Mass violence and mental health

Worldwide, in the first year of the new millennium, more than 300,000 people died as a direct result of violent conflicts. These deaths were not spread uniformly across the world but ranged from less than one per 100,000 in high-income countries to 6.2 per 100,000 in low- and middle-income countries. The consequences of violence are not limited to death. Torture, rape and violation of human rights are also used to terrorize and undermine communities, affecting them not only in terms of direct physical injury but also with effects on mental health and subsequent physical illness and disability (WHO, [2002]). Destitute states whose governments have collapsed provide fertile ground for the planning and preparation of these appalling acts of violence (Ghodse, [2006]).

Such events have a very long history, perhaps dating back to the very first human societies. They were undoubtedly employed deliberately by powerful states to create the historic, global empires of past millennia. However, the spectacular nature of recent events, with large numbers of civilian casualties, combined with the fact that they are now vividly reported worldwide, often within minutes, has made the world community feel very vulnerable. Specifically, major acts of violence, carried out by a small number of individuals in the cities of industrialized countries have made the consequences of mass violence much more real to populations who have escaped this experience for decades. It is now clear that no one and no place is truly secure while violence is endemic in various parts of the world.

There are of course many other types of violent behaviour in every society. These occur within and between families, in local neighbourhoods, streets and communities and include self-inflicted injuries and suicide as well as homicide and other acts of violence. Such is their frequency that they no longer attract much attention in the media unless they are against groups perceived as particularly defenceless such as children and the elderly, when they initiate community soul-searching and public enquiries. In general, however, non-conflict societal violence occurs so frequently that such events have almost been ‘normalized’. They are often seen as an inevitable part of the human condition, and are usually considered as ‘law and order’ issues. Taken together, according to WHO, an estimated 1.6 million people worldwide lost their lives to violence in 2000. About half of the deaths were attributed to suicide, nearly one-third were due to homicide, and about one-fifth were casualties of armed conflicts (WHO, [2002]). Because of the frequency of such events, and despite their normalization, they contribute to and accentuate feelings of insecurity within the community and lead to fearfulness and anxiety. However, this sort of violence is not generally considered to be susceptible to prevention, except perhaps in the context of completing risk assessments on particular individuals and in developing localized projects to promote healthier environments for young people, particularly in the first years of life.

Although the prevention of violence has received little systematic attention, a variety of explanations have been put forward for the dynamics for different types of violence including self-directed violence which is considered to be the fourth leading cause of death and the sixth leading cause of ill health and disability (WHO, [2002]; Cavanagh, Owens, & Johnston, [1999]). There is also information on the factors that put states at risk of violent conflict (Carnegie Commission, 1999). Whatever the causes, it is obvious that in addition to human misery, violence puts a significant burden on national economies in general and on health services in particular. In this context, it is important that the role of health professionals in dealing with the consequences of violence should be explored and accorded public health priority. It is also important for health professionals in general and mental health professionals in particular to be more articulate about the causes of individual and collective violence such as wars and terrorist acts.

The practice of medicine and the provision of healthcare have always been important during conflicts and wars and in response to other acts of violence, wherever they occur. The most immediate and obvious response is the provision of physical care to those who have been physically injured and this will always be the first priority. However violence has other consequences too and it is generally acknowledged that the associated psychological pain, anxiety and stress also require an immediate and long-term response. These reactions affect not only those directly involved in the act of violence, but also those who witness it as well as those who were part of the immediate, interventional response – those from the emergency services for example who attended the scene and healthcare professionals receiving casualties. Collectively, there maybe so many people involved that the community as a whole suffers from the psychological impact of the event, particularly nowadays when television brings graphic detail right into the home.

Although this is familiar territory to psychiatrists, the psychosocial impact on individuals, families and communities is an area that has generally been neglected apart from during the immediate aftermath. Then, as the event fades away from media attention it is all too easy for it to fade also from the attention of policy-makers and professionals until the next shocking event.

It is clear from the above that there are large gaps in our understanding of mass violence – why it happens, what we might do to try to prevent it and how we can best respond after it happens. These are big and daunting questions which can easily overwhelm professionals, just as mass violence overwhelms societies and services, engendering a dangerous sense of helplessness. However, the medical profession in general and psychiatry in particular can make a major contribution to tackling these issues.

For example, psychiatrists and psychologists may be able to contribute to scientific research on the reasons behind violence against society, including gaining an understanding of the nature of underlying ideological motivations. This is undoubtedly a very difficult area to research but there is interesting multidisciplinary work to be done in exploring the relationship between the causes of individual and group violence. At the moment the training of psychiatrists is sadly deficient in understanding the dynamics and therapeutic potential of group work.

Tackling this problem energetically is important if we are to prevent the development of a ‘sick’ society – one that is imbued with bitterness, resentment, revenge and aggression and which will provide an environment in which organized crime and violence can develop and flourish. There is already ample evidence, for example, that drug-related crime and the illegal arms trade can undermine the authority of the state and provide funding for politically related violence.

Although professional organizations may feel that it is unwise to become involved in the social and political factors that often are cited as the cause of violence, their detachment should not interfere with clear and unambiguous advocacy for human rights in all circumstances. Specifically, whatever the threat of violence, medical professionals in general, and psychiatrists in particular should remain focused on the needs of the patient and should resist political pressure to treat as mentally ill, those individuals whose behaviour may be inconvenient to those in power. Robust support for colleagues experiencing such pressure may, in the long term, contribute to the development of a healthier society with a lower risk of mass violence.

