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5 Conclusions and Recommendations for Effective Prevention and Response The discussions in the preceding chapters have emphasized the need for a public health approach to prevention and intervention for psy- chological reactions and symptoms that are related to terrorism. Terrorism events and the ongoing threats of terrorism will affect the gen- eral population. Illustrative was the February 7, 2003, elevation of the threat condition designation from the "elevated risk" to the "high-risk" category a decision based on specific intelligence that suggested places frequented by most Americans, such as hotels, apartment buildings, and malls, might be targets. The media continued to speculate about the possi- bility of a biological or chemical attack. News of the elevated threat condi- tion sent large numbers of people in some communities to stores to pur- chase duct tape, water, and plastic sheeting, leaving store shelves empty. The country's ongoing "war on terrorism" will force Americans to live with a new sense of uncertainty. Psychological consequences, although variable in degree throughout the population, will result. Based on its findings, the committee makes the following recommen- dations under a guiding principle of universal preparedness. Effective preparedness and response strategies will help to limit the psychological consequences of a range of terrorism events. Universal preparedness is the conceptual basis used to ensure that all hazards, all populations, and all phases are addressed. In considering preparedness for all populations, the committee underscores the importance of addressing issues for the nation's racial and ethnic minority groups whose needs are often not ad- equately met. It is also hoped that in such preparedness, lessons can be learned and potentially applied to the variety of other violent events that 135

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136 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM cause fear, anxiety, and stress in the communities in which Americans work and live. The committee's public health strategy, as outlined in Table 4-2, is a strategic vision for assessing the completeness and effectiveness of plans to address the variety of violent events that affect the population and to define and address gaps in preparedness and response. FINDINGS AND RECOMMENDATIONS Based on its findings and conclusions, the committee offers several recommendations, under the principle of universal preparedness for all hazards, all segments of the population, and all phases of the event. The committee has developed recommendations that are grouped into five categories: (1) preventive measures, (2) education and training for pro- viders, (3) workplace preparedness, (4) research needs, and (5) ensuring preparedness though a comprehensive public health strategy. The se- quence in which the recommendations are presented does not reflect a priority order. Finding 1: Terrorism involves the illegal use or threatened use of force or violence, and an intent to coerce societies or governments by inducing fear in their populations. Other acts of community violence can also be devastating to psychological health. Pervasive violence, such as repetitive urban assaults, school shootings, and workplace violence, are events that affect small and large, urban and rural communities. These events have elements that may be similar to terrorism in terms of psychological im- pact, and lessons learned from responses to terrorism may help to inform responses to these other events. Similarly, lessons learned from pervasive community violence may provide some benefits for examining responses to terrorism events. Preventive Measures Finding 2: Terrorism and the threat of terrorism will have psycho- logical consequences for a major portion of the population, not merely a small minority. Research studies that have examined a range of terrorism events indicate that psychological reactions and psychiatric symptoms clearly develop in many individuals. To optimize the overall health and well-being of the population, and to improve the overall response to ter- rorism events, it is necessary that these potential consequences be ad- dressed preventively as well as throughout the phases of an event. Recommendation 2-1: The Department of Health and Human Ser- vices (HHS) including the National Institutes of Health (NIH), the

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CONCLUSIONS AND RECOMMENDATIONS 137 Substance Abuse and Mental Health Services Administration (SAMHSA), and the Centers for Disease Control and Prevention (CDC), should develop evidence-based techniques, training, and education in psychological first aid to address all hazards and all members of society during the pre-event, event, and immediate post-event phases of a terrorism event in order to limit the psycho- logical consequences of terrorism. (Chapter 2, pages 61-62; Chapter 3, page 96) Techniques should be scientifically developed, implemented, and evaluated for their efficacy and effectiveness in decreasing distress, pro- moting healthy behaviors and positive coping, and limiting psychiatric illness. This training and education may help to reduce the negative im- pact of terrorism and other traumatic events while strengthening the natu- ral support structures of communities. In these efforts, HHS should part- ner with the Red Cross and the Department of Defense, and public and private mental health care providers among others. Recommendation 2-2: HHS, including NIH, SAMHSA, and CDC, should develop public health surveillance for pre-event, event, and post-event factors relevant to addressing the psychological conse- quences of terrorism and should develop methods for applying the findings of this surveillance through appropriate interventions for groups of special interest. (Chapter 2, pages 61-62) This public health surveillance will include the determination of back- ground rates of behavioral and psychological factors important in pre- dicting psychological consequences, and the need for mental health ser- vices and prevalence of event and post-event consequences and risk factors for negative psychological consequences. Agencies should develop a common protocol and work cooperatively to develop, implement, and sustain comprehensive public health surveillance across phases. Epide- miologic surveillance data obtained under this recommendation should also be utilized to establish baseline community goals such as those incor- porated in Healthy People 2010 (HHS, 2000~. Education and Training for Providers Finding 3-1: Many mental health professionals do not have specific knowledge with regard to disaster mental health. Training and education emphasizing psychological consequences and methods of response should be provided to professionals within the mental health fields, in- cluding school-based mental health practitioners such as school counse- lors, school psychologists, and school social workers.

