Given that terrorist activities today are chronic, modern terrorism has profound consequences for the mental health of tens of millions of people everywhere, both directly and indirectly. For these reasons, it is vitally important that psychotherapists of every kind, as well as politicians and all concerned citizens, understand the psychological consequences of modern terrorism in as much detail and depth as possible.
Towards this end, the primary purpose of this book is to attempt to address the impact of modern terrorism on the entire spectrum of humans’ psychological functions, including the effects of psychological trauma on individuals’ behavior and affective functions. To fulfill this promise, I have divided this rich collection of articles into three conceptually distinct, but inter-related, sections, discussed immediately below. As will be seen, they reflect the varied nature of psychological trauma, including Type I Trauma, Type II Trauma (a more complex constellation of symptoms that arises in victims subjected to continuous threat), and the effects of terrorism in exacerbating symptoms in cohorts of previously traumatized populations.
Before discussing these sections, I want to emphasize that, although the articles chosen for this book do not focus on therapeutic approaches to treating psychological trauma, I nonetheless feel it is important to address this issue, which I have done both in the ensuing discussion at appropriate places and at the end of this Preface. There, I also propose a theory of the caretaker role, which looks beyond the victim to the role of caretaker failure in contributing to the problem of systemic terrorist assaults on innocent civilians.
Organization of the Anthology
Section I includes articles that focus on solitary terrorist attacks, such as recently occurred in Madrid, London, and New York, and the consequent Type I Trauma responses related to a single terrorist event, especially post-traumatic stress disorder (PTSD). These terrorist events are often shocking or catastrophic, and usually totally unanticipated. Survivors of these events may suffer a wide array of symptoms, including intense fear, or even dissociation, where the individual’s awareness and ability to engage psychologically in the present is usurped by traumatic material or defenses. As a result, consciously or unconsciously, the world freezes at the trauma scene and ceases to unfold in a spontaneous, cohesive way. The subject is left in a state of insidious dread, and others objectively experience him or her as being distracted, detached, and emotionally absent. These symptoms are frequently associated with sleep disturbance, anxiety, and distressing trauma recollections (flashbacks).
At the epicenter of a terrorist attack, 90 percent of surviving victims may exhibit some adverse psychological reaction in the hours and days following the critical event. While the frequency of psychological distress dissipates as one moves in time or distance from its epicenter, a small but significant percentage of previously healthy individuals continue to bear significant distress. These findings have been demonstrated in demographic studies conducted with local and national populations exposed to trauma imagery. Following the September 11th terrorist attacks, for example, national surveys of stress reactions identified substantial symptoms of stress in Americans across the country (Schlenger et al., 2002; Schuster et al., 2001).
Most follow-up studies of trauma survivors demonstrate that victims, over time, “habituate,” or develop a certain tolerance towards such symptoms. A small but significant percentage of such individuals, however, remain in a state of hyper-vigilance and distressed by the visitations of traumatic recollections or flashbacks. Furthermore, in an unconscious attempt to shield themselves against further trauma triggers, such victims continue to engage in a variety of avoidance behaviors. This, in itself, can become disabling.
Multiple factors will influence the recovery process. Younger persons, for example, are more vulnerable than older persons. The amount of damage done to the individual, the amount of death or devastation that he or she has witnessed, the extent of exposure to the event, the absence of social supports, or the disruption of the continuity of the individual’s life may all impact negatively on trauma recovery. Yet for many victims there is an inner yearning for a life that exists beyond the trauma one that is safe, secure, peaceful, and calm.
At the time of this writing, spring 2007, America and countries in Western Europe have been spared the shock-frequency for the citizenry to be symptomatically affected by the tally of cumulative psychological damage. Following a single traumatic event, most healthy individuals will naturally regain the capacity to self-soothe and function as they had previously. The limited, available data appear to indicate that persistence of disabling symptoms decades beyond a single terror occurrence is very unusual for Type I traumatic incidents.
Section II contains articles that illustrate “Type II” or “complex trauma” proposed by Dr. Judith Herman in Trauma and Recovery (1992; for more detail see The PTSD Workbook by Williams and Poijula, 2002). In the context of this book, this trauma model is referred to as the “continuous terror” paradigm, especially as proposed by Shalev et al. (2006) in “Psychological Responses to Continuous Terror: A Study of Two Communities in Israel.” The uniqueness of the psychological effects of complex trauma that derives from this situation is not in its acute stress symptoms but in its ability to shape (and distort) how the victims think about themselves and the perpetrator, e.g., in the same way one often hears how an abused child believes he or she is “bad,” not the abuser. Such ongoing trauma, which creates a pervasive feeling of terror and helplessness in its victims, is described in the literature as a Type II Trauma.
