Psychosocial care responses to terrorist attacks: a country case study of Norway, France and Belgium

This is a country case study of the public authorities’ psychosocial care responses to terrorist attacks in Norway, France and Belgium. The scope was on acute and long-term psychosocial care for the civilian population as outlined on a national level by official bodies in these countries. We focused on the attacks that caused the largest number of deaths in each country in the past decade: the 22 July 2011 attacks in Oslo and Utøya, Norway; the 13 November 2015 attacks in Paris, France; and the 22 March 2016 attacks in Brussels, Belgium. These attacks caused multiple deaths and injuries and exposed thousands to a potentially traumatic event. We reviewed pre-attack plans and guidelines for psychosocial care responses to mass casualty incidents, and post-attack documentation of the actual organization and content of psychosocial care in response to the terrorist attacks under study. The nature and availability of such documentation were unknown beforehand. Consequently, this study is exploratory and descriptive. Data were collected and examined by two researchers from each of the three included countries, next synthesized by all researchers and an additional Dutch researcher with expertise in international guideline development on postdisaster psychosocial care and cross-national comparison of the quality of psychosocial support. The researchers had multi-disciplinary backgrounds in medicine, nursing, epidemiology, public health, mental health, political science, sociology and public administration.

The study included documents written in the national languages French, Dutch and Norwegian, and in English.

This study was based on publicly available documents. There was no collection or storage of sensitive personal data. It did not involve human participants and did not require consent.

There were between 32 and 130 fatalities, excluding the deaths of the perpetrators [34‐36]. The number of physically injured reported by the authorities ranged between 172 and 493 (Table 2) [37‐39]. All the attacks took place at more than one location. The 2011 Norway attacks comprised both an urban and a rural attack site. The Labour party and its members were designated targets of the attacks [40]. Many of the victims were youth; 33 of the 77 fatalities were adolescents under the age of 18 years [36]. One person of non-Norwegian nationality was killed [41]. There was no recent history of terrorist attacks in Norway before the 2011 attacks. The November 2015 attacks in France was a multi-site attack in Paris and its suburb. Excluding the deaths of the perpetrators, 130 persons were killed in the attacks, including one under the age of 18 years and 24 of non-French nationality [34]. These attacks occurred 10 months after multi-site terrorist attacks in the same area [8]. Moreover, several terrorist attacks took place in France in its aftermath, including a large-scale attack in Nice 7 months after [42]. The 2016 attacks in Belgium comprised two suicide bombings at the Brussels airport and one in the metro in the city centre. The rescue services recorded that 340 persons were injured in the Brussels attacks [43]. In total, 18 of the 32 who were killed in the attacks were of non-Belgian nationality [35]. No children were killed in these attacks [44]. Brussels had also been struck by a terrorist attack in May 2014, i.e., approximately 2 years before [35].

All three countries under study had well developed health systems with nearly universal health coverage where most of the healthcare fees were publicly funded (Table 2) [45]. A difference in the countries’ organization of healthcare lay within primary care and the role of the General Practitioner (GP). In Norway, over 99% of the population had a regular GP [46]. The GP was both an important provider and coordinator of different types of care and served as gatekeeper for further referral to specialist care [47]. In France, there was a semi-gatekeeping system where patients were encouraged to access specialized healthcare through referral from a regular GP through financial incentives [48]. A study revealed that 83% of the population in France had a regular GP in 2007 [49]. In Belgium, there was no gatekeeping system, and the specialist, such as a psychiatrist, may form the first point of contact with the patient [50, 51]. However, reimbursements of some healthcare workers (e.g., psychologists in ambulatory centers) are only possible when patients are referred by a physician [52]. Almost 95% of the respondents of a national health survey conducted in 2008 reported having a regular GP [53]. As for the organization of post-disaster psychosocial care to civilians, this was primarily the responsibility of the local municipalities in Norway [54] and of the regional health services in France [55]. In Belgium there was a split responsibility, where the federal authorities were first responsible for the acute psychosocial care, and later it was transferred to the local communities in the post-acute phase [56].

Tables 3, 4, 5 summarize the information we identified about the content, target populations, providers and timing of the psychosocial care interventions in each country after the attacks under study. The documentation we examined presented a variable range of formats, level of details and subject matter across countries. Consequently, we introduce the results from each country with a short description of the nature and levels of details of the documentation of the psychosocial care responses.

