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What to Expect after a Terror Attack
Here in Israel we are all too familiar with the gut wrenching feeling we get when we hear the sound of a boom that's followed a few minutes later by wailing sirens. "Where did it happen?" we wonder and our radio vigil begins.
There is nothing like a terror attack to instill fear and a sense of helplessness in us all.
Who is Affected?
The metaphor of concentric or exposure circles discussed earlier especially applies to a terror attack or a disaster. The inside circle includes those who suffered injury. The second circle includes those who were at the scene but weren't physically hurt. Although both can suffer post-traumatic stress disorder, those who were hurt will have a sharper reminder of the trauma for a longer period of time. In the third circle are the relatives and close friends of the injured. In the fourth circle are the acquaintances, distant relatives, etc. The outside circle includes those who experienced the terror attack through the media.
TV news 24-hours a day has brought terror attacks into people's living rooms in real time, enabling them to witness the events as they unfold and see the same events over and over again. One effect of this is that the lines between the circles become blurred.
After the attack on the World Trade Center, many people reported that they were watching news television for up to six hours a day. Many of them could not tear themselves away from the screen and watched the horror of the crashes literally hundreds of times. Such repetitious viewing can cause viewers to experience some of the same trauma as the inner circles.
The Flashback Syndrome
The "flashback syndrome" refers to someone who was in circle one or two in a previous attack. When a society, such as ours, experiences frequent attacks, this syndrome becomes increasingly common.
Sarah works in Jerusalem and was lightly injured many years ago in an explosion on a city bus. After each new terror attack, she experiences blinding headaches that incapacitate her for hours as well as flashbacks of the very second the bus exploded. Simon, who was present at a relatively minor attack, reported that he becomes anxious and unable to concentrate after each attack. Unfortunately there are hundreds, if not thousands of people who now fit into this category.
Some of those who are particularly sensitive to a sudden disaster are people who experienced a personal loss within the last year or so and who did not have the ability or possibility of working though that loss effectively.
Two examples are:
After the double murders in Tekoa, one young man, a friend of both boys, showed disturbing symptoms of depression, mood swings, and aggressiveness. This young man had lost his father earlier that year. After one difficult incident involving watching one of the younger siblings saying Kaddish, he confided, "I can't take seeing someone else (so young) having to say Kaddish." He identified so strongly with this young boy that he was reliving his original pain and his unresolved mourning for his father. It took a lot of courage for him to confront this pain all over again. With a little help he eventually found the internal resources to help the young boy and in return was able to comfort himself.
Another woman told me that she did not understand why she was so totally distraught (beyond the obvious reasons) after the Tekoa murders. Although she didn't know the families that well — nor did she really know the children — she was almost unable to function. After discussing funerals in general, she expressed her deep regret at not being at her father's bedside at the time of his death. She had visited him in the United States a month or so before he died but then had to return home to her family and her job. Saying this, she realized that she had never really come to grips with her father's death and her guilt feelings at not being with him at the end.
These stories illustrate how past traumas can heavily affect reactions to current crises. The reactions are natural, but a bit of extra help may be necessary.
How Are You Affected?
Everyone is affected by a disaster or terror attack. How you will be affected has to do with:
- Your location within the circle.
- Your normal reaction to acute stress.
- Your general physical and mental health prior to the attack.
Not all of us will experience the same depth and degree of distress, but you may find many of the symptoms listed below quite familiar.
- The incident runs through your mind over and over again. This is especially likely to happen if you were actually at the site, but it can also occur if you saw it over and over on TV. These memories may or may not be accompanied by sweating or a rapid heart beat.
- You may want to sleep more (to get away from it all).
- You may be afraid to sleep because of bad dreams.
- Nervous eating habits.
- Fear of leaving your immediate environment.
- You may have closed yourself up so that you socialize less or are less open to people.
- Interruption of daily routines. If you used to jog each morning you may find it very difficult to continue. You may feel totally apathetic about your usual routines, with a kind of "who cares" attitude to daily life.
- A sense of deep and inexplicable loss. You may feel depression and loss without being able to pinpoint any specific reason for it.
- You may feel temporarily disoriented, with difficulty concentrating.
- Physical ailments such as an upset stomach, headaches, dizziness or even flu symptoms.
Keep in mind that a traumatic experience affects both the psychological and the physiological aspects of our well being. It is natural to internalize stress, which may then take the form of a backache, sore throat, and high blood pressure. If you have a history of high blood pressure or heart problems, you should see your doctor and take special care to monitor your condition.
- Hormonal changes. Often women will totally miss their periods or experience other physical changes.
- Lethargy. While more common in situations of long-term stress, it often appears after a terrorist incident.
- Feeling that you cannot plan more then one day at a time.
- A sense of lack of control over your life.
- Impatience. You may become less patient with people, especially those close to you.
- Mood swings. Mood swings are common and can range from listlessness and depression to mania.
- Religious doubts. Deep-rooted questions concerning religious beliefs may crop up. In strongly religious people, this may be accompanied by feelings of guilt.
- Guilt for surviving.
And This is Normal???
Yes and yes. That is the most important point to remember. Each of us is affected in our own way.
