Journal of Traumatic Stress December 2014, 27, 639–646
Media Participation and Mental Health in Terrorist Attack Survivors Siri Thoresen,1 Tine K. Jensen,1,2 and Grete Dyb1,3 1
Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway Department of Psychology, Faculty of Social Sciences, University of Oslo, Norway 3 Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway 2
Terrorism and disasters receive massive media attention, and victims are often approached by reporters. Not much is known about how terror and disaster victims perceive the contact with media and whether such experiences influence mental health. In this study, we describe how positive and negative experiences with media relate to posttraumatic stress (PTS) reactions among survivors of the 2011 Utøya Island terrorist attack in Norway. Face-to-face interviews were conducted with 285 survivors (47.0% female and 53.0% male) 14–15 months after the terrorist attack. Most survivors were approached by reporters (94%), and participated in media interviews (88%). The majority of survivors evaluated their media contact and participation as positive, and media participation was unrelated to PTS reactions. Survivors who found media participation distressing had more PTS reactions (quite distressing: B = 0.440, extremely distressing: B = 0.611, p = .004 in adjusted model). Perceiving media participation as distressing was slightly associated with lower levels of social support (r = –.16, p = .013), and regretting media participation was slightly associated with feeling let down (r = .18, p = .004). Reporters should take care when interviewing victims, and clinicians should be aware of media exposure as a potential additional strain on victims.
Disasters and terrorist attacks receive massive and often worldwide media attention. The media play a vital role in supplying information to the public. Directly exposed victims have first-hand knowledge and may be essential sources of information. Hence, when consenting to be interviewed, victims play an important societal role. Some victims may also want to share their experiences so that the world community can understand what has happened and how the events have affected their lives. Moreover, media coverage may provide vital information to the victims themselves that may be useful in coping with the situation (Hawkins, McIntosh, Silver, & Holman, 2007). Nonetheless, media attention may also be burdensome. For example, journalists who are perceived as intrusive may annoy victims and their relatives, and negative emotions may be triggered by media reports (Kay, Reilly, Connolly, & Cohen, 2010). The media may add to anxiety in exposed groups by exaggerating danger and creating unnecessary fear (Vasterman, Yzermans, & Dirkzwager, 2005). Additionally, several studies have suggested that television viewing following disasters and terrorist attacks is related to increased posttraumatic stress (PTS) reactions in both children and adults in the general
population (Pfefferbaum, Doughty, & Reddy, 2002; Schlenger et al., 2002) and in directly affected groups (Ahern et al., 2002; Neria, DiGrande, & Adams, 2011). Journalistic analyses have revealed that media portrayals of events can vary from compassionate to hostile (Jemphrey & Berrington, 2000). Hence, the role of the media in the official discourse following disasters may guide attention and sympathy towards the needs of victims or add to the burden of the survivors and bereaved. Many terror or disaster survivors are approached by reporters, and some agree to be interviewed. These interviews may be emotionally challenging for both reporters who interview a distressed survivor and for the survivors being interviewed. Several research studies have explored how journalists are affected by working with war, terror, and disasters (e.g., Backholm & Bj¨orkqvist, 2012; Feinstein, Owen, & Blair, 2002). Less is known about how terror or trauma victims perceive the media coverage of their cases or their own participation in the media and how these issues relate to mental health. Maerker and Mehr (2006) investigated crime victims’ reactions to reading about, listening to, or watching media reports about the crimes that they were victims of. The majority of victims reported negative emotional reactions to the media reports (66% reported sadness and 48% reported fear), and such reactions were associated with posttraumatic stress disorder (PTSD) symptoms. We were able to identify only one study on the relationship between being interviewed by the media and mental health of the victims of mass trauma. This study was an investigation
Correspondence concerning this article should be addressed to Siri Thoresen, Norwegian Center for Violence and Traumatic Stress Studies, Postbox 181 Nydalen, 0409 Oslo, Norway. E-mail: [email protected] C 2014 International Society for Traumatic Stress Studies. View Copyright this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21971
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of Finnish adolescents who were exposed to a school shooting (Haravuori, Suomalainen, Berg, Kiviruusu, & Marttunen, 2011). The authors found that being interviewed by the media was associated with increased PTS reactions. In that study, one in five adolescents felt worse after being interviewed, and the authors suggested that this negative emotional affect may have contributed to the exacerbation of PTS reactions. Taken together, these studies support the view that media coverage may have a powerful impact on how victims of mass trauma are able to deal with their experiences, and the results should heighten our concern regarding the effects of media participation on victims. People may say things they regret or feel let down or betrayed by headlines or the angle of the story they participated in. On the other hand, media participation may contribute to positive attention and the regaining of agency. The manner in which an individual is portrayed in the media may also affect how other people respond to that person, potentially affecting the person’s social network positively or negatively. As social support seems to be one of the most important protective factors against PTS reactions (Brewin, Andrews, & Valentine, 2000), explorations of the potential relationships between media participation and social support are needed. The terrorist attack in Norway that occurred on July 22, 2011 included the explosion of a bomb in the capital of Oslo and the shooting attack on Utøya Island, which was hosting a summer camp for the Norwegian Labor Youth Party. The attack on Utøya Island resulted in the deaths of 69 young people, and an additional 56 individuals were admitted to hospitals with severe injuries. The shooting attack and the high levels of trauma exposure experienced by the survivors have been described in detail elsewhere (Dyb et al., 2014). The terrorist attack was followed by massive media attention. In Norway, the media continued to focus intensively on the terrorist attack and the terrorist for at least a year, and peaks in coverage occurred with certain events such as the psychiatric evaluations of the terrorist, the trial, and the first anniversary of the attack. In this study, we examined survivors of the 2011 Norway attacks who were present on Utøya Island at the time of the shooting participation with the media. We investigated positive and negative experiences with media, experienced stress and regrets about participation, and the association of these factors with PTS and social support.
