This Web site is a component of the SAMHSA Health Information Network
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Mental Health Response to Mass Violence and TerrorismCHAPTER II: Human Responses to Mass Violence and Terrorism
Violent incidents resulting in mass casualties and victimization send waves of shock and trauma throughout the community, the State, and often across the Nation. This chapter focuses on the physical and psychological effects of these tragic events and how they are expressed among different groups. Because the impact of mass violence is typically widespread, a population exposure model portrays the victim, family, responder, and community groups that may be affected. This model may help mental health response managers and planners identify priority groups for mental health services. TABLE 1: COMPARISON OF MASS VIOLENT VICTIMIZATION AND NATURAL DISASTERSTable 1 compares the attributes and effects of mass violent victimization and natural disasters. This template may provide a structure for further inquiry and study. Survivor characteristics. both risk factors and resiliency factors.are described. Risk factors contribute to the variability in individuals' responses to identical exposures to severe trauma, particularly over time.
The section on adult reactions to trauma, victimization, and sudden bereavement describes the range of potential physical, behavioral, emotional, and cognitive reactions experienced by traumatized and bereaved individuals. A graphic model of human responses to trauma and bereavement portrays the emotions and processes associated with coping with extreme trauma and loss. Three special populations addressed are children and adolescents, older adults, and cultural, racial, and ethnic groups. A model of responses to trauma and bereavement, practical assessment checklists, and tables are included in this chapter. The recommended reading section at the end of the chapter includes detailed information on the effects of traumatic stress and bereavement, research reviews, screening and assessment, and the combined impact of crime victimization and community trauma. Population Exposure ModelMental health providers new to responding to community disasters and widespread trauma must consider a community perspective as well as individual psychological effects. The collective social, political, environmental, and cultural impacts of community disaster interact with individual reactions and coping. A public health approach helps the provider develop a macro-view of the entire community and the gradations of effects and needs across population groups (Burkle, 1996). A concentric circle model, in Figure 1, depicts the spectrum of populations affected following large-scale disaster (Tucker et al., 1999; Wright, Ursano, and Bartone, 1990). Figure 1: Population Exposure Model
A: Community victims killed and seriously injured Bereaved family members, loved ones, close friends B: Community victims exposed to the incident and disaster scene, but not injured C: Bereaved extended family members and friends Residents in disaster zone whose homes were destroyed First responders, rescue and recovery workers Medical examiner's office staff Service providers immediately involved with bereaved families, obtaining information for body identification and death notification D: Mental health and crime victim assistance providers Clergy, chaplains Emergency health care providers Government officials Members of the media E: Groups that identify with the target-victim group Businesses with financial impacts Community-at-large The model's underlying principle is that the individuals who are most personally, physically, and psychologically exposed to trauma and the disaster scene are likely to be affected the most. This relationship has been consistently demonstrated in numerous research studies and reviews (Norris et al., 2002, Shariat et al., 1999; Young et al., 1998; Green, 1996; Marsella et al., 1996; Green and Solomon, 1995; Lurigio et al., 1990). The model may be used as a conceptual aid for planning because it portrays general trends. It is important to remember that models are generalizations. There will always be individuals within each category who suffer severe reactions requiring more intensive mental health assistance. Many of these individuals are at risk because of pre-existing vulnerabilities, another key consideration for planning and screening. These survivor-related risk factors are addressed later in the chapter. Traumatic Event And Stressor CharacteristicsAs shown in Figure 1, the level of exposure to the traumatic event and the stressors associated with that event are highly correlated with mental health outcomes especially in "most exposed" groups. However, not all events and traumatic stressors are equal in their potential for psychological impact. Eight dimensions of traumatic exposure associated with posttraumatic stress are:
(Green, 1993) Most of these dimensions are inherent in mass violence and terrorism. The level of community trauma is increased when there are both large numbers of victims relative to non-victims and high numbers of fatalities and serious injuries (Tierney, 2000). A prolonged recovery effort involving body-handling and delayed death notifications is related to increased posttraumatic stress in emergency workers as well as waiting families (Ursano and McCarroll, 1994). The grieving process is intensified and complicated when a loved one's death is sudden, violent, random, preventable, mutilating, and associated with multiple other deaths (Rando, 1996). In addition, when no physical remains of the deceased are identified, many families have even more difficulty accepting the death and memorializing their loved one.
