Psychology of Terrorism

Bruce Bongar, et al., Editors

OXFORD UNIVERSITY PRESS PSYCHOLOGY OF TERRORISM This page intentionally left blank Psychology of Terrorism

EDITED BY

Bruce Bongar Lisa M. Brown Larry E. Beutler James N. Breckenridge Philip G. Zimbardo

2007 3

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Library of Congress Cataloging-in-Publicaton Data Psychology of terrorism / edited by Bruce Bongar ...[et al.]. p. cm. Includes bibliographical references. ISBN–13 978–0–19–517249–2 ISBN 0–19–517249–3 1. Terrorism—Psychological aspects. 2. Disasters—Psychological aspects. 3. Victims of terrorism—Mental health. I. Bongar, Bruce Michael. [DNLM: 1. Terrorism—psychology. 2. Stress, Psychological —therapy. 3. Survivors— psychology. WA 295 P9743 2006] RC569.5.T47P83 2006 363.32019—dc22 2005034001

987654321 Printed in the United States of America on acid-free paper This book is dedicated to all those who ﬁght terrorism, to all those who strive to prevent terrorism, and to all those whose lives have been irreparably scarred by terrorism. This page intentionally left blank Foreword

How do I answer the preschooler who asks, ‘‘Why emotional focus for Western society. During the does that man want to kill us?’’ during a nightly following years we have had to confront the horror news broadcast. Why do wealthy suburbanites beg of significant civilian casualties, live with uncer- their primary care physicians to write prescriptions tainty and fear compounded by stumbling and infor Cipro (ciprofloxacin) when no outbreak of an- trusive efforts by government to protect us, all the thrax has ever occurred within hundreds of miles? while attempting to comprehend the willingness How do we provide explanations of dispositional of other people from different cultures to gladly die perceived risk, negativity bias, attributional error, in an effort to kill as many of us as possible. and social amplification to the nightly news re- As behavioral scientists and mental health porter who wants psychological sound bites? Not practitioners, the years since 9/11 have forced us to long ago few of us would have dreamed that we contemplate a range questions long overlooked by would face such questions. many of our colleagues. Should we regard those What happens to people, both as individuals who organize and perpetrate acts of terror as crim- and members of social groups, when we suddenly inals or revolutionaries; antisocial personalities or find ourselves forced to question our fundamental religious ideologues; psychopaths or self-sacrificing assumptions about our basic safety, security, and advocates of radical social change; or all of the well-being? What happens when that challenge above? What treatment strategies will prove most appears suddenly in the form of massive destruc- effective for helping people who experience post tion and loss of life from unanticipated sources traumatic stress, chronic reactive anxiety, burnout, and directions, accompanied by continuing threats and related physical symptoms? Does the develop- from others we do not know and whose motives ment of a complex fluctuating color coded threat we cannot comprehend? Today, we know the an- level system, and announcement that future attacks swer: anxiety, fear, dread, and terror. will almost certainly occur. facilitate or hinder Terrorism in human history dates back at least coping? Do existing treatment models actually work to biblical times, although September 11, 2001, or must we abandon conventional ideas for new brought the full psychological and societal impact intervention paradigms? What can we do to proof massively destructive terrorist acts into sharp mote resilience in coping with uncertain risk, viii Foreword chronic threat of future attacks, and inconsistent of historical events, as well as domestic terrorism messages from government authorities? Traditional such as the threats posed by the ‘‘Unabomber,’’ education and training of mental health profes- Oklahoma City Bombing, and postal anthrax sionals and behaviorally scientists has done little to incidents. prepare us for addressing these critical questions. As we prepare ourselves and our students to Bongar and his talented colleagues offer us serve the contemporary needs of society, the con- significant assistance in overcoming the gaps in our tents of this volume provide an incredibly valuable training. They have compiled a broad and deep and vital resource. The work of these contributors array of exceptionally useful information aimed at will enable our profession to more readily step for- helping readers both to understand the psychology ward and engage in research and clinical endeavors of the terrorist and the best scientifically grounded aimed at reducing both terrorist threats and the ac- remedies for the terrorized. These experts from companying psychological consequences. Although academic, medical, military, and clinical settings I rue the need for this excellent resource, I remain cover the full range of theoretical, clinical, social grateful for it. psychological, work site, developmental, and his- Gerald P. Koocher torical contexts. The authors also look well Boston beyond the scope of 9/11, addressing a wide range March 23, 2006 Acknowledgments

I, along with millions of others who watched New York City was always there in his soul). Before the events of September 11, 2001, unfold, felt my trip, I was honored to be invited as a special- the immediate shocking impact of the terrorist ist in clinical emergencies and crises to come to attacks—all the more so as my son frequently Washington, D.C. to discuss disaster mental health traveled on that fateful ﬂight from Boston to San and its role with regard to 9/11 with Dr. Bernadine Francisco and could have easily been on the plane Healy, the head of the American Red Cross. After that terrible day. As a clinical psychologist, I im- spending several days in New York City, and being mediately volunteered my services to the American astonished at the incredible resilience of this re- Red Cross (ARC). While awaiting an assignment to markable city and its people, I was able to meet at go to Manhattan, I completed the required ARC some length with Dr. Healey and her senior aid at Disaster Mental Health Level 1 training to work at a ARC headquarters. In this meeting, I emphasized disaster site. As both a scientist and a practitioner, I the critical role of the American Psychological As- was astonished to learn that scientiﬁcally validated sociation, through its Disaster Response Network methods were not being used for training, and the (DRN), and the efforts of Dr. Russell Newman and need to provide responders, victims proximally and senior DRN staff who served as vital resources that remotely affected with the best possible psycholo- stood ready to work closely with the ARC and its gical tools to deal with this horror became evident then head of disaster mental health, Dr. John and provided a challenge for me. Clizbe. While awaiting any available opening for an Most importantly, I had a remarkable evening ARC assignment to go back to New York City, I with the individual whom I consider to be the took it upon myself immediately to go to New York, foremost authority on suicide terror in the world, and without identifying myself in any way, in- Professor Ariel Merari. It was through this meeting formally assessed the situation as best I could. An at the Willard Hotel that I realized how little I and insight soon emerged. These people had attacked other interested mental health professionals really not just the United States of America, but my Dad’s knew about terrorism and what this heinous attack ‘‘home.’’ For my father, Moses Bongar, was a ‘‘true America would entail in the years to come. That New Yorker’’ (and though he traveled far and wide, evening with Ariel changed my life. For Professor x Acknowledgments

Merari shared with me his vast experience and that inevitable psychological trauma that is inherent in of his Israeli colleagues who have waged battle any human-created mass casualty event. against this ghastly sort of event since the founding Thanks to Joan and to her dedicated colleagues of the State of Israel. He quickly convinced me that and staff at OUP for guidance and assistance in America would soon find itself deluged with a preparing this massive missive. It is essential to panoply of so-called terrorism experts—all of acknowledge the magnificent role that OUP’s Jo- whom would be more than willing to provide their seph Zito, Jennifer Rappaport, Mallory Jensen, and learned opinions (often for a substantial fee). Un- Anne Enenbach played in making this book a fortunately, as I had already learned decades ago, reality. one good scientific study is worth a thousand I would be remiss in not acknowledging the ‘‘learned opinions.’’ Thus, Professor Merari inspired critical additional financial support for the con- me to coordinate the first ever American-based ference that was solicited by President Allen Calvin international conference on the psychology of ter- of the Pacific Graduate School of Psychology and, rorism. Science, rather than ‘‘opinion,’’ would be in particular, wish to thank Racky Newman and her the heart and soul of this endeavor. I would also be foundation and Rabbi Stephen Pearce of Temple remiss in not mentioning another remarkable, ac- Emanu-El for support of this event. complished Merari, Professor Dalia Merari, whose This book also owes a great debt to the input sage counsel helped me focus on what would be and wise counsel of Col. Larry James of the United of most interest and value in the applied sphere. States Army; an equal debt is owed to Captain My colleagues at the first North Atlantic Treaty Elizabeth Holmes of the United States Naval Organization conference on the prevention of sui- Academy (and to my colleagues Brad Johnson and cide terror, organized by Professors Ariel Merari Rocky Lall). I would also like to thank and ac- and Scott Atran, and held in Lisbon in 2004 were knowledge Dr. Patrick DeLeon for his sage coun- ever in my mind as we headed for the finish line. In sel. I also wish to thank my colleagues Drs. Paul particular, I wish to acknowledge Dr. Simon Wes- Stockton, Phillip Zimbardo, Larry Beutler, and ley and Professor Atran for their generous efforts to James Breckenridge for their dedicated work in educate me on the nuances and vital dimensions crafting a marvelous course on the psychology of of both basic and applied science after such evil terrorism at the United States Naval Postgraduate events. London and Madrid proved their pre- School (NPS) in Monterey, California. Professors science. At the NATO conference I also learned often dream of having a class of students so dedi- how science and its cutting edge applications can cated, so wise, and most importantly, so motivated be best mobilized through teamwork and discus- to learn that teaching is not a mere pleasure, but sion. At several dinners, I was fortunate enough to a life-changing event. The first class in the NPS be educated in the complexities of how science can Master’s degree program in Homeland Security impact assessment, risk management and inter- humbled all five of us with their amazing range of vention by a wise and wonderful colleague, Major intellect, experience and talents (both individually General Issac Ben-Israel. and collectively). You know who you are and I, for It is crucial to note that neither the initial one, will be forever grateful for the experience of conference in Palo Alto on the psychology of ter- being your student and your professor. rorism nor this book could ever have come to Any book of this magnitude rises or falls on the fruition without the faith and support of a truly perseverance, resiliency and good spirits of one’s remarkable woman, Joan Bossert of Oxford Uni- senior support staff. Laura Pratchett, my graduate versity Press (OUP). For it was Joan and the other student assistant from my PGSP-STANFORD leaders at OUP who, without missing a beat, im- doctor of psychology program, functioned at the mediately recognized that such a conference was level of a junior colleague rather than a beginning not only timely, but represented a sea change in graduate student (here her training in Scotland as a how psychological science and its application solicitor brought a laser beam focus to this old would be the key to understanding the role that professor’s tome). My former graduate students psychology would play in making a difference in Drs. Glenn Sullivan and Eric Crawford also insured how we assess, manage, treat, and prevent the that the conference from which this work sprung Acknowledgments xi was run like a Swiss watch (a Rolex for that matter). have been my hero. The reader may wonder about I also want to acknowledge that Dr. Sullivan will such an odd place to tell his son this—for both carry the torch on my own work on suicide terror father and son are old-fashioned guys who are long after I have sailed off to retirement. I am also easily embarrassed about telling each other how indebted to my personal assistant, Briana Breen, for much they love one another. Parents in all cultures her perseverance, resiliency and consistent good know that the greatest pride is the pride one takes spirits in getting this book completed through in the accomplishments of one’s children. her role as a senior coordinator. Briana tirelessly I am always indebted to my family and thank endured ‘‘herding cats’’—especially yours truly. my Mom, my amazingly gifted and talented sister From a personal standpoint, I also wish to Hallie, her husband James White and my Native acknowledge the incredible support of Professor American nephew and nieces, my wonderfully Larry Beutler, my beloved colleague and writing entrepreneurial brother Andrew, his wife Kim and partner of so many years—Larry was always there the boys, and my intrepid sister Debbie and her and his gimlet editorial eye suffuses many of the children in Israel. chapters herein. Blanche Dubois in the Tennessee I would also like to thank specifically for their Williams masterpiece, A Street Car Named Desire, unflagging support for the National Center on once remarked that ‘‘I have always depended on the Disaster Psychology and Terrorism, our dis- kindness of strangers.’’ More than 20 years ago, tinguished chair of psychiatry, Alan Schatzberg, Professor Phillip Zimbardo, already a legend as Dean Pizzo of Stanford Medical School, the chair of teacher of psychology, most generously recom- our joint doctor of psychology program, Bruce mended to his publisher that a young colleague Arnow, Javaid Sheikh of VAPAHCS, and last but be asked to review a critical chapter or two in his never least our visionary, President Allen Calvin of classic introductory text. That young professor the Pacific Graduate School. I would also like to Bongar (now grown a bit long in the tooth) hopes thank my friends and colleagues Eric Harris and that 20 years from now, if he is lucky, he will have Susan Brooks, Wendy and Sy Packman, Ben Patty the energy, intellectual mastery and drive that Phil and Bennie, Linda Crothers and Dani, my fellow continues to demonstrate to the world. Professors ‘‘Lotus Eaters’’ David Clark, Andrew Slaby, and lucky enough to have many years of mentoring Terry Maltsberger, Art and Barbara Frankel, David doctoral students know that if one is extremely and Marilyn Rigler, Don Bersoff, Kirk Hubbard, lucky, one has a few super stars, destined early on Bruce and Diane Ogilvie, and Kevin Murphy. In to surpass their professor’s own research and sci- addition, since 1978, I have been honored beyond entific accomplishments. It is clear that my col- measure to have as my esteemed friend and colleague and former doctoral student Dr. Lisa Brown league, the current president of the American Psy- is already on such a trajectory and her enormous chological Association, Dean Gerald Koocher. efforts, along with those of my colleagues Larry, Randy Travis, a famous American country- Phil, and Jim are ever present in this work. western balladeer, once sang the lyrics ‘‘your heroes Psychologists who wish to understand the will help you find good in yourself, your friends psychology of terrorism can learn much from our won’t desert you for somebody else.’’ Thank you sibling social sciences, in particular from the dis- RAH, IF, CSF, ACD, WS, SF, CR, WBG, HW, AM cipline of anthropology. My life-long friend, mo- PL, BCO, DR, MHE, DR, LGP, CR, JKG, JR, WSC ther of our son Brandon, and my former wife, the and JPJ, LV, CP, JP, GN, and SW. noted cultural anthropologist Professor Debbora For over twenty five years I have been privileged Battaglia, who for almost 13 years honored me by to be a scientific fellow among a remarkable band of allowing me to accompany her on many of her brothers and sisters, The Explorers Club, who have professional journeys. For most of my adult life, I ‘‘pushed the limits for more than a century’’—thank have not been a deeply religious person, but I you for allowing this ‘‘shrink’’ to learn that ‘‘home continue to thank God every day that our son was is where when you go there, they have to take not on that plane. you in.’’ Most of all, this book is dedicated to my son, While my colleagues Lisa, Larry, Phil, and Brandon Fortune Bongar—for so many years you Jim kindly and generously put their names and xii Acknowledgments considerable skills into this volume, as a bluewater (and most honestly critical audience) I have ever sailor with thousands of miles under my keel, I addressed. I am honored to have had the chance to know that to escape chaos, in the end someone must work with every contributor to this volume and take full responsibility as the ‘‘skipper’’ for all that is hope that each reader will find that the assembled contained herein. I fully accept such responsibility, chapters meet both their professional and personal and I trust that the readers of this book will soon needs. realize that all chapter authors involved in this Finally, to the sunshine of my life: John, Gordo, project strove at every juncture to provide the in- Frank, Las Vegas Larry, M, Jeff, Joel, Sarah, Robyn tended audience with the most accurate, useful and The Wonder Dog, to Donna Olsen Satterfield, my scientifically sound chapters possible. In particular I former internship supervisor who for 30 years has am indebted to Professors Tony Taylor and Douglas been my best friend, and last but never least, first Paton of New Zealand for inviting me to give a among equals, to My Funny Valentine, Cookie (who plenary address on the psychology of terrorism to taught me the real meaning of true love that lasts the New Zealand Psychological Society—the best forever—it was always you from the start). Contents

Foreword 6 Terrorism and the Media 81 Gerald P. Koocher vii Joel N. Shurkin Contributors xv 7 What Is Terrorism? Key Elements and History 87 I The Psychology of Terrorism Scott Gerwehr and Kirk Hubbard 1 The Psychology of Terrorism: Deﬁning 8 Psychological Aspects of Suicide the Need and Describing the Goals 3 Terrorism 101 Bruce Bongar Ariel Merari 2 Psychological Issues in Understanding 9 The Strategy of Terrorism and the Terrorism and the Response to Psychology of Mass-Mediated Terrorism 13 Fear 116 Clark McCauley James N. Breckenridge and Philip G. Zimbardo 3 The Need for Proﬁcient Mental Health Professionals in the Study of Terrorism 32 III Consequences of Terrorism Larry E. Beutler, Gil Reyes, Zeno Franco, and 10 The Role of Religion, Spirituality, and Jennifer Housley Faith-Based Community in Coping 4 War Versus Justice in Response to With Acts of Terrorism 137 Terrorist Attacks: Competing Timothy A. Kelly Frames and Their Implications 56 11 Psychological Consequences of Actual Clark McCauley or Threatened CBRNE Terrorism 153 Glenn R. Sullivan and Bruce Bongar II Terrorism 12 Psychological Weapons of Mass 5 The Staircase to Terrorism: Disruption Through Vicarious Classical A Psychological Exploration 69 Conditioning 164 Fathali M. Moghaddam Dennis D. Embry

xiii xiv Contents

13 Near- and Long-Term Psychological 22 Cultural Considerations: Caring for Effects of Exposure to Terrorist Culturally Diverse Communities Attacks 175 in the Aftermath of Terrorist Susan E. Brandon and Andrew P. Silke Attacks 338 14 The Response of Relief Organizations to David Chiriboga Terrorist Attacks: An Overview 23 The Psychological Consequences of of How the Red Cross and Other Relief Terrorist Alerts 357 Organizations Work in Conjunction Rose McDermott and Philip G. Zimbardo With Other Agencies 194 John A. Clizbe and Susan Hamilton V Prevention and Psychological 15 Understanding How Organizational Problems in Reaction to Acts of Bias Influenced First Responders Terrorism at the World Trade Center 207 24 Defusing the Terrorism of Joseph W. Pfeifer Terror 373 16 Warfare, Terrorism, and A. J. W. Taylor Psychology 216 25 Psychological Resilience in the Face of L. Morgan Banks and Larry C. James Terrorism 400 Lisa D. Butler, Leslie A. Morland, IV Assessment and Treatment Gregory A. Leskin 17 Terrorism Stress Risk Assessment and 26 Promoting Resilience and Recovery in Management 225 First Responders 418 Douglas Paton and John. M. Violanti Richard Gist 18 Evidence-Based Interventions for 27 Integrating Medical, Public Survivors of Terrorism 247 Health, and Mental Health Assets Josef I. Ruzek, Shira Maguen, and Brett T. Litz into a National Response Strategy 434 19 Neurobiological and Behavioral Dori B. Reissman, Stephan G. Reissman, Consequences of Terrorism: and Brian W. Flynn Distinguishing Normal From Pathological Responses, Risk Profiling, 28 Reflections on the Psychology of and Optimizing Resilience 273 Terrorism 452 Rachel Yehuda, Richard Bryant, Joseph Zohar, Laura Pratchett, Lisa M. Brown, and and Charles R. Marmar Bruce Bongar 20 Older Adults and Terrorism 288 Lisa M. Brown, Donna Cohen, and Appendix: Resources in Psychology Joy R. Kohlmaier of Terrorism 459 21 Children and Terrorism: A Family Matteo Bertoni and Brynne Johannsen Psychoeducational Approach 311 Maureen Underwood, John Kalafat, and Glossary 467 Nicci Spinazolla Index 475 Contributors

Editors versity Press Clinical Psychology Series and is the winner of both the Shneidman award for early Bruce Bongar is Calvin Professor of Psychology at career achievement and Dubin award for lifetime the Pacific Graduate School of Psychology and career achievement in the scientific understanding Consulting Professor of Psychiatry and Behavio- of suicide from the American Association of Sui- ral Sciences at Stanford University School of Medi- cidology, and is past president of Section VII, cine. He founded and is the executive director of Clinical Emergencies and Crises, of the Division of the National Center on Disaster Psychology and Clinical Psychology (Division 12) of the American Terrorism. Along with Larry Beutler, the Director Psychological Association. Professor Bongar is a of the Palo Alto Medical Reserve Corps (MRC) of fellow of the American Psychological Association, the Office of the Surgeon General of the United the Academy of Psychosomatic Medicine, and the States, Professor Bongar recently volunteered his American Psychological Society. A practicing clin- services and has joined the senior staff of the San ical psychologist and psychotherapist for almost Mateo County Coastside Medical Reserve Corp 30 years, Dr. Bongar is a licensed psychologist, a (MRC). Professor Bongar, along with his close chartered clinical psychologist of the British Psy- colleague Professor Ariel Merari, of Tel Aviv chological Society, and a Diplomate of the American University, will be undertaking an international Board of Professional Psychology. collaborative study to attempt to scientifically understand and prevent acts of suicide terror such as Lisa M. Brown is an Assistant Professor in the those that occurred on 9/11 and the bombings in Department of Aging and Mental Health, Florida London and Madrid—a study that grew out of Mental Health Institute, and the Department of the first NATO conference on the prevention of Psychiatry and Behavioral Medicine, University of suicide terrorism—organized by Merari and Scott South Florida. Brown is interested in how adults Atran. Dr. Bongar is an authority on suicide and cope with adverse personal or societal life events. life threatening behaviors and on clinical and legal Her research on mental health and disasters has standards of care. He founded the Oxford Uni- evolved from her longstanding interest in the

xv xvi Contributors effects of adverse events and pathological condi- fairs section of Division 18 (Public Service). He tions on the mental and physical health of older recently received the Division’s National Out- adults. Brown and her colleague John A. Schinka standing Researcher Award for his work in health have recently completed a longitudinal study that economics, risk adjustment, and other statistical examines the effects of the 2004 and 2005 hurri- modeling approaches to healthcare utilization. The canes on a cohort of elderly Floridians. She is cur- Department of Veterans Affairs Under Secretary for rently evaluating the effectiveness of a mental health Health recognized Dr. Breckenridge in 2005 for intervention that was developed to reduce hurri- his Robert Wood Johnson funded research on cane related distress and put into practice state- national patterns of intensive care and palliative wide after the 2004 hurricane season. Along with care alternatives. Kathryn Hyer, Brown is examining the response and recovery of long-term care facilities during Philip G. Zimbardo is internationally recognized disasters and working to develop policy and best as the ‘‘voice and face of contemporary psychology’’ practices to protect institutionalized adults. through his widely seen PBS-TV series, Discovering Psychology, his media appearances, best-selling Larry E. Beutler is the William McInnes Dis- trade books on shyness, and his classic research, tinguished Professor of Psychology at Pacific the Stanford Prison Experiment. Zimbardo has Graduate School of Psychology (PGSP), and is a been a Stanford University professor since 1968, Consulting Professor of Psychiatry and Behavioral having taught previously at Yale, NYU, and Co- Sciences at Stanford University School of Medi- lumbia University. He is now an Emeritus Professor cine. He is also a Visiting Professor of Homeland but is still teaching more new and intense under- Security and Defense at the Naval Post-Graduate graduate courses. He has been given numerous School in Monterey and the former Chair of the awards and honors as an educator, researcher, Ph.D. Program and Director of Clinical Training at writer, and service to the profession. Most recently Pacific Graduate School of Psychology. Beutler has he was awarded the 2005 Havel Foundation Prize published over 20 scholarly books and 350 sci- from the Czech Republic for his lifetime of research entific articles and papers on psychological as- on the human condition. Among his more than 350 sessment, training, and treatment. He is a Past professional publications and 50 books is the old- President of the Society for Clinical Psychology est current textbook in psychology, Psychology and (Division 12, APA), the Division of Psychotherapy Life, going into its 18th edition. His current re- (APA), and the International Society for Psy- search interests are in the domain of experimental chotherapy Research. social psychology with a scattered emphasis on everything and anything interesting to study from James N. Breckenridge is the Associate Director of time perspective to political psychology. Zimbardo the Stanford Center for Interdisciplinary Policy, is currently enmeshed in his major opus, Zimbardo Research, and Education on Terrorism. He retired is past President of the Western Psychological As- recently from his positions as Chief of the Psy- sociation (twice), President of the American Psy- chology Services at the Veterans Affairs Palo Alto chological Association, the elected Chair of the Health Care System. Breckenridge is also Professor Council of Scientific Society Presidents (CSSP) re- of Psychology at the Pacific Graduate School of presenting 63 scientific, math and technical asso- Psychology, and Director of Training of the PGSP- ciations (with 1.5 million members), and is now STANFORD Psy.D. Consortium, and Consulting Chair of the Western Psychological Foundation Professor of Psychiatry and Behavioral Sciences and President of the Philip Zimbardo Foundation at Stanford University School of Medicine. He that collects funds for college scholarships and teaches graduate courses in the psychology of computers for children in his ancestral Sicilian terrorism at the Center for Homeland Defense and village town of Cammarata. Zimbardo is also the Security at the Naval Post-Graduate School, where director of a new terrorism center sponsored jointly he is a Distinguished Senior Fellow. Breckenridge by Stanford and the Naval Postgraduate School, is also a Fellow of the American Psychological The Interdisciplinary Center for Policy, Education, Association and is chair-elect of the Veterans Af- and Research on Terrorism (CIPERT). Contributors xvii

Contributors Zeno Franco Col. L. Morgan Banks, PhD Pacific Graduate School of Psychology, Psychological Applications Directorate, Ft. Bragg, NC Palo Alto, CA Larry E. Beutler, PhD, ABPP Scott Gerwehr Naval Postgraduate School, Monterey, CA Defense Group Inc., Center for Intelligence National Center on the Psychology of Terrorism Research and Analysis, Santa Monica, CA Richard Gist, PhD Bruce Bongar, PhD, ABPP, FAPM Department of Psychology, University of Missouri– Pacific Graduate School of Psychology, Palo Alto, CA Kansas City, Kansas City, MO Department of Psychiatry and Behavioral Sciences, Principal Assistant to the Director, Kansas City Fire Stanford University School of Medicine, Department, Kansas City, MO Stanford, CA and National Center on the Psychology of Terrorism Susan Hamilton, PhD American Red Cross, Washington, DC Susan Brandon, PhD Department of Psychology, Yale University, New Jennifer Housley Haven, CT Pacific Graduate School of Psychology, Palo Alto, CA James N. Breckenridge, PhD Kirk M. Hubbard, PhD Naval Postgraduate School, Monterey, CA Operational Assessment Division, Central In- Lisa M. Brown, PhD telligence Agency, Washington, DC Aging and Mental Health Department, Larry James, PhD Louis de la Parte Florida Mental Health Department of Psychology, Tripler Army Medical Institute, University of South Florida, Center, Honolulu, HI and Tampa, FL and National Center on the Psychology of Terrorism National Center on the Psychology of Terrorism John Kalafat, PhD Richard Bryant, PhD Graduate School of Applied and Professional Department of Psychology, University of New Psychology, Rutgers University, Piscataway, NJ South Wales, Sydney, Australia Timothy A. Kelly, PhD Lisa D. Butler, PhD Fuller Graduate School of Psychology, Pasadena, Department of Psychiatry and Behavioral Sciences, California Stanford University School of Medicine, Gregory A. Leskin, PhD Stanford, CA National Center for Post-Traumatic Stress Dis- David Chiriboga, PhD order, VA Aging and Mental Health Department, Louis de Palo Alto Healthcare System, Palo Alto, CA la Parte Florida Mental Health Institute, Joy Kohlmaier, PhD University of South Florida, Tampa, FL Louis de la Parte Florida Mental Health John A. Clizbe, PhD Institute, University of South Florida, American Red Cross, Washington, DC Tampa, FL Donna Cohen, PhD Brett T. Litz, PhD Aging and Mental Health Department, Louis de National Center for Post-Traumatic Stress la Parte Florida Mental Health Institute, Disorder, Behavioral Science Division, University of South Florida, Tampa, FL Boston, MA Dennis D. Embry, PhD Shira Maguen, PhD PAXIS Institute, Tucson, AZ Post-Traumatic Stress Disorder Program, San Brian W. Flynn, EdD, RADM, U.S. Public Francisco Veterans Administration Medical Health Services, Ret. Center, San Francisco, CA Center for the Study of Traumatic Stress, Charles R. Marmar, MD Uniformed Services University of the Health San Francisco Department of Veterans Affairs Sciences, Bethesda, MD Medical Center, San Francisco, CA xviii Contributors

