In the days that followed 22 July 2011, the Norwegian health services were forced to acknowledge that nobody was prepared for the comprehensive assistance effort that was needed. Traditionally, Norwegian health services encounter their clients on an individual basis. Some situations, however, have a strongly collective aspect. Here, I will describe the experiences gathered from Tromsø municipality’s assemblies of survivors from Utøya.
Our assemblies addressed the entire group of adolescents in the local area (n = 20), with a total of 60 meetings over three years. The group, which gained a large response, was established on the initiative of the survivors, in parallel with other measures such as individual and family therapy in the adult and child psychiatric services. The sessions were chaired by two experienced psychiatric nurses in cooperation with the municipality and the specialist health services. The sessions have recently been discontinued, and we wish to summarise the group processes and their duration.
We need each other
The community of Utøya participants had been established before the incident. When the attack came, these young people faced it together from the start. They tried to help each other and hide or escape together. After the attack was over, they were all brought to Sundvollen Hotel. Thus, the young people were united through large parts of the incident, and for a long time they could only rely on each other. In the subsequent period as well, they jointly attended funerals, hospital visits and memorial services.
It soon became clear that these young people suffered extensive consequences: grief, pain, guilt for having survived, as well as problems in sleeping and concentrating. The traumas were overwhelming, and they needed to find some way of being able to «return to humanity» (1). Perhaps not as the same individuals they had been before, but as people who could still find the ability to work, as well as love and meaning in life. We knew that their age made them vulnerable. At the outset, however, the fact that this would also offer some opportunities was not so easy to foresee.
When these young people returned home, the situation occurred that they only wanted to be among themselves. At the early stage, we in the social and healthcare services perceived their strong desire not to prioritise parental contact as a problem. We thought that they needed to come out of their «bubble» and be reunited with those near and dear to them. We soon realised, however, that the young people were facing very real challenges. They knew that their parents had been terrified and that time was needed for that fear to recede. They did not dare to tell them the whole truth, because they believed that it would be unbearable for their parents to hear about the extreme degree of mortal danger to which they had been exposed.
The main reason was, however, that they needed each other even more. They also needed to be open in a way that would be impossible if their parents were present. Many were restless and worried about their friends, and others had found a soulmate who had accompanied them when fleeing and with whom they wanted to share everything. It is also worth noting that in terms of developmental psychology, it was difficult (for the older ones) to return to their parents at a life stage where detachment from parents is natural.
The nature of the sessions
Despite all the media attention and the public compassion after the incident, many of the young people were largely left to themselves with their troubling thoughts of having changed or being a failure. The sense of community in the group removed some of this loneliness. The purpose was to share thoughts within a caring framework. Social activities were also given priority, especially before the Christmas and summer seasons, with baking of ginger snaps and barbeque parties. The meetings, held every two weeks, comprised a planned psychoeducative topic and an unplanned session. Whereas the former was characterised by concentration and seriousness, the latter had an unrestrained style. Both were important, and jest and solemnity would often overlap.
The sessions provided an opportunity to recount difficult issues in a way that facilitated a simple response. This could be related to a specific problem, for example of being startled every time a bus door slammed shut. A typical comment would be that «I felt like that for a while too, but now I’m able to care very little about it». The special feature of such a group was that the participants could wait in making a comment of their own, and if they preferred to just listen, it was okay.
There was nearly full participation during the first autumn. Since then, the participation rate has varied, sometimes with half the group present, sometimes with only very few. Even in later periods nearly everybody turned up, such as in the autumn of 2012, when they had hoped in vain that the problems were over, but had to recognise that they needed the group. With time, the participants became more confident of each other, and the conversations matured, became more open and deepened. The mutual care and the need to find a meaning became more evident.
Regaining contact with their own potential
What was the key motive for attending the group sessions? Their backgrounds were varied, and this obviously played a role for their decision. Nevertheless, they were all suffering from the same trauma. For all of them, this was a dramatic rupture that complicated any reorientation – also because they were in a situation where they needed to make choices regarding further education and a future profession. So how could they find their way back to what they were or wanted to become?
