Working with victims of crime: A manual applying research to clinical practice (Second Edition)

10.0 Victims of Terrorism

Introduction

The focus of this chapter is on the person who comes to your office who has been harmed by terrorism. As we discuss the impact of terrorism, we will first define terrorism, focusing on the effects the terrorist wants to create. In that definition, the distinction will be made between single-incident terrorist attacks and ongoing terrorist activity.

We will then discuss the levels of victimization: from primary victimization to secondary victimization and the effects on those in society. The chapter will conclude with a review of the emotional and psychological effects of being a terrorist victim and important clinical issues. Finally, specific service-provider issues will be briefly noted, including a section on Web-based resources.

Terrorism defined

Although terrorists and other criminals may use the same violent means to reach their goals, terrorism can be distinguished by the following:

  1. use of force or violence;
  2. by individuals or groups;
  3. directed toward innocent civilians;
  4. intended to influence or force changes in political or social decisions and policies;
  5. by instilling fear and terror.
    (Marsella and Moghaddam 2004: 23).[10]

Thus, terrorists engage in violent criminal behaviour to meet political ends by putting pressure on decision makers and society (Ganor 2004). By focusing on political leaders and general community members, terrorists spread fear throughout society to increase attention to their political cause (Danieli, Brom and Sills 2004).  

The unpredictable nature of the violence is the core part of psychological warfare the terrorist uses to harm the community (Chemtob 2005; Ganor 2004). The role of media is important to the terrorist because it helps to spread fear and meet political goals; this is also a particular challenge to those recovering from trauma (Adessky and Freedman 2005; Pfefferbaum et al. 2004; Substance Abuse and Mental Health Services Administration (SAMSA) 2004; Weimann 2004). The challenge for people in the community is not only that they may react to the initial incident, but also that repeated reminders of the attack on news programs might deepen any trauma. In essence, the repeated media coverage of the terrorist attack helps to keep the attack and the terrorists’ political goals on the front burner.

Some researchers highlight the division of sub-state terrorism (non-government affiliated) and state-sponsored terrorism (supported by governments) (Marsella and Moghaddam 2004). It should be noted that state-sponsored terrorism adds the difficulty for victims of not having government support for prevention and treatment. In these cases, the government itself plans, finances or provides support to terrorist activities, typically against a subgroup in the country (Danieli et al. 2004). Workers delivering services to victims of state-sponsored terrorism may find even greater issues of mistrust in the helping relationship, especially trust in authority or government figures. For example, victims may feel that they might not get help and may not trust how information may be used and so refuse to contact the police.

Similar to other crimes, terrorism strikes at the heart of viewing the world as a safe and predictable place (Davidowitz-Farkas and Hutchison-Hall 2005)[11]. Part of the community’s way of coping with terrorism is to accept it as the “new normal.”  Danieli et al. (2004) point out that since 9/11, North Americans have developed new rules of how to act and relate to other people and the government. In other words, all of us have had our view of a safe world affected.

Ongoing terrorism or war can have a slightly different impact on the community. People are reminded frequently of the unsafe world; attacks­ become a reality of everyday life. These victims will often use many of the coping strategies discussed in earlier chapters such as distancing, denial or just acceptance of the reality of unpredictable attacks (Campbell et al. 2004; Wessely 2005). Researchers note that the ongoing threat of terrorism increases suspicion, distrust, and hopelessness in the general community, and breaks down social connections (Chemtob 2005: Engdahl 2004; Khaled 2004; Somasundaram 2004).

Looking at this more positively, some believe that such ongoing threats may also bring about positive personal and social change, so-called “post-traumatic growth” (Engdahl 2004; Fredrickson et al. 2003). Fredrickson et al. (2003) noted that positive emotions such as gratitude, interest or love helped people cope after the 9/11 attack and avoid depression. Many writers point out that professionals, paraprofessionals and the public at large can work together to build community strength (Berger 2005; Durodié and Wessely 2002; Heldring and Kudler 2005; Sederer et al. 2005; Sofka 2004; Somasundaram 2004). 