Clark McCauley, PhD Joel Shurkin Psychology Department, Bryn Mawr College, Bryn National Center on the Psychology of Terrorism Mawr, PA Baltimore, MD Rose McDermott, PhD Andrew Silke, PhD Political Science Department, University of Cali- School of Law, University of East London, Strat- fornia, Santa Barbara, CA ford, London, England Ariel Merari, PhD Psychology Department, Tel Aviv University, Tel Nicci Spinazzola, EdS, LMFT, LPC Aviv, Israel and Richard Hall Community Mental Health Center, National Center on the Psychology of Terrorism Somerville, NJ Fathali M. Moghaddam, PhD Glenn R. Sullivan, PhD Psychology Department, Georgetown University, Pacific Graduate School of Psychology, Washington, DC Palo Alto, CA and Leslie Morland, PsyD National Center on the Psychology of Terrorism National Center for Post-Traumatic Stress Dis- order, Veterans Affairs Pacific Island Healthcare A. J. W. Taylor System, Honolulu, HI School of Psychology, Victoria University of Douglas Paton PhD, CPsychol Wellington, Wellington, NZ School of Psychology, University of Tasmania, Maureen Underwood, LCSW Launceston, Tasmania, Australia and Morristown, NJ National Center on the Psychology of Terrorism John M. Violanti, PhD Joseph W. Pfeifer School of Public Health and Health Fire Department of New York, NY Professions, Social and Preventative Medicines, Laura Pratchett, LLB (Hons) State University of New York–Buffalo, Pacific Graduate School of Psychology–Stanford Buffalo, NY PsyD Consortium, Palo Alto, CA Dori Reissman, MD Rachel Yehuda, PhD Centers for Disease Control and Prevention, Psychiatry Department, Mount Sinai School of Atlanta, GA Medicine, New York, NY and Traumatic Stress Studies Division, Stephan G. Reissman, PhD, CEM Mount Sinai School of Medicine and Centers for Disease Control and Prevention, Bronx Veterans Affairs Medical Center, Atlanta, GA New York, NY Gil Reyes, PhD School of Psychology, Fielding Graduate Philip G. Zimbardo, PhD University, Santa Barbara, CA Psychology Department, Stanford University, Stanford, CA Josef I. Ruzek, PhD National Center for Post-Traumatic Stress Dis- Joseph Zohar, MD order, VA Palo Alto Health Care System, Palo Psychiatry Department, Chaim Sheba Medical Alto, CA Center, Ramat Gan, Israel I The Psychology of Terrorism This page intentionally left blank 1

The Psychology of Terrorism Deﬁning the Need and Describing the Goals Bruce Bongar

Terrorism is about one thing: Psychology. It is the psychology of fear. Philip G. Zimbardo, personal communication, April 2004

The past decade has witnessed a dramatic trans- or use poison on a large scale. These assassins were formation in the nature and use of terrorism. These an eleventh-century offshoot of a Shia Muslim sect changes have brought into high relief the need for known as the Ismailis, who believed that dying better psychological and social responses to ter- in the process of their assault was an act of self- rorism and man-made disasters. It is important sacrifice and guaranteed them a pathway into to note that a major strategic intent of modern heaven. By contrast, terrorist organizations today terrorists is to create huge numbers of secondary are often much larger, more loosely connected net- psychological casualties by means of large-scale works of full-time and part-time activists, and this physical attacks. The catastrophic acts of Septem- anonymity removes inhibitions to inflict broad, in- ber 11, 2001, and their aftermath have forced discriminate damage (Hoffman, 2001). military, medical, and psychological experts to re- The English word terrorism comes from the evaluate their understanding of mass casualty ter- re´gime de la terreur that prevailed in France from rorism. Given the relative newness of the discipline, 1793 to 1794, when a French revolutionary, we believe there is a great need for a text that covers Maximilian Robespierre, proclaimed that ‘‘Terror aspects of psychology relevant to terrorism. is nothing other than justice, prompt, severe, inflexible; it is therefore an emanation of virtue; it is not so much a special principle as it is a con- Definitional Issues sequence of the general principle of democracy applied to our country’s most urgent needs.’’ In 48 A.D., a Jewish sect called the Zealots carried McDermott and Zimbardo (this volume) tren- out terrorist campaigns to force an insurrection chantly point out that terrorism is not about war in against the Romans in Judea. These campaigns any traditional sense of destroying the material included the use of assassins—‘‘sicarii,’’ or dagger resources of an enemy nation and taking over that men—who would infiltrate Roman-controlled country; instead, terrorism is fundamentally about cities, stab Jewish collaborators or Roman le- psychology. Terrorist acts are designed strategi- gionnaires with a ‘‘sicae’’(dagger), kidnap members cally to incite terror and fright in civilian popula- of the staff of the Temple Guard to hold for ransom, tions. They further note that terrorists in most

3 4 The Psychology of Terrorism instances are neither crazy nor irrational—though in the early spring of 2004 by the nonpartisan their acts may be evil in the extreme. Many au- Council for Excellence that found that more than thorities have also found that there is neither a three-quarters of Americans expect the United States specific terrorist psychological profile nor a sin- to be the target of a major terrorist attack in the near gular psychopathological condition. future. A clear reality focus for such widespread Crenshaw (2000) has emphasized this defini- anxiety and fear was noted: tional dilemma and pointed out that the concept of terrorism is not well defined, that contradictions One distinct pattern in the litany of terrorist occur, that terrorism is a highly politicized term atrocities is that there has been an increasing used to describe the behavior of oppositional for- interest in well-planned attacks designed to net ces, and that the category of terrorism includes the highest numbers of civilian casualties. diverse practices that range from kidnappings to Charting data from the International Policy In- bombings intended to create mass casualties. Fur- stitute for Counter-Terrorism, Robert Axelrod, a thermore, he notes that there is ongoing political political scientist at the University of Michigan, pressure to define terrorist behavior in terms of observes that a very few terrorist attacks account psychopathology, and he clearly suggests that the for a very large percentage of all casualties. Not lack of extensive, reliable interview data or empiri- only does this trend call for anticipating attacks cal testing has made it difficult to draw dependable with ever broader political, economic, and so- and valid inferences. He concludes that, despite the cial effects, it also seems to point to an eventual political climate, personality factors and psycho- suicide attack using chemical, biological, or pathologies are not specific to terrorists and there nuclear weapons. Although that may take some is little evidence of gender differences; instead, ra- time to plan effectively, long-term planning has ther than individual factors, group dynamics within proven to be Al Qaeda’s hallmark. ‘‘God has close units with shared ideologies and solidarity ordered us to build nuclear weapons.’’ (Atran, play a much larger role. In 2002 Shamir and Shi- 2004, p. 70) kaki published the findings of their study, which This extensive review also underscored a examined the psychological processes applied by common misconception in the U.S. administration terrorists and terrorist organizations to justify their and media spin on the war on terrorism—namely, violence. They maintain that, ‘‘although there is no that terrorists are evil, deluded, or homicidal consensus over what terrorism is, most people seem misfits who thrive in poverty, ignorance, and an- to believe that terrorism is bad and should be era- archy. Atran further stated that dicated’’ (541). such a portrayal lends a sense of hopelessness to any attempt to address root causes because Contemporary Terrorism some individuals will always be desperate or deranged enough to conduct suicide attacks. The primary goal of terrorism is to disrupt society by Nevertheless, as logical as the poverty-breeds- provoking intense fear and shattering all sense of terrorism argument may seem, study after study personal and community safety. The target is an shows that suicide attackers and their suppor- entire nation, not only those who are killed, injured, ters are rarely ignorant or impoverished. Nor are or even directly affected. they crazed, cowardly, apathetic, or asocial. The Hall, Norwood, Ursano, Fullerton, and Levinson, 2002 common misconception underestimates the central role that organizational factors play in In a lengthy review on terrorism in the Washington the appeal of terrorist networks. A better un- Quarterly, Scott Atran (a research scientist at the derstanding of such causes reveals that the National Center for Scientific Research in Paris and challenge is actually manageable: the key is not at the University of Michigan) has pointed out that to profile and target the most despairing or most Americans currently feel no safer from ter- deranged individual but to understand and rorism, that they are more distrustful of many long- undermine the organizational and institutional standing allies, and that they are increasingly appeal of terrorists’ motivations and networks. anxious about the future. He cited a survey released (Atran, 2004, p. 73) The Psychology of Terrorism 5

It is also useful to remember that the attacks bers of the apocalyptic cult Aum Shinrikyo¯ man- on September 11, 2001, were intended to cause far aged to kill only 12 (and not 12,000) people in the more deaths and injuries than they actually did. Tokyo subway because of luck and inexperience, We know from the testimony of the 1993 World not moral or tactical constraint. This same orga- Trade Center bombers that terrorist planners be- nization had previously purchased a sheep farm lieved the buildings would topple when attacked, in western Australia in order to mine uranium not cascade down upon themselves; the original and construct a nuclear bomb (Stern, 1999). Only intent was to spread death and injury among fortuitous intervention by Japanese law enforce- countless inhabitants of Lower Manhattan and not ment forestalled a much larger tragedy. Even after merely among those who worked in the targeted the dismantling of Aum Shinrikyo¯, a myriad of skyscrapers. As British prime minister Tony Blair millennial cults that hope to provoke the apoc- has observed, modern terrorists ‘‘have no moral alypse through terrorism remain in our midst inhibition on the slaughter of the innocent. If (Lifton, 1999). they could have murdered not 7,000 [sic] but 70,000 does anyone doubt they would have done so and rejoiced in it?’’ (Blair, 2001). The al-Qaeda Psychological Impact leadership had met several years previously and explored attacking nuclear power facilities in It is impossible to say anything that is able to give a the United States (but actually had some qualms true idea of it to those who did not see it, other than this, that it was indeed very, very, very dreadful, and about the terrorist act ‘‘getting out of control such as no tongue can express. and decided not to do that for now’’ [Blair, 2001]). Daniel Defoe, Journal of the Plague Year When directly queried by a journalist who interviewed them in Pakistan about what ‘‘for now’’ The heinous events of September 11, 2001, have meant, a senior correspondent for Al Jazeera (an forever changed our awareness of the impact of mass Arabic-language television station in Qatar) said, casualty terrorism. Ariel Merari (personal commu- ‘‘for now, means for now!’’ (obviously leaving the nication, January 30, 2003) has stated that the only door open for future planning for such assaults; factors constraining the terrorists who seek to de- Blair, 2001). Credible intelligence sources have also stroy us are practical and technical, not political or discovered that the same group responsible for moral. Among the lessons learned by Merari and 9/11 were at least actively trying to secure mate- others on the front lines is that the strategic intent rials for either a radiological dispersion device of modern terrorists is to create huge numbers of and/or chemical or biological agents that could be secondary psychological casualties by means of large- used to attack U.S. targets (both in the United scale physical attacks. In the 1970s it was often re- States and abroad). peated that terrorists ‘‘want a lot of people watching, In addition, terrorism authorities such as Ariel not a lot of people dead’’; today it is more accurate to Merari of Tel Aviv University have been warning say that terrorists want a lot of people dead—and of the threat of ‘‘megaterrorism’’ since the early even more people crippled by fear and grief. 1990s. The goal of megaterrorists is not to achieve Government and military officials acknowl- political ends but simply to kill enormous num- edge that we are currently unprepared to care for bers of ‘‘enemy’’ civilians. An example of this the large numbers of medical and psychological brand of terrorism is the May 23, 2002, attempt casualties that would result from an attack invol- to detonate the Pi Gilot fuel depot in Tel ving weapons of mass destruction (WMD) and/ Aviv; had the terrorists succeeded, an estimated or bioterrorism. National authorities such as Leon 20,000–40,000 civilians living nearby would have E. Moores, a physician at the Walter Reed Army been killed (Dunn, 2002). Given the practical and Medical Center, have calculated that the number technologicalmeans—chemical,biological,nuclear, of casualties from a WMD attack would be in the or explosive—a single act of megaterrorism thousands but that the long-lasting psychological could easily claim the lives of 100,000 innocent consequences would have a devastating affect on civilians. millions of people. This hyperhomicidal form of terrorism is not Military psychologists have long known that restricted to al-Qaeda operatives. In 1995 mem- fear, stress, and exhaustion cause more casualties 6 The Psychology of Terrorism than do bombs and bullets. The ratios of psycho- treating thousands of victims, rescuers, and their logical to physical casualties can be enormous; for families. Sadly, the effort to deliver quality every one death directly caused by an Iraqi Scud mental health services was largely scattered, dis- missile attack on Israel during the Gulf War, organized, and understaffed and involved mostly there were 272 hospital admissions resulting from well- meaning but inadequately trained mental clinical psychological emergencies. The March 20, health professionals. The insufficient training of 1995, sarin attack in the Tokyo subway killed 12 those who rushed to help was not entirely their people and caused more than 4,000 nonaffected own fault; little training is available in disaster individuals to go to area hospitals, often with psy- mental health services (or in the psychological chogenic symptoms of chemical injury (World response to acts of terrorism), and even less (if Health Organization, 2001). any) training is available in treatment protocols that have scientific, empirical support for their Clearly, the impact on society can be much efficacy. It is important—and chilling—to note greater than initial casualty rates might imply. that some authorities (Rose, Bisson, & Wessely, The long-term psychological impact of the use or 2002; Van Emmerick, Kamphuis, Hulsbosch, & even threat of WMD is difficult to predict. Emmelkamp, in press) have concluded that pop- Changes in daily activity, depression and suicide ular models of disaster mental health response rates, and economic impact can last for years or (e.g., critical incident stress debriefing) are po- even decades, and current disaster experts have tentially harmful to victims of terrorist acts. no models to predict the ultimate need for psychological assessment or treatment services. Many experts contend, based on the Israeli ex- Critical Incident Stress Debriefing perience and other similar venues (e.g., Northern Ireland) that the strain on the medical resources Devilly and Cotton (2004) have critically reviewed and psychological strength of a society could the literature on critical incident stress debriefing potentially be crippling. (Moores, 2002) (CISD) and made a powerful conclusion: At present, the psychological science needed to It is surprising, perhaps, that CISD has become provide proper and effective treatment for victims so universally accepted despite the fact that of horrendous events such as September 11 and there is no data from randomized clinical trials for future potential terrorist events (including the demonstrating its efficacy as a clinical use of WMD) simply does not exist. Despite a intervention. ...Indeed, as noted earlier, two wealth of information about psychological assess- recent studies suggest that CISD is either in- ment and intervention following severe individual effective or actually worsens PTSD [posttrau- trauma (e.g., combat, rape), natural disasters, and matic stress disorder] symptoms instead of airplane crashes, for example, there is no wide- preventing the later development of PTSD, as is spread scientific or clinical consensus regarding generally believed. Obviously, much more re- the efficacy of these treatment interventions with search is needed. As we ask ourselves, people who are directly affected by a terrorist at- however, ...how CISD could have attracted so tack. A similar scarcity of scientific data exists many strong adherents in the absence of con- regarding appropriate treatments specifically de- vincing data, the answer may lie in the low signed for people not directly exposed to, but prevalence of PTSD among individuals exposed struggling to cope with, actual or threatened ter- to natural disasters. ...If most people exposed rorist acts. Obviously, such effects are magnified to natural disasters will never develop PTSD, by the 24/7 news cycle and the widespread avail- then most people exposed to natural disasters ability of Internet connectivity. who receive CISD will never develop PTSD. The pertinent question, therefore, is whether in- Treatment of Victims of Terror dividuals most at risk to develop PTSD following acute traumatization will have more favor- In the aftermath of September 11, an urgent need able outcomes if they receive CISD. Clearly we arose for the services of highly trained psycholo- must move beyond clinical impressions and gists and other mental health professionals in descriptive studies to rigorous randomized trials The Psychology of Terrorism 7

if we hope to learn whether CISD can actually threat of chemical and biological attacks, produced prevent the later development of PTSD among several recommendations for the direction of fu- acutely traumatized individuals.(p. 35) ture research. These organizations identified several ‘‘areas of concern’’ in which immediate progress was In their critical review of CISD, Devilly and necessary. It is important to note that little, if any, Cotton (2004) also extensively emphasized the meaningful work has so far been published in any of work of Litz, Gray, Bryant, and Adler (2002) and these areas (Table 1.1): Rose, Bisson, and Wessely (2002): In 2005 the American Psychological Associa- 1. It appears that there is sufficient evidence to tion’s primary instrument for disseminating profes- recommend that psychological debriefing not sional news (APA Monitor, February, 2005) reported be provided to individuals immediately after on the outcome of a conference that convened in trauma. ...There is consensus, however, that November of 2004, where more than 100 partici- providing comfort, information, support, and pants from federal, state, and local government meeting people’s immediate practical and Homeland Security and Defense entities and from emotional needs play useful roles in one’s major research institutions and universities came immediate coping with a highly stressful event together to discuss the possible development of a (Litz et al., 2002). curriculum in homeland security that would reflect 2. There is no current evidence that psychologi- the contributions of psychology and other behavioral cal debriefing is a useful treatment for the sciences. Suggestions and discussion topics included prevention of posttraumatic stress disorder the following: after traumatic incidents. Compulsory debriefing of victims of trauma should cease 1. risk assessment, perception, and communica- (Rose et al., 2002). tion 2. human behavior and social dynamics (e.g., Devilly and Cotton carefully examined the reasons motivation, culture, values) in disasters CISD might be harmful and found five major areas 3. human-centered design of the technologies of concern: involved in homeland security 1. the lack of choice 4. decision-making dynamics such as crisis and 2. poor timing stress management 3. retraumatizing the victim of terror 5. the need for psychologists to study the content 4. vicarious traumatization domains of homeland security from a beha- 5. superficiality (Devilly & Cotton, 2004, pp. vioral and social science perspective 39–40) 6. the realization that one’s sense of security is a psychological state Last, even given a more balanced observation drawing on the other side’s more clinical material, Murphy has also proposed that

It seems that what can be definitively and strongly A true understanding of the psychology of ter- said is that the research done so far has not rorism includes: (1) advance knowledge of how convincingly demonstrated that critical incident and why individuals become attracted to stress debriefings are useful in preventing post- terrorist groups and organizations and [the de- traumatic stress disorder or other pathological velopment of] interventions to reduce the like- reactions to trauma. A question that remains lihood that individuals will join such groups, unanswered is whether or not debriefing has (2) advance knowledge about the relationships beneficial effects that to date have not been between terrorists and terrorist groups and or- measured. (Devilly and Cotton, 2004, pp. 39–40) ganizations, and [the] use [of] that knowledge to develop ways of influencing and disrupting the functioning of these groups, (3) [increasing] Additional Research Issues our understanding of the ways individuals and groups react to terrorist events, to the antici- In 1999 the National Research Council and the In- pation of terrorism and to counterterrorism stitute of Medicine, in an attempt to address the strategies, with the goal of limiting the negative 8 The Psychology of Terrorism

Table 1.1. Recommendations of the National Research Council and the Institute of Medicine

Training: Identify resource material on chemical and biological agents, stress reduction after other traumas, and disaster response services; enlist the help of mental health professional societies in developing a training program for their members. The key to success in this attempt will be in offering continuing education credits and certification for mental health providers trained in chemical and biological attack response. (Breckenridge et al. 2003 have secured funding from the Office of the Surgeon General to provide training models, but this is still only one such funded training venue.) Screening and Assessment: Identify suitable psychological screening methods for use by mental health providers and possibly first responders, differentiating adjustment reactions after chemical and biological attacks from more serious psychological illness (e.g., panic disorder, PTSD, psychosis, depression) and organic brain impairment from chemical or biological agents. Conduct research to identify trauma characteristics and behavior patterns that predict whether long-term disability will be necessary. 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 and 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 little or no systematically collected data exist on fears and anxieties related to the possibility of purposefully introduced disease.

effects of terrorism and negative reactions to This conference, which brought together some of counterterrorism efforts, (4) develop[ing] ef- the foremost national and international authorities fective methods of communicating information on the psychology of terrorism (almost all of whom about terrorism risks to policy makers, first are authors of their respective chapters in this responders and the public in ways that are book) had the following as its goals: consistent with the best underlying behavioral 1. designing a strategy and making re- science (risk perception, communication tech- commendations on how to evaluate and niques, social influence) and [developing mate- deliver scientific, empirical treatment rials] that are informative to and understood by interventions for the victims of terrorism recipients, and (5) build[ing] resilience among and their rescuers the potential targets of terrorism and develop[ing] 2. training current and future mental healthcare methods of limiting the success of terrorists in professionals in the effective use of these spreading fear, anxiety and alarm. (2004, p. 5) treatments Furthermore, Murphy (2004) has pointed out 3. conducting scientific research on the psychol- that the most important weapon for a terrorist is not ogy of terrorism that will assist governmental a gun or a bomb but rather the uncertainty, fear, and community agencies in preventing, pre- and alarm that terrorist attacks and the threat of paring for, and recovering from mass casualty those attacks produce. He emphasizes that an im- assaults portant vulnerability of terrorists is not the techni- 4. organizing and training rapid-response teams cal wizardry of intelligence services but rather that of professional clinicians that will respond fact that terrorists always depend on others—other immediately and effectively in the event of members of their own groups, members of allied future national crises and emergencies groups, the societies in which they live and operate, 5. most importantly, emphasizing the role of family, friends, acquaintances—and are therefore psychological science (and not mere opinion) open to attack via the social networks that sustain in our understanding of the psychological di- them. Murphy concludes that, given the importance mensions of acts of terror of social and psychological factors in understanding and combating terrorism and its effects, the potential importance of the behavioral and social sciences Tactical and Strategic Perspectives in the war on terror is clear. The present book is the direct product of an Psychology can also contribute to our under- international conference held in the fall of 2002. standing of terrorist motivations and recruitment The Psychology of Terrorism 9 techniques, which can provide a basis for in- terrorist bullets are fired at civilians and bombs novative tactical and strategic-level counterterrorism explode. In recent years suicide bombers started programs. A comprehensive understanding of the exploding themselves in populated areas causing psychology of terror will also help to establish death and injury’’ (p. 69). a rational and defensible prioritization of potential Cowen (2005) has reported on the ideas of terrorist targets in the United States and abroad Danny Brom, the director of the Israel Center for based on the extent of the psychological impact the Treatment of Psychotrauma, who stated that created by an attack. In addition, there are pre- ‘‘as to terrorism we are not talking about PTSD; liminary indications that it may be possible to detect we are talking about an attack on the fabric of behavioral patterns and physical characteristics, such society. ...We have to develop resiliency-building as gait and facial expression, of suicide bombers as services.’’ Cowen says that Brom also suggested they approach a target (Merari, personal commu- that the educational system could be an alternative nication, July 2004). These indicators could provide delivery system for mental health services if proper security forces at the intended site of attack with a testing and training are provided and that, at the brief warning and an opportunity for interdiction. end of the day, we will become a stronger society Such research could also have broader prevention as the result of attempts to weaken us. Danieli, benefits and include knowledge of the terrorists’ Brom, and Sills (2005) have also emphasized the psychological makeup and motivations, which importance of fostering a community’s capacity would provide a basis for information operations for resilience, the centrality of traumatic grief, the programs to dissuade them from volunteering for a need for multicultural understanding in services mission or persisting in it. Such tactical programs and treatment, and for proactive community or- based on initial results in Israel have already helped ganization in the face of terrorism. increase the number of suicide candidates who have Pines (2004) has further commented that aborted their mission. ‘‘people who live in a country that was established From a strategic perspective, psychological on the ashes of the holocaust, who confront reg- research can advance the development of programs ularly the death and injury of young soldiers pro- to decrease support for terrorist attacks within tecting its borders, and of civilians under terrorist communities that generate such incidents. More attacks, are more acutely aware of death and con- generally, studies in the psychology of terrorism sequently of the significance of their own life’’ will support efforts by the United States to win (p. 70). She cites the work of Bleich, Gelkopf, and ‘‘the war of ideas’’ and attack adversary recruitment Solomon (2003), who found that Israelis reported efforts at the strategic level. It may also be possible lower levels of PTSD than do Americans living in to utilize technical means to detect potential ter- New York City after the terrorist attack of Sep- rorists, including suicide bombers, before they tember 11. She points out that the lowest levels of strike. Basic and applied research into the psy- PTSD were reported among settlers in the occu- chology of terrorism that examines behavioral pied territories, who feel that living where they do patterns and physical characteristics may well lead is a calling. However, it is not the mere living in to methods that directly support attack prediction Israel but the existential significance attached to and prevention (Atran, 2004). it that keeps them there (Pines, 2004, p. 75).

Brief Perspective on the Israeli Prevention Issues Experience At a 2004 NATO conference on the prevention of Pines (2004) has stated that ‘‘life in Israel is very suicide terrorism (organized by Scott Atran and Ariel stressful. Since its establishment in 1948, Israel has Merari and sponsored by the NATO Office of Sci- gone through five major wars. Even during times ence and Technology), Simon Wessely of the British of peace, soldiers are killed while protecting the Institute of Psychiatry suggested that, when psy- borders, and civilians live with a constant threat chological weapons lose their novelty, they lose their of terrorist activities. People’s bags are checked primary potency. Wessely believes that it is vital that whenever they enter public places and periodically the public receive sound and sensible information 10 The Psychology of Terrorism that is accurate and reassuring. It is also potentially challenges illustrated by the relative lack of success dangerous to (even inadvertently) amplify responses by even such a well-funded and well-trained ter- to biological and chemical weapons (e.g., inves- rorist group (Hoffman, 2001). tigators who are clad in ‘‘space suits’’) (Wessely, Flynn (2004) emphasizes that, although we Hyams, & Bartholomew, 2001). Moreover, he concurrently have ideas about how to treat people’s tends that the public’s general level of fear and anxiety psychopathological responses, we do not yet have may remain high for years, exacerbating preexisting intervention strategies for dealing with nationwide psychiatric disorders (Wessely et al., 2001; Wessely, stress reactions. Flynn further suggests that this personal communication, June 2004). Hall et al. lack of information resulted in a missed opportu- (2002) have described an additional role for psy- nity that could have ‘‘increased social support, chological science and practice in preparing a com- promoted positive coping behavior, and built po- munity for possible terrorist attacks by focusing their sitive cohesion among diverse groups’’ (2004, p. attention on the risks of collective behaviors (e.g., 165). Flynn also says that, in the future, mental panic and mass hysteria) or mass psychogenic illness. health professionals should be aware that our role They maintain that psychologists can play a role in involves an acceptance of the fact that pathologies educating the authorities and the public about the are not the only area of study and that we should risks and containment of panic. expand our scope to understand resiliency me- Pape (2003) has argued that terrorism itself chanisms. is not a form of psychopathology and, in fact, Stein et al. (2004) have examined the re- contends that terrorism—and in particular suicide lationship between psychology and terrorism and terrorism—can be seen as a logical strategic deci- described the latter as essentially a psychological sion by organizations. Pape drew this conclusion attack on a society’s social capital: ‘‘In this way, after examining information from all of the com- terrorism is fundamentally different from other pleted suicide terrorist attacks between 1980 and community-wide traumatic events. ...The natural 2001 and then inferring that we can reasonably course of reactions following a terrorist attack may conclude that suicide terrorism results in the be broader and more prolonged than reactions to achievement of the desired outcomes and that it is other disasters because a goal of terrorism is to therefore a mistake to assume that suicide terror- create such reactions’’ (p. 106). Hoffman (2001) ism is irrational. has stated that the true goal of terrorist attacks is Hall and his colleagues have posited that ter- to ‘‘rend the fabric of trust that bonds society’’ and rorism is the most disturbing kind of disaster be- to elicit ‘‘irrational, emotional,’’ and repressive cause it is caused not by natural, technological, countermeasures. Terrorists seek not only to in- or accidental forces but by deliberate, human flict physical damage to their victims but also to malevolence (Hall et al., 2002). They assert that leverage that damage to accomplish broader poli- the most psychologically taxing factor of terrorism tical goals, ranging from specific policy changes to is living in a heightened state of fear and alert that mass panic and public disaffection from existing an indiscriminate and undetermined threat will government authorities. ‘‘The primary goal of ter- strike without warning in the foreseeable future. rorism is to disrupt society by provoking intense Hoffman (2001) particularly mentions the work of fear and shattering all sense of personal and com- Barbera, Macintyre, and De Atley (2001), who, after munity safety. The target is an entire nation, not the sarin attack in the Tokyo subway, found that only those who are killed, injured, or even directly 73.9% of the 5,000 people seeking treatment were affected’’ (Hall et al., 2002, p. 2). suffering from psychological effects such as shock, It is also crucial not to extrapolate too broadly emotional upset, or a psychosomatic complaint. from the field of disaster mental health to the Hoffman (2001) further speculated on the limita- newly emerging area of the psychology of terror- tions in our current understanding of terrorist be- ism. Flynn has pointed out that ‘‘research is not havior and stated that it is generally assumed that nearly as extensive and complete as it needs to be terrorist groups are more likely to imitate previous and we are far too dependent on extrapolation from successful attacks than to develop innovative new other types of traumatic events’’ (2004, p. 164). ideas. However, no imitations of the Aum Shinrikyo¯ An excellent example of how different warn- attack have been attempted, perhaps because of the ings of terrorism are from the traditional warnings The Psychology of Terrorism 11 of impending natural disasters is presented by Cross, and undergraduate and graduate-level college Zimbardo and Kluger (2003), who underscore the and university students. However, we also believe need for effective psychological science in ex- that there will be an important secondary audience amining the color-coded level of alert—green- that includes police departments, fire departments, blue-yellow-orange-red—employed by the U.S. emergency medical personnel, military personnel, government as an early warning system for the local elected officials responsible for preparing for public. They have noted obvious flaws in the and responding to terrorist threats, and federal, system—especially the fact that the current system state, regional, and local government agencies. creates anxiety without providing instruction on how to remain safe. Instead of being a useful warning device, the color-coded warning system, References they maintain, has ‘‘a profoundly negative impact Asukai, N., & Maekawa, K. (2002). Psychological and on our individual and collective mental health ...a physical health effects of the 1995 sarin attack in ‘pre-traumatic stress syndrome’ and its effect on the Tokyo subway system. In J. M. Havenaar, our day-to-day lives is debilitating’’ (Zimbardo & J. G. Cwikel, & E. J. Bromet (Eds.), Toxic Kluger, 2003, p. 34). Furthermore, that system is turmoil: Psychological and social consequences of counterproductive in that it provides vague in- ecological disasters (pp. 149–162). New York: formation, which serves only to increase fear in the Kluwer Academic/Plenum. public (which, ironically, is the goal of terrorism; Atran, S. (2004, June). Mishandling suicide terrorism. Zimbardo & Kluger, 2003). Washington Quarterly, 27(3), 67–90. ———, and Merari A. (2004, June). NATO Office of Science and Technology Invitational Conference on the Prevention of Suicide Terrorism, Lisbon. Conclusion Blair, T. (2001, October). Part one of the speech by Prime Minister Tony Blair at the Labour Party The emerging field of the psychology of terrorism conference. Guardian Unlimited (UK). Retrieved thus ranges from first response to basic science, from February 4, 2006, from http://politics.guardian.co the epidemiological to the cross-cultural to the case .uk/speeches/story/0,11126,590775,00.html study, and from controlled clinical trials to rigorous Bleich A., Dycian, A., Koslowsky, M., Solomon, Z., & qualitative methodologies. In the following chapters Wiener, M. (1992). Psychiatric implications we address the goals of the various conferences and of missile attacks on a civilian population. groups that have sought to define this newly emer- Journal of the American Medical Association, 268, ging area. Within these chapters we present the 613–615. newest findings on treatment and clinical response Bleich, A., Gelkopf, M., & Solomon, Z. (2003). The psychological impact of ongoing terrorism and protocols. We also explore the theory and history of suicide bombing on Israeli society: A study of a terrorism and examine the larger cultural and social national sample. Journal of the American Medical psychological dimensions of this new field. The Association, 260, 612–620. authors of the subsequent chapters also explore a Cowen, D. (2005, March 16). Interview with Daniel wide range of subjects, such as the role of national, Brom. Canadian Jewish News, 4 state, and local agencies and volunteer groups in Crenshaw, M. (2000). The psychology of terrorism: An responding to terrorist threats, military response, agenda for the 21st century. Political Psychology, psychological consequences of terrorism, special 21(2), 405–420. populations, prevention, training, and research. Danieli, Y., Brom, D., & Sills, J. (2005). The trauma The hope is that this volume can fill the need for of terrorism: Sharing knowledge and shared care, a comprehensive resource for mental health clin- an international handbook. New York: Haworth. Devilly, G. J., & Cotton, P. (2004). Caveat emptor, icians, medical care providers, researchers, educa- caveat venditor, and critical incident stress tors, and others who respond to acts of terrorism. debriefing/management (CISD/M). Australian The primary audience will be mental health and Psychologist, 39, 35–40. primary care providers (specifically, psychologists, Dunn, R. (2002, May 24). Bomb explodes at Israeli fuel psychiatrists, emergency and primary care physi- depot. Sydney Morning Herald. Retrieved February cians, crisis intervention counselors, social workers, 4, 2006, from http://www.smh.com.au/articles/ public sector nonprofit agencies such as the Red 2002/05/23/1022038458284.html 12 The Psychology of Terrorism

