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A Guide For City-Led Response

Last updated:
22/04/2024
Publication Date:
28/03/2024
Content Type:

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Chapter 4: Psychosocial Support

While the experiences of those who have survived acts of terror, hate or violent extremism are deeply personal and context-specific, research has uncovered common layers of trauma and stages of grief among survivors and witnesses. These span from physical and medical effects to intrusive, long-term psychological trauma.

In the aftermath of an attack, fear has long-lasting implications on public health, safety and the economy. It is therefore crucial that all individuals impacted can access psychosocial support. 

Local authorities should not necessarily develop or oversee such mechanisms themselves. However, they often have the necessary reach, resources and credibility to co-ordinate the diversity of relevant actors, one of the most important (and challenging) tasks in emergency situations. This chapter outlines the various steps local authorities should undertake to build a co-ordination mechanism to provide tailored and comprehensive psychosocial support to the local population following an attack or other crisis situation.

Trauma is Not Dependent on Proximity

A study of survivors of terrorism in Israel found that 77% displayed symptoms of traumatic stress, while 59% showed signs of depression. The study also found that proximity to an attack was not always a key factor to determine the psychological impact on an individual, with witnesses just as likely to experience trauma as those who were directly targeted by attackers or experienced physical injuries. 

Collective Trauma 

Five years after the 1995 Sarin gas attacks in Tokyo (Japan), survivors continued to present “unexplained physical symptoms” likely resulting from post-traumatic stress disorder. In addition to individual impact, affected societies often suffer from “collective trauma”, manifesting as a shared feeling of “imminent pervasive threat, fear, terror and inhibition … a state of generalised insecurity, terror, lack of confidence and rupture of the social fabric”. These feelings of anxiety are especially acute in cases where a particular ethnic or religious community is targeted by attackers, ostensibly separating them from the rest of the population.

Situation Analysis 

Local authorities usually have a good understanding of the various actors operating on the ground (e.g., social services, counsellors, mentoring initiatives, extra-curricular clubs, non-formal education). Nonetheless, there may be resources and providers that are particularly grassroots, less well known to officials, or likely to be overlooked when there is an emergency. Local authorities may therefore find it helpful to establish a local psychosocial support working group, open to all service providers and supporting actors. Ideally, the local authority would assemble this group as a prevention effort and mobilise it in an emergency such as a terrorist attack, a natural disaster or a health crisis.


Establishing a Local Psychosocial Support Working Group

1. Assign an employee (or more, depending on needs) from the local authority as focal point(s) for partners and to administer the working group (e.g., maintaining related documents and databases, organising and leading meetings, liaising with partners).

2. Secure a space for the working group’s meetings and determine their recurrence.

3. Start collating the necessary documents, including:

  • Terms of reference that set out ‘membership’ criteria, principles to abide by (e.g., ‘do no harm’), roles and responsibilities (including actors outside the working group such as national agencies and the police), meeting guidelines, ways of working, etc.
  • A database of service providers and supporting actors including their main target audience or beneficiaries, the areas of support, their geographic reach, their method and the languages spoken (e.g., hotline, in-person counselling, social activities, group support circles).
  • A database of beneficiaries not necessarily including names and contact details, but rather various groups that might need psychosocial support (e.g., parents of victims in neighbourhood X); this will feed into a matrix that cross-checks that all groups needing support are covered by a service provider or support actor.
  • An evaluation log to continuously review the support available and challenges experienced by service users to improve provision. This review should take place at the regular meeting, where you can gather feedback from the various members of the working groups on demand for services, capacity and resource issues, equal access and so on. For example:
    • Is suitable support available across the city?
    • Are there any individuals who need support but are not currently receiving it?
    • Are services adapting to the cycle of trauma?

Identifying Service Providers and Support Actors 

1. Organise an open meeting for all stakeholders who can provide a frontline service or support people in need of psychosocial support in other ways (e.g., providing meals, keeping them company, contacting relatives, running errands). In larger cities, various meetings should be organised in different neighbourhoods to ensure the local authorities are aware of all potential partners.

2. Reach out directly to partners the local authorities are already aware of.

3. Use community engagement activities to identify other potential partners.

4. Set up a regular town hall for official partners and anyone willing to volunteer their time or expertise.

While volunteering can be an essential resource in times of crisis, it is vital to maintain standards in line with duty of care. For example, someone with no formal training should never be responsible for trauma counselling; equally, someone lacking the necessary background checks (e.g., a Disclosure and Barring Certificate in the United Kingdom) cannot be assigned to work with minors or vulnerable adults. It may seem excessive, but do not skip these steps even if you are desperate for added capacity or people seem well-meaning. If anything goes wrong, it will be much harder to justify why a volunteer was given access to victims or placed in roles beyond their knowledge if you have not followed basic procedures.

