5.

1 SOCIAL CATASTROPHE, TERRIRISM AND WAR

TRAUMATIC EVENTS

The effect of traumatic events on human functioning has been a subject of study for
many years. An abundance of research has examined traumatic events ranging from
individual events such as motor vehicle crashes and sexual assaults to community-wide
events such as natural disasters, commercial airplane crashes, and community violence,
as well as global events such as war.

As defined by the The Diagnostic and Statistical Manual of Mental Disorders—Fourth

Edition (DSM-IV), a traumatic event—or witnessing such an event—triggers fear,
helplessness, or horror in response to the perceived or actual threat of injury or death
to the individual or to another (APA, 1994). Traumatic events are usually perceived by
the individual to be life-threatening, unexpected, and infrequent, and are characterized
by high intensity (Ursano et al., 1994). However, traumatic events may be repeated
within a community, and in such environments the presence of a threat may become the
norm. Evidence suggests that the type and severity of outcomes often vary according to
the type of event (Freedy and Donkervoet, 1995).

The effect of exposure to a traumatic event is variable and specific to the individual;
both psychological and physiological responses can vary widely. Social context,
biological and genetic makeup, past experiences, and future expectations will interact
with characteristics of the traumatic experience to produce the individual's
psychological response (Ursano et al., 1992). In general, those exposed to a traumatic
event show increased rates of acute stress disorder, posttraumatic stress disorder
(PTSD), major depression, panic disorder, generalized anxiety disorder, and substance
use disorder (Kessler et al., 1995).

CONSEQUENCES: There is a spectrum of consequences ranging from distress

responses such as mild anxiety, to behavioral changes such as mild difficulty sleeping,
to the onset of a diagnosable psychiatric illness (see Figure 1-2). These consequences
generally can be placed into three categories of severity, which may also correspond to
strategies for intervention:

 The majority of people may experience mild distress responses and/or behavioral
change, such as insomnia, feeling upset, worrying, and increased smoking or
alcohol use. These individuals will likely recover with no required treatment, but
may benefit from education and community-wide supportive interventions.

 A smaller group may have more moderate symptoms such as persistent insomnia
and anxiety and will likely benefit from psychological and medical supportive
interventions.

 A small subgroup will develop psychiatric illnesses such as PTSD or major

depression and will require specialized treatment.

The number of people experiencing each of these outcomes varies directly with the
severity of the event and with proximity of exposure to it. Most people will experience
mild or infrequent symptoms, while only a few may experience frequent and/or severe
symptoms. Because terrorist attacks may cause violent injury, death, and destruction,
there often will be a targeted population that experiences extreme trauma, a widening
group of family members and friends who are also therefore directly affected, and an
even larger community and societal population who are confronted with the danger of
terrorism through the media and on a daily basis. Furthermore, the relative number of
people in any one of these categories is based not only on the population but also
characteristics of the event itself

The childhood experience of traumatic events induces immediate biological and

psychological reactions, some of which may persist for an extended period. The
psychological symptoms of traumatic events in children and adolescents are similar to
those recognized in adults, but often appear as age-appropriate expressions of the
stressful event.

Youth who have been exposed to violence have been more likely to develop
psychological problems and have poor functioning at home and school (Cohen, 1998;
Pynoos et al., 1995; Richters and Martinez, 1993). Recent studies indicate that about
one-third of children exposed to community violence develop PTSD (Berman et al.,
1996; Fitzpatrick and Boldizar, 1993). Youth exposed to traumatic events also can
develop depression, other anxiety disorders, substance use disorders, and problems
with school performance (Brent et al., 1995; Clarke et al., 1995; Saigh et al., 1997;
Singer et al., 1995; Weine et al., 1995). Widespread negative psychological effects have
also been reported following acts of violence on high school campuses, such as the
school shootings.

Biological research has demonstrated that, like adults, children exposed to traumatic
events show alterations in stress hormone systems. However, a unique difference
among children is the association of exposure to traumatic events with measurable
discrepancies in neurophysiological development. It is believed that prolonged levels of
significant stress may adversely affect the neurophysiological development of young
children in ways that may have long-term consequences for behavioral responses to
stress and later psychiatric illness (for reviews, see De Bellis, 2001; Glaser, 2000). It is
difficult to draw definitive conclusions from this research, however, since findings are
frequently confounded with preexisting risk factors for experiencing a traumatic event
that are also associated with differences in brain physiology.