Flynn, B. W. (2004, Summer). Commentary on ‘‘A na- Pines, A. (2004, June). Why are Israelis less burned tional longitudinal study of the psychological conse- out? European Psychologist, 9(2), 69–77. quences of the September 11, 2001, terrorist attacks: Rose, S., Bisson, J., & Wessely, S. (2002, April 22). Reactions, impairment, and help-seeking. Can Psychological debriefing for preventing post- we influence the trajectory of psychological con- traumatic stress disorder (PTSD). Cochrane Library, sequences to terrorism?’’ Psychiatry 67(2), 164–166. 1. Oxford, UK: Update Software (CD-ROM). Giuliani, R., & Von Essen, T. (2003). Foreign Press Shamir, J., & Shikaki, K. (2002). Self-serving percep- Center briefing: New York City after September tions of terrorism among Israelis and Palestinians. 11, 2001. Retrieved February 4, 2006, from Political Psychology, 23(3), 537–557. http://fpc.state.gov/23971.htm Stein, B. D., Elliott, M. N., Jaycox, L. H., Collins, R. L., Hall, M. J., Norwood, A. E., Ursano, R. J., Fullerton, Berry, S. H., Klein, D. J., et al. (2004, Summer). A C. S., & Levinson, C. J. (2002). Psychological and national longitudinal study of the psychological behavioral impacts of bioterrorism. PTSD Research consequences of the September 11, 2001, terrorist Quarterly, National Center for Post-Traumatic Stress attacks: Reactions, impairment, and help-seeking. Disorder, 13(4), 1–7. Psychiatry 67(2), 105–117. Hassett, A. (2002, September). Unforeseen conse- Stern, J. (1999). The ultimate terrorists. Cambridge, MA: quences of terrorism. Archives of Internal Medicine Harvard University Press. (162), 1809–1813. Stewart, J. B. (2002). Heart of a soldier: A story of love, Hoffman, B. (2001). Change and continuity in terror- heroism, and September 11th. New York: Simon & ism. Studies in Conflict and Terrorism, 24, 417– 428. Schuster. Lifton, R. J. (1999). Destroying the world to save it: Aum Van Emmerick, A. A. P., Kamphuis, J. H., Hulsbosch, Shinrikyo¯, apocalyptic violence, and the new global A. M., & Emmelkamp, P. M. G. (in press). Single- terrorism. New York: Henry Holt. session debriefing following psychotrauma, help or Litz, B., Gray, M., Bryant, R., & Adler, A. (2002). Early harm? A metaanalysis. Lancet. interventions for trauma: Current status and future Wessely, S. (2002). Protean nature of mass sociogenic directions. Clinical Psychology Science and Practice, illness. British Journal of Psychiatry, 180, 9, 112–134. 300–306. Moores, L. (2002). Threat credibility and weapons of ———, Hyams, K., & Bartholomew, R. (2001). mass destruction. Neurosurgical Focus, 12, 1–3. Psychological implications of chemical and Murphy, K. (2004, December). Mission statement biological weapons. British Medical Journal, 323, for a proposal for the establishment of a center 878–879. for the behavioral and social science of World Health Organization. (2001, October). World counterterrorism. Meeting held at Pennsylvania health report 2001—Mental health: New under- State University. standing, new hope. Geneva: Author. Pape, R. A. (2003). The strategic logic of suicide Zimbardo, P., & Kluger, B. (2003, May/June). Phantom terrorism. American Political Science Review, 97(3), menace: Is Washington terrorizing us more than 1–19. Al Qaeda? Psychology Today, 3, 34–36. 2

Psychological Issues in Understanding Terrorism and the Response to Terrorism Clark McCauley

This chapter begins with a brief effort to put mod- the word terror to refer to political violence goes ern terrorism in context. Thereafter, the chapter is back only to the French Revolution of the 1790s. divided into two main sections. The first deals with Threatened by resistance within France and foreign psychological issues involved in understanding the armies at French borders, the revolutionaries un- perpetrators of terrorism, including their motiva- dertook a Reign of Terror to suppress the enemy tions and strategies. The second deals with the U.S. within. This first violence to be called terrorism had response to terrorism, including issues of fear and the power of the state behind it. Terrorism today is identity shift in reaction to the events of September usually associated with political violence perpe- 11, 2001. I cannot offer a full review of the lite- trated by groups without the power of the state. Few rature related to even one of these issues, and for of these nonstate groups have referred to themselves some of them there is so little relevant literature as terrorists, although prominent exceptions include that I can only point in the general directions that the Russian Narodnaya Volya in the late 1800s and research might take. In using a very broad brush, I the Zionist Stern Gang of the late 1940s. Most apologize in advance to scholars whose knowledge nonstate terrorists see themselves as revolutionaries and contributions are not adequately represented or freedom fighters. here. A little theory can be a dangerous thing, State terrorism was not only first, it also con- especially in the hands of a nonspecialist in the tinues to be more dangerous. Rummel (1996) es- relevant theory. But the events of 9/11 warrant timates that 170 million people were killed by some additional risk taking in connecting psycho- government in the twentieth century, not including logical research to our understanding of the origins 34 million who died in battle. Most of the civilian and effects of terrorism. victims were killed by their own government or, more precisely, by the government controlling the area in which the victims were living. Stalin, Mao, Terrorism as a Category of Violence and Hitler were the biggest killers (42 million, 37 million, 20 million respectively), with Pol Pot’s Violence and the threat of violence to control killing of 2 million Cambodians coming in only people is an idea older than history, but the use of seventh in the pantheon of killers. By comparison,

13 14 The Psychology of Terrorism killing by nonstate groups is miniscule. Rummel Terrorist Motivations estimates that 500,000 were killed in the twentieth century by terrorists, guerillas, and other nonstate People become terrorists in many different ways groups. State terrorism is thus greater by a ratio of and for many different reasons. Here I simplify in about 260 to 1. Worldwide, Myers (2001) counts order to consider three kinds of explanation of the 2,527 deaths from terrorism in the 1990s. Three 9/11 attacks: They are crazy, they are crazed by thousand terrorist victims on September 11 is thus hatred and anger, or they are rational within their a big increment in the killing done by terrorists, but own perspective. My argument is that terrorism that event does not change the scale of the com- is not to be understood as pathology and that parison: State terrorism is by far the greater danger. terrorists emerge out of a normal psychology of Despite the origin of the term terrorism in ref- emotional commitment to cause and comrades. erence to state terror and despite the preeminence of state terror in relation to nonstate terror, terrorism Terrorism as Individual Pathology today is usually understood to mean nonstate terrorism. Nonstate terrorism includes both antistate A common suggestion is that there must be some- terror and vigilante terror, but it is usually antistate thing wrong with terrorists. They must be crazy or terrorism that is the focus of attention—violence suicidal or psychopathological. Only someone de- against recognized states by small groups without void of moral feelings could do the cold-blooded the power of a state. Most definitions of antistate killing that a terrorist does. terrorism also include the idea of violence against noncombatants, especially women and children, The Search for Pathology although the suicide bombing of the U.S. Marine Thirty years ago this suggestion was taken very barracks in Beirut in 1984 is often referred to as seriously, but thirty years of research has found terrorism, as is the 9/11 attack on the Pentagon. little evidence that terrorists are suffering from Antistate terrorism cannot be understood out- psychopathology. This research has profited by side the context of state terrorism. Compared with what now amounts to hundreds of interviews with the nineteenth century, the twentieth century saw terrorists. Some are captured and interviewed in massive increases in state power. The modern state prison. Some active terrorists can be found in their reaches deeper into the lives of citizens than ever home neighborhoods, if the interviewer knows before. It collects more in taxes, and its regula- where to look. And some retired terrorists are tions, rewards, and punishments push further into willing to talk about their earlier activities, parti- work, school, and neighborhood. The state culture cularly if these were successful. Itzhak Shamir and is thus ever harder to resist; any cultural group that Menachem Begin, for instance, moved from anti- does not control a state is likely to feel in danger Arab and anti-British terrorism to leadership of the of extinction. But resistance to state culture faces state of Israel. Interviews with terrorists rarely find state power that continues to grow. In the context any disorder listed in the Diagnostic and Statistical of growing state power, those who would contest Manual of Mental Disorders. against the state are likely to feel increasingly More systematic research confirms the interview desperate. results. Particularly thorough were the German stu- Much has been written about how to define dies of the Baader-Meinhof Gang. Although the ter- antistate terrorism, but I generally agree with those rorists had gone underground and their locations who say the difference between a terrorist and a were undisclosed, their identities were known. Ex- freedom fighter lies mostly in the politics of the cellent German records provided a great deal of in- beholder (see McCauley, 1991, and McCauley, formation about each member. Pre- and perinatal 1993, for more on this issue). The psychologi- records, pediatric records, preschool records, lower- cal question is how members of a small group school records, grade-school records, high-school without the power of a state become capable of pol- records, and university records (most had had itical violence that includes violence against non- some university education)—all of these were combatants. In the remainder of this chapter I combed for clues to understanding the trajectory to follow common usage in referring to antistate ter- terrorism. Family, neighbors, and classmates—all rorism simply as ‘‘terrorism.’’ those who had known an individual before the leap Psychological Issues in Understanding Terrorism and the Response to Terrorism 15 to terrorism—were interviewed. A comparison Indeed, terrorism would be a trivial problem if sample of people from the same neighborhoods, only those with some kind of psychopathology matched for gender, age, and socioeconomic sta- were terrorists. Rather, we have to face the fact that tus, was similarly studied. The results of these normal people can be terrorists and that we our- investigations fill several feet of shelf space but are selves are capable of terrorist acts under some easy to summarize. The terrorists did not differ circumstances. This fact is already implied in re- from the comparison group of nonterrorists in any cognizing that military and police forces invol- substantial way; in particular, the terrorists did not ved in state terrorism are all too capable of killing show higher rates of any kind of psychopathology. noncombatants. Few would suggest that the broad range of soldiers and police involved in such Terrorists as Psychopaths killing must all be suffering some kind of psy- Some have suggested that terrorists are antisocial chopathology. personalities or psychopaths. Psychopaths can be intelligent and very much in contact with reality; their Terrorism as Emotional Expression problem is that they are socially and morally defi- cient. They are law breakers, and they are deceitful, On October 11, 2001, when asked at a press aggressive, and reckless in disregarding the welfare conference why people in the Muslim world of others. They do not feel remorse for hurting hate the United States, President Bush expressed others. Just as some people cannot see color, psy- amazement and replied, ‘‘That’s because they don’t chopaths cannot feel empathy or affection for others. know us.’’ President Bush is not the only one to Explaining terrorism as the work of psycho- accept the idea that the 9/11 attacks were an ex- paths brings a new difficulty, however. The 9/11 pression of hatred. ‘‘Why do they hate us?’’ has attackers were willing to give their lives in the been the headline of numerous stories and edi- attack. So far as I am aware, no one has ever torials in newspapers and magazines. Despite the suggested that a psychopath’s moral blindness can headlines, there has been little analysis of what take the form of self-sacrifice. In addition, psy- hatred means or where it comes from. chopaths are notably impulsive and irresponsible. The mutual commitment and trust that is evident Hatred and Anger within each of the four groups of attackers and in The surprising fact is that, although a few psy- the cooperation among the groups is radically in- choanalysts have discussed hatred, very little psy- consistent with the psychopathic personality. chological research has focused on hate or hatred. It is possible that a terrorist group might re- Gordon Allport (1954) briefly mentioned hatred in cruit a psychopath for a particular mission if the writing The Nature of Prejudice, and Marilyn Brewer assignment requires inflicting pain or death with- (2001) has asked, ‘‘When does in-group love be- out the distraction of sympathy for the victims, but come out-group hate?’’ However, empirical research the undertaking would have to be a one-person on hatred, particularly research that distinguishes job, something that requires little or no coordina- it from anger, is notably absent. In contrast, there tion and trust. And it would have to offer a rea- is a large and well-developed literature on the sonable chance of success without suicide. emotion of anger. Does hatred mean anything more than strong anger? An example suggests that The Case Against Pathology hatred may be different. A parent can be angry Of course, there are occasional lone bombers with a misbehaving child, angry to the point of or lone gunmen who kill for political causes, and striking the child. Nevertheless, even caught up such people may indeed suffer from some form of in that violence, the parent would not hate the psychopathology. A loner like Theodore Kaczyn- child. ski, the ‘‘Unabomber,’’ who sent out letter bombs A few differences between anger and hatred in occasional forays from his wilderness cabin, show up in the way these words are used in ev- may suffer from psychopathology. However, ter- eryday speech. Anger is hot, whereas hatred can be rorists who operate in groups, especially those that cold. Anger is a response to a particular incident or can organize successful attacks, are very unlikely offense; hatred expresses a longer-term relation of to suffer from serious psychopathology. antipathy. We sometimes talk about hatred when 16 The Psychology of Terrorism we mean only strong dislike, as in ‘‘I hate broc- interest is the evolutionary key to anger. If each coli,’’ but even this usage suggests the sense of a person acted rationally on self-interest, the strong general and unwavering dislike, a dislike without could do anything they wanted to the weak. Both exceptions, and perhaps even the wish that broc- would realize that the weak cannot win, and the coli would be erased from every menu. weaker would always defer to the stronger. How- In The Deadly Ethnic Riot, Donald Horowitz ever, anger can lead the weaker to attack the stron- (2001) offers a distinction between anger and ha- ger despite the objective balance of forces. The tred that is consistent with the language just con- stronger will win, but will suffer some costs along sidered. Horowitz quotes Aristotle as follows: ‘‘The the way, and the possibility of these costs restrains angry man wants the object of his anger to suffer in the stronger and improves the bargaining position return; hatred wishes its object not to exist’’ (p. of the weaker. 543). This distinction begs for a parallel distinction This perspective suggests an evolutionary ad- in offenders or offenses, one that can predict when vantage for people for whom anger can conquer an offense will lead to anger and when to hatred. fear. The result should be a gradual increase in One possibility (see also Brewer, 2001) is that an the proportion of those who are capable of anger. offense that includes long-term threat is more Everyday experience suggests that, under certain likely to elicit the desire to eliminate the offender. circumstances, most people are capable of anger. The emotional reaction to threat is fear. Thus hatred What are those circumstances, that is, what are the may be a compound of anger and fear, or, as elicitors of anger? Sternberg (2003) suggests, a variable blend of There are basically two theories of anger (Sa- disgust, anger-fear, and contempt. bini, 1995, pp. 411–428). The first, which comes Another perspective is offered by Royzman, to us from Aristotle, says that anger is the emo- McCauley and Rozin (2004), who suggest that hate tional reaction to insult—an offense in which is not an emotion or a blend of emotions but rather someone is not accorded due respect or status. The an extreme form of negative identification. Nega- second, which emerged from experimental re- tive identification means feeling bad about the search with animals, says that anger is the emo- successes of others; negative identification means tional reaction to pain, especially the pain of frus- feeling good about the successes of others. Thus tration. Frustration is understood as the failure to the hater feels joy or pride when the target of hate receive an expected reward. These theories ob- is losing, hurting, or weakening, but feels anger, viously have a great deal in common. Respect that fear, or humiliation when the target of hate is is expected but not forthcoming creates a painful winning, gaining, or strengthening. Similarly love frustration. For our purposes, the two theories is an extreme form of positive identification, and differ chiefly in their emphasis on material welfare. the lover can feel either positive or negative emo- Insult is subjective, a social judgment, whereas at tions depending on what is happening to the loved least some interpretations of frustration include one. As extremes of the human capacity for iden- objective poverty and powerlessness as sources of tification, hate and love are the occasions of ex- frustration that can lead to anger. This interpreta- periencing many different emotions depending on tion of frustration-aggression theory was popular the situation of the one loved or hated. at the 2002 World Economic Forum, where many Whether or not hate is an emotion, hate has luminaries cited material deprivation as the cause some relation to anger and research on anger may be (or at least an important cause) of violence aimed able to help us understand the behavior of terrorists. at the West (A. Friedman, 2002).

The Psychology of Anger Individual Frustration and Insult Explanation of terrorism as the work of people The immediate difficulty of seeing the 9/11 terror- blinded by anger is at least generally consistent ists as crazed with anger is the fact, much cited by with what is known about the emotion of anger. In journalists and pundits, that they were not ob- particular, there is reason to believe that anger gets viously suffering from frustration or insult. Mo- in the way of judgment. In Passions within Reason, hammed Atta came from a middle-class family Robert Frank (1988) argues that blindness to self- in Egypt, studied architecture in Cairo, traveled Psychological Issues in Understanding Terrorism and the Response to Terrorism 17 to Hamburg, Germany, for further studies in archi- pathy for African Americans predicts support for tecture, and had a part-time job doing architectural busing and other desegregation policies. Unless drawings for a German firm. His German thesis, on self-interest is exceptionally large and clear cut, the ancient architecture of Aleppo, was well re- voters’ opinions are not self-centered but group ceived. According to Thomas Friedman’s (2002) centered. inquiries, several of the other 9/11 pilot leaders Similarly, Kinder recounts evidence that poli- came from comparable middle-class backgrounds tical action, including protest and confrontation, with similar threads of personal success. is motivated more by identification with group The origins of the 9/11 terrorist leaders are thus interest than self-interest. ‘‘Thus participation of strikingly different from those of the Palestinian black college students in the civil rights movement suicide terrorists that Ariel Merari studied in Israel in the American South in the 1960s was predicted for decades (Lelyveld, 2001). The Palestinians were better by their anger over society’s treatment of young, male, poor, and uneducated. Their motiva- black Americans in general than by any discontent tions were manifold but sometimes included the they felt about their own lives. ...Thus white several thousand dollars awarded to the family of a working-class participants in the Boston antibus- Palestinian martyr. The amount is small by Western ing movement were motivated especially by their standards but enough to lift a Palestinian family out resentments about the gains of blacks and profes- of abject poverty, including support for parents and sionals, and less by their own personal troubles’’ aged relatives and a dowry for the martyr’s sisters. (Kinder, 1998, p. 831). It is easy to characterize these suicide terrorists as Group identification makes sense of sacrifice frustrated by poverty and hopelessness, with frus- by people who are not personally frustrated or tration leading to anger against Israel as the per- insulted. The mistake is to imagine that self- ceived source of their problems. sacrifice must come from personal problems, ra- More recent studies, however, consistently ther than identification with group problems. This conclude that terrorists and suicide terrorists are error rests in ignorance of the fact that many not generally poor or uneducated. Rather they twentieth century terrorists have been people from have education and prospects at least average, of- comfortable circumstances, people with options. ten higher than average, in relation to the group The Baader-Meinhof Gang in Germany, the Red they come from (Atran, 2003; Krueger & Mal- Brigade in Italy, the Weather Underground in the eckova, 2002; Pape, 2005). It seems that the United States—these and many other post–World middle-class origins of the 9/11 leadership are not War II terrorist groups consisted mostly of people unusual and that personal frustration associated with middle-class origins and middle-class skills with poverty, poor education, and unemployment honed by at least some university education is not a useful explanation of terrorism. (McCauley & Segal, 1987). Explaining self-sacrifice If not angry about personal frustrations and as a result of personal problems is no more per- insults, terrorists may yet be angry about frustra- suasive for terrorists than for Mother Theresa or tions and insults their group has suffered. U.S. Medal of Honor winners. The power of group identification is thus the Group Frustration and Insult foundation of intergroup conflict, especially for In the Handbook of Social Psychology, Kinder (1998) large groups, where self-interest is probably max- summarizes the accumulated evidence that poli- imized by free riding, that is, by letting other group tical opinions are only weakly predicted by narrow members pay the costs of advancing group welfare self-interest and more strongly predicted by group that the individual will profit from. Here I am interest. The poor do not support welfare policies briefly asserting what I elsewhere argue for in more more than others, young males are not less in fa- detail (McCauley, 2001). vor of war than others, and parents of school-age The explanation of terrorists’ sacrifice as a fit children are not more opposed than others to of anger overcoming self-interest can now be re- busing for desegregation. Rather it is group interest formulated in terms of anger over group insult and that is the useful predictor. Sympathy for the group frustration. The potential origins of such poor predicts favoring increased welfare. Sym- anger are not difficult to discern. 18 The Psychology of Terrorism

are seen as responsible for terrorist attacks against Insult and Frustration as Seen by Muslims the United States. In an International Herald Tri- (and Others) bune-Pew poll of 275 ‘‘opinion makers’’ in 24 From Morocco to Pakistan lies a belt of Muslim countries, respondents were asked how many or- states in which governments have police and dinary people think that U.S. policies and actions military power but little public support. The gulf in the world were a major cause of the 9/11 attack between rich and poor is deep and wide in these (Knowlton, 2001). In the United States only 18% countries, and government is associated with of respondents said that many people think this; in Western-leaning elites for whom government, not 23 other countries an average of 58% said most or private enterprise, is the source of wealth. Political many people hold this opinion. In Islamic coun- threat to the state is not tolerated; imprisonment, tries 76% said most or many think this, and even torture, and death are the tools of the state against in Western European countries 36% said most or political opposition. As the Catholic Church in many people agree. Americans do not have to ac- Poland under Communism came to be the prin- cept the judgments of other countries, but we will cipal refuge of political opposition, so funda- have to deal with them. mentalist Muslim mosques are the principal refuge of political opposition to government in these Anger or Love? states. If group identification can lead to anger as a result In this conflict between Muslim governments of frustrations and insults suffered by the group, it and Muslim peoples, the United States and other remains to be determined whether there is any Western countries have supported the govern- evidence of such emotions in the 9/11 terrorists. ments. When the Algerian government was about Our best guide to the motives of those who carried to lose an election to the Islamic Salvation Front in out those attacks is the document found in the 1992, the government annulled the election, and luggage of several of the attackers. Four of the five Europeans and Americans were glad to accept pages of this document have been released by the lesser of two evils. Western countries have sup- the FBI, and Makiya and Mneimneh (2002) have ported authoritarian governments of Egypt, Jor- translated and interpreted them. I am indebted to dan, and Pakistan with credits and military Hassan Mneimneh for his assistance in under- assistance. U.S. support for Israel against the Pa- standing this document. lestinians is only one part of this pattern of sup- The four pages are surprising for what they do porting power against people. not contain. There is neither a list of group frus- Al-Qaeda is an association of exiles and re- trations and insults nor a litany of injustice to fugees from the political violence going on in justify violence. ‘‘The sense throughout is that the Muslim countries. Long before declaring jihad would-be martyr is engaged in his action solely to against the United States, Osama bin Laden was please God. There is no mention of any communal attacking the house of Saud for letting U.S. troops purpose behind his behavior. In all of the four remain in the holy land of Mecca and Medina after pages available to us there is not a word or an the Gulf War. Fifteen of the 9/11 terrorists ori- implication about any wrongs that are to be re- ginally came from Saudi Arabia, although most of dressed through martyrdom, whether in Palestine them seem to have been recruited from the Muslim or Iraq or in ‘the land of Muhammad,’ the phrase diaspora in Europe. The United States has become bin Laden used in the al-Jazeera video that was a target because it is seen as supporting the gov- shown after September 11’’ (Makiya and Mneim- ernments that created the diaspora. The United neh, 2002, p. 21). Indeed, the text approvingly States has, in effect, stumbled into a family feud. If cites a story from the Hadith, the collection of this scenario seems strained, consider the parallel sayings and actions attributed to the Prophet and between Muslims declaring jihad on this country his companions, about Ali ibn Abi Talib, cousin and for supporting state terrorism in Muslim countries, son-in-law of the Prophet, who is spat upon by an and the United States declaring war on any country infidel in combat. The Muslim holds his sword that supports terrorism against it. until he can master the impulse for vengeance—an It is important to recognize that it is not only individual and human motive—and strikes only Arab and Muslim countries in which U.S. policies when he can strike for the sake of God. Psychological Issues in Understanding Terrorism and the Response to Terrorism 19