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138 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Recommendation 3-1: Academic healthcare centers, professional as- sociations and societies for mental health professionals, and state boards of education, in collaboration with HHS, including SAMHSA, NIH, and CDC, should ensure the education and train- ing of mental health care providers, including community- and school-based mental health care providers on responding to the psychological consequences of terrorism. (Chapter 3, pages 93-94) An evidence-based models and implementation strategies should be developed. Any protocols that are developed should be evaluated. The goal of training should include instruction at various levels that will cor- respond to population needs and the risks associated with different types of events (for example, conventional explosives vs. biological). Training should address psychological consequences of terrorism and disaster re- sponse, including the provision of supervision. Disaster mental health curricula within graduate training programs should also be addressed to ensure that students are adequately trained. Finding 3-2: A broad spectrum of professional responders is neces- sary to meet psychological needs effectively. Those outside the mental health professions, who may regularly interface with the public, can con- tribute substantially to community healing. These professionals include, but are not limited to, primary care providers, teachers and other school officials, workplace officials, government officials, public safety workers, and faith-based and other community leaders. However, these profession- als will require knowledge and training in order to provide effective sup- port. Basic knowledge of psychological reactions, as well as training in support techniques and recognizing serious symptoms that necessitate referral, should be provided. Recommendation 3-2: Academic centers and professional associa- tions and organizations, in collaboration with HHS, including SAMHSA, NIH, and CDC, should ensure the education and train- ing of relevant professionals in health fields, including primary care providers, school-based health care providers, public health offi- cials, and the public safety sector, in the psychological conse- quences of terrorism. (Chapter 3, page 82; Chapter 4, pages 114-115~. Training should include identifying psychological consequences of terrorism and evidence-based psychological interventions, and risk com- . . mumcahon. Recommendation 3-3: SAMHSA, in collaboration with academic centers and state and local health care agencies, should ensure the provision of education and training in the psychological conse-

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CONCLUSIONS AND RECOMMENDATIONS 139 quences of terrorism for a range of relevant community leaders and ancillary providers. (Chapter 4, page 115) Training should include identifying psychological consequences of terrorism and evidenced-based psychological interventions. In addition to training, creative opportunities exist for public, private, and academic linkages. Innovative methods should be developed for a wide variety of departments and organizations (for example, communications, public health, public administration, law, business, schools of education) to con- tribute their expertise in service of preparing for and responding to the psychological consequences of terrorism. Workplace Preparedness Finding 3-3: The workplace is a newly recognized and important en- vironment in which to address public health planning for the psycho- logical consequences of terrorism. Some examples of new occupationally exposed groups include construction workers, postal workers, utility workers, public health workers, and children and teachers in schools. Implementation of universal preparedness is required for the workplace, but specific considerations will be needed for critical occupational sites. Recent terrorism events have created new workplaces and categories of responders and have exposed traditional first responders to new levels of job-related stress and risk exposure. Recommendation 3-4: The National Institute of Occupational Safety and Health (NIOSH) and the Department of Labor should collabo- rate to ensure the existence of appropriate guidelines to protect workers by incorporating the psychological aspects of preparedness into all planning and interventions. Because schools are a work- place for staff and students, the Department of Education should collaborate with state and local education systems to ensure pre- paredness. (Chapter 3, page 81~. Implementation of this recommendation will require collaboration with critical public and private business organizations to ensure training, dissemination, and implementation. The Department of labor and NIOSH should examine current plans for traditional first responders and ensure that guidelines are devel- oped for other responders. Agricultural terrorism has the ability to affect many workplaces, including American farms and the food production and distribution sys- tem at the federal, state, and local levels. The committee recommends that HHS, the Food and Drug Administration (FDA), and the U.S. Department

