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A Data Sources and Methods ' n order to respond to the study charge, several steps were undertaken to review the psychological consequences of terrorism, identify gaps ~ in preparedness and response, and provide options to optimize the public health response. Sources of data and information included the as- sembly of a committee with appropriate knowledge and expertise; input from consultants; review of the trauma, disaster, and terrorism literature; and hosting of a public workshop. STUDY COMMITTEE A seven-member study committee was convened to assess available data and respond to the study charge. The committee was comprised of members with expertise in disaster psychology, psychiatry, social work, public health, and emergency medicine. The committee convened for three two-day meetings on October 7-8, 2002, December 4-5, 2002, and February 24-25, 2003. CONSULTANTS Two consultants with expertise in mental health and public health provided voluntary service to the committee. They assisted in conceptu- alizing the framework for the integration of mental health and public health in responses to psychological consequences of terrorism. 155

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156 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM LITERATURE REVIEW The study committee was not charged with conducting an extensive review of the psychological sequelae of terrorism. Rather, the committee's focus was on providing options for response. Therefore, the literature re- view was limited to a brief examination of general trauma and disaster mental health studies and to recent and relevant data on psychological consequences of and responses to terrorism. The focus was on peer-re- viewed studies that assessed psychological reactions and symptoms fol- lowing a variety of traumatic events. PUBLIC WORKSHOP As part of the study charge, as outlined in Chapter 1, the study com- mittee hosted a one-day public workshop at its October meeting in order to assess the immediate and long-term consequences of terrorism; the needs of vulnerable populations; the current federal, state, local govern- ment, and private systems in place to respond to psychological conse- quences of terrorism; and the capacity of the current infrastructure to meet mental health needs. The agenda from the workshop is presented on the following pages. After opening remarks by Vice Admiral Richard Carmona, M.D., Sur- geon General; sponsor representatives; Ms. Susanne Stoiber, Institute of Medicine (IOM), Dr. Richard Nakamura, National Institute of Mental Health (NIMH); and Ms. Gail Hutchings, Substance Abuse and Mental Health Services Administration (SAMHSA); the first panel presented vari- ous aspects of the psychological consequences of terrorism. Dr. Roxane Cohen Silver addressed the psychological responses to traumatic events (including mental health and substance use), the impact of trauma for both short- and long-term functioning, and the similarities and differences between the consequences of terrorism and other types of trauma. Dr. Robert DeMartino discussed implications of terrorism in the United States for the population's mental health (including substance use); the differ- ences in psychological consequences for mass disaster events, perceived- threat events, and bioterrorism; and the implications of these differences for program coordination, evaluation, and outcomes assessment. Dr. Audrey Burnam provided a review of the mental health consequences of the attacks on September 11, 2001, including the impact on those affected directly and indirectly, implications for vulnerable populations (e.g., chil- dren, emergency responders, ethnic minority or immigrant populations), and the capacity of the infrastructure to meet mental health needs. After these presentations, two respondents, Drs. lames laranson and Elizabeth Todd-Bazemore, engaged in a discussion of considerations for special

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APPENDIX A populations . . niches. The second workshop panel reviewed response plans in place at the federal level, the effectiveness of responses, and ways to address gaps in current systems of response. The speakers addressed issues regarding the coordination and integration of services, training of key service provid- ers, and dissemination of information. Presenters included Mr. Paul Kesner, U.S. Department of Education; Mr. Seth Hassett, SAMHSA; Colo- nel Ann Norwood, Uniformed Services University of the Health Sciences; Dr. Dori Reissman, Centers for Disease Control and Prevention (CDC); Ms. Kathryn McKay Turman, Federal Bureau of Investigation (FBI); and Dr. Alfonso Batres, Department of Veterans Affairs (VA). Speakers on the third panel, Mr. Chip Felton and Dr. Betty Pfefferbaum, addressed state- and local-level responses, the effectiveness of responses, and ways to address gaps in current systems of response including the coordination of services, training of key service providers, and dissemination of information. Respondents Dr. Ruby Brown, Rever- end Deacon Michael Murray, and Dr. Judith Shindul-Rothschild discussed considerations for community- and faith-based approaches and the role of nursing in mental health responses. The fourth panel focused on the variety of ways to address gaps in nongovernmental systems of response and how to best coordinate ser- vices with federal and state efforts, train key health and human services providers, and disseminate information. Venues for intervention and ser- vice agencies discussed included the workplace, primary care, and the American Red Cross. In addition, lessons from international responses to terrorism and issues related to risk communications were addressed. Pre- senters included Ms. Kathleen D'Amato-Smith, Dr. Margaret Pepe, Dr. Margaret Heldring, Dr. Thomas Bornemann, and Dr. Ivan Walks. During the final session of the committee's workshop, committee members reviewed key points from the panels they had moderated. Dr. Monica Schoch-Spana provided an overview and summary of themes from the workshop. The session was then opened to the public for further discussion of gaps in knowledge needed to inform planning and pre- paredness, intervention approaches to limit adverse mental health conse- quences, and options to optimize the public health response. 157 including ethnic minority, refugee, and immigrant commu-