Rather than anger or hatred, the dominant life and death and links the individual to some message of the text is a focus on the eternal. There form of immortality. are many references to the Koran, and the vocabulary departs from seventh-century Arabic only The Psychology of Cause for a few references to modern concepts such as Most people believe in something more important airport and plane (and these modern words are than life. We have to because, unlike other ani- reduced to one-letter abbreviations). To feel con- mals, we know that we are going to die. We need nection with God and the work of God and to something that makes sense of our life and our experience the peace of submission to God’s will— death, something that makes our death different these are the imperatives and the promises of from that of a squirrel lying by the side of the road. the text. Invocations and prayers are to be offered The closer and more immediate death is, the more at every stage of the journey: the last night, the we need the group values that give meaning to life journey to the airport, boarding the plane, takeoff, and death. These include the values of family, re- seizing control of the plane, and welcoming death. ligion, ethnicity, and nationality—the values of our The reader is reminded that fear is an act of wor- culture. Dozens of experiments have shown that ship due only to God. If killing is necessary, the thinking about death—especially their own—leads language of the text makes the killing a ritual people to embrace the values of their culture more slaughter with vocabulary that refers to animal strongly (Pyszcznski, Greenberg, & Solomon, sacrifice, including the sacrifice of Isaac that 1997). Abraham was prepared to offer. These values do not have to be explicitly re- Judging from this text, the psychology of the ligious. Many of the terrorist groups since World 9/11 terrorists is not one of anger or hatred or War II have been radical-socialist groups with vengeance. The terrorists are not righting human purely secular roots: the Red Brigade in Italy, the wrongs but acting with God and for God against Baader-Meinhof Gang in Germany, the Shining evil. In the most general terms, this is a psychology Path in Peru, the Tamil Tigers in Sri Lanka. Animal of attachment to the good rather than a psychology rights and environmental issues can be causes that of hatred for evil. Research with U.S. soldiers in justify terrorism. For much of the twentieth cen- World War II found something similar; hatred of tury, atheistic communism was such a cause. Thus the enemy was a minor motive in combat perfor- there is no special relation between religion and mance, whereas attachment to buddies and not violence; religion is only one kind of cause in wanting to let them down was a major motive which people can find an answer to mortality. (Stouffer et al., 1949). This resonance with the What is essential is that the cause should have psychology of combat—one that is usually treated the promise of a long and glorious future. History as normal psychology—again suggests the possi- is important in supporting this promise. A cause bility that terrorism and terrorists may be more invented yesterday cannot easily be seen to have a normal than we usually recognize. glorious and indefinite future. Moreover, the history must be a group history. No one ever seems to Terrorism as Normal Psychology have had the idea that she or he alone will achieve some kind of immortality. Immortality comes as The trajectory by which normal people become part of a group: family group, cultural group, re- capable of doing terrible things is usually gradual, ligious group, or ideological group. A good parti- perhaps imperceptible to the individual. This is cipant in the group, one who lives up to its norms among other things a moral trajectory, such as and contributes to the group, will to that extent Sprinzak (1991) and Horowitz (2001) have de- live on after death as part of the group. The mean- scribed. In too-simple terms, terrorists kill for the ing of the individual’s life is the future of the cause, same reasons that groups have killed other groups embodied in the group that goes on into the future for centuries. They kill for cause and comrades, after the individual is dead. that is, with a combination of ideology and intense small-group dynamics. The cause that is The Psychology of Comrades worth killing for and dying for is not abstract but The group’s values are focused to a personal in- personal—a view of the world that makes sense of tensity in the small group of like-minded people 20 The Psychology of Terrorism who perpetrate terrorist violence. Most people middle-class background and education. For belong to many groups—family, coworkers, neigh- educated men, the power of ideas may substitute borhood, religion, country—and each of these has to some degree for the everyday reinforcement of a some influence on individual beliefs and behavior. like-minded group. Indeed, the terrorist document Different groups have different values, and the referred to earlier is a kind of manual for using competition of values reduces the power of any control of attention to control behavior, and this one group over its members. However, members of kind of manual should work better for individuals an underground terrorist cell have put this group familiar with the attractions of ideas. Probably both first in their lives, dropping or reducing every possibilities—a social world reduced to one group other connection. The power of this one group is despite physical dispersal and a group of in- now enormous and extends to every kind of per- dividuals for whom the ideology of cause is un- sonal and moral judgment. This is the power that usually important and powerful—contributed to can make violence against the enemy not just ac- the cohesion of the 9/11 perpetrators. ceptable but necessary. Every army aims to do what the terrorist group The Psychology of Cult Recruiting does: link a larger group cause with the small-group Studies of recruiting for the Unification Church (UC) dynamics that can deliver individuals to sacrifice. provide some insight into differences in vulerability Every army cuts trainees off from their previous to the call of cause and comrades (McCauley & lives so that the combat unit can become their fa- Segal, 1987). Galanter (1980) surveyed participants mily, their fellow soldiers become their brothers, in UC recruiting workshops in Southern California and their fear of letting down their comrades be- and found that the best predictor of who becomes a comes greater than their fear of dying. The power of member was the answer to a question about how an isolating group over its members is not limited to close the person feels to people outside the Uni- justifying violence. Many nonviolent groups also fication Church. Those with outside attachments gain power by separating individuals from groups were more likely to leave, whereas those without that might offer competing values. Those that use outside connections were more likely to join. This is this tactic include religious cults, drug treatment the power of comrades. centers, and residential schools and colleges. In Barker (1984) surveyed participants in Uni- brief, the psychology behind terrorist violence is fication Church recruiting workshops in London normal psychology; it is abnormal only in the in- and found that the best predictor of who becomes tensity of the group dynamics that link cause with a member was the answer to a question about comrades. goals. Those who said they were looking for ‘‘some- Some commentators have noted that the 9/11 thing but I don’t know what’’ were more likely to terrorists, at least the pilot leaders, spent long join. This is the power of cause, a group cause that periods of time dispersed in the United States. can give meaning to one’s life. Terrorist groups, How could the intense group dynamics typical of like cult groups, cut the individual off from other underground groups be maintained in dispersal? contacts and are particularly attractive to those There are two possible answers. The first is that without close connections and the meaning that physical dispersal is not the same as developing comes with group anchoring. Only those who have new group connections. It seems that the dis- never had the experience of feeling cut off from persed terrorists lived without close connections to family, friends, and work will see this kind of others outside the terrorist group. They did not vulnerability as a type of pathology. The rest of us take interesting jobs, become close to coworkers, will feel fortunate that we did not at this point in or develop romantic relationships. Although living our lives encounter someone recruiting for a cult apart, they remained connected to and anchored or terrorist group. in only one group—their terrorist group. The second possibility is that group dynamics The Psychology of Crisis can be less important to the extent that the cause— The psychology of cause and comrades is multi- its ideology—is more important. As noted pre- plied by a sense of crisis. Many observers have viously, the pilot leaders of the 9/11 terrorists were noted an apocalyptic quality in the worldview not poor or untalented; they were men with a of terrorists. Terrorists see the world precariously Psychological Issues in Understanding Terrorism and the Response to Terrorism 21 balanced between good and evil, at a point where slowly toward an apocalyptic view of the world action can bring about the triumph of the good. and a correspondingly extreme behavioral com- The ‘‘end times’’ or the millennium or the triumph mitment. Sprinzak (1991) has distinguished three of the working class is near or can be made near by stages in this trajectory: a crisis of confidence, in right action. Action—extreme action—is required which a group protests and demonstrates against immediately for the triumph of the good and the the prevailing political system with a criticism that defeat of evil. This ‘‘ten minutes to midnight’’ yet accepts the system’s values; a conflict of legiti- feeling is part of what makes it possible for normal macy, in which the group loses confidence in re- people to risk their lives in violence. form and advances a competing ideological and Consider the passengers of the hijacked flight cultural system while moving to angry protest and that crashed in western Pennsylvania. The pas- small-scale violence; and a crisis of legitimacy, in sengers found out from their cell phones that hi- which the group embraces terrorist violence against jacked planes had crashed into the World Trade the government and everyone who supports it. Center. They had every reason to believe that their Whether as someone joining an extreme group or plane was on its way to a similar end. Unarmed, as a member of a group that becomes more ex- they decided to attack the hijackers and sacrificed treme over time, the individual becomes more their lives in bringing the plane down before it extreme in a series of steps so small as to be nearly could impact its intended target, which was pro- invisible. The result is a terrorist who may look bably the Pentagon or the White House. When it is back at the transition to terrorism with no sense of ten minutes to midnight, there is little to lose and ever having made an explicit choice. everything to gain. Psychology offers several models of this kind The sense of crisis is usually associated with an of slippery slope (see McCauley & Segal, 1987, for overwhelming threat. In the case of the 9/11 ter- more detail). One is Milgram’s obedience experi- rorists it seems to be fear that fundamentalist ment, in which 60% of subjects are willing to Muslim culture is in danger of being overwhelmed deliver the maximum shock level (‘‘450 volts XXX by Western culture. The military and economic Danger Strong Shock’’) to a supposed fellow sub- power of the West and the relative feebleness of ject in a supposed learning experiment. In one once-great Muslim nations in the modern era are variation of the experiment, Milgram had the ex- submerging Muslims in a tidal wave of individ- perimenter called away on a pretext, and another ualism and irreligion. It is attachment to a view supposed subject came up with the idea of raising of what Muslims should be—and fear for their the shock one level with each mistake from the future—that are the emotional foundations of the ‘‘learner.’’ In this variation, 20% went on to deliver terrorists. They do not begin from hatred of the maximum shock. The 20% yielding cannot be at- West but from love of their own group and cul- tributed to the authority of the experimenter and ture, which they believe is in danger of extinction is most naturally understood as the power of self- from the power of the West. justification acting on the small increments in Similarly, the United States, mobilized by shock level. Each shock delivered becomes a rea- President Bush for a war against terrorism, does son for giving the next higher shock because the not begin from hatred of al-Qaeda but from love of small increments mean that the subject has to see country. Mobilization includes a rhetoric of crisis something at least a little wrong with the last shock and of impending threat from an evil enemy or, if there is something wrong with the next one. A more recently, an ‘‘axis of evil.’’ America’s anger clear choice between good and evil would be a toward al-Qaeda, and perhaps more broadly to- shock generator with only two levels, 15 volts and ward Arabs and Muslims, is not an independent 450 volts, but the 20% who go all the way never emotion but a product of patriotism combined see a clear choice between good and evil. with a crisis of threat. Another model of the terrorist trajectory is more explicitly social psychological. Group ex- The Psychology of the Slippery Slope tremity shift, which is the tendency for group The sense of crisis does not spring full blown upon opinion to become more extreme in the direction a person. It is the end of a long trajectory to ter- initially favored by most people, is currently un- rorism, a trajectory in which the person moves derstood in terms of two mechanisms: relevant 22 The Psychology of Terrorism arguments and social comparison (Brown, 1986, want to create fear and uncertainty far beyond the pp. 200–244). Relevant arguments theory explains victims and those close to them. They want their the shift as a result of individuals hearing new enemy to spend time and money on security. In arguments in discussion that are biased in the in- effect, the terrorists aim to lay an enormous bur- itially favored direction. Social comparison theory den on every aspect of the enemy’s society, one explains the shift as a competition for status in that transfers resources from productive purposes which no one wants to fall behind in supporting to antiproductive security measures. The costs of the group-favored direction. In the trajectory to increased security are likely to be particularly high terrorism, initial beliefs and commitments favor for a country like the United States, where an open action against injustice, and group discussion society is the foundation of economic success and and in-group status competition move the group a high-tech military. toward more extreme views and more extreme The United States is already paying enormous violence. taxes of this kind. Billions more dollars are going to The slippery slope is not something that hap- the FBI, the CIA, the Pentagon, the National Security pens only in psychology experiments and foreign Agency, and a new bureaucracy for the Depart- countries. Since 9/11, there have already been ment of Homeland Security. Billions are going to suggestions from reputable people that U.S. se- bail out the airlines, to increase the number and curity forces may need to use torture to get in- quality of airport security personnel, and to pay the formation from suspected terrorists. This is the National Guard stationed at airports. The costs to edge of a slope that leads down and away from the business activity are perhaps even greater. Long rule of law and the presumption of innocence. lines at airport security points and fear of air travel have cut both business and holiday travel. Hotel Terrorism as Strategy bookings are down, urban restaurant business is down; in short, all kinds of tourist businesses are Psychologists recognize two kinds of aggression: down. Long lines of trucks at the Canadian and emotional and instrumental. Emotional aggression Mexican borders are slowed for more intensive is associated with anger and does not calculate searches, and the delays necessarily contribute to the long-term consequences. The reward of emotional cost of goods transported. The Coast Guard and the aggression is hurting someone who has hurt you. Immigration and Naturalization Service now focus Instrumental aggression is more calculating—it in- on terrorism and have decreased their attention to volves the use of aggression as a means to other the drug trade. I suspect that the expenses of in- ends. The balance between these two in the be- creased security and the war on terrorism will far havior of individual terrorists is usually not clear outrun the costs of the losses at the World Trade and might usefully be studied more explicitly in Center and the reparations to the survivors of those the future. The balance may be important in de- who died there. termining how to respond to terrorism: emotional aggression should be less sensitive to objective rewards and punishments, and instrumental ag- Political Damage to the Enemy gression more sensitive. In the longer term, the damage terrorism does to Of course, the balance may be very different in civil society may be greater than any dollar costs those who perpetrate the violence than in those (see McCauley, this volume). The response to who plan it. The planners are probably more in- terrorism inevitably builds the power of the state strumental because they are usually thinking about at the expense of the civil society. The adage that what they want to accomplish. They aim to inflict ‘‘war is the health of the state’’ is evident to anyone long-term harm to their enemy and to gain lasting who tracks the growth of the federal government advantage for themselves. in the United States. The Civil War, World War I, World War II, the Korean War, the Vietnam War, Material Damage to the Enemy the Gulf War, and now the war against terrorism— Terrorism inflicts immediate damage in destroying in every war the power of government grows in lives and property, but terrorists hope that the direction and extent never recovered when the long-standing costs will be much greater. They conflict is over. Psychological Issues in Understanding Terrorism and the Response to Terrorism 23

Polls taken in the years preceding the terrorist ‘‘bomb factory’’ was in fact producing only medical attack on September 11 indicate that about half of supplies. adult Americans saw the federal government as a A violent response to terrorism that is not well threat to the rights and freedoms of ordinary citi- aimed is a success for the terrorists. The Taliban zens. No doubt fewer would say so in the after- did their best to play up U.S. bombing mistakes in math of those attacks, a shift consistent with the Afghanistan but were largely disappointed. It ap- adage that ‘‘war is the health of the state.’’ If more pears that civilian casualties of U.S attacks in Af- security could ensure the safety of a nation, how- ghanistan number somewhere between 1,000 and ever, the Soviet Union would still be with us. It is 3,700, depending on who is estimating (Bearak, possible that bin Laden had the Soviet Union in 2002). Although Afghan civilian losses may thus mind in an interview broadcast by CNN. ‘‘Osama approach the 3,000 U.S. victims of 9/11, it is clear bin Laden told a reporter with the Al Jazeera net- that U.S. accuracy has been outstanding by the work in October that ‘freedom and human rights standards of modern warfare. Al-Qaeda could still in America are doomed’ and that the U.S. govern- hope to profit by perceptions of a crusade against ment would lead its people and the West ‘into an Muslims if the United States extended the war unbearable hell and a choking life’ ’’ (Kurtz, 2002). on terrorism to Iraq, Iran, or Somalia. In 2006, as this chapter goes to press, the U.S. presence in Mobilizing the In-Group Iraq seems to have done all that Al-Qaeda could Terrorists particularly hope to elicit a violent re- hope for. sponse that will assist them in mobilizing their own people. A terrorist group is the apex of a pyramid of supporters and sympathizers. The base U.S. Reaction to 9/11: Some Issues of the pyramid is composed of all those who sym- of Mass Psychology pathize with the terrorists’ cause even though they may disagree with the violent means they use. In In this section I consider several psychological is- Northern Ireland, for instance, the base of the sues raised by the U.S. reaction to the terrorist at- pyramid is all those who agree with ‘‘Brits out.’’ In tacks of September 11, 2001. Has the United States the Islamic world, the base of the pyramid is all been terrorized? What kinds of identity shifts may those who agree that the United States has been have occurred after 9/11? hurting and humiliating Muslims for fifty years. The pyramid is essential to the terrorists for cover Fear After 9/11 and for recruits. They hope that a clumsy and overgeneralized strike against them will hit some There is little doubt that the events of 9/11, soon of those in the pyramid below them. The blow will followed by another plane crash at Rockaway enlarge their base of sympathy, turn the sympa- Beach, made Americans less willing to fly. In early thetic but unmobilized to action and sacrifice, and 2002, air travel and hotel bookings were still sig- strengthen their own status as leaders at the apex. nificantly below the levels recorded in the months Al-Qaeda had reason to be hopeful that U.S. before the attacks. Beyond the fear of flying, Amer- strength could help them. In 1986, for instance, icans evidently became generally more anxious the United States attempted to reply to Libyan- and insecure. At least some law firms specializing supported terrorism by bombing Libya’s leader, in the preparation of wills and trusts saw a big Khaddafi. The bombs missed Khaddafi’s residence increase in business after 9/11. Gun sales were up but hit a nearby apartment building and killed in some places after that date, suggesting a search numerous women and children. This mistake was for increased security broader than the threat of downplayed in the United States but was a public terrorism. Owning a gun may not be of much help relations success for anti-U.S. groups across North against terrorists, but, at least for some people, a Africa. In 1998, the United States attempted to gun can be a symbol and reassurance of control reply to al-Qaeda’s attacks on U.S. embassies in and personal safety. Pet sales were also reported up Africa by sending cruise missiles against terror- in some places after the September attacks. Again, ist camps in Afghanistan and against a supposed a pet is not likely to be of much help against ter- bomb factory in Khartoum. It appears now that the rorists, but, at least for some, a pet may be 24 The Psychology of Terrorism an antidote to uncertainty and fear. A pet offers by a cognitive appraisal that flying is safe, and the both an experience of control and the reassurance images of planes crashing interfere with this ap- of unconditional positive regard (Beck & Katcher, praisal. This interpretation is similar to the ‘‘safety 1996). frame’’ explanation of how people can enjoy the It is tempting to interpret a big decrease in air fear arousal associated with riding a roller coaster travel as evidence of a substantial increase in fear, or watching a horror film (McCauley, 1998b). but it may be that even a small increase in fear can If the safety frame is disturbed, the fear con- produce a large decrease in the willingness to fly. trols behavior, and, in the case of air travel, people When the stakes are high, a small change in risk are less willing to fly. One implication of this in- perception can trigger a large decrease in one’s interpretation is that, for at least some people, gov- clination to bet. Indeed, decreased willingness to ernment warnings of additional terrorist attacks fly need not imply any increase in fear. Some may in the near future would make no difference in already have been afraid of flying and found 9/11 the level of trepidation experienced—vivid crash not a stimulus to increased fear but a justification images may release the latent fear no matter what for acting on fears had previously been ridiculed the objective likelihood of additional crashes. and suppressed. Thus it may be only a minority Acting on the uneasiness experienced is a se- who felt an increased fear of flying after 9/11. parate issue. Warnings of future terrorist attacks Myers (2001) has offered four research gen- may affect the norms of acting on a fear of flying, eralizations about perceived risk that can help that is, the warnings may reduce social pressure to explain the increased fear of flying after 9/11. We carry on business as usual and lessen ridicule for are biologically prepared to fear heights, we par- those who are afraid of flying. Fear of flying is an ticularly fear what we cannot control, we fear im- attitude, and social norms undoubtedly have much mediate more than long-term and cumulative dan- to do with determining when attitudes are ex- gers, and we exaggerate dangers represented in pressed in behavior (Ajzen & Fishbein, 1980). vivid and memorable images. All of these influ- Indeed, the impact of government warnings ences can help explain the fear of flying, but only and increased airport security are very much in the last one can explain the reason that fear of need of investigation. President Bush was in the flying increased after 9/11. Fear of heights pre- position of trying to tell Americans that they ceded 9/11. On entering a plane, every passenger should resume flying and that new airport security gives up control, and the immediate risk of measures made flying safe again, even as security climbing on a plane is little affected by four or five agencies issued multiple warnings of new terrorist crashes in a brief period of time. attacks. These warnings had the peculiar quality Myers notes, however, that the risks of air of being completely unspecific about the nature travel are largely concentrated in the minutes of of the threat or what to do about it. The possible takeoff and landing. This is a framing issue: Do air downside of such warnings is suggested by re- travelers see their risk in terms of deaths per pas- search indicating that threat appeals are likely to senger mile—which makes air travel much safer be repressed or ignored if they do not include than driving—or do they see the risk as deaths per specific and effective action to avoid the threats minute of takeoff and landing? With the latter (Sabini, 1995, pp. 565–566). Even the additional perspective, air travel may be objectively riskier airport security measures may be of dubious value. than driving. It is true that many Americans seemed reassured Still, Myers may be correct in focusing on the to see army personnel with weapons stationed in importance of television images of planes slicing airports, although the objective security value of into the World Trade Center, but the importance troops with no training in security screening is by of these images may have more to do with control no means obvious. But if there is any value to the of fear and norms about expressing it than with the framing interpretation of increased anxiety, then actual level of fear. Myers reports a 1989 Gallup adding military security at airports may actually poll concerning commercial aviation that indicates increase travelers’ apprehension. Vivid images of that, even before 9/11, 44% of those willing to fly armed troops at airports may actually undermine were willing to admit they felt apprehensive about rather than augment the safety frame that controls flying. It is possible that this anxiety is controlled the fear of flying. Psychological Issues in Understanding Terrorism and the Response to Terrorism 25

Differences in security procedures from one sent to one corporation on one day and to a dif- airport to another can also exacerbate fear. A jour- ferent corporation the next day, even as another nalist from Pittsburgh called me not long after new counselor experienced the reverse transfer. The security procedures were introduced at U.S. air- importance of becoming familiar with a particular ports. His newspaper had received a letter to the corporate culture and setting, the personal con- editor written by a visitor from Florida, a letter ex- nection between individual counselor and the coriating the Pittsburgh airport for inadequate se- managers that control that setting, and the trust curity. The writer had been frightened because she developed between counselors and people needing was asked for identification only once on her way to assistance and referral in that setting—these were boarding her return flight from Pittsburgh, whereas, given little attention in the organization of coun- in boarding the Florida flight to Pittsburgh, she had seling assistance. It appears that the experience of been stopped for identification five times. the counselors working with WTC survivors has Fear of flying is not the only apprehension to not yet been integrated with the experience of emerge from 9/11. Survivors of the attacks on the those working with survivors of the Oklahoma World Trade Center (WTC), those who fled for City bombing (Pfefferbaum, Flynn, Brandt, & their lives that morning, may still be fearful of Lensgraf, 1999). There is a long way to go before working in a high-rise building and afraid even of we are able to develop anything like a consensus all of the parts of Lower Manhattan that were as- on ‘‘best practice’’ for assisting survivors of such sociated with commuting to and from the WTC. attacks. Many corporate employees who escaped the WTC In sum, fear after 9/11 includes a range of fear returned to work in new office buildings in reactions, including fear of flying by those with northern New Jersey. In these new settings, some no personal connection to the WTC, more general may have been retraumatized by frequent fire and anxieties associated with death from uncontrollable evacuation drills that associated their new offices and unpredictable terrorist attacks, and specific and stairwells with the uncertainties and fears workplace fearfulness among those who escaped of the same environment at the WTC. For these the WTC attacks. These reactions offer theoretical people, the horror of the WTC may have been a challenges that can be of interest to those interested kind of one-trial traumatic conditioning experi- in understanding the relation between risk appraisal ment, with follow-up training in associating their and fear (Lazarus, 1991), as well as to those who new work place with the old one. Their experience are interested in the commercial implications of and their fears deserve research attention. public fears. A small step in this direction was a December 2001 conference at the University of Pennsyl- Cohesion After 9/11: Patriotism vania’s Solomon Asch Center for the Study of Ethnopolitical Conflict. The conference brought After 9/11, all over the United States, vehicles and together eight trauma counselors from around the homes were decorated with the U.S. flag. Walls, United States who had been brought in to assist fences, billboards, and emails were emblazoned WTC corporate employees returning to work in with ‘‘God bless America.’’ Clearly, the immediate new office spaces. Several potentially important response to the attacks was a sudden upsurge in issues emerged at the conference. Perhaps most patriotic expression. The distribution of this phe- important is that the counselors were selected nomenon across the country could be a matter of and directed by corporate employee assistance pro- some interest. Was the new patriotism greater in grams with more experience in physical health New York City than elsewhere? Did it decline in than mental health problems. Thus the counselors concentric circles of distance from New York? Was were all contracted to use critical incident stress it greater among blue-collar than white-collar fa- debriefing techniques with everyone they assisted; milies? Was it greater for some ethnic groups than at least officially, no room was left for a counselor for others? Was it stronger in cities, possibly per- to exercise independent judgment about what ceived as more threatened by future terrorist at- approach might best suit a particular situation. tacks, than in suburbs and small towns? Similarly, because the counselors were seen as The attacks of 9/11 represent a natural ex- interchangeable resources, a counselor might be periment relevant to two prominent approaches to 26 The Psychology of Terrorism conceptualizing and measuring patriotism. In the Cohesion After 9/11: Relations in Public first approach, Kosterman and Feshbach (1989) distinguish between patriotism and nationalism. News reports immediately after 9/11 suggested a Patriotism is love of country and generally consid- new interpersonal tone in New York City. Along ered a good thing; nationalism is a feeling of with shock and fear came a new tone in public national superiority that is regarded as a source of interactions of strangers, a tone of increased po- intergroup hostility and conflict. Schatz, Staub, and liteness, helpfulness, and personal warmth. Several Lavine (1999) offer a distinction between critical reports suggested a notable drop in crime, espe- and uncritical patriotism. Critical patriotism refers cially violent crime, in the days that followed 9/11. to love of country expressed as willingness to cri- It would be interesting to know whether these ticize its policies and its leaders when these go reports can be substantiated with more objective wrong; uncritical patriotism refers to love of measures of social behavior in public places country coupled with a rejection of criticism—‘‘my (McCauley, Coleman, & DeFusco, 1978). Did the country right or wrong.’’ Critical patriotism is ac- pace of life in NYC slow after the attacks? That is, did counted the good thing, and uncritical patriotism people on the streets walk more slowly? Did eye the danger. contact between strangers increase? Did commercial Thus both approaches distinguish between transactions (e.g., with bus drivers, postal clerks, good and bad forms of patriotism, and both offer supermarket cashiers) include more personal ex- separate measures of these forms. That is, there is a changes? Did interpersonal distance in interactions scale of patriotism and a scale of nationalism, and between strangers decrease? This research will be there is a scale of critical patriotism and a scale of hampered by the absence of relevant measures from uncritical patriotism. In both approaches, there is NYC in the months before 9/11, but measures taken some evidence that the two scales are relatively now could lay the foundation for assessing change independent. Some people score high on patri- if the U.S. suffers future terrorist attacks. otism, for instance, but low on nationalism. Simi- larly, some people score high on critical patriotism Cohesion After 9/11: Minority and also score high on uncritical patriotism (an Identity Shifts inconsistency that seems to bother those taking the scale less than it bothers theorists). A few reports have suggested that minority groups What happened to these different aspects of experienced major changes of group identity after patriotism among Americans after 9/11? Since in- 9/11. Group identity is composed of two parts: creased cohesion is known to increase conformity private and public identity. Private identity is the and pressure on deviates, one might expect that way in which the individuals think of themselves patriotism, uncritical patriotism, and nationalism in relation to groups they belong to. Public identity increased, whereas critical patriotism decreased. is how people believe others perceive them. Another possibility is that scores on these measures were unchanged after 9/11 but that identification Public Identity Shift for Muslims and Arabs with the country increased in relation to other di- The attacks of 9/11 produced an immediate effect rections of group identification. That is, Americans on the public identity of Arabs, Muslims, and rating the importance of each of a number of those, like Sikhs, who can be mistaken by Amer- groups—country, ethnic group, religious group, icans for Arab or Muslim. Actual violence against family, school—might rate country higher in rela- members of these groups seems mercifully to have tion to other groups. been rare, with 39 hate crimes reported to the New It seems likely that both kinds of patriotism York City Police Department in the week ending increased, both scores on the patriotism scales and September 22 but only one a week by the end ratings of the relative importance of country. If so, of December (Fries, 2001). Much more frequent additional questions arise. Did nationalism and has been the experience of dirty looks, muttered uncritical patriotism increase more or less than the suggestions to ‘‘go home,’’ physical distancing, and ‘‘good’’ forms of patriotism? Was the pattern of discrimination at work and school (Sengupta, change different according to geography, educa- 2001). Many Arab Americans and Muslims say tion, or ethnicity? they have been afraid to report this kind of bias. Psychological Issues in Understanding Terrorism and the Response to Terrorism 27

