Multi-year study sheds light on long-term trauma impact

A recent two-day meeting at the Carolinum brought together experts from the Norwegian Centre for Violence and Traumatic Stress Studies (NKVTS) to share insights on the impact of the 22 July 2011 attack on Utøya with representatives from Charles University, other universities, and key institutions involved in post-trauma aid. This collaboration between Charles University and NKVTS was initiated following the tragic events of 21 December 2023 at the university’s Faculty of Arts. 

NKVTS, which advises the Norwegian government on violence and trauma, conducted a multi-year study providing critical findings on the long-term effects of emergencies on youth and their future well-being. Forum spoke to researchers Kristin A. Glad, a clinical psychologist, and Lise E. Stene, a research professor and medical doctor, to learn about their findings and how the lessons learned could be applied in similar situations, domestically as well as internationally.

Forum: I understand that coming back to respondents over a longer time frame (months and years) was a key aspect of the study: is it fair to say one of the main aims was to learn how people had been helped over time and whether the help they had received was effective?

Kristin A. Glad: I would say so. The main aim of this study was to investigate both the health consequences of the 2011 attack at Utøya and to identify people who weren’t helped sufficiently and who we could potentially help re-enter the healthcare system. We also wanted to understand how the attack affected peoples’ overall functioning and explore various aspects of their lives even long after the event. This included how they experienced the healthcare they received or their interactions with the media. Many of those affected by the attack had been contacted by journalists and many had spoken to the media and we wanted to learn more about that.

The media doesn’t always have the best track record when it comes to such a traumatic event; how did the survivors – or their loved ones – feel about the ensuing media coverage?

KG: We asked participants to describe their experiences, and while not everyone shared details, many described their contact with journalists. Many found the initial contact as intrusive and how they were approached was not seen as positive. However, during the actual interviews, attitudes changed: many found that the journalists were empathetic and took care to listen. The overall coverage itself was mixed—some felt it was too dramatized. Others, though, saw the media as a useful channel to share their stories with the world. So, the experiences varied. The overall feeling was that there were both negative and positive aspects.

Kristin A. Glad discusses the findings of a crucial impact study she and colleagues worked on closely. To her left, CU Vice-Rector L. Henebergová.

One of the things that stood out in your presentation at CU was the time frame—the first part of the study was done four to five months after the attack, and the last section was eight years later. Was it surprising to see that such deep trauma still persisted, with many of those affected—both survivors and their immediate families—still struggling?

Lise E. Stene: I think it was an eye-opener. We had expected that the trauma would decrease more over time, but in reality, many are still suffering. That said, there are a variety of different outcomes. There were different trajectories. For example, five ministers in the current Norwegian government are survivors of the Utøya attack. So, there are definitely different trajectories. While a large proportion of people – too large – is still struggling, there are also many who have healed significantly. We’re working to understand why some recover and others don’t. Why there are discrepancies.

KG: And we have a better idea now, looking back or in hindsight, and we have some hypotheses. One determining factor why the impact was so great is just the extreme brutality of this attack: being targeted by a person disguised as a police officer and then the huge loss of life. Another factor is the age of those who were targeted. The people he attacked were at a critical time in their lives—youth and young adults, when they were developing their identities, finishing school, and making decisions about their future. Such a traumatic event naturally affects how people see themselves and their future possibilities.

There is also trauma that came after: we found that about one-third of respondents in our study had received hate threats since 2011. This wasn’t something we initially looked at closely, but it’s worth noting.

Researchers Kristin A. Glad (left) and Lise E. Stene shared the results of an important longterm study in Norway which gauged the medical response to the attack at Utøya in 2011.

How is that possible? Were these reactions like people telling them to "Get over it" or “Stop talking about it”? How can anyone think along those lines?

KG: This is particularly prevalent among those who were politically active, as – even as young people at the camp on the island - they were targeted because of their political views. Many survivors, particularly those who were active in the media, faced personal threats like “You should have died...” or “I wish you were killed...”

LS: Many were politically engaged, so that added a layer of exposure and this has been an important factor to consider in our research. But even outside this specific context, negative reactions to such traumatic events seem more common than expected, and they can contribute to long-term health issues of those in recovery. Early on, when a tragedy like this unfolds, there’s often a lot of widespread support, but as time passes,  the responses can become negative.

You pointed out that the mere size of the island, which really isn’t that big, meant many of the people trying to escape or hide, still saw or heard most of the violence directly. That kind of horror is difficult to fathom.

LS: What also makes this unique is that it’s a human-made trauma. When trauma is inflicted by another person, it may deeply impact trust in others and your relations to others, which is specific to this type of experience. Additionally, media attention and trials can act as constant reminders later on, acting as external factors that trigger the trauma repeatedly.

