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 convincingly 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 to reduce psychological consequences through reduction of injuries that contribute to psychological casualties. Pre-event biological–physical activities 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 behaviors should be provided to the public in the pre-event phase. These include 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 strategies, 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 Planning. The psychological consequences of terrorism are an important determinant of the continuity of society, economic resiliency, health care utilization, 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 national response plan should be the coordination of efforts across the Centers for Disease Control and Prevention (CDC), National Institute of Mental Health (NIMH), and the Substance Abuse and Mental Health Services Administration (SAMHSA) to comprehensively address needs for response, 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 discussed 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 individual and community resilience and prevent adverse psychological effects. 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 community 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 strategy has been known by a number of names but is most commonly referred to as psychological first aid (PFA). Essentially, PFA provides individuals 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 effectiveness 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 evidence 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 developments that the skills are tested, practiced, refined, and generally maintained 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 consequences 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 responses to stressful and traumatic events; skills in active listening; understanding the importance of maintaining physical health and normal sleep, nutrition, and rest; and understanding when to seek help from professional 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 developed, education regarding substance use and abuse issues should also be included. Developmentally appropriate models are needed that be applied 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 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 appropriate 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 emergency contacts, stocking emergency supplies, and obtaining additional information (e.g., hotline numbers, Web sites, radio and television stations, 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 communicated, 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 suspected or when family reunification is not permitted. Controversial information 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 psychological 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 ethnic groups. Resources should address the language needs of various populations 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 windows; people who may need to evacuate but do not own automobiles; and people who are recent immigrants and may not be familiar with community services. The goal of public education materials is to achieve self-efficacy and enhance confidence in society's ability to help protect it.

There is some evidence to suggest that panic in the event of terrorist attack, particularly bioterrorism attacks (which may be more anxiety provoking because these threats are more unfamiliar and undetectable even though they can be very dangerous), is rare and preventable (Glass and Schoch-Spana, 2002). The public has the capacity to adapt and cooperate with officials in responding to threats and disasters. During the pre-event phase, the public should be made to feel that it is an active participant in preparedness, and community organizations that serve diverse populations should be involved in the development and dissemination of information. It is important that the public be educated prior to an attack. The population should be aware not only of what to do to protect individuals and groups, but also of what is being done at federal, state, and local levels to prepare and respond.

In addition to materials for the general public, basic preparedness information should be developed for and provided to the media and professionals who will interface with the community and can help to foster a sense of self-efficacy. The latter include health and mental health professionals, school officials, and workplace administrators or human resource departments. In addition, leaders in the faith-based community and civic organizations should be partners in preparations. Materials that are developed for lay and professional audiences should relay congruent descriptions and preparations (with the understanding that the level of detail and sophistication of information may vary) to avoid publishing contradictory information.

Identify Groups of Special Interest. The ability to identify and locate individuals who have not utilized mental health services but who may need them will be important. Identifying groups of special interest before an event occurs will make these efforts easier to achieve in the post-event phase. Many individuals within these groups may not require specialized mental health services after an event, however, strategies for education and promotion of positive coping and adaptation will be of benefit.

Children. Since compulsory education places school-age children in classes for an average of six hours per day, 180 days per year, schools become essential components of community preparedness, response, and recovery. Should a terrorism event occur during school hours, school personnel serve as de facto emergency response workers, responsible for the food, shelter, and physical and emotional well-being of the children in their care. Safety issues and contingency plans that are addressed prior to a crisis or terrorism event can give reassurance to parents whose children may require site evacuation, quarantine measures, reunion protocols, or sheltering in place for 24 to 72 hours. In addition, schools may be an effective way to provide information to parents about their own safety and well-being as well as that of their children. Safe schools and emergency response plans that are carefully considered, with input from parents and teachers and subsequent communication to students, create the sense that children will be physically and psychologically cared for and that they will not be left alone. The latter two factors are essential to the psychological well-being and recovery of victims of disaster and mass violence.

