Submitted: 1 April 2017. Accepted: 30 May 2017.
Terrorist attacks are not new but seem more prevalent than ever in this time of global uncertainty, political change and the ubiquitous coverage of unfolding tragedy through social media. For those directly affected by a terrorist incident, either by losing a loved one or themselves surviving an attack (and sometimes both), the traumatic experience of this type of disaster can be compounded by a sense of complete randomness. A heightened sense of personal risk and realisation of the vulnerability of people going about their daily business often brings a prolonged struggle to heal from the wounds of such sudden and violent assault. This results in a longer-term need for understanding, help with sense-making and broader psychosocial support.
Those who have been through the same or similar experiences can be especially well-placed to help and offer mutual support. In the context of post-terrorism support, peer support can be either mutual support among people affected by the same terrorist incident, or between the victims of different attacks. Best practice guidelines identify the importance of promoting social connectedness following mass trauma events (Hobfoll et al. 2007). Social support has been identified as the single most powerful protective factor for trauma victim connectedness (Norris & Stevens 2007). Mental health advocates have also highlighted the value of peer support in assisting relief from trauma and recovery as a vital complement to professional services delivering disaster recovery (Fisher et al. 2006). This approach reflects a shift towards understanding the role of those affected by disaster as being less ‘passive victims’ of disaster and more ‘active agents’ as providers of assistance by and for each other.
In this context peer-based support groups, appropriately organised and carefully facilitated, offer an important and effective form of psychosocial intervention. Three different approaches to the initiation and facilitation of peer support are:
The arrangements for the planning, organisation and provision of support groups may reflect variations or blending of the three ideal types and there can be advantages and disadvantages associated with each type.
The focus of this paper is two small-scale peer support programs initiated in London in response to two major, international terrorist incidents affecting British nationals. The first was the attacks of 11 September 2001 where 67 British citizens died and several other victims had UK family connections. The second is the Paris attacks of 13 November 2015 in which a British man was killed and a number of other British citizens were caught up in the series of coordinated attacks across the city.
The review of the peer support groups following these events reflects an unusual perspective and one that inherently challenges a simplistic victim and service provider dichotomy. Based on my personal experience as a bereaved relative from 9/11, I became actively involved in organising and participating in a peer support group in the UK after those attacks. This experience contributed to the evolution of a professional practice as a trauma psychotherapist and development of specialist interest in post-disaster psychosocial support. By 2015 I was working with a service funded by the UK Government’s Homicide Support Programme to provide specialist counselling and peer support. This brought me into contact with British survivors of the Paris attacks for whom a peer support group was initiated and facilitated.
On the morning of Tuesday 11 September 2001, four simultaneous terrorist attacks occurred in the USA; the main ones being the attacks on the New York World Trade Centre, where nearly 3000 people perished as the twin towers collapsed. Of these, 67 were British nationals and several others had UK family connections. Of the dead, some were UK residents who went to New York for a few days on a business trip, while others were living in the USA permanently. My own brother, a dual Canadian–Serbian citizen, went to New York from his home in Toronto to attend a conference on the 106th floor of the North Tower. No one survived from this floor.
After these attacks relatives needed information about their missing loved ones. Although it is not unusual in disasters for people to be considered ‘missing’ for some days, with 9/11 this uncertainty continued for weeks and months. Waiting for news and information was agonising for the families and their anguish was aggravated by confusing and often contradictory information from the media.
The main place for support was the Families Assistance Centre, opened in New York in the first week after the attacks. Its purpose was to provide a one-stop-shop for all support services required by the families; from police updates to financial and psychological help. Many UK citizens visited the centre briefly during their visits to New York but they could not make repeat visits over the months that followed or access the services from a distance.
Like many others, my need for psychosocial support in the aftermath was great. In addition to the stress of dealing with my own loss, I encountered numerous practical difficulties in obtaining information from the US regarding victim identification processes and how best to access charitable funds. I needed to finance another fact-finding trip to New York. I knew many support groups had been set up for the bereaved in the US and firmly believed I would benefit from meeting other people in the same situation, but such support groups were unavailable in the UK. At the time I did not know any other affected people in Britain so I channelled my energy into finding other 9/11 families. Repeated requests to officials for information or to share my details with others affected were met, at best, with ambivalence.