Attendees take in the details of the presentations at the Hall of Patriots at the historic Carolinum building in Prague.

The moment never really fully goes away, with trials and new developments in the news…

KG: Yes, it’s highly prevalent that such reminders—whether through new trials, or media coverage, or even a loud unexpected noise in one’s vicinity—can all trigger mental health reactions. These are all factors that can keep the trauma alive for a long time.

From your presentations at CU, it seems different countries or cultures respond differently to these kinds of events, whether as first-responders or providing medical attention afterwards. From what I understand, Norway has a community-based approach that played a role not only in the immediate response but also in healing. Is that accurate?

LS: I’d say that’s right. It’s interesting to compare the Norwegian approach to countries like France. Both are European countries and both have universal healthcare, but their responses are quite different. In Norway, the focus is on coping and hope, with a clear desire to avoid over-medicalising the response. Providers don’t want to interfere 'too much'. By contrast, France places more emphasis on ensuring people receive specialised help from the start. The fear there is the opposite: to ensure that those who need specialised attention get enough. It’s a challenge and it’s interesting to see how different countries put weight on different aspects and emphasise different things in their response.

Each country has its own approach—some are more community-based like Norway, while others focus on specialised psychiatric care. It’s also important for us to learn more about how the response might differ in places also like the Czech Republic and how services might adapt to different cultural and healthcare contexts.

After the tragic events of 21 December 2023 at Charles University, both official medical professionals as well as dedicated students of medicine, psychiatry, got involved. On many levels there was also a strong community-driven response. Many in the position to help did what they could and they showed a lot of solidarity and strength. According to many groups involved, over time, the need for continuous sustained help declined, and people began again to move forward with their lives, requiring less immediate or repeat counselling. That doesn’t mean the stress had fully disappeared, but they were able to continue. Does that align with what you have learned as researchers?

LS: Many people show resilience over time, even if they continue to face stress. At the same time, it is important to remember that even as people appear to heal on the outside, they might still need support in the future.

You said that gathering data during a mass disruptive event like this kind of attack or a natural or other disaster is very challenging because things are out of control. But it seems like you’ve done a great job salvaging data even from such a tragedy, which will be useful not only for your own healthcare system but also for neighbouring countries. Would you agree?

LS: Absolutely. And we’ve also been working with European partners, like those in France, to better coordinate research. The challenge now is that research is done in different ways across countries, and we can’t always be sure whether differences in findings are due to actual or real differences or just differences in methodology. This is a major weakness in current research. At the European level, it’s crucial not just to harmonise responses but also to align research methods. If we agreed on a common framework, we could better compare findings across countries and improve our practices.

So, aligning research methods is difficult but also essential.

LS: It’s challenging. However, in times of crisis, when people affected by such events may come from different countries or move between them, having harmonised research and responses would be a huge benefit. This requires resources and careful planning. We need to ensure that research isn’t just about publishing articles—it should be integrated into healthcare systems. The research should directly inform health practices, so we can monitor and adapt interventions in real time. Research needs to be actionable. If you see that certain interventions are working, you can adapt them. If needs are higher than expected, the intervention should be extended. If certain responses don’t seem effective, they can be adjusted. If we can establish a common research framework across countries, we’ll have better data and more effective practices to apply during such events. t’s a major challenge to find agreement across, for example, European or EU countries. But it’s also something we must work towards, because in the end, it benefits everyone—the survivors, the healthcare systems, and broader society. People have different opinions, but at the same time, it’s clear that collaboration is crucial to provide better help. Given the current context, many of us already feel burdened or overburdened by the number of conflicts, wars, and disasters that dominate the media landscape. It’s overwhelming.

I think what’s key here is that we need to find solutions through collaboration and more coordinated responses. Many people are eager to collaborate, but it requires proper coordination. That’s where support from entities like the European Union or higher authorities can be essential. It’s about finding that balance. One challenge today is that we don’t always know what the best approach is, so we need ongoing research. It’s important to follow up with proper research to continuously evaluate and improve what’s being done. Without specific interventions and clear research, it becomes difficult to measure the impact. Coordinating studies across countries would make them more effective, but right now, it’s fragmented. We struggle to get funding for individual studies, and even though they can be useful, they could be so much better if they were coordinated together.

When it comes to the process, how much did being part of the research help the participants? You’ve collected powerful stories or testimonies: did the process help them come to terms with the trauma of losing loved ones or friends?

