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4 Developing Strategies for Minimizing the Psychological Consequences of Terrorism Through Prevention, Intervention, and Health Promotion The preceding chapter reviewed priority needs for preparing for and responding to the psychological consequences of terrorism and the practical challenges in response, and identified gaps in the infra- structure. Interventions are required to ensure that these priority needs are met and gaps are covered. However, as discussed in the literature review in Chapter 2, scientific investigation of interventions to minimize and prevent the psychological consequences of terrorism is in its infancy. Although little is known about the short- and long-term psychologi- cal consequences of terrorism, some information can be gleaned from lit- erature examining the psychological consequences of other traumatic events, such as being a victim of interpersonal violence or of natural and other human-caused disasters. However, some caution is required in mak- ing conclusions about terrorism based on these other events. Many ele- ments of terrorism are very distinct from other forms of trauma. The most obvious and salient is the element of intent the purpose of terrorism is widespread infliction of psychological pain. The type of agent a threat or purposeful act of violence with conventional, chemical, biological, ra- diological, or nuclear weapons can make terrorism particularly devas- tating. The continued and looming threat of acts of terrorism can prolong the sense of fear and vulnerability. In addition to nature of the event itself, the characteristics of the affected population will dictate prevention and response efforts. The U.S. population is socially, economically, culturally, ethnically, linguistically, and geographically diverse, with a range of life experiences and levels of predisposition to psychological trauma. Com- bined with varying levels of exposure to a terrorism event, there will be a 99

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100 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM multitude of risk factors and psychological consequences that will require a range of interventions. While everyone is vulnerable in some way to these consequences, some subpopulations may be at greater risk. Age, degree of exposure (e.g., first responders, those located at the target of the attack), history of trauma (e.g., refugees, victims of crime or torture, those living in violent neighborhoods), or psychiatric illness will likely affect prevention and intervention needs. Most research studies investigating terrorism and other disaster events provide little in the way of evidence-based prevention and inter- vention strategies for addressing psychological needs regarding terror- ism events. However, the limits of terrorism data should not prohibit ac- tion. This chapter uses the adapted Haddon Matrix to discuss key issues that should be addressed in the event of a terrorist attack, options for systemic strategies, interventions to limit adverse psychological conse- quences of terrorism, and suggestions for ways to optimize the response to the public's health. Many of these strategies correspond to the ten func- tions listed as necessary for an adequately prepared infrastructure and also address the five areas identified as gaps in the preceding chapter (coordination of agencies and services, training and supervision, public communication and dissemination of information, financing, and knowl- edge- and evidence-based services). The interventions discussed in this chapter are based on what is known about responses to disasters, the small but growing evidence about consequences of terrorism events, and rea- sonable assumptions regarding ways to promote and protect the public's mental health. Discussion points include efforts in prevention; promotion of mental health; and interventions such as screening and assessing needs, treatment, dissemination of information, and training of service provid- ers. Potential interventions to minimize or prevent psychological conse- quences of terrorism are identified in this chapter. It is noted that many of these proposed strategies lack evidence of efficacy but represent the present consensus of experts. A substantial need is to evaluate the efficacy of each of these interventions. Attention to this need, identified in Chapter 3 as one of the significant gaps in the current infrastructure, will help address the critical problems in the nation's ability to plan for and effectively re- spond to terrorism. APPLICATION OF THE HADDON MATRIX The adaptation of the Haddon Matrix to the psychological conse- quences of terrorism offers a useful way to organize and categorize components of the mental health, public health, medical, and emergency response systems for prevention and intervention. The matrix provides a means to categorize known and hypothesized interventions. Community-

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 101 TABLE 4-1 Model for Organizing Responses to Terrorism Within Various Phases and Factors Involved in the Events Phases Factors Affected Individuals and Populations Terrorist and ~ Injurious Agent Physical and Social Environment Pre-Event Event Post-Event End Results and population-based strategies are crucial for the success of these efforts to ensure the public's psychological health prior to and following terrorist attacks. The process presented here may also have value beyond terror- ism events to include violent and traumatic events that occur with great frequency in our society. Employing strategies for these incidents may also render the nation better able to respond to terrorism. As developed in Chapter 1, the basic model for examining psychological responses is shown in Table 4-1. The expanded model in Table 4-2 adds an additional dimension within each cell to reflect interventions at the biological-physical, psycho- logical, and sociocultural levels. The table offers an example of a public health plan to assist in preparation for and response to the psychological consequences of a terrorism event utilizing phases and factors adapted from the Haddon Matrix. As discussed in Chapter 1, the model's pre- event, event, and post-event also correspond to the Department of Home- land Security's emergency management program of preparedness, miti- gation, response, and recovery. Factors related to the terrorist and injurious agent are not addressed here. The intent of illustrating these factors in the table is to present an example of the full array of factors that warrant the joint attention of all systems responsible for the health and safety of the public. The committee presents this more comprehensive strategy to illustrate the critical point that psychological consequences must receive comparable attention to other consequences in responses to terrorism. The reader is referred to Terrorism: Perspectives from the Behavioral and Social Sciences (NRC, 2002c) and Discouraging Terrorism: Some Implications of 9/11 (NRC, 2002a) for a