Method Participants and Procedure The police registered names and ages of individuals who were present at Utøya Island at the time of the shooting on July 22, 2011. All survivors were mailed invitations to participate in a study and subsequently contacted by phone. Face-to-face interviews were conducted by health professionals with specific training for this study. The interview was highly structured, and data were completed by the interviewer. An additional selfreport section was completed by the respondent, although the
interviewer was available for questions. After the self-report section was completed, the interview was ended with an evaluation of potential unmet needs. Wave 1 was conducted 4– 5 months after the terrorist attack; Wave 2 was conducted 14– 15 months after the terrorist attack. The response rate at Wave 1 was 66.3% (N = 325), and at Wave 2 the response rate was 58.2% (N = 285). At Wave 2, all survivors were invited to participate in the study, including those who did not participate in Wave 1. The present study used data from all participants at Wave 2 of the Utøya study. The 285 individuals who participated in Wave 2 of the Utøya study comprised 47.0% girls/women (n = 134) and 53.0% boys/men (n = 151). The mean age was 19.21 (SD = 4.25) years at the time of the shooting. The age range was 13 to 47 years of age, and 93.0% of the participants were under 25 years of age. The majority of participants (89.9%, n = 248) were of Norwegian ethnic origin. The study was approved by the Regional Committee for Medical and Health Research Ethics in Norway. Each participant provided written consent, and additional consent from the parents was provided for participants below the age of 16 years. Further details about the participants and procedures are described elsewhere (Dyb et al., 2014); no significant differences in gender or age were identified between participants and nonparticipants. The Dyb et al. article also describes the experiences and symptomatology of the Wave 1 sample. The participants had been exposed to threats to their lives or had witnessing experiences and grotesque impressions. Additionally, the majority of the participants had lost someone close in the terrorist attack. Measures The media attention following the terrorist attack was intense for several months following the attack, and again in relation to the trial which took place 9–11 months after the attack. Hence, in the current study we chose not to restrict media participation to the direct crisis aftermath. The measure of media participation was designed for this study, included in the self-report section, and completed by the respondent. We asked the four following dichotomous (yes/no) questions about the participants’ terror-related contact with the media: (a) “Were you contacted by the media about your experiences at Utøya Island on July 22, 2011?”; (b) “Were you interviewed by the media about your experiences at Utøya Island on July 22, 2011?”; (c) “Were you interviewed by the media about the trial following the terror attack of July 22, 2011?”; and (d) “Did you contribute your own texts to media related to the terror attack at Utøya Island or to the trial following the terror attack?” The following four questions measured the participants’ appraisals of their contact with the media: (a) “How did you perceive being contacted by the media about your terror experiences?” (rated on the following ordinal scale: 1 = very positive, 2 = positive, 3 = both positive and negative, 4 = negative, and 5 = very negative); (b) “Was your participation in the media
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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distressing to you?”; (c) “Was your participation in the media a positive experience for you?”; and (d) “Did you regret your participation in the media?” The latter three questions were responded to on an ordinal scale that ranged from 1 = not at all to 5 = extremely. PTS reactions over the past month were measured using the UCLA PTSD Reaction Index (PTSD-RI: Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998; Steinberg, Brymer, Decker, & Pynoos, 2004). The PTSD-RI is a 20-item scale in which responses are recorded on a 5-point scale that ranges from 0 = never to 4 = most of the time. Three items have two alternative formulations, and the highest score on each of these items is applied to calculate the total score. Hence, the total score is composed of 17 items that correspond to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for PTSD. In this study, the mean of these 17 items had a Cronbach’s α of .89. Although the UCLA index often is used as a self-report instrument, in this study professionals interviewed the participants face-to-face to ensure that they understood the questions and time frames. Perceived social support was measured with the Duke-UNC Functional Social Support Questionnaire (FSSQ: Broadhead, Gehlbach, DeGruy, & Kaplan, 1988), which comprises seven items: receiving attention, care, and support from close friends and family; care from close ones when sick; receiving advice and support from others regarding school, work, or personal matters; and being included in social activities with others. The statements had five possible responses: 5 = as much as I would like; 4 = almost as much as I would like; 3 = somewhat, but would like more; 2 = less than I would like; and 1 = much less than I would like. A mean score was calculated. The FSSQ has been shown to be valid and reliable (Broadhead et al., 1988), and the Cronbach’s α for this scale in the present study was .90. We also measured feeling let down. In line with the recommendations of Andrews, Brewin, and Rose (2003), we included a single item to measure what these authors termed “negative social support” from the Crisis Support Scale (Joseph, Andrews, Williams, & Yule, 1992). The participants were asked if they had felt let down by someone they thought would support them, on a 5-point Likert-type scale that ranged from 1 = not at all to 5 = very much for this item. The interviewer completed rating of PTS reactions, social support, and feeling let down. The sociodemographic information collected included gender, age, and ethnicity (non-Norwegian origin was defined by having both parents born abroad). Data Analysis Pearson’s χ2 tests were used for bivariate analyses of categorical variables, and Spearman’s ρ (for ordinal variables), and Pearson’s correlation (for continuous variables) were used for correlation analyses. No participants had more than two missing variables for the calculations of mean or sum scores, and the mean scores were calculated based on the means of the
valid items within each scale. Univariate associations between PTS reactions and the independent variables were assessed using univariate linear regressions. Adjusted associations between PTS reactions and media participation was assessed using multiple linear regressions, adjusting for potential confounders (demographics, social support, and feeling let down). Mediarelated factors were entered as categorical variables (1–5) in the regression analyses because these items were single, ordinal variables. Differences between mean PTS score in those participating and not participating in media interviews were tested with independent sample t tests. All tests were two-tailed, and the significance level was set at p ࣘ .05. Statistical analyses were performed using IBM SPSS statistics for Windows, Version 20.
Results Nearly all of the terror survivors were approached by the media, and the vast majority participated in interviews about their terror experiences and/or about the trial (Table 1). There were no significant differences between the genders regarding approaches from media (females: 94.8%, males: 94.0%), χ2 (1, N = 283) = 0.09, nonsignificant [ns]), being interviewed in the media about the terror experience, females: 86.9%, males: 89.7%, χ2 (1, N = 275) = 0.50, ns, or contributing own texts in newspapers, females: 26.1%, males: 21.9%, χ2 (1, N = 285) = 0.71, ns. There was a tendency toward greater participation in interviews related to the trial by males (60.8%) compared to females (49.3%), χ2 (1, N = 282) = 3.80, p = .051. The frequency of being approached by the media did not differ significantly between age groups, and 90.7% of young people between 13 and 16 years of age were contacted by media (Table 1). Older age groups were more often interviewed by the media about the terror experience compared to younger age groups. Nevertheless, the majority also in the younger age groups down to 13 years of age was interviewed by the media about both their terror experience and the trial. Among the survivors, being approached by the media was perceived by a minority as negative or very negative (10.5%, n = 28). Most participants regarded the approach by the media as either both positive and negative (63.8%, n = 171), or as positive or very positive (25.8%, n = 69). Girls/women had significantly less positive perceptions of being approached by the media than did boys/men, χ2 (4, N = 268) = 9.78, p = .044. There was no significant correlation between age and the appraisal of being approached by the media (Spearman’s ρ = 0.02, ns). As seen in Table 2, media participation was positively evaluated by the terror victims overall. In total, 12.5% (n = 31) of the victims perceived the media participation as quite a bit or extremely distressing, and 11.4% (n = 28) reported that they regretted participating (quite a bit or extremely). There were no significant gender differences for Distressing: χ2 (4, N = 248) = 6.27, ns; for Positive: χ2 (4, N = 245) = 8.72,
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 1 Frequency of Media Participation About Terrorist Attack Pooled and by Age Group Age group (years) Total
>18–25
>25
n
%
n
%
n
%
n
%
n
%
χ2
267 243 156 68
94.3 88.4 55.3 23.9
49 40 25 11
90.7 78.4 47.2 20.4
95 87 51 22
92.2 87.0 49.5 21.2
107 100 67 30
98.2 92.6 61.5 27.3
16 16 13 5
94.1 100.0 76.5 29.4
5.16 9.06* 7.57 1.78
Variable Approached by media Interviewed about event Interviewed about trial Wrote own texts
>16–18
13–16
Note. N = 275–285. * p < .05.
ns; for Had regrets: χ2 (4, N = 246) = 7.43, ns. There were age differences in the perceptions of media participation with the exception of older individuals who perceived participation as somewhat more stressful (Spearman’s ρ = .16, p = .015). The four media-related variables were all significantly, but moderately correlated (Table 3). For example, negative appraisal of being approached by the media was positively associated with perceiving media participation as distressing, and having regrets about participating, and negatively correlated with positive appraisals of participation. Negative appraisals of being contacted by the media were significantly correlated with feeling let down and higher levels of PTS reactions, but positive appraisals of the actual participation in the media were not significantly related to mental health or the social support variables. The perception of media participation as distressing and regrets about media participation were positively correlated with PTS reactions. The stressfulness of media participation was associated with perceived social support, while regrets about participation were associated with feeling let down. None of the three media participation measures (being interviewed about the terror, being interviewed about the trial, or contribution of own texts) seemed to be related to PTS reactions (analyses available in supplementary online materials). A potential association between being approached by the media and PTS reactions could not be investigated in this study
because nearly all of our participants had been approached by journalists. Perceptions of media participation as distressing and regrets regarding participation were univariately significantly associated with greater levels of PTS reactions (Table 4). These effects remained after each media-related variable was adjusted for demographics, social support, and feelings of being let down (not shown in Table 4). After adjusting all media-related variables for each other and for demographics, social support, and feelings of being let down, only the perception of media participation as distressing remained significant. Positive appraisals of media participation seemed to be unrelated to PTS reactions. Discussion The majority of the survivors of the shooting at Utøya Island were approached by the media and interviewed at least once. Our youngest participants (i.e., those under 16 years of age) were equally likely as the adult participants to be approached by reporters. The proportion of survivors who were contacted by the media was higher in this study (94%) compared to a Finnish study of adolescents exposed to a school shooting (75% of severely exposed; Haravuori et al., 2011). It is important to note, however, that the Finnish study focused on media attention in the immediate aftermath of the shooting, while the current study included media participation up to almost a year following
Table 2 Three Levels of Appraisal of Experiences With Media Participation by Gender Not at all/a little Female
Somewhat
Male
Female
Quite a bit/extremely Male
Female
Male
Variable
n
%
n
%
n
%
n
%
n
%
n
%
Distressing Positive Had regrets
64 37 78
55.7 33.1 69.0
89 45 110
66.9 33.8 82.7
34 48 19
29.6 42.9 16.8
30 47 11
22.6 35.3 8.3
17 27 16
15.8 24.1 14.1
14 41 12
10.6 30.8 9.1
Note. N = 245–248.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Table 3 Spearman Correlations for Key Variables Variable 1 Media approach negative 2 Media participation distressing 3 Media participation positive 4 Regret media participation 5 PTS reactions 6 Let down 7 Perceived SS
1
2
3
4
5
6
.39** −.47** .40** .22** .19** −.08
−.19** .59** .37** .10 −.16*
−.32** −.09 −.12 .08
.35** .18** −.21
.48** −.41**a
−.32**
–
Note. N = 239–285. PTS = posttraumatic stress; SS = social support. a Pearson correlation. * p < .05. ** p < .01.
