Developing hardiness (1) among the people affected by the attack

The experiences carried out with people affected by mass and natural disasters in certain Latin American countries, such as Colombia and Mexico, and with individuals and families who lived through acts of terrorism in Israel, tend to indicate that adopting certain concepts of hardiness (Kobasa, 1979), integrated into a psychoeducational and therapeutic model, can be useful as a preventive (Omer e Inbar, 1991) and post-traumatic (Inbar, 1992, 1994) intervention.

According to these authors, the development of certain “personality” characteristics is correlated with the capacity of some individuals to face stressful existential events, and might even account for it. The characteristics identified are: commitment and involvement, control, challenge and, we may add, flexibility.

Commitment and involvement

This characteristic refers to the development of a sense of significance and to the construction of meaning. It bears on cognitive appraisal (in the sense that the event lived through has a personal significance), it increases the feeling of identification with what is happening (not only with the pain, but also with the efforts of coping and recovery) and it allows a meaningful, non-personalised attribution of the event: in this way one avoids the negative and distorted attribution that consists in ascribing to oneself the guilt and the causality of the terrorist act.

Control

Control corresponds to the individual’s feeling of having an influence on their social environment, on events and on their own conduct during the crisis situation, as well as to the possibility of choosing, even in a limited way, between different options (such as confronting or avoiding).

Individuals who have developed a feeling of control over what is happening, or who perceive themselves as endowed with adaptive resources, will face stressful, anxiety-provoking or traumatising situations more effectively than those who appraise themselves as devoid of resources and of control capacities. Even in extreme situations such as acts of terrorism, those who possess a feeling of control, however relative, face them more effectively and express fewer symptoms of post-traumatic stress (Inbar, 1992). Different types of control can be developed by means of various cognitive techniques (Inbar, 1992):

Challenge

This characteristic refers to the perception of the crisis situation and of facing it as an emotional, behavioural and social challenge. Those who perceive it only as a psychological threat tend to face it in a maladaptive and ineffective way, and display more symptoms of post-traumatic stress disorder (PTSD). Despite the negative aspects of the crisis produced by acts of terrorism, such as that of the AMIA, it is possible, in the face of objective reality, to perceive the situation as a new opportunity for growth, development and learning. This therefore requires an open attitude and flexibility, for a renewed experimentation.

These “personality” characteristics can be educated, they can be trained and sustained by means of psychoeducational or therapeutic interventions, at the pre-warning and post-impact stages respectively. Adopting this model in the present situation would mean encouraging individual, group, family and community programmes that increase the commitment and involvement of the members of the various target groups: for example, active participation in programmes for the rehabilitation of the community.

The feeling of control can be developed by means of psychoeducational programmes centred mainly on cognitive, emotional and behavioural self-control (Mahoney, 1977; Melchenbaum, 1984; Inbar, 1988). But also by means of dynamic projects, in which the affected person is an active protagonist through demonstrations and expressions of community solidarity.

The challenge component is self-evident. It is a matter of facing reality, of carrying on despite what has happened, of changing what can be changed, of maintaining community education and of strengthening tolerance and democracy in the country, preventing harmful acts such as that of July from once again tarnishing the image of Argentine society.

Social and community outreach strategies (2)

The concept of reaching out corresponds to a social and community strategy aimed at identifying the people who may have been affected by the event and may need support, and at providing them with psychological counselling or assistance. Among the guiding principles of the crisis approach, the principle of proactivity stresses the importance of going towards the people affected, directly or indirectly, with diligence and effectiveness, rather than waiting for them to come forward spontaneously and ask for help.

In the case of the AMIA attack, affected people were identified in different circles of influence: the injured, the bereaved, colleagues at work or at school. During the seminars organised subsequently, we quickly identified target groups that had not previously been defined as relevant. For example, the survivors of the Holocaust, in whom the complete destruction of the community building brought significant traumatic experiences back to life.

Something similar occurred with certain combatants of the Falklands war. Under the supervision of the author of this article, a therapist carried out a series of interventions that proved useful in holding and supporting these former combatants, and in allowing certain cognitive and emotional changes in those who, following the attack, relived highly stressful and anxiety-provoking situations undergone during the fighting of 1982.

