Terrorism and Mental Health:What Should PsychiatristsKnow?

By: Dr Yasir Hameed (MRCPsych)Specialist Registrar

Norfolk and Suffolk NHS Foundation TrustNorwich

11 June 2015

Outline

My personal experience

Definitions and theories of terrorism

Situation in the UK

Mental illness in terrorists

Effects of terrorism on mental health

Is there hope?

My personal experience

I was born in 1978

Father was in army most of my childhood

Lived under the Iraq Iranian war, first Gulf war (1991),economic sanctions (1990-2003) and second Gulf war(2003) and its aftermath (until 2005)

Grieved for many relatives and friends (cousin 2004, father2005, older brother 2006) and many others.

Al Wasiti Hospital, Baghdad: 9th

April 2003 “Al Wasiti was a filthy, chaotic place, and, on this chaotic day,

the best Baghdad had to offer. It was filled with patients, gun-shot, broken and deathly ill.”

“There was not enough of anything there, neither bandagesnor antiseptic nor beds nor doctors.”

Canadian Medical Journal. 2009Aug 4; 181(3-4): E40

Definition of Terrorism

“The unlawful use of force or violenceagainst persons or property to intimidate orcoerce a government, the civilianpopulation, or any segment thereof, infurtherance of political or social objectives”

US Department of Justice 1996

Aims of terrorism: To create pervasive fear, anxiety and panic

To generate a collective and individual sense of helplessness,vulnerability and hopelessness

To reveal the ineffectiveness and/or incapability of the authorities toprovide security and safety against such opponents

To provoke the establishment into committing errors or over-reactionswhich will disaffect the general public or specific influential bodies

Alexander DA. Klein S (2006). Symposium: The challenge of preparation for a chemical,biological, radiological or nuclear terrorist attack. Vol.52 (2) p.126-131.www.jpgmonline.com

Terrorism in history

“Kill one,frighten tenthousand”

Origin of the word “Terrorism”

Derived from the regime “de la terreur” that prevalid in France from1793-1794. It was a devise of the state to strengthen the authorityof the new-found radical government.

“Terror is nothing other than justice, prompt, severe, inflexible; it istherefore an emanation of virtue; it is not so much a specialprinciple as it is a consequence of the general principle ofdemocracy applied to our country’s most urgent needs”

Maximilien Robespierre

The “Process” of Radicalisation

McCauley C and Moskalenko S: Mechanisms of political radicalization :pathways towards terrorism (2008). Terrorism and Political Violence. Volume :20 (3) . 415-433

Despite the identification of differing stages in theradicalisation process, all studies agree that there isa stage of individual change (for example, increase inreligiosity, search for identity)….

that is enhanced through external aspects (forexample, experienced discrimination or racism, or aperceived attack against Muslims such as the wars inIraq and Syria),….

and a move to violent radicalisation, usually takingplace when the individual socialises with likemindedpeople.

Theories of radicalisation

Biological theories: The overwhelming majority ofpeople who become radicalised to violence in theWest are young and male, generally aged betweenmid-teens and mid- 20s (Bakker, 2006; Wadgy,2007).

Psychological theories: The principal explanationshave centred upon some form of pathology (mentalillness or psychodynamic abnormality), repressedsexuality, or some other distinguishing personalitytrait.

Societal theories: poor or failed integration, theimpact of discrimination, and the experience ofdeprivation or segregation.

Social learning theory: based on Bandura's (1973,1998) social learning theory of aggression (bobodoll experiment) suggests that violence followsobservation and imitation of an aggressive model.

Analysis of terrorists’ mentality

“While nothing is easier than todenounce the evildoer, nothing ismore difficult than to understandhim.”

Fyodor Dostoyevsky 1821-1881

Lack of “standard model” of aterrorist After analysing the social, personal and situational

characteristics of more than 200 individuals who wereinvolved with 31 cases of Jihad terrorism in Europe, Bakkerconcludes that “there is no standard Jihad terrorist” (2008:53).