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106 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM discussion of the nature and determinants of terrorism and what terror- ists hold in value. The remainder of this chapter focuses attention on interventions tar- geting biological-physical, psychological, and sociocultural factors at the level of (1) affected individuals and populations and (2) the physical and social environment at each of three phases: pre-event, event, and post- event. Interventions directed at the physical-biological effects of terror- ism are discussed in greater detail in Biological Threats and Terrorism: As- sessing the Science and Response Capabilities (IOM, 2002a); Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response (TOM-NRC, 1999~; and Making the Nation Safer: The Role of Science and Technology in Countering Terrorism (NRC, 2002b). PRE-EVENT PHASE Many of the infrastructure functions discussed in Chapter 3 will be initiated during the pre-event (or preparedness and risk mitigation) phase of an event. Adequate preparation and mitigation of risk will be crucial to help decrease the physical, psychological, social, and economic disrup- tions caused by terrorism events. Functions involved during this phase include the provision of resources to ensure safety (function 1), skills and interventions to promote community resilience (function 2), education and materials for public, media, and service providers (function 7), locating individuals/groups of special interest who may require assistance (func- tion 10), communication of information to the public (function 7), training of service providers (function 8), and beginning surveillance of health and psychological consequences (function 3~. By initiating these actions dur- ing this phase, the capacity of the infrastructure to adequately handle ser- vice demands (function 9) can be strengthened. Affected Individuals and Populations Biological-Physical Attending to the physical health and safety of the public is identified as a necessary function for the infrastructure to provide. These activities may reduce psychological casualties by increasing the public's confidence and sense of mastery and reducing fear through communicating convinc- ingly to the public that the community is ready in the event of a bioterrorism event. Vaccinations, antibiotics, antidotes, and other supplies should be stockpiled. Training is needed for emergency, medical, and public health professionals in the spectrum of medical and mental health skills necessary to respond to incidents. Both of these activities will help

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 107 to reduce psychological consequences through reduction of injuries that contribute to psychological casualties. Pre-event biological-physical ac- tivities also include surveillance of population health and mental health to establish baseline prevalence rates for identifying physical and mental vulnerabilities and for comparison with post-event findings. Information and training on implementing effective disaster behav- iors should be provided to the public in the pre-event phase. These in- clude early recognition of an attack, knowledge related to survival and basic sustenance (evacuation, safety, knowledge of gas mask use, how to obtain antibiotics, shelter, food, environmental assessment), help-seeking indications (when to go for help or wait) and directions (public health, emergency medicine, medical care systems), effective evacuation strate- gies, and victim rescue procedures. This information will further increase the confidence of in the population by enhancing individual perceptions of self-efficacy and mastery. Psychological Integration of Psychological and Mental Health into Public Health Plan- ning. The psychological consequences of terrorism are an important de- terminant of the continuity of society, economic resiliency, health care uti- lization, and perception of threat and safety. To address the prevention, health care, and promotion needs related to psychological consequences of terrorism, this area must be integrated into national, state, and local planning. This will help ensure that the infrastructure is better able to meet needs and that gaps will be minimized. At the federal level, research support, education of health care providers, and development of model intervention plans can aid state and local planning. In order to improve responses for psychological consequences, a central focus of the new na- tional response plan should be the coordination of efforts across the Cen- ters for Disease Control and Prevention (CDC), National Institute of Men- tal Health (NIMH), and the Substance Abuse and Mental Health Services Administration (SAMHSA) to comprehensively address needs for re- sponse, research, and health care provision. This type of coordination of efforts across these and other agencies and with state and local services will help to address the gaps in coordination of agencies and services dis- cussed in the previous chapter. In order to begin integrating mental health principles and needs into the broader public health consciousness with regard to terrorism preparedness and response, these principles must be part of public health disaster plans. Design and Implement Psychological First Aid Training. The nation's infrastructure should provide interventions and programs to promote in-