From an organizational perspective, the U.S. Department of Education Office of Safe and Drug-Free Schools identified two important lessons learned about school response and recovery after the Oklahoma City bombing (U.S. Department of Education, 2002). One involves preparedness and the discovery that not every school is adequately prepared to deal with the full extent of a crisis of any kind; the other, that there are steps a school can take immediately to be better prepared. Regardless of the type of crisis, whether a school shooting or an event such as September 11, 2001, the following steps are important for school personnel to include in developing a school safety plan. Schools should have a comprehensive school safety plan that addresses a wide range of crisis situations.

• Develop plans with input from public and private agencies (for example, local law enforcement, emergency services, public health offices, Red Cross, mental health clinics) and ensure that plans communicate goals and assignments.
• Include a strategy to overcome potential communication difficulties with input from telecommunications experts.
• Conduct practice drills, based on the plan.
• Develop detailed procedures to provide accurate and timely information to students, parents, and faculty.
• Review plans and policies on a regular basis to ensure that they incorporate the latest areas of concerns (for example, terror hoaxes) as well as the latest technology (for example, cell phones).
• Include strategies to address the short- and long-term health and mental health needs of students, faculty, and parents.
• Initiate relationships with local health and mental health providers, and document roles and responsibilities in time of crisis.
• Include a process for screening persons who wish to volunteer during a crisis.
• Designate and train a person or group to act as lead official(s) for response to crisis situations.
• Work with mental health service providers, teachers, and parent groups to establish guidelines for activities that respect the developmental capacity of students to determine the most appropriate actions to take after a traumatic event occurs.

Since the majority of psychological needs of children will be met within the school setting, the educator or caregiver and parents will need support to understand the importance and impact of multilevel school-based mental health approaches and services in preventing, responding, and recovering from terrorism-related trauma.

The challenge will be to develop a strategy to incorporate the psychological needs of students and staff into safe school plans and identify the types of mental health services available to meet the specific needs of students, staff, and communities. The strategy also must include utilizing promising school-based models for readiness, response, and recovery and elements of effective mental health models that help schools prevent and respond to trauma.

Employees in the Workplace. The prime targets for terrorist attacks are often workplace sites. The 1995 Oklahoma City bombing; 1993 and 2001 World Trade Center attacks; 2001 Pentagon attack; and 2001 anthrax attacks that hit news organizations, Capitol Hill, and postal employees are examples. The management of distress in the workplace is important to ensure productivity. Organizations would benefit from incorporating mental health issues into Continuity of Operations or Business Continuity plans. Mental health issues should be an important part of these plans in order help organizations remain operational in the face of personal stress. In addition, consideration of appropriate disaster drills and responses is critical and includes potentially having floor leaders (with backups) to make decisions rather than rely on group process and the presence of alternate alarm systems (no electricity or loss of audio capability can impair many alarms). Preparation for sheltering in place can be extremely important for large organizations, where planning needs may include supplying employee medications, stocking food supplies, and developing policies for handling the many parents who will want to leave the premises to go to their children. Pre-event planning to centralize information sources could include establishing off-site family support centers that would have information from all local hospitals. Planning for a locator system to aid in finding employees and linking them with loved ones can be the most effective early intervention after a terrorist attack. In addition, it may also be important for organizations with employees who travel frequently to developing policies for addressing behaviors that may affect the workplace such as refusal to fly in airplanes or to travel. Leadership training can aid business leaders in understanding the needs related to grief, bereavement, and reconstituting employee groups.

First Responders. The community of traditional first responders, including emergency medical personnel, firefighters, and police, is a unique group with respect to disaster preparations. First responders are exposed routinely to difficult and stressful situations and in the event of terrorism will be directly exposed to the devastation that results from an attack. First responders are expected, as part of their jobs, to take on known and unknown risks. In addition to these first responders, other professionals such as health care providers will be directly exposed to recognized and unidentified hazards, particularly in the case of CBRN terrorism.

