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OCR for page 19
Introduction: Rationale for a Public
Health Response to the Psychological
Consequences of Terrorism
Much of the nation's attention since September 2001 has focused
on the "war on terrorism" and on ensuring the safety of the
nation. Efforts have included pursuing potential terrorists, de-
tecting potential terrorist plots, developing policies to vaccinate against
smallpox, and securing the nation's airports and landmarks. Often over-
looked, however, is the need to prepare the country for one of the primary
objectives of terrorism psychological injury. Terrorism is, after all, a di-
rect intent to terrorize. It is a psychological assault intended to intimidate
and instill fear in communities, societies, or populations. The stress asso-
ciated with the direct impact and lingering threat of terrorism raises obvi-
ous psychological concerns, particularly for the most vulnerable chil-
dren, those with mental illness, first responders, minority and immigrant
populations who have suddenly lost a secure environment. Although
the extent of the longer-term impact remains largely unknown, the poten-
tial for persistent psychological consequences is a concern. Physiological
responses to chronic stress can increase the risk of disease within the
population. The consequences for the public's health can be extensive as
the health care system is inundated with people who believe they may
have been exposed to harmful agents or who become alarmed over minor
symptoms. Following terrorism events, the demand for medical and men-
tal health care services can potentially exceed available resources. As
such, the need to prepare for and respond to the psychological conse-
quences of terrorism should be an important part of the nation's effort to
secure the health and well-being of its citizens, residents, and visitors.
The current focus on terrorism reminds us that other traumatic and
19
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20 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
violent events occur in many American communities and have for many
years. School shootings, workplace shootings, and the violence that
plagues so many of the nation's communities may similarly instill fear
and anxiety in individuals and communities. These ongoing issues and
events should not be forgotten. The need to psychologically prepare the
nation for terrorism events highlights the additional benefits of this kind
of preparation for other traumatic and violent events that affect U.S. com-
munities. Universal preparedness for all hazards (conventional explo-
sives, biological, radiological, chemical, nuclear terrorist attacks), all seg-
ments of the population, and all phases of events should be a priority for
the protection of the public's mental health.
CHARGE TO THE COMMITTEE
The Institute of Medicine (IOM) Committee on Responding to the Psy-
chological Consequences of Terrorism was established to highlight some
of the critical issues in responding to the psychological needs that result
from terrorism and to provide possible options for intervention. Specifi-
cally, the charge presented to this committee of seven members was as
follows:
The committee is asked to plan a workshop that addresses the mental
health issues that result as a consequence of terrorism. Topics of the
workshop will include:
· The immediate and long-term psychological consequences of both ter-
rorism involving weapons with immediate death and injury [mass vio-
lence events] (e.g., conventional explosives, chemical weapons) and ter-
rorism involving delayed or indeterminate risk of death and injury
[perceived-threat event] (e.g., bioterrorism, radiological terrorism, man-
caused contamination of water, air, food supply). Both mental health and
substance abuse will be addressed.
· Identification of vulnerable populations.
· The public health infrastructure that is available to address the men-
tal health needs of the population. This includes available strategies for
surveillance, screening, and follow-up for post-disaster distress.
· The capacity of that infrastructure to deliver efficacious intervention;
provide the necessary expertise, skills, and training for key health and
human services providers; and handle the anticipated increase in de-
mand for mental health services.
From the input of the workshop, the committee will:
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INTRODUCTION
1. Identify gaps in knowledge necessary to inform policies and proce-
dures for planning, preparedness, and intervention. Identify gaps in
planning, preparedness, and public health infrastructure necessary for
successful implementation of interventions. Consideration should be
given to the locus of responsibility (federal, state, local government, pri-
vate sector) for addressing the identified gaps.
2. Identify a variety of approaches to intervention to limit adverse men-
tal health consequences. These may range from public health messages
to individual counseling. Consideration should be given to the locus of
responsibility (federal, state, local government, private sector) for ensur-
ing and coordinating implementation. Mass violence events, perceived-
threat events, and chronic events may each require different interven-
tions. If there is an inadequate knowledge base, it may not be possible to
identify an appropriate approach or locus of responsibility; instead de-
velopment of new approaches may be called for.
