Professor Lars Wiesæth [photo: Heike Bartel]
In May 2012 I gave a paper at a colloquium marking the thirtieth anniversary of the Falklands-Malvinas War. Held at the University Nottingham and invite only (lest any scurrilous local media wanted to create a storm in a teacup), it was attended by, among others: veterans of both sides; the Argentine ambassador, Dr Alicia Castro; a lawyer from the UN, and expert in sovereignty disputes; a couple of Islanders (or “kelpers”); and a smattering of academics of different stripes, including yours truly who, invited late and struggling for a relevant subject (the period of Argentine history covered by my PhD was 1943 to 1976), spoke about ‘Microfascism and Shane Meadows’ This is England
‘. However, the most interesting paper, in my eyes, was presented by Professor Lars Wiesæth, a Norwegian expert in psychotraumatology who had been helping some British servicemen deal with their PTSD. So, when I heard he was visiting Nottingham in July last year, I took the opportunity to catch up with him for a chat, an abridged version of which was published by VIC
E. The following is a longer, though still abridged, version of our chat.
* * *
At 3.25pm on July 22, 2011, Anders Breivik, right-wing extremist and author of a 1500-page tract against multiculturalism, “cultural Marxism” and Islam, detonated a bomb in downtown Oslo outside the building containing the prime minister’s office, killing eight people. He then drove 25 miles to Utøya island, where the ruling Labour Party’s Youth Rally was being held, and began an hour-long shooting spree that ended up killing 69 more, most of them teenagers. It was Norway’s worst peace-time atrocity. Professor Lars Weisæth, for 20 years the incumbent in the world’s first academic chair in psychotraumatology and a pioneer in post-traumatic stress disorder, was asked to ‘crisis manage’ the fall-out.
Before we get to the events of 22 July 2011, could you tell me a little about how you came to be an expert in PTSD?
I am in the third generation of researchers in Norway in traumatic stress. Norway was actually the first country where researchers started to look at the consequences of the most severe trauma of World War II – the death camps. The Germans realized that to execute resistance fighters doesn’t work, because it makes people angry, instead of fearful. They understood that what might scare people is uncertainty, so they introduced this ‘Nacht und Nebel’ terror [literally, ‘Night and Fog’] and people disappeared, and were sent to the death camps where they should die slowly. When I was a student, from 1962, these studies were ongoing, and many of my teachers had been in concentration camps.
Part of my training was at the University of Oslo Psychiatric Clinic, where these studies were conducted, and that’s how I got into it. The first academic chair in psychotraumatology was created in Norway in 1978, a joint set-up between the medical faculty at the University and the medical corps in the military. My supervisor, Arne Sund, who got that chair, had his experiences from WWII and the Korean War, where they rediscovered “forward psychiatry”, which was developed in WWI to deal with shellshock… In forward psychiatry, the main idea with regard to combat-stress reactions was BICEPS: brevity, immediacy, contact, expectancy, proximity, simplicity. He reintroduced this in Norway in 1974, and then I started my research on trauma.
The new thing I introduced turned out to be very important, you might say, because it was a prospective method. Instead of looking back, I tried to follow people from the moment they had been exposed to the trauma. As soon as possible after a car crash, a rape, or whatever, you should be very precise in helping the person to grasp whatever has happened, so that it’s less liable to be influenced by secondary experiences. If you really are in trouble and ask yourself ‘why am I suffering so much?’ then you tend to attribute the cause of your problems to a concrete, discrete external event. ‘Since I’m really suffering so much, it must have been really bad’. It grows in your mind, in a way.
When did the wider medical community accept PTSD as an illness, and what, exactly, is it?
The PTSD diagnosis was introduced in 1980, and I had worked with it since 1975. I described the syndrome before it became a formal diagnosis. We had two diagnoses in the 50s and 60s from Norway that sort of anticipated later development of PTSD: ‘Concentration Camp Syndrome’ and ‘War Sailor Syndrome’. These two are aetiological diagnoses – the name of the illness points to the cause. And that is a tremendous relief. Instead of being an alcoholic, or a neurotic, or depressed, you say: “I suffer from the war sailor syndrome”. Much higher status. It guarantees that the cause will be treated – the event, and your experience of it.
