Improvised Explosive Devices2013 Boston Marathon Bombings reportHealth and explosive violence

Blood on the Streets of Boston: Mental health support and conclusions

This report is part of AOAV’s research on the bombing at the Boston Marathon in 2013. The full report, ‘Blood on the Streets of Boston’, can be read here. The main findings and summary can be seen here. The report considered the services that were offered to survivors and witnesses, see here. As part of the report it AOAV also researched the medical care and financial support provided to survivors – this report can be read here – and the health impacts the bombing had – here. It was also important to consider the ‘Victims’ Voices’, from those who survived the attack. To read these please go here, here, and here.

Mental Health Services

Mental health support for those physically injured

Care provided at medical centers

Medical care givers were aware that the survivors and their families would likely have mental health needs to a greater or lesser extent. Maureen Fagan, the Executive Director for the Center for Patients and Families at Brigham and Women’s Hospital, was responsible for the team coordinating patient and family care in the aftermath of the bombing. The hospital’s Employee’s Assistance Program provided mental health support to patients, families, staff, and staff family members.

The hospital cared for 40 patients, and 40 families. These families were basically living in the hospital for up to a month, and were being supported by the Center for Patients and Families. The Center provided services such as talk therapy, medication therapy, physical therapy, spiritual care and religion-based therapy. The mental health needs of patients and their families were reviewed multiple times per day in order to ensure they were being supported as required. Maureen showed AOAV the Center, explaining that each family was supported in a way that was unique to their harm and needs.

Massachusetts General Hospital has a whole team dedicated to psychological and psychiatric needs for patients. The hospital mobilised social workers and psychological support for those who were critically injured, as well as clergy where appropriate.

Karen Brassard was treated at Boston Medical Center. She told AOAV that a mental health worker checked up on her at least once per day for the duration of her hospital stay. The same happened at Tufts Medical Center, where her husband spent two and a half weeks. She said that, while her own priority was with their physical injuries, the mental health services would have been available immediately had they wanted them.

Care provided by state bodies

In the immediate aftermath of the bombings the Family Assistance Center provided information to the families of those who had been injured regarding the mental health services available to them. Atyia Martin, Director of the Office of Public Health Preparedness, told AOAV “the whole spirit was to make it easier for survivors.” The BPHC referred families to mental health care providers, enabling them to identify support services and groups very quickly. Some mental health counselling was also available at the Family Assistance Center.

The BPHC, through the Office of Public Health Preparedness, also offered support groups to the survivors and their families, beginning in May 2013. One of the groups, for amputees and the families of those who had been killed, was quickly disbanded. Donna Ruscavage told AOAV that these individuals already had a network of support, and that they were not ready to join such a group.

The second group, for those who had been injured but are not amputees, continued until May 2014, and was funded by MOVA. Almost 50 survivors joined the support group, Donna told AOAV, with an average of 15 to 20 attending each meeting. They worked with the Justice Research Institute in Boston, and had experts come to the groups
to do things like art therapy and a trauma and yoga workshop. A mental health clinician who had special training in trauma ran the group, working with people to inform them of the signs of PTSD, how trauma might affect their lives, and how to deal with this trauma. The support group received a no-cost extension from MOVA until December 2014, after which the activities will be transitioned to the Resiliency Center.

It was recognized that peer-support was extremely important. One way in which this support was encouraged was through the online program Yammer. Microsoft donated to the BPHC a three year licence to Yammer, a private, password protected social media site, to which the injured survivors all have access. Donna Ruscavage told AOAV that this program has been a great source of support for survivors, both in Boston and further afield. The group is monitored in order to identify significant problems, but largely functions as a peer-support mechanism.

From the hospitals, to the BPHC, to MOVA, mental health support was available to those who were injured and their families. Many survivors, however, had such severe injuries that their mental health needs were not tackled until months after the bombings. In addition, some support was provided not by trained trauma counsellors, but by other therapists, such as marriage counsellors.