3. Provide recommendations for options on how to optimize the public
health response to long-term and short-term mental health consequences
of terrorism.
21
During the 10-month study, the committee convened for three meet-
ings, in October 2002, December 2002, and February 2003, and hosted one
public workshop at the October meeting (see Appendix A for workshop
agenda and participants). The committee did not have the time or re-
sources to create a comprehensive response plan or to conduct an exhaus-
tive review of the literature regarding the psychological consequences of
terrorism. It is also beyond the scope of this report to consider the psy-
chology of terrorism and its causes. For further review of these topics the
reader is referred to Discouraging Terrorism: Some Implications of 9/11 (NRC,
2002a) and Terrorism: Perspectives from the Behavioral and Social Sciences
(NRC, 2002c). Rather, the intent of this report is to highlight the critical
issues for prevention and intervention and to provide possible options for
response.
There are a multitude of definitions of terrorism, and the range of
activities that can be considered as terrorist acts is vast and complex. In
its interpretation of the charge, the committee adopts as a guideline the
working definition of terrorism provided in Terrorism: Perspectives from
the Behavioral and Social Sciences (NRC, 2002c, pp. 14-15~:
illegal use or threatened use of force or violence; an intent to coerce soci-
eties or governments by inducing fear in their populations; typically with
ideological and political motives and justifications; an "extrasocietal" el-
ement, either "outside" society in the case of domestic terrorism or "for-
eign" in the case of international terrorism.
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22 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
This guiding definition allows for the consideration of events such as the
attacks on September 11, 2001, the Oklahoma City bombing, 2001 anthrax
attacks, and potential events involving the use radiological, chemical, or
nuclear weapons.
Terrorism: Perspectives from the Behavioral and Social Sciences proposes a
dimensional approach in considering the range of actors, actions, and con-
sequences involved in terrorism activities. At a basic level, dimensions
are organized in the following manner:
I. Actors
A. Perpetrators (including identification and visibility, organiza-
tion, and belief system)
B. Victims (includes national identity of victims and victim's con-
nection to his/her country)
C. Third parties (includes for example sponsors, collaborators,
and sympathizers)
II. Actions
A. Mechanisms of attack (includes physical, chemical, and
biological)
B. Nature of target (people and/or organizations)
C. Degree of violence
D. Scope of violence (localized, multiple simultaneous, or wide-
spread and continuous)
E. Degree of surprise
III. Consequences
A. Physical damage to infrastructure
B. Biological damage to people, plants
Environmental damage
Psychological damage
D.
E. Social disruption
F. Economic disruption
For a complete listing and explanation of dimensions, see NRC (2002c,
pp. 63-68~.
This dimensional view of terrorism illustrates the critical point that
terrorism includes a range of actors and a multitude of actions, and re-
sults in a variety of social, psychological, physical, and economic conse-
quences. Given these diverse consequences, terrorism has the ability to
disrupt numerous aspects of individual and community functioning.
Addressing the psychological needs of the population will help to facili-
tate recovery from a terrorism event.
Throughout this report, all forms of terrorism are included in the term
(conventional explosives, chemical, biological, radiological, nuclear) un-
less otherwise specified. The committee considers acts of terrorism car-
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INTRODUCTION
23
ried out in the United States and implications for the infrastructure's re-
sponse capabilities. The committee emphasizes the importance of pre-
paredness to limit adverse psychological effects and considers a range of
psychological sequelae from distress responses to psychiatric disorders.
The term psychological consequences is used by the committee as a glo-
bal one to describe the spectrum of emotional, behavioral, and cognitive
effects that result as a consequence of terrorism. The committee groups
this spectrum of consequences into three spheres, each falling within the
domain of psychological consequences. These spheres, which are de-
scribed in further detail in the section that follows, include distress re-
sponses, behavioral changes, and psychiatric illness.