The PTSD consists of three components. The first is re-experiencing the event, flashbacks, when it comes back to you in nightmares, recollections, intrusive memories, and so on. The second is the need to avoid reminders – there’s a natural tendency to avoid talking too much, thinking too much. The third component is the activation level.
This first component – in my opinion, why the brain has this super-memory of existential threat is that it’s adaptive to remember dangers. It helps survival. You digest it gradually by re-experiencing it. The avoidance response is also adaptive in that it helps you not to be exposed again, too early. And the third, the activation level, is an alarm reaction that guarantees that you will react swiftly if the event occurs. It’s a state of vigilance and alertness. However, if these reactions are strong, and they don’t recede, it may develop into what we call a post-traumatic stress disorder.
At what stage, then, were you called in to crisis-manage the terror event of July 22, 2011?
The same evening. I was on vacation in my summer house on the south coast of Norway, about 150 miles from Oslo. I was first called in by NRK, the national television station. They know me. I have been involved in all major disasters as a counsel, to give advice –I’ve been trained in hostage psychology, and I give advice to the police on negotiation with terrorists or kidnappers, and I was chief psychiatrist of the armed forces – that was combined with the chair – from 1984 to 2004.
Were you involved as the events were unfolding, advising about what information was made public?
No, I was driving back to Oslo. When I arrived in Oslo the situation was not clear. 10 had been regarded as killed but the big numbers weren’t out yet. Then I managed to talk to some of the victims during the night and on the next morning, so that I got a clear picture of what had happened. To give advice to the health authorities the next day – which I had to do; that became my role – I needed a clear idea, at the individual level, of what had happened. The details.
I advised on the establishment of an Information Support Centre, which was made in both places. That was a result of some planning we had made earlier. You need to invite family members to come to the site. You need to feed them, to house them, but most of all you need to inform them – ongoing information on what has happened, what is happening. You have to anchor families to the Information Support Centre, otherwise they will try to find out for themselves, by doing desperate things. This ISC was grasped by the World Health Organization in 1991 and included in the guidelines for how countries should respond to disasters.
When an event occurs, I diagnose it. There are three major types of large events: a company or organisational disaster, a local community disaster, when one community only is affected by an event, or a distant type of disaster – distant from the family – which this was.
If it’s a local event, you move your resources there. But it was clear immediately that the Utoya massacre was not. The 565 youngsters on the island came from all over Norway, and during the night we learned that 69 had been killed: 12%. You have families all over Norway, and they do not know what the fate of their child is. More than one thousand people met at this hotel, during the night and the next day.
So, whenever an event occurs, there are two questions I ask: Where is the family? And: Are these individuals who belong to a social system or did they just happen to be there? For example, if this had been an explosion at Oslo Central Station, it would have been all kinds of people. But I realized that both groups of people who had been attacked by Breivik belonged to very strong social systems: namely, the youth political organisation, or they are civil servants, and those are very strong identities. Based on the research that we have done, we have realized that if we manage to maintain the social system, and to utilize it, that would improve the therapeutic atmosphere.
Were there any tough decisions you had to make on the day of the massacre?
The main problem was that there were no exact numbers. In the government quarter, it was established that only eight people had been killed. But we didn’t know who had been there. There are 4000 people who work in this district – 70% of the Norwegian state apparatus concentrated within a radius of 300 metres, and 1700 offices were destroyed. But the main problem was on the island. It was dark. Nobody knew how many had been there. We learned finally that it was 565. So, the uncertainty about the number who’d been killed was the main problem. The police has a tradition – probably like the UK – that they only issue information that is certified. So, during that night, they only reported 10 people having been killed. But we had reason to believe it was many, many more. In my opinion that should have been said. Now they had created false hope. Of course, in the early morning hours, they could count the number of dead, you know. And that was really a shock. But that was the main problem.
Another problem was that – and today it sounds crazy – but many were hospitalised with serious injuries, and not all of them could be identified, actually. So when the police called the hospital to find out who had been hospitalised – because they were trying to establish control – the hospital refused to give out names. That’s an everyday thing, of course, but in a situation like this… It’s a typical symptom of stress: people cling to rules. They become more bureaucratic.
downtown Oslo shortly after the bomb explosion
How widespread was PTS?