An area of difficulty for first responders and other providers may be concern about how their families will manage in a crisis without them or how families will be protected and supported in the event of the responder's injury or death. Responders and providers also will likely have concerns about the safety of their families while they are at the scene of a disaster. This may impact a first responder's ability to perform his or her duties. These issues are similar to those facing members of the armed forces who are deployed and face risk of death or injury. The armed forces provide a number of services to care for families while soldiers are deployed, including family readiness groups, and access to medical care, child care, and other services. The military is continuously challenged to enhance the safety of its forces, provide resources for families, and provide ways for soldiers to communicate with their families, which give comfort to all parties. Leadership in first-responder communities may look to military models to develop and improve the support services (both social and psychological support) necessary to facilitate the efforts of their employees.

Ethnic Minority, Refugee, and Immigrant Populations. In addition to universal preparedness, including the provision of coping skills, building strengths and connections in the community, and distributing education and preparedness materials, minority, refugee, and immigrant populations may require further resources to prepare adequately for a disaster. For example, refugees or recent immigrants may be unfamiliar with or not fully understand community resources or may have fears or concerns based on previous traumatic experiences. A survey of recent immigrant school-aged children in Los Angeles revealed that one-third had clinical symptoms of posttraumatic stress disorder (PTSD) as a result of witnessing or being victims of violence (Jaycox et al., 2002). Following the September 11, 2001, terrorist attacks, a survey of East African immigrants revealed that 50 percent of respondents reported feeling less safe because of their ethnicity or religion, 65 percent had less faith in the government's ability to protect them, and 67 percent worried about their immigration status (Jaranson, 2002). These feelings may affect minority and immigrant community members' responsiveness to prevention and intervention strategies.

Approaches to preparedness and response must be culturally relevant. Racial and ethnic minorities are less likely to have access to physical and mental health care and the care that is received is more likely to be poorer in quality (HHS, 2001a; IOM, 2002b). Culture affects the ways in which psychological reactions and symptoms are described and expressed as well as how their meaning is interpreted by the individual. Not only does culture affect the expression and meaning of psychological reactions, but the ways in which people cope and adapt to difficulty and how likely they are to seek care and from whom (for further discussion see the Surgeon General's report on Mental Health: Culture Race, and Ethnicity, HHS, 2001a). Members of racial and ethnic minority groups are more likely to delay seeking treatment and are less likely to seek out conventional mental health services. Rather, help may be sought from primary care providers, faith-based leaders, and traditional healers.

Efforts should be made to enlist the support of community leaders and/or those who are trusted by the community to help in the preparation and provision of culturally appropriate support services. These populations may require specifically adapted and targeted materials that are in their languages and sensitive to their cultural, ethnic, religious, and worldviews, as well as providers who are sensitive to their needs and able to function effectively in their languages. Ongoing efforts should be made to recruit mental health and other professionals (including paraprofessionals) who reflect the diversity in the nation's communities.

Elderly and Veterans. Special considerations may be required to address the concerns and needs of senior citizens, who may be more isolated and have more health needs than the general public. Issues regarding evacuation and other safety precautions as well as potential effects of CBRN agents on individuals with compromised health or chronic health conditions should be addressed. Door-to-door and other focused outreach efforts may be required to provide information and education. Veterans may also require special considerations because their previous experiences with the trauma of war may make them more vulnerable to the psychological consequences associated with a terrorism event.

Train All Relevant Health Care Professionals in Disaster Mental Health and Psychological Consequences of Terrorism. Training of service providers in medical, public health, and emergency services to respond to a terrorism event is identified by the committee as another function to be provided by an effective infrastructure. Health care providers (for example, primary care practitioners, pharmacists, home health care providers) and mental health care providers require knowledge of expected community responses, resources, and specific elements of intervention and management of distress, behavioral change, and psychiatric illness. Primary care providers can expect patients to have somatic symptoms for which no diagnosis can be determined (Ursano et al., 2003), referred to as multiple unexplained (or idiopathic) physical symptoms (MUPS/MIPS). These symptoms may represent physical illness, concern about toxic exposure, or anxiety and depression. Education in differential diagnosis, treatment, and management is needed.

