PSYCHOLOGY OF TERRORISM
Oxford
University Press
Bongar,
Brown, Beutler, Breckenridge & Zimbardo (Eds)
2007
Timothy A. Kelly, Ph.D.
As the previous chapters so dramatically portray, the world changed on 9/11 and civilization is now, like it or not, enduring an age of terrorism. On that clear September day, the world watched in horror as the Twin Towers collapsed and thousands of innocent lives were lost. The television footage was horrendous, showing some plunging to their death from the flames, others fleeing monstrous clouds of dust in panic, and still others exhausted and covered in a ghastly soot from top to toe. On average, adults watched over eight hours of coverage that day (Schuster et al., 2001), enough to see the towers come down dozens of times, enough to traumatize the hapless viewer. Acts of terrorism are of course designed to do just that – to traumatize a population into submission (Linley et al., 2003). America has not submitted, but it has been traumatized by the terror of 9/11.
Where do people turn in times of trauma? Where is help to be found when the very infrastructure of society collapses as it did in New York City? A Rand survey conducted less than a week after 9/11 discovered that people relied primarily on two resources – one another, and their understanding of God. As the survey authors state, Òmost turned to religion, and also to one another for social supportÓ (Schuster et al., 2001, p. 1511). In fact, a full 90% reported turning to prayer, religion, or spiritual feelings. That is slightly above the 85% of Americans who report that religion is Òfairly or very importantÓ in their lives (Gallup, 2003). In a similar vein, survivors of the Oklahoma City bombing were found to consistently use Òpositive religious coping strategiesÓ as a means of working through the trauma of that attack (Harrison et al., 2001. p. 88).
Shortly after 9/11, the Department of Justice distributed the Office for Victims of Crime Handbook for Coping after Terrorism (U.S. Department of Justice, 2001). The handbook refers several times to the fact that victims of terrorism may need to consider Òprofessional or spiritualÓ counseling, meaning help from a counselor or from a minister[1]. Recognizing this fact, the city of New York provided generously for the thousands of workers charged with the grisly task of sorting through the rubble of the Twin Towers. Dozens of mental health professionals and clergy were brought in to make themselves available for the workers as needed. To whom does one turn when you have just recovered a coworkerÕs body, or perhaps the arm of a child, from the rubble? Mental health professionals can offer processing of thoughts and feelings that is certainly helpful in many instances. But for many trauma victims, clergy can offer more; a level of comfort, a means of grace, a touch of the divine in the midst of the struggle to cope with incomprehensible tragedy. So it has been found that in times of cataclysmic trauma, people turn first to clergy for emotional support, and only later, if at all, to mental health workers (Everly, 2003).
On the other hand, a religiously oriented person experiencing a life trauma may find that their religious beliefs do not necessarily help. They may struggle endlessly with the age-old question of theodicy – how to reconcile the reality of evil with the concept of an all-powerful and all-good God. This is most poignantly expressed as a syllogism:
á A good and omnipotent God must be willing and able to prevent evil.
á Evil exists.
á Therefore, God is either not omnipotent or not good.
For example, a study of Vietnam veterans suffering from Post-Traumatic Stress Disorder found that 74% have difficulty reconciling their religious beliefs with the trauma they experienced in Vietnam. Slightly over half (51%) stated that they abandoned their religious faith in Vietnam (Drescher & Foy, 1995). For these men, religion and spirituality did not help them to cope with the horror of warfare.
What is to be made of the fact that those traumatized by a terrorist attack turned in large numbers to religion/spirituality, yet many Vietnam veterans abandoned their faith? Do religion and spirituality provide a critical resource in times of national trauma, or is this a false hope? If it is indeed an important resource, precisely what aspect of religion or spirituality helps one to cope in time of trauma? This chapter will address these and related questions as they pertain to individual and community preparedness for terrorist attack. Since there is some confusion as to the definitions of basic concepts such as ÒreligionÓ and Òspirituality,Ó that will be the starting point. The chapter begins by introducing and defining key terms: spirituality, religion, faith-based community, post-traumatic stress disorder, post-traumatic depression, and post-traumatic growth. Next, current research on trauma care, and on the role of religion and spirituality in coping with trauma, will be reviewed. The chapter will close by discussing practical recommendations for Emergency Mental Health professionals, individuals, and faith-based communities in drawing on spirituality and religion to help cope with the trauma of a terrorist attack.
<1>Key Concepts and Terms
<2>Religion, Spirituality, and Faith-Based Community
Wars have been fought, and are still being fought, over which concept of God and definition of religion will stand. In fact, the terrorism the world faces today – primarily that of militant Islam – is often justified by the perpetrators as necessary in order to protect and expand a way of life based on strict religious beliefs. It is both ironic and tragic to note that militant Islamic terrorists kill in the name of God while at the same time many victims of their attacks turn to God in order to cope with the inflicted trauma. It is not surprising, then, that no precise definition of religion can be offered with which all theologians and policymakers would agree. Instead, this chapter offers a dictionary definition generic enough to reflect a pluralistic approach yet specific enough to be meaningful:
á Religion: Belief in a divine power to be worshipped and obeyed as the creator and ruler of the universe, expressed in conduct and ritual (WebsterÕs, 1979).
ÒSpirituality,Ó too, is a word with variable usage and meanings. Currently in post-modern America the term is frequently used to refer to a more personal, subjective, Òpsychological,Ó and less formalized type of religious orientation. Thus, a person can be spiritual without necessarily being religious. To some, it is more authentic to be spiritual in oneÕs own way than to be religious by following the directives of an organization such as a church, synagogue or mosque. However, this dichotomized view of religion and spirituality is problematic. After all, many traditionally religious men and women place a high value on spirituality as well, and hold that these are not mutually exclusive concepts. Perhaps it is more helpful to suggest that spirituality and religion are overlapping concepts with a difference in focus. Spirituality focuses more on individual and psychological expression, whereas religion focuses more on corporate and sociological expression. It is possible to experience one without the other, but many would say that they function best as two sides of one coin. A religious person lacking spirituality may be seen as superficial, and an anti-religious spiritual person may be seen as simply self-indulgent. In contrast, a person who is both spiritual and religious can be seen as demonstrating a credible maturity of faith and practice.