In the governmental quarter, about 25% suffered from PTS after 7 months. On Utoya, it was 70%, although that is now down to about 25%, after three years.
Can a whole society get PTSD?
We have done a national study of how the Norwegian population reacted. Grief was the main response. Half of the Norwegian population actually cried, on the first weekend, when it became clear what losses had occurred. Then about 40% were angry. Fear, which Breivik wanted to create, was far less frequent – a bit more frequently among young people in the Oslo district.
Is it possible for the families to suffer PTSD?
Usually, the families suffer losses, so you will have grief responses, and, of course, anxiety about the fate of their next of kin. But in this case there was a particular additional and very severe stress: namely, that a large number of the parents had had telephone contact with their sons and daughters before they were killed. Actually, while they were being killed. So, in this particular terror incident, the families took part in the ordeal, more than usually is the case. And that increases the risk of PTS – in addition to the grief. Talking was of course itself a risk, because Breivik could hear them. And the mobile phones among the dead were going off all the time, too – families trying to reach their young ones.
I read that one young boy, Anzour Djoukaef, a Chechen refugee, who’d been hiding for his life on the island, was actually arrested and prevented from phoning his parents. That must have made you angry?
Yes. Many of the youngsters believed that war had broken out. And there were many rumours that there was more than one killer. And the people who helped rescue some kids on their boats – actually, one is a patient of mine – he was also suspected of being an accomplice of Breivik. He rescued 20 people from this island. Evacuated them. He had a cabin on the next island. He made three trips on his boat, the first when the shooting was going on. So, extremely dangerous. He was watched by the police as well, afterwards. He became a bit grandiose. But he also had every reason to feel that he was important.
The fact that Breivik turned up in a police uniform must have had a huge impact on their PTS?
It did. A group of these youngsters that I have talked to were hiding in a small cave. Breivik shot one of them, the furthest out, and then continued on his path. But when a boat came, with policemen calling out “We’re here to save you”, they didn’t believe it. They thought it was an exercise. Some of the first killings were because people approached him. It obscured conditions for ‘early event identification’. He also called out: “I’m here to protect you, because there’s been a bomb in Oslo”. And when they went up to him, he shot them. It was really evil.
Was he insane, in your opinion?
We still discuss whether he was psychotic. In Norway, if you’re insane, you cannot be sentenced. In most other countries, it’s not enough to be psychotic [to escape trial]. It must also be the cause of your murdering. There must be a link between the psychosis and the crime. Norway is a very liberal country, and we feel that many, even schizophrenics, know what they’re doing. I think Breivik was psychotic along three dimensions: his grandiosity, his feelings of being persecuted, and the lack of affect. That is not what terrorists are usually like. To me, this is a very sick person: he smiles and kills, you know.
But is it possible to plan something so meticulously over such a long period of time and still be deemed insane?
Very good question, and that’s the other side. Along these three dimensions, he qualified for what you would call a partial psychosis, a paranoia. And these people can be extremely rational, extremely logical, very good at arguing and long-term planning. They know the difference between right and wrong, and they know when they commit an act that it is wrong. And that’s the reason I think that, in the end, the court concluded that he was sane. Probably, if we had had a different law, we could both have said that he’s partially psychotic, but he knew what he was doing and is sane enough to be sentenced.
It came out that he gave his mother a dildo for her birthday when he was a teenager. I never heard that from any other family. It is really getting involved in one’s mother’s sexual life. To me that is a breach of a boundary between generations and sexes, an early sign that something is very wrong. You know, the whole family was observed in a child psychiatric department when he was four or five years old. It was clear that something was disturbed. The childcare agency was worried that he was suffering from negligence, that he was a deprived little boy. But the mother was allowed to keep him.
I think it’s important to get as much knowledge as possible about the background of a person who becomes so extreme – whether it’s ideological or whether it’s psychological. If it’s a very disturbed background, the reasons become less political, huh? Particularly if one can recognise that he was partially psychotic.
