Historical perspective

Terrorism has been defined as violence involving attacks on a small number of victims, to influence a wider audience. Much that has been written about the psychology of terrorism has centered on the emotions, motivations, cognitions, and other aspects of the psychological profile of those who would perpetrate such violence. As Cooper noted, “The true terrorist must steel himself against tender-heartedness through a fierce faith in his credo or by a blessed retreat into a comforting, individual madness.” If the presumed gift of a wooden horse that secretly held in its belly attackers who were bent on surprise and violence qualifies by this definition, the roots of terrorism stretch back through antiquity. More recently, in the centuries from the Middle Ages to the Industrial Revolution, warfare was conducted according to an implicit code of rules that sought in its most caricatured instances to render military conflict a “civilized affair.” Eventually, international organizations such as the League of Nations, and later the United Nations, came about in part out of a need to hold conflict within some bounds, even if it could not be eliminated entirely. The Geneva Convention sought explicit agreement to rules of conduct on the part of potential adversaries before conflict had even emerged.

The goals underlying such efforts have proved elusive at best. As Crenshaw noted, “significant innovations” in terrorism occurred in 1968, with the onset of relatively routine diplomatic kidnappings and hijackings involving extortion or blackmail. The pattern of increase in terrorist activity since that time has been all too familiar. Silke has strongly argued the importance of researching this phenomenon with all of its implications. However, Silke, like Merrari before him, found that systematic inquiry by psychologists and psychiatrists fell short of what seemed to be needed.

The goal of this chapter is to consider psychological factors related to the effect of terrorism on a population and critical considerations for emergency response personnel. Although some specific guidelines may be derived, the purpose is to develop an awareness of psychologically contextual issues that may productively inform the judgments and decisions of service providers functioning in a terrorist-driven circumstance. First responders and caretakers are clearly among those in the population who can be affected most directly by terrorist events. Not only do they share in the danger of feeling overwhelmed and in the risk for problematic reactions, they also bear the expectations of others to remedy what might seem to be an impossible situation at times. Further, they share with those to whom they provide services, the need that the toll taken by terrorism upon them be monitored and managed. The alternative of implicitly adopting the false notion that first responders and medical practitioners are somehow above or immune to the psychologically harmful effects of terrorism invites multiple problems that have the potential of proliferating because of their effects on the service function. Accordingly, in the context of responding to terrorism, one of the imperatives for emergency medicine personnel must be to attend to the psychological needs of peers and of subordinates. For them, the sustained nature of the problem can exact a toll far exceeding the accustomed demands of providing emergency care.

Developmental perspectives

Although various aspects of the psychological effects of terrorism for both individuals and societal institutions can be considered, an overarching concept would provide coherence to considerations that might otherwise seem scattered. One such conceptually unifying theoretical perspective is the orthogenetic principle, a holistic developmental notion first articulated by Werner and later by Wapner and Werner. Briefly stated, the principle holds that all that occurs through development proceeds from the global and diffuses through increasing states of differentiation and hierarchic integration. In this context, “development” is not temporally defined nor is it tied to chronometry. Instead, the principle applies to any developmental phenomenon ranging, for example, from the microgenesis of thought behind each word spoken to the experience of an overall self-world relationship throughout the life span.

Through the prism of the orthogenetic principle, the developmental continuum from diffuse through integrated is conceived of as a dynamic one, within the context of which is the potential for developmental advance (toward increased integration) and/or dedifferentiation (regression to a more primitive developmental level). Movement forward (developmental advance) and/or movement backward (developmental regression) is not a discrete event but rather an ongoing process. Each advance in the direction of increasing differentiation brings with it the requirement that the parts of experience be hierarchically integrated (i.e., subordination of the differentiated parts to the whole) in a yet more refined fashion. Conversely, dedifferentiation leads to a less integrated experience with a correspondingly less refined sense of part-whole and of means-ends relationships and of the instrumentalities available for transacting with the environment thus construed. Developmental advance along that continuum brings with it an increasing sense of mastery, whereas dedifferentiation or regression to a more developmentally primitive level invites a growing sense of feeling overwhelmed.