The key to the formation of peer support groups in these early stages is understanding of people’s needs, empowerment and self-efficacy through bringing people together. In our case this was achieved through Disaster Action—an umbrella organisation of support groups formed in 1991 by bereaved people and survivors of terrorist attacks and other disasters (Eyre & Dix 2014). Based on their collective experience of mutual social support they instantly understood my need to be part of a group and, in many instances, had learned from the experience of initiating and facilitating peer groups themselves (horizontally). In addition, over the 10 years of existence, the organisation had secured the trust and respect of officials who could authorise information sharing and facilitate the coming together of the 9/11 families. In effect Disaster Action functioned as a vertical power broker1. Six months after the disaster the September 11 UK Families Support Group was formally created. At the time of writing, the group continues to meet and I remain one of the trustees.
The benefits of having the group varied over time and was not limited to mutual understanding and emotional support. In the early months dealing with the victim identification process was a pressing issue for most people and so the group organised regular briefings from senior police representatives. The value was being able to access official information first-hand about how the identification process was progressing in New York instead of dealing with conflicting information from the media.
Another early benefit of the group was sharing information and experiences in accessing charitable funds. Although families had high expenditure related to their loss (for example, travel to the USA and many international phone calls) their access to humanitarian funds was limited due to their distance from the US organisations distributing funds. The group made sure that the list of available funds was distributed and helped each other through complicated application processes. With the passage of time, this ‘power in numbers’ and being identifiable as a cohesive, representative group allowed government and others to consult with the group over decisions such as memorials. This included the creation of the September 11th Memorial Garden in London; a focal point for commemorations.
For a relatively short time, in addition to the regular information meetings, the group organised a small, therapeutic support group facilitated by an external psychotherapist. This subgroup was relatively short lived. Over the long-term peer support has been primarily about overcoming isolation and being in the company of others who share a common experience, albeit one that is profoundly difficult and unique to deal with. It is for this reason that the group has been a lifeline for many.
On 13 November 2015, 130 people were killed and many more injured in coordinated terrorist attacks across restaurants, cafés and the national football stadium in Paris. The deadliest attack took place at the Bataclan Theatre where over 1000 people were attending an American rock band concert. At 9:40pm, halfway through the concert, three gunmen wearing suicide belts burst in, firing indiscriminately into the crowd. 90 people were killed and hundreds of others injured in a traumatic ordeal lasting over two hours.
Given the proximity of France to Britain it is unsurprising that Britons were among the many nationalities involved. One British person died and a 15 people survived; some with physical injuries such as gunshot wounds.
It is often the case following mass traumatic events that it is difficult to determine the exact number of people affected. This is for several reasons, not least that many (perhaps most) people do not identify or present themselves to support services even when these exist and where proactive outreach is attempted. As with 9/11 the challenges with Paris were compounded by the bereaved and survivors being geographically disparate.
Research conducted by Victim Support with victims of terrorism, including Paris survivors, has highlighted shortcomings in the existing support framework in the UK for survivors and families (Barker & Dinisman 2016). The study highlights how British citizens affected by terrorism abroad encounter inconsistent referral mechanisms for accessing victim support organisations. They found that for some survivors and bereaved family members the waiting time to receive counselling or therapy services on the UK National Health System can feel too long. Accessing peer support groups, particularly locally, can also be problematic (Barker & Dinisman 2016).
This became clear when I met some of the Paris survivors in my role as a specialist trauma psychotherapist with ASSIST Trauma Care. This is a charity commissioned by the Ministry of Justice and Victim Support to provide specialist one-to-one psychotherapy to people affected by homicide or terrorism. Survivors reported that searching for, finding and accessing appropriately qualified therapists had been complicated and had caused secondary distress and trauma, compounding their sense of isolation and disorientation.