DISASTERS

Disasters are situations or events involving ecological disruption, threat to life or injury
that negatively affect large numbers of people and that overwhelm local capacity for
adaptation, usually by destroying infrastructure. Disasters vary widely in their scale,
scope and significance. It is useful to distinguish between natural and human-caused
disasters.

 Natural disasters include geophysical and meteorological events like earthquakes,

floods, tsunamis, tornados, volcanoes and drought.
 Human-caused disasters can be divided into:
(i) technological accidents, such as airline or other mass transportation accidents,
industrial accidents and structural collapses of bridges or buildings; and
(ii) (ii) willful or intentional events such as mass murders, terrorism, war and
genocide.

 The distinction between natural and human-caused, however, is often difficult to

make and may change with new information and interpretations; for example, the
destruction following an earthquake may become a human-caused disaster when it
is realized that most of the deaths are due to the collapse of houses built with
shoddy workmanship due to corruption in the construction industry.
 Many disasters span the natural and the human-caused because they stem from the
ways humankind has modified the environment (e.g. famine due to the interaction of
methods of intensive agriculture and drought).
 Natural and human-made disasters may co-occur and interact in ways difficult to
disentangle. For example, drought or famine can be caused by warfare and
warfare can be ignited by famine.
 The frequent coexistence and mutual aggravation of natural and human-
instigated disasters is central to the notion of complex emergency,
defined as a catastrophic situation marked by the destruction of a
population’s social, economic, and political infrastructure

A subset of the broader trauma literature has focused on the psychological

consequences of disasters. Disasters differ from other forms of traumatic events in
that, by definition, they are likely to affect larger segments of the population or
entire communities of individuals, causing widespread destruction and
distress.Norris and colleagues (2002b) reviewed 177 articles that examined 80
different disasters.1 The authors organized the most frequently documented negative
sequelae of disasters into five categories:

 Specific psychiatric illnesses (for example, PTSD, depression)

 Nonspecific distress (symptoms without a specific diagnosis, such as
demoralization, perceived stress, and negative affect)
 Health problems and concerns (for example, somatic complaints, sleep
disruption, increased use of sick leave)
 Chronic problems in living (for example, social disruption, family conflict,
financial and occupational stress)
 Psychosocial resource loss (for example, decreases in social participation and
perceived support)
The authors suggest that children were the segment of the population at greatest risk
for psychological trauma, behavioral changes, and impairment. There are three broad
approaches to the impact of trauma and disaster on mental health outcomes.

 The clinical psychiatric approach focuses on the effects of trauma in causing

psychopathological conditions like PTSD, depression and other potentially
disabling conditions. Individual vulnerability due to pre-existing personality
traits, coping styles and mental health problems help predict who will develop
persistent problems after trauma exposure.

 A second approach focuses on individuals’ resources and resilience. For example,

conservation of resources (COR) theory, developed by Hobfoll, groups resources
into four broad categories: object resources (e.g. material possessions with
either functional utility or symbolic value); condition resources (e.g. social roles
or status like marriage, employment, membership in groups or organizations);
personal characteristic resources (e.g. values, traits or attitudes like optimism,
sense of meaning and purpose); and energy resources (e.g. time, money,
information) [43]. Resource loss due to trauma is associated with distress [44].
Disasters produce distress and limit coping by reducing individuals’ resources in
each of these areas. Coping and adaptation, therefore, can be improved by
interventions that maximize these resources. Of course, these resource domains
are not independent but correlated in ways that reflect a community’s social
structure and dynamics.

 A third approach recognizes the dynamic nature of the interaction between

different resource domains and focuses on the role of social positioning in
 individual and group vulnerability and resilience. This more dynamic view could
be termed ‘social ecological’, in that it sees each person as located within a
system that has its own dynamics. Disasters differ from isolated traumatic events
affecting individuals in that they affect the whole community, which ordinarily
provides the secure base for each person’s adaptive responses to stress, trauma
and loss. Depending on the degree to which a disaster disrupts the social fabric
and weakens bonds between people, communities may respond with mobilization
and increased solidarity or with demoralization, disorganization and
disintegration.

