ("Get away; I'll take care of this; I remember when my kid was about this age.") Such behavior is usually indicative of ASD, PTSD, or some other kind of psychological trauma syndrome in development. That's why so much first responder training (based on experience) emphasizes things like "Don't look them in the face" or "Don't think of them as a person." Professional detachment is highly important if negative psychological reactions are to be avoided.

Some dead remains are likely to be in unidentifiable condition, and standard practice is to locate the skull and attempt to use forensic dentistry, which involves cutting the jaw muscles apart to take dental impressions. The sight of numerous skulls with their jaws wide open can be quite stressful. So is the opening of body bags with the facial injuries showing up first. It cannot be said with any certainty exactly what part of the death scene will lead to psychological trauma since it depends upon each individual. For some workers, it's the personal belongings of the victim that triggers trauma (a watch that stopped or is still ticking; a wallet with pictures of loved ones in it). For other workers, it's the "discovery" of stories that the dead body is telling (how far they crawled before they died; a message they wrote in blood; an attempt to protect or cover another victim). Sometimes, the worst trauma is finding a victim still alive and watching them die in your arms. Firefighters and police report that seeing another firefighter or police officer die this way produces the worst trauma impact.

In a terrorist catastrophe, there are some additional considerations. The bodies or pieces of bodies of suicidal terrorists may be found, and thought should be given to the possibility that such items may be booby-trapped. Israeli authorities have reported that some Palestinian suicide bombers were deliberately infected with the HIV virus and/or Hepatitis. Unknown contaminants and/or unexploded ordnance may be found at terrorist disaster sites, hence the need for protective equipment is paramount.

A sense of comradery develops among rescue workers at disaster sites, and the norms which emerge in such situations render the most respect to those who show the most "overdedication." This means that fatigue becomes the norm, and some workers (seeking to impress others) work for long hours without breaks. Many workers who do take breaks don't come back (because they've had enough), but others just keep piling it on themselves. Management sometimes has to step in and force them to leave the area. Frequently, a type of "dark humor" develops among the hardest (hardened) workers which is way "over the line." When relieved from duty, such workers and their comrades prefer to "get smashed" with excessive amounts of alcohol. Then, they frequently request time off from their regular duties when it is time to report back to their regular job. The transition to "normal" life is hard, with spouses often reporting increased irritability and domestic abuse at home. Memorial services for the victims and ceremonial services for the workers tend to help a little, but it is not uncommon for the trauma reaction to lead to a request for disability leave while at the same time a kind of "demanded pride" is expressed for having worked the scene.

Morbidity (the incidence of sickness in a population) and subdiagnostic distress (not sick enough to be diagnosed with an illness) tend to increase when there is a general perception of a life-threatening stressor, like terrorism, in the environment. Factors that increase the force of this stressor include: lack of predictability, low controllability, and a general uncertainty (fear or dread) about the health consequences due to an absence of useful information and an overabundance of news and rumors. Often, with terrorism, "information stress" occurs because people are unsure about if and when they will be attacked and the long-term consequences. This leads to a loss of confidence in institutions and a pervasive feeling of "unsafety" among the population. Now, it is possible for a population to be rallied and emboldened (with purpose) under such conditions, but that most likely occurs if the threat can be somehow "normalized" like comparing it to the common cold or using some other social work technique (McMillen 1999). The best thing to restore confidence is quick and decisive leadership by government officials, without delay.

The epidemiology of morbidity due to terrorism (like most hazards) will be prevalent among those who belong to high-risk groups. These groups include people who can be considered "psychologically vulnerable" to terrorism, such as the elderly, children, minorities, and disaffected segments of the population. People who are most likely to become "societal victims" of terrorism are those who already have some loss of confidence in the institutions of society -- those who already suffer from fear of job loss, economic insecurity, long commutes, eroded family ties, absence of social support, or the experience of bereavement for some other reason. Another group of people who are singularly affected by terrorism include "silent victims" -- those who think they're the strong and silent type, and think they're capable of blocking out the distress they feel.