This study covered three large-scale, multi-site terrorist attacks. There were differences between the attacks which may possibly have impacted the psychosocial care responses.

The study demonstrates that the geographical context is of importance for the psychosocial care response. Firstly, the resources and availability of professionals trained for providing psychosocial care may vary between urban and rural locations. Secondly, the geographical context may influence the facility of reaching and identifying exposed individuals. All the attacks under study struck the capital of their country, but the 2011 Norway attacks also involved a shooting spree on the small Utøya island in a rural municipality. The geographical limitation of the island made it possible to identify all those who had been directly exposed to the shooting spree on Utøya. This may have facilitated the implementation of a proactive outreach model. In France, the November 2015 attacks took place in various crowded places in the Paris urban area (suicide bombings outside football stadium, shootings at several cafes and restaurants and at a concert theater). In this context, survivors who were not seriously injured may have fled the scenes of the attacks before rescue personnel could identify them and offer psychosocial care. Consequently, access to care may for many have depended on self-referral. In this setting, information campaigns on the psychosocial care offers may be particularly important to reach individuals with or at risk of developing health problems after the attacks. This may also have been the case for the two attack sites in Brussels, Belgium (airport and metro station) and for the bombing in Oslo, Norway. Notwithstanding, the bombing in Oslo occurred in the government quarter in the midst of the summer vacation period. Those who were at work in the affected ministries were easily identified. Therefore, it may have been more difficult to identify all the exposed individuals after the attacks in Paris and Brussel.

Moreover, previous experiences impact the psychosocial care response. Paris was struck by terrorist attacks in January and November within the same year. Some neighborhoods were heavily affected by both attacks. Consequently, the emergency psychosocial units had recent experiences with providing care in this area upon which they could draw valuable experiences from in the psychosocial care response to the November attacks [66, 67]. In contrast to France, Norway had no recent experiences with terrorist attacks. This may have contributed to the fact that new models for follow-up were developed in response to the attacks in Norway, while France applied emergency psychosocial care units that had been developed in response to and activated after previous terrorist attacks. This was also reflected in the fact that terrorist attacks were addressed more specifically in the documents on psychosocial care responses in France also before the attacks, while in Norway and Belgium there was a broader focus on crises and catastrophes in general.

A particular feature of the 22 July Norway attacks in 2011 was that the terrorist survived and had a trial against him beginning 9 months after the attacks, lasting approximately 2 months [40]. The trial may have been a potent reminder of the attacks and possibly highly stressful for the survivors as many of them also testified. It may thus have been particularly beneficious that the proactive outreach was to be pursued for at least a year, i.e., throughout the end of the trial, with a designated contact person to ensure continuity in the follow-up.

The psychosocial care response depends on characteristics of those who were exposed. In the Brussels attacks, two of the suicide bombings occurred at an international airport [35]. A significant number of those affected lived and potentially needed follow-up in different countries. The majority (18 of 32) of the deceased were of non-Belgian nationality [35]. In the November 2015 Paris attacks, there were 24 persons of non-French nationality who were killed [34]. This may have been a challenge for the provision of psychosocial care, as the long-term follow-up must take place in different countries. In these circumstances, collaboration across borders is essential to coordinate acute and long-term follow-up of terror-exposed survivors and bereaved who are residents in other nations.

In Norway, there were many adolescents killed during the attacks, and many survivors were adolescents or young adults [36]. The young age of those concerned was one of the factors that favored the development of a proactive outreach model [57]. After the attack, the survivors and the bereaved from the Utøya attack were geographically dispersed in rural and urban municipalities across the entire country. Therefore, the long-term follow-up involved a large number of municipalities with different resources available. Since many survivors were adolescents and young adults on the brink of moving away from their family to begin their studies some weeks after the attack, the responsibility of the follow-up could change between different municipalities. The schools and educational institutions may be important in the long-term follow-up of youth, both to identify those in need of help and to provide psychosocial and educational support [9]. Indeed, recommendations on facilitating the return to school through practical and psychosocial support measures were sent to the schools after the Norway attacks [59, 60]. Even if children and adolescents were not directly exposed to the attacks in Paris and Brussels as in the Norway attacks, children may still have been highly affected as family members of victims or through media exposure. An article on the acute psychosocial support to children after the attack in Nice on July 14 2016 highlighted that up until then there was no pediatric component in the French emergency psychosocial units (CUMPs) [42]. The symptoms of stress and psychological suffering in children often differ from those in adults [82]. Their symptoms may also more easily be overlooked as children might not access health services by their own initiative but rely on their caregivers to access healthcare. Indeed, a study after the 2001 World Trade Center attacks in the US found significant levels of unmet needs among children in New York [14]. It is therefore important to develop public health strategies to identify and cover the needs for psychosocial care in children.

