Being held hostage in the Netherlands: A study of long-term aftereffects

Journal of Traumatic Stress, Vol. 2, No. 2, 1989

Being Held Hostage in The Netherlands: A Study of Long-term Aftereffects

Henk M. van der Ploegl and Wim Chr. Kleijn’ Accepted November 11, 1988

In the 1970s, The Netherlands were confronted with eight large-scale hijackings, in which a total of nearly 500 persons were held hostage. In 198S, the long-term aftereffects (up to 9 years) of these hostage takings were studied. Approximately one-third of the ex-hostages studied were found to suffer from negative effects resulting from the hostage-taking and mentioned symptoms related to DSM-III categories ‘>post-traumatic stress disorder” and “generalized anxiety disorder,” and a variety of medical symptoms. Twelve percent of the ex-hostages were found to be still in need of aftercare and help, even though nearly all of them had had several contacts with professional health care workers in the period follo wing the hijacking. A number of variables are described which are related to lower degrees of well-being and more negative aftereffects in ex-hostages, thereby suggesting the predictability of greater vulnerability in some hostages.

KEY WORDS: hostage-taking; aftereffects (long-term); human stress; life-events; terrorism; kidnapping.

INTRODUCTION

In the 1970s, citizens of The Netherlands were confronted with an alarming number of terrorist acts. Eight large-scale hijackings took place, in which a total of nearly 500 persons were held hostage. Some of the hostages were killed, some physically injured, but most regained their freedom, physically unharmed, after a period of time ranging from a few hours to several weeks.

‘University of Leiden, The Netherlands. 153

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154 van der Ploeg and Kleijn

During these incidents several experts predicted on radio, television, and in the newspapers the possible aftereffects in the hostages and members of their family. These predictions, which were generally not very unanimous and characterized by vagueness, lacking specification of time or place (e.g., “they will suffer from nightmares”), included many negative psychological and physical aftereffects (Meeuwisse and Van der Ploeg, 1979).

In the scientific literature of the seventies, little information about the short- and long-term consequences of modern terrorism was available (Jacob- son, 1973; Ford, 1973). Although studies of the aftereffects in victims of World War I1 (Eitinger and Strom, 1973; Bastiaans, 1957), as well as a number of case reports and studies of victims of violence and crime offered a source of information, these findings could not easily be generalized to victims of hijacking and hostage-taking.

In order to improve the organization of care and assistance to victims of modern violent acts, such as hostage-taking, one has to rely on scientifi- cally established data about the possible consequences for the victims and members of their family.

Therefore, a research programs was initiated to identify the psychological or psychosomatic changes manifested in the victims resulting from their hostage experiences. Two studies have been realized, each involving more than 200 victims. In the first study, investigating the short-term aftereffects, information was obtained on the basis of interviews and questionnaires (Bastiaans ef al., 1979).

According to this first study, anxiety related symptoms such as tenseness, insomnia, fears, and phobias were generally most prominent in the first 4 weeks following the event. After the first month, two-thirds of the ex- hostages reported negative effects. The symptoms included irritability, increased lability, fears, phobias, physical complaints, insomnia, feelings of unsafety, feelings of being misunderstood, and preoccupation with the experience. The longer-term effects (after 1 to 3 years) were more prominent for women than for men, and the intensity of effects was greater as the captivity had lasted longer, as the hostage was younger, and (s)he had a lower educational level. There was a clear relationship between short- and longer- term effects. In addition to negative consequences, positive ones were reported. About half of the hostages mentioned a greater ability to see the relativity of things and an improvement of their human relationships. The family members of the ex-hostages were also interviewed. They reported more or less the same kind of aftereffects as the hostages themselves, although the effects were less intensive (Bastiaans et al., 1979; Jaspers, 1980; Van der Ploeg, 1981. 1983; Bastiaans, 1982, 1985).