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108 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM dividual and community resilience and prevent adverse psychological ef- fects. Psychological first aid is a group of skills identified to limit distress and negative health behaviors (e.g., smoking) that can increase fear, arousal, and subsequent health care utilization. Every culture and com- munity has its own ways of coping with stressful events and managing reactions to difficult moments in life. In the past decade, there has been a growing movement in the world to develop a concept similar to physical first aid for coping with stressful and traumatic events in life. This strat- egy has been known by a number of names but is most commonly re- ferred to as psychological first aid (PFA). Essentially, PFA provides indi- viduals with skills they can use in responding to psychological consequences of terrorism in their own lives, as well as in the lives of their family, friends, and neighbors. As a community program, it can provide a well-organized community task to increase skills, knowledge, and effec- tiveness in maximizing health and resiliency. The success of PFA lies in its development as a potentially preventive measure of more serious psychological consequences. However, no evi- dence is yet available to assess its efficacy. PFA can be used to deal with the daily stresses of life (e.g., family strife, job stress, the academic and interpersonal challenges faced by schoolchildren). It is in these develop- ments that the skills are tested, practiced, refined, and generally main- tained as an active part of daily life. In this way, PFA may provide daily benefit, whether there are terrorism events or not. The development and implementation of PFA as a national strategy can serve as an intervention to provide possible benefits in dealing with the psychological conse- quences of smaller-scale random acts of violence discussed in Chapter 1 (disgruntled employees shooting and killing coworkers and supervisors, serial killers stalking women or children, racially motivated killings, hate crimes, and murder and violence occurring in most of our major urban areas). PFA generally includes education about normal psychological re- sponses to stressful and traumatic events; skills in active listening; under- standing the importance of maintaining physical health and normal sleep, nutrition, and rest; and understanding when to seek help from profes- sional caregivers (NIMH, 2002~. It is crucial that an evidence base for PFA be developed as well as models for training. As the evidence base is de- veloped, education regarding substance use and abuse issues should also be included. Developmentally appropriate models are needed that be ap- plied to individuals across age levels and racial/ethnic and cultural groups. Prepare Materials for Media and Public Education. During the pre-event phase dissemination of information to the public and media is essential. To prepare effectively for a terrorism event, the population will likely be

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 109 helped by the provision of concrete information about what to expect and what to do. The public should be provided specific plans of action and simple tasks and skills. During the pre-event period, it is important to help members of the public assess the potential risk to themselves and their families and determine what they can do before an event to protect themselves. This preparation will require widespread education with ap- propriate language and cultural considerations. Planning should include assessment of the most effective channels of communication for different segments of the population, such as radio, internet, television, billboards, and newspapers. Education materials should address various terrorist threats including explosives and chemical, biological, radiological, and nuclear (CBRN) events. People should be provided information about devising a family plan for reunification after an event, specifying emer- gency contacts, stocking emergency supplies, and obtaining additional information (e.g., hotline numbers, Web sites, radio and television sta- tions, identification of spokespersons [at the federal, state, and/or local level] who are appointed to communicate information). In the case of a terrorism event involving CBRN, other information should be communi- cated, including clear guidelines on recognition of symptoms of exposure, reduction of the risk of exposure to infectious agents, reduction of the spread of agents, and whom to contact or where to go if exposure is sus- pected or when family reunification is not permitted. Controversial infor- mation should be clarified, such as the value and potential side effects or hazards of vaccinations, use of gas masks, and sealing homes to create "safe rooms." Materials should offer understandable explanations of why a strategy is or is not recommended and educate the population to expect that conflicting answers may be heard while the best solution is being identified. Providing information about ways for people to physically protect themselves is one side of public information. To help prevent fear and limit uncertainty, the public should be made aware of normal psychologi- cal reactions to threats of violence, such as worry, anxiety, and difficulty concentrating, and how preparedness can help limit fear and promote effective coping. Materials should be adapted to local communities, cultures, and eth- nic groups. Resources should address the language needs of various popu- lations and consider variations in living environments. For example, CBRN terrorism precautions should be explained for people who live in apartments and do not have basements or interior rooms without win- dows; people who may need to evacuate but do not own automobiles; and people who are recent immigrants and may not be familiar with com- munity services. The goal of public education materials is to achieve self- efficacy and enhance confidence in society's ability to help protect it.