Consider, for example, notable religious leaders such as Mother Teresa and Dr. Inamullah Khan, Christian and Muslim recipients of the Templeton Prize, or Lord Jacobovits, former Chief Rabbi of Great Britain. Each of these remarkable people can be said to demonstrate a life that is both religious and spiritual. Acknowledging, then, that these concepts are distinct yet complementary, spirituality may be defined as follows:
á Spirituality: The individualÕs personal, subjective expression of their search for transcendent meaning and purpose, which may or may not involve organized religion.
With these definitions in mind, it is possible to state with some clarity what is meant by Òfaith-based community.Ó Since religious beliefs are not subject to empirical verification, and concepts of the divine are not subject to standard scientific tests, faith is a prominent component in both religion and spirituality. (Of course, even the hardest science requires faith in the empirical method and scientific interpretation, but that is another discussion.) Thus, religiously or spiritually oriented people are often described as Òpeople of faith,Ó and many consider themselves part of a community of those who believe as they do. (Though some are more individualistic and idiosyncratic in their faith, and do not associate with any religious organization.) The faith community typically revolves around a parish, church, synagogue, mosque, or some other anchor point for like-minded believers:
á The faith-based community is that group of like-minded believers with whom the individual participates and identifies regarding religious/spiritual beliefs and practices.
It is to such communities that survivors of terrorist attacks invariably turn for help.
<2> Post-traumatic Stress Disorder
The concept of psychological trauma following in the wake of physical trauma is generally well accepted by professionals and the general public alike. The central idea, as presented in Chapter 13 (??), is that a person who has experienced an overwhelming trauma may find afterwards that he is simply unable to cope well with lifeÕs stressors. Instead, he experiences debilitating symptoms that may continue unabated unless treated. During and after the World Wars of the 20th century, for example, many servicemen were found to have Òshell shockÓ and to be in need of hospitalization. The need for treatment for post-combat servicemen helped drive the expansion of VeteranÕs Administration hospitals, and sped the growth of clinical psychology. But it wasnÕt until after the Vietnam War that the term ÒPost-Traumatic Stress Disorder (PTSD)Ó was coined as a way to capture the disabling experiences endured by many combat veterans. PTSD is defined for mental health professionals in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000). It occurs after exposure to a life-threatening stressor that induces fear, helplessness and/or horror (e.g., combat, sexual assault, torture, terrorist attack, etc.). Exposure may involve being present and experiencing a direct threat of death or injury as was the case for those in the Twin Towers on 9/11, or it may involve witnessing such an event either close at hand or via media coverage (Linley et al., 2003). The result is a difficult array of symptoms such as feelings of extreme anxiety or panic, recurrent nightmares or flashbacks, reliving the event mentally and emotionally, ceaseless hyperactivity, and significant dysfunction at home or work.
Results of a national survey in the mid 1990s showed that PTSD was fairly widespread in America even before 9/11 (Kessler et al., 1996), and it is expected that rates rise after major disasters. For instance, nations that have experienced extreme conflict show extremely high rates of this disorder: Algeria (37%), Cambodia (28%), and Gaza (18%) (de Jong et al., 2001).
In sum, PTSD is a well-recognized emotional disorder, triggered by a traumatic event, that seriously impairs quality of life. If untreated, PTSD can result in permanent mental disability involving intense psychological suffering, social alienation and disorganization, decreased productivity in the workplace, and ongoing medical and legal expenses. Since a terrorist attack is by definition a potentially overwhelming traumatic event, survivors of such attacks are at high risk for PTSD. This is confirmed by research completed six months after 9/11 in New York City, which found that 36.7% of those who were in the World Trade Center met criteria for PTSD (Galea et al., 2003).
<2>Post-Traumatic Depression and Other Disorders
Survivors of a terrorist attack are clearly at risk for PTSD. They are also at risk for other emotional disorders which may either be related to PTSD, or totally distinct but triggered by the same trauma (Flannery, 1999). For instance, post-traumatic depression can occur as the survivor finds that, following a trauma, a profound sense of hopelessness and sadness becomes overwhelming and debilitating. Such depression may include loss of sleep and appetite, loss of motivation and energy, feelings of guilt or anxiety, and suicidal thoughts. Unless treated, post-traumatic depression may become chronic, and may lead to suicide attempts.
Other emotional disorders may also be triggered by trauma, though PTSD and post-traumatic depression are the most common. Trauma survivors may experience panic attacks, agoraphobia (fear of leaving the safety of oneÕs home), or psychosomatic pains such as stomach cramps or headaches. Survivors may also find that, for the first time, they struggle with drug and alcohol abuse or other high-risk behaviors. After 9/11, surveys found that the trauma of terrorist attack led large numbers of Americans to seek help for substance abuse (National Center of Addiction, 2001). It is not known why the same trauma evokes different disorders in different people, but it is clear that these disorders call for timely and effective help. If no help is available, these disorders may result in intense psychological pain, increase in accidents or illness, lost productivity in the workplace, permanent disability, or suicide (Flannery, 1999).
<2>Post-traumatic Growth
Whereas the fairly common experience of PTSD and related emotional disorders is well studied and well accepted, clinicians and researchers have more recently identified another possible sequelae to trauma that is only beginning to be understood – post-traumatic growth. Actually, the possibility of positive change resulting from negative events has been recognized through the ages in philosophy, literature and religion. Consider, for example, the mythological story of the Egyptian Phoenix – a great bird that was destroyed, only to rise again from the ashes. Or consider the actual story of Lance Armstrong, multiple winner of the Tour de France after surviving cancer. In his autobiography Armstrong discusses how the trauma of cancer and chemotherapy led to his resolve to become a world champion, stating that the Òtruth is that cancer is the best thing that ever happened to me (Armstrong, 2004, p.4).Ó Of course this does not mean that Mr. Armstrong welcomes the scourge of cancer, but that even the worst experience can lead to remarkable benefit. Thus the concept of new birth, or growth, resulting from trauma and suffering is not new.
