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PREPARING FOR THE PSYCHOLOGICAL CONSEQUENCES OF A PUBLIC HEALTH STRATEGY Committee on Responding to the Psychological Consequences of Terrorism Board on Neuroscience and Behavioral Health Adrienne Stith Butler, Allison M. Panzer, Lewis R. GolUfrank, Eclitors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the Na- tional Academy of Sciences, the National Academy of Engineering, and the Institute of Medi- cine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Institute of Medicine, and the National Institute of Mental Health and Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. The views presented in this report are those of the Institute of Medicine Committee on Responding to the Psychological Consequences of Terrorism and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Preparing for the psychological consequences of terrorism: a public health strategy / Committee on Responding to the Psychological Consequences of Terrorism Board on Neuroscience and Behavioral Health; Adrienne Stith Butler, Allison M. Panzer, Lewis R. Goldfrank, editors. p. ; cm. Includes bibliographical references. ISBN 0-309-08953-0 (pbk.) ISBN 0-309-51919-5 (PDF) 1. Mentalhealth services United States Planning. 2. Crisis intervention (Mental health services) United States Planning. 3. Terrorism Government policy United States. 4. Terrorism United States Psychological aspects. 5. Terrorism Health aspects United States. 6. Victims of terrorism Rehabilitation United States. [DNLM: 1. Stress Disorders,Traumatic prevention & control United States. 2. Terrorism psychology United States. 3. Disaster Planning United States. 4. Mental Health Services United States. WM 172 P927 2003] I. Butler, Adrienne Stith. II. Panzer, Allison M. III. Goldfrank, Lewis R., 1941- IV. Institute of Medicine (U.S.~. Committee on Responding to the Psychological Consequences of Terrorism Board on Neuroscience and Behavioral Health. RA790.6.P735 2003 362.2'0973 dc21 2003013770 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cul- tures and religions since the beginning of recorded history. The serpent adopted as a logo- type by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"I(nowin,g is not enough; we mast apply. Willing is not enough; we must dlo. " Goethe ........... ............................ . ........... ........ INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating soci- ety of distinguished scholars engaged in scientific and engineering research, dedi- cated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its mem- bers, sharing with the National Academy of Sciences the responsibility for advis- ing the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal gov- ernment. Functioning in accordance with general policies determined by the Acad- emy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing ser- vices to the government, the public, and the scientific and engineering communi- ties. The Council is administered jointly by both Academies and the Institute of Medicine Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www. nationa l-academies.org

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COMMITTEE ON RESPONDING TO THE PSYCHOLOGICAL CONSEQUENCES OF TERRORISM Lewis R. Goldfrank (Chair), Director, Emergency Medicine, Bellevue Hospital Center, Medical Director, NYC Poison Center, New York University Medical Center Gerard A. Jacobs, Director, Disaster Mental Health Institute, University of South Dakota Carol North, Professor of Psychiatry, Washington University School of Medicine Patricia Quinlisk, Medical Director and State Epidemiologist, Iowa Department of Public Health Robert I. Ursano, Director, Center for the Study of Traumatic Stress Professor and Chairman, Department of Psychiatry, Uniformed Services University of the Health Sciences Nancy Wallace, President, New Health Directions, Inc. Marleen Wong (Liaison to the Board on Neuroscience and Behavioral Health), Director, School Crisis and Disaster Recovery, National Center for Child Traumatic Stress, Director, Crisis Counseling and Intervention Services, Los Angeles Unified School District CONSULTANTS Thomas H. Bornemann, Director, Mental Health Programs, The Carter Center Daniel A. Pollock, Medical Epidemiologist, Centers for Disease Control and Prevention IOM PROJECT STAFF Adrienne Stith Butler, Study Director Allison M. Panzer, Research Assistant IOM BOARD STAFF Andrew M. Pope, Acting Director, Board on Neuroscience and Behavioral Health Catherine A. Paige, Administrative Assistant Rosa Pommier, Financial Associate COPY EDITOR Florence Poillon v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with pro- cedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integ- rity of the deliberative process. We wish to thank the following individu- als for their review of this report: Edward Bernstein, Department of Emergency Medicine, Boston University, Boston, MA Colleen Conway-Welch, School of Nursing, Vanderbilt University, Nashville, TN Brian W. Flynn, Rear Admiral/Assistant Surgeon General, U.S. Public Health Service (retired) Dennis Perotta, Bureau of Epidemiology, Texas Department of Health, Austin, TX Robert S. Pynoos, National Center for Child Traumatic Stress, University of California, Los Angeles Henry W. Riecken, University of Pennsylvania School of Medicine (emeritus), Washington, DC Monica Schoch-Spana, Center for Civilian and Biodefense Studies, Johns Hopkins School of Public Health, Baltimore, MD . . v''