While identical to Type I Trauma in its intensity and shock-effect, Type II Trauma is applied frequently and unexpectedly over an extended period. The predator (in this case the terrorists) uses the fear of impending death or mass-genocide as a weapon to ferment political change by creating a culture of terror. The constant fear of violation, the uncertainty of one’s future, the disruption of normal social functioning, and the political instability constitute the building blocks of the Type II Trauma paradigm. With it, the objective is the application of a multitude of fear triggers without the respite required for psychological reconstitution or physiological habituation. Through the application of fear, combined with the seduction of safety in exchange for political capitulation, this type of terror becomes an extremely powerful political tool.
Included in Section II on “continuous trauma” are case studies that demonstrate multiple traumatization that result from terrorism against civilians, compounded by the effect of governmental failure to protect its citizens from injury, separation or displacement. The examples in this section include the genocide in the former republics of Yugoslavia, and the current Intifada in Israel. As regards Israel, for example, Bleich et al. (2006), in “Mental Health and Resiliency Following 44 months of Terrorism,” point out that by 2004, 0.1 percent of the Israeli population had been killed or wounded by 13,000 terrorist attacks. This would represent an equivalent per capita of 300,000 American casualties. In addition, 47 percent of the Israeli population sampled continued to feel a sense of life-threatening danger. Following the subsequent unilateral evacuation of Gaza, hundreds of Israeli families remain “housed” in trailers, consisting of modified Formica containers. Communities have been deliberately dispersed in a brilliant military tactic of isolating the “enemy within.” Terrorist missile factories that rain fear and death over the skies of Sderot, Ashdot, and Ashkelon have replaced the once-thriving Jewish agricultural center of Gush Katif. Household leaders, once gainfully employed from the produce that miraculously sprouted from the desert, beg from communal coffers. Community leaders are held indefinitely in detention lest they mobilize attention or political support. In short, Gaza and the beautiful Mediterranean Port of Gush Katif, once the strategic southern flank of Israel, have been dismantled as a social experiment of appeasing an unrepentant predator.
In my estimation, this situation demonstrates to terrorists and their supporters that the paradigm of continuous terror ultimately fulfills its goal. As the enemy hijacks the victim’s ego-functions, the victim’s beliefs, emotions and political actions are “split off,” and he acts in concert with the thoughts, feelings, and behaviors imposed by his perpetrator. In other words, a structural dissociation sets in, as the victim unwittingly comes to identify with his persecutor, at the expense of sacrificing the “self” and isolating the “soul.” This loss of agency appears to be the ultimate psychological and spiritual consequence of boundary violation characterizing Type II Trauma.
Section III contains articles that focus on the long-term consequences for individuals of early trauma, decades later, and their continued vulnerability to trauma triggers throughout the life course. Thus, this section describes the long-term, more complex Type II Trauma syndromes that appear among survivors of a prolonged, repeated, and intense trauma. While it is not yet established that the “chronic survivor syndrome” is synonymous with the long-term effects that will persist after repeated acts of terrorism, the Holocaust survivor represents an opportunity to examine complex Type II Trauma among a homogenous population. Most survivors from the Holocaust settled in New York and Israel, where they remained a protected treasure of Jewish survival. While many of these survivors have led productive lives and maintained the Jewish European culture, many did this without the joy of life. With increasing frailty, illness, and loss, their continued will to live gradually has been overshadowed by an underlying sense of survivor-guilt, loss and despair. These findings are presented in the articles written by, among others, Shmotkin et al. (2003) and Sadavoy (1997), who examines a multitude of long-term trauma victims in older populations and adds significance to the enduring effects of different trauma events on diverse population samples.
The psychological, as well as physiological and social, responses to collective terror may be predicted by examining the data on Holocaust survivors, since they represent one of the few surviving communities meticulously studied regarding the effects of cumulative terror on civilian society decades following continuous threat.
I included in this section the article by Solomon and Prager (1992) on the reactivation of PTSD in Holocaust survivors following the Scud missile attack during the first Gulf War. The article by Kinzie et al. (2002), which covers Type II, or Complex, Trauma, is included in Section II since this unique study examines the effects of the September 11th attacks on five different ethnic groups of refugees previously traumatized as civilians in their native war-torn countries. Bosnian and Somalian patients showed the greatest deterioration in their subjective sense of safety and security consistent with the continuous terror paradigm.
“From the Editor’s Preface”