Special Issues

Victim Continuum

Terrorists have little concern for the individual victim, focusing instead on society. Since an attack can affect a wide range of people, we need to look at a continuum of victimization – i.e. we need to understand victims of terrorism not just as one big group, but as a range of people defined by their exposure to the attack. Figure T1 contains a breakdown of the victim continuum; each level of victimization (direct, secondary, community) may have its own particular issues (Jordan 2002; Levanon et al. 2005; SAMHSA 2004). Workers should be aware of this continuum to get a greater understanding not only of the victim sitting in the office, but also of the people in her life. Workers should note that this continuum is based upon the victim’s proximity to the location of the terrorist attack, not on the levels of potential trauma. Although one might guess that those closest to the attack will be more traumatized, this may not be the case. Personal history, previous trauma history, coping skills, and many other factors may affect how a person responds to an attack (Nader and Danieli 2004; Thielman 2004). However, there is research that indicates that direct victims of terrorism are more likely to report problems associated with PTSD, depression and anxiety (Gabriel et al. 2007; Whalley and Brewin 2007). Obviously, workers need to assess each victim’s level of trauma and need on a case-by-case basis.

Figure T1: The Continuum of Victims

Direct or Primary Victims

Those victims that are in the immediate area of the terrorist attack.This group can be divided into those who were physically injured, tortured or killed and those who witnessed the attack or were threatened (near misses) but not physically harmed. There seems to be agreement in the research literature that the level of psychological trauma is directly linked to the amount of direct harm (Ahern, Galea, Resnick, and Vlahov 2004; Baca, Baca-García, Pérez-Rodríguez and Cabanas 2004; Jordan 2002). Thus, it is most likely that it will be these direct victims who show up in your office.

Direct Professional/ Volunteer Victims

People who are at the scene of the terrorist attack as part of their job or as volunteers.
This includes police, fire fighters, emergency services workers, aid workersand other first responders who have much to do in their respective roles (Brom2005). Reporters from the media are also included in this group. Many of thesepeople may have some form of organizational training and support to deal withdifficult experiences or trauma, but may still need support and further assistancefrom Victim Services.

Indirect or Secondary Victims

This group includes the direct victims family members, friends, co-workers, etc.
All those people who are related to the victim in any way can be affected bythe attack, the harm to their loved one and coping with changes in themselvesand their loved ones. These are the “natural supports” of the victim(if the victim is still living).  These people may need support in understandingtheir own reactions and emotions or may need support in coping with the directvictim. Workers need to get direction from the client to decide what will bemost helpful. You may find it helpful to review Table 4 in this manual and thinkabout what type of support your client might need.

Community or Tertiary Victims

Those people in the community who are affected by the attack.
This may include people who have their daily routine affected, have work/school access problems, etc. This also includes those people who have been affected by images and reports on television. In a sense, the media creates other witnesses to the event, and these images can be very disturbing to some. Workers will need to gather a complete history to ensure they do not miss key issues (previous trauma, mental health issues, stressors, etc.) that might affect the reaction to the terrorist attack.

Re-victimized Victims

Those people who have been victims of previous terrorist attacks, but are now re-traumatized by a new attack or report of a thwarted attack. In other words, these victims may be deeply affected by television coverage of a current attack or a documentary of a previous attack (Ahern et al. 2004; Kinzie 2004). Furthermore, reminders of the original attack might cause any victim of crime to have difficulties coping. Workers need to help all victims learn to manage these potentially re-traumatizing experiences.

Trauma

The trauma commonly seen in victims of terrorism is much the same as the trauma associated with being a victim of any crime. Table 1 in the Common Reactions to Crime section of the main manual covers the issues that you will want to watch for in victims of terrorism. However, more needs to be mentioned on special issues with these victims including: acute stress and post-traumatic stress disorder, grief and complicated grief and survivor guilt. Workers are reminded not to see this list as covering all experiences that terrorist victims might express and that personal history, trauma history and cultural issues can influence reaction and healing (Nader and Danieli 2004; Thielman 2004).

Differences between victims of terrorism and other crime victims

There appears to be no research that specifically compares the differences in reactions between victims of terrorist attacks and other crime victims. From a clinical perspective, one can identify that the crime is the same – an assault, murder or rape is the same whether the perpetrator is motivated by political or other reasons. However, it is possible that the political nature of the crime may have an independent impact. Society’s reaction and the perpetrator’s motivation can cause additional distress (Herek et al. 1997; Herek et al. 1999; McDevitt et al. 2001). In a discussion focused on victim blaming, Shichor (2007) theorized that victims of terrorists could be seen by society as “more innocent” and thus be more likely to get support. However, he also noted that terrorist victims may also feel more helpless because they may feel they had less control over their victimization.