Americans’ reactions to Muslims and Arabs bias but also about their perception of what most after 9/11 pose a striking theoretical challenge. of the members of their group experienced. As How is it that the actions of 19 Arab Muslims elaborated earlier, the motivation for violence may can affect Americans’ perceptions of the Arabs and have more to do with group experience than per- Muslims that they personally encounter? The ease sonal problems. with which the 19 were generalized to an impression of millions should amaze us; ‘‘the law of Public Identity Shift for African Americans small numbers’’ (Tversky & Kahneman, 1971), in The attacks of 9/11 may also have produced an which small, unrepresentative samples are accepted effect on the public identity of African Americans. as representative of large populations, has not been Their sharing in the costs and threats of terrorist observed in research on stereotypes. Indeed, the attack may have strengthened their public status difficulty of changing stereotypes has often been as Americans. Several African Americans have advanced as one of their principal dangers. suggested that the distancing and unease they of- Of course, not every American accepted the ten feel from whites they interact with was idea that all Arabs are terrorists, but even those who markedly diminished after 9/11. The extent and dis- intellectually avoided this generalization sometimes tribution of this feeling of increased acceptance by found themselves fighting a new unease and sus- white Americans could be investigated in inter- picion toward people who looked Arabic. Whether views with African Americans. Again, the distinc- on the street or boarding a plane, Americans seem tion between personal experience and perception to have had difficulty controlling their emotional of group experience may be important in esti- response to this newly salient category. It seems mating the political impact of 9/11 on African unlikely that an attack by 19 Congolese terrorists Americans. would have the same impact on perceptions of Finally, an issue of great practical importance African Americans. Why not? is that of understanding the public identity of One possible explanation of the speed and Muslim African Americans as a minority within a power of the group generalization of the 9/11 minority. This group is likely to have faced con- terrorists is that humans are biologically prepared flicting changes after 9/11, with increased accep- to essentialize cultural differences of members of tance as African Americans on the one hand and unfamiliar groups. Gil-White (2001) has suggested decreased acceptance as Muslims on the other. The that there was an evolutionary advantage for in- distinctive attire of African American Muslims, dividuals who recognized and generalized cultural particularly that of the women of this community, differences so as to avoid the extra costs of inter- makes them readily identifiable in public settings. acting with those whose norms do not mesh with With the attire goes a community lifestyle that also local norms. This perspective suggests that we may sets this minority apart from other African Amer- have a kind of default schema for group perception icans. Thus, public reactions to Muslim African that makes it easy to essentialize the characteristics Americans should be very salient in their experi- of a few individuals encountered from a new group. ence, and researchers with entreé to their com- To essentialize means to see the unusual character- munity could investigate this experience. Again, istics of the new individuals as the product of an the distinction between the personal experiences unchangeable group nature or essence. Previous of individual respondents and perceived group familiarity with the group, a preexisting essence for experience may be important. the members, could interfere with this default; One way to learn about shifts in the public consequently, African terrorists would not easily identities of minorities is to study changes in the lead to a generalization about African Americans. mutual stereotyping of majority and minority. Ste- It would be useful to know more about the reotypes are today generally understood as percep- experience of Muslims and Arabs in the United tions of probabilistic differences between groups, States after 9/11, not least because those who ex- differences that may include personality traits, perience bias may become more likely to sym- abilities, occupations, physique, clothing, and pre- pathize with terrorism directed against the United ferences (McCauley, Jussim, & Lee, 1995). Thus, States. Interviews and polls might inquire not only researchers might ask both minority and majority about the respondents’ personal experiences of group members about whether and how 9/11 28 The Psychology of Terrorism changed their perceptions of the differences be- Here I want to focus on shifts in the private tween majority and minority. identities of minorities. As with public identity Perhaps even more important for under- shifts, the three minority groups of special interest standing the public identity of minorities would be are Muslim Arabs living in the United States, research that asks about metastereotypes. Metaste- African Americans, and Muslim African Amer- reotypes are perceptions of what ‘‘most people’’ icans. For each group, research can focus on believe about group differences. Although little changes since 9/11 in their feelings toward the studied, metastereotypes may be more extreme than United States and feelings toward their minority personal stereotypes; there is some evidence that group. What is the relation between changes in individuals believe that most people see more these two private identities? It is by no means marked differences between in-groups and out- obvious that more attachment to one identity groups than they do (Rettew, Billman, & Davis, means less attachment to others, but in terms of 1993). The public identity of the minority might behavior there may be something of a conservation thus be measured as the average minority in- principle at work. Time and energy are limited, dividual’s perception of what ‘‘most people’’ in and more behavior controlled by one identity may the majority group see as the differences between mean less behavior controlled by others. We have minority and majority. Related metastereotypes much yet to learn about the relation between more might also be of interest: the average minority in- particularistic identities, including ethnic and re- dividual’s perception of what most minority mem- ligious identities, and overarching national iden- bers believe about majority-minority differences, tity. the average majority member’s perception of what most majority members believe about these dif- Group Dynamics Theory and Political ferences, and the average majority member’s per- Identity ception of what most minority members believe about these differences. Public reaction to terrorist attacks is strikingly The attacks of 9/11 and their aftermath offer consistent with results found in research with a natural experiment in conflicting pressures on small face-to-face groups. In the group dynamics public identity. Research on the public identities literature that began with Festinger’s (1950) the- of minorities could enliven theoretical develop- ory of informal social influence, cohesion is at- ment even as the research contributes to gauging tachment to the group that comes from two kinds the potential for terrorist recruitment in groups— of interdependence. The obvious sort of inter- Muslim Arabs in the United States, Muslim African dependence arises from common goals of material Americans—that security services are likely to interest, status, and congeniality. The hidden in- see as being at risk for terrorist sympathies. In terdependence arises from the need for certainty particular, public identity shifts for Muslim African that can be obtained only from the consensus of Americans will be better understood by compar- others. Agreement with those around us is the ison with whatever shifts may obtain for African only source of certainty about questions of value, Americans who are not Muslim. including questions about good and evil and what is worth living for, working for, and dying Private Identity Shifts for. Private identity concerns the beliefs and feelings It seems possible that identification with large, of an individual about a group that person is part faceless groups is analogous to cohesion in small of. The most obvious shifts in private identity are face-to-face groups (McCauley, 2001). A scaled-up those already discussed as shifts in patriotism. Pa- theory of cohesion leads immediately to the im- triotism is a particular kind of group identification, plication that group identification is not one single that is, identification with country or nation, and thing but a number of related things. Research has increases in patriotism are a kind of private identity shown that different sources of cohesion lead to shift. This obvious connection between national different types of behavior. Cohesion based on identification and patriotism has only recently be- congeniality, for instance, leads to groupthink, come a focus of empirical research (Citrin, Wong, whereas cohesion based on group status or mate- & Duff, 2001; Sidanius & Petrocik, 2001). rial interest does not (McCauley, 1998a). Psychological Issues in Understanding Terrorism and the Response to Terrorism 29

Similarly, various sources of ethnic identifica- identification—heightened cohesion—in the group tion may lead to different behaviors. Individuals attacked. The nonobvious quality of this idea is who care about their ethnic group for status or conveyed by the many unsuccessful attempts to material interest may be less likely to sacrifice for use air power to demoralize an enemy by bombing the group than members who care about their its civilian population (Pape, 1996). group for its social reality value—for the moral In sum, I have argued that both origins and culture that makes sense of the world and the in- effects of terrorist acts are anchored in group dy- dividual’s place in it. Research on the effects of namics. Along the way I have tried to suggest how 9/11 on group identities might try to link various the response to terrorism can be more dangerous measures of group identification with different be- than the terrorists. haviors after 9/11: giving blood or money, community volunteer work, will revisions, changed References travel plans, and more time spent with one’s family. The distinctions between patriotism and Ajzen, I., & Fishbein, M. (1980). Understanding attitudes nationalism and between critical and uncritical and predicting behavior. New York: Prentice Hall. patriotism are steps in this direction. Allport, G. W. (1954). The nature of prejudice. Cam- Research on group dynamics has shown that bridge, MA: Addison Wesley. shared threat is a particularly potent source of Atran, S. (2003, March 7). Genesis of Suicide Ter- group cohesion; similarly, the threat represented rorism. Science, 299, 1534–1539. by the 9/11 attacks seems to have heightened feel- Barbera, J., Macintyre, A. G., & De Atley, C. A. (2001, ings of patriotism and national identification in the October). Ambulances to nowhere: America’s United States (Moskalenko, McCauley, & Rozin, critical shortfall in medical preparedness for catastrophic terrorism. BCSIA Discussion Paper 2006). Research also shows that high cohesion 2001-15, ESDP Discussion Paper ESDP-2001-07, leads to an acceptance of group norms, respect for John F. Kennedy School of Government, Harvard group leaders, and pressure on deviates (Duckitt, University. 1989). Similarly, the U.S. response to the 9/11 Barker, E. (1984). The making of a Moonie: Choice or attacks seems to have included a new respect for brainwashing? London: Basil Blackwell. group norms (less crime, more politeness), new Bearak, B. (2002, February 11). Afghan toll of civilians respect for group leaders (President Bush, Mayor is lost in the fog of war. International Herald Giuliani), and a new willingness to sanction de- Tribune, pp. 1, 8. viates (hostility toward those who sympathize with Beck, A., & Katcher, A. (1996). Between pets and Arabs and Muslims; Knowlton, 2002). people: The importance of animal companion- ship. West Lafayette, IN: Purdue University Press. Brewer, M. (2001). Ingroup identification and inter- Conclusion group conflict: When does ingroup love become outgroup hate? In R. D. Ashmore, L. Jussim, & D. In the first part of this chapter, group dynamics Wilder (Eds.), Social identity, intergroup conflict, and theory was the perspective brought to bear in un- conflict reduction (pp. 17–41). New York: Oxford derstanding the power of cause and comrades in University Press. moving normal people to terrorism. In particular Brown, R. (1986). Social psychology, the second edition. I suggested that the power of a group to elicit sa- New York: Free Press. crifice depends upon its terror-management value, Citrin, J., Wong, C., & Duff, B. (2001). The meaning which is another way of talking about the social of American national identity: Patterns of ethnic reality value of the group. conflict and consensus. In R. D. Ashmore, L. Jussim, & D. Wilder (Eds.), Social identity, Group dynamics research and the psychology intergroup conflict, and conflict reduction (pp. of cohesion also provide a useful starting point for 71–100). New York: Oxford University Press. theorizing the origins and consequences of group Duckitt, J. (1989). Authoritarianism and group identi- identification, including many aspects of public fication: A new view of an old construct. Political reaction to terrorism. Terrorism is a threat to all Psychology, 10, 63–84. who identify with the group targeted, and at least Festinger, L. (1950). Informal social communication. the initial result of an attack is always increased Psychological Review, 57, 271–282. 30 The Psychology of Terrorism

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The Need for Proﬁcient Mental Health Professionals in the Study of Terrorism Larry E. Beutler Gil Reyes Zeno Franco Jennifer Housley

The disciplines of psychology that are devoted to the press). In contrast, the most reliable figures re- understanding of terrorism and the treatment of presenting PTSD in the general population, fol- victims of terrorism are new and generally rely lowing the terrorist attack of September 11, 2001, on extrapolation of knowledge from related fields. places the incidence rate at about 4%, which in- However, while this strategy is effective in begin- dicates virtually no effect from 9/11. The incidence ning the process of illuminating this poorly re- rates of PTSD-like symptoms are higher in areas searched domain, it is also problematic. Not only that were directly affected by the terrorist attacks. have many of the conventional treatments used with In the New York City area, the estimated rates victims and responders proven to be less effective hover at about 11% and are noticeably lower than conventionally thought when applied to trauma in Washington, DC (Schlenger, Caddell, Ebert, generally (Litz, Bryant, & Adler, 2002), but serious Jordan, Rourke, et al., 2002). These latter results questions have also been raised about whether suggest that the prevalence rates approximate treatments that work for those exposed to civil, those reported by the NVVRS studies only in the natural, or even military-related disasters will work immediate aftermath of 9/11 and among those di- equally well with someone who has been exposed rectly affected. Even here, the rates of PTSD symp- to the systematic and planned acts of terrorists. toms decline quickly over time, returning to For example, incidence rates of symptoms that normative levels within 6 months to a year (Galea are suggestive of posttraumatic stress disorder et al., 2003; Resnick, Acierno, Holmes, Dammeyer, (PTSD) seem to be quite situation specific and & Kilpatrick, 2000). vary from one type of trauma to another. The most Because of such disparities between terrorist- widely cited figure representing PTSD in military initiated trauma and other forms of civilian and populations derives from the National Vietnam military trauma, many questions have been raised Veterans Readjustment Study (NVVRS), which in the field of trauma response about whether determined the likelihood of PTSD among those established treatments for civilian PTSD are who served during the Vietnam years to be about appropriate for terrorist-initiated traumas. These 30%, regardless of whether they were exposed concerns also stimulate questions about who might to combat (Marlowe, 2001; Wessely & Jones, in then provide the treatment. Is it sufficient for one

32 The Need for Proficient Mental Health Professionals in the Study of Terrorism 33 to have been trained in the use of widely practiced fearful of an almost omnipresent danger in the treatments for civil and military PTSD? An affir- environment. The fear generated by terrorist at- mative answer to this question fails to consider tacks extends into the most basic reaches of the both the fundamental differences present in the human mind, activating systems that have been nature of response to terrorism as a particular fundamental to our survival but long unused, and traumatic event and the associated differences that this may cause reactions that undermine one’s terroristic events may portend in the required emotional and mental well-being. treatment regimens. One of the difficulties of developing the ability This chapter explores what is currently known to predict and manage victims’ responses to ter- about how terrorism impacts victims in unique and rorism is the unavailability of systematic, empirical probably more profound ways than other forms research on the events that immediately follow a of catastrophic disaster, builds a theoretical fra- terrorist attack (Neria, Suh, & Marshall, 2004). By mework that explores the way in which terrorism nature these attacks are infrequent and unexpected specifically impacts traumatization and recovery, events and do not provide researchers with an and considers the effective treatment of victims of opportunity to systematically observe the response and first responders to terrorist attacks. From these of victims and create well-designed studies to ex- starting points, we then identify the particular skills amine effective treatment. Instead, behavioral sci- that constitute expertise in this arena, an approach entists who are interested in the aftereffects of this that contrasts with the more common procedure of form of violence have two basic options. They can evaluating one’s expertise on the basis of training, respond with a hurriedly constructed inquiry im- experience, and knowledge. The objective of these mediately following a mass-casualty event. Alter- considerations is to question the nature of expertise natively, they can search for analogous events that and training that might be advantageous for those have a higher base rate of occurrence and greater who treat the victims of terrorist attacks. The com- predictability and thus offer greater experimental prehensive view of terrorism and related trauma control. In order to bridge this gap between the presented here form a foundation for the creation available information and the knowledge that is of expertise that may be central for mental health needed to illuminate this developing area in psy- professionals working in this field. Such a foun- chology, we present findings drawn from both the dation of knowledge should begin to guide both relatively small body of literature dealing specifi- clinical practice and research. cally with the psychological sequelae of terrorist attacks, as well as a broader range of findings from other events that have been carefully selected to be Terrorism Versus Disasters: as analogous to terrorism as possible. Differential Psychological Response Psychological Responses to Terrorism The intentionality of an act of terrorism serves as a signal contributor, differentiating the responses A few large-scale studies examining the fear and of victims of a natural disaster from those of victims psychological symptoms associated with the dis- of a terrorist attack. The implication of intentional tress caused by the 9/11 attacks have been pub- malevolence, which can neither be effectively pre- lished. Additionally, findings from incidents that dicted nor prevented, and the concomitant feelings share the fundamental elements of terrorism, in- of uncertainty, distrust, and loss of control that cluding malevolent intent, unpredictability, the follow are fundamentally different from the ex- threat of future attack, and the possibility of envi- perience of fear associated with a naturally occur- ronmental contamination, provide insight into this ring disaster—even if the disaster is serious and unique area of study. Analogous events run the large scale. Whereas one can prepare for an earth- gamut from very serious incidents involving nu- quake or a hurricane, the nature of a terrorist act is merous casualties and mass panic (e.g., the cesium likely uncertain and defies effective preparation. 137 release and panic in Goiania, Brazil, in 1987), The most insidious forms of terrorism, such as in-garrison military incidents (e.g., the attack on the use of biological weapons, may be impossible Pearl Harbor), and individual or small-group to detect even after an attack occurs, leaving one events (e.g., domestic and gang violence) to the 34 The Psychology of Terrorism absurd (e.g., the panic caused by the ‘‘War of the malicious intent allows even those who are directly Worlds’’ broadcast in 1938). These comparable impacted to gradually delimit the event and to incidents allow us to examine the ways in which understand it as an unpleasant, though funda- the fear produced by terrorism differs from ‘‘fated’’ mentally ‘‘normal,’’ part of life. events such as natural disaster. Conversely, the causal attributions drawn from To understand psychological distress and the a terrorist event are much less orderly. Almost symptoms associated with trauma, we must first by definition, these acts are designed to invoke understand the fundamental psychological pro- a pervasive fear of an unknown, unpredictable, cesses that underlie fear and threat assessment. yet intentional threat. Where a naturally occurring Exposure to any disaster, whether generated by disaster is almost always bound by time or geo- humans or occurring naturally, can be expected to graphic location, terrorism is not similarly de- deeply impact the cognition, affect, and physical limited. Paul Slovic (2002), an expert in the field functioning of those who are in the path of the of risk perception, notes that the most feared forms catastrophe. However, we suggest that the inten- of terrorism, such as chemical or biological attack, tional nature of terrorism essentially alters these are ‘‘emergencies [that] contaminate in ways that perceptions. We argue that these differences are never seem to end’’ (p. 425). To the victims, the seen in the development of causal attributions that event has no apparent closure. are employed to explain the event, in the heuristics Further, whereas natural disasters are generally that may bias perception of it, and in risk assess- understood as the work of ‘‘fate’’ or an ‘‘act of God,’’ ments that assist us in estimating ongoing and the only causal attributions that can be drawn from future threats. terrorist activity is the malevolent intent of a human It appears that terrorist attacks differ systemat- agent, and often this agent is unknown to the vic- ically across each of these domains when compared tims. Thus, the exact message and rationale for the to natural disasters or accidental traumatization. assault are usually unclear to the immediate vic- Moreover, preexisting vulnerabilities, as well as tims, and the intended message is generally not peritrauma and posttrauma risk factors, are central meant for them specifically. Rather, the objective of to predicting which people will recover normally the assailants is to incite fear in the general popu- from a terrorist event and which will experience lation in order to draw the attention of political interrupted or delayed recovery. These elements leaders (Pfefferbaum, Pfefferbaum, North, & Neas, are developed in the following sections, and later 2002). The immediate causal attributions are based in the chapter they are integrated into a model that on the limited knowledge that the event is delib- describes threat assessment and its relationship to erately caused and malevolent in nature. Thus, a psychological trauma. victim’s abilities to understand, anticipate, plan for, and delimit the event are seriously impaired. Causal Attributions Without the availability of clear event con- The sense of causal understanding found after tingencies, victims are faced with several key ques- many natural disasters is often absent in the wake tions for which no clear answers are immediately of a terrorist attack. The dynamics of a hurricane, available, such as (1) Who was the intended target? tornado, accidental plane crash, or earthquake re- (2) Do I fit the target profile? (3) What is the like- present events that are easily understood by lihood of another attack? And, if so, (4) What fur- the public. Furthermore, clear causal attributions ther attack methods may be employed? Without about the event can be drawn, and expectations the ability to explain the event and without clear about the location, progression, and duration of answers to questions used to evaluate immediate the event are generally known or can be reasonably personal danger, a victim or witness to a terrorist estimated (Slovic, 2002). Based on experience of or event is left with little sense of personal control prior education about the disaster, first responders or agency. The result may be a profound sense of and potential victims can typically consider an im- helplessness and defeat. pending event with a sense of what to expect and the actions they can perform to mitigate the si- Heuristics tuation. In the worst-case scenario, an evacuation Because of the salience of the event and the un- plan can be devised. Importantly, the lack of predictability of terrorism, both direct victims and The Need for Proficient Mental Health Professionals in the Study of Terrorism 35 those secondarily exposed are likely to respond model of fear in these situations suggest that two disproportionately to event-related stimuli, placing factors may be central to understanding how them at greater risk for increased fear, anxiety, and people assign affective values to terrorist incidents. possible psychological difficulty. The analysis of The first factor can be described as dread risk, risk, formally referred to as risk assessment by re- a continuum beginning with low-dread events, searchers in this field, is a function that humans which are seen as controllable, not catastrophic, have instinctively performed long before recorded decreasing in risk over time, and generating little history (Slovic, 2002). Natural selection produced risk for future generations (Slovic & Weber, 2002). a refined system that enabled people to incorporate Conversely, high-dread events are viewed as hav- information of many types, analyze it based on ing a high mortality rate, being globally cata- past experiences, and produce an affective reaction strophic and inescapable, and increasing in risk capable of governing our behavior. This form of over time. risk assessment, called experiential risk assessment, A second factor is unknown risk, which begins is considered to be ‘‘intuitive, automatic, and fast’’ at the low-risk level with well-understood, ob- (Slovic, 2002, p. 425). Research on fear-related servable, non-novel events (Slovic & Weber, 2002). stimuli has demonstrated that people precon- If an event is high on the unknown risk dimen- sciously attend to threatening information (Ohman, sion, it is characterized by having delayed or per- Flykt, & Esteves, 2001). Operating largely outside sisting effect and being a novel threat that is poorly of consciousness and relying primarily on recalled understood (Slovic & Weber, 2002). Using this visual information and associative thoughts, experi- model, Slovic and Weber provide a two-dimensional ential risk assessment produces simple emotions— chart with unknown risk on the Y axis and dread a ‘‘gut feeling’’ about a given event (Slovic, 2002, risk on the X axis. Earlier research by Slovic allows p. 425). a wide variety of different threatening events to This form of reasoning is a powerful and be placed in this two-dimensional space, in which generally useful behavioral motivator. However, events that fall in quadrant I are viewed as the the emotionally charged images, feelings, physical most threatening. Examples of things found at the consequences, and media attention that are typical extreme end in quadrant I include DNA technol- outcomes of terrorist events may create an over- ogy, radioactive waste, nuclear reactor accidents, whelming fear and anxiety in both the direct vic- and nuclear fallout (earlier work by Slovic as cited tims and those secondarily exposed through the in Slovic & Weber, 2002). media (Pfefferbaum et al., 2002). Because experi- Because we are most concerned with the psy- ential risk assessment is rapid and largely auto- chological consequences of these events and the matic, it relies on the availability heuristic and is role of mental health response in combating se- vulnerable to the base rate fallacy, giving more quelae such as PTSD, depression, and drug abuse weight to recent, easily imagined, and highly following a mass-casualty event, it may be help- arousing events and overestimating their future ful to translate the model proposed by Slovic and likelihood (Chapman & Harris, 2002; Slovic & Weber (2002) into terminology that is typically Weber, 2002). Although these systems may in- used by disaster psychologists and first responders. itially play a vital role in a person’s survival, the Doing so helps us determine what constitutes an salience of the stimuli related to terrorism also ‘‘expert’’ who can provide discriminating help to plays into a fundamental signal-processing bias in the victims of mass terrorism. human risk assessment that may short-circuit the In addition to the factors already proposed by system, resulting in the elicited fears and anxieties Slovic, we also suggest an additional factor that has continuing beyond the point of utility and poten- not been carefully explored—the role of perceived tially putting the victim at risk for PTSD or other malevolent intent—to round out this matrix and serious psychological difficulties. to lend further assistance to the professional who attempts to establish priorities for effective inter- Risk Assessment vention. In analyzing the psychological risk in- Currently, very few models exist that specifically volved in a terrorist attack, psychologists, social describe the factors involved in risk perception as workers, other mental health professionals, and applied to terrorism. Initial efforts to provide a first responders may be assisted by evaluating the 36 The Psychology of Terrorism following dimensions: (1) the scale of the attack The resulting panic no longer ensures survival and (dread risk); (2) proximity to the attack (dread instead actually places the organism at risk for self- risk); (3) perceived personal threat (dread risk); injury and accident by virtue of the disorganized, (4) the type of weapon used (unknown risk); (5) goal-directed behavior that accompanies this hy- duration of threat (unknown risk); and (6) the peraroused state. Hyperarousal caused by a terrorist nature of the malevolent intent (adapted from attack may dispose the majority of the exposed Slovic & Weber, 2002). In general, as the value of population to an initial adaptive fear response. each of these dimensions increase, the risk of However, a smaller number of people may begin psychological harm also rises. showing symptoms of acute stress disorder (ASD), and a subset of this group may progress to PTSD. Terrorism and Traumatization In fact, research performed after the Oklahoma City bombing demonstrated that feeling nervous or Throughout this chapter we address concerns re- afraid immediately following the bombing was the lated to different two populations: the general best single affective predictor of later PTSD onset public exposed to a major terrorist event and the (Tucker, Pfefferbaum, Nixon, & Dickson, 2000). first responders, including firefighters, police offi- A powerful example of how we respond to risk cers, emergency medical technicians, military per- assessments that seem particularly threatening and sonnel, and other relief workers. Although some of how these assessments play into maladaptive hy- the considerations for each distinct population perarousal can be drawn from the Israeli experi- overlap, we approach them as having fundamental ence during the Gulf War. Two retrospective differences in training, expectations, and support studies of the rates of physical and psychological systems that cause them to differ in initial re- illness during 18 discreet attacks involving 39 sponse, later assessment of trauma symptoms, and missile explosions in Israel (Bleisch, Dycian, Ko- final recovery. Some of the key concepts that de- slowsky, Solomon, & Wiener, 1992) have shown scribe the process of traumatization may serve as that 27% of hospital admissions were due to un- an underpinning for understanding what first re- necessary atropine (a chemical warfare antidote) sponders experience. However, when undertaking injections, presumably due to stress reaction or to treat first responders, clinicians should incor- mishandling of the atropine injectors. Addition- porate the information that is specific to this po- ally, a substantial increase in acute anterior wall pulation in the assessment, planning, and delivery myocardial infarction and sudden out-of-hospital of treatment. deaths (as compared to five control periods) was also noted (Meisel et al., 1991). Hospital staff de- General Public termined that about 43% of hospital admissions One of the keys in understanding the variations during this time were for psychological rather than in anxiety created by external events is the un- physical symptoms (Bleisch et al., 1992). Inter- derstanding of the adaptive and evolutionary sig- estingly, the rates of heart attack and sudden death nificance of these responses. Wakefield (1992) attenuated rapidly after the initial attacks, sug- emphasizes the role of evolutionary events as a gesting that most people had adjusted to the new central theme in behavior. This perspective asserts threat fairly rapidly (Meisel et al., 1991). that every behavior has evolutionary significance. The SCUD missile attacks in Israel were in- That is, it increases the probability of the survival itially feared to contain chemical weapons, but only of the species. In the case of anxiety, arousal likely conventional warheads were actually used (Bleisch serves to motivate and activate an organism to et al., 1992). Even though the media overly dra- prepare itself for danger and thus reduces the matized the likelihood of mass exposure to che- chances of premature death. Various levels of mical or biological agents in Israel, it is critical arousal promote vigilance and reflect the levels of that disaster mental health providers and first re- danger expected by the organism. sponders view the use and even the threat of However, at some point, when the danger is nonconventional weapons as a special situation unpredictable and uncontrollable, as in the case of that may elicit a particularly strong fear response in terrorism, the result may be a level of arousal that the public (Slovic & Weber, 2002), generate a great is no longer adaptive but rather is dysfunctional. many psychological casualties, produce a high rate The Need for Proficient Mental Health Professionals in the Study of Terrorism 37 of false positive reports of exposure (Pastel, 2001), generate fear and stimulate flight in the event of and rapidly overwhelm public health resources. The unexplained illness or death. risk of evoking a particular type of fear-generated In addition to the fear and anxiety produced response, known as outbreaks of multiple un- by a mass-casualty event, by creating an event that explained symptoms (OMUS), tends to increase is unbounded by time (and potentially unbounded when unconventional weapons are introduced into by geography), terrorism also removes factors that the threat matrix (Pastel, 2001). are assumed to be central to healthy mental func- The concept of OMUS reflects a modern in- tioning, such as a sense of predictability, agency, terpretation of the more traditional descriptions and control. Research on Holocaust survivors has of ‘‘mass psychogenic illness’’ and ‘‘mass hysteria’’ demonstrated that victims made considerably fewer (Pastel, 2001, p. 44). In general, OMUS occur in attributions of internal control and many more response to an unobservable environmental con- external control attributions as compared to simi- tagion, real or imagined, and are denoted by a lar control participants (Suedfeld, 2003). In more host of somatic symptoms with no apparent phy- recent disasters, including the Chernobyl reactor sical cause (Pastel, 2001). Unlike classic mass accident and the Loma Prieta earthquake, even panic, OMUS occur relatively frequently (Small, those who were not directly victimized experi- Propper, Randolph, & Eth, 1991) and can be very enced a degradation of the optimistic bias that costly to both the government and private sectors. many researchers believe to be important in The effects of OMUS are often reinforced by maintaining mental health (Weinstein, Lyon, Roth- mass media, rumor, and highly visible response man, & Cuite, 2000). Similarly, people who were interventions and subsequent investigation. Ex- close to large-scale tornado damage but were amples of OMUS include those that surfaced at not directly impacted show significantly lower Three Mile Island and during the Alar-poisoning usage of self-protecting biases, many more intrusive panic (Pastel, 2001). In each of these cases, broad- thoughts about future tornados, a lowered per- cast and/or print media played a central role in ception of control over the damage caused by these inciting fear. events, increased feelings of personal vulnerability, While most cases of OMUS yield compara- and more feelings of anxiousness and depression tively harmless results, the picture becomes much in response to related stimuli (Weinstein et al., more complex in the event of a bona fide terrorism 2000). act or an accident involving a chemical, biological, So far we have primarily considered the af- radiological, or nuclear (CBRN) device. For ex- fective and cognitive components of trauma in ample, the radiological poisoning of 249 people in response to terrorism. While closely related to the Goiania, Brazil, in 1987 from contact with scrap perception of anxiety, the physical aspects of a metal that was contaminated with cesium 137 terrorist attack—including both physical exposure resulted in more than 5,000 unexposed people and immediate somatic response—must also be (of the 125,800 screened) demonstrating physical considered by practitioners who seek to assist symptoms (Pastel, 2001). The symptoms these victims effectively in the aftermath of such an event. 5,000 unexposed people exhibited were very Clear evidence was found demonstrating that similar to those of the much smaller number physical injury was one of the most predictive of people who were sickened by actual radiation factors in later onset of PTSD following the Okla- poisoning. This phenomenon made it difficult to homa City bombing (Tucker et al., 2000). The differentiate between the two groups. In the case of immediate physical response of those directly ex- a possible CBRN incident, the previously used posed, such as increased heart rate and trembling, terms for OMUS (e.g., mass hysteria) seem parti- has also been shown to be substantially correla- cularly inappropriate since the syndrome may be ted with PTSD and subclinical PTSD symptoms viewed as a powerful self-protective mechanism (Tucker et al., 2000). that encourages flight from an area containing Although we generally assume that proximity an unknown pathogen. It is plausible that OMUS to and the magnitude of an event are related and their concomitant social components, such as to the likelihood of later psychological difficulty ‘‘psychological contamination’’ (Pastel, 2001), may (Weinstein et al., 2000), PTSD symptoms follow- have an evolutionary component that served to ing large-scale events are evidently not correlated 38 The Psychology of Terrorism with proximity to the worst levels of destruction or probably should, be included in what we refer to exposure to greater loss of life (Goenjian et al., as victims of terrorist attacks. To a large extent, 2001). In a study of PTSD symptoms and de- they cannot be distinguished from the immediately pression in adolescent victims following Hurricane targeted bystanders who are the usual victims. Mitch in Nicaragua, investigators found that the Next to the immediate victims of an attack, first majority of victims’ subjective exposure ratings responders are the first to see its aftermath and are ‘‘did not follow a dose-of-exposure pattern’’ those who are called upon immediately to manage (Goenjian et al., 2001, p. 792). Moreover, no sig- the situation and treat those affected. However, nificant correlation was found between those in just because they may not be directly affected by the most badly damaged city where the greatest the initial terrorist action, they are still susceptible loss of life had occurred and victims in a to the aftermath and thus suffer many of the same nearby city that was not as severely impacted illnesses and symptoms that the victims they are (Goenjian et al., 2001). The authors of this study treating may develop. suggest that a ceiling effect may occur when the The first responder population is broad. Gen- severity of the event is sufficiently great, with the erally speaking, they are the professionals and vo- result that physical proximity becomes a less im- lunteers who arrive first on the scene following portant factor in the development of mental health a terrorist attack or are on the front line in caring for problems. victims. Some obvious examples include police of- While the precise mechanisms through which ficers, firefighters, and ambulance personnel. Oth- human intent to cause harm operates on risk ers include emergency room staff, hazmat teams, perception and fear have not been fully explicated, military personnel, utility crews, and volunteers. the events of 9/11 and other intentional tragedies Both victims and first responders share certain clearly differ from both natural disaster and un- characteristics within the context of terrorist events. intended mass-casualty events. Paul Slovic states First responders, like the general population, are that ‘‘a startling feature of the September 11 attacks subject to the unpredictability of the event and and the subsequent anthrax exposures and deaths the difficulty in simulating an exact replica during is the degree to which a handful of determined training exercises and, of course, can experience individuals, in a very short time, so greatly dis- strong emotional reactions. Each population uti- rupted the world’s most powerful nation’’ (2002, lizes an array of coping strategies to deal with the p. 425). trauma they witness. Treatments for psychological Any major disaster, whether caused by nature, conditions resulting from exposure to trauma over- unintentional human error, or intentional mal- lap between the general population and the first evolence, is likely to result in profound physical responders. Additionally, just as there are different injury, immediate fear, and potential long-term cultures present among the general population, psychological difficulties. However, we argue that different cultures are present among first respon- the combination of the perception of human in- ders. These features contribute to how a terrorist tentionality, the lack of ability to generate a co- event is appraised, what coping style is used, and herent set of expectations, the persistence of an how frequently treatment is sought if psychological unknown threat, and the ubiquity of the threat all harm is identified. serve to differentiate terrorism from other mass- Moreover, each first responder population has casualty events. These differences fundamentally a ‘‘culture’’ that is unique to their profession and alter human perceptions of the event, increasing that is shaped both by the services they provide their salience and heightening their arousal com- and by their level of investment in these services. ponents. In view of this, we suggest that the fear These factors contribute to the type of psycholo- generated by terrorism may be more persistent and gical impacts that result from emergency scenes. more potent in generating psychological sequelae For example, although firefighters and police of- than other forms of disaster. ficers both respond to emergency scenes, there are fundamental differences in their roles. A fire- First Responders fighter’s role is acute in nature and medically Thus far we have addressed victims and their oriented; they have little opportunity for ongoing treatment. However, first responders can, and contact with victims following an emergency. The Need for Proficient Mental Health Professionals in the Study of Terrorism 39

