In the aftermath of September 11th, an urgent need arose for the services of highly trained clinical psychologists to treat thousands of victims, rescuers, and their families. Sadly, the effort to deliver quality mental health services was largely scattered, disorganized, understaffed, and involved mostly well meaning but inadequately trained mental health professionals. The inadequate training of those who rushed to help was not entirely their own fault; there is little training available in disaster mental health services, and even less (if any) training available in treatment protocols that have scientific, empirical support for their efficacy. It is important, and chilling, to note that some authorities (Rose, Bisson, & Wessely, 2001; Van Emmerick, Kamphuis, Hulsbosch, & Emmelkamp, in press) have concluded that popular models of disaster mental health response (e.g., Critical Incident Stress Debriefing) are potentially harmful to victims of terrorist acts. The well-intentioned "trauma tourists" who descended upon New York and Washington might have actually compounded the suffering of victims and their families.
In 1999 the National Research Council and the Institute of Medicine, in an attempt to address the threat of chemical and biological attacks, produced several recommendations for the direction of future research in clinical psychology. The committee identifies several "areas of concern" in which immediate progress was necessary. It is important to note that little, if any, meaningful work has been published in any of these areas. These research areas are as follows:
1. Training: Identify resource material on chemical/biological agents, stress reduction after other traumas, and disaster response services, and enlist the help of mental health professional societies in developing a training program for mental health professionals. The key to success in this attempt will be offering continuing education credits and certification for mental health providers trained in chemical/biological attack response.
2. Screening and Assessment: Identify suitable psychological screening methods for use by mental health providers and possibly first responders, differentiating adjustment reactions after chemical/biological attacks from more serious psychological illness (e.g., panic disorder, PTSD, psychosis, depression), and organic brain impairment from chemical or biological agents. Research to identify trauma characteristics and behavior patterns that predict long-term disability may be necessary.
3. Communication: Develop health education and crisis response materials for the general public, including specific communication on chemical or biological agents. Additional information is needed on risk assessment/threat perception by individuals and groups and on risk communication by public officials, especially the roles of both the mass media and the Internet in the transmission of anxiety (or confidence). Some information is available in EPA studies of pollutants and toxic waste, but there is little or no systematically collected data on fears and anxieties related to the possibility of purposefully introduced disease.
4. Interventions: Evaluative research is needed on interventions for preventing or ameliorating adverse psychological effects in emergency workers, victims, and near-victims. Specific crisis intervention methods may be necessary for chemical or biological terrorist incidents, but in the absence of such incidents researchers might draw on studies of chemical spills, epidemics of infectious disease, and more conventional terrorist incidents.
It is clear that a national center on disaster psychology and terrorism is needed to conduct high quality research, evaluate existing interventions, and develop empirically-based treatment protocols. The work of this center would guide the efforts of researchers, practitioners, and national disaster relief agencies as they prepare for and respond to the broad range of complex sequelae resulting from terrorist acts. At present, there are no nationally recognized programs in clinical psychology (nor in the other mental health disciplines) that are fully prepared to provide the training necessary to develop researchers and practitioners capable of meeting these new challenges.
The establishment of national centers for research and clinical training has proved a highly successful means of combating many serious medical and psychological conditions. Recent events have underscored the urgent need for a national center on disaster psychology and terrorism. This center would coordinate the efforts of researchers, evaluate data collected, and develop scientific, empirical protocols for the treatment of those victimized by terrorism or other man-made, catastrophic events. At present, no such treatment protocols exist, because no body of relevant scientific knowledge exists to support them. A primary mission of this center would be to train current and future practitioners in the delivery of effective treatments to all whose lives are disrupted by terror. In addition, the center would serve as an educational resource for governmental and community agencies seeking the best methods for preventing, preparing for, and recovering from mass casualty assaults.