Trauma reactions do not follow a predictable path; each person is different (Silver et al. 2004).  Many victims of terrorism may feel initial distress (Lahad 2005; Schlenger 2004), but do not go on to develop any major psychological problems (Fredrickson et al. 2003; Friedman 2005; Galili-Weisstub and Benarroch 2004). Some people may experience problems and not seek help because they believe they can get better on their own, don’t want to appear weak or “crazy,” or do not know where to find help, or they avoid treatment to stop thinking about the attack (Vardi 2005). Workers are encouraged to closely assess how victims handle the loss they have suffered and to monitor possible difficulties they have in making meaning from being a victim of a political crime.

Post-Traumatic Stress Reaction (PTSD) and Acute Stress Disorder (ASD)

By far the most researched issue among victims of terrorism is stress symptoms, from short-lived problems to full-blown clinical disorders (Amsel et al. 2005; Courtois 2004; Friedman 2005; Hall et al. 2004; Jehel and Brunet 2004; Khaled 2004; Neria et al. 2006; Office for Victims of Crime 2005; Ohtani et al. 2004; Pat-Horenczyk 2004; Pfefferbaum, et al. 2004; Silver et al. 2004; SAMHSA 2004; Somasundaram 2004). Post-Traumatic Stress Disorder is discussed in Chapter 4 of the original manual on common reactions to crime victimization. Acute Stress Disorder (ASD) is an anxiety disorder that is similar to PTSD in its symptoms but does not last as long; it is typically seen as the initial anxiety reaction to trauma (see Figure 2 in the Common Reactions to Crime section of the main manual). Note that these symptoms may shift back and forth; for example a victim may avoid the trauma at one point and relive it at others (Danieli et al. 2004).

Researchers in Israel followed survivors of a missile attack on a shopping mall and found that 24% showed symptoms of acute stress disorder (ASD) (Kutz and Dekel 2006).  Those with ASD had a three times greater risk of developing PTSD. These same researchers found that roughly 25% of those exposed to a terrorist attack will develop PTSD (Kutz and Dekel 2006). For victims of ongoing terrorism, others report PTSD estimates as high as 40% (Jehel and Brunet 2004; Khaled 2004). Those who suffered directly from an attack and also dealt with changes in their daily living because of the attack (e.g. workplace or neighbourhood being bombed, daily living being affected by community changes) are at even higher risk of developing PTSD symptoms (Neria and Litz 2004). Neria et al. (2006) found that after 9/11, PTSD was more commonly seen in women, single people, immigrants, those with family histories of mental illness and those who were directly affected. Those victims that have PTSD show more fear of further terrorist attacks (Kutz and Dekel 2006), which likely interferes with their recovery. With victims traumatized to this extent, workers should seriously consider a referral to a mental health professional for ongoing treatment.

Green (1993) identified eight experiences that may place people at greater risk of developing PTSD:

  1. Threat to life and limb
  2. Severe physical injury
  3. Being intentionally injured
  4. Being exposed to awful or disgusting scenes
  5. Violent or sudden loss of a loved one
  6. Witnessing or learning of violence to a loved one
  7. Learning of personal exposure to a noxious agent
  8. Having caused the death or severe injury of another

Workers who encounter victims with stories containing these elements may want to watch for other signs of PTSD or refer the person to a mental health professional or family doctor for a more complete assessment.

Complicated grief

Several researchers have noted the complicated grief reaction seen in victims of terrorism who have lost a loved one (Freyd 2002; Malkinson et al. 2005; Neria et al. 2007; Pivar and Prigerson 2004; Raphael et al. 2004; SAMHSA 2004; Sofka 2004). In essence, the person is being challenged by both the loss of a loved one and the terrorist event itself (Malkinson et al. 2005).  This is a very difficult situation for people to handle.

Some researchers hold that anger often interferes with healthy grieving (Lebel and Ronel 2005). Anger at the terrorists seems to be linked to wanting them to accept responsibility and declare their guilt, rather than revenge fantasies or other elements of anger (Lebel and Ronel 2005). This focus on responsibility may be similar to victims of any crime who seek justice and want their perpetrators to admit guilt. There is also some evidence of the direct link between terrorist attacks and subsequent hate crimes against members of communities similar to the perpetrators (Volpe and Strobl 2005). Workers should note that the perpetrators of these hate crimes are not necessarily those people who were direct or indirect victims of the terrorist attacks. It is very important for workers to understand the victim’s anger as a normal reaction and work with him or her to help cope with the complex emotions and reactions they might experience (Dalenberg 2004).