TERRORISM AND THE PUBLIC'S HEALTH:
THE NEED FOR A PUBLIC HEALTH RESPONSE TO THE
PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Why Is the Public's Health Linked to Psychological Health?
Traditionally, psychological health has not received the same consid-
eration or support as physical health by local, state, and federal systems,
healthcare providers, or the general public. Those with psychiatric disor-
ders are often stigmatized and seen as flawed or weak by society. Treat-
ment for psychiatric disorders is generally provided in service systems
that receive inadequate funding and are separate from those providing
medical treatment. However, it is the general view of social scientists that
psychological disorders are determined by a combination of physical,
psychological, and social factors, and that the public's health is depen-
dent on psychological and physical well-being (HHS, 1999~. The separa-
tion of psychological and physical health service systems is not consistent
with this notion of combined determinants of health. Health is of primary
importance to any society because "many aspects of human potential such
as employment, social relationships and political participation are contin-
gent on it" (IOM, 2003~. Therefore, ensuring health should be a shared
societal goal.
The mission of the public health field is to ensure conditions in which
people can be healthy (IOM, 1988~. The field sets about this mission
"through organized, interdisciplinary efforts that address the physical,
mental and environmental health concerns of communities and popula-
tions at risk for disease and injury" (Association of Schools of Public
Health, 2003), and is focused on health promotion and disease preven-
tion, in addition to etiology, diagnosis, and treatment of disease.
It follows that the prevention and treatment of psychiatric disorders
and the promotion of psychological well-being should be an integral part
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24 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
of public health efforts. Leaders on national and global fronts have called
for this integration of health services. The World Health Organization
(WHO, 2002) and the U.S. Surgeon General (HHS, 1999) have identified
the need for a public health approach to mental illness that expands ef-
forts beyond treatment for the most severely affected individuals. Strate-
gies for a public mental health approach to psychological reactions to di-
saster among children have also been proposed (Pynoos, Goenjian, &
Steinberg, 1995~.
The implications for responses to terrorism are clear. As stated above,
the goal of terrorism is to induce terror and fear. Although relatively few
may be directly affected physically by a terrorism event, massive num-
bers may feel uncertainty, fear, and anxiety. Terrorism is primarily a psy-
chological assault that erodes our sense of safety and sense of security,
two of the most basic human needs. As such, the public's mental health
must be a central element of the nation's efforts to protect against and
counter terrorism.
Implications of Terrorism for the Public's Health
In response to the attacks on September 11, 2001, the United States
government initiated measures to ensure "homeland security." Funds
were allocated to detect and respond to threats of terrorism. While the
nation's security has traditionally been built on military, economic, and
more recently, information capabilities, the public's health should be
added as a critical component of national protection and defense (Ursano,
2002~. Our systems for medical and public health response are inadequate
to address the challenges presented by a major terrorism event (Barbera
and McIntyre, 2002), and the current organization and financing of medi-
cal and public health systems are problematic.
The public's health is dependent upon our public health infrastruc-
ture, the public and private medical care system, and our emergency re-
sponse system (see Figure 1-1~. The public health system addresses pub-
lic health practice and policies of personal and community or
environmental health protection, disease and injury prevention, health
promotion, and surveillance. The medical care system is an integral com-
ponent of the infrastructure responsible for the public's health, identify-
ing early cases involved in outbreaks of illness, monitoring ongoing
health, and providing interventions and treatment to populations at risk
and to those with disease. The emergency response system includes emer-
gency medical services, police, fire and emergency infrastructure response
capability (for example, water, electricity, communications). The mental
health system, which traditionally functions as a subset of the medical
care system, has not been supported to adequately respond to the perva-
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INTRODUCTION
-
Medical care
system
| Public / \ Emergency
health l I response
\ system V system
· Protection\ '/\_ Em,
· Prevention
· Promotion
25
· Public and private
\ · Outpatient/hospital
Mental health system
Emergency medical
services
· Police/fire
· Water/electric
· Communication
FIGURE 1-1 Systems responsible for the public's health. SOURCE: Ursano (2002~.
sive mental health needs that result from terrorism. The shared goals,
responsibilities, and responses of the public health, medical care, and
emergency medical systems in planning, preparedness, and intervention
will be crucial for effective response to terrorism events (Fullerton et al.,
2003~.