the terrorist attack. Unfortunately, we were not able to find any other studies with which we could compare our results. Contact with the media was nevertheless high in both of these studies and should perhaps be considered as an expected postdisaster challenge faced by highly exposed victims. Overall, being contacted by the media and media participation were evaluated more positively than negatively by the
terror victims. Among those who allowed themselves to be interviewed by the media, 13% found the experience distressing, and 11% regretted participating. These results are similar to those of the Finnish study in which 19% of the participants felt worse after being interviewed by reporters. It is important to note that the majority of the survivors of the current study reported that their media participation was a positive experience.
Table 4 Associations Between Appraisals of Media Participation and PTS Reactions Adjusteda
Unadjusted Variable
B
95% CI
B
95% CI
Valence of contact; Ref = Very positiveb Positive Both positive and negative Negative Very negative
0.002 0.323 0.302 0.782
[−0.40, 0.40] [−0.05, 0.70] [−0.17, 0.77] [0.23, 1.35]**
−0.138 −0.065 −0.022 0.047
[−0.51, 0.23] [−0.43, 0.30] [−0.49, 0.45] [−0.52, 0.61]
Was distressing, Ref = Not at allc A bit Somewhat Quite a lot Extremely
0.186 0.497 0.728 0.928
[−0.03, 0.40] [0.26, 0.73]** [0.42, 1.04]** [0.38, 1.48]**
−0.009 0.289 0.440 0.611
[−0.21, 0.19] [0.05, 0.53]* [0.12, 0.76]** [0.03, 1.19]*
0.138 0.060 −0.017 −0.478
[−0.22, 0.49] [−0.28, 0.40] [−0.37, 0.340] [−1.12, 0.16]
0.015 0.090 0.185 −0.108
[−0.27, 0.30] [−0.20, 0.37] [−0.12, 0.49] [−0.62, 0.41]
0.350 0.571 0.484 0.975
[0.16, 0.54]** [0.30, 0.84]** [0.15, 0.82]** [0.57, 1.38]**
0.103 0.187 −0.030 0.015
[−0.07, 0.27] [−0.08, 0.45] [−0.38, 0.32] [−0.45, 0.48]
Was positive, Ref = Not at alld A bit Somewhat Quite a lot Extremely Regret, Ref = Not at alle A bit Somewhat Quite a lot Extremely
Note. PTS = posttraumatic stress; CI = confidence interval; ns = nonsignificant. a Adjusted for gender, age, ethnicity, feeling let down, and current social support. b Overall p level for unadjusted model was < .01 and ns for the adjusted model. c Overall p level for unadjusted and adjusted model was < .01. d Overall p level for unadjusted and adjusted model was ns. e Overall level for unadjusted model was < .01 and ns for the adjusted model.
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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Taking part in media interviews was not associated with PTS reactions among Utøya survivors, but negative evaluations and regrets about participation were. This finding may indicate that media participation per se was not associated with harm or gain in terms of mental health. It may be that media participation is more difficult for individuals with a high symptom level, or that negative experiences with media participation may lead to an exacerbation of symptoms. Alternatively, in an effort to make meaning from their situations, individuals with high symptom levels may search for causes of their suffering and report negative experiences as a consequence of such attribution processes. Individuals with a high symptom level may be less in control of their emotions and may have reduced available cognitive capacity to cope efficiently with interviews and be less able to set adequate limits for their disclosures to the public. As a result, these individuals may find interviews more distressing, be less happy with their exposure, and possibly have more regrets about participating. In contrast, negative experiences of media participation may lead to increases in psychological symptoms. For example, media participation may trigger negative emotions, such as anger or shame, which may intensify psychological symptoms. Previous research has shown that media exposure can trigger negative emotions (Haravuori et al., 2011; Maerker & Mehr, 2006), and that such emotions are associated with PTS reactions (Andrews, Brewin, Rose, & Kirk, 2000). In addition, our findings did not lend support to any protective effect of positive experiences with media participation. A previous study indicated that media participation may be useful for some victims by contributing positively to their coping process (Englund, Forsberg, & Saveman, 2014). In the current study, positive experiences with media participation was unrelated both to PTS reactions and to social support. Media participation may also be viewed as a form of social interaction or communication. In our study, appraisals of the interactions with the media were associated with two different aspects of social support. First, negative appraisals of being contacted by the media and regretting media participation were both associated with feeling let down. Previous research has shown negative social support (such as feeling let down) to be predictive of increased symptom levels (Brewin & Holmes, 2003). Survivors of disasters and terrorist attacks may expect sympathy, support, and respect from both significant others and the public. The sense that reporters wish to exploit the situations of victims may lead to feelings of being let down. An expert group consisting of Utøya representatives concluded that experiences with media participation were mixed and several survivors and families had experienced intrusive behavior from media representatives (Norwegian Ombudsman for Children, 2012). Intrusive behavior from reporters has been described in previous research as potentially annoying and offensive (Hawkins et al., 2007). Media exposure may also be related to feeling let down in other ways. Individuals who share their experiences in the public domain may be met with unsupportive or critical attitudes from other survivors, from organizations, or from their significant others.
