3-4 page paper needed APA style -Victim-Focused Programs in the Criminal Justice System

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Clin Soc Work J (2017) 45:111–123 DOI 10.1007/s10615-017-0624-7

ORIGINAL PAPER

Lessons Learned from the Boston Marathon Bombing Victim Services Program

April Naturale1 · Liam T. Lowney2 · Corina Solè Brito1 

Published online: 27 April 2017 © Springer Science+Business Media New York 2017

mass violence events. This article shares what we currently know about traumatic stress reactions related to human caused mass violence events and provides program details, lessons learned and recommendations from the Marathon Bombing Victim Assistance program.

Keywords Boston marathon bombing · Mass violence · Disasters · Terrorist attacks · Victims of crime · Traumatic stress

The Boston Marathon Bombing

The Boston Marathon bombing event began on April 15, 2013, at 2:49  pm when pressure cooker bombs were deto- nated within seconds of each other near the finish line (at Copley Square, a prominent historic site). Nearly 27,000 participants were registered in the 2013 race and this mara- thon traditionally attracts about half a million spectators. Three people died at the scene and more than 200 others required medical attention. Many survivors received serious injuries including head injuries, hearing loss, and severed limbs as a direct result of the blasts; 14 survivors required amputations post examination (FBI, 2013; US DOJ 2014; Kotz 2013). Every year, the Boston Marathon is a highly publicized event that draws runners, their supporters, and spectators from all parts of the globe (including Bostoni- ans) and receives local, national, and international news attention. Reports and videos of the bombing—including graphic images of severely injured runners and specta- tors—were immediately televised and shared online, then via print media. This exposure continued for weeks thereaf- ter, then increasingly again around each anniversary time- frame. This intentional, human-caused mass violence at an event attended by hundreds of thousands and accompanied

Abstract The Boston Marathon bombing of April 15, 2013 involved the detonation of pressure cooker bombs near the finish line of the Boston Marathon. Three people died at the scene and more than 200 others required medical attention. Many survivors received serious injuries includ- ing head injuries, hearing loss and severed limbs as a direct result of the blasts and 14 survivors required amputations. The media reports included graphic images of severely injured runners and spectators that were shown repeatedly and continuously for months thereafter. This intentional, human caused mass violence at an event attended by hun- dreds of thousands and accompanied by graphic, gruesome, and extensive media exposure exacerbated the behavioral health risks in the affected community as well as those who observed the events in the media. The Massachusetts Office for Victim Assistance provided an immediate response and continues to provide victim assistance, behavioral health counseling and other supports through a Depart- ment of Justice/Office for Victims of Crime Antiterrorism Emergency Assistance Program grant to help those most affected. Many lessons were learned about the need for preparation, close working relationships and an understand- ing of the powerful psychological impact of terrorist and

* April Naturale [email protected]

Liam T. Lowney [email protected]

Corina Solè Brito [email protected]

1 ICF International, 9300 Lee Highway, Fairfax, VA 22031, USA

2 Massachusetts Office for Victim Assistance, 1 Ashburton Place, Suite 1101, Boston, MA 02108, USA

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by graphic, gruesome, and extensive media exposure exac- erbated the behavioral health risks and concerns for those both directly and indirectly involved, from survivors to the general public (Marshall 2006).

For 4  days, law enforcement searched for suspects throughout the area, culminating in Watertown, approxi- mately seven miles west of the city of Boston. The man- hunt for the perpetrators was highly televised and posted throughout internet news and social media outlets. The effects of these activities in the days leading up to the cap- ture of the alleged perpetrators were profound. Commu- nity members experienced an extensive lock down period and shooting events by both uniformed and plain clothed law enforcement. Public transportation, public institu- tions, and many businesses in the Watertown area were shut down, first in response to a request from authorities to stay indoors, and then to comply with a “shelter in place” advisory. These circumstances were highly unusual and while protective, also had the effect of increasing residents’ fear, especially school-aged children in the area (Gortych, personal communication, January 2015; Dupuis, personal communication, October 2015). The alleged bombers’ subsequent murder of a Massachusetts Institute of Tech- nology police officer and the shooting of a Massachusetts Bay Transit Authority police officer, further exacerbated the fear and anger that the bombing had imposed upon the affected community (DART, 2014). The manhunt finally ended with one alleged bomber dead, and his brother, the second alleged bomber, in custody.

The reality of the killings, the horrific and widespread nature of the physical injuries of so many victims,1 and the emotional aftermath experienced by these communities were just beginning to be recognized when the Massachu- setts Office for Victim Assistance (MOVA) began imple- menting their disaster response program. Some survivors reported experiencing intensifying emotional distress, find- ing it difficult to function with the challenges that each day brought, especially the continuous news coverage of the bombing which often included gruesome images and details of legal procedures surrounding the surviving alleged bomber, while other survivors experienced a delay in emotional responses (US DOJ 2004; SAMHSA 2014; Norris 2002).

This information was obtained from a needs assessment conducted by the MOVA, the state agency that would even- tually apply for and obtain a U.S. Department of Justice/ Office for Victims of Crime (DOJ/OVC) Antiterrorism

1 MOVA is aware that many people who have experienced a trauma prefer to use the term ‘survivor’ rather than ‘victim’ in referring to themselves, thus we interchange the terms as ‘victim’ remains in the language of our federal and state scope of services.

Emergency Assistance Program (AEAP) grant to provide post-disaster services to those affected by the Marathon bombing. MOVA and their funded partners worked directly with survivors, responders, and their family members through the fourth anniversary timeframe of the event.