Within that frame of reference, terrorism can be seen as an effort to bring about dedifferentiation and correspondingly more developmentally primitive functioning within populations and among the individuals that comprise them. Accordingly, interventions intended to address terrorism and its effects can be characterized as more or less facilitative of developmental advance and, correspondingly, of some increased level of mastery.

Acts of terrorism result psychologically in both direct and indirect destructive consequences of the sort that bring about developmental regression to a relatively less differentiated sense of one’s relationship with the surroundings. The direct consequences typically have a powerful immediacy in their effect on the consciousness of affected segments of the population. Those consequences may well prove precipitously dedifferentiating in their assault on the sensibilities of those persons who are affected. Indirect effects, on the other hand, can be less apparent, particularly in the immediate aftermath of the disaster, but their destructive influence on the population and upon its institutions may be equally, if not more, disruptive to the functioning of the society.

The orthogenetic principle provides, in effect, a reference point by which to gauge and monitor the psychological harm done by terrorism, as well as the potential efficacy of efforts intended to mollify the psychological impact of sudden and disastrous terrorist-driven events. Initially, consideration must be given to the psychological vulnerabilities of individuals and/or of groups with regard to the risk of developmental regression. In other words, what has been the effect of trauma and of related fears upon individuals’ cognitive, emotional, and valuative perceptions of and transactions with the physical, interpersonal, and sociocultural aspects of their surroundings? Stated differently, what changes have occurred with regard to what those affected by terrorism know with some confidence about the objects and places in their surroundings, how have their feelings about them changed, and what shifts have occurred in their attaching relative importance or unimportance to those objects and places? Likewise, how have knowing, feeling, and valuing shifted with regard to the interpersonal environment and in relation to their perceived environment of customs, responsibilities, and expectations? Second, how might a particular effort foster developmental advance in these areas? In other words, what is the best way to facilitate movement toward an approximation of pre-event psychological baseline?

The direct effects of terrorism are closely linked to the physical realities of the event (explosions, collapse of buildings or other structures, infectious outbreaks, etc.). According to Shalev, however, traumatic events such as acts of terrorism can also be described according to their psychological dimensions. The two are obviously intertwined. Indeed, as Shalev has also noted, “Shortly after exposure, the traumatic event ceases to be a concrete event and starts to become a psychological event.” Physical injuries, often of a mangling and grotesque sort, together with the tragic loss of lives, typically become the signature of the event in the popular mind. Those images serve as a reference both for on-site survivors and, as a result of media coverage, for those who learn of the disaster from a distance. Moreover, such images can quickly become an experiential template onto which both proximate and remote observers project their own sense of vulnerability and/or that of their loved ones. In the context of responding to terrorism, therefore, emergency interventions on behalf of victims, as well as the ancillary and administrative procedures established to support them, should emphasize not simply the reactive measures taken, but the proactively oriented steps as well. The goal is to impart the promise of mastery of the circumstance by conveying some sense that those acting as agents for the well-being of the affected remain able to act on their behalf. By the very nature of terrorism, some of those efforts may have to be shaped on an ad hoc basis. Even in that circumstance, however, it is important to establish and maintain an approach that is consistent in both appearance and substance with a relatively differentiated response, rather than one that conveys a global, diffuse, and relatively undifferentiated quality.

The destruction of property and infrastructure, the limits imposed on transportation, and the disruption of communication typically serve to further compound the effects of terrorism on the accustomed behavior patterns of those sectors of society that have been affected directly. Essentially, individuals as well as groups and organizations may be severely limited in the use of accustomed instrumentalities that they have habitually used as a means of transacting with their surroundings. Regression to developmental primitivity is a distinct risk for those persons and institutions thus deprived of the tools by which to manage ongoing experience and to meet needs that have been readily satisfied in the past.