Some of the Dutch hostage takings have been analyzed by other researchers. Wesselius (1982) stresses the importance of the role of the mental health adviser. Stofsel(l980) reports about the special aftercare program set

Hostages’ Aftereffects 155

up by the Dutch government to help the victims of a hijacked train. Ochberg (1978), and Ochberg and Soskis (1982) discuss terrorism in The Netherlands within the context of victim stress and coping theories. Other studies of the aftereffects of hostage takings in other societies and cultures are found in Jacobson (1973), Hillman (1981), Kentsmith (1982), Ploeger (1983). Terr (1981) has studied the detailed short-term reactions in a group of 25 victims of a schoolbus kidnapping. According to Terr (1983), the 4-year follow-up study demonstrated that every child suffered from post-traumatic effects. Brief treatment (5-13 months after the incident) did not prevent symptoms and signs 4 years later.

In the second study, which took place during 1983-1985, the long-term consequences of the hostage takings in The Netherlands were studied by means of written questionnaires (Van der Ploeg et af. , 1985). This article describes the results of this second study which focused on the long-term aftereffects of hijacking and hostage taking in The Netherlands in large groups of victims over a period up to 9 years after the event. Special atten- tion will be given to the impact of (preventive) care and assistance on the long-term consequences, because a proper organization of care and treatment may reduce the amount of negative effects or may even prevent these symptoms.

METHODS

The Terrorist Acts

The Occupation of the French Embassy in The Hague

In September 1974, 11 persons were held hostage for 4 days by three members of the Japanese Red Army.

The Hijacking at Scheveningen Prison

In October 1975,22 persons, members of a choir singing during divine service, were taken hostage by four prisoners. This experience lasted 5 days.

The Hijacking of the Train at Wijster

In December 1975, a Dutch train consisting of two coaches was brought to a halt by five South Moluccans. Some passengers managed to escape.


Three were killed by the South Moluccans. Twelve days later, the hijackers surrendered and the remaining 32 hostages were released.

The Occupation of the Indonesian Consulate in Amsterdam

In December 1975, a group of South Moluccans took 36 persons hostage in the Indonesian consulate in Amsterdam. Among the hostages were 14 children. One victim died. Fifteen days later, the terrorists surrendered and the remaining hostages were freed.

The Hijacking of a KLM DC9 Airplane

In September 1976, the City of Madrid, on flight from Nice to Amsterdam, was hijacked by three Palestinians. Following touchdowns in Tunisia and Cyprus, the hostages were released after hours of negotiation.

The Hijacking of the Train Near De Punt

In May 1977, a Dutch train was seized by nine South Moluccans; 96 passengers were taken hostage. In the first hours, 42 persons were released. Twenty days later, marines took the train by storm. During this action, two hostages and six hijackers lost their lives.

The Siege at the Junior School Bovensmilde

Simultaneously with the hijacking of the train near De Punt, four South Moluccans took 5 teachers and 125 school-children hostage at the junior school in Bovensmilde. Twenty Moluccan school-children were soon released. Four days later the remaining children and one teacher were released, because of a large-scale viral infection, which made full medical treatment necessary. Twenty days later, marines took the school by storm. The remaining teachers were freed.

The Occupation of the County Hall in Assen

In March 1978, three South Moluccans took 69 civil servants hostage. One victim was killed. The next day, marines took the building by storm and set the hostages free.

Hostages’ Aftereffects

Subjects

157

In order to study the long-term consequences, the victims’ current addresses were needed. These addresses could be obtained for a total of 251 victims still living in The Netherlands. Governmental decisions did not per- mit us to update the addresses of and to study the aftereffects in most of the Bovensmilde school-hostages (N = 100) and the civil servants in Assen (N = 68), so that the results of this study do not include these two groups. However, school hostages living outside Bovensmilde could be investigated and their data have been included in the results reported hereafter.