From a victimological perspective, there is an interesting "we-they" phenomena which occurs with terrorism, and this is only interesting because the field of victimology is sometimes concerned with social movements among victim groups. The "we-they" phenomenon is where one group of people feel they are the ones closest to the disaster, and are the ones experiencing the most trauma and/or doing something about it. Another group of people are seen as imposters who weren't there, didn't really feel things the way the first group did, and will never fully understand what it was like. The phenomena is similar to the well-known stigma contests which have been described in the victimological and sociological literature. It is unproductive and prevents adequate "closure" from a psychological point of view.

Another interesting phenomena is the fabrication of trauma. After the 9/11 attacks, New York City set up a Victim Compensation Fund to pay the surviving family members of anyone killed for economic damages (lost income and medical costs) and non-economic damages (pain and suffering). The average "survivor" received $250,000 plus an additional $100,000 for each dependent of the deceased. There are important gaps in the web of services for Compensation for Victims of Terrorism, but the point is that fraud and attempts to get undeserved money did occur. It is pure speculation to say this, but it may be that terrorism tend to brings out some sort of "looting" behavior or a motivation to get away with as much as possible under the circumstances.

The mental health effects of terrorism ripple through a population. One of the things that does NOT help is reliving the event, as it might be portrayed in Hollywood movies, documentaries, and so forth. Now, the free press has a right to do whatever they want, but much of the entertainment industry is geared toward sensationalism and bad timing when it comes to terrorism. It would be far more helpful if the media engaged in trust-building or public safety-assuring exercises as part of their responsible role. However, that is just this author's personal opinion, and surely there are those who might see this as advocating censorship or state-media propaganda, which is surely too strong a corrective action. Along these lines, the simple act of repetitive talking about the terrorism event may be harmful, which has consequences for the standard practice of debriefing in disaster trauma management. Debriefing may be harmful as part of the response and recovery phase with terrorism (Alexander 2000).

Yet another victim issue is the Good Samaritan problem. During a terrorist event, the law usually presumes that consent is granted to nonemergency personnel to attempt to save lives and/or resuscitate victims if no proper medical personnel are around. Ethical and moral obligations also require any off-duty medical personnel (other than ambulance drivers) to render assistance. Good Samaritan situations are controversial because they intrude upon the normal legal doctrines of consent and tend to encourage incompetence and vigilantism. One can be sued and/or fined for being a Good Samaritan in some jurisdictions. Some people may be so impacted by terrorism that they become "white hat" or "grey hat" hackers and engage in computer crime or other acts of vengeance (hate crime) against those perceived as the enemy. Not only do some individuals do this, but whole communities can get caught up in a tolerance for hate-biased crime. While other kinds of disasters generally only produce a "looting" effect, terrorism is the only kind that generally produces a "hate crime" effect, and that's probably because of the nature of psychiatric injury with terrorism.

Finally, there is the problem of alcohol, drugs, and medication abuse among victims of terrorism. Many survivors take up excessive drinking and other bad habits because life doesn't seem all that attractive any more. Many survivors frequently move to a new geographical area. It is unfortunate that these "self-coping" strategies are more common than seeking professional help. There is an urgent need to improve access to mental health services and to "de-stigmatize" help-seeking behavior for the psychological effects of terrorism. Mental health treatments for the impact of terrorism need to focus on "closure" or putting the event behind. The terrorist event, in my opinion, should be seen as something discrete that happened once and should not become the basis for continued fears and symptoms. However, most clinical treatments settle for "survivorship" as a kind of second-best therapeutic outcome. Being a survivor of terrorism (or any trauma) means establishing a new, stable identity which involves a mode of life focused on overcoming adversity, endless recovery, and perhaps becoming an outspoken witness or advocate against evil. It would be far more helpful if a way were found to achieve more ambitious therapeutic goals such as complete recovery. The victims of terrorism deserve better and whole communities and society as a whole need to heal. There are functional, dysfunctional, and neo-functional strategies in dealing with the impact of terrorism, as I've outlined elsewhere (O'Connor 1994), and since terrorism so greatly impinges upon so many sectors of society, the need exists for system-wide planning and comprehensive treatment of the consequences as a way to address the causes. In many ways, how we respond to terrorism mentally is the only way to win a war against it. As Chemtob (2005) puts it, terrorism is a psychological weapon and a national "psychosocial security policy" ought to exist which establishes psychosocial security as a human right.

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