Is there any standard length of time for these symptoms to last?
This question can be answered with another question: are there any standard people?
The length of time that people experience these symptoms depends on a number of factors:
The degree to which the incident threatens one's long-term security. The greater the likelihood of another incident, the longer the symptoms will last. There is a vast difference between a car accident and a terror attack.
Whether there were previous experiences that could trigger an additional reaction. These do not have to be first-hand experiences. It could be a close relative or friend who had a similar experience. However, experiencing trauma first-hand makes recovery much harder the second time.
If you have something else stressful going on in your life at that time. Everyone goes through bad patches in their lives. You could be having trouble with one of the kids, your marriage could be going through a rocky patch — or breaking up completely, you could have lost your job, someone in your family could be seriously ill...the possibilities are endless. The stress and trauma of a terror attack doesn't replace the existing stress in your life — they are added to it.
One's usual reaction to stress. Someone who "falls to pieces" easily will naturally have more trouble regaining his equilibrium. I have a relative who loves to become hysterical. She is always the first to call with some terrible news, whether it is my aunt's gall bladder operation or the latest divorce. She is the first to know and the first to broadcast. She also gets what she calls "palpitations". It doesn't take much to set her off, and she thrives on the attention she gets.
While she is an extreme example, there are many people who have difficulty dealing with any crisis. These people will naturally have greater trouble dealing with a traumatic experience and will need more support to get through it.
And how long will this take? Depending on the three above factors, it could be anywhere from a few weeks to months. Each of us has our own timeframe for healing.
What can I do to Help Myself?
A few rules of thumb are:
Understand that what you are going through is normal. Give yourself a chance to recover and don't rush things.
Learn from past experiences. All of us have gone through difficult situations in our lives. Ask yourself, "How did I deal with it in the past?" and take your clues from there. One friend told me that she began to finger paint following a particularly difficult divorce. After a few months she felt less of a need to paint and eventually stopped. Now with all the tension of terror attacks around her she felt the need to once again take out her colors.
Talk about how you feel with your significant others, although it may be difficult. If you and your spouse both went through the experience you may want to join a professionally led group. You may wish to talk to friends as well.
Organize local groups. Many settlements and neighborhoods, like Gilo in Jerusalem which suffered numerous shooting attacks during the years 2000- 2001, organized support groups according to language and neighborhood. Local professionals were recruited to run the groups, which generally met several times and then faded away, as the stress (hopefully) eased. What is important is that these groups enable everyone to see that others are also going through the same thing — much to many participants' amazement and relief. While women have less of a problem participating in such groups, it is often more difficult for men. They can be disguised as groups to "help the family cope," which most men will have no problem joining.
Try to get back into your normal routine as soon as possible. Getting back into your routine forces you into structured activity, which is always conducive to a healthier frame of mind.
Exercise. If you are used to exercising regularly, then put it right back high on your list of priorities. And if you haven't then this is definitely the time to begin. Exercise is beneficial in a variety of ways since it relieves stress and gives a general feeling of well being, which is particularly important at this time.
Wait for time to pass. The old adage that time heals is actually true. Things do get better — but at some point you may stop wanting it. You may prefer to sink into a morass of pain. You may even get angry when someone says that things will get better. Something in you may resist the process of healing. The convoluted logic behind this is that the pain enables you to maintain your contact with the one you lost.
Pray. No matter what your religious background, praying helps. We have all seen non-observant people at a bedside praying for a loved one. This is not hypocritical. Most people believe in a Higher Being even if they choose not to adhere to formal religious practices. Prayer also serves as a way to express love and care and hope.
You may wish to talk to a religious leader you respect and ask him the questions that plague us all after a tragedy.
Keep emergency information handy. Keep emergency phone numbers such as the police or medical assistance, as well as those of family or close friends in an obvious place, like the refrigerator or next to the phone. Being prepared for an emergency helps allay feelings of fear and uncertainty. Also let your children know where you can be reached when you are not at home. Knowing that a parent is available gives children a feeling of security. (It's always a good idea to do this.)
Talk to your children! They will see the difference in your behavior after an attack. They may be frightened to see you slumped in a chair when you used to go outside to play with them. Their first concern will be for themselves. "What is happening to Daddy?" translates into "What will happen to us?"
As we noted in Chapter 4 on Trauma and out Children, in general they will need reassurance that you are there to care about and for them and that you will be there to take care of them. Resume your normal routine with them. If you normally read them a bedtime story, find the strength inside yourself to continue. Sometimes when we can't muster up the strength for ourselves, we can find the strength to give to someone else and thus benefit twice.
If you handle the situation well, you will be teaching your children a valuable lesson in coping.
Spend more time with your family. If you are used to working long hours try to come home earlier until the tension has eased. This can sometimes be difficult since a common reaction is to try and lose yourself in your work, but in the long run being with family is healthier.
Go to funerals and memorial services. Believe it or not, going to funerals and memorial services actually helps. We see hundreds or even thousands of yahrzeit candles that have been lit at the sites of attacks. This is a gut reaction that enables people to express their pain and anger — and to be part of a community of grief. If several members of your family knew the victim(s), go to the service as a family. I have seen families, friends, and even total strangers standing together the day after an attack, holding on to each other and comforting one another.
