Professor Sir Simon WESSELY

King’s College London, UK

King’s Centre for Military Health Research, London, UK

Royal Society of Medicine, London, UK

(Corresponding Author: Professor Sir Simon Wessely, Institute of Psychiatry, King’s College London, Strand, London WC2R 2LS, United Kingdom; E-mail: simon.wessely@kcl.ac.uk.)

Terrorism is a psychological weapon, or it is nothing. By definition the purpose of terrorism is to spread an emotion – namely terror, or at least fear, in order to achieve goals that could not be gained by more conventional political or military means. It is par excellence a weapon of asymmetric warfare, but one where success or failure is entirely dependent on the psychological reactions of those who are the targets. In conventional military strategy victory is obtained when the enemy is unable to give battle, as happened with the German Army at the end of the First World War, but this objective is beyond the reach of those who chose to perpetrate a campaign of terror. Victory there comes when the targets of the campaign no longer wish to “give battle”, even though they could, because the political, rather than the military, wish to do has been lost. Terrorism is psychological warfare in its purest sense.

Perhaps surprisingly, although historians and political scientists(Anyone wishing to learn more could do worse than read anything written by the late Walter Laqueur on this topic.) have long been concerned with terrorism and its consequences, interest from the behavioural and psychological sciences has been relatively recent. It was on the rise in the 1990s, but given a dramatic boost by the iconic events of Sept 11th 2001.

This volume is concerned with the most immediate psychological consequences of being exposed to a terrorist incident. It uses the concept well known to those in surgery, military or emergency medicine known as the “Golden Hour”, where it has been well established that immediate interventions during that critical period immediately after injury make a major contribution to a person’s chance of survival. It provides a useful starting point for this volume, although one must be careful not to take analogies between physical and psychological medicine too closely, and indeed none of the contributors to this volume interpret an hour quite so literally.

So this volume is really about hours, days and even weeks rather than a single hour. And we are talking about mental health interventions, loosely defined. Now I can hear some readers already saying “surely, they are not going to be suggesting that everyone who has been caught up in a seriously traumatic event needs to see a psychiatrist straight away?” Rest assured we are not – it is clearly unfeasible, but fortunately it is also not just unnecessary, it is probably undesirable. Mental health interventions can and do happen without any mental health professional being audible or visible, except perhaps in the background giving advice, or even further in the background helping with planning and policy. We, and I include myself in this, do not need to see most, and perhaps even none, of those swept up in these events in this “Golden Hour”.

Instead most of the contributions to the book emphasise that in those early hours what matters most is our existing social networks of friends, families and colleagues. There is little point in listing the studies that show that first instinct that people have when confronted by large scale psychological trauma is to contact their family and friends – I am unaware of any evidence to the contrary. It was no surprise when our group showed that failure to make that contact led to a rise in anxiety following the 2005 London bombs – again, no surprises there [1]. But what was a surprise when we showed that this effect was still detectable six months later [2]. So, the first task of professional, planners and policy makers is to do what they can to facilitate doing what comes naturally. Perhaps the most useful thing that we can bring to the scene of the crime or emergency room is a large box of working mobiles and chargers. Mobile phones and chargers meant little to the civil defence authorities in the United Kingdom during the Second World War, responding to the impact of strategic bombing of our cities, but they knew what mattered when it came to immediate measures to support morale. Translate morale into “well being” and this could be written today, not 1941 [3].

“The morale of the bombed largely depends on the care they get in the first 36 hours…rest centres, facilities for children, information, health care and provision of food”.

Nor should we forget the literature on the failure of immediate single session psychological debriefing to reduce distress – indeed, in some studies it was shown to increase the rate of distress, rather than the opposite. There are a number of possible explanations for these findings, one being that it calls to attention disturbing and distressing traumatic imagery, but without the time or place to teach techniques to reduce such imagery. There is a time and a place for counselling or cognitive behavioural therapies, but a few hours after witnessing a ghastly event may not be it.

Of course, many people will already be experiencing distressing traumatic imagery anyway. The chapter by Emily Holmes and colleagues (Chapter 3.3) introduces the reader to a very novel approach, the concept of a “cognitive therapeutic vaccine”, again making an analogy to physical medicine, which if given early may prevent the reoccurrence of intrusive trauma memories that are at the relatively modern concept of post traumatic stress disorder, but not by a single session of individual counselling, but by setting out to do the opposite, by in their words.

“Engaging in a visuospatial task (i.e. one thought to require mental imagery) during memory consolidation (e.g. first hours post-trauma) competes for working memory resources with mental imagery and thereby interferes with the formation of intrusive memories of the trauma”.

They suggest that by getting the person to concentrate on non traumatic mental imagery it actively blocks the formation of traumatic mental imagery. If this is confirmed, and the authors are right to say that this is in its infancy, it could indeed represent a very significant step forward. This is not the only such approach – the contributions from Rachel Yehuda, Dominqiue de Quervain and colleagues (Chapters 2.3, 3.1) also explore equally radical pharmacological approaches, but are equally cautious in their conclusions. This is very much a space to watch.

We must also acknowledge that no matter what we think we can and cannot, should and should not, do in the immediate aftermath of disaster as mental health professionals (who make up most of the contributors and probably most of the readership of this book), we are dwarfed by the impact, for good or ill, of something far larger, and far less manageable, if it is manageable at all. Küey (Chapter 6.2) quotes to good effect several sources to point out that.