The authors of this article were tasked with implement- ing the victim services response to the event and will focus on the lessons learned from the implementation of this dis- aster response program. Our respect and gratitude are to the family members, survivors and responders who allowed us the privilege of working with them and who showed great courage in sharing their stories so that others might feel understood and cared for.

What We Know About the Effects of Human Caused Mass Violence and Terrorist Events

The literature shows that exposure to a disaster is the single most important predictor of adverse emotional outcomes and is compounded by a combination of the disaster type, size and scope of the incident, and other risk variables (Norris et  al. 2002). The psychological effects of a disas- ter are second only to death and injury, yet in most survi- vors, intense emotional distress is experienced for a limited amount of time (CMHS 2001; Myers and Wee 2005). After a natural disaster, about 90% of those affected will eventu- ally return to their pre-disaster level of functioning or make the necessary adaptations that will allow them to continue their routine activities without developing a mental dis- order (Norris et  al. 2002). In larger scope or scale events, human-caused incidents (particularly with intent to harm), the percentages of those with diagnosable conditions may increase to as high as 20% in the general population (Neria et  al. 2012). Posttraumatic stress symptoms are generally highest in the first year and lessen over time (Galea et  al. 2002) while depression, anxiety, and traumatic bereave- ment can last for longer periods (Norris and Rosen 2009; CDC 2006; Hobfall et  al. 2007). Incidents of mass vio- lence may lead to additional responses such as humiliation, a sense of responsibility for other’s deaths, survivor guilt, self-blame, and a sense of being unworthy of assistance. The inability to make sense of the randomness of victimi- zation may increase difficulty with recovery in survivors and can even cause family or friends to distance themselves from any association with the incident or those involved as a means of avoiding confrontation with this reality (US DOJ 2014; CMHS 2004).

Populations considered at higher risk for the develop- ment of mental health problems include those experiencing bereavement, those who sustained injury, have an injured family member, or witnessed injury to others, those whose lives were threatened, and those who experienced panic,

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horror or feared for their lives (Boscarino et al. 2002; Nor- ris et al. 2002). These exposure types are the most predic- tive of posttraumatic stress disorder (PTSD) although over- all numbers of people who develop a diagnosable mental disorder such as depression, PTSD, and other anxiety dis- orders are in the minority (Morganstein et  al. 2016; Neria et al. 2012; Norris et al. 2002; Galea et al. 2002). Regard- less of the numbers, the development of a mental illness in anyone is of concern and should be addressed as soon as identified.

Some additional factors that contribute to negative emo- tional effects post-disaster include the following:

Neighborhood/Community‑Level Exposure

In the case of the Boston Marathon bombing, neighbor- hood exposure is exemplified by the experience of Water- town and nearby communities. A community-wide lock- down accompanied by hovering helicopters, many shooting episodes, and public messaging that a manhunt for the per- petrator “at large” was active had longstanding negative psychological effects on many, especially school-aged chil- dren (Gortych, personal communications, January, 2015; Dupuis, personal communications, October 2015).

Age, Gender, and Ethnicity

Middle-aged adults are more adversely affected by disasters than other adult age groups (Norris et  al. 2002). Children can be more negatively affected than adults depending on the level of exposure to the event along with their devel- opmental level and ability to understand what is happening around them (NCTSN 2016). They are sensitive to familial disaster distress and conflict and research shows that paren- tal responses are the best predictor of children’s responses, especially in younger children (Gurwitch et  al. 2002). Women and girls in general are more adversely affected by disasters than men or boys (Norris et  al. 2002). Moth- ers are particularly at risk for substantial distress (Chemtob et al. 2011). Minorities are at greater risk if more severely exposed and/or if beliefs impede help-seeking behavior (Norris et  al. 2001). Establishing causation around eth- nicity itself is difficult, as certain groups are traditionally underserved, possibly due to language barriers, lack of trust in authority, or lack of outreach (Naturale 2006).

Psychological Resources

People with higher pre-disaster psychological symptoms can be strongly negatively affected by disasters (Norris et al. 2002). A lack of access to and use of psychological resources such as social supports can contribute to negative coping such as substance misuse, domestic violence and eating disorders

(Hobfall et al. 2007; Norris and Kaniasty 1996; Kaniasty and Norris 1995).

Resource Deterioration

Lower socioeconomic status and perceived resource loss have been associated with greater post-disaster distress (Nor- ris et al. 2002). What survivors determine as “resources” can affect their psychological state. For example, anecdotally, we often hear victims say that they are grateful to come away from a trauma event with their lives and that their physical possessions can be replaced. Still, the stress of needing medi- cal care, rebuilding one’s home and replacing everyday items needed to survive and/or losing local community supports such as schools and businesses that provide goods necessary for daily living (e.g., food and gasoline) can add to a survi- vor’s psychological stress.

Environmental Factors

The ecological perspective which looks at how individu- als act and accommodate within their environment empha- sizes that every aspect of a survivor’s life (familial, social, economic, cultural, educational, physical, intellectual, geographic, spiritual) has the potential to a have a strong impact on whether a person will develop a mental disor- der after a traumatic experience (Germain and Gitterman 1995). Two strong predictive factors for negative psycho- logical effects are previous life stress and social support from others (Dunmore et  al. 2001; Filipas and Ullman 2001; Zoellner et al. 1999). Recent research done with sur- vivors of individual trauma (e.g., assault, motor vehicle accidents) has consistently shown that the absence of social support impedes recovery (Zoellner et  al. 2011). Further, negative support reactions such as critical comments about the length of time taken for recovery, from family members in particular, seem to stand in the way of recovery among trauma victims in treatment for PTSD. In disaster studies, the size, vitality, and closeness of the survivor’s social net- work is also related strongly and consistently to positive mental health outcomes (Zoellner et  al. 2011; Norris and Kaniasty 1996; Kaniasty and Norris 1995). Disaster survi- vors who believe that they are cared for by others and that help will be available if needed fare better psychologically than disaster survivors who believe they are unloved and alone (Zoellner et al. 2011).