Questionnaires

The aftereffects have been studied with the use of structured, Dutch written questionnaires, to some extent consisting of scales with reported psy- chometric properties and normative data. In general, questions were related to the following topics: professional aftercare and medical consumption, including reference questions from a survey-study of the Netherlands Institute for Statistics (CBS, 1980); social support; (psycho)somatic effects, including questions from the VOEG questionnaire (Dirken, 1967); psychological effects; other effects (material, social); well-being, including a Dutch adaptation of the Affect Balance Scale (Bradburn, 1969) and translated questions developed by Andrews and Whitney (1976); life-events, including a Dutch adaptation of Holmes and Rahe life-events inventory (1967), CBS (1980); coping strategies, by means of the UCL (Schreurs, Tellegen, & Van de Wil- lige, 1984) comparable to Westbrook (1979). Three scales were used: “active coping style,” “depressive reaction style,” and “seeking for support style”; personality variables, including “neuroticism” and “extraversion” scales taken from NPV (Luteijn et af., 1975) comparable to Eysenck’s Personality Inven- tory (Eysenck and Eysenck, 1975), “state and trait anxiety” by means of the ZBV (Van der Ploeg et al., 1980), an adaptation of the STAI-form Y (Spiel- berger, 1983), “anger” by means of the ZAV (Van der Ploeg et al., 1982). an adaptation of the STAS (Spielberger et al., 1983); biographical data.

Separate questionnaires were constructed for the ex-hostages, members of their families, the school-children and their parents. Nearly all scales and questionnaires are known as reliable and valid instruments, but because of the adaptation to the layout and context of the questionnaire as a whole, their reliability was measured again in this study. Internal consistency coeffi- cients (Cronbach’s alpha) ranging from 0.77 (Bradburn’s Affect Balance Scale) to 0.90 for extraversion and trait and state anxiety were considered to be


satisfactory for this study. The intercorrelation pattern among the variables studied gave evidence of the validity of the scales.

Procedures

In 1983-1984, letters of introduction of the study were mailed to the ex-hostages. Next, a detailed cover letter was mailed together with the questionnaire. Each (adult) ex-hostage received a questionnaire for him/herself and another questionnaire to be answered by a member of the family. The adolescent ex-hostages received a “children’s” form and a questionnaire to be answered by one of the parents. The questionnaires could be returned anonymously, using postage-paid reply envelopes. Reminders were mailed after several weeks. Each ex-hostage could apply for a free copy of the book with results of the studv ‘- ler Ploeg et al., 1985).

RESULTS

Respondents

The response rate in the group of adult hostages was 70%, of which 138 questionnaires could be used for statistical analysis. In the group of members of the family (mostly spouses, parents, oldest children), a total of 76 questionnaires were returned which could be used for analysis. Meanwhile, the adolescent ex-hostages from the hostage-taking at the school in Bovens- milde returned 76% (N = 16) and their parents 90% of the questionnaires.

Aftereffects in the Bovensmilde School-Children

Although the number of school children that could be studied is only a fraction of the group that was taken hostage, the questionnaire results allow for some descriptions. The age range of the children at the time of the hostage taking was 6-14 years. In general, most of the effects of the hostage taking of the junior school could be observed in the first year after the event. There- after, the number of negative consequences is extremely limited. Sleeping difficulties and feeling tired are the most frequently reported aftereffects. In the long run, about half of the children (adolescents) still talk about their captivity every now and then. They also report feelings of anger when think- ing of the experience. In comparison to normative data, no differences can be observed in well-being, levels of stability, anxiety, and medical consumption (e.g., visits to doctors, use of medication). Finally, the use of after-care services related to the hostage-taking is rather low.

Hostages' Afterefferts 159

To some contrast, the parents of these children reported more negative aftereffects in their children. Based on comparable questions, the adolescent ex-hostages evaluated their well-being more favorably than their parents did.

Eight children (50%) still think of and talk about the hostage-taking and still have feelings of anger towards their former hijackers (after more than 6 years). However, the overall results based on the answers by the children and their parents show that nearly all the adolescent ex-hostages could cope with the event within one year after the experience. This finding con- trasts with the findings of Terr (1983). who found in the Cyear follow-up study of 25 victims of a schoolbus kidnapping, that long-term post-traumatic anxiety and fears existed in nearly all of the children.