KG: We don’t know for sure how much the process helped, but we can say that many of them found it to be a relief, especially in the early stages. They welcomed the opportunity to talk about their experiences without feeling like they were burdening their families or friends. When speaking to loved ones, they often hold back certain details to protect and shield them, but with us, they felt they could share everything. One key aspect of this study is that healthcare professionals conducted the interviews. At the end of each interview, we asked participants if they had any unmet health needs. This gave us the chance to help them get the care they might need, either by referring them back to healthcare services or by providing immediate support. The ability to evaluate their needs and help them access proper care were very important aspects of the study.

LS: Exactly. This approach was made possible thanks to the funding from the Norwegian health directorate. They recognised the need for more knowledge and the importance of monitoring to provide better follow-up for those who hadn’t received sufficient help. Then, it was interesting to see that some people felt they received more help than they needed, while others felt they didn’t receive enough. In addition to the immediate benefits of being interviewed, many participants saw their involvement as a way to help future victims of similar tragedies. Despite the pain, they were motivated by the idea that their experiences could lead to better help for others. When planning research, there’s often a concern about interfering with people’s healing by reminding them of painful memories. But for many, sharing their stories felt meaningful, as it could contribute to improving future responses to similar traumatic events.

It seems that these kinds of events—school shootings, environmental disasters, and other tragedies—are becoming more common, and we need to be better prepared for them, not just in terms of human-caused disasters but also those stemming from natural or environmental factors. How should we better prepare for these situations?

LS: It’s crucial that we approach preparedness with a long-term view, considering both human-made and natural disasters. This requires ongoing collaboration, better research, and a coordinated effort at the international level. It’s about building a system that’s flexible yet comprehensive, so we’re ready for whatever challenges arise.

As a result of your study, do you think that communities in Norway will be better prepared? Will changes be implemented in a way that they'll be able to deal with such a situation, should something like this sadly ever be repeated, next time?

KG: Changes already have already been implemented in the revision of the guidelines. In terms of proactivity and increased awareness, it has shaped the Norwegian response. But it’s a continuous process, something that has to be improved over time. Even though the study is unique in its design internationally, there are many questions we can’t answer yet. To address these questions, we need to plan before the event occurs, which is challenging but necessary because disasters will happen. It is possible to be much more prepared, but it requires collaboration, willingness to fund the framework, and the ability to launch it rapidly when something happens.

LS: There are also challenges regarding legal aspects, such as confidentiality and knowing who is affected. For example, at Utøya there were youth who weren’t on the island during the shooting but had been there shortly before, had heard what was happening from the landside, and knew people who were affected. And they weren’t included in the follow-up programme, which led some to feel that the response was unfair, as they were left out of additional counselling or support. But you have to draw the line somewhere. It’s a challenge to draw a line on who gets included in a specific intervention program, as some will inevitably miss out. We have learned that disasters often expose gaps in our response. The importance of collaboration is key, and we must be prepared for the unexpected, as these events can happen at any time. So, yes, it’s an important step, but we must continue to adapt, and we have learned that disasters often expose gaps in our response. The importance of collaboration is key, and we must be prepared for the unexpected, as these events can happen at any time.

Regarding the trauma survivors, and the process they went through during the interviews, were there any positive outcomes for them?

KG: Yes, and this is a key aspect that often goes unacknowledged in trauma research. We have found that many survivors reported positive personal changes after coping with the trauma, though this isn’t to say that trauma itself is beneficial. The important point is that people often find meaning or strength through their experiences. These positive changes include becoming stronger, more empathetic, or more appreciative of life. Even when we surveyed the parents, a significant percentage observed positive changes in their children. This shows that people can experience what’s called post-traumatic growth.

How does this finding tie into the wider societal impact of the tragedy? Is there a broader effect?

KG: It’s hard to say if there has been a lasting change in people's awareness of their roles, but there is definitely a conversation about preparedness at the community level. There’s a discussion in Norway, especially in light of the Ukraine situation and broader European instability, about how communities can be better involved in response efforts. It's essential that local players, including individuals and groups, are able to support each other, especially when national systems are overwhelmed, like in a disaster situation or even in the case of war.

Lastly, from what we have been talking about. It seems clear that the lessons from this tragedy be applied elsewhere, for instance, in Czechia. What advice can we offer to other countries to improve preparedness and response?

LS: There are definitely lessons that can be applied elsewhere. For example, the importance of proactive outreach in schools is critical. We also found that students’ academic performance is closely linked to their mental health symptoms. So, schools need to provide support to help students thrive again, even if they can’t perform at their usual levels right away. The goal is to keep them engaged academically and socially without allowing them to drop out, which can worsen their mental health. The key takeaway for schools is to provide ongoing support, identify at-risk individuals, and offer targeted interventions. Early, proactive support can prevent the vicious cycle of falling behind in school and ultimately improve the recovery process for those affected.