Workers are reminded to pay close attention to cultural issues with respect to dealing with grief (Nordanger 2007). Workers should research the victim’s culture to understand what normal grieving is within his or her home community. Nordanger found that Ethiopian victims grieving wartime losses tended to use avoidance techniques such as thinking about other things, distracting themselves or focusing on the future to deal with grief. In particular, they saw confronting or dwelling on loss as inviting other health, social/family or spiritual problems. Workers might also consider whether to encourage grieving victims to seek help from healers and spiritual advisors from their own community (Nordanger 2007).

Depression

Several researchers noted increased depression among survivors of terrorist attacks (Engdahl 2004; Gabriel et al. 2007; Khaled 2004; Miller and Heldring 2004; Neria et al. 2006; Neria et al. 2007; SAMHSA 2004; Schlenger 2004). Depression is described in Figure 3. In a sample of highly traumatized people who survived ongoing terrorist attacks, Khaled (2004) found that 23% were depressed. In samples of children and youth, however, researchers have found lower rates: 8% among children (Pfefferbaum et al. 2004) and about 15% among youth (Pat-Horenczyk 2004). It is interesting to note that there seems to be a delayed response with depression, typically peaking at roughly 6 months after the terrorist incident (Miller and Heldring 2004). Additionally, Neria et al. (2006) noted that victims of 9/11 were at higher risk of suicidal thoughts, especially if linked with other issues such as depression.

Survivor guilt

The issue of guilt in those who survive a terrorist attack appears in some reports (Danieli et al. 2004; Courtois 2004; SAMHSA 2004; Thielman 2004). This seems to be part of meaning-making, so the person not only wonders why they were a victim but also why they survived while others were injured or died. In particular, Thielman (2004) notes that there appear to be cultural differences in whether a person reports survivor guilt, but also recommends looking for depression when you encounter survivor guilt. Workers need to help victims of terrorism understand that survivor guilt is not an uncommon reaction. Furthermore, you can help victims make sense of the attack, its impact on their life and get them to incorporate that knowledge into a future focus. Obviously, if this reaction is causing much distress, a referral to a mental health professional may also be helpful.

Reactions to being held hostage

Many terrorist groups will use hostage-taking as a method of exerting pressure. Hostages often feel helpless, hopeless, dazed, afraid of death or torture, in shock, and have distorted thoughts and feelings (Hillman 1983). Hillman (1983) also described a state of “learned helplessness,” where the hostage begins to do whatever is asked, without question. Turner (1985) speaks of the hostage moving from feeling fearful and confused to having feelings of isolation and boredom, asking “why me”, reviewing his life, making up rituals and planning for the future. Frankly (1963), a psychiatrist who survived Nazi concentration camps, would argue that it is this “future focus” and surviving for something greater than oneself (such as family, work, spirituality) that helps some people survive being held captive.

Another issue for hostages is the possible development of Stockholm Syndrome, also know as Hostage Identification Syndrome (HIS). This is a condition wherein a hostage bonds with the hostage-taker during the holding phase of the crime (Wilson 2003). Turner (1985) identified several factors that seem to increase the chances of HIS: face-to-face contact, shared language, previously held beliefs or sympathies, and length of captivity. The bond is less likely if the victim is aware of the risk of HIS or if there is unnecessary violence. Workers may need to seek consultation or refer clients to mental health professionals if they feel the victim is struggling with these types of issues.

Special Issue: Child Victims

How children cope with terrorist attacks has received some attention in the research literature (Campbell et al. 2004; Courtois 2004; Galili-Weisstub and Benarroch 2004; Joshi and O'Donnell 2003; Kaplan et al. 2005; Nielsen et al. 2006; Pat-Horenczyk 2004; Pfefferbaum et al. 2004). Children can be direct victims, indirect victims, or even members of the community who witness the event on television. Joshi and O'Donnell (2003) point out that children exposed to trauma can develop behaviour problems, aggression, emotional difficulties, mental health problems, academic problems, and become socially withdrawn. Others have also pointed to behaviour problems in youths exposed to terrorist attacks (Campbell et al. 2004). Courtois (2004) also points out that children may be more prone to dissociation [12] thanadults. Similar to adults, those children who were direct victims are more likelyto show more severe symptoms (Pfefferbaum, et al. 2004). Workers need to be awarethat children may have difficulty directly communicating why they are having problems, so it is important to be watchful for these behaviours. Therefore, there are special issues that should be noted when dealing with this group that may be best addressed by mental health professionals or colleagues with experience working with children.