When death and destruction are deliberately planned and caused by other persons, survivors, family members, and the larger community are horrified by the tragedy, evil intent, and unnecessary losses. They may be both enraged and terrified by their inherent vulnerability to such random, yet deliberate acts. Incessant questioning "Why me?," "How could this have happened?," "Why my child's school?," "What terrible thing is going to happen next?" interacts with the need to blame and demand justice. Survivors feel confused, out of control, frightened, and unable to make sense of an act that seems incomprehensible. Since the goal of mass murder of innocent civilians appears outside the bounds of rational human behavior, the perceived vulnerability of future attacks causes many to live with high levels of anticipatory anxiety and hyper-vigilance. Research comparing the psychological effects of human-caused versus natural disasters has yielded equivocal results (Norris et al., 2002 Green and Solomon, 1995). Considering the consequences of causation exclusively, studies have not consistently demonstrated that one type of disaster is "worse" than the other. When the eight dimensions listed previously also are considered, however, terrorist acts and mass violence that result in a significant number of deaths and serious injuries can be expected to have profound and long-lasting physical, emotional, and financial effects for many survivors and family members (Norris et al., 2002; Office for Victims of Crime, 2000; Green, 1993). Traumatic events intentionally perpetrated through human design "may be qualitatively different in a psychological sense than threat or injury arising from nature or mishap, since betrayal by other human beings must be dealt with in addition to the vulnerability and helplessness caused by the sudden threat"(Green, 1993). Deliberately human-caused disasters may be motivated by terrorism targeting innocent people, prejudice and hate toward a group, revenge and a misguided desire to "get even," social tensions resulting from oppression and poverty, or by the delusional paranoia or obsessions of a person with untreated or undiagnosed mental illness. Terrorist acts are calculated, yet are designed to be unpredictable. The ruthless intent underlying terrorism is to harm and kill defenseless people for political or sociocultural purposes. Terrorists seek to intimidate a civilian population. The killing of innocent people becomes a vehicle for delivering a message. When children are among those who are killed, the community loses its sense of being able to protect and provide safety for its children. "The great threat of terrorism is that anyone, anytime, anywhere can be a target. No one is immune; no one is protected" (American Psychological Association Task Force, 1997). Mass acts of violence may be motivated by hate and may target victims based on their race, religion, ethnicity, gender, sexual orientation, or country of origin. Victims of hate crimes are attacked due to a core characteristic that is immutable. Instead of feeling they have suffered a random act of violence or one that was economically motivated, victims, as well as the larger targeted group, continue to feel vulnerable to intentional attacks. Victims of bias crimes may confront institutional prejudice as they seek medical care or the prosecution of criminals, causing them to feel betrayed by the American system (Office for Victims of Crime, 1995). Survivor CharacteristicsFor decades, clinicians and researchers have grappled with why survivors, when exposed to identical trauma and tragedy, respond with considerable variability, especially over time. Some survivors incorporate catastrophic experiences into their life stories and find meaning or increased selfrespect through their suffering. Others continue to feel devastated and embittered, suffer lasting psychological problems, and fail to find a path to resolution that allows them to move on with their lives. Characteristics of the individual survivor can provide a buffer from long-term effects or may set the stage for great difficulty. In the immediate aftermath of a large-scale, severely traumatic event, highly exposed survivors' physiological and psychological reactions primarily are linked to the event. As time passes, characteristics within the individual survivor play increasingly important roles in alleviating or worsening psychological reactions. Biological, genetic, personality, temperament, and socioeconomic factors as well as prior traumatic life events contribute to the survivor's vulnerability to traumatic events (Shalev, 1997, 1996; Yehuda and McFarlane, 1997). Predictors of an increased risk for trauma-related psychiatric problems include a prior, preexisting, or family history of psychiatric disorder or substance abuse; neuroendocrine vulnerability; early and prior traumatization; family instability; female