It is not yet clear which factors can account for these differences. Terr, of course, used different study methods, and also reports that symptom severi- ty was related to the child's prior vulnerabilities, family pathology, and community bonding. Earls et af. (1988) interviewed children and their parents, inhabitants of an area of rural Missouri, all victims of a disaster of severe flooding. None of the children could be diagnosed in terms of DSM-111 Post- Traumatic Stress Disorder, but they state that already existing psychosocial problems of parents and their children clearly influenced, and aggravated the late effects in the child. Another potentially important factor relating to long-term aftereffects could be the way in which after-care is made available to the victims. In the case of the hostage-taking at the school in Bovens- milde, special psychological and medical care was organizaed to assist the parents and was in operation soon after the start of the hostage-taking, even before the children were freed. On the general basis that the children and their parents were normal, healthy people, but having to cope with an ex- treme situation, a community based program was quickly realized, involving (among others) psychologists, general practitioners, and schoolteachers. Special governmental funding for a range of activities was made available for a period of about 2 years.

Long-term After-effects

Psychological and Behavioral Consequences

The hostages and their family members (spouses, parents, oldest children) report several psychological symptoms or complaints resulting from or related to their experiences (see Table I). The number of ex-hostages report- ing various symptoms is larger than that number in the group of members of the family 0, c 0.01). Frequently mentioned effects are: tenseness, anxieties, and sleeping difficulties. The number of symptoms mentioned by the

van dcr Plocg and Klcijn

Table 1. Aftereffects (Negative. Psychological) Reponed by Hostages and Their Family Members (More than One Answer is Possible)

Hostages Family Members Toral (“V = 133) (hi = 77) (,V = 210)

Symptoms N To N To N q o

None Sleeping difficulties Nightmares Tiredness Tenseness Anxieties Phobias Worries Guilt feelings Depressive mood Nervousness Problems with spousc Sexual problems Problems with family Problems at work Problems ai school Orher svmmoms

3 3 25 41 31 24 18 33 25 45 34 41 31 16 I2 22 17 I S I I 16 I2 22 17

8 6 2 2 4 3

16 I2 3 2

I I 8

38 49 I 1 I4 4 5

IS 20 21 27 I5 20 2 3

10 13 I I 8 10 8 10 9 I2

I I I 1 I I 6 8

- -

71 34 52 2s 28 13 48 23 66 31 56 27 18 9 32 IS 16 8 24 I I 30 14 I7 8 2 I 5 2

17 8 4 1

17 8 &

hostages shows that 25% report no effects at all. 16% report one symptom, 13% two, 13% three, and 34% report four or more symptoms. For the family members these percentages are 49, 5. 22, 8, and 16, respectively. In total 71% state that these effects, especially anxieties, worries, sleeping problems, and problems at work, are causally linked with their traumatic experiences.

In the long run (6 to 9 years after the event) 32’70 of the hostages and 19% of their family members report long-lasting negative psychological aftereffects. Anxiety-related symptoms, similar to criteria used in DSM-111 for “Generalized Anxiety Disorder” are dominant among these respondents. In measuring anxiety as a trait (Spielberger, 1983). however, the averages of hostages and family members are nearly identical to those of randomly selected Dutch inhabitants, matched for sex and age. Furthermore, 46% of the hostages and 29% of the family members report longer-lasting avoidance behavior or phobias (similar to DSM-I1 I criteria in “Post-Traumatic Stress Disorder”). In general, those who were taken hostage in the trains or in the airplane (a public, anonymous situation) tend to avoid these kind of situations more often than those who were taken hostage in one of the buildings (who were generally among familiar persons). These hostages (prison, embassy. consulate, school) tend to avoid these kinds of situations more often.

Hostmges’ Aftereffects 161

For about 33% of the ex-hostages, phobic reactions disappeared in the first year after their regained freedom. It took between 1 and 6 years for the others to overcome their avoidance tendencies.

When comparing the stressfulness of the hijacking and kidnapping with other recently experienced major life events, about 60% of the victims rate it the most stressful event in their lives, 25% the second most, and 10% the third most.