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140 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM of Agriculture (USDA), in collaboration with state and local departments of health, ensure that psychological consequences are considered in pre- paredness and response plans. Because schools are a workplace for both staff and students, the committee recommends that the Department of Education in collabora- tion with state and local education systems ensure that universal pre- paredness is required in schools to address planning for psychological consequences of terrorism for students and teachers. Research Needs Finding 3-4: Research following terrorism events presents a multi- tude of practical and ethical challenges. Utilizing findings from research on other traumatized populations is not an adequate substitute, and sup- port of disaster-specific and terrorism-specific research is necessary to provide information pertinent to the population and its needs for inter- vention. This research can be facilitated by improving cooperation and coordination among federal funding and regulatory agencies as well as by developing the high-quality methodology necessary for the conduct of these investigations. Recommendation 3-5: Federal agencies such as CDC, NIH, SAMHSA, and NIOSH should coordinate research agendas, coop- erate in establishing funding mechanisms, and award timely and sufficient funding of research on best practices to inform and guide interventions that will address the psychological consequences of terrorism. (Chapter 2, pages 61-62; Chapter 3, page 96~. These federal research agencies should develop an integrated and coordinated research agenda directly addressing psychological conse- quences of terrorism across the pre-event, event, and post-event phases to ensure the development of individual, population, community, and clini- cally based interventions. All areas of importance should be studied and duplication of research avoided. Topics of study may include, but are not limited to, the characteristics of terrorism that may differentiate its impact from other disasters; impact of terrorism on functional indicators such as marital and family relationships and school performance, understanding varied effect of terrorism events, and the impact of media accounts of terrorism events on psychological consequences. Whenever federal funding agencies such as the Health Resources and Services Administration (HRSA), CDC, NIH, and SAMHSA provide grants for the implementation of new interventions, a portion of that fund- ing should be mandated for evaluating those interventions. Research on the psychological consequences of terrorism should

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CONCLUSIONS AND RECOMMENDATIONS 141 not only assess psychiatric disease in the affected population but also ad- dress restoring family, social, school, occupational, community, and indi- vidual functioning and building individual and community resilience. Institutional review boards should be encouraged to review re- search proposals on the psychological consequences of terrorism, cogni- zant of the short turnaround time required for obtaining early postdisaster data and the unique difficulties and challenges of disaster research. HHS should initiate a review of institutional review board procedures in order to establish rapid review procedures for proposals addressing the psy- chological consequences of terrorism. Research funding organizations should develop more timely mechanisms for consideration and review of research proposals as well as mechanisms for funding needed large awards in a short time. Research should be developed to evaluate the sources and mecha- nisms of lack of coordination among agencies at all levels. Strategies for effective coordination and communications should be identified and re- sulting effects on response capabilities during crisis evaluated. Ensuring Preparedness Through a Comprehensive Public Health Strategy Finding 4: Management of the psychological consequences of terror- ism (and similar community events) is a pressing public health issue. Psy- chological interventions are needed for the pre-event, event, and post- event phases of terrorist attacks. Such interventions are necessary to address potentially affected individuals and populations, the injurious agents, and the physical and social environment, as identified in the committee's example public health strategy. The nation's present mental health system is an essential, but inadequate, resource to meet all the ex- pected needs. Recommendation 4-1: HHS and the Department of Homeland Secu- rity should analyze federal, state, and local preparedness for terror- ism to ensure that the nation's public health infrastructure is pre- pared to adequately respond to the psychological consequences across a continuum of possible terrorism events, including weap- ons of mass destruction. The committee's example public health strategy should serve as a base from which components of the infra- structure are evaluated. (Chapter 4) Organizing pre-event, event, and post-event interventions to protect, minimize effects, and respond to consequences will require the joint ef- forts of the mental health, public health, medical care, and emergency response systems in the United States. Using the example public health

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142 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM strategy provided by the committee will permit the evaluation necessary to define preparedness gaps and ensure that the appropriate infrastruc- ture is available for response. Recommendation 4-2: Federal, state, and local disaster planners must address psychological consequences in their planning and pre- paredness and their response to pre-event, event, and post-event phases of terrorist attacks. Consideration should be given to needs associated with different types of events and to needs of various segments of the population. Adequate federal, state, and local prioritization and funding of resources and support should be pro- vided to ensure psychological preparedness and response. (Chapter 3, Chapter 4) All health, safety, and security planning by the Department of Homeland Security should include mental health preparedness and re- sponse to mitigate and prevent negative psychological consequences. The groups and organizations that should be involved in plan- ning to ensure a comprehensive response include, but are not limited to, the following: The American Red Cross, the Department of Veterans Af- fairs, the Department of Defense (including the National Guard and Re- serve), the Department of Education, state emergency management plan- ners, mental health practitioners, workplaces (workplace health programs), schools (including school health programs), faith-based com- munities, and primary care practitioners. Local capability should be developed to verify credentials and professionally screen and schedule volunteers who may offer services af- ter a terrorism event. Liaisons should be made with other local agencies, such as police, to help efficiently mobilize volunteers. HHS, including the Surgeon General's Office, should collaborate with the National Organization of Broadcasters and national and local media in the development of a code of conduct for broadcasting and re- porting on terrorism events that enhances the dissemination of official messages, improves access to essential societal information, and respects the principles of the freedom of expression.. These enhanced relationships and enhanced means of communication may help to minimize hoaxes and copycat events and the development of negative psychological conse- quences, as well as facilitate effective responses.