gender; lower education level; and poverty (Halligan and Yehuda, 2000). Women have a higher prevalence of depression, anxiety, and PTSD (Kessler et al., 1994) and may have increased vulnerability due to sociocultural and biological factors. In addition, pre-existing attachment disturbances or difficulties with separation anxiety contribute to the likelihood of developing persistent traumatic grief or experiencing complicated bereavement (Jacobs, 1999). Each predictor or risk factor tips the balance of the survivor's vulnerability in the direction of increased risk. With multiple risk factors, their accumulated weight increases the potential for long-term psychological consequences. Experience in communities following natural disasters has shown that survivors with serious and persistent mental illness have many of the same needs for social and psychological support as the general population (Center for Mental Health Services, 1996). When housing, medication, and case management services remain stable, most people with mental illness function reasonably well and, at times, heroically, following disasters. Post-traumatic stress reactions should not be interpreted automatically as exacerbations of pre-existing illness. Likewise, survivor resilience is enhanced through the absence of psychiatric or substance abuse problems, biological and neuroendocrine "protection," family stability, and financial resources. Survivor resilience is linked to being able to understand, tolerate, and cope effectively with the inevitable aftermath of severe trauma: intrusive thoughts, sleep disturbances, numbness, and anxiety (Yehuda and McFarlane, 1997). The ability to self-regulate emotions and reactions is in part related to the survivor's cognitive appraisal of the event and his or her resulting trauma symptoms (e.g., "These are temporary, normal reactions" versus "I'm going crazy;" "I'm dead inside;" "My reactions indicate I'm in real danger;" "The disaster is over" versus "Nowhere is safe;" "I attract disasters.") (Ehlers and Clark, 2000). For many survivors, social support contributes to resilience. The survivor must be able to engage with family, friends, and social support networks to derive a sense of connectedness and comfort from such interactions (Kaniasty and Norris, 1999). Cultural, racial, or ethnic group affiliation may promote resilience through social, family, and community support. Cultural beliefs, traditions, and rituals may provide mechanisms to understand the tragedy and move through the recovery process. Alternatively, poverty, violence, and family disruption associated with disenfranchised groups can compound the effects of overwhelming trauma and loss. The experience of marginalization can deepen inner coping strength, or it can erode the person's capacity to tolerate life's relentless challenges. Table 2 summarizes key risk and resiliency factors. Assessing these risk factors in combination with the survivor's degree of trauma and loss exposure provides a preliminary way to identify the most vulnerable survivor groups. These factors may be included in a brief screening checklist to help mental health providers determine those in greatest need of mental health support. TABLE 2: Survivor Characteristics
Research following the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City provides a case example of the significance of survivor characteristics and their association with psychological outcomes. North et al. (1999) found that nearly half of the blast survivors studied had one or more active postdisaster psychiatric disorders, and one-third met the criteria for PTSD at 6 months after the bombing. Two-thirds (66 percent) of the respondents with a previous psychiatric disorder at any time in their lives suffered a psychiatric disorder after the bombing, compared to 29 percent with no psychiatric history. Conversely, when the researchers looked at those study participants who had PTSD, they found that 74 percent had not experienced it before the bombing. Similarly, 56 percent who experienced major depression after the bombing had no pre-disaster history of it. Women had twice the rate of PTSD as men, and more than twice the rates of depression and generalized anxiety order. Immediate Adult Reactions to Trauma, Victimization, And Sudden BereavementSurvivors' acute reactions immediately after a lifethreatening violent incident range from detached shock and numbness to fright, panic, and hysteria. Many survivors experience disbelief and some degree of disorientation. Most are focused on communicating with family and loved ones. Some may require emergency medical attention for stress reactions and others desperately want to help with rescue efforts. Emotional turmoil is common. Survivors may go through, virtually simultaneously, a range of emotions such as anger that rises to rage, fear that rises to terror, confusion that rises to feelings of