This diversity in ‘Jihadists’ profiles is attributed by Devi(2005) to the many differing reasons for their joining theJihad (in Al-Lami, 2009).

Literature has found that…

Not all terrorists are mentally ill

Not all terrorists are from impoverished or disadvantagedbackground

No all terrorists are religious fanatics, and many belong to seculargroups

There is increasing trend to involve children and women

Regularly found among terrorists: poor self esteem, a sense ofhopelessness, shame, a need for revenge, and a sense ofvulnerability

Alexander D and Klein S (2005) The Time-bomb of Terrorism. Journal of the Royal Societyof Medicine Volume: 98.557-62

Radicalisation of British Muslims A survey of 608 British adult Muslims from east London and

Bradford found that 2.4% showed some sympathy for violentprotest and terrorist acts, with women as likely to expresssympathy as men.

Participants who showed the most sympathy with violentprotest and terrorist acts were more likely to report milddepression.

They were also more likely to be born in the United Kingdom,aged under 20, in full time education, and from wealthyfamilies

Bhui K, Warfa N, Jones E. Is violent radicalisation associated with poverty, migration, poor self-reportedhealth and common mental disorders? PLOS One 5 Mar 2014

Factors that were associated with less support forterrorist acts were having more friends, feelingsafer and more satisfied with life, being unable towork because of housewife responsibilities ordisability, and not being born in the UK.

British Jihadists

Role of religion?

Much disputed point in literature.

7/7 terrorists’ political radicalisation was linked to theirincreasing religiosity (Awan, 2007a).

Strong commitment to religious belief wasdemonstrated as the principal motivating factor forinvolvement in Islamic terrorism among incarceratedterrorists (Bell, 2005a; Ibrahim, 1988; Sageman, 2005in Wadgy, 2007).

But…

The majority of Muslims are moderate in their faithand do not subscribe to radical Islam or Jihad,arguing that these doctrines abuse religious labelsfor violent ends (Abbas, 2007; Githens Mazar,2008)

The plurality and diversity of beliefs containedwithin Islam (Demos, 2006)

The actions of Islamic terrorists as almost entirelypolitical and not at all theological (Abbas, 2007a).

The Prevent Strategy

The Prevent strategy, published by the Government in 2011, ispart of an overall counter-terrorism strategy, CONTEST.

The aim of the Prevent strategy is to reduce the threat to the UKfrom terrorism by stopping people becoming terrorists orsupporting terrorism.

The Prevent strategy addresses all forms of terrorism.

It also refers people to the "Channel programme", a de-radicalisation process that uses psychologists, social workersand religious experts to help counsel thousands of peopleconsidered vulnerable to extremist ideas.

Returnees

Some of them will be DISILLUSIONED and can bereintegrated into society.

Others will be mentally DISTURBED and needpsychological support.

But there will also be a number who are outrightDANGEROUS.

Treating terrorists and victims? Merin O, Goldberg S, Steinberg A. Treating terrorists and victims: a

moral dilemma (2015) The Lancet. Vol 385.1289.

International law differentiates between patients, prisoners of war,and terrorists, defining the latter as “unlawful combatants” who arenot protected by the Third Geneva Convention, unlike prisoners ofwar.

After treating the Boston marathon suspected terrorist, the head ofemergency medicine at Beth Israel Deaconess Medical Centeradmitted “some staff battled second thoughts and anxiety oversaving the life of a suspected terrorist”

Punishment is not the role of the medical staff ; rather, their dutyand obligation is to preserve life and restore health.

Women and radicalisation It is a reductionist view, and above all, incorrect

that females join ISIS primarily to become “jihadibrides”

Majority are attracted by the idealistic goals ofreligious duty and building a utopian ‘Caliphatestate’, belonging and sisterhood andromanticisation of the experience

Increasing within ISIS propaganda is thismessage: women are valued, not as sexualobjects, but as mothers to the next generation andguardians of the ISIS ideology.

