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CHAPTER ONE:
WHAT TO EXPECT AFTER A TERRORIST 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. As Dr. Batya Ludman aptly put it "The goal of terror is to induce fear or terrorize. Losing hope comes from our sense of hopelessness due to our lack of control and our inability to predict the future."

Who is Affected?

Visualize concentric circles looking like a bull's-eye. The center circle represents being at the actual scene and/or suffered injury. The second circle represents having a friend or family member killed or injured - or having your home damaged. A third circle slightly farther from the center, would represent relatives and close friends of the injured or having a friend's or neighbor's home - or the children's school being damaged. A fourth circle would represent the acquaintances, distant relatives, etc of someone injured. The fifth circle included those who witnessed the attack through the media. The circle furthest from the center represents hearing about it, but not actually experiencing any visual stimulation.

Twenty-four-hour-a-day TV news has brought terror attacks into people's living rooms in real time, enabling them to witness events as they unfold and to see them 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 television news 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.

Many people do not realize that the number of psychological casualties resulting from a terror incident can be 10 or even 15 times the number of physical victims.

The Flashback Syndrome

Sarah was lightly injured many years ago in an explosion on a city bus in Jerusalem. 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 disaster are people who experienced a personal loss within the previous year or so and did not have the ability or possibility of working though that loss effectively.

Two examples:

After the double murders in Tekoa, a young man who was 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 when he observed 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 having been 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?

• Your location within the circle.
• Your normal reaction to acute stress.
• Your general physical and mental health prior to the attack.
• Your ability to control its reoccurrence; naturally in a case of a terror attack we have no control what so ever.
• Whether the disaster be predicted. In the case of hurricanes or other natural disasters there is often some degree of predictability. The magnitude of the symbolic loss. When a home is broken into or destroyed, the ideal of one's home as a place of protection is destroyed. We feel violated and no longer at peace within its walls

All of us do experience the same 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/or 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 miss their periods or experience other physical changes.
• Lethargy. While more common in situations of long-term stress, it often occurs after a terrorist incident.
• The 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?

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.

Conversely, the greater the likelihood of another incident, the longer the symptoms will last. After the World Trade Center attack, psychologists were worried that another attack within the next month would complicate the recovery of those directly affected and spread fear and instability throughout the US. The worst case is when after a series of attacks, there is a respite - before the next attack. People begin to breathe again and to hope. If that lull is broken then all the symptoms become far more acute. People become more despondent and fear to hope.

Whether there were previous experiences that could trigger an additional reaction.

Other stresses your life at that time.

One's usual reaction to stress.

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 above three 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?

Understand that what you are going through is normal.

Learn from past experiences.

Talk about how you feel with your significant others.

Organize local groups.

Try to get back into your normal routine as soon as possible.

Exercise.

Wait for time to pass.

Pray.

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.

Talk to your children!

As we will see in the next chapter, 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 about 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 doubly.

If you handle the situation well, you will be teaching your children a valuable lesson in coping.

Spend more time with your family.

Go to funerals and memorial services.

So After All This When Do I Seek Help?

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 can't cope on a daily basis. If you fear leaving home. (I am not referring to objective fear in situations where people are being shot at on the road.)
• If you fear being in a crowd. This does not apply obviously to fear of being in a crown out of fear of suicide bombers, which is natural.
• 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."

The Great Conflict

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 answer differs in each situation.

Debbie's 15 year-old son, Yoni, was burnt in a bomb attack. 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 her fear of what 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. Often, 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 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 were directed at an outsider, thus minimizing any lingering resentment or bad feelings about the decision within the family. (What was the compromise?)

Debriefing

The term "debriefing" is a professional term. It is also called critical incident stress management. In a debriefing, survivors of 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 (usually between 72 hours and a week). Debriefing should be done on a one-on-one basis or with a small group. Attempts to debrief 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 the first debriefing because everyone involved 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.