chaos, self-blame that evolves to profound guilt, sorrow that evolves into grief, and relief that is experienced as euphoria (Young, 1989). Each survivor's personal experience before, during, and after mass violence is unique. Even though all have gone through the same incident, and may experience a similar range of post-trauma reactions, each survivor's thoughts and perceptions, the specifics of what was witnessed, and how it touched him/her are part of a personspecific pattern. Research findings suggest that those who have more extreme, pronounced, acute reactions are more likely to develop long-lasting and severe posttrauma responses (Bryant and Harvey, 2000; North et al., 1999; Young et al., 1998). Post-trauma reactions are expressed through different pathways: physical, behavioral, emotional, and cognitive. Complex biopsychophysical interactions between parts of the brain, different neurotransmitter systems, and neurohormones play a role in increasing or regulating arousal symptoms associated with traumatic stress (Halligan and Yehuda, 2000; van der Kolk, 1996). These complex internal processes underlie the more observable reactions listed below. Additional research is needed to more fully understand these complex interactions and their application to clinical assessment and intervention. The following lists of posttrauma symptoms enumerate the range of common survivor reactions. Physical Reactions
Behavioral Reactions
Emotional Reactions
Cognitive Reactions
Long-Term Responses Of AdultsEarly mental health intervention efforts focus on normalizing post-trauma reactions and informing survivors that their reactions are normal responses to abnormal events. The majority of survivors experience a gradual reduction in the intensity and pervasiveness of their post-traumatic symptoms, taking months to years depending on the level of exposure and the presence of vulnerability risk factors (Green and Solomon, 1995). A minority of survivors will develop conditions that reach diagnostic thresholds for PTSD, depression, and anxiety. Others will suffer significant psychological distress over an extended period of time with symptom severity that falls short of a diagnosable disorder.
Research on the psychological effects following different types of disasters is difficult to compare and use for predictive purposes (Tierney, 2000). Study measurements have been taken at different time intervals, after different types of disasters, using different instruments, and have examined different outcomes. In general, researchers have found a considerable range (4 to 54 percent) in the proportion of survivors experiencing diagnosable mental disorders following disasters and other traumatic events (Green and Solomon, 1995; American Psychiatric Association, 1994). The majority of studies have examined the effects of natural disasters, yet most experts agree that the psychological impact of criminal mass victimization involving mass casualties are at the higher end of the range (Norris et al., 2002; Center for Mental Health Services, 2000b; Office for Victims of Crime, 2000). These findings were supported by studies following the Oklahoma City bombing (North et al., 1999; Shariat et al., 1999). The dichotomy of "normal" versus "abnormal" reactions implied in the maxim "normal reactions to an abnormal situation" is restrictive and carries potential stigma. While useful in the beginning to help survivors understand, accept, and cope with their inevitable and disturbing symptoms, psychological support and treatment for those experiencing higher levels of distress also should be destigmatized. Over time, the individual survivor's risk and resiliency factors described earlier in the chapter, in addition to their level of trauma and loss exposure, have increasing influence over mental health outcomes. In general, survivors who lack effective social supports, who lack psychological resilience, or who experience the chronic life stressors associated with lower social class and marginalization are at greater risk (Tierney, 2000). When traumatic circumstances surround the sudden death of a loved one, or when the bereaved was also involved as a victim in the event or witnessed the death, the bereaved must cope with both trauma and grief. For many survivors and loved ones, post-traumatic reactive processes override mourning, and grieving is initially blocked (Raphael, 1997; Rando, 1993). Instead of cherishing reminders of the deceased, the person may avoid them because they conjure up traumatic memories. During the grieving process, the contents of dreams typically reflect longing for the deceased by experiencing them as alive and then feeling a harsh sense of loss upon waking and realizing that the person is dead (Raphael and Martinek, 1997). Trauma-based dreams can be nightmares and may involve re-experiencing the trauma with intense fear and feelings of vulnerability upon waking.