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vIll REVIEWERS Merritt Dean Schreiber, National Center for Child Traumatic Stress, University of California, Los Angeles Arieh Y. Shalev, Department of Psychiatry, Hadassah University Hospital, Jerusalem Neil l. Smelser, Department of Sociology (emeritus), University of California, Berkeley Bradley Stein, RAND Health; Department of Child Psychiatry, University of Southern California, Los Angeles Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the con- clusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Lester N. Wright, Deputy Commissioner and Chief Medical Officer, New York De- partment of Correctional Services, and Charles Tilly, Joseph L. Buttenwieser Professor of Social Science, Columbia University, New York, NY. Appointed by the National Research Council and Institute of Medi- cine, they were responsible for making certain that an independent ex- amination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Re- sponsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Acknowledgments Several individuals and organizations made important contributions to the study committee's process and to this report. The committee wishes to thank these individuals, but recognizes that attempts to identify all and acknowledge their contributions would require more space than is avail- able in this brief section. To begin, the committee would like to thank the external sponsors of this report. In addition to funding provided by the Institute of Medicine, funds for the committee's work were provided by the National Institute of Mental Health and the Substance Abuse and Mental Heath Services Administration, U.S. Department of Health and Human Services. The committee thanks Farris Tuma and Robert DeMartino, who served as the Task Order Officers on this grant. The committee would next like to thank consultants Thomas H. Bornemann, Director of Mental Health Programs, The Carter Center, At- lanta, GA, and Daniel A. Pollock, Medical Epidemiologist, Centers for Dis- ease Control and Prevention, Atlanta, GA. These individuals provided invaluable contributions to the committee's deliberations. They are not responsible for the final content of the report. The committee found the perspectives of many individuals to be valuable in providing input regarding the psychological responses to ter- rorism, recognizing vulnerable populations, and identifying gaps in vari- ous systems of response. Several individuals and organizations provided important information at an open workshop of the committee. The com- mittee greatly appreciates opening and sponsor comments provided by VADM Richard Carmona, Surgeon General, US Public Health Service; IX

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x ACKNOWLEDGMENTS Susanne A. Stoiber, IOM Executive Officer; Richard Nakamura, Acting Di- rector, National Institute of Mental Health; and Gail P. Hutchings, Acting Director, Center for Mental Health Services, Substance Abuse and Men- tal Health Services Administration. Workshop speakers included, in or- der of appearance, Roxane Cohen Silver, Department of Psychology and Social Behavior, University of California, Irvine; Robert DeMartino, Cen- ter for Mental Health Services, SAMHSA; Audrey Burnam, Health Divi- sion, RAND Corporation; James Jaranson, Center for Victims of Torture, University of Minnesota; Elizabeth Todd-Bazemore, Disaster Mental Health Institute, University of South Dakota; Paul Kesner, Safe and Drug Free Schools Program, US Department of Education; Seth Hassett, Center for Mental Health Services, SAMHSA; Col. Ann Norwood, Dept. of Psychia- try, Uniformed Services University of the Heath Sciences; Dori B. Reissman, Bioterrorism Preparedness and Response Program, Centers for Disease Control and Prevention; Kathryn McKay Turman, Office of Victim Assistance, Federal Bureau of Investigations; Alfonso R. Batres, Readjust- ment Counseling Services, Department of Veterans Affairs; Chip Felton, Center for Performance Evaluation and Outcomes Management, New York State Office of Mental Health; Betty Pfefferbaum, Department of Psy- chiatry and Behavioral Sciences, University of Oklahoma College of Medicine; Ruby E. Brown, Community Resilience Project, Arlington County Department of Human Services; Reverend Deacon Michael E. Murray, Interfaith Crisis Chaplaincy; Judith Shindul-Rothschild, Boston College School of Nursing; Kathleen D'Amato-Smith, formerly of Merrill Lynch Employee Assistance Program; Margaret M. Pepe, American Red Cross Disaster Services; Margaret Heldring, America's HealthTogether; Thomas H. Bornemann, The Carter Center; Ivan C.A. Walks, formerly of Department of Health, District of Columbia; and Monica Schoch-Spana, Center for Civilian Biodefense, rohns Hopkins University. The commit- tee thanks each of these individuals. A summary of major themes from the workshop is presented in Appendix A. Finally, the committee would also like to thank the many individuals who provided information pertinent to the committee's charge including Shauna Spencer, Washington, DC, Department of Mental Health; Dan Dodgen, Jan Peterson, Georgia Sargeant, and Susan Brandon, American Psy- chological Association; William Goldman, University of California, San Francisco; Sandro Galea, New York Academy of Medicine; Steven Mirin and Lloyd Sederer, American Psychiatric Association; Susan Solomon, Of- fice for Behavioral and Social Sciences Research, National Institutes of Health; Robert Pynoos, University of California, Los Angeles; Glenn Fiedelholtz, Science Applications International Corporation; Randal Quevillon, University of South Dakota; and Terri Tanielian, RAND.