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124 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM from their homes may be difficult to enforce. Effective communication of the need for isolation and evacuation may facilitate these actions. Recover, Identify, and Bury the Dead. Body recovery, identification, and burial are psychologically important to the bereaved family and friends of the victims. Efficient completion of these activities as soon as possible after the event may allow people to advance the process of grieving and begin to achieve closure. Psychological Continue Psychological First Aid. In the immediate aftermath of a terror- ism event, PEA should be focused on reducing physiological arousal, mobilizing support, and reuniting families. Family reunification may be facilitated by the implementation and announcement of registration and tracking systems for evacuated individuals. Effective risk communication is also part of this effort and is described further below. A CBRN terrorism event will present unique challenges. After such an event, people will be more likely to seek the help and advice of pri- mary care rather than mental health care providers. Health care providers will play an important role in responding to the physical and psychologi- cal needs of people who are exposed and unexposed. Individuals may be concerned about immediate and long-term effects (for example, cancer). Quarantine and isolation may limit family reunification. The inability of people to be with loved ones who may be ill or dying will create signifi- cant psychological distress. People may choose not to bring sick family members to the hospital for fear of separation, which may lead to spread of contamination or contagion. Grief and its resolution may be impeded if traditional funeral and burial rites cannot be performed because of inad- equate decontamination of the body. Physicians and officials may be pre- sented with an ethical challenge when family members desire to remain with exposed individuals, placing themselves and potentially others at substantial risk. Conduct Individual, Group, and Population Assessments to Identify Specific Needs in Response to Event. There are two approaches to the management of psychological consequences of terrorism in populations. These conceptual approaches are important and complementary means to address the issues; they involve consideration of (1) assessment, triage, and interventions on an individual level; and (2) the populations affected and the expected consequences that will have to be addressed. As dis- cussed, one of the most significant gaps in responding to psychological

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 125 consequences of terrorism is the lack of knowledge and evidence base to inform practice and policies. Individual Assessment, Triage, and Treatment. This model of approach- ing the problems of individuals after disasters is illustrated in Figure 4-1. Each individual must initially be screened to identify those at high risk for psychiatric disorders, such as PTSD or other anxiety disorder, depres- sive disorder, or substance-related disorders. The next step is to refer those with a high likelihood of psychiatric illness for more comprehensive evaluation by mental health professionals and refer those screening nega- tive to community-based management. This determination of the pres- ence or absence of psychiatric illness is a pivotal decision point for direct- ing the individual to the most appropriate intervention system. Research on people directly exposed to the Oklahoma City bombing (North et al., 1999) indicated that symptoms of avoidance or numbing (e.g., avoiding thoughts, feelings, and reminders of the event; feeling de- tached) (group C; see Chapter 2 for criteria of PTSD) were very strong indicators of PTSD. Thus, group C symptoms might help identify people at highest risk for mental illness, especially PTSD. This group should be referred for more comprehensive evaluation and management by mental health professionals. It is important to note that even those with no previ- ous psychiatric illness are at risk of PTSD after terrorism events (North, 1999~. Perhaps as many as 40 percent of those diagnosed will have no previous history. Therefore symptoms must be recognized and responded to in these atypical patients, who may require adapted treatments. Also specific psychological treatments for injured and burned individuals are not yet developed but are much needed. As discussed in Chapter 2, disasters affect almost everyone exposed to them in some way. Depending on the severity of the event, most people will likely experience mild to moderate distress responses or behavior changes. A national survey after the September 11, 2001, attacks found that 90 percent of adults reported one or more symptoms of stress (e.g., feeling upset, difficulty concentrating, feeling irritable, trouble sleeping) (Schuster et al., 2001~. Many such responses and behavioral changes can be considered ordinary reactions to extraordinary events. Most people are resilient and will recover without developing psychiatric illness. How- ever, the distress of people without a diagnosable psychiatric disorder should not be minimized. The distress can be managed with community- based interventions including the application of psychological first aid and utilization of basic support and reassurance, stress management and problem solving skills, and linkage to community resources. Previous research clarifying the timing of onset and duration of psy- chiatric disorders and distress after disasters and terrorism suggests the appropriate time frame for responding to mental health needs of indi-