The MA Office for Victim Assistance (MOVA) Marathon Bombing Response Program Goals

The goals of MOVA’s Marathon Bombing Response Pro- gram were informed by several resources, previous events

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that the DOJ/OVC and MOVA had experienced, a needs assessment conducted to obtain input from the victim and provider communities, and a review of the empirical litera- ture. Overall, the program sought to provide timely relief through immediate and ongoing assistance services offered to the survivors and their families through liaisons, referred to as”victim navigators.” The navigator’s role was essen- tially that of case management/advocacy, helping the sur- vivors to identify their needs and access all of the services that were made available to them. Services included crisis response, consequence management, crime victim compen- sation, criminal justice support (e.g., victim participation in criminal justice proceedings), crisis counseling, emer- gency transportation and travel, compensation for medical and mental health costs, compensation for lost wages and funeral expenses, temporary housing, emergency food and clothing, repatriation of remains, outreach and education, victim notification and vocational rehabilitation.

The program’s long-term goals were to help steer indi- viduals and the community onto a recovery path, increase opportunities to support and build community resilience, and increase the capacity of the community to continue to address these concerns after the program ended. MOVA wanted to enable the local victim services and other pro- vider agencies who participated in the response to: (1) increase their awareness of the need to work with each other prior to and in response to disaster situations, and (2) offer provider agencies the opportunity to participate with other emergency management staff in planning and training for the provision of future disaster response services.

There are limits to reaching every single affected survi- vor based on lack of self-identification, stigma around help seeking and the recognition that the majority of people will return to their pre-disaster level of functioning or make positive adaptations especially with the use of good coping skill and social supports. With this understanding, the over- all goals of the program were met in terms of the delivery of stated services and successful efforts at education and outreach to survivors, family members and the community at large.

Needs Assessment Data

Needs assessment data informed service delivery plan- ning and incorporated feedback from survivor and family forums, provider reports, community activities related to the disaster, and direct case studies. Survivors were ini- tially more focused on receiving victim compensation (e.g., lost wages from injury or attending to an injured family member, concerns over continued medical care/ surgery, and invisible injuries including mental health concerns, traumatic brain injury and hearing loss). The

majority of survivors requested assistance with mental health concerns—both for themselves and their family members. Many victims lived outside of the Boston area and requested centralized information and other commu- nications via internet (e.g. email, websites, and telecon- ferences, etc.). An update to the Needs Assessment was informed by outreach efforts (telephone contact) with approximately 500 survivors by the MOVA program staff just after the second anniversary timeframe.

Summary of Services

The response program was tasked with attempting to reach all identified victims/survivors throughout the Common- wealth of Massachusetts and, wherever possible, through- out the U.S. The service delivery design focused on meet- ing those with high-risk needs that were identified based on the literature. Members of this group included survivors with injuries such as amputations and disfigurement, burns, traumatic brain injuries, deafness and partial loss of hear- ing, tinnitus, and loss of vision; family members and other loved ones and close friends and coworkers of those killed and those injured; survivors who were direct witnesses of the event or were present at the event; and school-aged chil- dren exposed to the bombing struggling with school partic- ipation, emotional distress, and fear responses around loud noises similar to gunshots and helicopters as experienced in the disaster (Gortych, personal communications, Janu- ary 2015; CMHS 2001; Norris et  al. 2002). An outreach strategy was developed to reach additional groups at risk such as first responders (e.g., those exposed to the scene’s fear and chaos and/or treated patients with gruesome inju- ries) and their family members; survivors with prior trauma experiences and/or mental illness; and survivors with medi- cal problems, limited mobility, or other functional and access needs. A large scale media/communications plan was designed to provide outreach, information, and educa- tion to the entire community. A behavioral health response plan that included training to approximately 70 mental health clinicians and delivery of disaster specific interven- tions was made available to all affected survivors free of charge to help mitigate the development of and address the negative psychological outcomes resulting from the disas- ter and its’ aftermath.

Phased Activities Post Incident

In the first year of the response, crisis intervention ser- vices were provided at the same time providers navigated the victim compensation structure and helped survivors with their “core daily needs of recovery.” This included

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assistance with government, financial, legal, and employ- ment benefits and school advocacy. Groups were organ- ized groups that brought survivors together to share their experiences and support each other. These services contin- ued throughout the duration of the program. By the second anniversary, the staff developed opportunities for survivors and their families to come together in various ways meant to support recovery and build resiliency. Forums were held with speakers who shared information and resources. Peer support groups were introduced and recreational peer to peer activities were organized routinely. Staff conducted outreach to reach those affected in the Watertown Schools, Watertown Police Department, and the MA Institute of Technology Police. During year 2, the Behavioral Health Response program was launched offering evidence-based short-term methods of reducing trauma-related symptoms. As part of the behavioral health response, every victim that had authorized MOVA to access their contact information was notified of the free interventions and expanded victim compensation services.

The public memorials recognizing the anniversary time- frame of the bombing provided staff and partner agencies an opportunity to attend and offer a compassionate presence and support. Informational materials highlighting what to expect leading up to the anniversary and helpful coping activities were distributed directly to survivors, parents, staff, and children within the most highly affected schools and to the general public in the affected communities.