Nevertheless, a large number of victims also report positive aftereffects; 44% of the hostages and 24% of the family members mentioned one or more lasting positive changes as a result of the captivity. Frequently mentioned aftereffects are: the ability to see the relativity of things, closer relationships with others, greater emotional involvement, conscious enjoyment, reinforce- ment of the self, increased insight. increased assertiveness. Especially in the group of hostages, more positive consequences than negative consequences are reported in the long run. The first study reported that on the short term, positive consequences were found in 46% of the hostages and in 32% of the family members (Bastiaans et al., 1979). Comparing these percentages from the first and second study it may be concluded that the number of positive consequences on the short- and the long-term are nearly identical. The number of negative consequences shows a much clearer decrease on the long term.

Psychosomatic Consequences

The psychosomatic consequences have been studied with various methods. In total 34% of the hostages and 23% of the family members report one or more psychosomatic symptoms. Their self-reported complaints include various kinds of pain (headache, backache), respiratory diseases (hyper- ventilation, bronchial asthma, allergy), circulatory diseases (hypertension, cardiac problems), nervous diseases (various kinds of somatic oriented neu- rotic problems), sleeping difficulties, and excessive tiredness, all symptoms similar to DSM-I11 criteria for the “Generalized Anxiety Disorder.”

Psychosomatic aftereffects have also been studied with a scale for which normative data, obtained from randomly selected persons of comparable sex and age, were made available. Statistical analysis demonstrates that in the group of hostages five self-reported symptoms are mentioned with a significant (p = 0.05) larger frequency 6 to 9 years after their captivity. These symptoms are: migraine or severe headache, intestinal problems, rheumatic problems and pains, skin diseases (eczema), and stomach problems. In the group of members of the family, the same type of analysis shows an increased risk for migraine or severe headache.

We also studied various aspects of medical consumption. In comparison with normative data, the hostages do not differ with respect to visits

van der Ploeg and Kleijn 162

to the general practitioner, visits to consulting physicians, admissions to hospi- tals, use of medications, or staying at home because of illness. For the members of the family, no differences are found between their pattern of medical consumption and normative data either.

Coping, A fter-care, and A fter-effects

The amount of aftereffects and the need for aftercare were studied using multiple regression analyses.

For a group of 63 persons, who explicitly stated their names on the questionnaires, data were available from the first and second study. For this group it was possible to relate variables from the first study (1979) to out- comes in the second study (1985).

By combining the scores on several scales from the second study (anxiety, psychological, and psychosomatic distress items from ZBV, NPV, and VOEG) a dependent variable was created indicating “negative aftereffects.” In the long run 25% of the hostages reported hardly any aftereffect and 22% reported many (severe) consequences; the others were in between. By group- ing 18 variables used in the first study into four groups (experiences during the hostage taking, well-being before the hostage taking, behavior and complaints after the hostage taking, and biographical variables) partial correla- tions were computed between these variables (within each group) and the dependent variable (negative aftereffects). Interrelations among the variables show that the amount of aftereffects is correlated with the amount of stress at the beginning and at the end of the captivity (r = 0.30, p < 0.05; more stress implies more threat and danger, such as shooting, and actions by marines). Those with a larger number of coping strategies used to overcome the event reported less negative consequences (r = 0.29, p < 0.05). Those with a large number of physical symptoms and complaints before the hijacking and kidnapping (psychosomatic reactions in relation with stressful events) reported more aftereffects in the long run ( r = 0.44, p < 0.001). Hostages who feel that aftercare and treatment has to be offered with an outreaching strategy, rather than asking for help on individual initiative of the hostages, reported more negative consequences, too (r = 0.27, p < 0.05). Finally, those with a lower level of education reported more negative effects up to 9 years after their captivity (r = 0.42, p < 0.001). A multiple regression analysis, entering these five variables together, showed the explained variance in the prediction of the amount of negative aftereffects to be 49% (as can be seen in Table 11).