Second, the experience of the media participation as distressing was associated with lower levels of perceived social support. Social support is considered to be one of the most important protective factors against mental health problems following trauma (Brewin et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003). Individuals with strong social networks may be better able to cope with the potential stress of being the focus of public attention. Whether media exposure affects the social support of victims requires further exploration. Following terrorism and disasters, the media have the crucial societal task of informing the general population about what happened and aiding the understanding of the events’ consequences. Directly exposed victims are important sources of information for the media. The results of this study indicate that media interviews with terror victims can be achieved without doing harm. Overall, terror victims positively appraised their contact with the media, and being interviewed by the media was not associated with PTS reactions. The manner in which the interview is performed and how the interview is perceived by the interviewee may be key to its effect. Negative experiences of media participation may represent an additional strain to victims of mass trauma. Our study also suggests that better protection and increased support for victims with high symptom levels are needed when victims interact with reporters. Additionally, media representatives need to understand that they may add to the burden of survivors if they are not sufficiently careful. Strict adherence to ethical standards would most likely increase the victims’ abilities to cope and take control of the interview situations. Reporters and editorial offices need knowledge and ethical awareness to guide their contact with survivors, their strategies for providing survivors a sense of control, and their strategies for creating headlines and framing stories. Clinicians should be aware of media exposure as a potentially important additional strain to the victims. The Utøya study has a longitudinal design, but the current investigation used cross-sectional data, and no causal inferences can be drawn. Media participation, appraisals, and regrets were measured retrospectively, and current mental health may have influenced the participants’ evaluations. Although the response rate was adequate in this sample, we unfortunately have little information about the nonresponders. Previous analyses have shown that responders do not differ significantly from nonresponders in terms of age and gender (Dyb et al., 2014). It is possible, however, that responders differ from nonresponders on aspects related to variables included in this study. For example, individuals with a high symptom load may have been more reluctant to participate. As appraisals of media participation were associated with PTS symptoms, negative appraisals of media participation may have been underestimated. The media attention toward the terrorist attack was massive and prolonged. Media participation in this study was not limited to the direct crisis aftermath, but included contacts with the media in relation to the trial that took place 9–11 months after the terror. Several potentially important aspects of the variety of experiences with the media exist that our measures of media participation could
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Terror Victims in the Media
not capture. In the initial aftermath of this attack, the media reports were primarily focused on sympathetic descriptions of survivors’ experiences and the public support for the victims. Gradually, certain salient themes began to emerge, and the focus of the media became more critical and confrontational. We have no data about when our participants took part in media interviews, how many interviews they took part in, or their reasons for dissatisfaction. The generalizability of our results could be limited by aspects of the sample, aspects of the traumatic event, or the cultural setting. Each traumatic event, however, will occur in a specific cultural setting with specific samples. The following factors are relevant to the current study: (a) the sample was likely not a particularly vulnerable group before the terrorist attack; (b) the sample consisted of politically active young people who might have been more willing than other groups to expose themselves in the media and take part in the public discourse compared to victims of other terrorist attacks; (c) some of the participants had received media training as a part of their political training before the event (Norwegian Ombudsman for Children, 2012), and this may have increased the coping abilities of these individuals; and (d) the media reports were generally sympathetic and minimally critical or judgmental in terms of blaming the victims. More research is needed to establish whether our results can be replicated in other samples of terror or disaster victims and whether these results would generalize to individuals who have been exposed to other traumatic events such as violence and sexual abuse. The strengths of this study include the use of face-to-face interviews with trained clinicians and the comprehensiveness of the data collection. Additionally, the adversities faced by the survivors of Utøya were most likely unrelated to their personal histories, and the trauma exposure was nearly identical in men and women and across ages (Dyb et al., 2014). Future research should focus on several aspects of media participation that were not investigated in this study, preferably with longitudinal designs. For example, future research should focus on the number of media participations, early versus later media contacts, more detailed appraisals of the various contacts with media, and descriptions of what specific aspects of media participation were perceived as negative versus positive. Also, research on the combined effect of media participation and the use of social media could expand our understanding of coping in the aftermath of terror. References Ahern, J., Galea, S., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, D. (2002). Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry, 65, 289–300. doi:10.1097/01.nmd.0000116465.99830.ca
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Andrews, B., Brewin, C. R., Rose, S., & Kirk, M. (2000). Predicting PTSD symptoms in victims of violent crime: The role of shame, anger, and childhood abuse. Journal of Abnormal Psychology, 109, 69–73. doi:10.1037/0021-843X.109.1.69 Backholm, K., & Bj¨orkqvist, K. (2012). Journalists’ emotional reactions after working with the Jokela school shooting incident. Media, War & Conflict, 5, 175–190. doi:10.1177/1750635212440914 Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. doi:10.1037//0022006X.68.5.748 Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review, 23, 339–376. doi:10.1016/S0272-7358(03)00033-3 Broadhead, W. E., Gehlbach, S. H., DeGruy, F. V., & Kaplan, B. H. (1988). The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Medical Care, 26, 709–723. doi:10.1097/00005650-198807000-00006 Dyb, G., Jensen, T. K., Nygaard, E., Ekeberg, Ø., Diseth, T. H., Wentzel-Larsen, T., & Thoresen, S. (2014). Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway. British Journal of Psychiatry, 204, 361–367. doi:10.1192/bjp.bp.113.133157 Englund, L., Forsberg, R., & Saveman, B. I. (2014). Survivors’ experiences of media coverage after traumatic injury events. International Emergency Nursing, 22, 25–30. doi:10.1016/j.ienj.2013.03.010 Feinstein, A., Owen, J., & Blair, N. (2002). A hazardous profession: War, journalists, and psychopathology. American Journal of Psychiatry, 159, 1570–1575. doi:10.1176/appi.ajp.159.9.1570 Haravuori, H., Suomalainen, L., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). Effects of media exposure on adolescents traumatized in a school shooting. Journal of Traumatic Stress, 24, 70–77. doi:10.1002/ jts.20605 Hawkins, N. A., McIntosh, D. N., Silver, R. C., & Holman, E. A. (2007). Early responses to school violence. A qualitative analysis of students’ and parents’ immediate reactions to the shooting at Columbine High School. Journal of Emotional Abuse, 4, 197–223. doi:10.1300/J135v04n03_12 Jemphrey, A., & Berrington, E. (2000). Surviving the media: Hillsborough, Dunblane and the press. Journalism Studies, 1, 469–483. doi:10.1080/14616700050081786 Joseph, S., Andrews, B., Williams, R., & Yule, W. (1992). Crisis support and psychiatric symptomatology in adult survivors of the Jupiter cruise ship disaster. British Journal of Clinical Psychology, 31, 63–73. doi:10.1111/j.20448260.1992.tb00968.x Kay, L., Reilly, R. C., Connolly, K., & Cohen, S. (2010). Help or harm? Symbolic violence, secondary trauma and the impact of press coverage on a community. Journalism Practice, 4, 421–438. doi:10.1080/17512780903 429829 Maerker, A., & Mehr, A. (2006). What if victims read a newspaper report about their victimization? A study on the relationship to PTSD symptoms in crime victims. European Psychologist, 11, 137–142. doi:10.1027/10169040.11.2.137
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Neria, Y., DiGrande, L., & Adams, B. G. (2011). Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: A review of the literature among highly exposed populations. American Psychologist, 66, 429–446. doi:10.1037/a0024791
Andrews, B., Brewin, C. R., & Rose, S. (2003). Gender, social support, and PTSD in victims of violent crime. Journal of Traumatic Stress, 16, 421–427. doi:10.1023/A:1024478305142
˚ Norwegian Ombudsman for Children. (2012). Katastrofeekspertene A leve etter Utøya [Report: Disaster experts. How to live on
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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after 22, July 2011]. Retrieved from http://barneombudet.no/wpcontent/ ˚ uploads/2013/09/Katastofeekspertene-A-leve-etter-Utøya.pdf Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52–73. doi:10.1037/0033-2909.129.1.52 Pfefferbaum, B., Doughty, D. E., & Reddy, C. (2002). Exposure and peritraumatic response as predictors of posttraumatic stress in children following the 1995 Oklahoma City bombing. Journal of Urban Health, 79, 354–363. doi:10.1093/jurban/79.3.354 Pynoos, R. S., Rodriguez, N., Steinberg, A. M., Stuber, M., & Frederick, C. (1998). UCLA PTSD Index for DSM IV. Los Angeles, CA: University of California.
Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., . . . Kulka, R. A. (2002). Psychological reactions to terrorist attacks. Findings from the National Study of Americans’ Reactions to September 11. Journal of the American Medical Association, 288, 581–588. doi:10.1001/jama.288.5.581 Steinberg, A. M., Brymer, M. J., Decker, K. B., & Pynoos, R. S. (2004). The University of California at Los Angeles post-traumatic stress disorder reaction index. Current Psychiatry Reports, 6, 96–100. doi:10.1007/s11920004-0048-2 Vasterman, P., Yzermans, J., & Dirkzwager, A. J. E. (2005). The role of the media and media hypes in the aftermath of disasters. Epidemiological Reviews, 27, 107–114. doi:10.1093/epirev/ mxi002
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Media Participation and Mental Health in Terrorist Attack Survivors Siri Thoresen,1 Tine K. Jensen,1,2 and Grete Dyb1,3 1
Norwegian Centre for Violence and Traumatic Stress Studies, Oslo, Norway Department of Psychology, Faculty of Social Sciences, University of Oslo, Norway 3 Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway 2
Terrorism and disasters receive massive media attention, and victims are often approached by reporters. Not much is known about how terror and disaster victims perceive the contact with media and whether such experiences influence mental health. In this study, we describe how positive and negative experiences with media relate to posttraumatic stress (PTS) reactions among survivors of the 2011 Utøya Island terrorist attack in Norway. Face-to-face interviews were conducted with 285 survivors (47.0% female and 53.0% male) 14–15 months after the terrorist attack. Most survivors were approached by reporters (94%), and participated in media interviews (88%). The majority of survivors evaluated their media contact and participation as positive, and media participation was unrelated to PTS reactions. Survivors who found media participation distressing had more PTS reactions (quite distressing: B = 0.440, extremely distressing: B = 0.611, p = .004 in adjusted model). Perceiving media participation as distressing was slightly associated with lower levels of social support (r = –.16, p = .013), and regretting media participation was slightly associated with feeling let down (r = .18, p = .004). Reporters should take care when interviewing victims, and clinicians should be aware of media exposure as a potential additional strain on victims.
Disasters and terrorist attacks receive massive and often worldwide media attention. The media play a vital role in supplying information to the public. Directly exposed victims have first-hand knowledge and may be essential sources of information. Hence, when consenting to be interviewed, victims play an important societal role. Some victims may also want to share their experiences so that the world community can understand what has happened and how the events have affected their lives. Moreover, media coverage may provide vital information to the victims themselves that may be useful in coping with the situation (Hawkins, McIntosh, Silver, & Holman, 2007). Nonetheless, media attention may also be burdensome. For example, journalists who are perceived as intrusive may annoy victims and their relatives, and negative emotions may be triggered by media reports (Kay, Reilly, Connolly, & Cohen, 2010). The media may add to anxiety in exposed groups by exaggerating danger and creating unnecessary fear (Vasterman, Yzermans, & Dirkzwager, 2005). Additionally, several studies have suggested that television viewing following disasters and terrorist attacks is related to increased posttraumatic stress (PTS) reactions in both children and adults in the general
population (Pfefferbaum, Doughty, & Reddy, 2002; Schlenger et al., 2002) and in directly affected groups (Ahern et al., 2002; Neria, DiGrande, & Adams, 2011). Journalistic analyses have revealed that media portrayals of events can vary from compassionate to hostile (Jemphrey & Berrington, 2000). Hence, the role of the media in the official discourse following disasters may guide attention and sympathy towards the needs of victims or add to the burden of the survivors and bereaved. Many terror or disaster survivors are approached by reporters, and some agree to be interviewed. These interviews may be emotionally challenging for both reporters who interview a distressed survivor and for the survivors being interviewed. Several research studies have explored how journalists are affected by working with war, terror, and disasters (e.g., Backholm & Bj¨orkqvist, 2012; Feinstein, Owen, & Blair, 2002). Less is known about how terror or trauma victims perceive the media coverage of their cases or their own participation in the media and how these issues relate to mental health. Maerker and Mehr (2006) investigated crime victims’ reactions to reading about, listening to, or watching media reports about the crimes that they were victims of. The majority of victims reported negative emotional reactions to the media reports (66% reported sadness and 48% reported fear), and such reactions were associated with posttraumatic stress disorder (PTSD) symptoms. We were able to identify only one study on the relationship between being interviewed by the media and mental health of the victims of mass trauma. This study was an investigation
Correspondence concerning this article should be addressed to Siri Thoresen, Norwegian Center for Violence and Traumatic Stress Studies, Postbox 181 Nydalen, 0409 Oslo, Norway. E-mail: [email protected] C 2014 International Society for Traumatic Stress Studies. View Copyright this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21971
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of Finnish adolescents who were exposed to a school shooting (Haravuori, Suomalainen, Berg, Kiviruusu, & Marttunen, 2011). The authors found that being interviewed by the media was associated with increased PTS reactions. In that study, one in five adolescents felt worse after being interviewed, and the authors suggested that this negative emotional affect may have contributed to the exacerbation of PTS reactions. Taken together, these studies support the view that media coverage may have a powerful impact on how victims of mass trauma are able to deal with their experiences, and the results should heighten our concern regarding the effects of media participation on victims. People may say things they regret or feel let down or betrayed by headlines or the angle of the story they participated in. On the other hand, media participation may contribute to positive attention and the regaining of agency. The manner in which an individual is portrayed in the media may also affect how other people respond to that person, potentially affecting the person’s social network positively or negatively. As social support seems to be one of the most important protective factors against PTS reactions (Brewin, Andrews, & Valentine, 2000), explorations of the potential relationships between media participation and social support are needed. The terrorist attack in Norway that occurred on July 22, 2011 included the explosion of a bomb in the capital of Oslo and the shooting attack on Utøya Island, which was hosting a summer camp for the Norwegian Labor Youth Party. The attack on Utøya Island resulted in the deaths of 69 young people, and an additional 56 individuals were admitted to hospitals with severe injuries. The shooting attack and the high levels of trauma exposure experienced by the survivors have been described in detail elsewhere (Dyb et al., 2014). The terrorist attack was followed by massive media attention. In Norway, the media continued to focus intensively on the terrorist attack and the terrorist for at least a year, and peaks in coverage occurred with certain events such as the psychiatric evaluations of the terrorist, the trial, and the first anniversary of the attack. In this study, we examined survivors of the 2011 Norway attacks who were present on Utøya Island at the time of the shooting participation with the media. We investigated positive and negative experiences with media, experienced stress and regrets about participation, and the association of these factors with PTS and social support.