This interplay of trauma and grief often intensifies symptoms common to both. The traumatically bereaved person can experience trauma and grief processes simultaneously as well as in an alternating sequence.with hallmark symptoms of each. Assessment and intervention must be responsive both to distinct post-traumatic and bereavement processes as the person's psychological response moves between the two. When a victim's physical remains are not found and identified, the bereaved family must adapt alternative funeral and burial rituals. Families can be plagued with thoughts and questions about the circumstances of death and how much their loved one might have suffered, without physical evidence of how and where the person died. These challenges to the grieving process are often compounded by the lengthy process of criminal prosecution and sentencing. When the traumatic death results from a mass-casualty incident, the individual death may get lost in the broad scope of the tragedy. The loved one's death becomes subsumed in the larger event's label (e.g., "Columbine Massacre," "Oklahoma City Bombing," "September 11th," "9/11"). This loss of the individuality of the death can seem dismissive and minimize personal losses (Spungen, 1999). Model of Human Responses to Trauma and BereavementSurvivors and bereaved loved ones go through a repetitive up-and-down emotional and physical process as they work through extreme trauma and unexpected bereavement. This nonlinear process can seem endless and relentless. Initially, the psychological enormity of the tragic event overwhelms the psyche; the mind simply cannot take it in all at once. Self-protective mechanisms kick in, usually unconsciously, that allow the person to distance temporarily from the horror of it all. Internal "monitors" allow the person to take in what he or she can manage of the harsh realities and then to numb or partially disconnect for respite. A survivor or family member may be able to deal with the "facts" of the tragedy only by keeping emotions about those facts compartmentalized. Victoria Cummock, whose husband was killed on Pan Am Flight 103, writes eloquently from experience about this process: Denial is an adaptive reaction that protects survivors of homicide from the full force of the tragedy. This coping mechanism is a gradual and graceful way to deal with the murder of a loved one, allowing families the time that they need to make the transition from shock and denial into the grieving process. (Cummock, 1996) Gradually, the facts and realities associated with the event become more deeply understood. Small and large losses become apparent. When a person has difficulty tolerating, regulating, or managing the emotions and physical sensations associated with this unfolding, avoidance and denial may be used instead of other coping strategies. Periods of feeling "more normal" are punctuated with trauma-based bolts of fear and anxiety, and upwellings of grief and longing. For many, this gradual adjustment to new realities occurs in conjunction with an onslaught of post-traumatic symptoms and traumatic grief reactions. Prominent features that may develop in the person's life are disturbed sleep, intrusive upsetting thoughts, yearning for the event not to have happened, jumpiness and agitation, selfdoubts, anxiety about the future, profound sadness, and questioning basic assumptions about the world and humanity. Becoming stable and getting adequate rest is a priority when these symptoms are intense and constant. Temporarily distancing from triggers and reminders may help survivors reduce this reactivity and their emotional swings. The time required to reach the sense of "coming to terms with the new realities," "reclaiming life," and "reconstructing one's life" is variable. Experiencing extreme trauma and suffering through homicide of a child, spouse, or significant other can take years to integrate into the tapestry of one's life in a way that allows one to embrace the future with hope. Some survivors can "get stuck" in enduring anxiety, phobic avoidance, post-traumatic stress syndromes, depression, or substance abuse problems. These reaction patterns need to be addressed so the survivor may resume the process of working through the trauma and loss and finding ways to live with what has happened. 
