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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
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:
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.
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-
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
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-
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-
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?
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
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
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
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
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
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
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.