The Red Cross provides extensive training in the effects of disasters on individuals and communities and the needed disaster mental health support systems. Several academic programs are also available for education and training in disaster responses of communities and mental health needs. In addition, SAMHSA and the professional societies provide education programs for a limited number of mental health providers.

Train Other Relevant Service Providers. Given the number of people who may experience psychological consequences related to a terrorist attack, most without severe symptoms, it is not reasonable to assume that mental health professionals should meet all needs. There is a wealth of ancillary professionals, including teachers and faith-based leaders who can help alleviate psychological distress. However, these professionals, like those mentioned in the section above, should receive some training regarding common psychological reactions and symptoms associated with exposure to traumatic events and develop a basic knowledge of supportive techniques such as listening to fears and anxieties in order to assess the community. Ancillary professionals should also be trained to recognize more severe symptoms that necessitate more rapid and sophisticated interventions as well as how and to whom to refer these individuals.

Sociocultural

Identify Population Characteristics Important to Intervention. Using a public health model, syndromic surveillance of psychological symptoms in the population should be monitored. In order to begin developing strategies to prevent psychological disorders and promote mental health, the World Health Organization (2002) called for information in several areas that are important to monitor. These also relate to terrorism events:

• Prevalence and incidence of psychiatric disorders
• At-risk individuals and populations
• Health and socioeconomic outcomes of psychological problems
• Community perceptions of risk and needs for prevention
• Biological, psychological, and social risk and protective factors
• Comorbidity

Surveillance is crucial to efforts to limit the psychological impact of terrorism because it will allow for the targeting of interventions after traumatic events. For example, research after the 1995 Oklahoma City bombing suggests that there are number of risk factors that may predict psychiatric illness. Preexisting psychiatric illness, previous trauma, and other negative life events are among factors that may increase the likelihood of a person developing PTSD after a terrorism event (North et al., 1999). Syndromic surveillance of these population characteristics and types of symptoms may allow for more rapid identification of individuals who might benefit from psychiatric and other forms of intervention and for deployment of services that will meet varying societal needs. Population estimates of psychiatric illness such as PTSD and other anxiety disorders, depressive disorders, personality disorders, and substance-related disorders would provide an indication of population needs. Surveillance of possible indicators of substance use for later comparison with post-event levels would be useful; these indicators might include levels of alcohol consumption, and sales of alcohol, benzodiazepines, antidepressants, and pain killers. In addition, other social variables, such as the availability of community and family supports or the presence of marital and family discord or violence, may further help to identify needs. Precise estimates of the concentration of families with children; racial and ethnic minority, immigrant, and refugee groups; the elderly; and veterans will allow for identification of populations with more specific needs, such as providers with knowledge of the special considerations required by these groups.

Issues regarding confidentiality are important to consider in screening and monitoring psychological symptoms. Essential ethical issues have been addressed in the reporting of other sensitive public health concerns such as HIV/AIDS. Strategies used to assess and track sensitive illness may serve as examples of ways to approach surveillance of psychological symptoms.

Develop Geo-Mapping of Populations, Potential Targets, and Community Resources. The identification of community services prior to an event will allow the nation and its localities to assess the adequacy of resources that are available to meet mental health and substance-related treatment needs after a terrorist attack. Service settings such as community mental health clinics, outpatient and inpatient hospital services, substance abuse treatment centers, concentration of private practitioners, food banks, and other social services should be identified and categorized. Comparing the location and concentration of these services with population estimates of psychological symptoms, psychiatric disorders, and concentrations of high-risk groups will allow for early identification of areas of disproportionate need.

Identify and Implement Methods for Educating the Public. To facilitate the effective and coordinated dissemination of information, public health, medical, and mental health professionals should have long-standing and well-established relationships with the media. These pre-event communications will help facilitate smooth dissemination of information to the public and help prevent release of conflicting or confusing information, which may create fear and anxious behaviors in the population. This may demystify and create an educational foundation. As discussed in the previous chapter's section on infrastructure gaps, evidence-based strategies are needed to design public communication messages and mechanisms.