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158 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM PSYCHOLOGICAL CONSEQUENCES OF TERRORISM AND SYSTEMS FOR RESPONSE Workshop hosted by the Committee on Responding to the Psychological Consequences of Terrorism Date: Monday, October 7, 2002 Location: Hubert Humphrey Building, Department of Health and Human Services 200 Independence Avenue, S.W., Room 800 Washington, D.C. 8:30 a.m. WELCOME AND INTRODUCTIONS Lewis R. Goldirank, M.D. Committee Chair OPENING REMARKS VADM Richard Carmona, M.D. Surgeon General United States Public Health Service SPONSOR REMARKS Susanne A. Stoiber IOM Executive Officer Richard Nakamura, Ph.D. Acting Director, National Institute of Mental Health Gail P. Hutchings, M.P.A. Acting Director, Center for Mental Health Services Substance Abuse and Mental Health Services Administration

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APPENDIX A 9:00 a.m. 159 PANEL ON THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Moderator Robert J. Ursano, M.D. Committee Member Speakers Roxane Cohen Silver, Ph.D. Professor, Department of Psychology and Social Behavior University of California, Irvine Robert DeMartino, M.D. Associate Director, Program in Trauma and Terrorism Center for Mental Health Services, U.S. Public Health ~ . service Audrey Burnam, Ph.D. Director, Health Division, Center for Research on Alcohol, Drugs, and Mental Health The RAND Corporation Respondents James Jaranson, M.D., M.A., M.P.H. Medical Director Center for Victims of Torture University of Minnesota Elizabeth Todd-Bazemore, Ph.D. Associate Professor Disaster Mental Health Institute University of South Dakota 10:00 a.m. QUESTIONS FOR PANELISTS 10:15 am BREAK

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160 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 10:30 a.m. PANEL ON INTERVENTIONS FEDERAL LEVEL RESPONSES Moderator Marleen Wong, L.C.S.W. Committee Member Speakers Paul Kesner Program Specialist Safe and Drug Free Schools Program U.S. Department of Education Seth Hassett, M.S.W. Acting Chief, Emergency Services and Disaster Relief Branch Center for Mental Health Services Substance Abuse and Mental Health Services Administration Col. Ann Norwood, M.D. Associate Professor of Psychiatry Uniformed Services University of the Health Sciences Dori B. Reissman, M.D., M.P.H. Senior Medical Officer Bioterrorism Preparedness and Response Program National Center for Infectious Diseases Centers for Disease Control and Prevention Kathryn McKay Turman Program Director Office of Victim Assistance Federal Bureau of Investigations Alfonso R. Batres, Ph.D., M.S.S.W. Chief Officer Readjustment Counseling Services Department of Veterans Affairs

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APPENDIX A 11:30 a.m. QUESTIONS FOR PANELISTS 11:45 p.m. BREAK FOR LUNCH 1:00 p.m. PANEL ON INTERVENTIONS STATE- AND LOCAL-LEVEL RESPONSES Moderator Nancy Wallace, C.S.W. Committee Member Speakers Chip Felton, M.S.W. Associate Commissioner and Director Center for Performance Evaluation and Outcomes Management New York State Office of Mental Health Betty Pfefferbaum, M.D., J.D. Chair and Professor Department of Psychiatry and Behavioral Sciences University of Oklahoma College of Medicine Respondents Ruby E. Brown, Ph.D. Program Manager, Community Resilience Project Arlington County Department of Human Services Reverend Deacon Michael E. Murray, M.A. Director, Interfaith Crisis Chaplaincy Taunton, Massachusetts Judith Shindul-Rothschild, Ph.D., R.N. Director of Psychiatry and Mental Health Boston College School of Nursing 2:00 p.m. 161 QUESTIONS FOR PANELISTS

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162 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 2:15 p.m. 3:15 p.m. 3:30 p.m. 3:45 p.m. PANEL ON INTERVENTIONS OTHER RESPONSES Moderator Gerard A. Jacobs, Ph.D. Committee Member Speakers Kathleen D'Amato-Smith, C.S.W. Former Clinical Coordinator, AVP Merrill Lynch Employee Assistance Program Margaret M. Pepe, ).D., Ph.D. Mental Health Officer American Red Cross Disaster Services Margaret Heldring, Ph.D. Executive Director America's HealthTogether Thomas H. Bornemann, Ed.D., M.S. W. Director, Mental Health Program The Carter Center Ivan C.A.Walks,M.D. Former Chief Health Officer and Director Department of Health, District of Columbia QUESTIONS FOR PANELISTS BREAK DISCUSSION Moderator Lewis R. Goldirank, M.D. Committee Chair

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APPENDIX A Reviewers Robert J. Ursano, M.D. Marleen Wong, L.C.S.W. Nancy Wallace, C.S.W. Gerard A. Jacobs, Ph.D. Monica Schoch-Spana, Ph.D. Center for Civilian Biodefense Johns Hopkins University 4:45 p.m. CLOSING REMARKS Lewis Goldfrank, M.D. 5:00 p.m. ADJOURN 163