Those who were physically distant from Boston were not able to benefit from mental health services to the same extent as those within the city. Many of the services available are in Boston, and much of the support has ultimately been peer-based. One survivor, who lives in Minnesota, told AOAV that much more should have been done to emotionally support such victims. She spent months trying to reach out to the survivor community in Boston with little success. A mental health worker from the One Fund reached out to her months after the attacks, but by that point it was too late. She was able to virtually communicate with the survivor community, but joining such a close group so long after the bombings made her feel much worse. She said that Boston was very protective of its survivors, and not keen to let outsiders in to talk to them, but “since I’m already an outsider, I can talk.”

Mental health support for first responders and hospital staff

Most of those who had close contact with survivors and their families had never experienced anything like the damage and destruction caused by the bombings. Dr. Paul Biddinger from Massachusetts General Hospital told AOAV that the psychological impact on the staff there had been huge. “People needed help for a long time. People needed different kinds of help. Some people wanted group therapy, some people want personal therapy, some people want to talk right away, and some people want to talk later.”

Massachusetts General has a team dedicated to providing psychological support for their staff. A debriefing was held for the staff within days of the bombings, providing information about this sup- port. There was constant outreach to employees, and they were encouraged to ask for help if they needed it.

The same was true at Brigham and Women’s Hospital. The Employee Assistance Program, alongside psychiatrists, trained social workers and counsellors dedicated to staff provided assistance to staff members who were affected by the bombings. Eric Goralnick, the Medical Director of Emergency Preparedness, told AOAV that, as well as specialist services, a peer-to-peer counselling group was established.

The blasts had a huge impact on members of the police who were at the finish line, and those who saw the aftermath of the explosions, Sergeant Mike McCarthy from the Boston Police Department told AOAV. The Police Department required everyone to go to counselling, including the Police Commissioner. The Police Department has a support unit providing lecturing and mental health counselling, and were very proactive in providing mental health services to anyone who needed it or asked for it. Other first response teams, such as the Fire Department, had their own psychological support systems in place.

The Office of Public Health Preparedness also made sure that their employees received support. Dr. Robert Macy, who is well known in trauma response and post-traumatic stress management, provided services to the staff of the Office of Preparedness of the BPHC. This response was also provided to other employees of the BPHC.

‘Boston Strong’

Over and again AOAV was told that “they messed with the wrong city.” In the aftermath of the bombings, this rhetoric led to ‘Boston Strong,’
a message that the city, the community, and the survivors would not let the attacks destroy them. It was unquestionably a phrase symbolizing hope, resiliency and strength.

Some survivors have taken ‘Boston Strong’ to heart, and it has provided them with an added feeling of support and strength. However, it had
a destructive effect on some of those who were struggling to deal with what had happened. Manya Chylinski said that in the aftermath of the bombing it felt like “you’re supposed to be Boston Strong, suck it up. And if you’re having trouble, you’re not Boston Strong and then you’re not part of the team.”

Manya thinks that Boston Strong, and some aspects of the One Fund, “have deepened the divides between the types of victims and…helped people feel more isolated.” The continued emphasis on those with physical injuries, combined with ‘Boston Strong,’ had the effect of discouraging some from asking for help. Those with mental and emotional problems particularly felt the pressure to be ‘Boston Strong,’ which had a negative impact in the long term.

However, the vast majority of individuals AOAV spoke with identified with ‘Boston Strong,’ and felt that it aided in both their personal recovery and the recovery of the city.


This research demonstrates the devastating effects the use of IEDs in populated areas have, and that they have an impact far beyond the headline casualty figures.

Alongside those directly killed and injured are the countless more who suffer physically, emotionally and financially. Even in Boston, which has good medical and financial resources, individuals will suffer from lifelong effects due to their physical injuries and the psychological impact of the bombings.

The response to the Boston bombings can largely be used as an example of good practice in how to respond to an IED attack, and how to support the victims. Firstly, a huge amount of preparation and training had been done in the years prior to the bombings. This preparation crucially included meeting with those who had responded to IED attacks previously, and incorporating their lessons learned into emergency plans. Those responsible for responding to the attacks were aware of the difficulties responders had had previously, and made plans to avoid such problems. Critically, all involved in responding to the attacks had trained with each other. Police, other first responders, and health care professionals knew and trusted each other to do their jobs, primarily because of advanced planning. The extensive training undertaken by the city of Boston undeniably saved lives.