The psychological health of the public is critical to sustaining the
nation's capabilities, values, and infrastructure. Responses to critical
events such as terrorism emphasize the need to address the psychological
effects of these events on the population; locally, regionally, and nation-
ally. For example, thousands in three regions of the country were directly
affected by the attacks on September 11, 2001, and millions across the
nation were exposed and potentially psychologically affected through me-
dia coverage. As discussed earlier in this chapter, possible manifestations
of terrorism in the population include behavioral changes, distress re-
sponses, and psychiatric disease (see Figure 1-2~. Behavioral changes re-
fer to actions such as avoiding air travel; increased smoking or alcohol
consumption; and neglect of healthy routines and habits such as appro-
priate exercise, nutrition, and rest. Other more adaptive behavior changes
may include gathering information to prepare for future events, increas-
ing contact and communication with friends and family, or volunteering.
Changes in behavior may be made to reduce the perceived risk of harm
(for example, by avoiding air travel) or they may reflect inner states of
mind (for example, smoking, neglect of healthy routines). Distress re-
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26 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
Distress
responses
For example:
· PTSD
· Major depression
Psychiatric
Iness '
-
/ Behavioral
changes
For example:
· Insomnia
· Sense of vulnerability
/
For example:
· Change in travel patterns
· Smoking
· Alcohol consumption
FIGURE 1-2 Psychological consequences of disaster and terrorism. NOTE: In-
dicative only; not to scale. SOURCE: Ursano (2002)
spouses include, but are not limited to insomnia and increased feelings of
anxiety, anger, and vulnerability. The occurrence of psychiatric disease
includes, for example, posttraumatic stress disorder (PTSD), and depres-
sive disorder.
The threats to life and the propagation of fear created by a terrorist
attack can infect a community, much as a microbe creates an infectious
disease outbreak. This phenomenon of terrorism requires new attention
to and coordination of the public's mental health. Events such as the fall
2001 anthrax attacks; the September 11, 2001, attacks; and the 1995 Okla-
homa City bombing place demands on systems that support the public's
health. These increased demands raised two important questions for this
committee:
1. How can and should the psychological needs of a society im-
pacted by terrorism be met by the mental health, medical care, public
health, and emergency response systems?
2. What are the current and proposed components of these systems
to address the effects of terrorism on the population?
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INTRODUCTION
27
Redefining the Relationship Between
Psychological Health and Public Health:
Terrorist Act as Agent
Public health's analysis of the distribution, frequency, determinants,
and control of disease in populations has served as a basis for health
policy. Epidemiologic principles of infectious diseases enhance the un-
derstanding of disease outbreaks and illustrate the processes of transmis-
sion. The principles are reflected in the epidemiologic triad, namely: (1)
an external agent, (2) a susceptible host, and (3) an environment that
brings the host and agent together, resulting in disease (CDC, 2003) (see
Table 1-1~. The agent (for example, microbe or toxin) refers to a factor
necessary for the introduction of the disease or condition. The susceptible
host refers to the characteristics of the individual (for example, age, gen-
der, behavior) that influence a person's exposure, susceptibility, or re-
sponse to the agent. The environment is an extrinsic factor (for example,
climate, sanitation, health services) that affects the opportunity for the
agent and host to interact. A vector (or vehicle) may carry the agent to the
host.
William Haddon, Jr., a leading figure in the field of epidemiology,
expanded the use of the triad of epidemiologic factors and applied these
public health concepts to the understanding and prevention of injuries
(Haddon, 1972; 1980~. This was a novel application because the field of
injury prevention at that time had largely been outside the purview of
public health. Haddon considered energy transferred to humans as the
agent. Injury resulted when the energy in excess of that which the human
body was able to safely sustain was transferred through an object (vehicle
or vector) to the victim (host). These factors interacted within a physical
or social environment to produce injury (see, for example, Table 1-2~.