Service providers and support actors can include families, community leaders, religious or traditional leaders/healers, community health and social workers, educators (formal/informal), women’s groups, youth clubs, community planning groups, volunteer networks, local charities and businesses, etc., as long as they receive proper training.

ResilienceNet – OneWorldStrong.org 

A mobile application that connects individuals, survivors, first responders and refugees to relevant practitioners, services and resources, regardless of geographic location. ResilienceNet offers a range of services, including educational, peer support, violence prevention and secure chat services. The platform is dedicated to providing survivors, first responders and refugees with the help and support they require to move forward with strength and resilience.

Learn more: ResilienceNet Mobile App | OneWorldStrong

Unbroken Cities

Greater Manchester Mayor Andy Burnham and Liverpool City Region Mayor Steve Rotheram (United Kingdom) launched a network of cities and charities to support the recovery of Ukraine after the war. It came as a response to a request for support from Lviv (Ukraine) Mayor Andriy Sadovyi to support his vision for a national rehabilitation programme, Unbroken, to help his country recover from the trauma of war. The two UK mayors have offered to convene mayors from some 20 cities across the UK and US to provide Lviv and Ukrainian organisations with strategic and technical support from cities that have experienced terror attacks and extremist violence, as well as opening up their medical and charitable networks in support of Lviv.

Learn more: Unbroken Cities Network | OneWorldStrong

Initial Identification of Beneficiaries

Identifying beneficiaries should start as soon as possible, and the list of names should be reviewed regularly at the working group meetings. The following groups can serve as a starting point to identify potential beneficiaries:

  • Direct victims and survivors. Those physically injured and other individuals present at the scene; a report on victim support following terrorist attacks in the United Kingdom argues that those “who are ordinarily classified as ‘witnesses’ who were in close proximity to the incident or at the scene shortly after should be considered and treated as survivors by all of the agencies involved in assisting victims, and be able to access adequate support services”.
  • Next of kin. Families and other individuals close to the direct victims or survivors.
  • Emergency services. Law enforcement officers, fire department and ambulance personnel and other first-line responders, who need to be educated about the potential long-term effects they might experience from such events.
  • Secondary victims and survivors. Individuals and members of communities who relate to the victims (e.g., the Jewish community following the 2018 Tree of Life Synagogue attack).
  • Government employees. Staff within the local authority who may be in any of the categories above, especially those most closely involved in crisis management and response
  • Other considerations: 
    • Cross-border survivors. For example, individuals who were visiting your city at the time of the attack. The International Network Supporting Victims of Terrorism and Mass Violence provides comprehensive guidelines to address their specific needs. 
    • Diasporas. Nationals living abroad or individuals living in your city whose hometown has been hit by a terrorist attack. These people will require information and potentially psychosocial support and will have specific needs such as translation.
    • Multilingual. The working group should ensure it has professionals speaking different languages, to translate or interpret information and provide remote support.

Support service providers should not be restrictive in who can have access, as attacks or crises can have a mental health impact on individuals not directly affected by the violence. Following the 9/11 attacks (United States), people as far as Denmark reported symptoms of post-traumatic stress disorder related to the terrorist attack in New York, with similar findings following the 2011 attacks in Norway. 

In the early stages local authorities may need to prioritise, so those in greatest need can access immediate care. However, in the longer-term, cities should aim to serve a wider constituency, emphasising community outreach and engagement in order to identify additional people in need of psychosocial support.


Response

Needs and Risks Assessments

Psychosocial support should be tailored to the needs and risks of each individual as much as possible. The Local Working Group should collaborate to identify needs and conduct risk assessments, determining which care pathway is most appropriate in each case and who will take ‘ownership’ for that individual. The local authority can provide a joint framework to conduct and compile these assessments, as well as ensure regular updates from providers (in line with privacy restrictions and doctor–patient confidentiality). 

There are at least five dimensions related to well-being that should be included:

  • Psychological or social. Such needs can range from those requiring medical follow-up for syndromes such as post-traumatic stress disorder or depression to less severe issues linked to emotional well-being, where beneficiaries might need an external actor (e.g., a community support group) to help them cope.
  • Information and advice. The aftermath of an attack or incident may be very disorienting and overwhelming. Individuals might simply need advice on legal issues, how to deal with their employer or professional commitments, or how best to manage attention from media and journalists, and public visibility.
  • Physical health. While this category could encompass mental health, we refer in particular to visible injuries, especially long-term ones, and the associated effect on self-perception or identity. Such injuries can be a persistent reminder of trauma, require significant changes to a person’s lifestyle and capabilities, or make them identifiable in public.
  • Practical and safety. Practical problems, ranging from damage to property to difficulty in accessing a phone or accommodation, “often act as reminders of what people have been through and make it harder to get their life back together”. It is crucial to consider the digital aspects of addressing practical and safety concerns, and the potential for victims to become targets of hateful abuse, accusations, and misinformation and disinformation online (as, for example, took place for parents of children killed in the Sandy Hook shooting in Newtown (Connecticut, United States). Basic e-safety measures, such as limiting public access to social media accounts, should be introduced, and broad privacy guidance and advice given on reporting harmful content.
  • Financial. There are various potential financial dimensions related to wellbeing after an attack, for example, direct victims and next of kin may suffer from financial difficulties due to funeral costs and lost wages, as well as damage to personal property.

It has become common practice for crowdfunding to take place for victims of terror attacks (e.g., London Bridge or Christchurch attacks). While such practices can be pivotal in ensuring that survivors receive the appropriate level of support they need, decentralised crowdfunding efforts can equally be harmful, with a psychological impact on survivors and fuelling further polarisation. For example, following the August 2020 Kenosha shooting (Wisconsin, United States) in which two people were killed, a crowdfunding site raised hundreds of thousands of dollars to pay for the legal defence of the perpetrator accused of intentional homicide. 

Ensuring a Comprehensive Support Package

The OCHA Inter-Agency Standing Community’s intervention pyramid for mental health and psychosocial support in emergencies illustrates that a “key to organising mental health and psychosocial support is to develop a layered system of complementary supports that meets the needs of different groups”. Through continuous collaboration and regular meetings, the Local Working Group can identify what aspects of support are being addressed and by whom, and what gaps remain.


Survey

  • Identify which working group actors are covering which needs, as per the risk assessment. This should be added to the database.
  • Determine what other support mechanisms exist and which needs they are covering (e.g., national level compensation schemes).

Identify Gaps

  • Using the survey, determine whether all needs from the assessments are being addressed through current service providers and support actors. If you identify specific gaps, explore whether you can organise training for community providers or grassroots groups to fill them.
  • Revise your assessment continuously, using the regular meetings to evaluate the response and identify new trends or challenges.

Long-Term Support

The Local Working Group should consider ways to commemorate or remember the events as a community. Public outreach is central here, as memorial mechanisms should be guided by the victims and wider community:

  1. At the individual level, “crisis counselling related to birthdays of victims, holidays, important family anniversaries, and [at least] the first anniversary of the event” will be important.
  2. At a collective level, symbols “have the ability to strengthen identity and generate solidarity to encourage proper conduct, order and confidence. Symbols may be cultural emblems such as flags, logos, places or buildings, or events and performances such as rituals of mourning, candlelit demonstrations, wreath-laying ceremonies, memorial processions, etc.”.

Communicating Services & Supporting Vulnerable Groups

The Local Working Group should take a proactive approach to ensure the whole population is aware of available support, including more hard-to-reach communities. While each service provider will publicise their specific offer, the local authority can ensure it has a centralised platform to facilitate coordination among service providers. Communications should be clear and disseminated widely, to “help address any confusion over where people should go to if they need assistance” and there should be common information across all partners’ platforms including websites, social media and direct engagement.

ContentDissemination ToolsOther Considerations
What is the current situation?

Where can I get information?

Where can I go for care?

Does the care vary if I am a direct or indirect victim?

How can I deal with practical issues surrounding work, finances, etc.?

What are my rights re compensation/redress?
Websites

Flyers, brochures, billboards

Media (e.g., print, radio, TV) 

Social media

Helplines

Direct messaging (e.g., text campaigns and alerts)

Partnership with tech platforms and search engines to have location-based alerts (e.g., used during COVID-19 or elections)
Literacy rates: consider visual content or recording messages

Language needs: consider translation and interpretation services

Culture: communicate in person or through less direct channels or social media

Lessons for Post-Disaster Psychosocial Care 

A 2022 report on psychosocial care responses to attacks in Belgium, France and Norway found that despite the existence of international guidelines on post-disaster psychosocial care, there were important differences between the three studied countries in the psychosocial care responses to large-scale terrorist attacks. The report found that to build better practices, a survey of the content and organisation of post-disaster psychosocial care in different countries should be established as well as a cross-country framework for monitoring and evaluation research. It is essential to gain knowledge across national borders on the quality and efficiency of different psychosocial care responses to strengthen our preparedness for terrorist attacks and similar mass casualty incidents internationally.