The Boston Marathon has historically received annual local, national, and international news coverage. Due to the unprecedented nature of this incident, it received exten- sive media air time, and videos of the actual bombing, full of graphic images of severely injured runners, spectators, and rescue and recovery staff, were repeatedly televised and shared on social media continuously for weeks. Much of this news coverage violated social rules of privacy and even many journalists’ own recommendations for coverage of traumatic events (DART Center for Journalism, 2014). This intense and extensive exposure exacerbated the behav- ioral health risks and concerns for those both directly and indirectly involved in the disaster (Hopwood and Schutte 2016). In response, MOVA subsequently created a media campaign to provide messages of support, hope, recov- ery, and resiliency and to raise awareness of the long term impacts of violence on families, first responders, and chil- dren. For many, learning that some of their symptoms are expected and common in a post-disaster environment and the reassurance that the symptoms will likely decrease over time can be a supportive behavioral health response (Draper 2006). The media campaign was launched prior to the third anniversary and included television and radio commercials delivered via mainstream networks, featur- ing actual survivors sharing their own stories about the

incident, their reactions, and what helped them cope. Lis- teners were guided to the Marathon bombing hotline and website as sources of educational information and for vic- tims/survivors to find services and resources. Related social media ads were developed and posted on Facebook and Twitter. The media messaging provided psychoeducation around trauma-related symptoms in a non-pathologizing way, normalizing common reactions.

By the third year of the program, services reached into the Boston Public School (BPS) system. The funding allowed the BPS to identify and support students, fami- lies, and staff members most effected by the trauma of the bombing and other characteristics that created high risk cir- cumstances. This work helped BPD to launch their trauma- informed schools initiative and develop a sustainability plan for long term services. Watertown Schools received their own funding as their community was exposed to the incident in a greater degree during the hunt for the alleged bomber and the resulting shoot out which destroyed to a large degree, the sense of safety in that community. In addi- tion to their direct exposure to swarms of heavily protected and armed law enforcement personnel, multiple shooting incidents, and hovering helicopters, these school-aged chil- dren experienced the anxiety of their parents, caregivers, and other adults around them. This was considered by some to be a second, separate but related traumatizing aspect of the Marathon bombing.

The Boston Police Department (BPD) received mara- thon bombing response funding and worked closely with MOVA to support affected responders and their families with stress management, wellness, and peer support activi- ties. They were also provided with disaster-specific behav- ioral health interventions as needed. These services were aimed at reducing the symptoms associated with mass vio- lence response efforts. Fortunately, the BPD had an existing peer support structure with staff already trained and was receptive to integrating the marathon-related services. They were able to expand their current structure and increase the number of staff qualified to administer these peer support activities.

Lessons Learned

Disaster Response Relationships

MOVA is an independent state agency established to serve all victims of crime in the Commonwealth through fund administration, training, policy implementation, and some limited direct referral services. Each of these components made the agency an especially important provider to estab- lish services for victims of the marathon bombing and the events that followed. Yet, MOVA was not an established

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partner in any of the emergency response protocols that existed. In one call to an official in a partner state agency to determine how MOVA could assist, they were asked, “Why would MOVA work on this response?” The lack of recogni- tion and, more importantly, understanding of the agency’s role would present a continuous challenge in the days and months to follow.

Even though Massachusetts had been involved in the response to families impacted by the 9/11 attacks in 2001, the relationships that were established between with responding agency personnel, were not formalized with any Memorandums of Understanding or contracts in a sys- temic manner. The result is that as personnel left, so did the established relationships with the many emergency response partner agencies and a mutual understanding of agency roles. It was necessary to reintroduce these response agencies to each other in the midst of the marathon tragedy, an effort which was exceedingly more difficult at that time.

One strategy initiated was bringing together over 30 agencies that interacted with survivors to serve as a “Con- tinuum of Care Working Group.” Participants included state and city responders, federal law enforcement, Victims of Crime Act (VOCA) funded community providers, the American Red Cross, and members of the private sector. The meeting gave participants opportunity to learn about each other, including individual roles and missions, and real-time activities related to the incident. Shared informa- tion also ensured participants were aware of the messages being delivered to survivors, enabling timely, accurate, and consistent communication, which in turn served vic- tims well by decreasing anxiety and establishing a sense of trust and legitimacy in the agencies. The Continuum of Care Working Group allowed participants to be engaged on equal footing and talk openly about law enforcement, advocacy, behavioral health needs, special populations, and the very basic unique needs of survivors. The group identi- fied service gaps and made recommendations about how to address them.

Planning and Program Implementation

Victim services response should be immediate and sys- temic, starting with notification when an event occurs and clear protocols for where their programmatic role begins and ends to help meet victims’ immediate and long term needs. To effectively address the needs of crime victims, victim services should be: (a) ongoing and unique to the group impacted; (b) adjusted as needs change and become longer term; and (c) informative and instructional, allow- ing local providers to tailor and sustain services as long as needed. This allows service providers to build relation- ships with survivors, effectively assess needs, and inform

responses through a victim services lens. It is the local, city, and statewide victim service providers who remain in the community and can continue to be a source of sup- port, resources and referrals long after the time limited disaster resources end.

Thus it follows that disaster and emergency prepar- edness activities need to be regular and ongoing. State and local government, law enforcement, and emergency management leadership structures must be trained and informed about what victim service agencies can offer in the wake of a tragedy. In order for this to happen, all disaster response and victim services agencies must be represented at the state, city, and local community emer- gency management planning committees pre and post incidents. It is essential that agencies spend time learning about each other before an incident occurs to ensure the most effective and efficient response possible.