Using this same strategy, another set of multiple regression analyses was performed to predict the amount of negative consequences explicitly at- tributed to the hostage taking. These analyses were run for the group of


Table Il. Multiple Regression Analysis Relating Measurements from the First Study to Outcome Variables (Negative Aftereffects) in the Second Study (for

a Subgroup of Victims Known by Name, N = 63)

Beta F Test

Stress (beginning and ending of hostage taking) 0.19 p = 0.06 Variety in coping behavior during hostage taking -0.26 p c 0.05 Psychosomatic complaints before hostage taking 0.42 p < 0.001 Aftercare has to be offered 0.27 p c 0.05 Educational level -0.11 N S Multiole correlation R = 0.70

hostages plus their family members (N = 213). A large number of negative aftereffects may be predicted (explained variance is 46%) by: more symptoms and complaints at the time of study, a higher social inadequacy score (more introvert), a less frequent use of active coping strategies, a larger use of the coping strategy “depressive reactions,” a lower level of education, being older, in need of an outreaching offer of aftercare, more frequently and more recently talking about the hostage event, a more frequent use of health services, and having experienced a larger number of major life events.

Outreach Treatment and A fter-care

After release, almost a11 victims and the members of their families were offered some kind of aftercare or treatment. This outreaching strategy by social workers, psychologists, psychiatrists, and the general practitioners was considered the most effective way of helping the victims overcome their problems and prevent negative aftereffects as much as possible.

Besides during their contacts with the G.P. and other health care workers, the hostages also talked a lot about their experiences with close friends and relatives. In this study of the long-term aftereffects, it was found that 36% of the hostages talked most about their captivity in the first year after the event, 35% talked most during the first and following 7 or 8 years, and 29% still talked about their experiences in the last three months preceding our study. Usually the spouse, other members of the family, friends, relatives, and other hostages were among the most significant persons to talk with. In the group of members of the family. 46% still talked about their (hostage) experiences in the last 3 months preceding the study. The percentages for the members of the family are statistically significantly different (higher) than the results for the hostages themselves (p < 0.05).

A strong need for aftercare at the time of the study is reported by 12% of the hostages and 11% of the family members. This need for aftercare is

164 van der Plwg and Kleijn

somewhat stronger among the less educated, and/or younger persons. Espe- cially G.P.3, psychologists, or psychiatrists are mentioned as the persons one wants to consult professionally.

Interrelations between several variables show that those who still talked about the hijacking and kidnapping during the three months preceding the study, are also among those who had a stronger need for aftercare during this period. That subgroup also more frequently reports to have missed various forms of treatment, which may have contributed to their present need for help.

Finally, we studied the current well-being and consequences in relation to the amount of treatment and aftercare given to and accepted by the ex- hostages. Although there are important differences between the various strategies for treatment offered after the first Dutch hijackings and those in the second half of the seventies, some general findings can be reported. First, it was found that an outreaching offer for help is generally appreciated. Se- cond, this outreach was usually made within the first week after the end of the captivity. In case there was a delay in the active treatment offer some of the hostages evaluated this negatively, which supports the evidence that an outreaching strategy is favored. Third, some of the hostages preferred not to be approached by health care workers. They wanted to decide about possible treatment themselves. Among the hostages with a positive evaluation of the treatment outreach, the coping strategies “depressive reactions” and “in need of social support” have been found more frequently. Fourth, in case the first offer of aftercare was made by the G.P., the level of well- being in the long run seems to be somewhat higher (Kendall’s tau 0.20, p < 0.05). This level of well-being is also related to the delay between the regained freedom and the first contact with one of the health care workers. In case the delay was 1 month or more, the level of well-being (many years later) is lower (Kendall’s tau .29, p < 0.01). Fifth, the amount of negative aftereffects is related to an outreaching offer for treatment versus the hostage asking for help him/herself. Outreach and less negative aftereffects are related (Kendall’s tau 0.21, p < 0.05). Also other contacts with health care workers

Tabk 111. Relationship between Timing of First Contact with Health Care Workers and Long-Term Negative Aftereffects (N = 72 Ex-hostages; Percentages Are

Given)