A key objective of psychosocial care after terrorist attacks is to identify persons at risk and prevent that they develop PTSD or other long-term health problems. Two fundamental questions are how to identify persons at risk and how to follow them up. Proactive outreach and active monitoring depend on the definition of a target population: who should be included in potential screening assessments? With respect to the attacks in Paris and Brussels, we did not find any recommendations of active monitoring with systematic screening assessments in the long-term aftermath of the attacks. Even if there were two target populations that were quite easily defined after the 2011 Norway attacks, one could, as previously mentioned, also have identified individuals at risk of developing PTSD or other health problems that could be eligible for inclusion in systematic screening programs based on the acute psychosocial care provided after the attacks in France and Belgium. Screen and treat approaches have been recommended after disasters, as survivors with mental health problems are often not detected through regular healthcare pathways [83]. Yet, problems with registration of victims or data sharing may be an obstacle to implement screening assessments [27]. As for the attacks in Norway, the geographical limitation of the Utøya island where the shooting spree took place and the shared affiliation to a workplace community at the site of the bombing in the government quarter in Oslo, may have facilitated the identification of individuals at risk of posttraumatic health problems and the implementation of long-term screening assessments. Nonetheless, a follow-up with screening assessments beyond the acute phase has also been implemented after terrorist attacks at metro stations and concerts arenas, such as the London 2005 bombings, the Manchester Arena 2017 bombing and the Utrecht 2019 tram shooting in the Netherlands [83‐85]. The establishment of screening programs for longer-term follow-up seems thus more determined by different policies for psychosocial care between countries rather than characteristics of the attacks. Indeed, citizens in the UK who had been affected by the Paris or Brussels attacks were invited to a screen and treat program [86]. Notwithstanding, more research is needed to appraise the efficiency, advantages and disadvantages of screening programs and of other types of psychosocial care interventions.

One of the objectives of this study was to better understand how the psychosocial care responses may have been influenced by the nature of the health systems. The countries’ health systems differed for instance in terms of gatekeeping and the share of the population with a regular GP. In Norway, there was a principle of lowest effective care with a regular GP scheme where over 99% of the population had a regular GP that served as a gatekeeper for referrals to specialized health care [46, 54]. The fact that primary care services played a fundamental role generally in healthcare may have facilitated the organization of a primary care based follow-up also in the context of the terrorist attacks. Indeed, research indicates that the use of GPs was more common in survivors of the Utøya attack in Norway than in survivors of the 13 November attacks in France [87‐89]. The psychosocial care response in Norway relied on multidisciplinary primary care services, including both health professionals and other professionals, in the local municipalities. Contrastingly, the emergency psychosocial units (CUMPs) in France were organized at a regional level and were mainly composed of practitioners in specialized mental health care, such as psychiatrists, psychologists and psychiatric nurses. Although there were not systems with full gatekeeping and therefore more direct access to specialized health services, the majority of the population had a regular GP also in France and Belgium [49, 53]. The mental health and psychosocial support guidelines published by the Inter-Agency Standing Committee (IASC), include a triangle model with four levels. The broad base of the triangle consists of “basic services and security” and narrows down towards the apex upwards via “community and family support” and “focused non-specialized support to, eventually, “specialized clinical mental healthcare”. With every step upwards in the triangle a more specialized level of care is utilized [90]. European guidelines for post-disaster psychosocial prescribe a similar “stepped care” model [22, 25, 91]. Within such a model, a regular GP, for instance, may facilitate the coordination and continuity of care, and research indicates that long-lasting patient relationships with a regular GP are associated with positive health-related outcomes [92, 93]. The regular GP may further have an overview of the affected individuals’ prior health problems and social situation, which may be valuable in post-disaster follow-up. Due to a high workload and workforce pressures, it may nonetheless be challenging to organize a proactive post-disaster follow-up with the GPs [76]. We have not found data on the use of different types of healthcare in the civilian survivors of the Brussels attacks in 2016. There are multidisciplinary crisis teams in Belgium, but we do not know if or to what extent they intervened in the aftermath of the attacks [94]. However, there were organizational factors with potential implications for the post-attack psychosocial care. There were reports of a lack of follow-up in the longer-term after the Brussel attacks [72, 95]. This might have been a failure related to the split responsibility between the federal and community-level services. The federal services were responsible for the coordination of the psychosocial care in the acute aftermath, and next the responsibility for the provision of psychosocial care was transferred to the community level in the long-term [56]. This study covered three high income countries with a relatively high degree of publicly funded healthcare. Even if these countries may be better equipped to provide health services to their citizens than low income countries, the delivery of psychosocial care after terrorist attacks and similar mass casualty incidents remains complex and challenging [96, 97].