For the past 10 years a growing number of researchers have been studying this intriguing concept. Although terms used vary,[2] the concept is the same – long term positive outcome following crisis. As a result, a growing body of literature has found that a significant number of persons who have been victimized by trauma experience post-traumatic growth (Affleck & Tennen, 1996; Arnold, Calhoun, Tedeschi & Cann, 2005; Linley & Joseph, 2004; McMillen, 1999; Tedeschi & Calhoun, 1995; Tedeschi, Park & Calhoun, 1998; Woodward & Joseph, 2003).
It is possible to experience growth after illness, bereavement, and other major life stressors. And it is also possible to experience growth after the severe trauma of a terrorist attack. But just what does post-traumatic growth mean, and how is it best understood? Most researchers suggest that it consists of positive changes in interpersonal relationships, positive changes in life philosophy, and/or a sense of peace and optimism in the face of adversity. As a result, the post-trauma individual ends up at a significantly higher level of functioning at home, at work, and with others. This positive change is labeled Òpost-traumatic growth.Ó
It is important to note that post-traumatic growth is not the same thing as resilience or recovery (e.g., Bonanno, 2004, 2005), topics which are addressed in Chapter 21 (??). It is certainly true that many people are able to recover from even a disastrous trauma and carry on, especially with the support of friends and family. These are emotionally strong people who have the ability to return to normal functioning with little help, and who will likely not experience PTSD. But post-traumatic growth means more than just recovering oneÕs normal state of functioning, as important as that is. It means that the victim of trauma actually ends up surpassing their pre-trauma state of functioning, such that they report being significantly better off for having suffered the event. This does not at all suggest that the trauma is therefore welcomed or trivialized, nor does it mean that there is no negative impact from the trauma. It is possible for a survivor to go through periods of severe anxiety and grief on the way to post-traumatic growth. But it does mean that the final outcome is actually superior to the starting point.
In sum, there are three possible outcomes to trauma: PTSD, recovery, and post-traumatic growth. Not only do these outcomes yield different experiences for the victims of trauma, but they require different treatment responses as well, as is now being recognized by trauma care researchers.
<1>Trauma Care and the Role of Religion and Spirituality
<2>Critical Incident Stress Management – a Trauma Care Standard
Every major metropolitan area across America has designated resources for meeting community needs after a disaster, whether that involves food and housing, healthcare, or mental healthcare. Emergency Mental Health (EMH) services are designed to meet the mental health needs of individuals and communities after a major disaster such as a terrorist attack (Flannery, 1999). These services typically are coordinated from a central crisis-response center, and involve those who have been selected and trained to serve the community as EMH professionals in time of crisis. Thus in any given area there should be a team of psychiatrists, psychologists, social workers and/or other mental health practitioners who are ready to serve when called upon. But what guides the services that EMH professionals offer? The most widely recognized treatment approach is known as Critical Incident Stress Management (CISM; Everly & Mitchell, 1999), which provides a paradigm for post-crisis care. CISM is designed to reduce the acute psychological distress suffered by victims of a trauma such as terrorist attack, and to reduce the incidence of emotional disorders such as PTSD that may be triggered by that trauma.
CISM necessarily requires planning and preparation on the part of emergency care agencies, such as selecting and training EMH professionals and developing area plans. Once implemented, there are four primary treatment components, which can be helpful both for the general population of an affected area and for disaster workers attending the general population:
o Individual acute crisis counseling, consisting of one-on-one counseling sessions, with or without medications. This is typically offered as soon as possible to those who are severely traumatized, and who may have difficulty with daily life functioning.
o Brief small group Òdebriefings.Ó These group discussions are designed to reduce acute symptoms such as high anxiety levels, grief, etc, by working through such feelings. The goal is to offer this service early on so as to defuse what could otherwise become debilitating emotional trauma.
o Longer term small group discussions known as ÒCritical Incident Stress DebriefingÓ (Mitchell & Everly, 1996). The goal of long term debriefing is to work through traumatic events and achieve a sense of closure so that victims can move on with their life without difficulty. This may take weeks or months of focused effort, especially for those who have difficulty expressing negative thoughts and feelings.
o Family crisis intervention procedures. Living with traumatized individuals can be hard on a family unit, or on others who live or work closely with the victim. This intervention involves EMH professionals going into the neighborhoods and homes of trauma victims and offering family therapy and other supportive / problem-solving services that may be called for.
The goal of these interventions is to reduce pathological symptoms, build caring networks of friends and family for ongoing support, and restore a sense of mastery and purpose in life. If the interventions do not adequately meet the needs of those impacted by the trauma, CISM calls for referrals for psychological assessment and treatment on an as-needed basis. CISM has been found to have empirical support (Everly, Flannery & Mitchell, 2000; Everly & Mitchell, 1999), and is seen by many as an international standard of trauma care for mental health needs (Mitchell & Everly, 2000). For this reason, it was widely offered as a standard ÒblanketÓ intervention after 9/11 for all individuals exposed to the trauma of the World Trade Center attack (Miller, 2002).