Figure 2 captures elements of this "working through" process. It incorporates the interweaving of trauma and grief reactions and the roller coaster of emotions that survivors often describe. For some individuals, the "event" may not be actual exposure to the shooting or trauma, but enduring the threat and anticipation while being aware that others were being killed or injured. This normal process moves back and forth from periods of high to low intensity. The high peaks and low valleys suggest the intensity of these emotions may sometimes be overwhelming and warrant additional medical, psychological, or spiritual support. The stars in Figure 2 represent reminders and triggering events that can activate intensification of symptoms and reactions, often causing the person to question if he or she will ever feel "normal" again or if "backsliding" is occurring. Potential triggers include holidays, birthdays, surprise encounters with personal reminders of the deceased or the event, necessary official procedures, particular media stories, delayed receipt of belongings or identified remains, and anniversaries of the event. Because these mass violent events are also crimes, the criminal justice system is actively engaged. The phases and events in the criminal justice process often continue over a period of years and can be extremely distressing for victims and loved ones. Triggering criminal justice procedures include the investigation, arrests, hearings, continuances, trials, verdicts, sentencing, and appeals. When the alleged perpetrators have not been arrested, the absence of justice can contribute to difficulties in moving toward closure. When considering the challenging human process of coming to terms with horrific life events, key points to keep in mind are listed below:
Children and Adolescents: Priority Considerations And ReactionsA child experiences disasters, violent victimization, and sudden death of loved ones within the context of his or her stage of psychological development, life and family situation, and critical caretaking relationships. Incomprehensible, terrifying events can stimulate overwhelming and unfamiliar physical reactions and emotions that can be traumatizing to children. The boundaries between fact and fantasy, and internal and external experience can become blurred. The child's universe can become chaotic and filled with potential danger. A young child relies on the stability and predictability of his or her environment, and the secure availability of dependable caretakers. Family, significant adults, pets, playmates, school, and neighborhood are important features in a child's world. When a major traumatic event occurs, much of what is known and familiar may be disrupted, if not destroyed. Human-caused violence may confound the child's trust in adults or in human nature. The child may experience feelings of homicidal rage toward the perpetrator, which may be disorienting and frightening. Children commonly arrive at erroneous conclusions, sometimes implicating themselves in causing or worsening the incident, which can result in feelings of guilt and shame. A review of studies on childhood traumatic stress found that:
As children move into adolescence, they become more concerned with peer acceptance, appearing competent, and achieving independence from their families. Underlying this movement toward separation is the simultaneous wish to maintain the more dependent role of childhood. When a major traumatic event directly impacts the adolescent's parents, caretakers, school, or immediate community, it can disrupt the normal developmental process. Fears, anxieties, and vulnerabilities associated with a younger age may resurface. The normal self-centeredness of adolescence may give way to preoccupation with death and danger, a sense of alienation, or feelings of guilt (Vogel and Vernberg, 1993). In general, as adolescents mature, they are more likely to experience and express the post-traumatic symptoms associated with adult trauma responses (Cohen, Berliner and March, 2000).
The subjective experience of a child or adolescent during a traumatic event involves "intense moment-to-moment perceptual, kinesthetic, and somatic experiencesaccompanied by appraisals of external and internal threats" (Pynoos, 1996). Children process information and experience and express emotions in qualitatively unique ways (Center for Mental Health Services, 2000c). They may use selfprotective dissociation to control their overwhelming emotions, leaving memory gaps or amnesia for parts or all of the event. Anxiety-inducing reminders may seem strange and confusing in their effects, causing the child to feel less secure. Traumatic Event and Stressor Characteristics As with adults, the closer and more exposed children or adolescents are to the traumatic event, the more affected they are likely to be (Pynoos, 1996; Vogel and Vernberg, 1993). Children's subjective experiences and perceptions regarding a traumatic event are significant as well. For example, if the child thought that a parent was killed, thought the parent was safe when there actually was danger, or thought that he could have prevented the tragedy, his or her trauma responses are likely to be linked to these perceptions. Dimensions of a traumatic event and related stressors associated with greater posttraumatic reactivity and longterm difficulties include:
Most child experts agree that when faced with severe trauma that is sufficiently shocking and terrifying, posttraumatic reactions are inevitable for most children and may be expressed immediately or become apparent over time (Gordon and Wraith, 1993). While family stability and supportive protection and communication contribute to the child's resilience and aid recovery, they do not prevent symptoms from occurring altogether. Post-Trauma and Grief Reactions Children and adolescents may experience physical, emotional, behavioral, and cognitive reactions in varying levels of intensity and sequencing. Children may appear to cope well, yet may struggle with fears and selfdoubts. Some children and adolescents will have pervasive and intense reactions to seemingly low levels of exposure; others will appear to have minimal reactions to high degrees of traumatic exposure. Siblings and friends of children who were primary victims may have vicarious reactions, also experiencing symptoms. Watching disaster news coverage and viewing destruction, devastation, and human carnage and suffering can be terrifying to children. Children who have witnessed the disaster only through the media also can experience symptoms. Parents, school administrators, teachers, and caretakers need to work together to protect children from media exposure. When children do view disaster scenes on television, thoughtful explanations and emotional support are indicated. When the young person is coping with both trauma and grief reactions, responses can be multilayered, with a confusing mix of feelings related to the loss of their loved one interspersed with post-trauma symptoms and periods of shutting down emotionally to avoid pain. Efforts at relieving traumatic anxiety often take psychological priority over mourning (Pynoos and Nader, 1993). A review of the reactions below provides ample evidence of the potential for significant psychological and developmental disruption (Gordon and Wraith, 1993; Pynoos and Nader, 1993; Vogel and Vernberg, 1993).