Barker and Dinisman (2016) found that in the absence of a recognised definition of a ‘victim’ of terrorism ‘witnesses’ are not always considered to be victims by agencies and organisations involved in supporting them. This situation, they state, may have implications for the support they receive. Survivors spoke of mixed experiences in accessing help. Those who had physical injuries tended to be recognised as legitimate victims and were put in touch with victim support services. However, those who had minor injuries or walked away without physical wounds did not seem to be recognised as victims. As such, they struggled to understand what their rights were and what sort of support was available. The need for organised peer support is even more important for those affected by terrorism abroad because of cross-border complexities (Victim Support Europe 2017).
In the absence of clear, coordinated information and psychosocial support for Paris survivors the need for mutual support seemed great, so I offered and facilitated a support group for survivors. I was keen to offer the value of a ‘multidimensional’ approach, sharing the benefits of my experiences after September 11 where appropriate and drawing on my expertise as a trauma therapist with the help of a fellow psychotherapist.
As with September 11, a key challenge was effective outreach. Even when official lists of victims became available, gatekeepers remained wary of sharing details of the group to people on those lists. However, access to internet resources and social media means that today it is much easier for survivors to find each other and share information from the grassroots up. Two survivors with whom I was working promoted the group through a Paris-based social media site dedicated to victims of the attacks and so other people learned about the group in this way.
The first meeting of the group was held in March 2016, four months after the attacks. As expected, the number attending was small. The meeting was difficult to access for some; being held in London and on a weekend. However, based on experiences of facilitating similar groups, the value of the group cannot be reduced to quantitative measures, such as numbers attending.
By March 2017, the group had met 10 times and these regular monthly meetings lasted for 2.5 hours. Discussion topics included the first anniversary of the attacks and dealing with the media; both aspects familiar to me and I could draw on personal information and experience.
‘Disaster time’ differs from other timelines. At the time of writing, a criminal trial is forthcoming and as this group still exists, it is too early for formal evaluation. However, my observations and comments from group members suggest that the main benefits for survivors has, most fundamentally and powerfully, been in meeting each other and understanding they are not alone in their experience. Importantly, although some of the participants had previously met on social media, face-to-face contact has been beneficial for them.
The group interaction, managed from a therapeutic perspective, helped each member make sense of the events. As one survivor said, ‘What happened at the Bataclan is like a puzzle that I’ve been able to piece together by talking to other people’. Group members have also shared information about resources such as compensation from the French government. Survivors without access to formal information-sharing platforms were unaware of their entitlement. As such, just as with the 9/11 group, the Paris peer support group addressed many aspects of psychosocial need and emotional support.
The survivors have expressed a wish to expand the group to include survivors and bereaved people of recent attacks such as the Tunisia shootings and Brussels attacks (both in 2015) and Westminster attacks (2017). The aspiration is to build on the example set by Disaster Action by connecting group members with people affected by previous events and develop peer facilitators for future support groups. If achieved, this would be an example of multidimensional support, potentially with further therapeutic benefit for givers and receivers.
This review has focused mainly on the value of the peer groups and the challenges to organising them. Challenges include:
While the case for the value of peer support after disasters has been made by others, this does not always translate into the inclusion of peer support groups in psychosocial preparedness, planning or response. The establishment and organisation of particular disaster peer support groups will inevitably vary with the unique social and organisational setting and circumstances of each disaster.
The aim of this review has been to illustrate what the initiation, organisation and facilitation of peer support groups can mean in practice with a view to encouraging more reflection, discussion and research within the emergency management community. Further research and evaluation is necessary to fully understand the impact on and implications for the organisation, management and support of this approach within psychosocial practice.
The author would like to thank Anne Eyre for her assistance with the preparation of this article.
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Jelena Watkins is a London-based psychotherapist working for ASSIST Trauma Care and in private practice, specialising in disaster trauma. Jelena was an executive board member of Disaster Action for over a decade and a founding member of September 11 UK Families Support Group. She facilitated a support group in London for people bereaved by the 2004 Asian Tsunami as part of the British Red Cross Tsunami Support Network.
1 Shortly after this, Disaster Action facilitated a first meeting of UK bereaved and survivors affected by the Bali bombings of 2002.