It was beyond the scope of this study to analyze the roles of the victim support organizations in the provision of psychosocial care in different countries, yet our results indicate that victim support associations played important roles for long-term psychosocial care in all countries, though in somewhat different ways. In France, the victim support associations that were members of the French Victim Support and Mediation Institute offered free psychological consultations to victims of the terrorist attacks [69]. In Norway and in Belgium, support organizations for and by those affected by the terrorist attacks provided important peer support as well as initiatives to promote the rights and interests of those affected by attacks, but they did not have a responsibility for organizing healthcare services. The organization, roles and experiences of victim support organizations in different countries merit further attention in future research.

There is still a scarcity of knowledge about the most efficient ways of organizing and providing psychosocial care in response to terrorist attacks [28]. Our study suggests that the characteristics of the attacks and the health systems are central in the shaping of the psychosocial care response. The organization and providers of psychosocial care must be adapted to the overarching health system. Different actors may be best suited to provide psychosocial care in different countries. Anyhow, it is important that policies designate relevant actors in the provision of post-disaster psychosocial care. Furthermore, that the designated providers of psychosocial care ideally receive training in advance tailored to their role and responsibilities. Notwithstanding, the heterogeneity of the psychosocial care responses to the three terrorism cases outlined in this study reflects the need of internationally recognized standards for the planning, delivery and evaluation of psychosocial care after terrorist attacks and other mass casualty events. Although European and other international guidelines for post-disaster psychosocial care exist, they lack a standard or a practical model on how to effectively register affected individuals (or combine registrations from different agencies) considered as target populations for psychosocial care and health monitoring on the short and longer term as well as a psychosocial care evaluation framework [17‐20]. In a meta-analysis of two decades of post-disaster psychosocial care in the Netherlands, registration was identified as a recurring problem in the acute phase with negative consequences for the recovery phase [22]. Recently, registration problems were again found to hinder the proactive longitudinal health monitoring with psychosocial care backup organized by the local municipal health region in the 2 years after the Utrecht tram shooting on 18 March 2019 [85]. A reliable registration generated in the hours and days after the attack could provide an overview of the target population, broader than those killed and severely injured, and aid the short and long term psychosocial follow-up by health authorities, practitioners and researchers. If a practical registration standard or model is developed internationally, this could benefit the psychosocial care response to terrorism across country borders. Since terrorism is an international threat and the victims often have different nationalities, a mapping of existing structures for mental health services and psychosocial care in different countries may facilitate the coordination of the follow-up of victims when an attack strikes. This study indicates that, without harmonization of health monitoring and evaluation models, the methods and interventions applied to screen and support target groups over time and to evaluate services will differ in focus, quality and quantity. A standardized framework integrated in international psychosocial care guidelines may, when implemented nationally and locally, strengthen the public health response to terrorist attacks internationally. This study indicated that better documentation is needed about the planned as well as the actual provision of psychosocial care after terrorist attacks. The World Health Organization has emphasized the need for clear plans for psychosocial care after disasters [16]. Some of the aspects that should be covered are an identification of all relevant stakeholders and resources, validated questionnaires for needs assessments and mental health status, guidelines for care of children and a plan for assessment for psychosocial distress in the community. Monitoring of psychosocial care interventions through systematic data collection may guide the decision-making on, e.g., whether ongoing interventions should be modified and for how long they are needed. This could facilitate an ensuing evaluation of the effectiveness of specific interventions. A systematic data collection in the early, intermediate and long-term phases could further lay the foundation for research providing more generalizable knowledge. Since terrorist attacks are unforeseen events, a framework for monitoring, evaluation and research should be established in advance [90]. It could then be efficiently adapted and implemented when an attack occurs. An international discussion and agreement on a set of relevant measures on health, socioeconomic status and healthcare utilization to be assessed across countries and attacks could improve the comparability of results and strengthen our knowledge on best practices for psychosocial care responses to terrorist attacks and other mass trauma.