Ensure Adequate Public Health and Mental Health Care Systems. The capacity to handle a large increase in demand for services to address psychological consequences in the event of a terrorist attack is identified as a necessary function for the adequate preparation for and response to psychological consequences. Various laws and regulations impact on public health and mental health activities, and add complexity to planning and responses. These must be considered in the pre-event planning stage. For example, The Health Insurance Portability and Accountability Act of 1996 (HIPPA) guidelines should be developed for use in the event of a major incident requiring large public health responses.

Independent of the increased demands that may be associated with a major terrorism event, the nation's mental health care system is currently unable to meet the psychological needs of society. The availability of public mental health and substance-related treatment resources for the population is inadequate, particularly in urban, rural, and frontier areas where facilities are scarce, presenting a challenge to providing services for many groups of special interest. Arguably, services are needed most in these areas, where resources are lacking and poverty and its associated stressors are more prevalent. Racial and ethnic minorities, immigrants, refugees, and those in lower socioeconomic strata are disproportionately concentrated in these areas. The impact of job loss and economic consequences of a terrorism event may have a particularly dramatic impact on these communities. A fundamental shift in the national perspective of the value and importance of psychological health and the needs of such populations must occur to ensure the adequacy of systems to serve them. Because of long-standing challenges for mental health systems, the integration of mental health into public health planning becomes important in promoting the utilization of relevant components of the available infrastructure to address the public's health.

Biological–Physical

Ensure That Buildings, Planes, Water, and Food Are Tested and Protected. Other measures that will attend to the physical health and safety of the public include pre-disaster planning that includes testing the structural integrity of buildings and the safety of airplanes, water, food, et cetera. Adequate detection, alarm, and containment systems should be developed and maintained, and people trained in their use. Requirement of systematic programs to ensure safety may help to provide some reassurance to individuals and the public, thereby alleviating anxiety.

Psychological

Develop an Effective Risk Communication Strategy. Much like the dissemination of educational information discussed above, during the pre-event period, timely and consistent communication of information regarding the prevention of terrorist attacks may help alleviate fear and anxiety and provide confidence in the government's ability to protect the public. This crucial function is a significant gap in the infrastructure, as discussed in Chapter 3. The necessary messages and channels for communication should be developed in the pre-event phase so that they are ready to use during and after the event. The public should be educated regarding specifically where to look for information during a crisis, what to look for (for example, if authorities require public assistance), and what types of warnings may be used to inform them (for example, seasonal education, watches and warnings). It will be important during this phase to establish a tracking system for those who may be evacuated from homes, schools, and other places of employment as well as a registration system for people transported to hospitals. A likely scenario in a terrorism event is anxious individuals (potentially putting themselves at risk by leaving places of safety) searching for children and loved ones.

As an example, media and health authorities have used public health strategies that were learned from the first West Nile virus outbreak in subsequent years; before the summer season began, the public was told to repair window screens, eliminate small pools of water around houses, and wear insect repellent. Then as mosquitoes were studied and shown to carry the virus, and birds and people became ill, the public was repeatedly reminded of these pre-event strategies for protection in addition to being educated about potential signs and symptoms of the disease. The lack of specific treatment for the disease was emphasized, which highlighted the need for prevention. Subsequently, as syndromic surveillance and entomologic surveillance demonstrated evidence, the public was warned of large-scale responses such as spraying of insecticides in neighborhoods and the appropriate personal response (e.g., closing windows to limit exposure to insecticides).