Developmental dedifferentiation in the wake of terrorist-driven events and the resulting increase in stress that may in turn compromise health can also result from sociological factors. In the past, populations could be expected to unite when confronted with a common foe. Attacks or states of siege were typically seen as the work of “outsiders.” As a result, those who comprised the population attacked were the “insiders,” united at least to that degree and able to take some measure of comfort from the availability and presumed goodwill of neighbors. In a terrorist environment, however, there is the distinct danger that neighbors may seem suspect. “Cells” of terrorists may operate anywhere and, thus, danger may be perceived as potentially stemming even from those who seem to be “insiders” or members of the same targeted population. Therefore the cohesiveness that usually occurs within a population on the heels of an attack may be severely compromised. Further, anyone exhibiting characteristics similar to those associated with the assumed perpetrators of the terrorism may become the object of suspicion, if not attack. Backlash effects can then lead to divisiveness and thereby compound the resulting stress experienced by individuals within the population. Given the demonstrable relationship between stress and health, it is incumbent upon caretakers and service providers to remain mindful of this potential psychosocial complication and to temper their interventions with sensitivity.

These and other direct effects of terrorism can severely tax and compromise the psychological resources and abilities required to cope with the demands of daily living. The resulting dedifferentiation would be further compounded if some semblance of predisaster infrastructure and service capability is not restored relatively soon after the focal event or if no believable estimation is issued as to when such restoration will occur. Accordingly, an important part of an effective emergency response includes providing accurate information regarding system level plans and prospects for returning to a pre-event baseline of service delivery. Although meeting this requirement of comprehensive care might be subsumed under the principle of providing reassurance, it is important from a developmental perspective that it not be trivialized. Further, it is important that information provided not be false or contrived, particularly because subsequent determination of intentionally misleading facts having been provided would probably compound the psychological damage it may have been intended to relieve. Instead, a straightforward acknowledgment that information is not available is much more helpful, particularly when accompanied by an indication that facts will be sought out and shared when they become known.

Offering reassurance without misleading patients is a concern that applies to all aspects of clinical care. Providing services in response to terrorism is no exception. In fact, by virtue of the sense of the potentially overwhelming danger that seems to linger in the wake of terrorist-driven events, that requirement, particularly when viewed from a developmental perspective, becomes a salient one. To err by presenting patients with excessive ambiguity invites the projection of fears that might be much more extreme than the reality, however harsh. Such projections could well prompt developmental regression in the experience of self-world relationships. On the contrary, the other extreme of seeking to reassure patients by straining the limits of believability can not only destroy trust and encourage regression but also render its future restoration difficult at best. Accordingly, patients’ psychological well-being and developmental advance are best served by clinicians relating with honesty tempered by empathic consideration for patients’ subjective experience.

Observable instances of terrorism differ in terms of the degree and extent of their physical destructiveness. More circumscribed acts of terrorism, such as a bomb being detonated outside a police station or a polling place, would obviously have a correspondingly less-pervasive and/or less-extensive effect on infrastructure and the operation of societal institutions. Developmental regression, however, remains a danger. Those individuals upon whom the event directly impinges by its actual occurrence or by the fear that its having been threatened was intended to cause might well experience a disruption in their perception of “self-world relationships” and their ability to manage themselves productively. Their reaction, in other words, could prove analogous to that which would likely occur on a larger scale in the wake of more extensive incidents. Moreover, even those not directly affected by the event could well come to experience themselves as operating in a context of potentially sudden and unexpected hazard such that their actions might well become more tentative and fearful and less purposefully goal oriented.

Indirect, destructive effects of human-made disasters are often subtle and insidious in their erosive effect on the developmental level of functioning of societal institutions, as well as on that of the individuals within them. The frequent absence of immediate and overt indications of those effects notwithstanding, disruptions in cognitive, emotional, physical, and behavioral functioning in significant segments of the population can be anticipated in the aftermath of a terrorist event. These may be sustained by lingering (if not growing) fear and by feelings of helplessness in the face of an unseen and perhaps unidentified perpetrator who may strike again with no warning. The resulting perception of risk represents a strong challenge to the capacity of individuals and groups to cope with the demands of everyday life with the same level of efficiency that characterized their pre-event behavior. Thus clinicians may well note that lapses will occur in patients’ (as well as in peers’ and subordinates’) previously accustomed patterns of judgment, decisiveness, establishing and maintaining priorities, and other related psychological functions. Organizations, as well as individuals, are likely to experience these changes to varying degrees. Such effects may very well linger for a significant period after the terrorist event. For those in authority to provide supportive oversight of groups assigned various responsibilities therefore takes on an even greater importance than usual.