Negative Aftereffects Timing of First Contact with 1 2 3 4 Aftercare Minor Major

Too early - - 1,4 1.4 Right on time 13.9 16.7 33.3 13.9 Too late - 1.4 8,3 9 .7


and a proper timing of the treatment offer are related to the amount of aftereffects. Delays in the treatment (offer) seem to be related to more negative consequences (Kendall’s tau 0.18, p < 0.05). This result is also shown in Table I11 somewhat differently. In summarizing these final analyses, an active outreaching offer for help was appreciated, especially when the offer was made right on time. Deviations from this pattern seem to be related to more negative aftereffects and a lower degree of well-being, up to 9 years after the hijackings.

DISCUSSION AND CONCLUSIONS

A substantial number of hostages and their family members report a variety of negative and positive aftereffects up to 9 years after the Dutch hijackings. Anxiety related symptoms are most prominent. During the 3 months preceding the study, 30 to 46% of the hostages and their family members still talked occasionally about their experiences. On the long term, 12% of the hostages and 11 Vo of the family members are still in need of professional -treatment because of their problems.

Comparison of the results of the first study (1979) with the second (1985) shows that the amount of negative aftereffects has decreased. But psychological symptoms, anxieties, tenseness, and sleeping problems are still wide- ly experienced. An important increase has been found in (psycho)somatic symptoms in the long run. These somatic problems have not been found to the same extent as on the short term. The amount of positively evaluated consequences in the long run is almost similar to the amount reported on the short term. Those hostages who had to cope with other major life events besides having been held hostage, reported a large number of negative aftereffects, suggesting a greater vulnerability. Although about ten percent of the hostages and family members are still in need of treatment, hostages and their family members do not report a greater use of health care facilities or self-medications than the general population.

At the time of our studies, the family members were not automatically included in the activities of health care providers. In the mid-seventies a family approach, especially in the case of victims of traumatic stress, hardly existed. Some members of the family explicitly complained about feeling neglected, some even suffered from amounts of signs and symptoms ap- proaching the amount of aftereffects in ex-hostages, thereby competing, as it were, with the ex-hostages for the level of victimization. The “unexpect- ed” large amount of long-term aftereffects in the group members of the family may be explained by the amount of threat experienced by these persons, the lack of aftercare offered to this group by health care providers, and their ambiguous role: helper and victim at the same time. For co-victims not only


suffer themselves, they also have to render some kind of first aid, being the primary source of social support. On the other hand, the victims had to be aware of problems and need of help in their spouses, and/or members of the family, while they themselves were also in great need of help. This com- plicated process may account for the large scale of long-term negative consequences and the relatively great need of professional treatment (1 1 'To) in the group of family members. In the future, studies of aftereffects in victims of traumatic experiences should be extended to the group of family members.

The before-mentioned results were established with the use of a rather lengthy, written questionnaire. The final response rate of 70% was considered satisfactory. In some groups of hostages the response rate was above average, in others below. Systematic trends between the various hijackings and response tendencies have not been found. But the use of the written questionnaire and the general descriptive methodology of the 1985 study allowed us to find a large number of retrospective findings. In general, interrelations between subscales and items reveal a reliable and valid response pattern to the questionnaire. Furthermore, some of the results of the 1985 study were closely related to the findings of the 1979 study, in which each hostage and hidher family member was interviewed, which adds support to the methods used and the results reported.

In the Dutch study of the Bovensmilde school children, relatively few negative aftereffects were found. Terr (1983) reported a large number of long- term negative consequences. Pynoos et af. (1987) described the effects of a sniper attack in school age children. Earls et af. (1 988) reported aftereffects in children victimized by a natural disaster, a severe flooding. Differences among these victimized children, the type of psychotrauma, the appraisal of thesituation, psychopathology before the event, psychopathology (and aftereffects) in the parents, the type and extent of help, support and aftercare given, and interactions among these kind of variables, may all account for differences found among these various studies. In the Dutch school children, a large scale outreaching treatment offer was made. In fact, an extensive project-staff "treated" the community of Bovensmilde, and it seems that in some of these children the immediately organized program prevented long- term aftereffects.