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126 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Screened psychiatrically il Screened distress/ behavior change ILL ~.4 it' :..' Psychiatric disorder diagnosed 4| No psychiatric disorder diagnosed ~;~;;~ I health professionals I Psychological first aid, education, reassurance, support, link to community resources FIGURE 4-1 Model of postdisaster triage, referral, and management based on psychiatric screening and diagnosis. viduals alter disasters and terrorism incidents. After the Oklahoma City bombing, most PTSD emerged quite rapidly. Of those with PTSD who were directly exposed to the bombing, 76 percent developed symptoms the same day, 94 percent developed them within the first week, 98 percent within the first month, and none after six months. All cases proved to be chronic, lasting more than three months. These results suggest that as- sessment and treatment can be initiated quickly and that treatment needs will be longterm. Population-Based Assessment. Within the population, there will be vary- ing degrees of exposure, with a relatively small subset being directly ex- posed, a larger subset being indirectly exposed, and a still larger subset being exposed at a distance (for example, through the media only). Char- acteristics of the affected population and subpopulations are also consid- ered (for example, seriously and persistently mentally ill treatment popu- lation, first responders, media personnel, mental health professionals) as well as characteristics of the disaster agent (for example, conventional weapons versus biological agent, small with few fatalities and injuries versus large, brief versus ongoing). It might be expected that people in the directly exposed group will be more likely to develop psychiatric illness, . . . . . . . independent of a preexisting psychiatric illness because the intensity of the event supersedes the effects of these preexisting characteristics. For those in less exposed groups, PTSD is more likely to result from a pre- existing psychiatric illness. Although individual triage and intervention should not be based on the population to which an individual belongs or the type of disaster that occurred, these characteristics can help predict

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 127 the expected population responses and guide the development of neces- sary systems. Knowing the rate of PTSD in various subpopulations for example, directly, indirectly, and distantly exposed populations of firefighters (who in Oklahoma City had far more alcohol abuse than PTSD) can help determine how much psychiatric intervention and how much other treatment will be needed. This information may help decide the number of psychiatrists, psychologists, social workers, and so forth, to place in clinics where individuals will be triaged versus the need for other services such as substance abuse programs and substance abuse screen- ing, public education, et cetera. Consider Intervention Needs for Groups of Special Interest. During the pre-event phase, groups of special interest and their particular needs are identified. In the post-event phase treatment considerations are made. First Responders. Numerous studies indicate the potential risk of psy- chiatric distress and illness in first responders. Although further study is needed, there is some evidence to suggest that rescue workers may not be at greater risk for developing PTSD and major depression after a terror- ism event than those directly affected (North et al., 2002a; 2002b). Under- standing the base rates of illness in these groups is important in planning appropriate interventions for postterrorism event exposure. A study of firefighters in Oklahoma City indicated that the lifetime prevalence of alcohol use disorders was nearly 50 percent in those surveyed (North et al., 2002b). After the 1995 bombing, diagnoses of alcohol use disorders were made in almost 25 percent of the group and most of these individu- als had a preexisting disorder. These findings suggest that rescue workers with a history of substance-related disorders may be at increased risk of relapse in the aftermath of a terrorism event and should be targeted for immediate assessment and intervention. The prevalence of alcohol use disorders in the population underscores the need for addressing these issues before a disaster occurs. Providers of Health and Mental Health Services. During this phase of the event, mental health workers' knowledge of federal, state, and local gov- ernment agency operations; the Stafford Disaster Relief and Emergency Assistance Act of 1988; and networks of Voluntary Organizations Active in Disaster (VOAD) is particularly important (Jacobs and Kulkarni, 1999~. This knowledge will help disaster workers negotiate complex systems and provide more effective and coordinated care. Disaster and trauma work will inevitably affect those health and men- tal health care professionals who provide care to individuals experienc- ing the psychological consequences of terrorism. The work can affect a provider's view of him or herself, family relationships, and friendships. While clinicians should always be aware of when they need to remove