Even with good planning, there are inherent chal- lenges to administering funding for human services in the midst of a crisis. It is complex to contract with providers to deliver necessary services for those impacted. MOVA reached out to the behavioral health provider agencies with existing contracts and asked them to provide crisis intervention and behavioral health supports in the imme- diate aftermath of the bombing. These agencies then had the opportunity to extend their contracts and expand their service delivery through the next several years. Working with existing contracted agencies not only provided them with the time to identify their scope of work and appro- priate budgets, it also proved quicker program implemen- tation and less burdensome than contracting from scratch. The challenge with some of these agencies was to ensure they were providing evidence-based interventions that helped address the specific needs of those affected by the bombing, people experiencing a traumatic stress response, rather than quickly diagnosing for serious men- tal illness, using psychopharmacology before allowing a natural return to pre-disaster functioning or reverting to offering general psychodynamic psychotherapy which may provide support, but often does not address the trauma symptoms directly.

To help address this concern individual clinicians were invited to participate in disaster behavioral health specific training events that the marathon bombing program was offering and allowed them to apply as contractors through a Master Services Agreement. The contracting proved to be very time consuming as many private practitioners were unfamiliar and overwhelmed with the application process even with online accessibility. Preparing these contracts ahead of a disaster or executing them as soon as possible post incident would have increased the availabil- ity of these clinicians early on in the response.

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Staff Capacity

MOVA was established to serve all victims of crimes, not one specific population or event. This reality created several challenges for the agency and all of the providers funded by the federal grant to deliver Marathon Bomb- ing related services. Staff and tasks associated with the incident could not supplant existing daily responsibilities to clients that any of the agencies were already serving through a large number of existing contracts.

Most of the victim services agencies in the state were in the midst of planning and participating in National Crime Victims’ Rights Week. In the acute and immediate phases of the marathon bombing event response, atten- tion to the disaster response was the priority, but agencies also had to continue to care for existing providers and consumers. Victims of other crimes were still in need. The large influx of urgent tasks required extensive repri- oritization and planning. Mostly it created internal con- flict and much stress for many agency staff.

The AEAP grant application allowed MOVA to hire direct services and grants management staff as necessary to fulfill the goals of the program. Writing job descrip- tions, posting positions, and hiring candidates all take significant time and in the case of grants management, MOVA waited until after applying for the grant to post the openings. In retrospect the need for staff dedicated to the marathon bombing incident were immediate.

In the case of a future tragedy, and knowing now the scope of work associated with similar incidents, MOVA would make the call to post for the new positions imme- diately upon deciding to apply for the AEAP grant, even if the hires would be made on a temporary basis. Just managing the needs assessment and grant application processes takes work away from staff who are expected to maintain their traditional workload. New hires or consult- ant assistance could ease this burden.

Another concern around staff is that many community- wide disasters create a shared trauma event, or an event where the response staff have experienced the same expo- sure to the trauma as those they are helping (Tosone et al. 2011). In addition, many staff bring their own history of traumatic experiences to the present situation. While MOVA was aware of the importance of promoting self- care for employees, it was difficult to create activities that were not already part of the structure of current opera- tions. Additionally, staff were resistant to taking time for their own self-care as they measured, and in most cases, invalidated  their needs against the needs of the bomb- ing victims. Creating more opportunities for staff to dis- cuss and address their own experiences would likely have reduced some of their concerns and distress. It is highly recommended to create, early on, formal and informal

opportunities to help staff talk through these issues (Salston and Figley 2003).

The Issue of Inequity

One Fund Boston was established within hours of the trag- edy on April 15th and served as a central donation point to support victims of the Boston Marathon bombing. It was seeded by corporate donations, but swiftly began attract- ing individual donations, and events were organized to feed it. Amazingly, the fund raised $61 million in private dona- tions for those with physical injuries resulting from the bombing. Separate, incredibly generous offers of help were made from around the world and over time, some survi- vors would be provided everything from medical supports to trips and vacations. However, this generous community response was starkly different than what more traditional crime victims (e.g., survivors of somewhat stigmatized sex- ual assault, domestic violence, and community violence) would receive (Filipas and Ullman 2001). The inequity was disturbing to many crime victims who were not marathon bombing survivors and to staff who had to negotiate the system to provide services to all victims in need.

Eventually MOVA would receive an $8.3 million AEAP grant to specifically serve marathon victims. This was more money than the agency had administered statewide for all crime victims in 2012. Staff struggled with how to ensure an effective and appropriate response to survi- vors of the incident, while not neglecting others they were charged to support. To address this issue, it was decided that—when building services for marathon survivors—the new infrastructure and capacity would eventually be able to support services for everyone served. Some examples include: training efforts that were offered to agencies and individual providers across the state who might be work- ing with bombing survivors even though they were not part of our program; a media campaign that provided messages directly to marathon bombing survivors but also normal- ized distress reactions for all victims of crime in an effort to destigmatize help seeking; the development of a navigator system that provided an identified liaison for each survivor / family affected that will remain part of our structure; and trauma services within the Watertown and Boston Public schools that serve marathon victims and those exposed to other traumatic events.

A significant learning from the bombing was that victim definition is extremely important and powerful. The strat- egy employed to address potential inequity was to create a broad, inclusive definition of victims that would allow support of current survivors, those triggered from previ- ous events such as 9/11 families, veterans, and other vic- tims of crime and survivors who had not yet come forward. Leadership worked to message within the community their

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intent to build infrastructure to serve all victims and advo- cates provided information regarding services available under both the AEAP funding and the Victims of Violent Crime Compensation (MA AGO 2016).