Haddon added to this model an additional dimension that reflected
phases in the process of sustaining an injury. He termed these phases
pre-event, event, and post-event. A contribution of this model, termed
TABLE 1-1 Use of the Public Health Model to Understand
and Organize Factors Involved in Transmission of Disease
Factors
Infectious Disease Model: Lyme Disease
Agent
Host
Vector or vehicle
Environment
Spirochete
Human
Tick
Wooded area, lack of protective clothing
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28 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
TABLE 1-2 Use of the Public Health Model to Understand
and Organize Factors Involved in the Transmission of Injury
Factors
Injury Model: Car Crash
Agent
Host
Vector or vehicle
Environment
Energy
Human
Car
Speeding without wearing seat belt
TABLE 1-3 Haddon Matrix Applied to the Prevention of Car Crash-
Related Injuries
Factors
Phases
Human
(Host)
Car
(Vehicle or Vector)
Speeding without
Seat Belt (Environment)
Pre-event
Driver's
education
Event Use of
seat belts
Post-event First aid
End Result Injured
passengers
Building of cars with
crumple zones and
airbags
Activation of antilock
breaks and deployment
of airbags
Use of emergency
equipment to rescue
victims
Damaged car
Guard rails and divided
highways
Witnesses contact
emergency medical
services
Emergency care and
rehabilitation
Damage to property and/
or other cars
the Haddon Matrix (see Table 1-3), was that understanding the factors
contributing to injury in each cell would lead to improved prevention of
and interventions for injuries.
The Haddon Matrix represents a landmark in injury prevention and
is widely used to help categorize what is known about prevention and
control and to help set priorities in a public health approach to motor
vehicle collisions and other major causes of morbidity and mortality.
Similarly, epidemiologic principles have been applied to other public
health hazards such as firearm injury (Kellermann et al., 1991) and heroin
use (Ionas, 1972) to guide prevention and intervention efforts. The use of
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INTRODUCTION
29
the adapted Haddon Matrix for psychological injuries resulting from ter-
rorism lends itself to a logical examination of components of the mental
health and public health systems needed to respond adequately to the
needs of the public.
In conceptualizing this model to help organize responses to psycho-
logical consequences of terrorism, the committee views the terrorist act or
threat and the resulting fear and dread of future attacks as the agent affect-
ing the population. Alternate labels for the terms host, vector or vehicle,
and environment are also offered (see Table 1-4~. The host is redefined as
the individuals and populations affected by terrorism or those persons who
are the targets of the terrorist act. At the level of the vector or vehicle, the
terrorist and his or her act are fused and become the terrorist and injurious
agent (for example, individuals crashing airliners, shooting others, or con-
taminating food or water supplies). The vector can also refer to the way
the terror is propagated. Thus the media, particularly television, may
also become a vector. The environment is further defined as the physical
and social environment. It is not only the physical setting, but also the
broader community context in which the event occurs.
The consequences of and responses to terrorism are, in some respects,
similar to other disasters. However, there is a crucial difference between
terrorism and other kinds of disasters. In a natural or unintentional hu-
man-caused disaster (for example, transportation or technological catas-
trophes), the agent can be viewed as the energy transferred to individuals
and/or property, in the form of a hurricane, earthquake, or crash. How-
ever, in the case of terrorism, the agent is a purposeful and malicious act.
The terrorist act often has political or ideological motivations and is a
strategy of those with limited political, military, or social strength attack-
ing those with substantial strength (NRC, 2002a). This adds a psychologi-
cal dimension to terrorism that makes it unique with regard to other forms
of disasters. By adapting the Haddon Matrix, the model can be devel-
oped for psychological injuries as shown in Table 1-4.
TABLE 1-4 Application of the Public Health Model to Understand and
Organize Factors Involved in the Psychological Consequences of
~ ~ .