<3>Research on the Effectiveness of Trauma Care
Until recently it was assumed that CISM, and related approaches, constituted state-of-the-art effective treatment for all trauma victims. The assumption was that all individuals exposed to life-threatening stressors would benefit from the services detailed above. After all, common sense suggests that it is helpful to work through grief and anxiety following trauma and loss, and that the alternative is to deny emotions at oneÕs own risk. Surprisingly, a growing literature demonstrates that that is not the case (e.g., Bonano & Kaltman, 1999; Stroebe & Stroebe, 1991; Wortman & Silver, 1989). As it turns out, not only is CISM sometimes ineffective, but it may actually be harmful in some cases. One review of grief therapies, which overlap considerably with CISM strategies, found that 38% of the individuals receiving treatment actually got worse (Neimeyer, 2000). CISM is likely helpful for some trauma victims who are who are spiraling downwards emotionally and need help to process negative feelings and thoughts. But it is not necessarily appropriate for those who have a different experience in reaction to trauma (Bonano, 2004).
Thus, it seems increasingly clear that there are differential treatment needs among survivors of a terrorist attack. Some may benefit from CISM and related treatment approaches, as detailed in Chapter 16 (??). But according to Dr. George Everly, Jr., who heads up the International Critical Incident Stress Foundation, many need what might be called Òpastoral crisis intervention.Ó Everly defines this as Òthe use of traditional pastoral interventions applied within a context of sound emergency mental health skills,Ó and states that pastoral crisis intervention is Ònowhere . . . more useful than in response to real or threatened terrorismÓ (Everly, 2003, p.1). Thus a well-recognized proponent of CISM acknowledges the limitations of that approach to post-trauma treatment, as well as the unique relevance of spiritual and religious resources.
<2>The Role of Religion and Spirituality in Coping with Trauma
Terrorism demoralizes a population with fear, anger, paranoia and grief. Those who have lost loved ones are devastated, and witnesses (even via media) are horrified. Trust in oneÕs community and government may fail, and the very fabric of society may seem to be crumbling. Saathoff and Everly point out that such feelings have the potential to spread by contagion, such that the population inadvertently spreads the intended impact of a terrorist attack by losing perspective and resolve (Saathoff & Everly, 2002). We thus further terrorize ourselves. If CISM is not capable of neutralizing such trauma sequelae for all victims, what recourse is there?
One recourse is to draw on the near-universal human experience of faith, spirituality, and religion. These resources have been historically neglected by the field of psychology for various reasons, yet are now recognized as strongly related to mental health (Hill & Pargament, 2003; Kelly & Strupp, 1992; Miller & Thoresen, 2003). Perhaps one could add that this rediscovery is coming in the nick of time, as America faces an enemy capable of destruction on the order of a nuclear war, yet without the predictability of the cold war. Thankfully, because of the rediscovery of the role of spirituality in mental health, there is a growing literature on the topic of spirituality and trauma – sometimes referred to as Òreligious coping.Ó Researchers have found that positive religious coping is associated with lower rates of depression, and with fewer symptoms of psychological distress such as those found in PTSD (e.g., Calhoun et al., 2000; Drescher & Foy, 1995; Everly, 2003; Harrison et al., 2001; Meisenhelder, 2002; Overcash et al., 1996; Pargament, Tarkeshwar, Ellison, & Wulff, 2001; Pargament et al., 1990; Sowell et al., 2000). More specifically, research points towards three key resources that religion and spirituality provide for victims coping with the trauma of a terrorist attack: openness to religious growth, engagement in spiritual reflection, and involvement in faith-based community.
<3>Openness to Religious Growth
In earthquake-prone California, much has been learned about the type of building construction that can withstand a major earthquake. Standard building practices produce rigid structures that are unable to flex or sway in response to a tremor, and these buildings are much more likely to suffer damage or even collapse. Earthquake-resistant structures are built with flexibility so that they may give and sway during a quake. Although the swaying can be unnerving for those inside, it protects all from harm. In like manner, a person experiencing a major trauma is going to discover whether their faith and spirituality is rigid or flexible. A rigid approach to religion means that simplistic concepts are held onto at all costs, such as Òa faithful person will not suffer tragedy.Ó A person with this (or similar) rigidly held religious belief is left with only three options after experiencing a major trauma. They may attempt to deny that the trauma was as bad as it seems, thus maintaining their belief that they are not subject to lifeÕs tragedies despite evidence to the contrary. They may draw the depressogenic conclusion that the tragedy proves they lack faith. Or they may abandon their religious beliefs altogether since the trauma experience was not consistent with their unrealistic and rigid theology. Needless to say, none of these options are desirable. Neither a life in denial, nor depression, nor a life shorn of faith, will help the victim cope with the trauma of a terrorist attack.
The alternative is to be flexible in response to the trauma, and open to change and growth as a person of faith. This means holding onto oneÕs religious beliefs even while searching for answers, and turning to oneÕs understanding of God in a heartfelt manner for help and direction. Where better to turn in time of overwhelming trauma? As noted above, after the 9/11 terrorist attacks 90% of the people turned to prayer, religion, or spiritual feelings. In short, they turned to God as a source of comfort, strength, and understanding. For a person of faith, only in God can ultimate meaning and purpose be found – especially in the face of death and terror. This means trusting that God exists and is greater than all traumas, and being open to spiritual growth and change even in the midst of pain and suffering.
There is empirical evidence to suggest that openness to religious growth is not only helpful for coping with trauma, but is related to post-traumatic growth. Calhoun, Cann, Tedeshi, and McMillan (2000) tested 54 students who had experienced a major traumatic event within the past three years. Post-traumatic growth was measured with the Posttraumatic Growth Inventory (Tedeshi & Calhoun, 1996). Openness was measured with the Quest Scale (Batson, Schoenrade, & Ventis, 1993), which includes a subscale on openness to religious change (e.g., Òthere are many religious issues on which my views are still changingÓ). Five other variables thought to be related to post-traumatic growth were also measured, including Òearly event rumination.Ó When a simultaneous multiple regression equation was run, with post-traumatic growth as the dependent measure, only two of the variables were significantly predictive of growth – openness to change and early event rumination (discussed below). Thus, openness to religious change is found to be an important factor in the very desirable outcome of post-traumatic growth. This suggests that a willingness to learn and grow, coupled with a focus on oneÕs understanding of God, function together as a powerful coping mechanism after a trauma-inducing event.