The Bethnal Green’s Girls

Role of Mental Illness

Psychiatric Disorders Associated with Aggression

Paranoid schizophrenia

Bipolar Disorder

Brain injury

Alcohol and substance abuse can also lead to aggression

Personality traits Antisocial personality disorder Paranoid personality disorder Narcissism

The Power of Graphic Violence

Mental health following terrorist attacks

Lack of systematic empirical research

30–40%of people directly affected by terrorist action are likely todevelop PTSD

Many more may develop Acute Stress Disorder & otherconditions.

20% are likely still to be experiencing symptoms 2 years later.

Less is known about the mental health impact on children, butthis too appears to be considerable

Less evidence that rescue workers and members of theemergency services are at high risk of developing disorder

Whalley MG and Brewin CR. Mental health following terrorist attacks. British Journal of Psychiatry(2007). 190(2). 94-96

Normal individual reaction toterrorists’ attack1- Emotional reaction: shock

2- Cognitive dysfunctions: disorientation, images,memories, hypervigilance

3- Change in social interaction

4- Physical reaction: hyper arousal, insomnia

(Alexander and Klein, 2006)

Complex PTSD Complex PTSD: the experience of

multiple or chronic and prolonged,developmentally adverse, traumaticevents, most often of an interpersonalnature and early life onset.

Bessel A. van der Kolk (DutchPsychiatrist) developed the concept ofdevelopmental trauma disorder forthose experiencing the effects ofcomplex trauma.

PTSD by proxyWitnessing the trauma of another person is often enough to

create post-traumatic effects in the witness as well, especially ifthat person is still young and impressionable.

ISIS use “secondary traumatisation” to create empathy andsparking an identification with victims elsewhere, and thenseduce them into a violent movement to strike out at anyone theyperceive as the enemies of Islam.

A reduction in suicide in England and Wales has been reportedafter the attacks of 11 September 2001 in the USA. It may beplausible therefore to expect a much greater impact on suicidein the UK in response to the events of 7 July 2005.

Suicide rate during 12 weeks before and after 7 July 2005.

A brief but significant reduction in daily suicide rate wasobserved a few days after the terrorist attack in London on 7July 2005. Further reduction was also observed on the 21 July2005, coinciding with the second wave of attacks.

No similar reduction in suicide was seen during the same periodin the previous 4 years. No evidence of any longer-term effecton suicide.

Salib E, Cortina-Borja M. Effect of 7 July 2005 terrorist attacks in London on suicidein England and Wales. The British Journal of Psychiatry Dec 2008, 194 (1) 80-85.

Effect of 7 July 2005 terrorist attacks inLondon on suicide in England and Wales

Doctors as terrorists Islamic State creates jihadi health service

‘There is actually a really goodmedical service being providedhere. Lots of hospitals, lots ofservices provided.’

Long term effects

A 9-year-old’s experience of life in a detention centre.From: ‘Seeking refuge, losing hope: parents and children inimmigration detention’, by Mares et al. Australasian Psychiatry, 10:91-96. 2002.

Role of religion in healing

Positive religious coping is associated withlower rates of depression and with fewersymptoms of psychological distress such asthose found in PTSD (e.g., Calhoun et al 2000)

Three key resources that religion provide:Openness to religious growthEngagement in spiritual reflection Involvement in a faith-based community

Conclusions Islam is a religion of moderation, tolerance, and believes in

accepting all other religions, so actually extremists defyIslam.

The link between mental illness and terrorism is complex.

Mental health professionals should be aware about effects ofterrorism and how to respond in disasters.

We are required to do more to help in early identification andmanagement of risks of radicalisation and extremism.

We also need to promote the culture of tolerance andacceptance in our countries.

There is HopeMetin Health House Project -Dohuk (Kurdistan-Iraq)2014-2015

“So long as our relationship is definedby our differences, we will empowerthose who saw hatred rather thandialogue”

President Barack Obama’s speech tothe Muslim world in Cairo, April 2009

There is hope