In some cases, when for various reasons (priority, awareness, available resources) reaching out could not be implemented in due time with secondary target groups, it can be effective to begin it even several months after the impact and to direct it towards affected people or survivors not identified until then: employees of the surrounding shops, injured or not, the bereaved, people who had to identify bodies, members of the rescue teams, and so on. The experience conducted with young people who took part in the rescue activities and with members of the Argentine rescue team confirms the relevance of this approach.

For the outreach process to be effective, it is necessary to:

Adopting and implementing the model set out here also has preventive aims. It should be remembered that some individuals present no “abnormal” symptoms or manifestations in the short term, in the period immediately following the impact; taking this possibility into account, it is therefore useful to apply reaching out while seeking to identify potentially affected people, as described above.

The factors that influence outreach activities

The recovery environment after the event

A community that legitimises recourse to professional mental health resources, to counselling and even to therapy makes reaching out easier, by avoiding possible stigmatisation, the social labelling of “needy” or “incompetent”.

Cultural attitudes towards mental health

In connection with the above, cultural attitudes towards mental health take on importance: to what extent do the beliefs, norms, expectations and convictions of the people affected, of their relatives and, most particularly, the messages of community and religious leaders encourage or hinder the effective use of psychoeducational and health services? In the case of Buenos Aires, those who had relevant and adequate experience and knowledge — for example, having taken part in seminars given by followers of Pichon Rivière, or having attended training courses for community leaders — showed greater confidence, greater readiness to relearn, and made better use of mental health services.

The probability that the event will be repeated

This factor is of fundamental importance, inasmuch as the statements of those in charge of the security forces, the preventive measures (such as the concrete barriers in front of sensitive buildings, which can significantly reduce the destructive effects of another attack) or the relative impunity of the perpetrators and accomplices of the attack can reactivate or sustain the trauma.

Reaching out strategies must have continuity (for at least eighteen months) and accessibility (that is, people must be able to reach and use mental health services easily); they must avoid stigmatisation (which consists, among other things, in making the victim responsible for their own victimisation); they must adapt to the language and the idiosyncrasy of the different target groups; they must inspire credibility and choose, with the right timing, the appropriate circumstance, the one in which the people affected require it, in particular when they can come into contact with their dysfunctional or maladaptive cognitions, emotions and conducts, which then makes change, learning or the therapeutic process possible.

Those with experience of mass disasters know that, at certain phases of the post-impact, when the people affected directly or indirectly feel intense emotions (shock in the survivors; bitterness, anger and resentment in the relatives; euphoria in the members of the rescue team), psychological help has a limited scope and concentrates on holding, support, ventilation and abreaction. It is only after some time, when these emotions give way to others, such as depression and anxiety, that psychological help is really considered and potentially effective. And this occurs precisely at the moment when reaching out and psychotherapy services tend to withdraw, because of the restriction of resources — not only budgetary, but also political, motivational or conceptual. The same is true of international aid, which withdraws, diminishes or disappears entirely once its objectives have been reached (objectives that are sometimes political and not necessarily substantial, that is to say professional).

Another important condition for the development of reaching out is the expectation of an end and of results: in other words, the belief, in the affected person, that psychotherapeutic interventions are in general effective and that they come to an end after a relatively clear span of time, giving way to a reintegration, as rapid and effective as possible, into the tasks that were theirs before the event or the traumatic experience.

The stages of psychological debriefing

As we mentioned in the previous issue of Perspectivas Sistémicas, psychological debriefing is used as an immediate intervention with the survivors of the event and the members of the rescue and assistance teams. The intention is to prevent the appearance of long-term psychological symptoms and to allow survivors, rescuers and assistance teams to reach a cognitive and emotional coherence of what they have lived through. This technique comprises three distinct phases, linked to the objectives mentioned above:

Those who implement psychological debriefing as a preventive and therapeutic technique usually divide these three phases into different stages (Mitchell, 1983; Hodgkinson, 1988; Inbar, 1994):

What has just been set out makes it possible to observe the differences that exist between the models which privilege above all ventilation or abreaction and the model described here, in which fundamental aspects of the development of the feelings of self-control, competence, participation, commitment, involvement and psychological challenge are brought to the fore, to which is added the conviction that, despite the tragedy, we can carry on, in another way, growing and creating.