Norris and colleagues (2001) propose that when at least two of the following four
characteristics of disasters are present, the mental health impact will be greatest:

 Widespread damage to property

 Serious and ongoing financial problems
 Human error or human intent that caused the disaster
 High prevalence of trauma (injuries, threat to life, loss of life)

With the exception of “serious and ongoing financial problems,” these important
characteristics of disaster experiences are specific to the event phase. Understanding
how specific aspects of disasters relate to specific outcomes will help facilitate planning
for mental health interventions in the aftermath of disasters.

Post-Event. The presence or absence of psychosocial support is significantly associated

with outcomes. When people feel that they have been neglected or forgotten by their
government or community, they are more likely to have long-term adverse effects from
a disaster experience (Norris et al., 2002b). In addition, as mentioned above, ongoing
financial stress, job loss, and other post-event negative occurrences are associated with
more severe adverse psychological consequences.

Positive Psychosocial Consequences

Although less well documented than the negative effects, the experience of a disaster or
other traumatic event may result in a positive impact on both individuals and the
community. A small but growing literature exists on the process of posttraumatic
growth, describing the development of adaptive coping mechanisms and feelings of self-
efficacy following exposure to traumatic events (e.g., Calhoun and Tedeschi, 2001).
Thus, the experience of a traumatic event can also promote resilience for future
traumatic events.

The communal experience of overcoming a disaster may promote greater community

cohesion. Altruism and volunteerism frequently increase in the aftermath of a disaster.
These are phenomena that can be beneficial both to those receiving the assistance and
to those who volunteer, since the perception of self-efficacy and the ability to “do
something” can help people to cope with the disaster experience.

TERRORISM

Schmid accurately describes a core feature of terrorism that gives it its potency: a
calculated exploitation of people’s emotional reactions due to the ‘causing of extreme
anxiety of becoming a victim of [what appears to be] arbitrary violence’. This is crucial
to thinking about the effects (and hence attractiveness to extremists) of terrorism and is
developed further by Friedland and Merari who describe what they see as two
predominant characteristics of terrorism:

(1) a perception of the threatened and actual danger posed by terrorists which is
disproportionate to the realistic threat posed by the capabilities of terrorists, and

(2) that terrorism has the ability to affect a set of ‘victims’ far greater than those
suffering from the immediate results of a violent terrorist act.

 The immediate aims and results of terrorist violence (intimidation, injury or death,
the spreading of a general climate of uncertainty among the terrorists’ audience and
target pool) are thus often secondary to the terrorists’ ultimate aims (and it is
hoped, from the terrorists’ perspective, political change), which are often espoused
in the group’s ideology or aspirations.

 In this sense, and adding to this list of terrorism ‘traits’, terrorism is often
accurately referred to as a form of sophisticated psychological warfare: outside of
the immediate event, terrorism might be thought to reflect enhanced arousal and a
sensitivity to environmental events associated with violence.

 Terrorists use violence to achieve political change, and while the motivations vary
considerably across the plethora of groups we call terrorists, their principal methods
remain remarkably similar. Terrorist violence is conducted with weaponry that
mostly includes guns and bombs, the former a traditional yet paradoxical symbol of
revolutionary liberation. Although the means of terrorism have remained similar for
many years, technological developments have meant that there is an ever-increasing
array of modalities through which terrorist violence may be expressed. In particular,
terrorism today is complemented with the availability of publicly accessible
information on what would previously have been considered military secrets.
Internet has seen a host of material potentially of tactical value to terrorists being
transmitted through this medium. This includes information useful as the basis for

 identifying potential targets, as well as more dramatically, guides to bomb-making.

 Terrorism, a subset of human-caused disaster, can have a particularly devastating

impact on psychological functioning. Terrorism carries with it a potentially greater
impact than other disasters on distress responses, behavioral change, and
psychiatric illness by virtue of the unique characteristics of terrorism events.

 Thackrah notes that terrorism has also been a synonym for ‘rebellion, street
violence, civil strife, insurrection, rural guerrilla war and coup d’état’. Terrorism can
of course be seen as a form of warfare in general terms, but terrorist campaigns
distinguish themselves from what we conceive of as war-like campaigns through a
number of surface dissimilarities.

 War is mostly used to refer to conflict between states, whereas terrorists are not
‘state’ entities in the same sense in that, to give one rudimentary distinction, they do
not have the ability to hold what governments’ term a foreign policy.