Method Participants and Procedure The police registered names and ages of individuals who were present at Utøya Island at the time of the shooting on July 22, 2011. All survivors were mailed invitations to participate in a study and subsequently contacted by phone. Face-to-face interviews were conducted by health professionals with specific training for this study. The interview was highly structured, and data were completed by the interviewer. An additional selfreport section was completed by the respondent, although the
interviewer was available for questions. After the self-report section was completed, the interview was ended with an evaluation of potential unmet needs. Wave 1 was conducted 4– 5 months after the terrorist attack; Wave 2 was conducted 14– 15 months after the terrorist attack. The response rate at Wave 1 was 66.3% (N = 325), and at Wave 2 the response rate was 58.2% (N = 285). At Wave 2, all survivors were invited to participate in the study, including those who did not participate in Wave 1. The present study used data from all participants at Wave 2 of the Utøya study. The 285 individuals who participated in Wave 2 of the Utøya study comprised 47.0% girls/women (n = 134) and 53.0% boys/men (n = 151). The mean age was 19.21 (SD = 4.25) years at the time of the shooting. The age range was 13 to 47 years of age, and 93.0% of the participants were under 25 years of age. The majority of participants (89.9%, n = 248) were of Norwegian ethnic origin. The study was approved by the Regional Committee for Medical and Health Research Ethics in Norway. Each participant provided written consent, and additional consent from the parents was provided for participants below the age of 16 years. Further details about the participants and procedures are described elsewhere (Dyb et al., 2014); no significant differences in gender or age were identified between participants and nonparticipants. The Dyb et al. article also describes the experiences and symptomatology of the Wave 1 sample. The participants had been exposed to threats to their lives or had witnessing experiences and grotesque impressions. Additionally, the majority of the participants had lost someone close in the terrorist attack. Measures The media attention following the terrorist attack was intense for several months following the attack, and again in relation to the trial which took place 9–11 months after the attack. Hence, in the current study we chose not to restrict media participation to the direct crisis aftermath. The measure of media participation was designed for this study, included in the self-report section, and completed by the respondent. We asked the four following dichotomous (yes/no) questions about the participants’ terror-related contact with the media: (a) “Were you contacted by the media about your experiences at Utøya Island on July 22, 2011?”; (b) “Were you interviewed by the media about your experiences at Utøya Island on July 22, 2011?”; (c) “Were you interviewed by the media about the trial following the terror attack of July 22, 2011?”; and (d) “Did you contribute your own texts to media related to the terror attack at Utøya Island or to the trial following the terror attack?” The following four questions measured the participants’ appraisals of their contact with the media: (a) “How did you perceive being contacted by the media about your terror experiences?” (rated on the following ordinal scale: 1 = very positive, 2 = positive, 3 = both positive and negative, 4 = negative, and 5 = very negative); (b) “Was your participation in the media
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distressing to you?”; (c) “Was your participation in the media a positive experience for you?”; and (d) “Did you regret your participation in the media?” The latter three questions were responded to on an ordinal scale that ranged from 1 = not at all to 5 = extremely. PTS reactions over the past month were measured using the UCLA PTSD Reaction Index (PTSD-RI: Pynoos, Rodriguez, Steinberg, Stuber, & Frederick, 1998; Steinberg, Brymer, Decker, & Pynoos, 2004). The PTSD-RI is a 20-item scale in which responses are recorded on a 5-point scale that ranges from 0 = never to 4 = most of the time. Three items have two alternative formulations, and the highest score on each of these items is applied to calculate the total score. Hence, the total score is composed of 17 items that correspond to the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for PTSD. In this study, the mean of these 17 items had a Cronbach’s α of .89. Although the UCLA index often is used as a self-report instrument, in this study professionals interviewed the participants face-to-face to ensure that they understood the questions and time frames. Perceived social support was measured with the Duke-UNC Functional Social Support Questionnaire (FSSQ: Broadhead, Gehlbach, DeGruy, & Kaplan, 1988), which comprises seven items: receiving attention, care, and support from close friends and family; care from close ones when sick; receiving advice and support from others regarding school, work, or personal matters; and being included in social activities with others. The statements had five possible responses: 5 = as much as I would like; 4 = almost as much as I would like; 3 = somewhat, but would like more; 2 = less than I would like; and 1 = much less than I would like. A mean score was calculated. The FSSQ has been shown to be valid and reliable (Broadhead et al., 1988), and the Cronbach’s α for this scale in the present study was .90. We also measured feeling let down. In line with the recommendations of Andrews, Brewin, and Rose (2003), we included a single item to measure what these authors termed “negative social support” from the Crisis Support Scale (Joseph, Andrews, Williams, & Yule, 1992). The participants were asked if they had felt let down by someone they thought would support them, on a 5-point Likert-type scale that ranged from 1 = not at all to 5 = very much for this item. The interviewer completed rating of PTS reactions, social support, and feeling let down. The sociodemographic information collected included gender, age, and ethnicity (non-Norwegian origin was defined by having both parents born abroad). Data Analysis Pearson’s χ2 tests were used for bivariate analyses of categorical variables, and Spearman’s ρ (for ordinal variables), and Pearson’s correlation (for continuous variables) were used for correlation analyses. No participants had more than two missing variables for the calculations of mean or sum scores, and the mean scores were calculated based on the means of the
valid items within each scale. Univariate associations between PTS reactions and the independent variables were assessed using univariate linear regressions. Adjusted associations between PTS reactions and media participation was assessed using multiple linear regressions, adjusting for potential confounders (demographics, social support, and feeling let down). Mediarelated factors were entered as categorical variables (1–5) in the regression analyses because these items were single, ordinal variables. Differences between mean PTS score in those participating and not participating in media interviews were tested with independent sample t tests. All tests were two-tailed, and the significance level was set at p ࣘ .05. Statistical analyses were performed using IBM SPSS statistics for Windows, Version 20.
Results Nearly all of the terror survivors were approached by the media, and the vast majority participated in interviews about their terror experiences and/or about the trial (Table 1). There were no significant differences between the genders regarding approaches from media (females: 94.8%, males: 94.0%), χ2 (1, N = 283) = 0.09, nonsignificant [ns]), being interviewed in the media about the terror experience, females: 86.9%, males: 89.7%, χ2 (1, N = 275) = 0.50, ns, or contributing own texts in newspapers, females: 26.1%, males: 21.9%, χ2 (1, N = 285) = 0.71, ns. There was a tendency toward greater participation in interviews related to the trial by males (60.8%) compared to females (49.3%), χ2 (1, N = 282) = 3.80, p = .051. The frequency of being approached by the media did not differ significantly between age groups, and 90.7% of young people between 13 and 16 years of age were contacted by media (Table 1). Older age groups were more often interviewed by the media about the terror experience compared to younger age groups. Nevertheless, the majority also in the younger age groups down to 13 years of age was interviewed by the media about both their terror experience and the trial. Among the survivors, being approached by the media was perceived by a minority as negative or very negative (10.5%, n = 28). Most participants regarded the approach by the media as either both positive and negative (63.8%, n = 171), or as positive or very positive (25.8%, n = 69). Girls/women had significantly less positive perceptions of being approached by the media than did boys/men, χ2 (4, N = 268) = 9.78, p = .044. There was no significant correlation between age and the appraisal of being approached by the media (Spearman’s ρ = 0.02, ns). As seen in Table 2, media participation was positively evaluated by the terror victims overall. In total, 12.5% (n = 31) of the victims perceived the media participation as quite a bit or extremely distressing, and 11.4% (n = 28) reported that they regretted participating (quite a bit or extremely). There were no significant gender differences for Distressing: χ2 (4, N = 248) = 6.27, ns; for Positive: χ2 (4, N = 245) = 8.72,
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Table 1 Frequency of Media Participation About Terrorist Attack Pooled and by Age Group Age group (years) Total
>18–25
>25
n
%
n
%
n
%
n
%
n
%
χ2
267 243 156 68
94.3 88.4 55.3 23.9
49 40 25 11
90.7 78.4 47.2 20.4
95 87 51 22
92.2 87.0 49.5 21.2
107 100 67 30
98.2 92.6 61.5 27.3
16 16 13 5
94.1 100.0 76.5 29.4
5.16 9.06* 7.57 1.78
Variable Approached by media Interviewed about event Interviewed about trial Wrote own texts
>16–18
13–16
Note. N = 275–285. * p < .05.
ns; for Had regrets: χ2 (4, N = 246) = 7.43, ns. There were age differences in the perceptions of media participation with the exception of older individuals who perceived participation as somewhat more stressful (Spearman’s ρ = .16, p = .015). The four media-related variables were all significantly, but moderately correlated (Table 3). For example, negative appraisal of being approached by the media was positively associated with perceiving media participation as distressing, and having regrets about participating, and negatively correlated with positive appraisals of participation. Negative appraisals of being contacted by the media were significantly correlated with feeling let down and higher levels of PTS reactions, but positive appraisals of the actual participation in the media were not significantly related to mental health or the social support variables. The perception of media participation as distressing and regrets about media participation were positively correlated with PTS reactions. The stressfulness of media participation was associated with perceived social support, while regrets about participation were associated with feeling let down. None of the three media participation measures (being interviewed about the terror, being interviewed about the trial, or contribution of own texts) seemed to be related to PTS reactions (analyses available in supplementary online materials). A potential association between being approached by the media and PTS reactions could not be investigated in this study
because nearly all of our participants had been approached by journalists. Perceptions of media participation as distressing and regrets regarding participation were univariately significantly associated with greater levels of PTS reactions (Table 4). These effects remained after each media-related variable was adjusted for demographics, social support, and feelings of being let down (not shown in Table 4). After adjusting all media-related variables for each other and for demographics, social support, and feelings of being let down, only the perception of media participation as distressing remained significant. Positive appraisals of media participation seemed to be unrelated to PTS reactions. Discussion The majority of the survivors of the shooting at Utøya Island were approached by the media and interviewed at least once. Our youngest participants (i.e., those under 16 years of age) were equally likely as the adult participants to be approached by reporters. The proportion of survivors who were contacted by the media was higher in this study (94%) compared to a Finnish study of adolescents exposed to a school shooting (75% of severely exposed; Haravuori et al., 2011). It is important to note, however, that the Finnish study focused on media attention in the immediate aftermath of the shooting, while the current study included media participation up to almost a year following
Table 2 Three Levels of Appraisal of Experiences With Media Participation by Gender Not at all/a little Female
Somewhat
Male
Female
Quite a bit/extremely Male
Female
Male
Variable
n
%
n
%
n
%
n
%
n
%
n
%
Distressing Positive Had regrets
64 37 78
55.7 33.1 69.0
89 45 110
66.9 33.8 82.7
34 48 19
29.6 42.9 16.8
30 47 11
22.6 35.3 8.3
17 27 16
15.8 24.1 14.1
14 41 12
10.6 30.8 9.1
Note. N = 245–248.