The research therefore seems to suggest that there are two possible responses to trauma relevant to personal growth. One response focuses inward on self, holds rigidly to grievances, and increases the misery of post-traumatic stress. The other focuses outward on oneÕs understanding of God, is open to learning new things in the midst of suffering, and leads to post-traumatic growth. It is important to note that for some, the latter may be very difficult for a variety of reasons. Thus it is never appropriate to blame a person for the anguish of their post-traumatic stress. The only correct response to such a one is compassion. But at the same time, it is important that trauma victims be made aware of the potential benefits of openness to religious growth. In that way, those who are so inclined will be encouraged to access this important resource and experience its benefits.
<3>Engagement in spiritual reflection
If being open to religious growth is a significant help when coping with trauma, by what mechanism does that help occur? After all, ÒopennessÓ is a fairly static concept, seemingly more attitudinal than behavioral. Just what does a person do who is turning to God and open to post-trauma growth? Among other things, they think carefully about what happened and all that it means for them. An appropriate visual metaphor would perhaps be RodinÕs Thinker, sitting with elbow on knee and chin on fist while contemplating. After experiencing a traumatic event such as a terrorist attack, there are a series of questions that inevitably press in on the mind. What should I conclude from this terrifying experience? How do I make sense of it? Why did it happen? Where was God? What must I do now to be safe? These and related questions flow through the victimÕs consciousness, and it is easy to become preoccupied with the search for answers. If such thinking leads nowhere and no answers are found, discouragement follows and adds to the weight of post-trauma distress. But if reflection leads to new realizations and conclusions that help explain not only the event but also deeper questions regarding lifeÕs ultimate meanings, that is another matter. Productive, positive spiritual reflection is a significant help for victims struggling to cope with trauma.
It should not be surprising that constructive cognitive processes constitute a significant coping mechanism for dealing with trauma. Since the rise of Cognitive Therapy in the 1970s and 80s (e.g., Beck, 1976; Ellis, 1987; Meichenbaum, 1977) it has been clear that negative cognitive processes are related to many forms of psychopathology. Changing those negative cognitions thus leads to improvement. In fact, cognitive therapy and related cognitive-behavior therapy, which target specific negative cognitions, have been found to be more effective in the long run than medication in treating anxiety disorders (Gould, Otto, Pollack, & Yap, 1997). Additionally, most therapists currently declare themselves to be cognitive-behavioral in orientation (Craighead, 1990). Although the focus has traditionally been on diminishing negative thought processes in order to relieve pathology, ongoing work by Martin Seligman adds a complementary positive point of view. Seligman points out that psychology as a field has tended towards a negative focus on psychopathology, and argues for a more positive and optimistic mental health focus to include concepts such as a personÕs strengths, values, and life-goals (e.g., Seligman, 1990). It is this broader view of the importance of cognitive processes – including both positive and negative cognitions – that is most relevant for spiritual reflection. Spiritual reflection thus draws on concepts found in cognitive psychotherapy, but incorporates a positive focus such as is found in SeligmanÕs work.
Here too, there is empirical evidence to suggest that spiritual reflection is not only helpful for coping with trauma, but also related to post-traumatic growth. The same study referenced above included a ÒruminationÓ scale, defined as Òrecurrent [event related] thinking, including making sense, problem solving, reminiscence, and anticipationÓ (Calhoun et al., 2000, p.522). The scale items covered:
á Deliberately thinking about the event to try to make sense out of it,
á Deliberately trying to make something good come out of the struggle with the event,
á Deliberately trying to see benefits in the event,
á Thinking about the meaning or purpose of life (p.524).
Using the multiple regression equation referenced above, the researchers found that early event related rumination was related not just to coping with trauma, but to post-traumatic growth. Calhoun et al. note that there is a negative, intrusive, unabated type of rumination (negative cognitive process) that is unhelpful. Thus, simply obsessing over worries in a circular manner does not help. But constructive reflection does help, and contributes significantly to post-traumatic growth. This means that the trauma victim takes the time to think over the event, what to make of it, and what it means, in a positive manner that leads at least in part to satisfactory answers.
In this way spiritual reflection, functioning as a mechanism for openness to change, leads to positive outcomes in trauma victims. According to the research, it needs to occur early on, and it must lead at least in part to satisfactory conclusions that help make sense of the trauma event. A critical discrimination is between positive spiritual reflection that is productive, and pointless rumination that continues endlessly without conclusion. The latter simply adds to the agony of trauma, but the former constitutes a powerful tool for coping with the trauma of terrorist attack. Not only so, but it adds to the likelihood that the victim will experience post-traumatic growth.
<3>Involvement in faith-based community
A trauma victim engaging in spiritual reflection, and open to religious growth, is more likely to cope well with post-traumatic stress and to experience post-traumatic growth. But individual efforts can go only so far, and most victims turn to family and friends as well – a healthy instinct given the universal need for community and support. For those who are already part of a local faith community, that community constitutes a third resource that is not to be overlooked. A mosque, church or synagogue plays a unique role in coping with trauma since it can provide both social support and a shared belief system which together offer effective help. The social support reminds victims they are not alone and encourages them to hang in there with others who are struggling to work through similar trauma. The shared belief system provides a meaningful theological/philosophical framework for thinking through what has occurred, and helps the victim to avoid extreme and counterproductive conclusions. This is not so if the religious culture is one of rigidity, punishment, and harsh theological teachings (such as ÒGod is punishing you because of your lack of faith / disobedienceÓ). A punitive faith community only adds to the burden of post-traumatic stress. But a faith community that is marked by love and acceptance, as well as a reasoned and wholesome theology, provides a critical resource for the victim of trauma.