This study provides new insight into the planned and applied psychosocial care interventions after terrorist attacks in three European countries. Since there is little research on the best practices for post-disaster psychosocial care, it is especially important to synthesize grey literature on practices across countries. Information on the content, providers and rationales of psychosocial care interventions, and whether changes were made when applied after terrorist attacks, may be primarily found in grey literature [33]. The data were reviewed and discussed by a multidisciplinary team of researchers, and the analysis covered documents in the national languages (French, Dutch and Norwegian) in addition to English. This study is exploratory and may help determine future research priorities and initiate a mapping of psychosocial care responses across countries. This study does not assess the quality and efficiency of the countries’ psychosocial care responses, but it highlights the importance of gaining such insight. Several limitations apply to this study. Our analysis depends on the accuracy and accessibility of plans, guidelines, policies and other documents describing the psychosocial care responses in the different countries. The documents identified from the respective countries varied in form and content, and they did not allow for an accurate comparison of the psychosocial care responses between countries. Therefore, it was not evident to define which documents to include or not or to compare the psychosocial care responses. It cannot be guaranteed that all relevant information has been found. We may have missed relevant documents due to confidentiality or that they were otherwise difficult to obtain. Nonetheless, we endeavored to search information in a variety of ways.

Furthermore, we aimed at gaining insight into what the national authorities envisaged and required in a psychosocial care response in their country. We therefore assessed plans, guidelines and documentation on a national level and not at lower administrative or geographical levels where there may also be important information on psychosocial care responses. The information we retrieved on psychosocial care differed between countries in terms of the level of details. The descriptions of the psychosocial care responses that we identified were most detailed for the 2011 Norway attacks and least detailed for the 2016 Brussels attacks. It is important to underscore that detailed descriptions do not necessarily mean that the actual care provided was sufficient. Similarly, a lack of detailed descriptions does not necessarily indicate that there was a lack of care. The content and quality of the plans do not necessarily reflect the content and quality of the psychosocial care actually provided. We assessed the plans and other relevant literature on psychosocial care approximately five (Belgium), six (France) and ten (Norway) years after the attacks under study. The time difference might have influenced the availability of literature. Grey literature is often not available in academic databases and might eventually be removed from the web sites of official bodies. It may therefore become more difficult to retrieve as time passes, e.g., as new guidelines or plans are developed. Moreover, recommendations for psychosocial care may change over time; experiences from earlier attacks may have influenced those occurring later. We included one case of terrorism from each country. The responses to the attacks under study may not be representative for the psychosocial care provided after other terrorist attacks or other mass trauma neither in the same country nor in other countries. Furthermore, the data we retrieved on the percentage of the population who had a regular GP were not necessarily comparable. In Norway, the percentage was based on register data, whereas it was based on surveys with self-reported and potentially more inaccurate data in France and Belgium. The latter dated from 2007 and 2008, respectively, and the situation might have changed since. More recent numbers from 2019 indicated that 9.9% of the population in France did not have a regular GP or other regular physician [98]. We have not succeeded in finding more recent data on the percentage of the population with a regular GP in Belgium, however, it has been reported that 82% of the insured population in Belgium had contact with a GP in 2017 [50]. It is important to underscore that this study did not assess the quality of different types of health systems. Health systems are complex and it was beyond the scope of our study to do a complete assessment of the available psychosocial services in each country. More comprehensive data on this are available elsewhere [47, 48, 94, 99, 100].

Finally, this study covered three Western European countries with relatively accessible and well developed healthcare. Although there were differences between the countries under study, the organization, availability and documentation of psychosocial care responses to terrorist attacks may differ further with respect to countries with less developed and less accessible healthcare.