Following violence, a variety of tasks present themselves: the most immediate involves dealing with survivors and the bereaved as well as the wider community. The scale of modern attacks is such that, despite the very best of emergency planning, specialist services could be overwhelmed which is all the more reason for professionals to be well prepared. For example, they need to be expert in the management of those mental disorders that are common after mass violence/disasters and to have prepared others too. The educational needs of doctors and other professionals can be planned for and met before the disaster happens. Among the individuals who require their support are likely to be those who have lost a family member, a friend or a colleague; those more directly involved; those suffering from posttraumatic stress disorders. Helping the family and friends of the individual(s) who perpetrated the violence may be particularly challenging for some – but they too have needs that must be met. At the same time, it is important to be aware of the risk of ‘medicalizing’ problems that would otherwise be handled informally within the community.

Attention also needs to be paid to strategic issues. The media obviously plays an important role in reporting events but may also influence responses to them. Judicious use of the media can therefore be vital (Njenga, Nyamai, & Kigomwa, [2003]) in the aftermath of violent acts and it may be appropriate for psychiatrists to offer advice and support to policy-makers so that the public's natural feelings of insecurity are not increased by the hasty announcement of inappropriate actions. This can be particularly important when mass violence occurs ‘out of the blue’, in the course of an otherwise ordinary day. Who does not remember where they received the news on 9/11 or other vivid atrocities? Such ‘terrorist’ events lead to a range of undefined fears that may be reinforced and spread by how the media reports them. A widespread sense of panic can then ensue, putting pressure on politicians to respond and to be seen to be responding; this can be particularly difficult when different groups within society may have opposing views. In this situation, a well-prepared medical profession, that has given such issues measured consideration, should have an important role to play in advising government on how best to respond.

During their period of office at the Royal College of Psychiatrists, John Cox as President and Hamid Ghodse as Vice-President thought that the issue truly deserved a careful examination by the College. John Cox convened an Advisory Group meeting at the College to examine the potential role of Psychiatry and the Royal College in understanding and responding to the human tragedies unfolding around the world as a consequence of mass violence and particularly in the aftermath of 9/11.

This Advisory Group, consisting of eminent scientists, practitioners and advocates from different fields within psychiatry as well as from other disciplines such as religious studies and theology, met only twice, in the autumn of 2001. However their debates and discussions were so wide ranging that they brought new and different perspectives to the Group's understanding of this very complex problem. Indeed, the collective knowledge and experience of the participants was so rich that it seemed important to share it with others in the health and caring professions, with policy-makers and politicians as well as other advocates in public and social policy.

The group made several recommendations including developing a training pack, accessible reading lists and further publications in this field. Nevertheless, it was understood that these issues were complex as well as controversial and that most mental health professionals at that time required a period of reflection about the personal and public reactions to what for many was a vivid traumatic experience. The discussions also included very cogent reflections on the roles and responsibilities of psychiatrists both as doctors as well as citizens.

Since then the editors, like most readers of this journal, have reflected on the mental health causes and consequences of violence in general and mass violence in particular. John Cox has re-read Paul Tournier's lucid book The Violence Within referred to by John Clark ([2007]), and like several contributors was impressed with the imaginative philosophical and theological reflections of Rene Girard. Responsibilities as Secretary General of the World Psychiatric Association also brought him face to face with efforts at conflict resolution in the Middle East and elsewhere. Hamid Ghodse also reconsidered his perspectives on psychiatry and in particular his responsibilities as Member and former President of the United Nations International Narcotics Control Board, taking into account the massive increase in global communication (the oxygen for the terrorist) and the difficulties seeking international solutions to threats of all kinds including those related to international organized crime and the problems associated with ‘failed’ states. He also drew on his experience as Director of the College's Board of International Affairs and from his relations with governments and states globally.

Thus the editing and direction of this special issue has been for them no isolated academic ‘ivory tower’ task. Like all the members of the original advisory group and the contributors to this special issue, their thinking has changed as the world has changed.

The Editors were exploring the possibilities for publication when the Editor of the International Review of Psychiatry suggested having a special issue of the journal dedicated to the theme of mass violence and mental health. Most participants in the Advisory Group were approached for individual contributions from their own perspective, knowledge and expertise and invited to write on the general theme of violence with an emphasis on the causes and consequences of mass violence in relation to mental health. We asked the contributors to search not only for a greater understanding of the links between violence and mental health but also to provide examples of hopeful innovations from theoretical and clinical perspectives. We wanted the volume to be thoughtful and well referenced as well as including informed opinion on a subject that, despite having a history that goes back to the time when man first left the cave, is still lacking a unified theory of its causes and, sadly, a definitive permanent solution.

All of the important points referred to in this introductory paper and many other related topics have been addressed eloquently and in depth by the authors of the different papers in this special issue. They provide important material on some of the major issues surrounding mass violence and mental health and illustrate the spectrum of related health and social problems in a modern world.

It is hoped that all the papers in this volume, some based on original research, some based on review papers, selected by eminent scientists, religious experts and clinicians and politicians will be of value to the wide readership of the journal. It is also hoped that the publication will influence governments and contribute to a greater understanding of the adverse health consequences, on both civilians and the military, of wars, rumours of wars, international terrorism and political violence.