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128 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM themselves from direct provision of services or supervisory activities in order to obtain self-care, this may be particularly important after terror- ism events. Minority, Immigrant, and Refugee Populations. As discussed above, mi- nority, immigrant, and refugee populations may be at higher risk for nega- tive psychological consequences based on prior experiences of traumatic events and language or cultural needs that are different from the majority of the population toward which intervention strategies are targeted. Rural populations. Residents of the rural and frontier areas of the United States will, of course, vary in their psychological responses to ter- rorist acts based upon the specifics of the incident, exposure, and indi- vidual differences. In the event of agricultural terrorism, rural popula- tions may be particularly in need of assistance. Some general issues pertaining to rural and frontier responses are noted here (personal com- munication, Randal P. Quevillon, Department of Psychology, University of South Dakota, April 29, 2003~. Many rural areas have been under chronic economic pressures and the ongoing stress of these circumstances has taken a toll on the resilience of many rural dwellers. The quality of sharing and working together that is often a strength for rural dwellers responding to life's exigencies may not necessarily extend to mental health concerns and psychological reactions. In part because of the high stigma associated with psychological problems and symptoms, rural dwellers did not, during the farm crisis of the 1980s, tend to seek formal assistance nor did they share concerns with neighbors and exchange social support in mental health areas. This relative isolation when dealing with psychologi- cal concerns may take place in the future in psychological responses to terrorism. Despite the higher interconnectedness of rural social networks as compared to urban counterparts, psychological reactions and stress symptoms that would follow a terrorist attack might be faced in isolation or on family units. In addition, rural dwellers may be skeptical of federal programs and communications. This may lead to relatively high distrust levels in re- sponse to official communications about terrorist attacks and particularly descriptions of weapons of mass destruction events and recommended responses. Individuals in rural areas tend to do more of their routine busi- ness with people they know and are used to a "relationship basis" for transactions. Communications and assistance efforts in rural areas will be more effective if they make use of the networks and systems already in place and if they utilize indigenous persons wherever possible. Because most rural area are seriously underserved by both medical and mental health professionals, external resources must be brought in to bolster lo- cal efforts to respond to terrorist acts. However, since local professionals know their communities and have built trust and credibility as well as a

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 129 track record of working together with other agencies/professionals, they need to have a central place in planning and execution of response efforts and in providing context to others coming to the area to provide assis- tance. Children in Schools. There is national support for the belief that schools are a natural place to support children (IOM, 1997; Weist, 1997~. The RAND surveys conducted after September 11,2001 (Stein, 2002) indicated that schools play an important role after terrorism, providing education programs on history of conflicts and comparative religions, counseling for children, and mental health and safety information to parents. Delivering mental health services through the school system to ad- dress psychological needs and consequences requires multidisciplinary coordination of training and action plans to place sufficient skills and re- sources in the schools where they are needed. Work to ameliorate the negative effects of terrorism on children actually begins by ensuring that teachers, parents, principals, and other school adult caretakers address their own traumatic experiences. Disrupted home and school environ- ments; personal, financial, and property losses; changes in spousal, fam- ily, and work relationships; illness; and debilitating injury are adult fac- tors that mitigate against the social and emotional support available to vulnerable children. Evidence-based treatments for terror-related psychiatric disorders have yet to be determined. However, the literature indicates that cogni- tive behavioral therapy (CBT) is recommended for the treatment of youth PTSD (Cohen, 1998) and depression (Brent et al., 1997; Kaslow and Thompson, 1998; Lewinsohn et al., l990~. Such therapies have been shown to be effective for children with a history of sexual abuse (Deblinger and Heflin, 1996; King et al., 2000) and single-incident trauma (March et al., 1998~. In addition to child-focused trauma treatment, education for par- ents about their child's PTSD symptoms has also been recommended (Rigamer, 1986) and incorporated into a school-based mental health inter- vention project for traumatized Latino students exposed to life-threaten- ing violence (Kataoka et al., 2003~. In the immediate aftermath of trauma, psychological first aid has been widely utilized to calm the emotional dis- tress of children, decrease the sense of emotional isolation, and focus on building coping responses. School-based interventions with adolescents in Bosnia-Herzogovina utilized a public health model that provided gen- eral psychosocial support to the general population of students, offered specialized support to students at high risk of distress and disturbance, and established a professional network for consultation and referral (Saltzman et al., 2003~. Employees in the Workplace. The informal components of a workplace response vary greatly among organizations and individuals, but there are