Today, in terms of news, we are continuously, “reading, watching, viewing, listening, checking, snacking, monitoring, scanning, searching, clicking, linking, sharing, liking, recommending, commenting and voting,” and thus, “journalism today is interactive, interconnected, participatory, more open, more global, multi-platform, multi-linear, producing a constant stream of data, analysis, and comment”.

He is of course talking about the world of social media, and whilst there is no denying the impact of social media on how we think, experience, react to and organise our responses to terrorism in particular and disasters in general, what we do about it is another matter entirely. The lesson of King Canute comes to mind. (Canute, or Cnut as he should be better called, is probably best remembered for his probably mythical demonstration of the limits of kingship when he showed that all powerful though he was, he could not stop the flow of the tides. However, it is worth remembering that he was himself no stranger to use of terror- see for example his mutilation of Saxon hostages at Sandwich to create terror in his enemies.)

By now I hope the reader is champing at bit, anxious to get on with the real business of reading the book. But please, bear with me just for a moment longer, for a word of caution. Not about the contributions, but about the context in which we should view mental health reactions to terrorism, whether early or late.

Because what is unusual about terrorism is not how successful it has been, but how unsuccessful, unless one measures success by time spent queuing in airports. Does it create panic on the streets? Rarely. Not discussed, because there was no need, the considerable body of literature that shows that when exposed to the kind of acute incidents generated by terrorism, panic is the exception, not the rule. A fire in a crowded nightclub with obscured exits is a far more potent generator of panic than most terrorist incidents. The evacuation of the World Trade Centres, carried out by and large without any assistance from the emergency services, is often and correctly quoted as an example of an orderly self-directed evacuation. Images of people fleeing from Brussels Airport or the immediate vicinity of the Palace of Westminster need to be examined carefully before the actual reasons for large numbers of people seemingly fleeing “in panic” can be discerned. In fact, more often than not people will move towards the incident to offer assistance if left to themselves. When we talk about “first responders”, we should remember that the people already on the scene have started to respond themselves before the “blue light” services appear. All of this was the subject of a previous NATO workshop looking at the psychological consequences of terrorism in the immediate aftermath of 9/11 [4].

But what about the longer-term impacts? Just how effective is terrorism there? The political and psychological impact of man-made accidents, such as Chernobyl or Bhopal, are more long-lasting and pernicious than those of terrorism. Deliberate attempts by modern states at war to provoke terror, panic, demoralisation and ultimately defeat, such as the use of strategic bombing in the Second World War first against the United Kingdom and then against Germany, were not just ineffective, but counter productive [5].

So this book is by and large about how to prevent or manage adverse mental health consequences than might happen to people caught up in an act of terrorism. And it is right and proper that you do this, since it seems that terrorism is going to remain an unwelcome visitor to many of our shores for the foreseeable future (Although it is worth looking at the list of countries that currently account for most of the deaths from terrorism at the moment, as listed in the Duckers, Ursano, Vermetten chapter (Chapter 1.2), to realise that the burden falls almost entirely on Africa, the Middle East and Afghanistan, rather than the high income countries that seem to generate most of the research on the topic.), generating not just physical but also mental casualties. But just as not everyone involved in an act of terrorism needs surgery, whether in the Golden Hour or beyond, nor does everyone need mental health interventions either.

So, planners, policy makers, or just us as citizens, let us be careful not to do the job of the terrorist for them. Instead we must never lose sight of the simple fact that the commonest reaction to terrorism, whether it be by individuals, populations and societies, is fortitude and resolution [6]. Not for nothing does the first chapter that you can now open begin with an essential truth (Ursano and colleagues, Chapter 1.1).

“Most research has shown the majority of people will be resilient following a terrorist attack and return to full function; some may even feel increased ability to manage stressors in the future”.

We should be asking ourselves not why is terrorism so successful, but why it is so unsuccessful. Unless of course you measure success in time spent queuing in airports.

References

[1] G.J. Rubin, C. Brewin, N. Greenberg, J. Simpson, S. Wessely, Psychological and behavioural reactions to the bombings in London on 7 July 2005: cross sectional survey of a representative sample of Londoners, British Medical Journal 311 (2005), 606–610.

[2] G. Rubin, C. Brewin, N. Greenberg, J. Hacker Hughes, J. Simpson, S. Wessely, Predictors of persistent distress following terrorism: a seven month follow up survey of reactions to the bombings in London on 7 July 2005, Br J Psychiatry 190 (2007), 350–356.

[3] Public Record Office, HO 199/442 “Report on Liverpool and Manchester 10th Jan 1941”

[4] S. Wessely, V. Krasnov (eds), Psychological Reactions to the New Terrorism: A NATO Russia Dialogue, IOS Press, 2005.

[5] E. Jones, R. Woolven, W. Durodie, S. Wessely, Public Panic and Morale: Second World War Civilian Responses Reexamined in the Light of the Current Antiterrorist Campaign, Journal of Risk Research 9 (2006), 57–73.

[6] W. Durodie, D. Wainwright, Terrorism and post traumatic stress disorder: A historical review, Lancet Psychiatry 6 (2019), 61–71.