If you go into many extreme religious or political milieus, you’ll find a lot of people there who are psychologically disturbed, at least according to my notions. Breivik felt he had a mission on behalf of Norwegian society to defend the country. That was his defence in court. It’s almost like a religious crusade. The danger with this kind of cultural, ideological or religious sanction is that our actions are seen as loyal and justified. Most of the evil in the world today is conducted by people who feel they are doing a good thing.
Is there a qualitative difference between PTS arising from this type of event, an atrocity ‘out of the blue’, and that from other situations of extreme danger?
I have compared the different causes of danger, the source of why your life is at stake, and there is a scale: natural disasters, human error – let’s say in a traffic accident – human negligence, and finally violence: terror, war, criminal violence. With a natural disaster, nature is dangerous but not evil, so your self-esteem, your sense of value, is not harmed. There’s no-one to blame. Force majeure: an act of God. If you’re exposed to a natural disaster, that’s a pure danger. You’re not humiliated, so that’s less psychologically harmful. But there are two factors that are now changing this in the global perspective, First, people are discovering in the poor part of the world that natural disasters do not need to kill people. Earthquakes don’t kill people. Poor houses do, and that’s man-made. The second thing is the climate crisis. A flood, a storm, is it really natural? Or is it negligence?
I try to tell these youngsters that you’re an innocent victim. A murderer has tried to kill you, and your friends. But, because he attacked these two social systems, it was also an attack on Norway – particularly on the Labour Party and on the government. So you’re not just an innocent victim. You’ve also become a participant in an important struggle: an attack on our democracy. This has two effects. First, it provides a meaning, and that is crucial, because if I’m being maimed for life, it was not accidental, although I paid a heavy price.
What did you do in the aftermath?
My main work over the next weeks was to organise psychiatric support in the government quarter. We followed the company model: the employer takes responsibility, in this case the government. The employees are offered health screening by their employers’ services. The advantage is that they know these people well. They know the type of work that the 17 government ministries are doing. They have links to the leaders at all levels. The main challenge was to find suitable jobs that the people could manage, so they could still be productive and feel they were a part of the workforce. A primary family physician would not be in such a position to know the details, the possibilities to modify the work so that it fits with the person’s capacity.
PTS causes cognitive disturbances. It reduces your ability to concentrate. It affects your memory. So, intellectual functions are adversely affected.
What about with the Utoya survivors?
They went home, you know, and since they lived all over Norway, each youngster was assigned one person in their municipality’s crisis team – which usually consists of a medical doctor, a psychiatrist, a psychologist, a teacher, a chaplain, a couple of nurses and social workers.
But, again, one of my main jobs was to arrange the return to the island. I had recommended that everyone who had lost someone on the island to visit there, and everyone who had survived to return. It was beneficial. We found that if the bereaved family is invited to the site of death, the large majority report that they get a fuller understanding of what had happened. For most it will make it less difficult to grasp and accept what happened – where Breivik had stood when he fired the shots, how rapid death came, etc.
The second thing we have found is that the site of death gives a sense of closeness to the dead person, almost like the grave. The third effect is that many families feel they have a duty to do this. It reduces the guilt. It’s like a service they owe the dead person. To find out what happened to you, and where did you die.
Then you have the symbolic, ritual effect on those kids, many of whom were quite scared before they did this. It is anti-phobic. Reality is less frightening than all the fantasies you can have. So that was a huge arrangement, with about one thousand people.
Was there any ‘survivor guilt’?
That has been a pronounced psychological reaction in many. Because we’ve found that in other disasters people struggle with difficult decisions – I call them impossible decisions – about their own survival, how much they can do to help others. That’s a very painful part of the post-traumatic stress syndrome in situations like this.
And, finally, how do people get over this?
The main ways of healing are the traditional ones. Psychotherapeutic. Working through the experience, taking part in the grief over your lost friends – it’s a gradual, long-term process. These are healthy people, so it’s likely that not that many will have chronic problems. But it’s like war – you can never guarantee that all soldiers will avoid permanent psychological injury. It’s too violent for that. You must have the memory, but you shouldn’t have the re-experiences, though. You need to turn the flashbacks into a bad memory from earlier in your life – not something that keeps coming back to you with the quality of “oh, it’s happening again”.