Future programs should carefully explore how the defi- nition of victims used will inform the needs assessment and affect the fund and service distribution process.

Victim Services Navigators and Outreach

Prior to the Boston Marathon bombing, MOVA’s role deliv- ering “direct services” to victims consisted of providing resources and referral assistance to survivors working with the many different funded programs or partners. In the early days after the bombing it was readily apparent that MOVA required “all hands on deck” to meet the varied needs of those impacted. Any MOVA or Attorney General Victim Service personnel who had ever provided direct services to crime victims was assigned to staff the Family Assistance Center (FAC) which the City of Boston established. Navi- gators worked collaboratively with the numerous FBI Vic- tim Specialists brought in from around the country to meet with survivors and their families. It became very clear that the affected population was large and very diverse in their cultural and socioeconomic backgrounds as well as their injuries and needs. A significant number of the injured had families who were struggling financially and emotionally to provide the support their loved ones needed. Many families travelled from out of town, were staying at hotels, taking time off work, and incurring significant costs. The injured and their families needed to deal with the shock of their experience while simultaneously making medical deci- sions, filling out victim compensation, One Fund and other applications/paperwork, understanding the role of various agencies and representatives, and speaking to law enforce- ment. Survivors incurred stacks of mail that included important and less important offers and opportunities, all of which required their attention just to be sorted.

MOVA determined it was necessary to have a position based upon best practices in the field of victim advocates. As a result, the agency developed a job for “Navigators” who assisted individual victims of the bombing, and the related events in Watertown and Cambridge. These Navi- gators were charged with providing significantly more ser- vices directly to victims than had been done previously. They helped victims to understand their own needs, pro- vided crisis counseling and psychoeducation, assisted with applications for federal and state benefits, sought access to behavioral health services, and provided information about various additional resources. Over time, the Naviga- tors would build relationships with the victims they were serving and provide assistance and mental health support at survivor-led activities, anniversaries, and the trial of the

offender. These Navigators provided a much needed, con- sistent presence to the survivors they assisted, gaining trust and legitimacy. They obtained feedback, hearing from vic- tims directly about whether they liked or didn’t like the ser- vices and if the felt their needs were met.

One of the lessons around navigation was the need to conduct outreach to those beyond the direct victim com- munity. The limits in reaching some survivors in the com- munity was partly due to the focus on the MA Resiliency Center, where the expectation was that victims and other affected community members would come to a designated site for services. As with many other disaster response pro- grams, this was not as successful as anticipated. Once a FAC closes down, having staff go out into the community is the most successful mode of reaching those affected (Natu- rale 2006). Alternately, outreach from the response staff often got lost in the early days because of the multitude of organizations trying to contact survivors. An outreach plan included as part of the continuing Navigators’ services or the addition of designated outreach workers may have helped reach unidentified victims. Combining geomap- ping and needs assessment data could have provided details about the geographic areas reached and untapped sectors informing program response staff to revise their outreach strategies and adjust their efforts to reach any newly iden- tified populations or those for whom original efforts were unsuccessful.

External Challenges of Overwhelming Information, Offers and Routes to Accessing Resources

Survivors received an overwhelming amount of informa- tion from multiple sources. Navigators and victim special- ists met with survivors in the wake of the tragedy to help them sort their stacks of regular mail. They received, in many cases, well intentioned direct and electronic informa- tion about services, how to plan and apply for financial sup- ports, and how to receive further information from munici- pal, state, and federal authorities. Communities made offers of vacations, trips, prosthetics, medical equipment, and oth- ers offered survivor’s professional services at no, limited, or full cost.

The timing of this influx of information was during the same period that most survivors and their families were addressing many of their medical needs and suffering from the negative effects of trauma. This is of real con- cern as one of the domains that trauma can impact sig- nificantly is cognition, with a potential to impair memory, highly influence decision making, impulsivity/reactivity, judgement and thinking in general (SAMHSA 2014; Nor- ris et  al. 2002). The extent of a traumatic event’s effect can be seen in the other domains of emotional, behavio- ral, physical and spiritual responses, but even without the

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impact of the trauma, the volume of information alone would have been overwhelming.

Navigators often spent significant amounts of time with survivors and families assisting them in wading through piles of communications to determine the most pertinent and valid offers of assistance and information. While advocates worked to provide information about resources’ with individual victims, other important infor- mation was often missed. This is one area in which vic- tims of terrorism are at a distinct disadvantage caused largely by the high numbers of victims and the high pro- file nature of the event. Media distributes information often without considering how survivors will interpret it. The focus is often about the offender(s), the scale of the event, and whether the public is still in danger. The right to information is at the core of U.S. federal and state victim rights laws (U.S. DOJ 2016). Crime victims have rights to information about the criminal proceeding involving them, their role in it, case updates, the results of the proceeding, and other information about the case and the offender before and after the proceedings. There is usually also some basic language about the right to be informed of available resources but not about how to access these supports. Information is power and in the case of traumatic events, it can reduce anxiety (Hamblen et  al. 2009). It would be helpful if community agencies responding to a mass tragedy event could, during their planning process, identify one trusted information source and create a comprehensive list of resources to share with the survivor community. This designated point agency could coordinate communications to the survivors in an effort to reduce duplication, eliminate advertisements, screen media and other self-interest requests, and stream- line resource and referral details.

