Table 3 Information identified about the psychosocial care response, Oslo and Utøya 22 July 2011 attacks, Norway. Acute = first hours/days after attacks. Medium/long-term = weeks/months/years after the attacks

Acute

Anyone affected by the attacks.

Municipal primary care based multidisciplinary crisis teams. In Oslo, there was a multidisciplinary standby crisis service at the out-of-hours primary care centre that could alert other personnel if needed, e.g., from psychiatric clinics. Ambulance crew and health personnel at the attack sites.

Municipal multidisciplinary crisis teams across the country provided acute psychosocial care to victims of the attacks and their relatives/close ones, as the survivors, their families and the bereaved lived geographically spread in all regions of Norway. Immediate support for psychosocial shock reactions and at-site crisis response based on Hobfoll’s principles of psychological first aid (sense of safety, calming, sense of self- and community efficacy, connectedness, hope).

[21, 38, 54]

Acute

Ministerial employees affected by the bomb and their relatives. Overall 310 were at work. In total, there were around 3500 employees.

Occupational health services of the Ministries with specialist support.

A drop-in crisis centre for ministerial employees and their relatives was set up at a hotel nearby the site of the bombing, where they were offered defusing to alleviate acute stress as well as support in groups. Information meetings were arranged.

[38, 57]

Acute

Survivors of the Utøya youth camp attack (495 survivors, mostly adolescents and young adults) and their families, and families of the 69 persons killed.

Primary care crisis team of affected municipality composed of a medical officer for health (MOH), a chaplain and staff from the social services, with assistance from crisis team in neighbor municipality, personnel from nearby psychiatric clinics and paramedics. At the provisional crisis centre there was access to medical doctors, psychiatrists, psychologists, nurses, a chaplain and imam.

Acute psychosocial care and psychological first aid. In the first hours, the MOH, who was also a regular GP in the affected municipality, had coordinator responsibility and requisitioned a hotel nearby the Utøya island as a crisis centre. A more comprehensive psychosocial emergency response was organized from 02 a.m. on 23 July (around 7 h after the shooting ended), comprising sessions with group counselling, individual counselling, information meetings and health checks at this provisional crisis centre. It was open until 1 p.m. on July 26

[38, 58]

Acute

Relatives of the severely injured.

Multidisciplinary psychosocial crisis team at Oslo University Hospital (OUH) Ullevål composed of adult and child & adolescent psychiatrists, psychologists, nurses, social workers, clerical staff and a chaplain.

Separate crisis centres were established for relatives of survivors and relatives of the deceased/missing persons to provide acute psychosocial care and information.

[38]

Acute

Relatives of missing persons and the deceased.

Multidisciplinary psychosocial crisis team at OUH Rikshospitalet. In addition, there was a police-run crisis centre which was initially at a police station, next moved to a hotel in city centre the day after the attacks.

See above. OUH Rikshospitalet is at a different location in Oslo than Ullevål.

[38]

Acute/ Medium/ long-term

Non-organised voluntary helpers in boats or at the Utøya camp site.

Team composed of a psychiatrist, psychiatric nurse and public health nurse dispatched to the camp site the first 2 days following the attacks. Next, there was a drop-in arrangement at the council premises in Hole municipality attended by a team of health personnel and group sessions led by a psychiatrist and a clinical social worker.

Meetings were arranged at the camp site café the 2 days following the attacks. Over the following 3 weeks, there was a drop-in arrangement at the council premises in Hole municipality for all volunteers. A week after the Utøya attack, the head of the local municipality’s crisis team (clinical social worker) set up groups for regular follow-up in conjunction with the head of a close-by psychiatric centre (psychiatrist). Weekly sessions were held for approx. 20–30 participants at a time. This follow-up was originally planned through the first 3 months after the attacks, but the group wished to continue with monthly sessions.

[38]

Medium/ long-term

Anyone affected by the attacks.

Municipal multidisciplinary crisis teams, regular GPs, specialized mental health services.

A general principle of using the lowest effective level of care. Principles of psychological first aid were to be pursued as well as facilitation of controlled re-exposure. Watchful waiting as described in the NICE guidelines (i.e., regularly monitoring persons with some symptoms not (yet) receiving active interventions). If needed, referral to specialized treatment by regular GP. Trauma-focused Cognitive Behavioral Therapy (TF-CBT) or Eye Movement Desensitization Reprocessing (EMDR) were recommended if there was a need for specialized treatment of PTSD.

[38, 54]

Medium/long-term

Ministerial employees affected by the bomb in the governmental quarter and their relatives.

Occupational health services, with specialist support from national health authorities and psychologists. Regular GPs to issue sick leaves or referrals to specialized mental health services if needed.

The occupational health services invited the exposed employees to a consultation including a screening assessment and at least three follow-ups after 3–4 weeks, 3–4 months and 12 months. If there was a need for referrals to specialized psychiatric services and/or sick leaves, this was generally to be issued by their regular GPs. Two factors were emphasized in the selection of this corporate model: to get back to normal early and take part in the workplace community with other colleagues present at the bombing, which aimed at their workplace.

[38]

Medium/long-term

Survivors of the Utøya youth camp attack and their families.

Municipal multidisciplinary crisis teams, designated contact persons, other primary care or specialized health personnel as outlined by the municipality.

The municipalities should proactively contact the survivors of the Utøya attack. It was recommended that each survivor was given a designated contact person in the municipality that would ensure continuity in the follow-up, which focused on stabilization, practical assistance and support. Furthermore, that the contact was frequent early on and eventually adapted to personal need. The follow-up was to be maintained at least 1 year after the attack and include screening assessments to be conducted at 5–6 weeks, 3 months and 1 year after the attack. If the contact person was not a health practitioner, he/she was to make sure that such screening was performed by a health practitioner that could refer to specialized treatment if needed. The screening instrument was developed based on experiences from school shootings, the 9/11 terrorist attacks and Hurricane Katrina. The follow-up was to be adapted to the municipality’s available resources and competence. Recommendations were also sent to schools and universities on facilitation of practical, educational and social support to youth affected by the attacks. Moreover, during the first 18 months, weekend reunions were organized for the bereaved and one-day reunions for the survivors and their families.

[38, 57, 59,60,61,62]