 Terrorist tactics, from the point of view of the terrorist, must differ from those seen
in conventional warfare: if terrorists, traditionally small in number and rarely
sophisticated in resources, were to engage in warfare with reasonably symmetrical
boundaries, they would be destroyed. Terrorists do not have the same level of
resources at their disposal, since by the very illegal nature of terrorism they are
semi-clandestine individuals serving clandestine organizations. Instead, terrorists
adopt ‘guerrilla tactics’ in a process of constant attrition, rather than resembling the
 victories and defeats of symmetrically-based wars in which levels of technical
sophistication and resources are, to a degree, matched. A central aspect of
successful terrorist strategy is that by actually determining the ‘theatre’ of war (and
giving their enemies no choice in the matter), terrorists redress this inequality of
resources.

 Terrorism is distinguished from conventional warfare and other forms of violence

used by liberal democratic states and governments in several other basic, but
identifiable, ways. Some of these distinctions (even though we might dispute them)
will be of benefit later in trying to systematically define terrorism. Hoffman
addresses the distinction as follows:

o Even in war there are rules and accepted norms of behaviour that prohibit
the use of certain types of weapons (for example, hollow-point or ‘dum-dum’
bullets, CS ‘tear’ gas, chemical and biological warfare agents), proscribe
various tactics and outlaw attacks on specific categories of targets.
Accordingly, in theory, if not always in practice, the rules of war…codified in
the famous Geneva and Hague Regulations on Warfare of the 1860s, 1899,
1907 and 1949—not only grant civilian non-combatants immunity from
attack, but also:Prohibit taking civilians as hostages; Impose regulations
governing the treatment of captured or surrendered soldiers (POWs); Outlaw
reprisals against either civilians or POWs; Recognise neutral territory and the
rights of citizens of neutral states; and Uphold the inviolability of diplomats
and other accredited representatives.

o There is no doubt that terrorists’ disregard for such boundaries is what

contributes to their description as terrorists. Groups such as the Basque ETA,
the Colombian FARC, Palestine’s Hamas or the Sri Lankan Tamil Tigers do
not recognize any particular ‘guidelines’ of war and frequently and
purposefully attack non-combatant civilians and military personnel whom at
the time of the attack are either unarmed or considered offduty. Again, the
targets of terrorist violence are symbolic ones and terrorism in this way is
very impersonal, but not representative of an unambiguous and discriminate
form of violence (which in itself may be an unrealistically achievable ‘ideal’,
given the vagaries of conventional warfare). Yet, despite this, there is often a
sense of implicit boundaries that may not be breached, especially at a local
level.

o To reiterate, only democratic state bodies have a mandate by which they are
regarded as having legitimacy to develop and engage in war-making
strategies. This may of course be a reflection of ‘power in numbers’: in
Ireland the Provisional IRA leadership does not recognize the rights of either
the British or Irish governments to pass laws and declare legislation. Instead
the PIRA leadership body, or Army Council, views itself as the direct
descendant of the 1918 Dáil Éireann (Irish Government) and as such sees
itself as having (although this has not been, and never could be, enforced by
the PIRA) the moral right to govern over the island of Ireland as a normal
government. At most, the PIRA leadership has simply asserted their
entitlement to this right by making reference to higher order revolutionary
principles such as ‘the rights of the people’. This is a common feature of
many terrorist groups.

o Linn adds the following to the discussion: When compared to terrorism,

conventional war has clear norms: there is a neutral territory which is
 recognised by the fighting forces, the armed forces are identified…there is an
awareness that the use of armed forces against civilians is exceptional or
aberration. In contrast, terrorism is aimed at the destruction of established
norms. Unlike guerrilla fighters who are not only breaking the laws of war,
who know who is their enemy and attack only the superior combatants,
terrorists blur the combatant-non-combatant distinction by saying that ‘WAR
IS WAR’ and that any attempt to define ethical limits to war is futile.

WAR

Ethnic conflict, organized violence and wars have been major causes of suffering, ill
health and mortality throughout history. In recent decades, the number of victims and
survivors of traumatic events has significantly increased as war, armed conflict and
political upheaval have engulfed civilian populations worldwide, contributing to
additional burden of disease, death and disability.