In contrast, because the role that police officers heavily on cognition and memory and, as such, play extends beyond the emergency scene, they may be deeply impacted by preexisting risk factors may have more contact with victims in postcrisis that cue trauma-related recollections. In the fol- situations. Thus firefighters have a culture that lowing sections, we consider both preexisting and centers around the acute care of victims, whereas posttrauma risk factors that influence the devel- that of police officers centers around continual opment of psychological effects following a terrorist exposure. attack. Key differences between populations of victims and first responders must be considered by the Risk Factors: General Public knowledgeable professional who intervenes. First Several vulnerability factors have been associated responders have responsibilities in disaster situa- with higher rates of PTSD-like symptoms in ret- tions, whereas victims may not. For example, first rospective studies and include prior exposure, par- responders must identify and address the effects of ticularly early in life, to violence or other major disasters on the general population and may utilize traumatic events, gender (females are at greater coping strategies that are unique to their trades risk for chronic PTSD), age (younger victims are both in type and intensity. The health and safety of generally at greater risk), intelligence, concurrent others depend on the health and skill of the first mood disorder, neuroticism, and a low level of responders. This charge carries with it emotions social support (Litz, Gray, Bryant, & Adler, 2002; such as the fear of failure, which in turn can affect McNally, Bryant, & Ehlers, 2003). Several attempts the way in which first responders deal with trauma have been made to demonstrate that these vul- situations. nerability factors cause higher levels of PTSD symp- Addressing each population based on its un- toms through prospective studies, and the results ique culture can assist us in identifying barriers have largely supported the initial retrospective to predicting susceptibility to mental health diffi- findings (McNally et al., 2003). These results culties, determining which method of prevention have largely been derived from pre- and post- might be most useful, choosing an effective ap- deployment testing of troops and have demon- proach to mental health education and training, strated that those with more serious PTSD and learning which type of intervention may be symptoms scored lower on IQ tests (and that IQ called for. does not change after deployment), were more likely to have personality traits of hypochondriasis, psychopathic deviate, paranoia, and femininity The Effects of Exposure to Terrorism based on Minnesota Multiphasic Personality In- ventory (MMPI) scores, and exhibited more nega- In this section we build upon the topics presented tivism toward their deployment (McNally et al., in the prior two portions of the chapter to round 2003). Litz et al. (2002, p. 114) state that ‘‘It has out a model that helps explain the fundamental become axiomatic that prior exposure to poten- psychological differences between intentional acts tially traumatizing events (PTEs) is a risk factor of terrorism and natural disasters and how they set for chronic PTSD stemming from a subsequent the stage for either normal or interrupted recovery. PTE.’’ Prior exposure is represented in affect laden A more comprehensive perspective on the psy- memories that are activated by a current event chological sequelae of terrorism and their treat- or trauma, and then serve to exacerbate and sen- ment will enable us to begin constructing effective sitize the individual to that event. These incipient, mental health measures and allocate limited re- internal cues from memory may be important sources in an emergency more efficiently, as well as features that reduce the capacity for adapting and manage the incredibly high cost of response to and resilience. recovery from terrorism. We argue that the basic For example, in determining which factors psychological and physical responses to terrorism, precipitate PTSD and explain why some people such as the affective components of fear, are later develop it and others, similarly exposed, do not, processed through an increasingly complex matrix Dalgleish (2004) concludes that PTSD is a joint involving causal attributions, heuristics, and risk function of at least three separate aspects of cog- assessment. These more complex activities rely nitive representation. These include the presence 40 The Psychology of Terrorism of associative networks in which prior stressors ac- type, timing, and the destructive agent used. These tivate remembered and rehearsed cognitive path- can affect the stress level of first responders in ways; verbal or prepositional representations; and different ways. For example, because they are con- schemas or preexisting beliefs about oneself and sidered more preventable, human-induced events others. Memories and associational pathways alone precipitate stronger feelings of anger and blame are insufficient to account for the variations in re- than natural disasters. Paton (1996) states that sponse. Also needed is a language system through events that occur during nighttime hours are per- which these events are processed and the activation ceived as more threatening than those that occur of self-related schemas that lend themselves to feel- during the day. ings of helplessness and hopelessness. Another factor related to timing is the degree In addition to the risk factors that may be present of uncertainty associated with a threat. The events prior to a traumatic event, several factors have been of 9/11 can serve as an example since it was unidentified that may serve as peri- and posttraumatic clear whether additional attacks were forthcoming. markers for future psychological difficulty: A related stressor has to do with whether there was warning before the disaster. In addition, Paton 1. People with many or very severe ASD symp- states that ‘‘invisible’’ threats, such as chemical or toms that appear 1–2 weeks following a trau- radiation hazards, may elicit more reaction than matic event. Particular attention should be visible threats such as flooding. Finally, the greater given to these people if these symptoms are the number of threats associated with the disas- comorbid with high rates of rumination. This ter, the greater the reaction felt by emergency appears to be one of the best, simplest, and workers. The 9/11 catastrophe illustrates how one most straightforward screening methods cur- incident can yield multiple threats. Fires, the col- rently available. lapse of buildings, death, suffering, and health 2. People who experience high levels of physical hazards were just a few of the many threats that symptoms, such as a rapid heart rate, after both victims and first responders faced during that having been removed from the trauma stimu- incident. lus. These types of measures may be particu- A second grouping of the stressors identified larly useful for Emergency Medical by Paton (1996) involves the perceptions of the Technicians (EMTs) and physicians. events by the first responders and the way in 3. People who experience ASD or PTSD symp- which their ability to do their jobs is affected. toms in conjunction with signs of clinical de- Having insufficient opportunity for effective ac- pression are at higher risk for developing tion, knowing the victims and/or their families, chronic PTSD. receiving additional job-related responsibilities, 4. People who display a high level of active and having to meet increased emotional, physical, avoidance or precautionary symptoms and time demands can all trigger additional stress 5. People who make maladaptive attributions for first responders. Lack of adequate resources about their symptoms can negatively affect their ability to perform 6. People with serious physical injuries as their jobs and can thus also result in stress. In result of the trauma event addition, unrealistic expectations can make re- 7. People with low levels of social support? covery from trauma more difficult (McCammon, (list adapted from Litz et al., 2002; McNally et al., Durham, Jackson, & Williams, 1988). Another 2003). complicating factor is the degree and duration of emotion suppression following an emergency situation (McCammon et al., 1988). Risk Factors: First Responders The third group of stressors relays the im- Again, the risk factors for the general public serve portance of the organizational structure in which as a foundation for understanding the vulner- the first responders are working. Changes to this abilities of first responders. However, a number of structure can result in additional stress. For ex- specific psychological risk factors should be con- ample, interagency coordination difficulties, considered for members of special response teams, flicts, or failure can have adverse effects on the including characteristics of the event itself, such as emotional and functional capabilities of emergency The Need for Proficient Mental Health Professionals in the Study of Terrorism 41 workers, and feelings of inadequacy and help- presented earlier and to explain the model, we lessness can ensue. Emotions such as these can suggest the following hypothetical timeline: hamper workers’ ability to perform their job suc- First, immediately following a terrorist attack, cessfully and efficiently. There are many roles that affected individuals must assess the objective need fulfilling in disaster situations, and constantly threats in the environment, including perso- having to change roles, such as going from saving nal physical injury, exposure, physical someone’s life to speaking with the media, can put symptoms of shock, observing injury to oth- extra strain on first responders as well. ers, witnessing death, and fearing for the Although there may be little one can do to survival of one’s family members. affect the time, type, or nature of a future terrorist Second, both during and after a mass-casualty attack or other unforeseen disaster situation, some event, these objective threats may generate the of these stressors can likely be reduced through immediate affective responses of fear and training and preparedness work. For example, anxiety. As people move from the experience establishing firm roles and responsibilities, proof the traumatic event into recovery, they viding sufficient resources, ensuring adequate le- begin to process the event more deeply. vels of staffing for shift rotations, and requiring During this assessment phase, risk factors for additional preparatory training may all contribute PTSD, such as exposure to prior trauma, be- to supporting a first responder in the line of duty come increasingly salient and may deeply and assisting in reducing the degree of stress felt in impact the cognitions and memories related such a situation. to the event. Similarly, resiliency factors may be important at this stage in shielding the A Proposed Model of Threat Assessment individuals from what otherwise might lead to and Trauma problematic thought and memory patterns Based on the more detailed understanding of fear revolving around the event. It is also at this and threat assessment developed in the preceding assessment stage that causal attributions and sections, we suggest a model of terrorist response heuristics may be applied, both of which rely that addresses six major factors grouped into three heavily on cognitive and memory processes. time categories: Thus, mediators such as risk and resiliency factors, along with cognition and memory, are 1. Peritrauma and immediate posttrauma phase central to a victim’s subjective (or secondary) Factor 1. initial (objective) threat assessment threat assessment. Terrorist attacks may be Factor 2. immediate physical response particularly powerful in influencing the Factor 3. immediate affective response secondary appraisal of fear-related stimuli 2. Assessment phase (posttrauma) because they elicit thoughts that revolve Factor 4. mediators (prior traumatization, around threat persistence (unboundedness), other risk factors, training, etc.) (these im- malevolence, and fear of the unknown (CBRN pact factor 5) devices, etc.). Factor 5. cognition and memory (these im- Finally, in the resolution phase, a victim’s fear pact factor 6) and psychological symptoms either begin or Factor 6. subjective threat assessment abate as their subjective threat assessment 3. Resolution phase (continuing) wanes. However, if the subjective threat as- Either the individual continues to feel sessment does not decrease, the individual threatened and experiences ongoing symp- may be at risk for developing ASD or PTSD. toms, or the threat is downgraded and the symptoms begin to abate. Normal Versus Interrupted Recovery By being familiar with these factors, a practi- Practitioners should remain aware that, even in tioner can begin to categorize the experiences a normal recovery, many psychological and physical victim has had and construct a comprehensive symptoms associated with the traumatic event treatment plan in case the person’s natural re- may be present and can persist for some time (Litz covery process fails. To synthesize the information et al., 2002). However, if one’s response to the 42 The Psychology of Terrorism trauma is normal and the individual has the usual researchers and theorists in the field of trauma sources of support and resilience, recovery may psychology. be relatively rapid, and the victim may return to baseline in days or weeks. Alternatively, the as- Specific Disorders Associated With sessments, modulators, and risk factors may dis- Mass-Casualty Terrorist Events pose a person to be traumatized to such a degree that resilience is impaired, and the normal re- The following descriptions of psychological dis- storation of mental health may be delayed or in- orders that may occur after exposure to a mass- terrupted. casualty event are drawn from the DSM-IV-TR, Furthermore, research on disaster victims has except where noted, and we have used the language not always shown congruent symptoms across all employed there in order to ensure congruity be- event types (Brewin, Andrews, Rose, & Kirk, 1999; tween these paraphrased descriptions and the actual Goenjian et al., 2001; Morgan, Grillon, Lubin, & diagnostic criteria for the disorders. The descrip- Southwick, 1997), and differences in correlations tions are intended for informational purposes only. between the age of the adults and distress in vic- We refer the reader to the DSM-IV-TR for more tims and first responders have also proven difficult details, specific symptoms, and formal diagnostic to pin down. Some studies have found that older procedures. rescue workers and victims tend to be more resilient in the face of disaster, while others have PTSD found that older victims are most at risk, and still others have demonstrated that those in their According to the DSM-IV-TR, posttraumatic stress middle years are most likely to be affected (Tucker disorder may occur following exposure to an ex- et al., 2000). Similarly, we can expect that different tremely traumatic stressor when a person has di- types of terrorist attacks will result in nuances rectly witnessed situations that result in actual or in healthy and pathological recovery. threatened mortality or physical injury and the The types of psychological trauma and other individual’s response to this situation includes a after effects that are associated with major mass- strong affective component of intense fear, help- casualty events include PTSD, ASD, major de- lessness, and/or horror. One or more cardinal symp- pressive disorder (MDD), burnout, anxiety, sleep toms of reexperiencing, three or more symptoms disorders, and drug and alcohol abuse. In some of avoidance and/or numbing, and two or more rare instances the practitioner should also be pre- symptoms of increased arousal are needed to meet pared to handle OMUS (Bleisch et al., 1992; Pastel, the full clinical criteria. The symptoms must be 2001; Tucker et al., 2000). We briefly describe the present for at least 1 month and are considered clinical diagnostic criteria for each of these dis- to be acute if the symptoms last for less than orders (or theoretical formulations for trauma- 3 months; they are considered chronic if they related syndromes not listed in the Diagnostic and persist for more than 3 months. Children may Statistical Manual of Mental Disorders (DSM-IV- present slightly differently, especially with regard TR)) as well as how they manifest in postdisaster to reexperiencing, with repetitive play that is situations. thematically related to the trauma event and night- However, the majority of what remains of this mares with no specific content. Trauma reenactment chapter focuses on treating acute stress disorder in younger children may be common. and preventing chronic PTSD since these two associated conditions encapsulate the central pro- ASD blems associated with the trauma exposure with Acute stress disorder is largely similar to PTSD which mental health practitioners must deal and but is shorter in duration and focuses more on are the general focus of the literature on the psy- the dissociative symptoms than PTSD does (Bre- chology of catastrophic events. We also highlight win et al., 1999). The DSM-IV-TR suggests that these disorders because their treatment among ASD ‘‘is the development of characteristic anxiety, victims of mass-casualty events is poorly under- dissociative, and other symptoms that occur within stood and because the efficacy of the treatments one month after exposure to an extreme stressor.’’ that have been used to date are hotly debated by Symptoms must last at least 2 days before diagnosis The Need for Proficient Mental Health Professionals in the Study of Terrorism 43 can be made. As with PTSD, the victim must both large-scale disaster may increase the risk for an witness an event that threatened or resulted in onset of PTSD. However, the clinical diagnosis of serious physical harm to the victim or others and generalized anxiety disorder (GAD) requires that present an intense affective response including the symptoms be present most of the time during a fear, helplessness, or horror. Three or more dis- 6-month period. Those who suffer from GAD find sociative symptoms must be present, one or more it difficult to control their worry and exhibit at reexperiencing symptoms must occur, and notable least three of the following symptoms: restlessness, avoidance, anxiety, or arousal symptoms are re- fatigue, impaired concentration, irritability, muscle quired for this diagnosis tension, sleep disturbance (either in falling asleep, staying asleep, or sleeping restfully). In children, Depression only one of these symptoms is necessary to meet A major depressive episode is diagnosed following clinical diagnostic criteria. a period of 2 or more weeks in which an individual reports a depressed mood or anhedonia toward Sleep Disorders most normal activities. Depression is generally A diagnosis of primary insomnia is indicated associated with a set of vegetative symptoms, such when an individual has difficulty falling or stay- as sleeping difficulties and lethargy. Thoughts about ing asleep or experiences nonrestorative sleep for personal worthlessness and suicide often occur. a period of 1 month or more. Primary insomnia Especially in mass-casualty situations, symptoms causes serious distress in important life functions related to bereavement should be separated from and is not due to biologically based sleep pro- a potential diagnosis, and treatment should speci- blems such as apnea or circadian rhythm upset. In fically address bereavement concerns if the indi- trauma-exposed people, nightmare disorder may vidual has lost close relatives or friends. Depression also occur. This is typified by repeated awakenings has frequently been reported among those who from sleep with detailed recall or extended and were subjected to the terrors of 9/11 (Galea et al., extremely frightening dreams, usually involving 2002). threats to personal survival, security, or self- esteem. The nightmares must cause significant Burnout difficulty in some aspect of life functioning to meet Although not a DSM-IV-TR category, burnout can clinical criteria and must not occur during the nonetheless result from high-stress occupational course of another disorder, such as PTSD. situations and can detrimentally affect job performance. It is helpful to consider burnout as both a Drug Abuse and Dependence process and a result. A person who experiences Because of the wide variety of drugs that may be burnout may progress through different stages, abused or for which dependence may develop, and the symptoms are similar to those of stress, we concentrate here on the general criteria for anxiety, and depressive disorders. Eventually, after substance abuse and dependence. Clinicians who experiencing prolonged levels of high stress and suspect specific forms of drug use in trauma- anxiety, an individual may socially withdraw and exposed clients should refer to the DSM-IV-TR for become apathetic and possibly resentful. Follow- further information. Due to the ubiquity of and ease ing this stage, the person may become depressed in obtaining alcohol, clinicians should be particu- and exhibit many of the classic signs of depression. larly alert for signs of alcohol abuse in trauma vic- In addition to anxiety and depression, substance tims. The criteria for substance abuse include a abuse is also associated with burnout. Burnout maladaptive pattern of substance use that leads to is preventable and can often be identified by the one or more of the following domains: failure to individual once provided with education about the fulfill major obligations at work, school, or home; condition. recurrent use of the substance when its ingestion puts the individual at risk for physical harm; legal Anxiety difficulties related to the use of the substance; and Subclinical anxiety symptoms may be quite com- continued use of the substance despite social or mon after a mass-casualty event. Evidence suggests relational problems associated with intoxication. that feeling afraid or anxious immediately after a These criteria must be met within the space of a 44 The Psychology of Terrorism

12-month period. As with depression, drug abuse individual and community intervention framework is particularly likely to increase following terror known as critical incident stress management attacks, judging from the results of follow-ups on (CISM) (Litz & Gray, 2004). The CISD system has 9/11 victims (Vlahov et al., 2002). been used as the sole treatment intervention for numerous police and fire departments throughout OMUS the country for the better part of the last two dec- Outbreaks of multiple unexplained symptoms are ades (Litz & Gray, 2004). not part of the DSM-IV-TR taxonomy of psycho- With the increasing popularity of CISD, the logical disorders. Instead, this is a phenomenon absence of alternative treatments, and the pur- that has been periodically observed in response ported benefits of the intervention, many govern- to specific environmental factors. OMUS has been ment agencies, not-for-profit relief organizations, referred to as ‘‘mass anxiety’’ or ‘‘mass hysteria’’ in and private corporations felt compelled to offer earlier formulations; however, because the phe- it following traumatic incidents and often made nomenon is probably an evolutionary response to attendance compulsory for victims. Thus, CISD a potential unknown, invisible pathogen, it should evolved from an intervention specific to emergency not be viewed as an inherently dysfunctional re- responders to one that became the standard of care sponse (Pastel, 2001). OMUS may generate real for nearly all victims of disasters, even though it somatic symptoms, including vomiting, diarrhea, was not originally designed for use with the gen- rashes, and breathing difficulty, which are difficult eral public. Mitchell argues that it is not appro- to distinguish from symptoms of actual exposure priate for civilian casualties who have been directly to a CBRN device (Pastel, 2001). The phenomenon impacted by a disaster (those with serious injury or is also denoted as ‘‘psychological contamination’’ who have experienced the death of a relative), and or the ‘‘social transmission’’ of symptoms (Jones, there is little empirical evidence to support its use Craig, Hoy, & Gunter, 2000; Small et al., 1991). in this more general context (Litz & Gray, 2004). Typically, OMUS occur in environments where As originally formulated, CISD was intended a potential pathogen causes one person to feel to be a single-session group intervention. Within ill; then a number of other people report similar the treatment group, a mental health professional symptoms without being similarly exposed (Small trained in CISD leads a discussion that follows a et al., 1991). The phenomenon is viewed as a seven-step progression: (1) introduction; (2) fact social and psychological response to potential phase (in which the event is re-created through the environmental contamination, often in the absence participants’ stories); (3) thought phase (in which of actual threat or personal exposure, resulting in the participants describe their thoughts during somatic symptoms that quickly spread through the the crisis); (4) reaction phase (in which the par- affected population and are usually transient but ticipants may experience catharsis); (5) symptom may recur with exposure to the location of the phase (in which each participant’s current symp- initial illness (Small et al., 1991). toms are discussed); (6) teaching phase (in which symptoms are normalized through psychoeducation); and (7) reentry phase (event closure; re- Current Intervention Approaches ferrals are given as necessary) (Everly & Mitchell, and Myths of Treatment 1999). The CISD model suggests that the intervention should take place as soon as possible fol- The most frequently used model for reducing lowing a traumatic event, typically within 24–72 trauma in an attempt to prevent PTSD and other hours. serious psychological consequences is critical in- The treatment model focuses primarily on cident stress debriefing (CISD) (Litz & Gray, 2004). talking through the trauma and reliving the emo- This model was developed by Jeffery Mitchell in tional experiences of the event in a protected en- the early 1980s and was originally designed to vironment (Litz & Gray, 2004). When conducted provide comprehensive stress management ap- with police officers, firefighters, or other first re- proaches for use with first responders (Mitchell, sponders, the CISD groups are usually formed 1983). The system later evolved into a broader with prestanding units who experienced the same The Need for Proficient Mental Health Professionals in the Study of Terrorism 45 event. The theoretical framework of CISM suggests responders, and the originator of the CISD inter- that the sharing of the experience assists in the vention has suggested that it may not be appro- normalization of symptoms and provides a frame- priate for the general public. Finally, alternative work for reliving the event through the multiple approaches have not been extensively developed perspectives of the participants. and empirically examined as comparisons to the CISD model. Myth: Talking It Through Prevents As a result of this increased interest, three Traumatization major meta-analyses of the CISD treatment system were undertaken and have recently been published Until recently, common wisdom within the trauma (Litz & Gray, 2004). These reviews examine the treatment community held that ventilating the relatively few randomized controlled trials (RCTs) victim’s emotions immediately following the event probing the efficacy of CISD that are available. We was requisite in preventing the later onset of PTSD. consider two of these meta-analyses in detail. The However, there is increasing empirical evidence to first was conducted by Rose, Bisson, & Wessely in suggest that early treatment for trauma may inter- 1998 as part of a Cochrane Review. This study was fere with the mind’s natural healing processes (Gist subsequently updated in 2001 and served as the & Lubin, 1999; Litz et al., 2002; McNally et al., first major review of RCTs of the efficacy of the 2003; Rose, Bisson, & Wessley, 2001). In fact, CISD treatment system. there is some suggestion that interventions that Using established search criteria, the authors focus heavily on the emotional reliving of the event of the Cochrane Review identified 11 studies that in the days immediately following the tragedy may involved the use of single-session psychological actually put people who might otherwise recover debriefing with participants who had recently been normally at increased risk for PTSD (Rose et al., exposed to a trauma. All of the interventions used 2001). After a traumatic event, an individual ty- a variation of emotional recounting of the event. pically experiences dissociative symptoms, such as The authors of the review also noted that the emotional numbing, detachment, reduced aware- quality of most of the studies was poor (Rose et al., ness, derealization, and depersonalization. These 2001). The Cochrane Review poses some com- symptoms may actually be normal, healthy reac- pelling and disturbing questions about the use of tions to highly stressful events (McNally et al., CISD and related treatment systems. 2003). Dissociation may in fact serve as a tem- These meta-analyses found no quantitative porary buffer, allowing an individual to process support for the contention that single-session stressful information without attending to the debriefing leads to a reduction in PTSD risk. The events in consciousness. However, the CISD model report also entertains the possibility that this type encourages mental health professionals to pierce of early intervention may instead hinder recovery this protective veil and reintroduce the power- and increase the risk of chronic PTSD. Two of the ful emotional reaction to the trauma as soon as long-term follow-up studies included in the review possible. found that those receiving a single treatment fol- The CISD intervention model has recently lowing a traumatic event had worse prognoses for come under increased scrutiny for several reasons. mental health difficulty as compared to the con- Litz & Gray (2004) list a number of concerns with trols. Further, Rose and his colleagues found that the CISD approach. First, at a theoretical level, the debriefing did not reduce other psychological dif- debriefing seems to not consider the natural course ficulties associated with exposure to trauma, in- of psychological healing that takes place for most cluding depression and anxiety (Rose et al., 2001). people following trauma. Second, most of the stu- The authors of the review suggest that single- dies examining the CISD model have been au- session psychological debriefing treatments may thored by the group that developed it and have not suffer from the following problems that reduce been replicated in other settings. Third, the ma- this intervention’s efficacy: (1) The interventions jority of the studies of CISD suffer from critical may be too short; (2) the follow-up may be too methodological flaws. Fourth, the CISD model was short to show results; (3) the treatment timing originally developed for the treatment of first may be incorrect; and (4) the idea of debriefing 46 The Psychology of Terrorism may have been incorporated into contemporary conclusions of advocates of CISD/CISM, there is culture, rendering formalized intervention un- no sufficiently rigorous empirical support for the necessary. Each of these possibilities warrants fur- use of CISD/CISM in the secondary prevention of ther investigation. chronic PTSD. Controlled studies reveal it to be The review by Rose et al. (2003) hypothesizes therapeutically inert when applied to individuals’’ reasons for the observed negative or null outcomes (Litz & Gray, 2004, p. 101). In light of these with single-treatment interventions. The first is the findings, a conference convened by the National suggestion that those who experience shame or Institute of Mental Health concluded that CISD guilt reactions in response to a traumatic event should not be used as an intervention with trauma may be at risk when only a single, emotion-laden victims, a view seconded by the British National treatment is provided and further exploration Health Service (Litz & Gray, 2004). In response, of these emotions is not offered. Second, psy- dramatic shifts in the world of trauma intervention chological debriefing may attach an unnecessary have begun to occur as several major insurance stigma to the normal recovery symptoms observed agencies have discouraged large organizations from in trauma victims. Rose and colleagues note that hiring CISD counselors to provide this interven- ‘‘Debriefing, by increasing awareness of psycholo- tion because it is increasingly viewed as prior art, gical distress, may paradoxically induce distress in no longer the standard of care, and a lawsuit risk people who would otherwise not have developed (Yandrick, 2004). it’’ (Rose et al., 2003, p. 9). Finally, the authors of this review argue that psychological debriefing Myth: Most People Are at Risk may be problematic because it subscribes to the dubious notion that all victims experience the One of the common misconceptions about ter- traumatic event and progress through recovery in a rorism and trauma is the expectation that a large fairly uniform manner. These hypotheses should proportion of the affected population will develop serve as the basis for future research examining full-blown PTSD symptoms in the months fol- both the efficacy and the possible dangers of lowing the event (McNally et al., 2003). In fact, the single-session, emotion-driven treatment systems general public and even direct victims appear to for trauma. be surprisingly resilient. In the wake of what was A second set of meta-analyses performed by arguably the most significant act of terrorism in Litz and his colleagues (2002) sought to confirm peacetime, the events of September 11, 2001, and expand upon the findings of the Cochrane surprisingly few people used the psychological and Review. These analyses examined the results of other support services offered by the 9,000 pro- six RCTs involving psychological debriefing. The fessional and paraprofessional counselors who inclusion criteria for this meta-analysis differ were rushed to New York following the tragedy somewhat from those found in the review by Rose (McNally et al., 2003). The Project Liberty pro- et al. (2001). However, the same pattern of results gram, a federally funded initiative designed to emerged. The findings confirmed that psycholo- provide counseling to affected New Yorkers, esti- gical debriefing provided no more relief of symp- mated that 25% of the city’s inhabitants would toms than could be expected with natural recovery need counseling and prepared to meet the need for over time. A small difference in effect size indicated psychological services for a staggering 2.5 million that psychological debriefing may result in greater victims, yet just slightly more than half a million levels of PTSD symptoms following treatment. city residents used these services (McNally et al., However, Litz and colleagues caution against in- 2003). terpreting these findings or those of the study by In fact, in summarizing PTSD prevalence data Rose et al. (2001) as providing definitive evidence gathered by several researchers following the 9/11 of negative side effects with the use of this treat- attacks, McNally and colleagues (2003) stated that, ment approach (Litz et al., 2002). while predictions of significant distress surged, the As a result of the mounting evidence showing actual rates of PTSD symptoms ranged from just that CISD may not be as effective as hoped, one of 7.5% to 20% in the general public who had been the leading researchers in the field of acute stress near Ground Zero at the time of the attacks. Four treatment has concluded that, ‘‘Contrary to the months later, a similar study with participants The Need for Proficient Mental Health Professionals in the Study of Terrorism 47 living near the World Trade Center site found that individuals. These interventions differentiate be- the proportion of the population experiencing tween immediate response, which occurs in the PTSD-like symptoms dropped to 1.7% (McNally hours following a terrorist event, and the more et al., 2003). One national study of PTSD preva- long-term treatment of people who have residual lence following 9/11 found slightly higher num- symptoms. Together they compose the content of bers, with 17% of the sample meeting criteria 8 the knowledge that mental health practitioners weeks after the attacks and falling to 5.8% after 6 should apparently have as they anticipate providing months (Litz & Gray, 2004). Similarly, estimates care to survivors. of PTSD rates in Israeli civilians (ostensibly due to ongoing terrorist activity) found that between Do’s and Don’ts in the Immediate 2.7% and 9.4% of respondents met the criteria for Aftermath of Terror PTSD (depending on the stringency of the inclusion criteria). Only 5.3% felt they needed to seek Mental health professionals must be trained to professional treatment for stress related to terrorist respond to disasters such as terrorist attacks with a activity, while more than 60% of the participants broader range of skills than that required in the reported feeling that their lives were threatened office practice of psychotherapy. Various initiatives (Bleisch, Gelkopf, & Solomon, 2003). have been set in motion to provide them with the Several studies following the 9/11 tragedy tools they need to treat these victims. found similar results, and a number of researchers Various recommendations have been made for in the field have suggested that, even though many how best to intervene with those at psychological people may initially exhibit stress symptoms, this is risk following terrorist events. CISD is no longer a a fundamentally normal process, and most people treatment intervention one should use lightly or recover from the trauma without the high rate of simply because one has been instructed to do so. chronic psychological illness that was initially pre- Newer approaches derived from empirically based dicted (Litz et al., 2002; McNally et al., 2003). treatments are becoming available for the emer- Furthermore, while a high proportion of people gency mental health responder. In the remainder who were representatively sampled across the na- of this chapter, we present a brief overview of tion endorsed items indicating that they had ex- current recommendations. However, additional perienced stress-related symptoms following the research-based information is forthcoming and events of 9/11, there is little evidence to suggest practitioners should view this effort as an initial that the majority of those who were exposed effort to build the ground work for future work. through the media were at risk for developing PTSD Mental healthcare workers should actively seek out (Pfefferbaum et al., 2002). Moreover, those with new information as it becomes available because severe symptoms immediately after a major trau- of the fledgling nature of this field. For example, matic event are no more likely to develop chronic the area of psychological first aid (PFA) appears to PTSD than those who experience lesser symptoms be gaining strength as an alternative to CISD, and (McNally et al., 2003). These findings, as well as the research findings in this area should inform prac- progression of recovery they suggest, should be tice as they become available. central to our understanding of the human re- Emerging treatments focus on the unique as- sponse to intentional mass-casualty events. pects of victims of terrorism. Thus, treatment conceptualizations are becoming more specific and refined. For example, despite the developing belief What Mental Health Professionals among researchers in this field that early psycho- Need to Know About Intervention logical intervention may be contraindicated, this does not imply that no support should be offered Based on mounting evidence that single-session to individuals immediately following a trauma psychological debriefing treatments provide no event. To the contrary, social support has been benefit and may even hinder the recovery process, repeatedly shown to help prevent chronic PTSD, researchers and clinicians have become increas- and, perhaps more importantly, negative social ingly interested in developing and using alterna- contacts immediately following a critical incident tive treatment systems with disaster-traumatized appear to increase the risk of PTSD (McNally et al., 48 The Psychology of Terrorism