There is a growing literature recognizing the importance of the local faith-based community organization in times of personal or corporate trauma. Harrison et al. found that although punitive religious reframing is to be avoided, Òit appears that seeking congregational support and reframing the event in benevolent terms have positive health benefitsÓ (2001, p. 86). Meisenhelder states that: Òattending religious services brings people together in a supportive environment, where pain can be acknowledged and comforted. The shared belied system in itself decreases the sense of isolation accompanying crisis or trauma. . . . People who use positive religious coping see their life as part of a larger spiritual force, and try to find the lesson for them in the crisisÓ (2002, p. 775). The lesson found could refer to, for example, a new appreciation for the sanctity of life and the importance of being more other-oriented. These researchers seem to support what is generally well-recognized – that participation in the local faith-based community can be good for body and soul, especially in time of crisis.
Each of these three responses to trauma is helpful for coping with the enormous stressors a victim experiences. But the three together constitute a comprehensive strategy for survival and growth that is hard to match with standard treatment plans. The trauma victim does well to adopt an attitude of openness to religious growth, to think through concerns in constructive spiritual reflection, and to link up with their faith-based community. Such a strategy provides powerful help in coping with trauma, and increases the victimÕs likelihood of eventually experiencing post-traumatic growth rather than PTSD. Perhaps this is why almost half of Americans surveyed after 9/11 reported that their faith was actually stronger after the terrorist attack (Wagner, 2001).
<1>Recommendations and Next Steps
It is clear that spirituality, religion, and faith-based community play a potentially
key role in coping with the trauma of a terrorist attack. Although these resources have
historically been neglected by the mental health profession, there is a growing recognition of the importance of spirituality/religion and faith-based programs for mental health services (Kelly, 2003; Miller & Thoresen, 2003). In fact, this is precisely where many turn in time of crisis. More importantly, research shows that help is found there in a way that sometimes surpasses that which is available via standard mental health care. Such help not only provides a resource for coping with trauma, but also increases the victimÕs likelihood of experiencing post-traumatic growth. A nation locked in combat with terrorism cannot afford to overlook such a resource.
Practically speaking what does this mean for the Emergency Mental Health professional, the individual, and the faith-based community? What steps can be taken in preparation for and in response to terrorist attack? Furthermore, what additional research is needed in order to better understand this important resource?
<2>For Emergency Mental Health Professionals
The standard protocol for emergency mental health care – Critical Incident Stress Management (CISM) – needs major modification. As noted above, CISM is likely helpful for some trauma victims who are spiraling downwards emotionally and need help to process negative thoughts and feelings, but not for others who have a different experience in reaction to trauma. Emergency Mental Health (EMH) professionals must be trained to differentiate between those who would benefit from CISM and those who would not, especially since the misapplication of CISM can be harmful. Differentiation may involve using an assessment instrument capable of clearly identifying appropriate candidates for CISM versus other treatments or strategies. Those in need of treatment but not likely to respond well to CISM could be referred to other modalities such as cognitive-behavioral therapy or exposure therapy. Those not in need of treatment should be encouraged to access other resources such as family and friends, or the spiritual/religious resources discussed above.
Since the field is so rapidly advancing, the EMH professional must not rely on traditional, outdated protocols for emergency mental health care. Instead, it is critical to keep up with the literature, with conferences, and with training opportunities. Increasingly, researchers are turning their attention to developing strategies for working with survivors of terrorism (e.g., Gil-Rivas, Holman, & Silver, 2004; Kelly, 2004, 2005). One of the findings is that some members of a community are predictably more at risk than others for being negatively impacted by trauma. For instance, a recent study found that adolescents with a history of mental illness or learning difficulties were more Òat-riskÓ for difficulties following 9/11 than the general population (Gil-Rivas, Holman, & Silver, 2004). Accordingly, EMH professionals should be trained to assess for these and other risk factors among the target population before prescribing care. Services and supports can then be tailored to meet individual needs rather than being automatically offered to all comers.
It is important to note that a person of faith (one for whom spiritual and/or religious matters are of high importance) may benefit from CISM or other treatment modalities as well as from faith-based resources. It is not an Òeither-orÓ scenario, so whether or not the person of faith receives professional care, they should also be encouraged to access their full spectrum of spiritual/religious resources. For this reason, EMH professionals need to be trained to understand the importance of spirituality and religion as coping resources in time of trauma. In sum, they must be ready to provide CISM when clearly indicated, refer to cognitive-behavioral or other treatment modalities as needed, encourage all victims to turn to family and friends, and encourage people of faith to draw on their spiritual/religious resources – including faith-based community.
<2>For the Individual
According to the Department of Homeland Security there are several ways that an individual can prepare for time of crisis, including purchasing needed items (emergency food; radio and flashlight; duct tape and plastic for creating a Òsafe room,Ó etc.), and developing plans for meeting and communicating with loved ones in time of disaster. But how is one to prepare to draw on spiritual/religious resources in time of trauma? Following are recommendations for individuals preparing for and responding to trauma such as a terrorist attack:
<3>Preparation for Crisis
1. Do not be satisfied with religious/spiritual beliefs that are rigid and unrealistic, and that cannot flexibly respond to crisis. For example, if your belief system leads you to expect that no harm may possibly come to you or your loved ones (as long as you are faithful, obedient, etc.), you are less likely to cope well with trauma. It may be helpful to expand your theological understanding until it can assimilate the reality of tragic things sometimes afflicting good and faithful people. At that point you will be better prepared to weather a crisis.
2. Practice productive spiritual reflection regularly as a natural part of life during times of peace so that, when crisis comes, this resource will not be foreign to you. This may involve prayer and meditation, study of religious writings, spiritual journaling, or discussion of key theological issues with like-minded others. Such practices prepare you for crisis by familiarizing you with positive spiritual reflection, making it less likely that you will end up falling into fruitless rumination post-trauma.
3. Align yourself with a faith-based community that is capable of providing interpersonal support during time of crisis. The faith community must have a belief system you are comfortable with, and that can account for lifeÕs tragedies in a realistic and meaningful manner. A faith-based community built primarily upon superficial interactions, wherein members are smiling and friendly but seldom wrestle with lifeÕs difficulties, will not do. Only a community whose members support one another in meaningful ways, and who shares a wholesome and realistic theology, will be a helpful resource in time of crisis.