Finally, spokespersons should be identified and trained (HHS, 2002). It will be important to establish credible and consistent sources of information. In dealing with matters of safety, the public will likely be very aware of inconsistencies and conflicting information. Effective spokespersons will require skills in how to deliver sensitive information. Training of spokespersons should include an understanding of basic principles from social science disciplines including sociology, social psychology, and community psychology. Knowledge regarding individual and group behavior under stressful situations, and how information is received and perceived, will help officials more effectively communicate with a diverse public. Principles of risk perception (see, for example, Slovic, 1987) will help individuals responsible for the public's health and safety understand the ways in which people assess and respond to risk. This line of research is beginning to be applied to terrorism. For example, a recent study by Lerner and colleagues (2003) investigated how emotions related to the September 11, 2001, terrorist attacks affected individuals' responses to risk. Results revealed that those experiencing more anger had more optimistic beliefs and those experiencing fear had more pessimistic beliefs about risks from both terror- and non-terror-related events. Participants felt that they were less vulnerable to risks than the average person and were less likely to take precautions. In addition to training in principles of communication, salient examples from the recent past may be studied and provide information for teaching and training of spokespersons.

Provide Information That Educates Populations About Expectable Responses and Coping Strategies That Would Increase Community Resilience. In addition to communicating information about physical risk and protection, information regarding the range of potential psychological responses to terrorism events and to the threat of events is important to provide. Much like risk communication provides protective measures, the public would benefit from strategies to increase not only positive personal coping and adaptation, but community resilience as well (for example, volunteering and donating supplies).

Sociocultural

Develop Terrorism Response Plans. Response plans detailing the federal, state, and local agency roles in organizing prevention, detection, and intervention efforts, including mental health response, should be in place in the pre-event phase. A large representation of the mental health community, including substance-related services, should be involved in pre-event planning. Their expertise will be crucial for integrating needed psychological issues into preparedness plans and may help to improve the coordination of services following a terrorism event.

Ensure That the Community Is Appropriately Represented in Pre-Event Planning. Traditionally, leaders in federal, state, and local agencies develop planning for mental health services. The larger community—that is, citizens, leaders, and consumers of services—should be a part of preparedness and response planning. These individuals, although not experts in financing, organization, or delivery of services, are experts in the needs of the community and informal resources within the community that may augment planned interventions. Development should be a joint effort. Representation of the community may help to promote confidence in plans that are put into place.

Address and Ensure Equity in the Allocation of Resources. As discussed in the previous chapter, financial support for responding to psychological consequences of terrorism is a gap in the infrastructure requiring attention. In the event of a terrorist attack, unstructured and unsystematic methods for attending to financing of psychological needs and the allocation of resources will be insufficient. The equitable distribution of resources is essential to community recovery. Those who are more able to find or reach resources are not necessarily the most in need. Those who make decisions about resource allocation must have input and representation from diverse parts of society to ensure that all elements of a community are heard and responded to. Ombudsmen can serve an important role in providing rapid information in culturally sensitive language on difficult decisions about distribution of resources and timing of resource distribution.

Biological–Physical

Implement Public Health and Mental Health Response. Information and supplies gathered in the pre-event phase can be utilized to help people during the event and immediate post-event period. Risk communication will keep the population informed and oriented about the level of danger and need to take appropriate actions.

Provide Basic Needs. Basic needs such as physical safety, shelter, food, and water should be made available as soon as possible.

Provide Appropriate Interventions. Interventions should take place to address the immediate needs caused by physical injury and/or exposure to CBRN agents.

Psychological and Sociocultural

Implement Psychological First Aid. During this phase, the affected population should make use of PFA skills and of information provided or taught during the pre-event phase.

Affected Population Responds Appropriately. If the population makes appropriate use of skills provided in the pre-event period, responses may occur quickly and efficiently. Rapid and well-organized responses on the part of individuals, communities, and responders will be particularly important in the event of CBRN attacks.

Distribute Information Appropriate to the Event. The public is given information that will provide for its immediate safety, such as instructions for evacuation or steps to contain agents.

Biological–Physical

Respond to Alarms. The goal is for all detection systems, alarms, and containment procedures to function flawlessly at the time of need. When an attack is detected, people will be directed away from the area of attack, thereby reducing injury's toll. Expeditious and appropriately directed dispatch of emergency personnel can reduce physical damage and thereby minimize psychological casualties.