A Family Assistance Center (FAC) where families could gain access to all available information and services was established early on in the response. In an attempt to main- tain privacy, the FAC was placed in an out of the way loca- tion and the details were not disclosed in public or shared with the media. Thus, some family members experienced difficulty accessing the FAC. It is recommended that in future events, planners consider placing a FAC near hos- pitals or other settings where survivors are being attended to, be more open about the location, and increase security to restrict the media from invading the privacy of victims and their families. A related issue involved the Health Insurance Portability and Accountability Act (HIPAA) (U.S. H.H.S. 1996) which restricts sharing of health care information without informed consent of the patient. While this legislation is designed to protect people in routine situ- ations, it inhibits necessary information sharing in an emer- gency. There is a need for legislation that is designed for emergency situations to address how to inform families if

and where a victim is receiving treatment in the aftermath of a disaster.

Victims and their families need to know how to access emergency shelter, financial assistance, food, and other immediate, basic resources. The bombing did not discrimi- nate between those that had a lot of money and those who did not. Many survivors and their families experienced serious financial hardships. There were at least 20 family members who traveled to Boston solely to support their injured family member. As a result, these family members were unable to continue working and used vacation time or unpaid time to care for their loved one. Some were staying in hotels and/or paying Boston’s expensive parking rates. The financial toll was a huge burden for many of them until they were given information about available resources and eventually, their expenditures were covered by Victim Compensation.

A large number of survivors needed to know how to rap- idly replace identification, financial documents, and credit cards that were left behind in what had been labeled a crime scene. Many were temporarily unable to perform the basic activities of daily living like buying groceries, obtain- ing money from the bank, and picking up their kids from school, because so much depends on our ability to identify ourselves and access money.

Victims needed to know how to access Victim Com- pensation and Assistance and other government supported financial assistance. Survivors who sustained permanent disabilities were eligible to apply for disability benefits but there are specific rules about when and how to access both short term, private disability funds and longer term, gov- ernment benefits. The applicable rules are complex and can be quite confusing to survivors who are already trying to cope with extensive medical concerns, emotional reactions, and life changes.

A major learning regarding bomb blasts is that many with hearing loss and traumatic brain injury resulting from these kinds of injuries (often referred to as “invisible injuries”) do not initially realize they are injured. Ring- ing in the ear or sustained loss of focus was overlooked by many marathon bombing survivors who went home feel- ing “lucky” to be able to walk away from the disaster in comparison to others. Later, they would realize they had significant problems functioning and needed to seek medi- cal treatment. Many survivors who were suffering hearing loss and tinnitus felt isolated and required assistance being screened, understanding assistive technology, and receiving modifications to their homes. The Massachusetts Commis- sion on the Deaf and Hard of Hearing was brought in as a contracted partner, establishing services that included peer support to address the concerns related to these injuries and help survivors’ families learn to support their loved ones. If staff had been able to identify and communicate with the

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population of those within the blast zone, providing mes- saging regarding this critical information could have been prioritized. Recommendations to see a physician as soon as possible may have gone a long way to help these survivors feel less isolated in their experience and influenced their availing themselves of services at the optimal time. It may have at least allowed them to make an initial connection to medical services and behavioral health care.

There were other significant physical injuries from the blasts that are similar to those you see in veterans of wars. Many have pieces of metal or shrapnel embedded in their bodies that cannot be removed causing chronic pain, and emotional injuries as well, leaving some survivors unable to do their jobs. Another effect of this intentional, human caused violence was that a number of survivors expressed that they experienced a change in their life view and felt that they needed a career change that had “meaning” or was a means to give back and express gratitude. In order to ensure survivors could be empowered to work and support themselves, the University of Massachusetts Institute for Community Inclusion (ICI) provided vocational rehabili- tation services. ICI staff work with any survivor in under- standing their professional / employment goals and helping them to achieve them.

The Need for Disaster Trained and Trauma Informed Clinicians

While it might seem self-explanatory, most people who have never accessed mental health services before will not likely see themselves as having this need, even after a trau- matic event (Wang et al. 2007; CMHS 2001). But research shows that everyone who witnesses a disaster is affected by it in some way to some degree, though the expression of responses can be different—even among people with the same level of exposure (Meyers and Wee 2005; Hob- fall et  al. 2007). Social supports and crisis intervention are immediate and ongoing needs which may show up after people have taken care of their basic survival needs and attempt to move towards a recovery path. Survivors may first start to realize they are having negative behav- ioral health responses weeks or months after an incident. It can take time for survivors to realize that these distress responses are disaster related and may be interfering with their work, relationships, and their ability to function on a day-to-day basis.

A significant finding too, was that in the midst of Boston, where there are a high number of subject mat- ter experts and trauma focused mental health treatment organizations, there was still a lack of individual clinicians skilled and experienced in disaster specific evidence based treatment, especially in communities outside of Boston proper. Many clinicians offered traditional psychodynamic

psychotherapy services which was supportive, but did not reduce the trauma associated symptoms, and survivors were suffering. Thus, specialized training on post disaster distress was offered through the experts at the National Center for Posttraumatic Stress Disorder to qualified prac- titioners. These clinicians were then able to offer treatment to referred Marathon bombing survivors, family members and responders with costs covered by the antiterrorism grant funds. Clinicians also expressed the need for ongoing supervision and case conferencing. These supports helped clinicians learn from peers about the broad impacts of this disaster from each different case. They also learned to keep the work focused on addressing bombing related trauma symptoms and understand how these issues infiltrated vari- ous aspects of their clients’ daily living and emotional and relational mental health.