 War has always exposed both combatants and civilians to trauma but, with the
adoption of new methods of warfare, recent years have seen a dramatic increase
in the proportion of civilian casualties.
 During World War II, about 50% of the direct casualties were civilians; in the
1980s this figure rose to 80% and by 1990 it was fully 90%, with the largest
number being women and children [64].
 War and political conflicts have structural causes and often occur in societies
that are already facing economic hardship. The collapse of formal economies and
the emergence of economic crises in the marginal areas of the global economy
lead to further impoverishment, food insecurity and ethnic and religious tensions
over diminishing resources.
 Consequently, predatory practices, rivalry, political violence and internal wars
may erupt.
 In the last 60 years there have been over 200 wars and armed conflicts, in which
the main targets are often the poorest sectors of society and marginalized ethnic
groups.
 Armed conflict results in significant psychiatric morbidity but the pattern varies
across cultures. In a study of 3048 respondents in Algeria, Cambodia Eritrean
refugees in Ethiopia and Gaza in Palestine, de Jong, Komproe and Van Ommeren
compared rates of depression, anxiety disorders, PTSD and somatoform
disorders among those exposed to armed-conflict-associated violence and those
without such exposure [66].
o Overall, PTSD was the most common disorder for those directly exposed
to violence,
o while anxiety disorders were the most common disorder for those not
directly exposed.
o There were high levels of comorbidity of PTSD with anxiety or mood
disorders in Algeria and Cambodia.
o However, there was also substantial variation in the overall prevalence
and relative rates of disorders, which was due not only to the nature or
severity of the disorder but to cultural variations in modes of expression
 of distress. For example, in Cambodia, anxiety disorders were more
common than PTSD among those exposed to violence.
o Somatoform disorders were more common among those exposed to
violence only in the Palestine sample.
 The health consequences of political violence and wars extend beyond death,
disease and trauma-related psychiatric illness, to include the pervasive effects of
destruction of the economic and social institutions and the whole fabric of
society.
 As such, the consequences of violent conflict can be observed not only in
individuals – in their biographies and life trajectories – but also in collective
memory and identity and communal strategies for coping with violence and
adversity [65,67].

REFUGEES

Refugees fleeing war or persecution are very vulnerable as they cannot count on
protection from their own state, and it is often their own government that is responsible
for threatening and persecuting them.

 The 1951 Refugee Convention defines a refugee as someone who ‘owing to a

well-founded fear of being persecuted for reasons of race, religion, nationality,
membership of a particular social group, or political option, is outside the
country of his nationality, and is unable to or, owing to such fear, is unwilling to
avail himself of the protection of that country’ [68].
 The Refugee Convention obligates governments to provide a safe haven for
those fleeing persecution. However, many countries treat refugee claimants with
suspicion and have policies aimed at discouraging others from seeking asylum
[69]. These policies of deterrence, which may include detention under harsh
conditions, have serious mental health effects [70].
 Epidemiological studies have demonstrated both short- and long-term effects of
trauma on refugee mental health and disability. For example, a survey of
Vietnamese refugees who resettled in Australia found that 8% of the participants
had mental disorders [71]. Trauma exposure was the strongest predictor of
mental health status.
 Although the risk of a mental disorder decreased over time, people who suffered
more than three traumatic events had a higher risk of mental illness after 10
years compared with people with no traumatic exposure. A longitudinal study of
Bosnian refugees found that fully 45% met DSM-IV criteria for depression, PTSD
or both [72].
 For refugee children as well as for adults, the quality of their post-migration
reception in the new country is a better predictor than pre-migration trauma
exposure of mental health [75].
 Survivors of political violence, persecution or torture, who must flee their
countries of origin to survive, suffer complex losses and transitions associated
with forced migration, the process of seeking asylum and the enduring dilemmas
of exile [69].
 The process of convincing immigration authorities that one has been tortured
and so has a valid claim to refugee status may in itself become a situation of
psychological retraumatization [69,76,77]. This may be exacerbated by the fact
that such individuals may be reluctant to divulge experiences like torture, rape
or other forms of trauma in health care settings.
 Refugees also may have continuing fears for the safety of family left behind and
uncertainty about the possibility of reuniting with loved ones.
 Despite the profound impact of trauma on wellbeing, post-migration factors
including social supports, employment and occupational status are among the
strongest predictors of positive outcome [73,74,78]. Effective resettlement
policies and programmes can therefore make a significant contribution to
refugee mental health.