Respond to Surveillance System. Surveillance conducted in the pre-event phase will allow for responses that are targeted to areas of special need.

Involve Public Health, Emergency Preparedness, and Medical Care Systems. Public health, emergency medicine, and medical care systems should respond in a coordinated manner immediately after the disaster, each communicating relevant information to government agencies.

Monitor Immediate Threats. All immediate threats should be monitored.

Psychological and Sociocultural

Communicate Risk and Proposed Response Effectively. It has been suggested that the provision of clear, credible, and timely information during and after an attack, particularly a bioterrorism attack, is a critical aspect of response (Glass and Schoch-Spana, 2002). The public will require reassurance and optimism in addition to instructions for personal protection and information regarding response measures from designated spokespersons including infectious disease emergency physicians, medical toxicologists, and other medical personnel depending on the type and extent of the event. The importance of immediately available, consistently open, and honest communication cannot be overstated. The public must have trust in its officials to help limit unnecessary anxiety and decrease fear. The public must be aware that an organizational system and a communication system are in place and functioning. Trusted and designated spokespersons (for example, the health commissioner) must provide clear, concise, and consistent messages. The media and the public should have easy access to information (for example, through regular press conferences, widely available phone numbers for call-in questions, Web sites). Media and calls, issues, and questions from the public should be monitored so that answers and clarifications can be disseminated. Messages may require modification if perceived needs remain unrealized.

Surveillance of the event must be accurate and current, so that the spokesperson is perceived as “an expert” and continues to be trusted by the media and the public. The spokesperson must be able to “shift gears” as more information is learned. Information should be shared with appropriate partners so they can help in dissemination efforts. At all levels, there should be an understanding of political concerns, realities, and needs in order to comprehensively understand the issues. If political or contentious issues exist, a forum for discussion may be helpful such as town hall meetings or moderated call-in radio programs.

Public health officials should enlist the help of “stakeholders.” For example, using mental health professional organizations to help disseminate messages may be beneficial. Finally, those charged with serving as spokespersons must help the public put risk in perspective (in other words, the risk versus the benefits of certain actions). This will allow the individual to decide how concerned to be about the risk and what precautions to take. Similarly, honest and ongoing communication during and after an event regarding possible sustained risk and efforts for recovery may enable people to feel less helpless.

Biological–Physical

Minimize Secondary Consequences. Decontamination can be frightening to both those being subjected to or involved in the procedure and those observing it. Taking care to explain the procedure to those involved and removing the activities from public view may help reduce anxiety and fear.

Triage and Treat as Necessary. The provision of basic communication and medical services continues in this phase. Efficient triage and treatment of injury will reduce physical damage and lessen the psychological impact. Isolation of contaminated individuals and evacuation of people 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 terrorism event, PFA 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 primary care rather than mental health care providers. Health care providers will play an important role in responding to the physical and psychological 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 significant 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 inadequate decontamination of the body. Physicians and officials may be presented 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 discussed, one of the most significant gaps in responding to psychological consequences of terrorism is the lack of knowledge and evidence base to inform practice and policies.

Individual Assessment, Triage, and Treatment. This model of approaching 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, depressive 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 negative to community-based management. This determination of the presence or absence of psychiatric illness is a pivotal decision point for directing the individual to the most appropriate intervention system.

FIGURE 4-1

Model of postdisaster triage, referral, and management based on psychiatric screening and diagnosis.

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 detached) (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 previous 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. However, 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 psychiatric disorders and distress after disasters and terrorism suggests the appropriate time frame for responding to mental health needs of individuals after 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 assessment and treatment can be initiated quickly and that treatment needs will be longterm.