So After All This When Do I Seek Help?
Dave's wife, Jody, went out one Saturday night to meet a friend from abroad. Unfortunately they met on Ben Yehuda Street for coffee half an hour before two bombs went off. Jody returned home shaken, and though neither she nor her friend were actually hurt, she was both traumatized and plagued by guilt for having exposed her friend to such an experience. However, except for stating how terrible it was, Jody refused to discuss the details of what happened with Dave. He was unsure of how to react, Should I force my wife to talk about it? Or, should I just let her work it out on her own?"
I wouldn't even try to force her to discuss it. But yes, I would encourage her to talk. It has been shown that the more time passes, the more difficult it is to deal with trauma. But it may be more difficult for Jody to open up to Dave, specifically because he is her husband. We play certain roles in our relationships. It may be far easier for Jody to speak to someone outside the family than to a family member.
Most of the symptoms listed above are universal. Problems arise when time passes and the symptoms don't ease — or actually worsen. As noted above, recovery time is unique for each person. It depends on the individual's ability to deal with stress, whether or not he has undergone similar incidents previously, as well as external factors. However, if someone is living in a situation where he is repeatedly exposed to life threatening situations, professional assistance should be sought.
Seeking help is nothing to be ashamed of or embarrassed. It is usually the fastest way to recover. Some useful indicators of when you should seek help are:
- If you feel you can't cope on a daily basis. If you fear leaving home. (I am not refering to objective fear in situations where people are being shot on the road.)
- If you fear being in a crowd.
- If you experience deep, overwhelming sadness and depression that doesn't seem to leave.
- If your tension begins to interfere with your relationships with other people.
- If you begin to grow frightened by your own reactions to certain situations, such as displaying irrational anger that is disproportionate to what triggered it.
- If you begin to become dependent on alcohol or drugs to get through the day.
- If you feel you are "losing it".
Remember that seeking help doesn't mean that you will be on the couch for the next year. Sometimes only a few meetings are needed to learn how to cope and begin to heal yourself.
The Great Conflict
What do you do when there is a direct conflict between the parents' desire to protect a child (who may even be 20 years-old) and the child's desire to know or experience. This is an issue that ALWAYS comes up. It is also an issue that can easily become a powder keg and set off emotionally-charged repercussions — especially where older children are concerned.
While it is as natural for parents to want to shield their children as it is for children to demand that their requests be taken into consideration, the circumstances and individuals involved in each case are different — so that the right answer is also different with each case.
Debbie has a 15 year-old boy, Yoni, who was burnt in a bombing. As soon as he regained consciousness he began to ask questions about the friends who were with him when the bomb went off. Debbie tried to postpone telling him until he was better but he persisted until she wasn't able to keep the information from him anymore and acknowledged that one of his friends had been killed. Yoni demanded to be able to go to the funeral, and even got the doctor's permission to do so. Debbie was adamantly opposed to his going because of what she was afraid it would do to him emotionally and physically.
While the problem in this case is very specific, conflicts between parent and child about what's best for the child are common. Many times the best solution is to refer the dilemma to a professional who is outside the family circle (if possible). In this case, Debbie was able to bring in the hospital psychologist into the decision-making process. This served two purposes. First, the professional was able to take both sides into consideration and try to find a compromise. Secondly, any anger about the decision and/or its repercussions would be directed at an outsider, thus minimizing any lingering resentment or bad feelings about the decision within the family.
"Tell me about it" is probably the most useful sentence you can say when talking to someone about his experience. That is why the debriefing technique is becoming more and more widely used to help rescue workers and victims of all sorts of catastrophes recover from the emotional trauma caused by their experiences.
The term "debriefing" is a professional term. In a debriefing, those involved in a catastrophe are asked to relate everything they remember about it, in the order in which they remember the events occurring. The emphasis is on eliciting a factual account of what happened, rather than the participants' emotional reactions to it.
Experience has shown that many people, especially professionals who deal with disasters all too often, have reservations about participating in sessions where the emphasis is on their emotions. Such sessions are perceived by them as being either too "touchy feely" — or an admission that they can't cope emotionally. However, those same people usually have no problem participating in a session whose stated aim is to gather information in order to get a clear and complete picture of exactly what took place. This enables them to confront their experience in the company of people who understand what they went through — something that allows their emotional wounds to begin to heal.
A specially trained person should run debriefing sessions. It is essential that the debriefing be held as close to possible to the incident (preferably within 48 hours). Debriefing should be done on a one-on-one basis or with a small group. Attempts at debriefing with large groups have not been successful.
Approximately 20% of the victims of a terrorist attack suffer from some form of Post-Traumatic Stress Disorder. However, it is not possible to detect such a disorder in that first debriefing because everyone there is inevitably suffering from some form of emotional trauma. That is why it is very important to have a second meeting with the victims 2-3 weeks after the event. By that time the initial trauma has subsided so that developing long-term trauma related disorders can be easily detected — and dealt with early on.