<3>Post-Trauma Response
1. Remember the importance of your faith, your spirituality, and your religion, and that these resources can make all the difference as you struggle to cope with tragedy and loss. Remember who you are spiritually, and where to turn for help.
2. Be open to religious change as detailed above, and deliberately avoid rigid attitudes and unrealistic expectations. Instead of focusing inward on self, focus outward on your understanding of God – on seeking God. Expect that some of your assumptions will be challenged and be willing to let them be modified or expanded. Expect that managing the trauma may change your spiritual/religious understanding in significant and helpful ways and be open to that. Expect that post-trauma suffering will hurt, but that it will also create new things in your life that will come to have deep and satisfying spiritual significance.
3. Embrace spiritual reflection early on as a key resource for handling a time of crisis. This does not mean to engage in pointless rumination, but to put time and energy into productive prayer and meditation, discussion, etc., as you search for answers. Remember that it is appropriate and needful to do so, and that consequently you may not be as focused as usual on lifeÕs daily tasks for some time. Journal your thoughts and prayers and share them with loved ones and members of your faith community. Do not be afraid to draw conclusions that might have seemed quite foreign to you before the trauma (e.g., ÒThere is a struggle in this broken world between good and evil, with real consequences and innocent casualties. Therefore it is best to actively support the good, and to live life to the full in a godly manner.Ó). It is a time for growth.
4. Become fully engaged with your faith-based community, whether synagogue, church, mosque, or other faith-related organization. Remember that this will not help if your faith community is rigid and harsh, perhaps with a focus on punishment. But if it is a community of compassion and sound shared beliefs, it will serve as a tremendous resource for all members. Attend functions, volunteer for programs and activities, and become as involved as possible. This will not only provide needed support for you, but will also allow for your support to be given to others – which is healing for both parties. It will also allow for discussion of core existential and theological questions that are the natural sequelae to major trauma events.
5. Expect that these resources will not only help you to cope with post-trauma stress, but that you may also experience post-trauma growth.
6. Do not hesitate to access standard mental health resources as needed – such as mainline psychotherapy and medication, or CISM – for emotional needs that may persist. To do so does not negate the value of your spirituality/religion or faith, as it is not an Òeither-orÓ matter.
<2>For the Faith-Based Community
Unfortunately, not all faith-based communities rise to the occasion when crisis hits. It was reported that in Manhattan, post 9/11, some of the local church pastors immediately left to stay with family and friends in other areas (A. D. Hart, Ph.D., personal communication, Oct 3, 2003). This seems something akin to dereliction of duty, as the faith-based community has a critical role to play in time of disaster. Following are recommendations for faith-based communities desiring to prepare for crisis, and to be ready to help their members in an effective and compassionate manner.
<3>Preparation for Crisis
1. The faith-based organizationÕs governing body should recognize the importance of preparation for terrorist attack, especially those located in large metropolitan areas or near high-value terrorist targets. This should include discussion among the membership, as well as with national representatives (if applicable). Making an effort to be prepared for potential disaster is consistent with most theological traditions, and is one example of caring for the faith community. A clear decision should be made to allocate the time and resources necessary for planning and preparation.
2. Once the decision to move ahead with planning and preparation has been made, the governing body (or those tasked) should locate and appropriate any and all available resources. There are at least three sources to consider:
a. Faith-based communities with a national leadership organization should look to that organization for help with plans and resources. If such help is not yet available, the national organization should be strongly encouraged to move in that direction. There is no excuse for any national faith-based organization to ignore critical current issues, and this one is of primary import.
b. Local government disaster relief agencies should be contacted so that their emergency plans may be coordinated with those of the faith community in a mutually helpful manner. It may be helpful for a representative of the faith community to begin attending emergency preparation meetings, which are generally open to the public. Such interest and help would likely be welcome by the relief agency.
c. Federal government agency web sites should be accessed so that plans and resources available there may be had. There are many government-sponsored websites filled with relevant and helpful information for individuals and communities wanting to prepare for terrorist attack (e.g., Centers for Disease Control and Prevention, Department of Homeland Security, Federal Emergency Management Agency, National Institute on Mental Health, and the Substance Abuse and Mental Health Services Agency). One or more faith community members could be tasked with downloading relevant information and presenting it to the governing body (see websites listed in Ch 30 (??)).
3. With resources in hand, the faith-based organization needs to put in place a plan of action to be followed in time of crisis. This may involve stipulating which staff or members cover which function, how members will be contacted and communication maintained, what resources (housing, emotional support, etc.) will be offered, how to liaison with local emergency services, etc. In this way, the faith-based community becomes prepared to take a major role in time of post-trauma recovery. This will of course dramatically benefit the faith-based communityÕs members, and it also positions the organization to be of help to the wider community.
<3>Post-Trauma Response
1. Remember the critical importance of the ÒfaithÓ part of your faith-based community, and where your help ultimately comes from.
2. Make sure that all organization staff and representatives stay local, stay engaged, and make themselves available on an as-needed basis.
3. Implement the faith-based communityÕs plan of emergency action with courage and compassion, knowing that to do so is to provide a tremendous resource both to members and to the wider community.
4. To the extent possible ensure that all community members are accounted for, and that they feel accepted, supported and encouraged throughout the post-trauma time period.
5. Focus on the importance of talking through all that has occurred in the context of the faith communityÕs shared beliefs. Make sure that multiple, ongoing opportunities are provided for such discussion, and that all questions are taken seriously.
6. Encourage members to help one another to cope with the extreme stress of a terrorist attack, to be open to religious growth, to engage in productive spiritual reflection, and to participate in as many faith-community activities and programs as possible. Encourage members to expect that they will experience strength for coping, and to be open to post-traumatic growth.