Population-Based Assessment. Within the population, there will be varying degrees of exposure, with a relatively small subset being directly exposed, a larger subset being indirectly exposed, and a still larger subset being exposed at a distance (for example, through the media only). Characteristics of the affected population and subpopulations are also considered (for example, seriously and persistently mentally ill treatment population, 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 preexisting 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 the expected population responses and guide the development of necessary 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 screening, 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 psychiatric 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 terrorism event than those directly affected (North et al., 2002a; 2002b). Understanding 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 individuals 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 government 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 mental health care professionals who provide care to individuals experiencing 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 themselves from direct provision of services or supervisory activities in order to obtain self-care, this may be particularly important after terrorism events.

Minority, Immigrant, and Refugee Populations. As discussed above, minority, immigrant, and refugee populations may be at higher risk for negative 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 terrorist acts based upon the specifics of the incident, exposure, and individual differences. In the event of agricultural terrorism, rural populations may be particularly in need of assistance. Some general issues pertaining to rural and frontier responses are noted here (personal communication, 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 psychological 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 response 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 business 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 local efforts to respond to terrorist acts. However, since local professionals know their communities and have built trust and credibility as well as a 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 assistance.

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 address psychological needs and consequences requires multidisciplinary coordination of training and action plans to place sufficient skills and resources 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 environments; personal, financial, and property losses; changes in spousal, family, and work relationships; illness; and debilitating injury are adult factors 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 cognitive 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., 1990). 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 parents about their child's PTSD symptoms has also been recommended (Rigamer, 1986) and incorporated into a school-based mental health intervention project for traumatized Latino students exposed to life-threatening violence (Kataoka et al., 2003). In the immediate aftermath of trauma, psychological first aid has been widely utilized to calm the emotional distress 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 general 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 some key elements that can take place in any size workplace and are essential 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 communication 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 productivity 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 involved in an integrated response. Outreach to medium and small businesses is critical, especially with services in the post-event environment. Groups such as the Employee Assistance Professionals Association, Rotary, and Business Councils should be involved as partners in efforts to address psychological consequences.

The unique elements of some workplace settings are important considerations when designing workplace systems for response. Some employees will be concerned that seeking treatment will affect the perceptions 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 potential for law enforcement officers, members of the military, and airline pilots to even initially address their personal concerns (National Partnership 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 accessible anonymous service outside the workplace may be preferable to ensure 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 preparedness helped to decrease the psychological impact of the attack and continue to publicize available services to the public in general and provide targeted messages to specialized segments of the population who may be at greater risk for adverse consequences. Steps should be undertaken 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 PFA, additional or targeted services may have to be provided to special populations, as discussed above. The availability of these services should be widely publicized to the appropriate populations.

Produce Public Information and Warnings. The broadcast of public information and warnings will help ensure that the public has the information needed to protect itself in the event of further threats. Potential psychological 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 promotion has been defined as the enhancement of the capacity of individuals, families, groups, or communities to strengthen or support positive emotional, cognitive, and related experiences (Hodgson et al., 1996). As discussed in Chapter 2, disaster events can produce positive consequences and closer ties with others. Some research has indicated that 35 to 95 percent 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 terrorist 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 that form because of displacement, group meetings to foster discussion of ways to rebuild communities, and outreach to those who may feel isolated 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 members the resources to help one another. As noted in the discussion of gaps in Chapter 3, evidence-based models for community recovery and resilience building are lacking.

Leaders in the faith-based community have a critical role in promoting 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 understanding in the aftermath of traumatic events. Leaders in this community will minister to congregations, towns, and cities as they advance through the grieving process.

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 emergency planning for possible future events. Findings from such evaluations 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. Living 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 reassures the population that the authorities are working to reduce the danger and will contribute to the restoration of a more normal and safe environment. This might be accomplished, for example, by cleaning up hazardous 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 securing physical safety and infrastructures (inspection of food and water supplies; restoring sanitation and communication facilities and transportation 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, providing further reassurance to the population. Advancements in monitoring that are based on current event evaluation should be emphasized.

Psychological

Limit Secondary Exposure. Although the evidence linking media exposure 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 communication 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 memorials, 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 individuals 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.