Communications and Public Messaging

The “Boston Strong” slogan adopted after the marathon bombing served the greater community, putting forth a message that supported a sense of unity, strength, and empowerment. MOVA staff remained concerned that the use of the terminology, especially so early on after the disaster, would set many survivors up for a “fall” later on when they did not feel “Boston Strong” and the real- ity of their “new normal” set in. Indeed, many survivors expressed to Navigators and other staff that they didn’t feel “strong.” Many reporting wondering if something was wrong with them as they interpreted the messaging to mean their recovery timeline was lagging behind others. Some reported feeling they had a responsibility to respond at an “accepted” level. The response program’s media campaign ran during service delivery and was designed to be a broad- reaching informational and educational intervention geared towards both the general population from the affected com- munities and specific victims. The information helped to normalize distress responses to traumatic events with the intent to decrease anxiety through a better understanding of common and “normal” responses to an abnormal event (Hamblen et al. 2009).

As part of the media campaign, the “AskMOVA.org” website was created to establish one place all crime vic- tims in Massachusetts could visit to gain accurate and streamlined information and created sustainable, reusable resources which addressed the current need and will help in the next crisis. This was a lesson learned from Project Lib- erty, New York’s 9/11 mental health response, which used a “one stop shop” approach at the New York City piers and the mental health hotline “Lifenet” for all disaster-related crisis calls and referrals (Draper et  al. 2006; Norris et  al. 2006).

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Through the media campaign and direct outreach to vic- tims, information and support was offered surrounding the time of the incident’s anniversary and during other times when victims could be “triggered” or have strong remind- ers of the horrible aftermath of the bombing (e.g., when recreations of the event were frequently aired on commer- cial previews of the Hollywood movie based on the inci- dent). Many survivors responded with comments about how helpful it was to have information about coping strat- egies and recommendations for planning ahead for these triggers. They also noted how comforting is was to see the victim advocates at the anniversary events and movie screenings knowing they could reach out for support when they needed it.

In general, there continues to be a need for increased awareness of the negative physical, social, emotional, spiritual and financial impact of the trauma experienced by disaster survivors and victims of terrorism. While the level of public support for Boston marathon survivors was unusual, how families and communities cope is universal, not unique (Neria et  al. 2012). It is important to normal- ize distress reactions to trauma and violence for survivors by providing psychoeducational information about the known impacts of these traumatic events (e.g., “If you can’t sleep or are afraid to go to busy places, that is normal and help is available”) and reduce stigma around help seeking by allowing individuals to identify themselves as victims/ survivors. MOVA provided this information during family forum sessions months after the bombing, and a year later in the media campaign. Dissemination of this information to survivors and the broader community should be a prior- ity in the aftermath of these events.

Conclusion

While every disaster is different, the human responses are the same, even though different cultures vary in their means of expression (CMHS 2001). Humans are horrified by incidents of mass violence and terrorism and often have difficulty making meaning of such incidents when perpe- trated intentionally by our fellow human beings (NCPTSD 2016). The Boston Marathon bombing was unique in many ways, stemming from the race’s hometown feel (even with international participants and observers), to the extraordi- nary immediate medical care available in the field and the nearby hospitals that saved lives, to the self-sufficiency with which the city picked itself up and continued its regu- lar activities, to the rapid construction of the memorial to the fallen MIT officer and more.

Still, many of the experiences noted here and by the victims’ families, survivors, responders, and response pro- gram directors have been echoed by those in prior terrorist

incidents in the U.S., including the Oklahoma City bomb- ing, the September 11, 2001 terrorist attacks, and mass violence events such as the Virginia Tech shootings, the Aurora killings, and the massacre in Newtown. This article is an attempt to share experiences, lessons learned and rec- ommendations in the hope that we as a nation can continue to identify best practices and learn from each other. No template will serve every event response perfectly. People and communities vary widely even in small towns across America—many with their own rituals and traditions—due to the mix of races and ethnicities that make us a cultur- ally integrated country. Thus, every disaster response pro- gram needs to be tailored to the population that it is serv- ing, attending not only to the type, size and scope of the incident itself, but also to the demographics of the affected areas (CMHS 2001).

This article also shares programmatic details that might inform those who will help in the aftermath of the next event, so that they do not feel they have to start from nothing. Our strength lies in our ability to reach out to each other and know that we are not alone; we are all in this together. The evidence of this lies in the actions that we continue to see in victims who help each other, in our emergency and disaster responders, our medical and behav- ioral health professionals, our victim services providers, our government workers and among friends, neighbors, and even strangers every time an event occurs.

Acknowledgements The MA Office for Victim Assistance Mara- thon bombing response program services are offered for free and are (partially) supported by the MA Office for Victims Assistance through an Antiterrorism Emergency Assistance Program cooperative agreement number 2014-RF-GX-K002 from the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice (OVC/ OJP/DOJ). The article reflects the opinions of the authors and does not reflect the opinion of the OVC/OJP/DOJ. This project was (par- tially) supported by the Massachusetts Office for Victim Assistance through and Antiterrorism Emergency Assistance Program (AEAP) cooperative agreement number 2014-RF-GX-K002 from the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. The opinions, findings, conclusions and recommendations expressed in this article are those of the authors and do not neces- sarily reflect the views of the State of Massachusetts or the Office of Justice Programs.

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April Naturale PhD is a trauma specialist at ICF and architect of the marathon bombing behavioral health response. She directed the mental health response to 9/11 in NY and continues to provide disas- ter preparedness and response consultation throughout the U.S. and internationally.

Liam T. Lowney is the Executive Director at the MA Office for Victims of Crime and oversees the marathon bombing victim services response.

Corina Solè Brito is a technical specialist with ICF where she serves as the communications product manager for ASPR TRACIE specializing in messaging to healthcare professionals, emergency managers and others working in disaster medicine and healthcare sys- tem preparedness and response.

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