. . errorlsm
Epidemiologic Terms
Psychological Terms
Agent Violent act or threat
Host Affected individuals and populations
Vector or vehicle Terrorist and injurious agent, the way terror is propagated
Environment Physical and social environment
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30 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
To this model is added a second dimension to reflect pre-event, event,
and post-event phases. These phases also correspond to the Department
of Homeland Security's emergency management program of prepared-
ness, mitigation, response, and recovery. The Department's mission is to
protect the nation from all hazards through activities targeted at each of
these phases. Pre-event strategies include preparedness (through man-
agement of first responders and the development of a national training
and evaluation system) and risk mitigation (promoting structures and
communities that have a reduced chance of being impacted by disasters).
Event phase efforts correspond to the Department's response efforts car-
ried out by emergency and other federal response assets. Finally, the post-
event phase of the matrix corresponds to the Department's recovery phase
which is focused on restoration after loss of life and health, destruction of
families, fear and panic, loss of confidence in government, destruction of
property, and disruption of commerce and financial markets.
Table 1-5 illustrates how this modified Haddon Matrix can be used to
examine the September 11, 2001, attacks on the World Trade Center. Table
1-6 illustrates how the matrix analysis can then be used to formulate inter-
ventions to prevent or reduce the psychological impact of the event.
TABLE 1-5 Matrix of Phases and Factors Involved in the Psychological
Impact of Terrorist Attacks World Trade Center (WTC) Attack, 2001
Factors
Affected Terrorist and Physical
Individuals and Injurious and Social
Phases Populations Agent Environment
Pre-event Psychological Vulnerability of Vulnerability of WTC
unpreparedness for aircraft to to attack (structural,
the attack hijackers symbolic nature,
height)
Event Exposure to the Aircraft turned Towers collapse
violence of the attack into weapon of
mass destruction
Post-event Inadequate assessment Numerous bomb Relocation of Lower
and treatment of threats Manhattan residents
psychological consequences
End results Distress responses,behavioral Terrorists gain
change, psychiatric illness greater visibility
Disruption of
support networks
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INTRODUCTION
3
TABLE 1-6 Interventions for Psychological Consequences of Terrorism,
Using Phases and Factors of World Trade Center Terrorist Attacks, 2001
Factors
Phases
Affected
Individuals and
Populations
Terrorist and
· ~
Injurious
Agent
Physical and
Social
Environment
Pre-event Design and implement
psychological first aid
training
Event Population uses skills taught
during pre-event phase
Post-event Assessment, triage, and
treatment of psychological
. . .
mauves
End results Limit distress responses,
negative behavior changes,
and psychiatric illness
Communicate
efforts to limit
actions of terrorist
and agent on the
public (e.g.,
increased security
at airports)
Have plans in place
detailing federal,
state, and local
agency roles in
prevention and
detection including
mental health
response
Mobilize trauma Communicate that
workers to respond organizational
to survivors and
families of victims
Communicate
that response
to attack will help
decrease impact
of future attacks
Minimize loss of
life and impact
response systems
are in place and
working
Adjust risk
. , .
communication,
emphasizing the
positive
Minimize disruption
in daily routines
As discussed at the outset of this chapter, adequate preparation for
the range of terrorism events may serve an added benefit of helping to
inform responses to other commonly occurring violent events that can
also be devastating on psychological health. Violent and fearful events
such as shootings in schools and places of employment and the violence
that plagues many of the nation's urban centers take place across this
country on a smaller scale and are far less publicized. Random acts of
violence have always existed disgruntled employees shooting and kill-
ing coworkers and supervisors, serial killers stalking young women or
children, racially motivated killings, hate crimes, and murder and vio-
lence occurring in many communities. These acts have occurred with
greater frequency than the types of dramatic terrorism events we have
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32 PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM
recently experienced. Responding to the mental health needs of the pub-
lic that arise as a consequence of terrorism provides an opportunity to
also address the psychological effects of a variety of violent events and
other disasters. In turn, applying and practicing strategies for prepared-
ness and intervention in these other violent events, which are associated
with a greater incidence of morbidity, mortality, and psychological in-
jury, will also serve to make the nation better prepared to respond to the
new terrorism threats. The cost of doing nothing neglecting the public's
mental health, whether the event results from suicide bombers, perpetra-
tors of biological attacks, or gang violence is enormous because violence
and terrorism undermine the nation's security and prosperity and limits
the health potential and well-being of our population.