There was a high level of coordination between agencies in responding to the attacks and the victims. The Boston Public Health Commission, through its Medical Intelligence Center, coordinated the initial response, meaning that all responders had a central point of contact. The same is true of the assistance to victims. The Family Assistance Center served as a central support mechanism for victims and their families in the weeks after the bombings. This centralised mechanism streamlined processes for victims and their families, simplifying their initial access to support services.

The speed of the victim assistance response
can be applauded. A center was established for family members to receive support within hours of the bombings. A more permanent center was established within two days. The One Fund was created and donations could be made less than 36 hours after the attacks. The speed of response meant that victims and their families had access to services almost immediately.

The creation of a singular charity can also be
seen as a positive aspect of the response. The transparent nature of the One Fund shows exactly how much was donated and how funds were distributed. The One Fund demonstrated the need to learn from experience and a willingness to adapt. Between the first and the second distribution the One Fund realized that it was important
to consider the severity of individuals’ injuries,
not merely their length of hospital stay. The One Fund also responded to criticism of its handling
of those with psychological injuries and traumatic brain injuries by determining that future donations will go to the provision of services, not to cash payments to individuals. This willingness to adapt should be seen as a positive aspect of the charitable response.

However, it must be noted that luck played a significant role in the fact that a small number of people were killed in relation to the number of those injured. Those with severe injuries required hospital treatment within minutes of the attack. This treatment was able to be provided because ambulances and police vans were at the scene when the bombs detonated, and roads were closed due to the marathon. The rapid extraction of victims happened at least partially due to good luck.

Not all aspects of the response to the attacks can be applauded however. Many facets of the response came from charitable action. The One Fund was entirely voluntary, raising $80million from private donations. Lawyers, mental health workers, architects and builders donated their services and time at no cost. This is an entirely unsustainable response. In a country such as
the US a charitable response can be seen as a positive response since there are thankfully very few attacks. However, should attacks take place with any sort of regularity, this response would likely tail off quickly. The State should not rely on charitable organisations and voluntary services to support the victims of explosive weapon attacks, no matter how rare they may be. Without the sup- port provided by the likes of the One Fund, many survivors would be facing financial difficulties with little recourse to support from the State.

While the State itself has an inclusive definition of ‘victim,’ other aspects of the treatment of victims in the aftermath of the bombings created layers of victims. The choice of the One Fund to sup- port only those with physical injuries had a knock on effect for those suffering from psychological injuries. Public officials and media outlets spoke of the victims only as those who were killed or physically injured, there was little mention of those with psychological issues.

When speaking of those affected by such attacks, the media and public officials should recognise that individuals can suffer from psychological as well as physical injuries as a result of IED attacks.


Prevent future attacksScreen Shot 2015-02-03 at 18.05.45

  • States, the international community and local leaders should work together to stigmatise the use of explosive weapons in populated areas.


  • States should prepare for mass casualty incidents, including IED attacks.
  • States should share experiences and best practice to learn how best to respond to IED attacks.
  • Those who responded to the bombings in Boston should share their lessons learned.

Treatment of victims of IED attacks

  • Those treating IED victims should be aware of the deep psychological impact of these incidents.
  • Hospitals should train staff to spot symptoms of trauma and mental distress, assess victims’ risk factors and provide referrals to mental health and counselling services.


  • The rapid setting up of a central coordination centre in response to an major IED attack reduces confusion or duplication of efforts.
  • A central information centre for survivors and families should be established, providing help on accessing support services in an accessible location.

Categorisation of victims

  • Victims should not be categorized in a narrow manner; not only those who are physically injured suffer harm in IED attacks.
  • Victims are not just those killed and physically injured – those suffering from psychological harm should also be considered by both officials and the media.
  • The Convention on Cluster Munitions provides a useful definition of ‘victim’ as “all persons who have been killed or suffered physical or psychological injury, economic loss, social marginalization or substantial impairment or the realization of their rights…they include those persons directly impacted by cluster munitions as well as their affected families and communities.”

To read the whole report, please click here.