7. Be ready to refer members with ongoing emotional needs to standard mental health resources such as mainline psychotherapy, medication, and CISM. This must not be seen as a sign of ÒfailureÓ any more than would visiting a doctor for penicillin to treat an infection.
8. Expect the unexpected, and be ready to improvise or change plan of action quickly, creatively, and as often as needed.
<2>Research Recommendations
Although much is known about the importance of the three spiritual/religious resources detailed above in responding to trauma, the research literature is still nascent on these and related topics. There is a pressing need, made more-so by the threat of terrorist attack, to push ahead with comprehensive and programmatic research to build on the foundation that has been laid. Following are some of the areas that warrant priority attention:
1. Emergency Mental Health professionals must be able to accurately differentiate between those trauma victims who would benefit from CISM and those who would not. Reliable and valid assessment instruments and protocols must be developed for this purpose. For instance, a brief, psychometrically sound survey with high discriminant validity (few false positives regarding need for CISM) would be of tremendous help.
2. In a similar fashion, Emergency Mental Health professionals must be able to clearly identify those who are likely to benefit from their personal spiritual/religious resources post-trauma. A brief survey or interview protocol addressing this topic would be of great help in identifying people of faith or others who would want to be referred to those resources and would benefit from them (e.g., the Religious Commitment Inventory, Worthington et al., 2003).
3. The concept and clinical reality of post-traumatic growth is clearly relevant to trauma care, as shown above. There are several psychometrically sound measures of post-traumatic growth now available (e.g., the Post-Traumatic Growth Inventory, Tedeschi & Calhoun, 1996). Research applying these measures to different populations in different trauma scenarios, and with sufficiently high numbers of participants to generate firm conclusions statistically, would add to the growing literature on this important topic. Especially important would be research addressing facilitation of post-traumatic growth, and exploring its course and clinical importance.
4. The three spiritual/religious resources so far identified in trauma research are of critical importance. Openness to religious growth, engagement in spiritual reflection, and involvement in faith-based community all have very practical and clinically significant applications for victims of trauma such as a terrorist attack. Additional research replicating these findings and also identifying other spiritual/religious resources would help expand current understanding as well as strategies for coping with disaster. Eventually, an array of evidence-supported spiritual resources and strategies could be identified and incorporated in EMH trauma care protocol.
<1>Conclusions
The world changed on 9/11, and life in America is not likely to be as secure as it once was for a long time to come. The ever-present threat of a suicidal/homicidal religious terrorist breaking through the nationÕs security apparatus cannot be ignored. It is only prudent, therefore, for the nation to begin preparing for the ÒnextÓ 9/11, even as we fervently hope it will never occur and do all that can be done to prevent it. Furthermore the next 9/11 may be significantly worse than the first, especially if it involves biochemical or radioactive weapons designed to kill large numbers of unsuspecting citizens.
In such a scenario society would by necessity turn to binding up the wounds of survivors and rebuilding what was destroyed. Since some of the most grievous wounds are psychological rather than physical, attending to psychological post-trauma needs becomes a top priority. This chapter has explored a topic that has historically been overlooked by policymakers and mental health professionals alike – spiritual/religious resources that can help in time of crisis. As we have seen, these resources can be as healing as standard mental health services and, in many cases, are more readily desired by trauma victims. Such a resource cannot be ignored at this time of potential peril. It is of utmost importance that federal, state and local agencies charged with emergency preparedness and care (including but not limited to the newly created Department of Homeland Security), take note. The once-neglected spiritual factor must be included in policy deliberation, research priorities, and treatment considerations. Why? Because it is almost universally perceived by survivors as of utmost importance, and it can provide great help in time of need.
On a more philosophical/theological note, one cannot reflect on the importance
of spirituality and religion in time of crisis without coming face to face with some of the most enduring and perplexing questions ever to face humankind. Does God exist? If so, how do we know? Either way, how do we explain the reality of what appears at times to be a very broken world filled with unwarranted tragedies? How can it be that life is at times absolutely wonderful, and at other times hellish beyond belief? In light of that, just what is the purpose of life?
Such questions may seem irrelevant to public policy and crisis care, but they are not. For the individualÕs ability to productively address such questions (i.e., spiritual reflection; shared beliefs) determines to some extent how well they will be able to cope with the trauma of a terrorist attack. It would of course be inappropriate in a pluralistic society for any government agency to promote a given set of answers to these fundamental life-questions. The strength of a free and democratic society is precisely that it allows citizens to reach their own religious/philosophical conclusions and pursue their own destiny as they see fit, as long as social and legal norms are respected. This is in marked contrast with cultures that demand allegiance to a given set of philosophical or theological propositions, such as is seen with militant Islam. In fact, were militant Islam to spread, one of the first rights to be lost would be that of freedom of religion.
But it is not inappropriate for AmericaÕs pluralistic government agencies to recognize the importance of spiritual/religious resources to most citizens, especially during times of crisis, and to promote access to those resources as desired by the survivors. To continue to neglect this topic would be to deprive trauma victims of a powerful coping resource after the next 9/11. Thus policymakers at all levels of governance would do well to attend to the content of this chapter. In so doing we are perhaps recognizing that the effort to create a Ònaked public squareÓ (Neuhaus, 1984) devoid of all things religious and spiritual was in large measure mistaken. In a pluralistic society that champions freedom of religion (among other basic rights), what is needed is not a naked public square but simply an open public square where all ideas – theological, philosophical, governance and policy-related, etc. – are welcomed in the marketplace of public opinion and debate. Let the individual, not governmental or religious authorities, decide which ideas to adopt.
This chapter exemplifies an open public square approach in that it recognizes the importance of religion, spirituality, and faith in response to the disaster of a terrorist attack. When crisis strikes, when the next 9/11 occurs, give surviving victims permission to draw on their own spiritual and religious resources, and help them to do so by following these recommendations. This will help a stricken community to find strength and prevail, even in the face of terror.
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