Table T1: Common reactions of children by age (SAMHSA 2004; 24)

  • Young Children

    • Helplessness and Passivity
    • Heightened arousal and agitation
    • Generalized fears and anxieties
    • Cognitive confusion
    • Inability to comprehend and talk about event or feelings
    • Sleep disturbances, nightmares
    • Anxious attachment, clinging
    • Regressive symptoms
    • Unable to understand death as permanent
    • Grief related to abandonment of caregiver
    • Somatic symptoms

  • School-Aged Children

    • Responsibility and guilt
    • Repetitious traumatic play and re-telling
    • Reminders trigger disturbing feelings
    • Sleep disturbances, nightmares
    • Safety concerns, preoccupation with danger
    • Aggressive behaviour, angry outbursts
    • Irrational fears and traumatic reactions
    • Close attention to parental anxieties and reactions
    • Preoccupation with “mechanisms” of death
    • Concentration and learning problems
    • School avoidance
    • Worry and concern for others

  • Adolescents

    • Shame, guilt, humiliation
    • Self-consciousness
    • Post-traumatic acting out
    • Life-threatening re-enactment
    • Rebellion at home or school
    • Abrupt shift in relationships
    • Depression, social withdrawal
    • Decline in school performance
    • Desire for revenge
    • Radical change in attitude
    • Premature entrance into adulthood
    • Detachment from feelings

Developmental level

Although there is debate about which age group is most likely to develop problems after a terrorist attack (Pat-Horenczyk 2004), a child’s age and other developmental issues are important to look at when working with child victims. Galili-Weisstub and Benarroch (2004) point out caregiver reaction can have a direct impact on very young children (under two years old). Preschoolers are also affected by caregiver reaction, but are able to ask questions and talk about their reaction. With preschoolers one might also want to watch for other signs of distress such as excessive clinginess, emotional outbursts and irritability, behaviour shifts or even returning to behaviour they had outgrown (Kaplan et al. 2005). School-aged children may tend to show sleep difficulties, problems at school and other more behavioural problems (Kaplan et al. 2005). As with the other younger groups, parental reaction and modeling appears to affect school-aged children as well.

Finally, adolescents seem to have a greater sensitivity to trauma reaction, perhaps related to the conflict between wanting to be an independent person and still needing support because of the trauma (Kaplan et al. 2005). Adolescents have shown increased fear (Addington 2003; Ronen et al. 2003) and nightmares after an attack. More concerning is that this effect is seen even two years after the event (Nielsen et al. 2006). Table T1 was developed with information taken from an excellent resource (Mental health response to mass violence and terrorism: A training manual SAMHSA 2004) and may be of help to workers wanting a summary. Note that children can experience many of the same reactions as adults when faced with trauma.

Caregiver reaction

Often parents and other caregivers will want advice on how to talk to children about the terrorist attack (Miller and Heldring 2004). As noted above, caregiver reaction can have a positive or negative impact on children (Galili-Weisstub and Benarroch 2004). Caregivers not only model how to emotionally handle victimization, they also help the child to better manage her reaction to the attack. Workers can teach parents what signs might be related to trauma or other reactions to terrorist attacks, such as those listed above. Caregivers need to reassure children that they are safe and they need to be able to listen to their children’s concerns. Professionals or paraprofessionals used to working with children may also be needed to help the child feel safe, understand and accept the attack, work through issues and cope effectively to return to normal age-appropriate activities and daily living (SAMHSA 2004). Caregivers themselves may need support to deal with their reactions while creating a home life that is healing (SAMHSA 2004).

Clinical Issues

As Neria and Litz, (2004) indicate, the victims of terrorism need to rebuild their lives and reconnect to feelings of safety, comfort, and protection in order to recover. Workers can help victims of terrorism reach this goal. As with other crime victims, this is not a matter of returning to a pre-crime state, but, rather, fitting the experience into their new reality (Casarez-Levison 1992). Stage of recovery, trauma prevention strategies, meaning-making, trauma history, identification of strengths, and accessing support all influence the victim’s recovery process.