Young Children (1.5 years):
School-Aged Children (6.11 years):
Pre-Adolescents and Adolescents (12.18 years):
Older Adults: Priority Considerations And ReactionsThe wisdom and experience accrued over a lifetime can provide older people with tools to cope with the losses, changes, and painful emotions associated with mass trauma and victimization. They may have successfully adjusted to deaths of family members and friends, or to losses of physical abilities, life roles, and employment. Most have been touched, at some point in their lives, by the vagaries of random, unexpected life events as well as crime victimization. Research following natural disasters has shown that social support is often mobilized when the older person's life or health is threatened, but assistance is less forthcoming when the older person is faced with property damage or disruptions in daily living (Kaniasty and Norris, 1999). When older adults have entered the "elderly" stage in the aging process and have health problems or have become physically frail, their experience of the tragedy often is influenced by their physical needs. A sudden, threatening, traumatic event evokes fear, helplessness, and a vulnerability in many survivors. When an older person already feels increasingly vulnerable due to changes in health, mobility, cognitive abilities, and sensory awareness, the feelings of powerlessness associated with the trauma can seem overwhelming (Young, 1998). Sudden evacuations from nursing homes, residential facilities, motor home parks, senior apartment complexes, or moves from one facility to another often are disorienting and confusing. Cognitive decline may make it more difficult for older persons to understand evacuation instructions or emergency assistance information and to begin the process of coping with unexpected, disruptive changes (Massey, 1997). Sensory impairment may cause elderly survivors to not respond to offers of help.
The untimely, traumatic deaths of children or grandchildren may be especially difficult for older adults. An important sense of continuity of the family, its traditions and legacies, may be lost. Family support and contact important to the elder may be diminished due to the next generation's preoccupation with the aftermath of the tragedy and their immediate losses. With the reduced availability of family support, the elder may fear being moved to an institution. This fear may cause underreporting of concerns, difficulties, and reactions related to traumatization and bereavement.