2003). Further, feelings of nihilism and despair assumed to be 1–2 weeks (Litz & Gray, 2004), that are associated with chronic PTSD are best the practitioner should begin considering more addressed by assisting the client to build (or re- aggressive intervention. build) a strong social support network through reengagement in social activities (Miller, 2002). Minimum Intervention Guidelines for Responding to Victims and Psychological First Aid Rescuers During Crises

Borrowing from a model developed to treat re- It is imperative that the ways in which we help crisis fugees, it appears that the most important first step victims reflect the best scientific knowledge avail- in psychological treatment is to reestablish a sense able. However, because of the nature of science, of safety and to provide basic services such as food, what we know and what we can recommend are shelter, and contact with loved ones. Miller (2002) always changing. Because of the way that scientific states that, immediately after a trauma event, ‘‘Phy- information accumulates, we are likely to find out sical care is psychological care.’’ This approach, more quickly when something does not work than termed ‘‘psychological first aid,’’ is not envisioned as when it does. Thus, we have learned many things a treatment program (Litz et al., 2002). Psycholo- from scientific research that we initially believed gical first aid differs from psychological debriefing should have been helpful, yet some have turned out models in that its primary focus is the provision of to be ineffective and even harmful (Gist & Woodall, physical comfort and psychoeducation to normalize 2000; Litz et al., 2002; Rose, Bisson, & Wessely, symptoms; in short, it puts in place a referral system 2001; Rose, Brewin, et al., 1999; Rose, Wessely, & for people who feel the need for more assistance. Bisson, 1998). At the same time, we are finding that Also contrary to the CISD model, Litz and his col- many of the commonsense procedures and fun- leagues (2002) state that ‘‘This position recogni- damental ways of providing assistance are surpri- zes that most people do not suffer from PTSD [or singly helpful to people in crisis. more accurately ASD] in the immediate days after Despite the extensive instruction that is fre- an event; rather the majority of people will have quently offered and the treatments that are accepted transient stress reactions that will remit with time’’ as if their use represents factual and scientifically (p. 128). derived knowledge, actual scientifically generated Through the use of psychological first aid, the and supported knowledge about what best to do in practitioner is also able to strengthen preexisting the immediate wake of trauma is quite limited. social networks that may encourage more natu- There are, however, some general guidelines that ral debriefing (e.g., with family members or co- can be derived from research studies. We have workers), approaches that have been found to often compiled these into a straightforward list of basic be more effective and better received than overt, do’s and don’ts for the clinician who is seeking practitioner-led debriefing (Gist & Lubin, 1999). to assist victims and rescuers in the first hours Finally, this approach also allows the psychologist, and days following a major community crisis. These social worker, or other mental health professional recommendations represent the best knowledge to passively monitor the progression of recovery that is available at the present time. and to enable them to flag those who are at high risk for PTSD, monitor them, and step in as needed. Things to Do While psychological first aid provides an ap- The following points offer some guidance as to propriate framework for general intervention, specific actions and approaches a clinical practi- Bryant & Harvey (2000, p. 84) note that ‘‘There is tioner can engage in to provide effective support now convergent evidence that approximately 80% following a terrorist attack or similar mass-casualty of individuals who are diagnosed with ASD sub- event: sequently suffer chronic PTSD.’’ In light of this finding, effective, early interventions are needed 1. Remember that effective first response comes for the subset of victims who fail to recover natu- not from your role as a healer but rather from rally. If a reduction in symptoms is not apparent your role as one who provides comfort, direct after an appropriate period of time, which is support, and useful information. You are most The Need for Proficient Mental Health Professionals in the Study of Terrorism 49

effective as a source of accurate information, should be carefully structured to promote ex- immediate guidance, and direct assistance with pectations of resilience and recovery rather the needs and demands of the present. If than providing laundry lists of pitfalls and victims have lost their home, it is far more symptoms. important to reduce the immediate feelings of 8. Direct victims and rescuers to community re- stress by providing shelter than it is to listen sources that offer comfort and assistance. empathically to the feelings of helplessness Connect victims with sources of aid that will that loss entails. In the face of loss and threat, provide direct and continuing support (e.g., it is also more effective to provide immediate family, community, faith-based resources). calming and instrumental care than to en- 9. Rescuers are critically affected by the tendency courage early ventilation and catharsis. to identify with victims and to the effects of 2. Get your hands ‘‘dirty’’—get into the field—in exhaustion—help them to establish and order to make sure that physical and medical maintain boundaries, pace their efforts and needs are addressed. It is very helpful in later expectations, and control emotions during contacts to have met people first in these set- protracted encounters. tings and to have initially provided immediate 10. Work with a companion whenever possible, and pragmatic forms of help before attempting and let the coworker help you maintain per- to offer more personal levels of support. spective and objectivity. 3. Provide information and guidance at very practical levels. Arm yourself with as much Things to Avoid information as you can garner and commu- The following points offer some guidance as to nicate it clearly and systematically to those you specific actions and approaches a clinician should encounter. Relate your information clearly, avoid following a terrorist attack or similar mass- using only fully authoritative sources (do not casualty event: be a vehicle for rumors and misinformation). 4. Establish a working relationship with the cli- 1. Emotion-focused debriefing in the immediate ent. Make sure that your role is understood aftermath of trauma—by its many labels, in- and that the client has given permission for cluding psychological debriefing (PD), CISD, you to assist. Make known your identity, cre- and multiple stressor debriefing (MSD)—has dentials, relationships to other organizations not been shown to be effective in preventing (e.g., Red Cross, employer of rescue person- later difficulties and may even cause problems nel) very clearly, and establish the objectives to become entrenched or more severe over for the encounter. Do not proceed unless the time. ‘‘Debriefing,’’ as used here, includes any individual is willing to accept your help. approach that involves (a) revisiting and re- 5. Ensure that physical and safety needs (e.g., constructing the details and feelings associated medical, shelter, food) are provided before with the traumatic event and any of the fol- addressing the emotional impacts of the lowing additional procedures: (b) encourage- trauma. Keep the initial focus on meeting ment to explore and deepen one’s basic needs and preserving stamina. reexperiencing of the emotion-laden events; 6. Provide a clearly defined objective and end (c) normalization of reactions, especially ele- point for the contact and relationship. Tell ments of negative feelings; and (d) education people what to expect. Most of the time, you regarding the signs and symptoms of PTSD. will need to provide one or more direct re- While doing these things often seem to be a ferrals for subsequent assistance. Ensure that good idea, the evidence is strong and accu- the options your provide reflect a wide range mulating that these are aspects of help giving of possibilities. that should be avoided during the initial stages 7. Emphasize the client’s strengths rather than of trauma reaction. weaknesses or deficits. Provide reassurance 2. Some examples of other treatments that are (‘‘this will pass’’; ‘‘you will get through this’’) frequently used but whose effects have not yet and maintain a sense of calm. If handouts or been demonstrated scientifically to be helpful written information are used, these materials include reexposure therapy, eye movement 50 The Psychology of Terrorism

desensitization and reprocessing (EMDR), are very resilient and do not need long-term as- thought field therapy (TFT), acupuncture, and sistance. However, during the first days and weeks various patent remedies. Cognitive therapy following a crisis it is difficult to reliably distin- (CT) has been found to be effective in high- guish those who will have prolonged difficulty and risk populations and in those whose problems those who will not. A clinician should not attempt persist beyond the initial reaction, but even to make formal mental health assessments until 2 this approach should be avoided during the or more weeks have passed. Nonetheless, a brief, immediate aftermath period. Any continuing initial screening, as long as it does not interfere ‘‘treatment’’ should be used only if indicated by with providing immediate physical and medical as- careful evaluation. sistance, along with support, encouragement, and 3. Avoid being the primary focus for the provi- comfort, might help identify those who should be sion of assistance and emotional or social recontacted after a few weeks and considered for support. Healthy resolution may ultimately more prolonged treatment. depend on fostering a sense of self-efficacy and mastery of the threat and challenge. The Initial Screening greatest risk to helpers and clinicians may be Screening of risk factors can be accomplished with ‘‘overhelping,’’ or what some have called ‘‘the four basic, relatively unobtrusive queries: tyranny of urgency.’’ This is the tendency to go too far in helping people do what they need to 1. Have the individuals experienced other intense do for themselves or even doing for them what exposures or instances of trauma (has anything can best be done by their own families and like this happened before)? reference groups. 2. Is there any history of prior mental health 4. The vast majority of those who are exposed to treatment or of circumstances for which the even severe trauma will not experience PTSD individuals or others thought treatment should and will recover through their own resources have been sought? and in their own time. Thus, it is important to 3. Do the individuals have at least one other respect the natural recovery process and to person with whom they can talk and share avoid presuming that someone needs profes- their problems? Has doing so seemed pro- sional mental health assistance. Be ‘‘invisibly ductive and helpful in the past? supportive.’’ People recover at different rates 4. Were the individuals exposed (in their judg- and by different means. Let victims set their ment) to particularly gruesome or disturbing own pace, talk about things that are important aspects of this event? to them, and seek their own space. Some people need a period of withdrawal; beyond Follow-Up Evaluation this, it is important that victims feel empow- Persons experiencing lingering difficulties after the ered to take some steps on their own in order initial impact has passed (generally 2–6 weeks) to gain a sense of personal agency. Do not should be evaluated for further mental health as- push them to discuss—before they are ready— sistance within the context of an established pro- or to do something that they are reluctant fessional relationship. These services are generally to do. best provided by agencies and professionals within 5. Do not be too formal. Don’t carry or wear the the local community, where enduring therapeutic badges of distance, such as a clipboard or a relationships can be developed. white coat, which might mark you as a ‘‘re- Where further treatment is indicated, empiri- moved,’’ clinical observer. Respect the client’s cally supported, conservative approaches such as privacy and keep the relationship open. CT spread across four or five sessions should be among the primary considerations. Therapists Follow-Up Treatment attempting longer-term interventions should seek specific training and supervision in these ap- In the weeks following a traumatic incident, most proaches and especially in their application to trau- people will recover in response to psychological matic exposure. Case management that includes first aid and the minimalist treatment. Most people social work and systems advocacy should also be The Need for Proficient Mental Health Professionals in the Study of Terrorism 51 considered as a critical adjunct to ensure that con- multiple times over several weeks, allowing a tinuing or emergent instrumental needs continue to supported processing of the event (Litz & Gray, be supportively addressed. If more intensive follow- 2004). Under the watchful eye of a trained prac- up is indicated by the persistence of debilitating titioner, serious issues that may be left unidentified anxiety after a few weeks, there are several treat- and unresolved in a single session may be detected ments that have been found to be useful for re- and addressed. Initial controlled trials have de- storing normal functioning. monstrated that when CBT and PE techniques are used with ASD patients, the intervention drama- Prolonged Exposure tically reduces PTSD rates at follow-up, with only 15% of the participants continuing to meet criteria, While the CISD model relies on a single-exposure compared to 67% in a supportive counseling con- intervention, more rigorously constructed short- trol condition (Bryant & Harvey, 2000). While term interventions involving imaginal exposure CBT combined with PE is perhaps the best ap- over a number of sessions have demonstrated sig- proach currently known, care should be taken nificant reductions in PTSD symptoms (Bryant & if the patient is acutely traumatized, suicidal, ex- Harvey, 2000). These findings were identified in periencing concomitant mental health problems, studies of traumatic reactions to sexual and non- or under stress because of continued exposure. sexual assault, and lowered rates of PTSD were The powerful effects of exposure therapy may over- found during a 3-month follow-up after cessation whelm these clients, leading them to drop out of of treatment. However, although this intervention therapy (Bryant & Harvey, 2000). approach appears to be effective in reducing symptoms for some people, initial studies indicate Other Treatment Considerations that these results occur in only about half of the victims who are treated (Bryant & Harvey, 2000). The field of trauma treatment has received in- Based on preliminary findings, in vivo exposure creasing attention from a wide variety of re- may also be an effective treatment for PTSD pre- searchers and theorists in psychology and related vention; however, little systematic research has fields since the events of September 11, 2001. been undertaken in this area (Bryant & Harvey, While much of the research currently under way 2000). Prolonged exposure (PE) techniques are will explore the efficacy of various components of typified by recalling the traumatic event for a per- psychological debriefing, CBT, and other ‘‘talk iod of not less than 50 minutes. The approach aims therapies,’’ pharmacological interventions are also to completely activate the fear-related memories being examined. Some research has pointed to of the event long enough to cause habituation to continued physical arousal symptoms following the the stimulus (Bryant & Harvey, 2000). removal of victims to safety as an indicator of risk for PTSD onset. Based on this model, some have suggested that pharmacological interventions that Cognitive Behavioral Therapy suppress the sympathetic nervous system response, Based on the limited literature currently available, such as propranolol (a beta-blocker), may be ef- elements of cognitive behavioral therapy (CBT) and fective in disrupting the immediate fear response PE appear to be the most appropriate tools in and, in turn, serve to lower the risk of PTSD. While the reduction of initial stress symptoms and ASD this is just one emerging treatment model, it illus- symptoms and in the prevention of chronic PTSD trates that practitioners need to remain vigilant as (Litz et al., 2002). The key features of CBT and PE new research informs a changing standard of care. treatment that may assist a trauma victim typically include elements from PE and include imaginal exposure to trauma-related memories, graduated in Special Considerations vivo exposure to avoided situations, cognitive re- for First Responders structuring, and homework tasks to support the therapeutic process (Bryant & Harvey, 2000; Litz A common perception of emergency personnel et al., 2002). One of the critical components of this is that they are somehow stronger people, both approach is that the intervention is carried out emotionally and physically, than most and that this 52 The Psychology of Terrorism strength allows them to do their jobs and remain environmental factors and emotional reactions. unaffected by the tragedy and trauma they witness. For example, prebriefings on what to expect were Their attraction to their professions seems to sug- associated with adaptive capabilities in FEMA gest a solid personality that responds quickly and workers and assisted in mitigating the stress of appropriately in emergency situations. However, understanding what they were about to go through even if these perceptions are rooted in fact, emer- in responding to an emergency (Garcıá, 2003). gency response workers are still subjected to re- This implies that briefing first responders on what peated stress. Exposure to mass-casualty incidents, to expect at an emergency scene could assist by repeated exposure to stressful situations, and al- desensitizing them and therefore reduce the stress ways being on alert for the next call can contribute associated with responding to an emergency scene. to potential psychological injury over the course of a Additional training might include educating re- career or in the aftermath of a disaster. These ad- sponse workers about the mental health resources verse effects can come in various forms and include available through their employer and in their emotional, cognitive, and somatic effects. However, community. there are certain identified resilience mechanisms While those who do not work in the field of and coping strategies that can assist in buffering trauma or death and dying may find the humor against such adverse effects. of emergency personnel morbid and distasteful, it Efforts to assist first responders have empha- serves a valuable purpose in relieving stress and sized intervention techniques, but attention should helping them transition from one call to the next. also be focused on preparatory strategies to pro- Studies on the use of humor by emergency person- mote adaptation and minimize impact prior to a nel have shown that, among experienced para- mass-casualty event (Paton, 1996). Emergency re- medics, humor was ranked higher than other coping sponse workers are often involved in repeated mechanisms, including talking with friends and fa- training for various aspects of their jobs. Two of mily, socializing, going out, and exercising (Rosen- the goals of training are practice and preparation— berg, 1991). Pretrained subjects in Rosenberg’s practice in using problem-solving abilities in novel study stated that humor relieved tension and served situations and preparation for doing one’s job and as a tool by which they could cognitively and emo- for knowing what to expect while doing it. tionally refocus themselves to regain perspective and Training is often considered in the functional even transcend a situation. Experienced paramedics perspective of engaging in and practicing job-related said that humor provides a mental break and assists duties. But performing these responsibilities some- them in returning to a normal state of mind. In times extends beyond one’s capacity to accomplish addition, those paramedics who used humor less functional tasks, such as starting an intravenous (IV) showed higher levels of stress. Subjects of this study injection. A professional must be mentally able to also communicated that humor has limits and that follow through with those tasks in a disaster situa- overreliance on it to the exclusion of other coping tion and maintain a state of psychological health mechanisms is counterproductive. over the long term in order to ensure an extended In a study on leisure coping used by police and career in the emergency response field. emergency response workers, it was found that Predisaster psychology training could benefit leisure coping and both short- and long-term stress emergency response workers, for example, by coping are positively related (Iwasaki, Mannell, helping them determine what psychological stres- Smale, & Butcher, 2002). This relationship extends sors they are susceptible to and learn how to beyond the benefits of general coping. Coping with recognize when victims, their coworkers, or they short-term stress includes stress reduction, and themselves are experiencing adverse psychological coping with long-term stress includes benefits as- effects. Such instruction can also help them learn sociated with both physical and mental health. to communicate effectively with others and to Leisure activities also seem to benefit emergency practice coping mechanisms to deal with such response workers through mood regulation, tem- stress. Also, training provided to desensitize porary escape from job-related stress, companion- emergency response personnel to situations they ship with friends and family, and the fostering might encounter could provide benefits through of feelings of empowerment, perceived control, and increasing their familiarity with the associated a positive attitude toward life. The Need for Proficient Mental Health Professionals in the Study of Terrorism 53

Firefighters and police officers, as well as other Bleisch, A., Dycian, A., Koslowsky, M., Solomon, Z., emergency response professionals, experience a & Wiener, M. (1992). Psychiatric implications of strong bond both within individual departments missile attacks on a civilian population. Journal and across the country. When the news that fire- of the American Medical Association, 268(5), fighters in New York City had perished during the 613–615. Bleisch, A., Gelkopf, M., & Solomon, Z. (2003). 9/11 crisis reached firefighters on the West Coast, Exposure to terrorism, stress-related mental health the emotions felt for their ‘‘fallen brothers’’ were symptoms, and coping behaviors among a na- profound. Many tears were shed among this group tionally representative sample in Israel. Journal of of tough workers, and those who were not sent the American Medical Association, 290(5), 612. to Ground Zero confronted feelings of helpless- Brewin, C., Andrews, B., Rose, S., & Kirk, M. (1999). ness, grief, and despair. Departments around the Acute stress disorder and posttraumatic stress country implemented ‘‘boot collections’’ (using fire disorder in victims of violent crimes. American boots to hold the donations) at public places to Journal of Psychiatry, 156(3), 360–366. send money to the families of their ‘‘brothers.’’ Bryant, R., & Harvey, A. (2000). Acute stress disorder: A Departments held moments of silence for the fire- handbook of theory, assessment, and treatment. Wash- fighters who had lost their lives. The bond felt ington, D.C.: American Psychological Association. Chapman, C., & Harris, A. (2002). A skeptical look at between professionals in their respective fields is September 11th: How we can defeat terrorism by arguably a strong one, and it may assist emergency reacting to it more rationally. Skeptical Inquirer, response professionals in coping with trauma in 26(5), 29–34. that they rarely experience it alone. Dalgleish, T. (2004). Cognitive approaches to post- McCammon and colleagues (1988) questioned traumatic stress disorder: The evolution of multi- emergency response workers about the frequency representational theorizing. Psychological Bulletin, with which they used particular coping mechan- 130, 228–260. isms in response to two disaster situations. In the Everly, G., & Mitchell, J. (1999). Critical incident stress case of an explosion at an apartment building, management (CISM): A new era and standard of care behaviors they deemed helpful included remind- in crisis intervention (2d ed.). Ellicott City, MD: ing themselves that things could be worse, looking Chevron. Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., at the situation realistically, being more helpful to Bucuvalas, M., Gold, J., et al. (2002). Psychological others, thinking about the meaning of life following sequelae of the September 11 terrorist attacks in the event, and talking to others about the incident. New York City. New England Journal of Medicine, 346, 982–987. Acknowledgments. This research was performed Galea, S., Vlahov, D., Resnick, H., Ahern, J., Susser, E., while the third author (Zeno Franco) was on appoint- Gold, J., et al. (2003). Trends of probable post- ment as a U.S. Department of Homeland Security traumatic stress disorder in New York City after (DHS) fellow under the DHS Scholarship and Fellow- the September 11 terrorist attacks. American ship Program, a program administered by the Oak Journal of Epidemiology, 158, 514–524. Ridge Institute for Science and Education (ORISE) for Garcıá, E. (2003). Supporting the Federal Emergency DHS through an interagency agreement with the U.S. Management Agency rescuers: A variation of Department of Energy (DOE). Oak Ridge Associated critical incident stress management. Military Med- Universities ORISE is managed by DOE contract icine, 168(2), 87–91. Gist, R., & Lubin, B. (Eds.). (1999). Response to disaster: number DE-AC05–000R22750. Psychosocial, community, and ecological approaches. All of the opinions expressed in this chapter are Philadelphia: Taylor & Francis. the authors’ and do not necessarily reflect the policies Gist, R., & Woodall, S. (2000). There are no simple and views of DHS, DOE, or ORISE. solutions to complex problems. In J. M. Violanti & P. Douglas (Eds.), Posttraumatic stress intervention: Challenges, issues, and perspectives (pp. 81–95). References Springfield, IL: Charles C. Thomas. Goenjian, A., Molina, L., Steinberg, A., Fairbanks, American Psychiatric Association. (2000). Diagnostic L., Alvarez, M., Goenjian, H., et al. (2001). and statistical manual of mental disorders: DSM-IV- Posttraumatic stress and depressive reactions TR (4th ed.). Washington, DC: Author. among Nicaraguan adolescents after Hurricane 54 The Psychology of Terrorism

Mitch. American Journal of Psychiatry, 158(5), Pastel, R. (2001). Collective behaviors: Mass panic and 788–794. outbreaks of multiple unexplained symptoms. Iwasaki, Y., Mannell, R. C., Smale, B. J., & Butcher, J. Military Medicine, 166(12), 44–46. (2002). A short-term longitudinal analysis of Paton, D. (1996). Training disaster workers: Promoting leisure coping used by police and emergency well-being and operational effectiveness. Disaster response service workers. Journal of Leisure Re- Prevention and Management, 5(5), 11–18. search, 34(3), 331–339. Pfefferbaum, B., Pfefferbaum, R., North, C., & Neas, B. Jones, T., Craig, A., Hoy, D., & Gunter, E. (2000). (2002). Does television viewing satisfy criteria for Mass psychogenic illness attributed to toxic exposure in posttraumatic stress disorder. Psy- exposure at a high school. New England Journal of chiatry, 65(4), 306–309. Medicine, 342(2), 96–101. Resnick, H., Acierno, R., Holmes, M., Dammeyer, M., Litz, B., & Gray, M. (2004). Early intervention for trauma & Kilpatrick, D. (2000). Emergency evaluation in adults. In B. Litz (Ed.), Early intervention for and intervention with female victims of rape and trauma and traumatic loss. New York: Guilford Press. other violence. Journal of Clinical Psychology, 56, ———, Bryant, R., & Adler, A. (2002). Early 1317–1333. intervention for trauma: Current status and future Rose, S., Bisson, J., & Wessely, S. (2001). Psychological directions. Clinical Psychology: Science and Practice, debriefing for preventing post traumatic stress 9(2), 112–134. disorder (PTSD) (Cochrane Review). Cochrane Marlowe, D. H. (2001). Psychological and psychosocial Library, 3. Oxford University Press: Update Software. consequences of combat and deployment. Santa Rose, S., Brewin, C. R., Andrews, B., & Kirk, M. Monica: RAND. (1999). A randomized controlled trial of individual McCammon, S. L., Durham, T. W., Jackson, E. J., & psychological debriefing for victims of violent Williams, J. E. (1988). Emergency workers’ crime. Psychological Medicine, 29, 793–799. cognitive appraisal and coping with traumatic Rose, S., Wessely, S., & Bisson, J. (1998). Brief events. Journal of Traumatic Stress, 1(3), 353–372. psychological interventions (‘‘debriefing’’) for McNally, R., Bryant, R., & Ehlers, A. (2003). Does early trauma-related symptoms and prevention of post- psychological intervention promote recovery from traumatic stress disorder (Cochrane Review). posttraumatic stress? Psychological Science in the Cochrane Library, 2. Oxford University Press: Public Interest, 4(2), 45–79. Update Software. Meisel, S., Kutz, I., Dayan, K., Pauzner, H., Chetboun, Rosenberg, L. (1991). A qualitative investigation of the I., Abrel, Y., et al. (1991). Effect of Iraqi missile use of humor by emergency personnel as a strategy war on incidence of acute myocardial infarction for coping with stress. Journal of Emergency and sudden death in Israeli civilians. Lancet, Nursing, 17(4), 197–202. 338(8788), 660–661. Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Miller, L. (2002). Psychological interventions for Rourke, K. M., Wilson, D., et al. (2002). terroristic trauma: Symptoms, syndromes, and Psychological reactions to terrorist attacks: Find- treatment Strategies. Psychotherapy: Theory/ ings from the National Study of Americans’ Research/Practice/Training, 39(4), 283–296. Reactions to September 11. Journal of American Mitchell, J. (1983). When disaster strikes ...the critical Medical Association, 288, 581–588. incident stress debriefing process. Journal of Slovic, P. (2002). Terrorism as hazard: A new species of Emergency Medical Services, 8, 36–39. trouble. Risk Analysis, 22(3), 425–426. Morgan, C., Grillon, C., Lubin, H., & Southwick, S. ———, & Weber, E. (2002, April). Perceptions of risk (1997). Startle reflex abnormalities in women with posed by extreme events. Paper presented at the sexual assault–related posttraumatic stress disorder. Risk Management Strategies in an Uncertain American Journal of Psychiatry, 154(8), 1076–1080. World, April 12–13, Palisades, New York. Neria, Y., Suh, E. J., & Marshall, R. D. (2004). The Small, G., Propper, M., Randolph, E., & Eth, S. (1991). professional response to the aftermath of September Mass hysteria among student performers: Social 11, 2001, in New York City: Lessons learned from relationship as a symptom predictor. American treating victims of the World Trade Center attacks. Journal of Psychiatry, 148(9), 1200–1205. In B. Litz (Ed.), Early intervention for trauma and Suedfeld, P. (2003). Specific and general attributional traumatic loss (pp. 201–215). New York: Guilford. patterns of Holocaust survivors. Canadian Journal Ohman, A., Flykt, A., & Esteves, F. (2001). Emotion of Behavioural Science, 35(2), 133–141. drives attention: Detecting the snake in the grass. 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peri-traumatic responses. Journal of Behavioral Health Weinstein, N., Lyon, J., Rothman, A., & Cuite, C. Services and Research, 27(4), 406–416. (2000). Changes in perceived vulnerability fol- Vlahov, D., Galea, S., Resnick, H., Ahern, J., Boscarino, lowing natural disaster. Journal of Social and Clinical J. A., Bucuvalas, M., Gold, J., & Kilpatrick, D. Psychology, 19(3), 372–395. (2002). Increased use of cigarettes, alcohol, and Wessely, S., & Jones, E. (in press). Psychiatry and the marijuana among Manhattan residents after the ‘‘lessons of Vietnam’’: What were they, are they still September 11th terrorist attacks. American Journal relevant? War and Society. of Epidemiology, 155, 988–996. Yandrick, R. M. (2004). Traumatic event debrieﬁngs Wakeﬁeld, J. C. (1992). The concept of mental disorder: getting second thoughts. Crisis Management Inter- On the boundary between biological facts and social national. Retrieved April, 2004, from http://www values. American Psychologist, 47, 373–388. .cmiatl.com/news_article59.html 4