Stages of recovery

We can view victims of terrorism, like other crime victims, as moving from a previctimization status to victimization, transition and, eventually, reorganization (Casarez-Levison 1992). Workers may want to refer to earlier chapters to help match victims to key services. Initially, the victim might require practical support (housing, food, medical ­attention, etc.), crisis intervention, short-term emotional support, information, and so forth. Further along the recovery path, there may be more need for meaning-making efforts or grief counselling. In other words, workers need to attend to their assessment of the victim, matching interventions to identified needs.

Trauma-prevention strategies

International and local businesses have been employing staff training around dealing with traumatic events (e.g. hostage taking) as a way to inoculate their staff in the event of a terrorist activity. Given the wide range of possible reactions it is challenging to fully prepare people for the chaos (Hall et al. 2004). However, the public expects government and community organizations to have a clear and effective plan (Lahad 2005; Laor et al. 2005). Similarly, several authors note that the media can be used to help the public at large understand what has happened and what to do (Durodié and Wessely 2002; Reyes and Elhai 2004; Ross 2004; Thielman 2004). Since this public health approach uses the same method of service delivery as the terrorists use to spread fear, it should reach much the same audience (Ross 2004; Thielman 2004).

Meaning-making: Telling the story

Recall the model in Part One and the fact that crime victims need to understand and make meaning from what has happened. Successful meaning-making among victims of terrorism can result in increased appreciation for life, a reorganization of their priorities, and a realization that they are stronger than they had thought (Danieli et al. 2004; Frankl 1963). Through telling their story, the terrorist victim can begin to make sense, in a controlled way, of what has happened (Kutz and Bleich 2005) and also reinterpret the situation (Adessky and Freedman 2005). Unlike uncontrolled reliving of the event, the retelling helps regain a sense of mastery over their life (Amsel et al. 2005; Kutz and Bleich 2005).

Meaning-making: Allowing emotion

It is important for all crime victims to be able to express their feelings in an open manner. The victim might express anger, sadness, hopelessness, or any range of emotions and the role of the worker is to allow this expression but also to help to make meaning (Kutz and Bleich 2005). Note that trauma victims may receive both direct and indirect messages from people in their lives that they should not express their feelings and emotions (Danieli et al. 2004). Thus, it becomes even more important to provide an environment that encourages and supports such sharing.

Trauma history and re-traumatization

Workers also need to be aware of two aspects of trauma with victims of terrorism: previous trauma and repeat trauma (Adessky and Freedman 2005). First, 9/11 had the strongest impact on people who had a history of trauma (Danieli et al. 2004; Neria et al. 2006; SAMHSA 2004). Thus, in seeing a more severe reaction, workers may want to get a trauma history from the person since only some of the current symptoms and issues may be related to the terrorist attack. Second, once traumatized, the person is more vulnerable to re-traumatization by other events (Kinzie 2004). During this confusing and sensitive time the victim can be quite vulnerable. Of particular note, watching television coverage related to the terrorist event can have a negative effect on the trauma reaction of both adults and children (Delahanty 2007; Miller and Heldring 2004).

Identification of strengths

Many researchers and clinicians focus on strengths shown during and after the terrorist attacks (Danieli et al. 2004; Fredrickson et al. 2003; Raphael et al. 2004). Some talk about the natural “heroic period” that occurs during the attack, when strangers risk themselves for victims and a honeymoon period characterized by kindness and generosity (Reissman et al. 2005). Others point to resiliency in coping with the attack, as well as, meeting the needs of the victims and community (Fredrickson et al. 2003; Friedman 2005; Danieli et al. 2004; Heldring and Kudler 2005; Raphael et al. 2004; Ross 2004; SAMHSA 2004; Sederer et al. 2005). Peterson (2002 cited in Danieli, Brom and Sills 2004) used the Internet to examine Americans’ values, strengths, and virtues before and after 9/11 and found an increase in levels of love, gratitude, hope, kindness, spirituality, and teamwork. Spirituality, either through participating in religious activities or more private approaches, is often mentioned as a major coping strategy in dealing with terrorist attacks (Berger 2005; Nader and Danieli 2004; Pat-Horenczyk 2004; Sofka 2004; Thielman 2004; Yeh et al. 2006). Workers should be respectful of the victims’ personal choices and offer help by finding appropriate ways for them to access their strengths.