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130 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM some key elements that can take place in any size workplace and are es- sential to promoting recovery from a trauma. The initial response on the part of an employer to a terrorist attack should be to assess the threat and attempt to eliminate any immediate danger. Psychological interventions can begin at this stage through the use of accurate and honest risk com- munication about level of risk and ways to avoid it. The absence of this practice by leaders of the organization may erode trust, which may be difficult to rebuild. Similarly, leaders and managers take on an important role in psychological recovery after a terrorist attack. They often are looked to by employees as examples of appropriate responses to model, and they can help create a sense of normalcy throughout the organization. Leaders and managers should understand that some people will need additional help in order to cope and should acknowledge differences in responses (Bushnell, 2002~. Furthermore, they should be able to recognize that work-related symptoms such as absenteeism and decreases in pro- ductivity may indicate problems with coping. Leaders and managers should know how and to whom to refer their employees. Employee assistance programs, unions, medical departments, human resource departments, and health insurance companies should all be in- volved in an integrated response. Outreach to medium and small busi- nesses is critical, especially with services in the post-event environment. Groups such as the Employee Assistance Professionals Association, Ro- tary, and Business Councils should be involved as partners in efforts to address psychological consequences. The unique elements of some workplace settings are important con- siderations when designing workplace systems for response. Some em- ployees will be concerned that seeking treatment will affect the percep- tions or opinions of supervisors. This issue is especially salient when treatment with medication is involved. This type of intervention may indicate that an employee is not fit for duty, which may limit the poten- tial for law enforcement officers, members of the military, and airline pilots to even initially address their personal concerns (National Partner- ship for Workplace Mental Health, 2002~. Some workplace environments have a culture that is not conducive to seeking help for psychological issues. Seeking help or publicly sharing fears may be seen as a weakness. Alternative strategies may be necessary in such cases. An easily acces- sible anonymous service outside the workplace may be preferable to en- sure confidentiality, and initiatives such as group debriefings may be less useful. Sociocultural Communicate That Preparedness Helped Decrease Impact of the Attack. In the post-event phase, officials should communicate how pre-

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 131 paredness helped to decrease the psychological impact of the attack and continue to publicize available services to the public in general and pro- vide targeted messages to specialized segments of the population who may be at greater risk for adverse consequences. Steps should be under- taken to review actions taken before and during the event to assess how efficacious they were and what changes are indicated. Similar steps should be undertaken to review interactions between spokespersons and the media and public. Surveys may be conducted to assess the public's understanding and perceptions of the events and of risk communication strategies. Publicize Availability of Services Targeted to Appropriate Segments of the Population. In addition to the implementation of PEA, additional or targeted services may have to be provided to special populations, as dis- cussed above. The availability of these services should be widely publi- cized to the appropriate populations. Produce Public Information and Warnings. The broadcast of public in- formation and warnings will help ensure that the public has the informa- tion needed to protect itself in the event of further threats. Potential psy- chological consequences can be relayed via media messages with instructions regarding normative reactions and when people should seek help, from whom, and contact information. Promote Family and Community Cohesion and Support. In addition to the prevention and mitigation of psychological consequences, mental health promotion is a concept not to be overlooked. Mental health promo- tion has been defined as the enhancement of the capacity of individuals, families, groups, or communities to strengthen or support positive emo- tional, cognitive, and related experiences (Hodgson et al., 1996~. As dis- cussed in Chapter 2, disaster events can produce positive consequences and closer ties with others. Some research has indicated that 35 to 95 per- cent of survivors of disasters report gaining something positive from their experience (McMillen, 1999; McMillen et al., 1997~. Resilience, or positive outcome in the face of adversity, should be actively promoted after a ter- rorist attack to facilitate healing. Based on empirical data from literature on psychosocial resources following natural and human-caused disasters, several conclusions regarding implications for interventions have been reached (Norris et al., 2002a). Nuclear and extended families, as the basic units comprising communities, can serve as prime targets for response efforts and promoting resilience. Parents and other adults can support one another and serve as models for positive adaptation and coping for children. Communities should provide forums for collective grieving to express unity and collective action, social activities for new communities

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132 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM that form because of displacement, group meetings to foster discussion of ways to rebuild communities, and outreach to those who may feel iso- lated in order to foster inclusiveness. Keeping in mind cultural, ethnic, and worldview sensitivity, families should be encouraged to talk about experiences, resume normal activities as much as possible, and negotiate conflict effectively to minimize negative interactions that are caused by the stress and strain of a traumatic event. Because the majority of people will not require individual treatment from mental health professionals, the goal of these strategies is to help bolster communities and give mem- bers the resources to help one another. As noted in the discussion of gaps in Chapter 3, evidence-based models for community recovery and resil- ience building are lacking. Leaders in the faith-based community have a critical role in promot- ing healing after an event. A national survey conducted after the attacks on September 11, 2001, indicated that nearly 60 percent of respondents reported they were likely or very likely to seek support from a spiritual care provider, 43 percent reported they were likely or very likely to go to their physician, and 40 percent indicated they were likely or very likely to seek help from a mental health provider (Roberts, 2002 as cited by Murray, 2002~. Turning to spirituality can help people find comfort and under- standing in the aftermath of traumatic events. Leaders in this community will minister to congregations, towns, and cities as they advance through the grieving process. Level of the Physical and Social Environment Biological-Physical Evaluate Effectiveness of Emergency Plan and Disaster Response. An evaluation of the effectiveness of emergency plans should be carried out as an integral part of post-event response. This may help to improve emer- gency planning for possible future events. Findings from such evalua- tions should be shared with the community since openness throughout this process will assure people that diligent efforts were made to respond. It may also help to minimize the distrust that may arise when there is a perception that authorities are trying to cover up an inadequate response. Mitigate Ongoing Health Risk and Secure Physical Environment. Liv- ing in an environment where there is ongoing contamination of the air, water, or food supply, or where people do not feel safe, may constitute a stressful experience for many people. Mitigating ongoing health risks re- assures the population that the authorities are working to reduce the dan- ger and will contribute to the restoration of a more normal and safe envi-