Following the traumatic death of adult children who are also parents, grandparents may assume the parenting role with their grandchildren. They are faced simultaneously with grieving the death of their own child, assisting their grandchildren to cope with the loss of their parent(s), giving up their lifestyle and routines, and making numerous adaptations and changes to accommodate becoming a parent again. When health and financial issues are present for the grandparent(s), their stress load may seem unmanageable. Health status, cultural background, prior traumatization, religious affiliation, proximity of family and other social support, and living situation influence the older adults' experience of mass violence and terrorism. A gradual building of trust and rapport is necessary to effectively assess mental health needs (Center for Mental Health Services, 1999b). Cultural and Ethnic Groups: Priority Considerations And ReactionsActs of terrorism and mass violence inevitably touch people from different cultures and diverse backgrounds. Victims of the September 11 terrorist attacks came from many different countries. Some were U.S. citizens, some had visas to work or study in the United States, some were illegal immigrants, and some were visiting for other purposes. Death, community trauma, and violent victimization were interwoven. Rituals surrounding death, the appropriate handling of physical remains, funerals, burials, memorials, and beliefs of an afterlife are deeply embedded in culture and religion. The serious injury of a family member in the United States brings families from different cultures in contact with Western medicine; the health care delivery system is made even more challenging when English is not the primary language. Cultural and ethnic groups with histories of violent oppression, terrorism, and war in their countries of origin may experience community violence in the United States through the lens of their prior traumatization. Those who have suffered from political oppression and abuses of military power in their countries of origin can find the high visibility of uniformed personnel highly distressing, if not retraumatizing. When it is assumed that the perpetrators of mass violence are from a particular part of the world or ethnic group, members of that group living in the United States may face threats and harassment. For example, after the September 11 attacks, violence against citizens of Middle Eastern descent and those who had similar physical attributes was reported frequently. These individuals became victims of hate-based crimes, harassment, and intimidation, while at the same time coping with their own losses and reactions to the terrorist attacks. Survivors from particular groups may live in a context of poverty, discrimination, or marginalization as illegal immigrants and face high rates of violent crimes in their neighborhoods. Exposure to chronic community violence influences how an individual responds to a discrete, largerscale violent event. When members of a group have had prior contact with law enforcement and have experienced stereotyping and prejudice, they may be suspicious of the primary role of law enforcement in controlling the crime scene. When cultural, racial, or ethnic groups within a community are affected by an incident involving mass criminal victimization, mental health providers must consult with community leaders, crosscultural experts, and culturally competent mental health practitioners to effectively assess mental health effects and needs. Cultural and ethnic norms and traditions dictate what constitutes "mental health" and "mental illness," how traumatic stress and grief are experienced and expressed, how the mental health responder is perceived, and who is considered "family." Over-diagnosis is common when Western mental health professionals work with people from different cultures (Paniagua, 1998). Ethnocultural studies following natural disasters, industrial accidents, and terrorist attacks within the United States and around the world have found universal as well as culturespecific features in post-trauma responses (deVries, 1996).
Biophysical research findings suggest that all people experience similar underlying physical and biological responses to severe trauma, but that the psychological and behavioral manifestations vary across cultures (Marsella et al., 1996). Considerable variation exists across cultures regarding tolerance for the expression of strong emotions. Culture may place differential emphasis on particular symptoms, assign unique attributions to the intensity of their experience as well as expression, and shape the general tone of emotional life to which a person should aspire. The threshold at which "normal" is demarcated from "abnormal" may vary by gender, ethnicity, and cultural group (Manson, 1997). Adding complexity, there is variation within cultural groups due to generational differences, levels of acculturation, multicultural influences, and life situations within the United States. Mental health responders must be cautious about generalizing culturespecific characteristics to every member of that group; they must learn to ask effective questions and be open to revising assumptions. The Los Angeles civil unrest of 1992, following the acquittal of four police officers in the beating of Rodney King, resulted in 52 deaths, 2,664 injuries, and more than 12,500 arrests (Center for Mental Health Services, 2000b). This outbreak was fueled by underlying, unresolved issues among racial, cultural, and ethnic groups in the community; high unemployment and poverty; and high levels of gang and drug activity. Effective mental health assessment and intervention had to take into account the many layers of cultural influence and differences in this disaster involving mass violence. Bridging cultural differences and language barriers was a priority, if mental health providers were to access and assist affected groups. Recommended Reading Doka, K. J. (Ed.). (1996). Green, B. L. (1993). Green, B. L. (1996). Janoff-Bulman, R. (1992). Marsella, A. J., Friedman, M. J., Gerrity, E. T., et al. (1996). Massey, B.A. (1997). McIntyre, R. V. (Ed.) (1999). Norris, F. H., Friedman, M. J., Watson, P. J., et al. (2002). Paniagua, F. (1998). Pynoos, R. S. (1996). Exposure to catastrophic violence and disaster in
childhood. Rando, T. A. (1993). van der Kolk, B. A., McFarlane, A. C., Vogel, J. M. and Vernberg, E. M. (1993). Wilson, J. P. and Keane, T. M. (Eds.). (1997). |
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