Presently Existing and Needed Components of Mental Health and
Public Health Systems
A shift from the traditional focus on the psychological health of indi-
viduals toward a community- and population-based emphasis will be cru-
cial for the success of measures to prevent and limit the psychological
sequelae and to improve the public's mental health in response to attacks
or threats of terrorism. The use of the Haddon Matrix for thinking about
the psychological effects of terrorism as an injury offers intriguing possi-
bilities not only for understanding various levels of risk and opportuni-
ties for intervention, but also for integrating psychological health into a
public health framework. By examining a specific factor at a given point
in the phases of the injury, one can identify risk factors and groups, inter-
vention approaches, locus of responsibility for the strategy, gaps in knowl-
edge, and further research needed to guide intervention. These compo-
nents of the health system should address strategies to promote health
behaviors (for example, attention to healthy routines, seeking informa-
tion/education, increasing family and community cohesion); protection
from trauma exposure; the needs of vulnerable populations (for example,
children, the seriously mentally ill, first responders); attending to dis-
rupted well-being and emergent disease (for example, PTSD, major de-
pression); and capabilities for health surveillance and triage.
CONTENT AND STRUCTURE OF THE REPORT
The purpose of this report is to identify gaps in the knowledge neces-
sary to guide policy and procedures for response, provide a variety of
approaches to interventions, and offer recommendations to optimize the
public health response to the psychological consequences of terrorism.
The committee addresses these issues through use of the adapted public
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INTRODUCTION
33
health model described above to discuss how psychological needs can
best be met by mental health, medical care, public health, and emergency
response systems.
Chapter 2 provides a brief overview of the literature on the psycho-
logical consequences of trauma, disasters, and terrorism. Although it is
beyond the scope of this report to provide an exhaustive review of the
literature, Chapter 2 highlights the psychological sequelae following a
variety of traumatic events for both the general population and vulner-
able populations. For an additional review of the responses of individu-
als and organizations to terrorism events and the threat of terrorism, the
reader is referred to Making the Nation Safer: The Role of Science and Technol-
ogy in Countering Terrorism (NRC, 2002b).
Chapter 3 reviews existing systems for response to psychological
r cow J r r J Car
_ _ _ _ _ _ _ _ _ _ . _ . _. . _ _ _
needs at federal, state, and local levels. it identifies gaps in the knowl-
edge needed to inform policies and practices and also identifies gaps in
planning, preparedness, and the current infrastructure.
Chapter 4 provides a more detailed and expanded version of the pub-
lic health strategy for organizing responses to terrorism, which was intro-
duced in this chapter. The model serves as the basis for the committee's
discussion of the need for integrated public health, medical care, and men-
tal health systems and provides a variety of approaches to planning, pre-
paredness, and intervention. Finally, Chapter 5 provides the committee's
recommendations for ways to achieve effective preparedness and re-
sponse.
Finding 1: Terrorism involves the illegal use or threatened use of
force or violence to instill fear in populations, and an intent to co-
erce societies or governments by inducing fear in their populations.
Other acts of community violence can also be devastating to psy-
chological health. Pervasive violence, such as repetitive urban as-
saults, school shootings, and workplace violence, are events that
affect small and large, urban and rural communities. These events
have elements that may be similar to terrorism in terms of psycho-
logical impact, and lessons learned from responses to terrorism may
help to inform responses to these other events. Similarly, lessons
learned from pervasive community violence may provide some ben-
efits for examining responses to terrorism events.
Representative terms from entire chapter:
haddon matrix