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Table 3 Spearman Correlations for Key Variables Variable 1 Media approach negative 2 Media participation distressing 3 Media participation positive 4 Regret media participation 5 PTS reactions 6 Let down 7 Perceived SS
1
2
3
4
5
6
.39** −.47** .40** .22** .19** −.08
−.19** .59** .37** .10 −.16*
−.32** −.09 −.12 .08
.35** .18** −.21
.48** −.41**a
−.32**
–
Note. N = 239–285. PTS = posttraumatic stress; SS = social support. a Pearson correlation. * p < .05. ** p < .01.
the terrorist attack. Unfortunately, we were not able to find any other studies with which we could compare our results. Contact with the media was nevertheless high in both of these studies and should perhaps be considered as an expected postdisaster challenge faced by highly exposed victims. Overall, being contacted by the media and media participation were evaluated more positively than negatively by the
terror victims. Among those who allowed themselves to be interviewed by the media, 13% found the experience distressing, and 11% regretted participating. These results are similar to those of the Finnish study in which 19% of the participants felt worse after being interviewed by reporters. It is important to note that the majority of the survivors of the current study reported that their media participation was a positive experience.
Table 4 Associations Between Appraisals of Media Participation and PTS Reactions Adjusteda
Unadjusted Variable
B
95% CI
B
95% CI
Valence of contact; Ref = Very positiveb Positive Both positive and negative Negative Very negative
0.002 0.323 0.302 0.782
[−0.40, 0.40] [−0.05, 0.70] [−0.17, 0.77] [0.23, 1.35]**
−0.138 −0.065 −0.022 0.047
[−0.51, 0.23] [−0.43, 0.30] [−0.49, 0.45] [−0.52, 0.61]
Was distressing, Ref = Not at allc A bit Somewhat Quite a lot Extremely
0.186 0.497 0.728 0.928
[−0.03, 0.40] [0.26, 0.73]** [0.42, 1.04]** [0.38, 1.48]**
−0.009 0.289 0.440 0.611
[−0.21, 0.19] [0.05, 0.53]* [0.12, 0.76]** [0.03, 1.19]*
0.138 0.060 −0.017 −0.478
[−0.22, 0.49] [−0.28, 0.40] [−0.37, 0.340] [−1.12, 0.16]
0.015 0.090 0.185 −0.108
[−0.27, 0.30] [−0.20, 0.37] [−0.12, 0.49] [−0.62, 0.41]
0.350 0.571 0.484 0.975
[0.16, 0.54]** [0.30, 0.84]** [0.15, 0.82]** [0.57, 1.38]**
0.103 0.187 −0.030 0.015
[−0.07, 0.27] [−0.08, 0.45] [−0.38, 0.32] [−0.45, 0.48]
Was positive, Ref = Not at alld A bit Somewhat Quite a lot Extremely Regret, Ref = Not at alle A bit Somewhat Quite a lot Extremely
Note. PTS = posttraumatic stress; CI = confidence interval; ns = nonsignificant. a Adjusted for gender, age, ethnicity, feeling let down, and current social support. b Overall p level for unadjusted model was < .01 and ns for the adjusted model. c Overall p level for unadjusted and adjusted model was < .01. d Overall p level for unadjusted and adjusted model was ns. e Overall level for unadjusted model was < .01 and ns for the adjusted model.
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Taking part in media interviews was not associated with PTS reactions among Utøya survivors, but negative evaluations and regrets about participation were. This finding may indicate that media participation per se was not associated with harm or gain in terms of mental health. It may be that media participation is more difficult for individuals with a high symptom level, or that negative experiences with media participation may lead to an exacerbation of symptoms. Alternatively, in an effort to make meaning from their situations, individuals with high symptom levels may search for causes of their suffering and report negative experiences as a consequence of such attribution processes. Individuals with a high symptom level may be less in control of their emotions and may have reduced available cognitive capacity to cope efficiently with interviews and be less able to set adequate limits for their disclosures to the public. As a result, these individuals may find interviews more distressing, be less happy with their exposure, and possibly have more regrets about participating. In contrast, negative experiences of media participation may lead to increases in psychological symptoms. For example, media participation may trigger negative emotions, such as anger or shame, which may intensify psychological symptoms. Previous research has shown that media exposure can trigger negative emotions (Haravuori et al., 2011; Maerker & Mehr, 2006), and that such emotions are associated with PTS reactions (Andrews, Brewin, Rose, & Kirk, 2000). In addition, our findings did not lend support to any protective effect of positive experiences with media participation. A previous study indicated that media participation may be useful for some victims by contributing positively to their coping process (Englund, Forsberg, & Saveman, 2014). In the current study, positive experiences with media participation was unrelated both to PTS reactions and to social support. Media participation may also be viewed as a form of social interaction or communication. In our study, appraisals of the interactions with the media were associated with two different aspects of social support. First, negative appraisals of being contacted by the media and regretting media participation were both associated with feeling let down. Previous research has shown negative social support (such as feeling let down) to be predictive of increased symptom levels (Brewin & Holmes, 2003). Survivors of disasters and terrorist attacks may expect sympathy, support, and respect from both significant others and the public. The sense that reporters wish to exploit the situations of victims may lead to feelings of being let down. An expert group consisting of Utøya representatives concluded that experiences with media participation were mixed and several survivors and families had experienced intrusive behavior from media representatives (Norwegian Ombudsman for Children, 2012). Intrusive behavior from reporters has been described in previous research as potentially annoying and offensive (Hawkins et al., 2007). Media exposure may also be related to feeling let down in other ways. Individuals who share their experiences in the public domain may be met with unsupportive or critical attitudes from other survivors, from organizations, or from their significant others.