Support networks

As noted earlier, victimization occurs on a continuum. The victim of a terrorist hostage taking may be seen as a primary victim. However, the victim’s family, friends, community, and helping professionals are also victims of the terrorist attack to different degrees. This becomes very important when looking at the victim’s support networks, since this is where the victim often turns first when they need help. Research shows that seeking support is a successful coping strategy to address ongoing distress (Miller and Heldring 2004). There is a consensus that most victims of terrorist attacks do not seek professional help for psychological reactions to terrorist attacks (Adams et al. 2004; Ben-Gershon et al. 2005; Neria 2005; Raphael et al. 2004).

Victims prefer not to talk to professionals, but rather to rely on their natural support network (Leymann and Lindell 1992). Canadian statistics indicate that crime victims sought assistance from a formal help agency (victim services, crisis centres, help lines, health or social services) in 9% of incidents; the rest (90%) relied on their natural support network (Gannon and Mihorean 2005). The stress of helping the victim cope can become overwhelming (Mikulincer et al. 1993; Nolen-Hoeksema and Davis 1999). Furthermore, natural supports themselves may be struggling with the terrorist attack and not be as helpful or available (SAMHSA 2004). Thus, workers may find that they are working with an identified victim, but have many other victims in the background, struggling with issues. This may require working with many people and you as the worker taking a variety of supportive roles (e.g. emotional, appraisal, informational, instrumental; Table 4, page 26 of the original manual).

Provider Issues

Self-care for those working with victims of crime is exceptionally important, as discussed in Chapter one. After a terrorist attack, self-care habits are even more important because of the initial crisis atmosphere and later service needs (Waizer et al. 2004). Many professionals report having trouble coping with their reactions to terrorist attacks (Colarossi et al. 2005; Shamai 2005), thus there are additional self-care-related issues that one should consider when working with victims of terrorism. Recognizing early symptoms of distress, talking to others, recognizing your skills and limitations, building personal resources and building an acceptance of the difficulty of the work are all important (Danieli 2005). This section focuses on key areas for workers to understand when working with victims of terrorism.

Personal views

Although this may be a difficult issue for some to grasp, all those working with victims of terrorism need to examine their views on the political goals of the terrorists. As a person who works with victims, there is little doubt that you have empathy for the victim and a negative reaction to the criminal. However, in the case of terrorism you may find that even though you do not agree with the use of violence, you may be sympathetic to the terrorists’ cause. On the other hand, you may disagree with both their actions and their goals. Either way, these personal feelings may influence your work with victims. Furthermore, you may have strong views, either positive or negative about the reaction of other authorities or governments to the terrorist attack. The political nature of terrorism makes it much more complicated to process. Your role is to help the victim deal with being victimized. Ignoring your own personal reaction to the efforts of terrorists (not their actions), however, could interfere with your effectiveness. Thus, you may want to use supervision, consultation, discussion groups/ workshops or keeping a journal to process these reactions and set clear boundaries.

Vicarious traumatization

Like other crimes, the violation associated with terrorism can have a profound impact on you as a worker. You need to assess your own reaction: Are you having intrusive thoughts or images, or spending much time thinking about the victim’s ordeal? You may want to explore the personal impact of the terrorist attack on your own life (Danieli 2005). Depending on the nature of the terrorist attack, you may be dealing with a mass tragedy or ongoing incidents, which can create vicarious trauma (Fraidlin and Rabin 2006). You can discuss these issues on teams, in consultation or supervision. If you feel your reaction is interfering with your ability to do good work, then it makes sense to seek therapy to deal with these feelings.

Acceptance

Danieli (2005) noted that to heal and grow we need to accept that our lives will not be the same. This “new normal” impacts all parts of our lives: victims, workers and society (Danieli et al. 2004). As those who work with people experiencing distress from a traumatic event (crime or otherwise), we see many people dealing with challenges to their view of a safe and just world. The “new normal” also impacts you and as you come to accept the new reality, you can help your clients accept it as well. Of importance, acceptance does not mean you cannot improve the “new normal.” In fact, helping victims of terrorism improves the “new normal” one person, family or group at a time.