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Preface Our study panel began deliberations with significantly divergent views on the meaning of the concept of "psychological consequences" and the definition of terrorism. In addition we had many perspectives on the appropriate preventive and therapeutic roles of public health and mental health systems with respect to the psychological consequences of terrorism. We agreed that terrorism affected humans in all walks of life and that societal terrorists are as diverse as the individuals they terrorize in society. We reflected on those in the inner city where chronic violence is rampant, those attacked by Timothy McVeigh in Oklahoma City, and those who died in the Al-Qaeda World Trade Center attack. We knew that the biological and physical consequences of terrorism were less prevalent than the emotional, behavioral, and cognitive consequences. When we thought as a panel representing numerous disciplines, a unifying public health strategy became apparent. Since the forms, mani- festations, and effects of terrorism are so diverse, we chose to adopt a public health plan to assist in preparation for and response to the psycho- logical consequences of terrorism. We chose the Haddon Matrix, which utilizes the factors (affected individuals and populations, terrorist and injurious agent, and physical and social environment) and phases (pre- event, event, and post-event) that permit an analytic modeling of the psy- chological consequences of terrorism. This strategy allows the investiga- tor to utilize public health methodology to analyze the biological- physical, psychological, and sociocultural characteristics at each phase of a terrorist event for each factor under consideration. It is our belief that the power of this strategy is that it necessitates the Xl

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X11 PREFFACE participation of all members of a society to achieve preparedness. This modeling allows for the demonstration of areas of nonparticipation, non- compliance, noncollaboration, and systemic inadequacies. It is our hope that in preparing for the unknown, investigators will also study local forms of violence serial rapists and school shootings and the behaviors of Theodore Kaczynski, Timothy McVeigh, the pur- veyor of the anthrax letters, and Al-Qaeda. Utilizing this approach will facilitate the roles of investigators from the fields of public health, mental health, and emergency preparedness in analyzing the available counter- measures. The last line (end results) of the Haddon Matrix truly is the bottom line in the development of an integrated societal approach that avoids adverse end results. If we can assist in limiting the number of adversely affected individuals and populations, in limiting the adverse effects on the physical and social environment, and in affecting the behavior and efficacy of terrorists and their agents by motivating the development of countermeasures, we will have been successful. Federal, state, and local authorities as well as communities will be better prepared when individual response plans are integrated. Local and regional collaborative networks must emphasize the use of newly em- powered and educated personnel in a continuum from the school and workplace to those providing primary health care and emergency re- sponse as well as those in the broad areas of mental health and public health The establishment of these networks will allow effective coordina- tion and cooperation among and within agencies. This demanding type of collaboration emphasizing honest inter- and intra-agency criticism will facilitate the creation of a level of societal competence that is the greatest force in confronting terrorism. The integration of all those who partici- pate in emergency preparedness into a public health structure depends on rigorous continuing education and improvement. This integration em- powers local communities, permitting the flexibility and creativity neces- sary to respond to the psychological consequences of terrorism. Finally, we recognized that preparing the entire society necessitates incorporating rational public health education into childhood education, into the efforts of faith-based organizations, into the workplace, and throughout each community whenever educational opportunities arise. This education must demystify the complexities of our modern world, permitting a better understanding of human risk while focusing exten- sively on the dehumanizing effects on children and adults of observing interpersonal violence of any sort from domestic violence to random

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PREFACE . . . XIll shootings to explosive assaults. By recognizing that preparation for the psychological consequences of terrorism is an ongoing social problem, we will devote our energies to an understanding of the factors and events essential to inform strategies to achieve population health. I believe that our work will assist in achieving these essential societal goals. Lewis R. Goldfrank, M.D. Chair Committee on Responding to the Psychological Consequences of Terrorism

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Contents Executive Summary 1 Introduction: Rationale for a Public Health Response to the Psychological Consequences of Terrorism Charge to the Committee, 20 Terrorism and the Public's Health: The Need for a Public Health Response to the Psychological Consequences of Terrorism, 23 Content and Structure of the Report, 32 2 Understanding the Psychological Consequences of Traumatic Events, Disasters, and Terrorism Traumatic Events, 34 Disasters, 40 Terrorism, 45 Research Challenges and Needs, 61 Summary, 62 3 Current Infrastructure in the United States for Responding to the Psychological Consequences of Terrorism Federal Government Systems for Response, 65 State and Local Government Systems for Response, 76 Private Sector Systems for Response, 79 xv 1 19 34 64

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XVI Capacity of the Infrastructure to Respond to the Psychological Consequences of Terrorism, 84 Gaps in the Current Infrastructure, 92 Summary, 96 4 Developing Strategies for Minimizing the Psychological Consequences of Terrorism Through Prevention, Intervention, and Health Promotion Application of the Haddon Matrix, 100 Pre-Event Phase, 106 Event Phase, 120 Post-Event Phase, 123 Desired End Results, 133 Application of the Example Public Health Strategy, 134 5 Conclusions and Recommendations for Effective Prevention and Response Findings and Recommendations, 136 References Appendixes A Data Sources and Methods B Committee and Staff Biographies CONTENTS 99 135 143 155 164