The catastrophic acts perpetrated on September 11, 2001 have forced military, medical, and psychological experts to re-evaluate their current understanding of mass casualty terrorism. As Ariel Merari, former head of the Israeli Defense Forces' Hostage Negotiations and Crisis Management Team, has noted, the only factors constraining the terrorists who seek to destroy us are practical and technical, not political or moral. Among the lessons learned by Merari and others on the front lines is that the strategic intent of modern terrorists is to create huge numbers of secondary psychological casualties by means of large-scale physical attacks. In the 1970s, it was often repeated that terrorists "want a lot of people watching, not a lot of people dead"; today, it is more accurate to say that terrorists "want a lot of people dead, and even more people crippled by fear and grief."
Government and military officials acknowledge that we are currently unprepared to care for the large numbers of medical and psychological casualties that would result from any attack involving weapons of mass destruction (WMD) and/or bioterrorism. National authorities such as Leon E. Moores, M.D., of the Walter Reed Army Medical Center, have calculated that the number of casualties from a WMD attack would be in the thousands, but that the long lasting psychological consequences of such an attack would have a devastating affect on millions of individuals.
Military psychologists have long known that fear, stress, and exhaustion cause more casualties than do bombs and bullets. The ratios of psychological to physical casualties can be enormous; for every one death directly caused by an Iraqi Scud missile attack on Israel during the Gulf War, there were 272 hospital admissions resulting from clinical psychological emergencies. The March 20, 1995 sarin attack in the Tokyo subway killed 12 people and caused over 4,000 non-affected individuals to present to area hospitals, often with psychogenic symptoms of chemical injury (World Health Organization, 2001). As Dr. Moores writes, Clearly, the impact on society can be much greater than initial casualty rates might imply. The long-term psychological impact of the use or even threat of WMD is difficult to predict. Changes in daily activity, depression and suicide rates, and economic impact can last for years or even decades, and current disaster experts have no models to predict the ultimate need for psychological assessment or treatment services. Many experts contend, based on the Israeli experience and other similar venues (e.g., Northern Ireland) that the strain on the medical resources and psychological strength of a society could potentially be crippling (Moores, 2002).
At present, the psychological science needed to provide proper and effective treatment for victims of horrendous events such as September 11th simply does not exist. Despite a wealth of information about psychological assessment and intervention following severe individual trauma (e.g. combat or rape), and following natural disasters and airplane crashes, there is no widespread scientific or clinical consensus regarding the efficacy of these treatment interventions with individuals directly affected by a terrorist attack. There is a similar scarcity of scientific data regarding appropriate treatments specifically designed for people not directly exposed to, but struggling to cope with actual or threatened terrorist acts.
The National Center on Disaster Psychology and Terrorism, located in Palo Alto, California has been established to address the psychological issues that have developed along with the escalating
threat of terrorism in the 21st century. The immediate goals of the National Center are to: develop, evaluate, and deliver scientific, empirical treatment interventions for the victims of terrorism and their rescuers; train current and future mental healthcare professionals in the effective use of these treatments; conduct scientific research that will assist governmental and community agencies to prevent, prepare for, and recover from mass casualty assaults; organize and train "rapid response" teams of professional clinicians that will respond immediately and effectively to future national crises and emergencies; and to convene biannual international conferences on disaster psychology and terrorism, the first of which was held in October 2002. The proceedings of this groundbreaking meeting of authorities in the field will be published as, The Oxford Book of Psychology and Terrorism, in the coming year. To learn more about the Center, visit www.ncdpt.org.
Moores, L. (2002). Threat credibility and weapons of mass destruction. Neurosurgical Focus, 12, 1-3.
Rose, S., Bisson, J. I., & Wessely, S. (2001). Psychological debriefing for preventing post traumatic stress disorder (PTSD) (Cochrane Review). In: The Cochrane Library, 4. Oxford: Update Software. Abstract available online at: http://www.cochrane.org/cochrane/revabstr/ab000560.htm
Van Emmerick, A. A. P., Kamphuis, J. H., Hulsbosch, A. M., & Emmelkamp, P. M. G. (In press). Single session debriefing following psychotrauma, help or harm: A metaanalysis. The Lancet.
World Health Organization. (2001). The Word Health Report 2001.