Lessons for Long-Term Psychosocial Care

The After Action Report (AAR) for the Response to the 2013 Boston Marathon Bombings (Massachusetts, United States) identified a number of best practices and areas of improvement in this area. The AAR identified as a best practice the continued provision of mental health services by state and local mental health services for several weeks following the bombings. The report found that “emotional support and healing for the community remained a high priority” and that “resources continued to be made available to the public and were well advertised through various media outlets”.

Strong Cities heard the same from survivors of the bombings, but an area that has been raised as a significant lesson learned is that over the long-term, as more people recognise the need for and seek out support, mental health services and associated processes need to be available

The AAR identified as an area for improvement, mental health services for non-public safety personnel, healthcare and human services providers. The review found that “the mental health needs of some healthcare and human services providers who supported individuals impacted by the bombings were not adequately addressed”. It further stated that the “City of Boston personnel who were part of the Boylston Street recovery effort and felt the stress of physically working in the impacted area did not have their mental health needs adequately addressed”. The AAR recommended to provide psychological first aid training for healthcare employers and human services employers to provide them with skills to identify signs of psychological trauma in their employees. Ensuring long-term access to mental health support for first responders and all personnel and providers involved in response efforts is crucial. 

Triggers for Post-Traumatic Stress Disorder (PTSD)

In Kumanovo (North Macedonia), community police officers have warned against the use of fireworks before the New Year holiday and at weddings, as the noise might trigger trauma following clashes in 2015 (also known as Operation “Divo naselje”). The clashes were a series of shootouts which erupted during a raid between Macedonian police and an armed group called the National Liberation Army, which saw eight Macedonian policemen and 10 militants killed, and a further 37 officers injured. 

For survivors of two mass school shootings in Parkland (Florida) and Santa Fe (Texas) (United States) in 2018, fireworks are a challenge and can trigger symptoms of post-traumatic stress. Some young survivors asked their communities to show sensitivity during Fourth of July (Independence Day) celebrations and be aware of the impact fireworks might have on the students and faculty facing the short and long-term effects of the school shootings. 

The U.S. National Center for PTSD recommends that citizens who want to be sensitive about their fireworks should have a conversation with their neighbours about how the sounds might affect them, or at least alert them as to what time they plan to set off fireworks.

Lessons for Psychosocial Care for Bereaved Families

Following the 2011 mass shootings in Oslo and Utøya, the Norwegian government launched a proactive outreach programme to prevent unmet help needs (in line with the country’s health care model). The majority of survivors received one or more types of primary health services both directly after the attack and the following year. Most survivors used specialised mental health services. 

A study published in 2015 (updated in 2019) included recommendations from those who an took part in the proactive outreach programme that may offer guidance to cities when considering the provision of care for bereaved families. More than 80 bereaved parents and siblings gave the following advice about what is important in the delivery of support following a traumatic loss: 

  • Reach out and offer help. 
  • Repeat the offer if it is at first refused. 
  • Assign a contact person to ensure continuity in the delivery of support services.
  • Include the bereaved, both those with psychological and biological closeness
    to the deceased, in support programmes. 
  • Base support on competence and communicate it with empathy.
  • Be flexible, listen to what they need, but take charge when required. 
  • Provide clear information at an early stage about how the death happened, normal grief and crisis reactions, what will happen next, where and from whom they may receive help. Repeat the information.
  • Connect them with a psychologist and other professionals as required. 
  • Help them get in contact with others who shared the experience. 
  • Offer adaptations at school and work without them having to ask for it. 

Another study published in Scandinavian Psychologist reviewed a programme, organised by the Norwegian Directorate of Health, which brought together bereaved families over four weekends to process and learn about grief. This proactive follow-up included group sessions, plenary lectures, workshops and social activities, with themes changing over time and reflecting important post-attack milestones, such as the trial, verdict, commission report and the grief process.

Lessons for Psychosocial Care for Young People 

A qualitative study of psychosocial care for hospitalised young survivors of the 2011 Utøya attack in Norway highlighted key considerations for health-care workers in providing care for young people. 

Three overarching categories emerged related to: 

  • Remembering the past
  • Dealing with the present 
  • Preparing for the future 

The study found that “[f]or the youths in the study, talking with hospital staff about their traumatic experiences was mostly perceived as positive and linked to various helpful outcomes. In addition to engaging in the trauma narrative, staff needed to comprehend and address how the traumatic experiences and the hospitalisation resulted in the survivors’ extended fear and changed appraisals about the world and themselves. Having the time to stay physically and mentally close to the youths and engage in everyday interaction was crucial in rebuilding their sense of safety and bringing back normalcy. The hospital staff played a significant role in strengthening the survivors’ confidence in own capabilities and trust in others. The different professionals in the hospital contributed to various aspects of psychosocial care, and both trauma-focused interventions and commonplace conversations and actions were emphasised as important and meaningful approaches.”

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