Second, the experience of the media participation as distressing was associated with lower levels of perceived social support. Social support is considered to be one of the most important protective factors against mental health problems following trauma (Brewin et al., 2000; Ozer, Best, Lipsey, & Weiss, 2003). Individuals with strong social networks may be better able to cope with the potential stress of being the focus of public attention. Whether media exposure affects the social support of victims requires further exploration. Following terrorism and disasters, the media have the crucial societal task of informing the general population about what happened and aiding the understanding of the events’ consequences. Directly exposed victims are important sources of information for the media. The results of this study indicate that media interviews with terror victims can be achieved without doing harm. Overall, terror victims positively appraised their contact with the media, and being interviewed by the media was not associated with PTS reactions. The manner in which the interview is performed and how the interview is perceived by the interviewee may be key to its effect. Negative experiences of media participation may represent an additional strain to victims of mass trauma. Our study also suggests that better protection and increased support for victims with high symptom levels are needed when victims interact with reporters. Additionally, media representatives need to understand that they may add to the burden of survivors if they are not sufficiently careful. Strict adherence to ethical standards would most likely increase the victims’ abilities to cope and take control of the interview situations. Reporters and editorial offices need knowledge and ethical awareness to guide their contact with survivors, their strategies for providing survivors a sense of control, and their strategies for creating headlines and framing stories. Clinicians should be aware of media exposure as a potentially important additional strain to the victims. The Utøya study has a longitudinal design, but the current investigation used cross-sectional data, and no causal inferences can be drawn. Media participation, appraisals, and regrets were measured retrospectively, and current mental health may have influenced the participants’ evaluations. Although the response rate was adequate in this sample, we unfortunately have little information about the nonresponders. Previous analyses have shown that responders do not differ significantly from nonresponders in terms of age and gender (Dyb et al., 2014). It is possible, however, that responders differ from nonresponders on aspects related to variables included in this study. For example, individuals with a high symptom load may have been more reluctant to participate. As appraisals of media participation were associated with PTS symptoms, negative appraisals of media participation may have been underestimated. The media attention toward the terrorist attack was massive and prolonged. Media participation in this study was not limited to the direct crisis aftermath, but included contacts with the media in relation to the trial that took place 9–11 months after the terror. Several potentially important aspects of the variety of experiences with the media exist that our measures of media participation could
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
Terror Victims in the Media
not capture. In the initial aftermath of this attack, the media reports were primarily focused on sympathetic descriptions of survivors’ experiences and the public support for the victims. Gradually, certain salient themes began to emerge, and the focus of the media became more critical and confrontational. We have no data about when our participants took part in media interviews, how many interviews they took part in, or their reasons for dissatisfaction. The generalizability of our results could be limited by aspects of the sample, aspects of the traumatic event, or the cultural setting. Each traumatic event, however, will occur in a specific cultural setting with specific samples. The following factors are relevant to the current study: (a) the sample was likely not a particularly vulnerable group before the terrorist attack; (b) the sample consisted of politically active young people who might have been more willing than other groups to expose themselves in the media and take part in the public discourse compared to victims of other terrorist attacks; (c) some of the participants had received media training as a part of their political training before the event (Norwegian Ombudsman for Children, 2012), and this may have increased the coping abilities of these individuals; and (d) the media reports were generally sympathetic and minimally critical or judgmental in terms of blaming the victims. More research is needed to establish whether our results can be replicated in other samples of terror or disaster victims and whether these results would generalize to individuals who have been exposed to other traumatic events such as violence and sexual abuse. The strengths of this study include the use of face-to-face interviews with trained clinicians and the comprehensiveness of the data collection. Additionally, the adversities faced by the survivors of Utøya were most likely unrelated to their personal histories, and the trauma exposure was nearly identical in men and women and across ages (Dyb et al., 2014). Future research should focus on several aspects of media participation that were not investigated in this study, preferably with longitudinal designs. For example, future research should focus on the number of media participations, early versus later media contacts, more detailed appraisals of the various contacts with media, and descriptions of what specific aspects of media participation were perceived as negative versus positive. Also, research on the combined effect of media participation and the use of social media could expand our understanding of coping in the aftermath of terror. References Ahern, J., Galea, S., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., & Vlahov, D. (2002). Television images and psychological symptoms after the September 11 terrorist attacks. Psychiatry, 65, 289–300. doi:10.1097/01.nmd.0000116465.99830.ca
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Andrews, B., Brewin, C. R., Rose, S., & Kirk, M. (2000). Predicting PTSD symptoms in victims of violent crime: The role of shame, anger, and childhood abuse. Journal of Abnormal Psychology, 109, 69–73. doi:10.1037/0021-843X.109.1.69 Backholm, K., & Bj¨orkqvist, K. (2012). Journalists’ emotional reactions after working with the Jokela school shooting incident. Media, War & Conflict, 5, 175–190. doi:10.1177/1750635212440914 Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. doi:10.1037//0022006X.68.5.748 Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review, 23, 339–376. doi:10.1016/S0272-7358(03)00033-3 Broadhead, W. E., Gehlbach, S. H., DeGruy, F. V., & Kaplan, B. H. (1988). The Duke-UNC Functional Social Support Questionnaire. Measurement of social support in family medicine patients. Medical Care, 26, 709–723. doi:10.1097/00005650-198807000-00006 Dyb, G., Jensen, T. K., Nygaard, E., Ekeberg, Ø., Diseth, T. H., Wentzel-Larsen, T., & Thoresen, S. (2014). Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway. British Journal of Psychiatry, 204, 361–367. doi:10.1192/bjp.bp.113.133157 Englund, L., Forsberg, R., & Saveman, B. I. (2014). Survivors’ experiences of media coverage after traumatic injury events. International Emergency Nursing, 22, 25–30. doi:10.1016/j.ienj.2013.03.010 Feinstein, A., Owen, J., & Blair, N. (2002). A hazardous profession: War, journalists, and psychopathology. American Journal of Psychiatry, 159, 1570–1575. doi:10.1176/appi.ajp.159.9.1570 Haravuori, H., Suomalainen, L., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). Effects of media exposure on adolescents traumatized in a school shooting. Journal of Traumatic Stress, 24, 70–77. doi:10.1002/ jts.20605 Hawkins, N. A., McIntosh, D. N., Silver, R. C., & Holman, E. A. (2007). Early responses to school violence. A qualitative analysis of students’ and parents’ immediate reactions to the shooting at Columbine High School. Journal of Emotional Abuse, 4, 197–223. doi:10.1300/J135v04n03_12 Jemphrey, A., & Berrington, E. (2000). Surviving the media: Hillsborough, Dunblane and the press. Journalism Studies, 1, 469–483. doi:10.1080/14616700050081786 Joseph, S., Andrews, B., Williams, R., & Yule, W. (1992). Crisis support and psychiatric symptomatology in adult survivors of the Jupiter cruise ship disaster. British Journal of Clinical Psychology, 31, 63–73. doi:10.1111/j.20448260.1992.tb00968.x Kay, L., Reilly, R. C., Connolly, K., & Cohen, S. (2010). Help or harm? Symbolic violence, secondary trauma and the impact of press coverage on a community. Journalism Practice, 4, 421–438. doi:10.1080/17512780903 429829 Maerker, A., & Mehr, A. (2006). What if victims read a newspaper report about their victimization? A study on the relationship to PTSD symptoms in crime victims. European Psychologist, 11, 137–142. doi:10.1027/10169040.11.2.137
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Neria, Y., DiGrande, L., & Adams, B. G. (2011). Posttraumatic stress disorder following the September 11, 2001, terrorist attacks: A review of the literature among highly exposed populations. American Psychologist, 66, 429–446. doi:10.1037/a0024791
Andrews, B., Brewin, C. R., & Rose, S. (2003). Gender, social support, and PTSD in victims of violent crime. Journal of Traumatic Stress, 16, 421–427. doi:10.1023/A:1024478305142
˚ Norwegian Ombudsman for Children. (2012). Katastrofeekspertene A leve etter Utøya [Report: Disaster experts. How to live on
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
646
Thoresen, Jensen, and Dyb
after 22, July 2011]. Retrieved from http://barneombudet.no/wpcontent/ ˚ uploads/2013/09/Katastofeekspertene-A-leve-etter-Utøya.pdf Ozer, E. J., Best, S. R., Lipsey, T. L., & Weiss, D. S. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52–73. doi:10.1037/0033-2909.129.1.52 Pfefferbaum, B., Doughty, D. E., & Reddy, C. (2002). Exposure and peritraumatic response as predictors of posttraumatic stress in children following the 1995 Oklahoma City bombing. Journal of Urban Health, 79, 354–363. doi:10.1093/jurban/79.3.354 Pynoos, R. S., Rodriguez, N., Steinberg, A. M., Stuber, M., & Frederick, C. (1998). UCLA PTSD Index for DSM IV. Los Angeles, CA: University of California.
Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., . . . Kulka, R. A. (2002). Psychological reactions to terrorist attacks. Findings from the National Study of Americans’ Reactions to September 11. Journal of the American Medical Association, 288, 581–588. doi:10.1001/jama.288.5.581 Steinberg, A. M., Brymer, M. J., Decker, K. B., & Pynoos, R. S. (2004). The University of California at Los Angeles post-traumatic stress disorder reaction index. Current Psychiatry Reports, 6, 96–100. doi:10.1007/s11920004-0048-2 Vasterman, P., Yzermans, J., & Dirkzwager, A. J. E. (2005). The role of the media and media hypes in the aftermath of disasters. Epidemiological Reviews, 27, 107–114. doi:10.1093/epirev/ mxi002
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
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