The answer was not clear, and a natural impulse was to study how the others were coping with their challenges. For some, this involved long periods of functioning well, but also sudden «plunges» into despair and uncertainty after long periods of thinking that everything was now as it should be. It could also involve other attempts at finding solutions, such as getting drunk. Therefore, the other participants in the group were crucial: the young people could be open about the matters that bothered them, be they family issues, poor school grades or too much alcohol. Together, they found a way of being in the world.
In the encounter with fellow sufferers, a context is established. Although they perceived themselves as changed, they were met within the group as the individuals they had been before. In the group, it was also permitted to feel weak, despite the fact that they were at a stage in life where many others tend to feel strong and optimistic. Through this familiarity with each other’s small victories, the idea emerged that «I can do that too» – at least in time.
The explanation as to why some participants chose to repeatedly leave the group and then come back could be that they attempted to cope without it, but after a while felt that they needed to return. In this way, they found that although the continuity of their lives had been disrupted, it had not been broken. The group turned into a family-like transitional object that each of them needed to resume the development typical of their age group (2). Within the group they were not made isolated victims who were left alone with their wounds. In the community nuances emerged, and successful as well as less successful attempts at finding solutions could be discussed. Humour also played a part. While alone, their mood might be not very cheerful, but in the company of others, brighter aspects could also be discerned. This reflection enabled them to discover a road forward.
The strength of the collective
Those who lived through the Utøya massacre were undoubtedly in need of individual treatment, and most of them made use of this option. So for what reason did so many choose to attend the sessions? The gateway to individual therapy is usually the recognition of having a personal mental problem. The road ahead, however, lies in the community that represents opportunities for individual growth.
At an early stage we could observe fruitful processes in the group: the ability to socialise, reflection, resonance, hope and a sense of being useful (3). Symptoms and diagnoses could be held at bay and the whole thing assumed a «normalised» character – a mixture of care, laughter and deep sincerity. The internal group processes appeared to be the most important element. The development of each individual largely came to depend on how well his or her friends were doing.
The literature on group sessions in trauma therapy (after the acute stage) is not overwhelming. A review article on international experience (4) describes group approaches in positive terms, referring to good outcomes from therapy groups based on trauma-focused cognitive behavioural therapy (5), although the author is reluctant to draw any conclusions because of the small number of studies. Others point to the value that groups may have in combination with other interventions (6).
Group approaches were not included in the recommendations issued by the Directorate of Health after the Utøya tragedy. The issue of group sessions was meticulously discussed, and our colleagues gave us support to go ahead. Some objections were also voiced, including the concern that such sessions might delay the reestablishment of natural networks. Other expressed concerns regarding destructive consequences of trauma-based sessions. There is nothing in our experience or the feedback from the young people that validates these concerns.
For understandable reasons we have no measurements of the therapeutic effect. Observations indicate, however, that the group activities had a profound effect on the participants. In a Questback survey in the spring of 2013 they reported that the sessions had been crucial for them, and that they regarded the group as their own forum.
Our main approach consisted in careful monitoring of how the young people developed and cooperating with them without any preconceived notions. As professional leaders we needed to be clear and open yet persistent, and take what has been termed «watchful waiting» seriously – for years.
Our task was obviously to represent the adult world and responsibility, but it was even more important to provide a framework that enabled the survivors to support each other. In this way they could progress jointly, often at a varying pace, through the various stages of the crisis. At the final stage of the period of group sessions, the young people were preoccupied with post-traumatic growth. They knew that the incident would stay with them for life, but they could also see that they had developed, and that the crisis had provided them with an opportunity they neither could nor wanted to be without. We saw that the collective provided the solidarity that proved to be so important from the very start. It was also completely crucial that we as leaders were able to accommodate the young people’s efforts – their determination, sincerity and laughter – to help them «come home» (1).