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MINIMIZING THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM 133 ronment. This might be accomplished, for example, by cleaning up haz- ardous sites or by encouraging people to take appropriate precautions to avoid harmful health effects (e.g., keeping windows closed to minimize the amount of dust and debris present in indoor air). Attention to secur- ing physical safety and infrastructures (inspection of food and water sup- plies; restoring sanitation and communication facilities and transporta- tion services) will improve the public safety and facilitate return to usual life. Attention to safety, including fire control, and security of disaster sites will further reduce physical and psychological casualties. Monitor Ongoing Threats. Ongoing threats should be monitored, pro- viding further reassurance to the population. Advancements in monitor- ing that are based on current event evaluation should be emphasized. Psychological Limit Secondary Exposure. Although the evidence linking media expo- sure to traumatic events and psychological consequences is correlational, the public may benefit from very limited viewing of repeated depictions of the violence associated with terrorism events. Adjust Risk Communication, Emphasizing the Positive. Risk communi- cation during the post-event phase should focus on communicating to the public that response and management measures helped to minimize the impact of the attack. This information should be used in future pre-event planning and communication. Sociocultural Establish Strategies for Community Healing. The planning of memori- als, services, and anniversaries may help communities express their grief, unite, and heal. Devising a public mental health strategy may also assist communities, groups (workplace and schools), as well as families and in- dividuals to cope with trauma reminders. In addition, informal supports may offer significant help in promoting healing. Resources provided by family, friends, support-group, and other network ties may serve as a powerful asset in promoting effective coping. DESIRED END RESULTS The purpose of an integrated approach to responding to and prepar- ing for terrorism events is the prevention and mitigation of adverse psy- chological consequences. These consequences include the three domains

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134 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM discussed throughout this report: distress responses, negative behavioral changes, and psychiatric illness. The goal of comprehensive preparedness and response is to limit decreased productivity and performance of work- ers and to reduce physical injury, both of which are linked to psychologi- cal injury. In addition, preparation for terrorism events and effective population responses to these events may be used as an opportunity for growth and empowerment characteristics that individuals will hope- fully carry with them beyond the acute phase of the event. Finally, the broader societal goal, beyond the objectives for individual citizens, is to minimize disruption to the daily routines of life and promote community cohesion, the very things that terrorists seek to destroy. APPLICATION OF THE EXAMPLE PUBLIC HEALTH STRATEGY As discussed at the beginning of this chapter, psychological conse- quences and the specific prevention and response strategies will be de- pendent on a host of factors including the type of threat or event (conven- tional explosives, CBRN), nature of the event (for example, single-site versus multisite, continuous or repeated versus single event), degree of exposure, and particular population or subpopulations involved. Various features of an event or threat will carry different risks for psychological consequences and these risks will vary for susceptible populations. In ad- dition, hoaxes and false alarms may carry alternate dimensions of risk. The example public health strategy is offered to organize and catego- rize known and hypothesized interventions. It is proposed to serve as a basic plan from which more detailed and tailored plans may be derived to fit the variety and complexity of terrorism events that may arise. Meth- ods to achieve these elements and strategies for coordinating systems will need to be tested and evaluated. It is hoped that the committee's plan will stimulate further development and investigation of elements that will provide the necessary framework for effective planning and re- sponse in order to protect the public's health during the nation's ongoing war on terrorism. Finding 4. Management of the psychological consequences of ter- rorism (and similar community events) is a pressing public health issue. Psychological 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 popu- lations, the injurious agents, and the physical and social environ- ment, as identified in the committee's example public health strat- egy. The nation's present mental health system is an essential, but inadequate, resource to meet all the expected needs.