In the study of Hillman (1981) of adult hostages, the period of captivity lasted on the average much shorter than the Dutch events. Hillman describes the existential fears and anxieties and stresses the importance of the appraisal and subjective evaluation of the hostage situation. Long-term negative consequences were found as a result of a few hours of captivity in some of the Dutch victims, too. The Dutch results, however, can be regard- ed as the resultant of studying a large number of persons, victimized under


a great variety of conditions. Irrespective of all individual differences, some general patterns could be observed and were reported. The resemblance with the results by others is striking, which stresses the importance of closely ex- amining general diagnostic criteria, like “post-traumatic stress disorder” and “generalized anxiety disorder.”

In the Netherlands, the strategy for an outreaching treatment offer was introduced after 1975. In general, the hostages of the earlier hijackings and kidnappings had to apply for help themselves. Later some kind of treatment was offered to most of the victims, although the outreaching offer was not successful in a number of cases and for various reasons. In the present study some evidence has been presented that an active outreaching treatment strategy is appreciated in most of the cases. Such a well-timed strategy has proved to be rather beneficial, as it is related to a higher level of well-being and less negative consequences.

In general, a first group of health care providers will be brought together immediately after the hijacking. This group consists of workers a t a local level and some experts at a regional and national level. In The Nether- lands, there is still an official interdepartmental group of experts, organized within a governmental committee, in order to assist those involved in the aftercare. Local, regional and/or national professionals (and volunteers) visit each victim and hidher family at home within one week after the release of the victim. The victim and hidher family are, generally, stimulated to talk about the events and the immediate reactions in a friendly, permissive atmosphere. They are informed about, e.g., some strategies to cope with the mass media, about “normal” reactions to the various stressors, strains and stress, and about individuals, organizations and addresses capable of offer- ing help and after-care without many formal barriers, i.e., victims are informed about possibilities for support and help. In most cases, a second house-call (either in person or by telephone) will be made after a few weeks. Furthermore, the G.P. will be instructed to offer help and to visit the victim and hidher family, and/or the victims are advised to contact the G.P. In order to give appropriate help, the G.P. will beinstructed by the project- staff, or, as was done in 1977, all G.P.’s in The Netherlands received written instructions on ‘how to approach and help hostage victims’ by the governmental committee. Essential in all these activities is to offer the victims and their family members some form of support, to offer them a possibility to know where to apply for help in case they need it, to advise them to talk about their experiences and to express their emotions and worries. In case of medical problems, the appropriate persons will be contacted to look after these, and in case of social and material problems these will be dealt with, too. This outreaching treatment will not be forced upon the victims, but offered. Some are not yet ready to accept the offer and need some time. Some


have to solve material problems first before they are able to cope with the immaterial aspects of the trauma. The outreach may include help with material (and social) aspects in order to facilitate the psychological approach. Cru- cial is not to wait until the victims apply for help themselves, for they may never do so, but to let them know that support and treatment possibilities are available.

In the near future we may expect problems to arise for some of the hostages. The shift from psychological to somatic consequences has not been foreseen. In case this trend continues, an increasing number of hostages may be suffering from psychosomatic symptoms, which in turn may cause addi- tional psychological concomitting signs and symptoms. This may happen in other hostages, in hostages in other countries, but also in victims of severe forms of violence and in individuals who have had to cope with a number of major life events. Careful descriptions and studies of other victims and highly stressed individuals may reveal some of the above-described findings. Another challenge will be to reveal efficient coping strategies and outreaching treatment plans to prevent and to reduce negative long-term aftereffects.

ACKNOWLEDGMENTS

Part of this research has been made possible by a grant of the “Praeventie-fonds,” The Hague, The Netherlands. The authors wish to express their thanks to S. J. Huisman, M. L. Stoffels, E. T. van Buuren, and M. Wostmann for their help in various parts of the study.

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Being held hostage in the Netherlands: A study of long-term aftereffects