Indirect effects of a human-made disaster also include a significant increase of pressure upon public health systems for resources and services. Those demands typically occur in two phases. First is an obvious requirement to respond to direct casualties of the disaster. It is necessary, however, to also anticipate a predictable increase in stress-related illness that typically follows such events. In addition to psychiatric reactions, such as depression and posttraumatic stress disorder, rates of physical stress-related illnesses also rise when the psychological resources of a population are taxed by trauma. Psychiatric problems, not restricted in their increased incidence to the immediate aftermath of focal terrorist events, tend to increase within a traumatized population about 3, 6, and 18 months after the event. The increased incidence rates of these and of stress-related physical illnesses in particular may well extend much further. Accordingly, planning for health care within a population exposed to a human-made disaster must adopt a long-term view that takes the continuing effect of trauma on the health of an exposed population into account.

When negligence or incompetence results in death and/or destruction, those who perceive themselves as being at risk from its recurrence are likely to experience emotions ranging from fear and anger to distrust of societal institutions and their stewards. Intentional events of destruction such as acts of terrorism, however, may have even more disruptive immediate and delayed psychosocial effects. Similarly, the devastation wrought by a naturally occurring disaster may be greater in terms of casualties and damage to infrastructure, yet the psychological impact of the terrorist-driven disaster may still prove more extensive. Why is this the case? One reason has to do with perceived intentionality on the part of the potential causal agent of the danger.

A central tenet of most teleologically oriented theoretical perspectives in psychology (including the holistic developmental system of conceptual constructs) is that individuals impose meaning upon their experience and transact with the surroundings thus construed. When the source of a seemingly amorphous but apparently present danger is perceived as intentionally malevolent, the safety of self and others feels particularly at risk. When that potential source of danger is hidden from view and perhaps anonymous as well, feelings of fear and helplessness are further compounded. Moreover, locations usually perceived as safe provide little comfort and do not satisfy the wish to hide in protected places.

It is important to recall that problematic reactions to destructive occurrences are typically not restricted to individuals who directly witness the event. As previously noted, media coverage of events may in some ways leave those who are more distant with an even broader and potentially more destabilizing view than is available to those who are closer to the event but whose view of it is less expansive. In either case, the psychological effects can severely tax the ability of those affected to function with a level of efficiency that characterized their pre-event baseline. Further, persons affected by virtue of their relatedness to victims of a disaster and/or by disruption of their relationship with societal systems affected by the disaster (e.g., supply systems for food, water, and medical services) may be at extreme risk for problematic reactions. Specifically, they may well be left in an ego-dystonic state of perceived inefficacy, vulnerability, and dysphoria. Those effects can be profound. Indeed, those who remain thus affected for 1 year may not recover.

As noted previously, one consequence of the dedifferentiating effect of exposure to critical events upon perception is to reactivate developmentally primitive perceptual tendencies and to vaguely experience a profound and panic triggering sense of helplessness in the face of what seems to be overwhelmingly threatening. Given the continuing availability of that frame of reference, terrorists who are intent on wreaking havoc and who seem to strike without warning may recall the feelings that perhaps long ago were as overwhelming as they might be to the child who was fearful of monsters in the shadows. Just as the child looked to a parent to “put on the light” and check for danger, those affected by a terrorist event look to authorities for reassurance. They seek to put aside their feelings of terror, and, to some degree, to master the ongoing experience. Moreover, just as the child needed reassurance on more than one occasion, populations look to perceived authorities such as service providers, for repeated signals that problems are being addressed.