War Versus Justice in Response to Terrorist Attacks Competing Frames and Their Implications Clark McCauley

Often lost in discussion of the September 11, 2001, terrorism. ‘‘On September the 11th, enemies of attacks on the World Trade Center (WTC) is the freedom committed an act of war against our coun- fact that a very similar attack, with similar moti- try. ...Our war on terror begins with al Qaeda, but vation and related perpetrators, occurred eight it does not end there. It will not end until every years earlier. On February 16, 1993, a truck bomb terrorist group of global reach has been found, in the basement parking garage of the WTC killed stopped and defeated’’ (Bush, 2001). six, injured hundreds, and damaged property to Within the rhetoric of war, however, there has the extent of half a billion dollars. The bomb was been frequent recourse to the rhetoric of criminal designed to topple one of the towers into the other justice. ‘‘Whether we bring our enemies to justice or and to bring both towers down. The man behind justice to our enemies, justice will be done. ...We this plan, Ramzi Yousef, noted regretfully that if he will come together to give law enforcement the had had a little more funding his design would additional tools it needs to track down terror here have succeeded and killed tens of thousands (Kirk, at home’’ (Bush, 2001; White House Press Ofﬁce, 2002). The U.S. response to this attack was police 2003). work and prosecution. After trials and convictions, The rhetoric of justice and the rhetoric of war six Arab men are in U.S. prisons, and a seventh may appear complementary, as in the often- person is still being sought. debated qualiﬁcations of ‘‘just war.’’ But closer On September 11, 2001, a second attack on inspection indicates that these two kinds of rhetoric the World Trade Center brought down the Twin instantiate two very different frames for under- Towers and caused nearly 3,000 deaths. The 9/11 standing the nature of the terrorist threat and the perpetrators were similar in origins and moti- appropriate response to it. In this chapter I explore vation to the 1993 perpetrators; indeed one of the inconsistent and even contradictory implica- the planners of the 9/11 attacks, Khalid Shaikh tions of these frames, and I suggest that more em- Mohammed, is Ramzi Yousef’s uncle. Despite the phasis on the criminal justice frame offers some similarity of the attacks, the U.S. response was important advantages for what all of us agree will strikingly different. Rather than criminal justice be an extended U.S. effort to secure itself from proceedings, the U.S. response was a war on terrorist attacks.

56 War Versus Justice in Response to Terrorist Attacks 57

Framing and Human Judgment certainty to risk when comparing gains but preferred risk to certainty when comparing losses. The power of framing effects has been demon- These results opened a gold rush of studies to strated in two decades of research in psychology learn more about when and how different frames and economics. Perhaps the most famous demon- can affect human judgment in ways that are, stration is Tversky and Kahneman’s (1981) ‘‘Asian statistically at least, mysterious or even irrational disease problem.’’ Several hundred people were (Shafir & Le Boeuf, 2002). One indication of the randomly divided into two groups, so that the two significance of this research is that Kahneman’s groups would on average be very similar. Each work on framing effects was cited in the award group was given a different problem. of his Nobel Prize in economics in 2002. The demonstrated power of framing effects is the foun- Problem 1. Imagine that the United States is dation for the argument of this chapter, namely, preparing for an outbreak of an unusual Asian that war and justice may have importantly different disease, which is expected to kill 600 people. implications for how the United States responds to Two alternative programs to combat the disease terrorist threats. have been proposed. Assume that the exact scientific estimates of the consequences of the programs are as follows: A Framing Analysis of the Difference Program A: If Program A is adopted, 200 Between 1993 and 2001 people will be saved. Program B: If Program B is adopted, there is One way to think about the results of the Asian a one-third probability that 600 people will be disease problem is that most people prefer a sure saved and a two-thirds probability that no one gain to a chance of larger gain (‘‘risk averse for will be saved. gain’’) but prefer a chance of losing nothing to a Which of the two programs would you favor? certainty of losing something (‘‘risk seeking for Tversky and Kahneman (1981) found that loss’’). This understanding can be applied to the 72% of the group reading Problem 1 favored Pro- problem of terrorism if we assume that, after 9/11, gram A. The prospect of saving 200 lives with terrorism was expected to kill 600 American civi- certainty was more attractive than the probability lians the following year. As with most applica- of a one-in-three chance of saving 600 lives. tions of formal models, this analysis excludes many complications, including the loss of lives—both Problem 2. The second group read the same foreign civilians and U.S. military—associated with story of the threat of Asian disease but with the war on terrorism. In defense of this exclusion, it different program options. might be argued that U.S. leaders and U.S. citizens Program C: If Program C is adopted, 400 do not weigh these lives as heavily as civilian deaths people will die. in the United States. Program D: If Program D is adopted, there If we translate 600 lives threatened by Asian is a one-third probability that nobody will die disease into 600 lives threatened by terrorism, the and a two-thirds probability that 600 people effect of framing as gain versus framing as loss will be will die. as follows. Two antiterrorism programs are available: Which of the two programs would you favor? criminal justice and war. Presented in terms of saving Surprisingly, 78% of the group reading Pro- lives, criminal justice promises for certain to save blem 2 favored Program D. The prospect of 400 200 lives from terrorism, whereas war has a chance people lost for certain was worse than the prob- of saving all 600 lives. Presented in terms of lives ability of a two-in-three chance of losing 600. The lost, criminal justice gives up 400 lives for certain, surprise value of the difference in the results for whereas war offers a chance of losing no lives to the two problems is that they offer exactly the terrorism. If we focus on saving lives and if we are same alternatives, except that Problem 1 is framed risk averse for gains, we will prefer criminal justice to as gain (people will be saved) and Problem 2 is war as the response to terrorism. However, if we framed as loss (people will die). The results in- focus on lives lost and if we are risk seeking for loss, dicate that the participants in this study preferred we will prefer war to criminal justice. 58 The Psychology of Terrorism

One might argue about how the probabilities September 13, 1993. The trial lasted 6 months, should change as we move from the Asian disease with the presentation of 204 witnesses and threat to the terrorist threat, but the point survives more than 1,000 pieces of evidence. On March 4, that framing the response to terrorism in terms 1994, the jury convicted the four defendants— of saving lives is likely to favor criminal justice, Mohammed Salameh, Nidal Ayyad, Mahmud whereas framing it in terms of lives lost is likely Abouhalima, and Ahmad Ajaj—on all 38 counts to favor war. It is not difficult to see how, im- against them. On May 25, 1994, a judge sentenced mediately after 9/11, with 3,000 deaths fresh and each defendant to 240 years in prison and a personalized in the televised suffering of relatives $250,000 fine. and friends of the dead, the predominant framing On February 7, 1995, authorities in Pakistan was in terms of lives already lost and lives to be arrested Ramzi Yousef, who was then extradited lost in future terrorist attacks. This framing in turn to the United States. On November 12, 1997, favored war as the response to the 9/11 attacks. Yousef was found guilty of masterminding the In contrast, the six deaths caused by the 1993 1993 bombing, and on January 8, 1998, he was attack on the WTC did not rise out of the everyday sentenced to life in prison without parole. In a death toll of car accidents and homicides. As at- related case, Sheikh Omar Abdul Rahman, a blind tention to the 1993 deaths was small, the framing cleric who preached at mosques in Brooklyn and of the response to terrorism was less about lives Jersey City, was sentenced to life imprisonment on lost and more about saving lives by bringing the October 1, 1995, for conspiracy to bomb New terrorists to justice. York City landmarks (not specifically for the 1993 Thus research on framing can help explain WTC bombing, however). why criminal justice was the predominant frame In contrast, the beginning of a war is typically for the U.S. response to the terrorist attack on the a declaration from one government to another that WTC in 1993, but war was the predominant frame a state of war exists between them. The casus belli for the response to a 9/11 terrorist attack similar to does not usually require investigation or discovery; the one in 1993 in all but the death toll. Never- an attack or ultimatum is typically the clear occa- theless, the rhetoric of bringing enemies to justice sion of war. In the case of al-Qaeda, the declaration remains available in public discourse in the United of war against the United States is usually identi- States, mixed with and sometimes submerged fied with a May 26, 1998, news conference in in the rhetoric of the war on terrorism (Bush, which Osama bin Laden appeared with the two 2005), and it is useful to draw out the divergent sons of Sheik Omar Abdul Rahman, the spiritual implications of these two frames. Whereas Roth leader of those convicted of the 1993 attack on (2004) brought a human-rights framework to this the World Trade Center. Within 11 weeks of the comparison, I focus on the psychological im- declaration, al-Qaeda attacked U.S. embassies in plications of war and criminal justice in response Kenya and Tanzania with bombs that killed 224 to terrorism. people, including 12 Americans. The U.S. response was not a declaration of war against al-Qaeda but a campaign to kill al-Qaeda Justice Versus War: In the Beginning members and to destroy their bases, notably by cruise missile attacks on al-Qaeda bases in Afgha- The beginning of a criminal justice response to nistan. It was only after the 9/11 attacks that Pres. terrorism is the specification of a violation of George W. Bush declared war on terrorism, not the criminal code. Charges are brought against just on al-Qaeda but on all terrorists with inter- defendants, if necessary against criminals unknown national reach. The logic of the extension was that until investigation uncovers the identity of the per- any terrorist group with international reach was petrators. Once identified, the criminal defendants an ally or a potential ally of al-Qaeda. are brought to trial, and a jury determines their guilt The expansive definition of enemies in the war or innocence. on terrorism points to a notable difference between In the case of the 1993 attack on the WTC, war and criminal justice. The beginning of a crim- four suspects were apprehended within a month of inal justice response to war is precise and limited the blast. They went on trial in a federal court on in requiring the specification of criminal code War Versus Justice in Response to Terrorist Attacks 59 violations and of particular individuals accused of theless, the rhetoric of war calls on the ideal case in these violations. Even conspiracy charges have to which the enemy is a state and its people. be substantiated by evidence of some material link When enemy combatants represent a national between the conspirator and a criminal act, planned or ethnic group, that whole group is seen as the or accomplished. In contrast, a declaration of war enemy or at least as having a tendency and po- designates a group enemy—typically a nation—and tential to serve the enemy. After the United States often more than one nation joins the list of enemies declared war on Japan, Japanese civilians could be as alliances come into play. The war on terrorism is rounded up without trial and put in detention larger than a war on al-Qaeda, and the expansion camps for years. Similar if lesser actions were taken of enemies is typical after a declaration of war. against Italian Americans after the United States In sum, those who were sought for the 1993 declared war on Italy in World War II. In England, WTC attack were individuals; those who were World War I made it expedient for the royal family sought for the 2001 WTC attack were an ill- to give up its identity as the House of Hanover defined group of Arabs and Muslims—al-Qaeda— to become the House of Windsor. and terrorist groups everywhere. There is a parallel in the war on terrorism. After identification of the 9/11 attackers as Muslim Arabs, a wave of hostility and even occasional Criminals Versus Combatants violence was visited on many in the United States who were identified (in some cases incorrectly— This difference in specificity leads immediately to Sikhs, for instance) as Arab or Muslim (Arab Amer- another difference: the labeling of the enemy. The ican Institute, 2002; Kaplan, 2006). This hostility targets of criminal justice are criminals, that is, contributed to the war on terrorism insofar as it lawbreakers, norm breakers, individuals who are helped support the roundup and imprisonment, not generally seen as typical of the group they come without charges, hearing, or habeas corpus, of from. The United States has criminal gangs, in- nearly a thousand Arab and Muslim noncitizens cluding those that are predominantly Italian, pre- living in the United States (Parker & Fellner, dominantly Colombian, predominantly Russian, 2004). In another way, however, this group-level and predominantly Chinese. It is true that some attribution of suspicion and responsibility was prejudicial association between such gangs and counterproductive: It hindered U.S. security forces their larger ethnic group is often made in public seeking information and assistance against terror- images and occasionally found even in political ists from Arab and Muslim citizens of the United discourse, but in general the association is weak. States. Americans do not generally feel hostility toward Thus the difference between criminal and or discriminate against Italians because there is a combatant is clear in this respect: Criminals are Cosa Nostra. atypical and soldiers are representative. Criminals In contrast, war is typically declared on a state act in their own interest; soldiers act for their na- that is seen to represent a people or a nation. The tion. It is an irony of the war on terrorism that war last war formally voted by the U.S. Congress was implies combatant status for the terrorists and re- against Germany and Japan. When it is not easy to sponsibility for terrorist acts to those the terrorists specify a nation-representing state, even violence claim to represent. Understood as criminals, ter- that looks like war does not get a formal declaration rorists represent only themselves, and those they of war. The U.S. military presence in Korea was claim to represent can be asked to help apprehend formally a ‘‘police action’’ under UN auspices, the them. Vietnam War was properly the ‘‘Vietnam Conflict’’ insofar as the U.S. Congress never declared war, and the U.S. intervention in Panama in 1989 was to Small Versus Large Enemy safeguard 35,000 American citizens there from a drug-trafficking tyrant, Gen. Manuel Noriega. The Along with the difference between criminal and war-making power of the U.S. president as com- combatant comes an implication about the size mander in chief no longer requires a formal of the enemy. In war, an enemy state usually declaration of war from the U.S. Congress. Never- represents millions of citizens and commands 60 The Psychology of Terrorism significant armed forces. Thus a declaration of war patriotism that is experienced as the exhilarating is a declaration against a very large enemy. The warmth of unity, common values, common pur- argument for war against terrorism is that even a pose, and common sacrifice (LeVine & Campbell, small number of terrorists can use modern tech- 1972, pp. 31–32). nology (fully fueled aircraft in the case of the 9/11 In contrast, the criminal justice system has to attacks) to inflict horrendous damage. Without compete with many other public interests and denying this argument, it is important to note that priorities. Even if the public perceives that crime is the war on terrorism can give an exaggerated im- a major and escalating problem, criminal justice pression of the size of the terrorist enemy. does not automatically take first place in the allo- Even if we think of al-Qaeda as more a fran- cation of public resources. Political leaders often chise than a state or corporation, it probably does compete on the basis of what they promise to do not amount to more than 5,000 people worldwide. about crime and criminals and what resources Perhaps 18,000 went through the al-Qaeda train- the criminal justice system should have. However, ing camps in Afghanistan before these were de- they seldom claim, at least in the United States, stroyed, and perhaps one-quarter of these are that crime is the only problem. It is almost always still alive, connected, and committed to violence linked to problems of education, jobs, housing, (Robb, 2004). A network of 5,000 would be large and welfare policy, and these issues compete with for a criminal conspiracy (such as the Cosa Nostra the criminal justice system for resources in rein the United States perhaps), but tiny by the sponding to crime. standards of wartime enemies. Declaring war on It is difficult in a democracy to maintain a state terrorism conduces to seeing terrorism as larger of war indefinitely. Other priorities begin to re- than it actually is. This bias plays well for the assert themselves; the mobilizing advantage of war terrorists, raising their self-esteem and their status sooner or later begins to fade. This has been the among those who sympathize with the cause they fate, in the United States, of the ‘‘war on poverty’’ claim to advance. and the ‘‘war on drugs.’’ Thus the war on terrorism is ill adapted to a long-term strategy against terrorism. Unfortunately, there is every reason to Competing Priorities Versus Survival believe that terrorism is a long-term problem. It is not a group or a cause but a strategy, one that has A declaration of war is a declaration of mortal threat, been around for millennia (e.g., the Jewish sicarii an announcement of the utmost danger that calls for of the first century AD). No one is predicting how the utmost sacrifice. A criminal justice procedure is long the war on terrorism will take, only that it business as usual. Violent criminals are indeed a will last as long as it takes. threat to society but not one that calls for national mobilization. One implication of declaring war on terrorism is that the threat to the United States is Police Work Versus Combat: Expertise a danger to national interest that can go as far as endangering the survival of the nation. War on terrorism asserts a military response to This difference is important because engaging terrorism. This has implications with regard to the a mortal threat brings a massive shift in priorities. expertise deployed. Military forces are trained A declaration of war implies that, until it is won, to fight an enemy military: Find them, fix them, the war has top priority. All other values and destroy them. From the evidence of Napoleon’s priorities are put on the back burner until the war campaigns, von Clausewitz developed his famous is over. The public agenda is fighting the war, and treatise, On War: ‘‘To sum up: of all the possible any cost is acceptable in the context of asking aims in war, the destruction of the enemy’s armed young people to pay the ultimate price. The war forces always appears as the highest’’ (von Clause- gets first and unlimited call on resources of money, witz, 1989, p. 99). This perspective encouraged a time, and talent; political preferences are formed clear distinction between combatants, men in uni- around policies and personalities in terms of their form, and noncombatant civilians—a distinction perceived value for prosecuting the war. The pre- that has been eroding since the French Revolution dictable result of external threat is an increase in (McCauley, 2005). War Versus Justice in Response to Terrorist Attacks 61

Here the focus is on military expertise. Modern the criminal justice framing of response to terror- armed forces are composed of highly specialized ism points to untapped potential in understanding components with a ratio of tail to tooth that is terrorism with data and theory from criminology perhaps ten to one, that is, ten people in logistics (LaFree & Dugan, 2004). and coordination for each one at risk in combat. Land, sea, and air forces depend on complex information systems to focus intricate and powerful Police Work Versus Combat: Values weapon systems against the enemy. These systems are essential in fighting another modern army but Procedurally, the criminal justice system has to deal relatively ill suited for fighting terrorists who explicitly with the values of privacy and civil rights. emerge from and disappear back into civilian pop- Police and district attorneys can always imagine ulations. The difficulties of even the best-trained how their work would be forwarded and public army in fighting terrorism and insurgency are evi- safety improved by changes in procedure or law dent in the U.S. experience in Afghanistan and Iraq. that would give them greater access to citizens’ fi- In both places, overwhelming military power has nancial, health, telephone, and travel records or not yet been able to find and destroy the enemy. greater leeway in interrogation and use of the re- Fighting terrorism effectively is more like police sults of interrogations. Defense attorneys can al- work than military combat. Effective police work ways imagine how clients’ rights can be enlarged or requires understanding a local culture, knowing the protected against the procedures sought by police details of social and physical geography in a local and district attorneys. Judges are required to ima- area, developing local relationships, and cultivating gine both sides. Perhaps the most important aspect local sources of information. This kind of expertise of the criminal justice system is that it brings people is very different from integrated arms and large- from the same training—law school—to an in- scale logistics. It is no disgrace to a modern army stitutionalized competition of public interest in to recognize that it is ill prepared for police work security with private interest in individual rights. or the kind of economic and community develop- Indeed, many lawyers have the opportunity to ment work that can support effective police work. work both sides of this competition during their At a minimum, effective police work requires professional careers—as prosecuting attorney at speaking the local language, but learning foreign one time and as defense attorney at another time. languages is not typically a high priority in military In contrast, the military has no professional training. experience of balancing competing values. The Beyond the local level, the story is similar. Inter- military hierarchy is consistent and unidimensional. national cooperation is crucial for fighting interna- Winning is the only value. MacArthur’s Message tional terrorists. Putting together patterns of indi- From the Far East, memorized by every West Point vidual behavior and networks of contacts requires cadet, is paradigmatic: ‘‘From the Far East I send sharing intelligence across borders—something at you one single thought, one sole idea—written in least as difficult as sharing between the FBI and the red on every beachhead from Australia to Tokyo— CIA within the United States. International police There is no substitute for victory!’’ In the U.S. mili- cooperation is a better model of this kind of sharing tary, it is a kind of cross-cultural experience to work than international military cooperation; police and with another branch of the armed services: army security services are more likely than the military to officers working with air force or navy officers, for have useful information about individual terrorists instance. There is no parallel to the competition of and terrorist groups. perspectives that exists for attorneys; there is no It is worth noting briefly that, along with the career path for officers to serve first in fighting U.S. difference in expertise of those fighting crime and enemies and then to serve the enemy fighting the those fighting war, there is also a difference in United States. the expertise of those studying crime and those The criminal case against the perpetrators of the studying war. Researchers who focus on crime are 1993 WTC bombing brought prosecuting and de- generally based in sociology and criminology, fense attorneys to a contest in which both sides whereas researchers who study war are more often came from the same professional preparation, and from political science and psychology. In particular, the contest included a negotiation of individual 62 The Psychology of Terrorism rights versus the public’s right to security. The war and increased action for the cause the terrorists against terrorism has no such balancing act; the claim to represent. A terrorist group is only the apex officers who plan and command and the soldiers of a pyramid in which the base is all who agree with who follow are little practiced in representing the the terrorist aims even if they do not agree with the perspective or rights of the enemy. This, in brief, attacks on civilians that are the hallmark of ter- is the story of the violations of human rights of rorism (McCauley, 2002). For the Irish Republican prisoners at Abu Ghraib and likely of prisoners at Army, for instance, the base of the pyramid has Guantanamo as well. Police are required to practice been all those who agree with ‘‘Brits out.’’ As- every day the rights of suspects; soldiers are not cending in the pyramid, numbers decrease but similarly practiced in the rights of prisoners. commitment, risk taking, and support for killing Nor are soldiers drilled in the rights of non- civilians increase. combatants. The distancing phrase for civilian ca- The terrorists cannot survive without the cover, sualties of military campaigns is ‘‘collateral damage.’’ information, money, and new recruits that come The U.S. military in Afghanistan was, by modern from the pyramid. Anything that cuts off the standards, unusually successful in avoiding civilian terrorists from the pyramid is a mortal threat; casualties. Yet approximately 3,000 civilians were anything that increases mobilization of the base of killed in the U.S. campaign that defeated and dis- the pyramid behind terrorist leadership is a suc- persed the Taliban and its al-Qaeda allies in Af- cess. Here is where the strategy of jujitsu politics ghanistan (Herald, 2002). It is not only fire power enters the contest between terrorists and the state. that kills civilians. Increased mortality associated The best scholars (Crenshaw, 2002) and the most with the U.S.-led embargo of Iraq between 1990 thoughtful terrorists (Marighella, 1970) recognize and 1998 is estimated to have included at least that a crucial terrorist goal is to provoke a state 100,000 deaths among Iraqi children under 5 years response that will mobilize the uncommitted of age (Garfield, 1999). Modern war would be im- among those who sympathize with the terrorists’ possible if killing noncombatants were strictly goals. As jujitsu is the art of using the opponent’s proscribed and prosecuted. strength against him, so jujitsu politics is the art In short, war brings a unidimensional scale of of provoking the enemy to a response that will value in which nothing can compete with the value mobilize support against them. of winning, whereas criminal justice brings an For terrorists, the promise of a military re- institutionalized and well-practiced competition sponse is that military values do not give much of values. In time of war, talk about money cost attention to collateral damage. In Bombing to Win, or opportunity cost or human-rights cost is un- Robert Pape (1996) reviews twentieth-century patriotic; in the criminal justice system, these costs military thinking about using aerial bombing to can be counted in the balance of competing values destroy the morale of enemy civilians. Sometimes and priorities. this thinking goes as far as explicitly aiming for the mass killing of civilians; sometimes it goes only so far as recognizing the impossibility of avoiding Judicial Error Versus killing them. Such thinking has not disappeared, as Collateral Damage mentioned earlier in relation to the civilian casualties in Afghanistan. Such casualties continue as Terrorism is the warfare of the weak, the strategy of the U.S. occupation of Afghanistan continues. Si- those who cannot win by conventional means and milarly, the U.S. occupation of and war on terror- who see their cause as sinking toward extinction ism in Iraq cannot avoid civilian casualties. The (McCauley, 2002). Terrorists have many goals: increase in hostility toward the United States in polls publicity for their cause, a recovered sense of power in Islamic countries provides the foundation for and agency against the power that is crushing them, increased support and more recruits for al-Qaeda. and revenge and justice against those who have In contrast, the criminal justice response to done terrible things to their friends and their cause. the 1993 bombing brought five of six indicted Less commonly recognized is the terrorist goal that perpetrators to trial but provided no warrant for is essential for the survival of a terrorist group: punishing their friends and neighbors. The crim- mobilization of sympathizers to increased support inal justice system also makes mistakes, but these War Versus Justice in Response to Terrorist Attacks 63 are more likely to lead to imprisoning the wrong strengths and weaknesses of these two frames for people than to killing the wrong people. A crimi- the U.S. response to a continuing terrorist threat. nal justice response to terrorism offers terrorists War has a clear beginning and a clear and not- a much smaller opening for jujitsu politics. too-distant end; criminal justice is a never-ending effort to control and ameliorate a problem that will not go away. War targets a unified enemy group— Justice Versus War: In the End a people or a nation; criminal justice targets individual perpetrators of criminal acts. War recog- As war has an official and explicit beginning, so it nizes the enemy as large and dangerous; criminal should have an official and explicit end. There justice makes the enemy small and tawdry. War is unconditional surrender (World War II) or ne- puts every other public interest and value on the gotiated surrender (World War I) or at least a truce back burner; criminal justice has to compete for agreement to mark the end of war. Even wars that resources year after year in the national scale of are described as police actions or humanitarian in- priorities. War puts the military in charge of re- terventions have an end. The Korean War stalemate sponse; criminal justice puts lawyers and police in ended in a truce, and the Vietnam War ended with a charge. peace treaty, the withdrawal of U.S. troops, and the The differences between legal and military sub- fig leaf of an international control commission to cultures bring other important differences. Military ensure the peace. It is worth noting that the Vietnam professionals are focused on winning as the single War was the longest the United States has fought, scale of value; police, prosecutors, defense attor- enduring from 1964 to 1973. neys, and judges are experienced in balancing the In contrast, the criminal justice system faces a public’s right to security against individual and problem without end. No one expects that crime civil rights. Military mistakes often get people kil- will be exhausted or beaten or that it will surrender. led, including enemy civilians; criminal justice No one expects that crime will sign a peace treaty or mistakes put the wrong people behind bars but even a truce. There has never been a society with- seldom put innocents into coffins. Military mis- out rules or one without sanctions for violation of takes mobilize terrorist sympathizers behind ter- those rules. What it lacks in mobilizing power the rorist leadership; criminal justice mistakes are criminal justice system makes up in staying po- smaller and can be redressed with retrial and wer. Police, prosecuting attorneys, defense attor- compensation. The collateral damages from mili- neys, judges, and prisons together constitute a tary strikes and military occupation of foreign criminal justice system that is expected to go on lands are a rich contribution to jujitsu politics; indefinitely into the future, along with the criminal criminal justice operations and mistakes offer less acts that they respond to. opportunity for advancing the terrorist cause. The criminal justice response to the 1993 at- Despite its limitations, war offers unique ad- tack on the WTC continues today. One of the vantages over criminal justice as a response to ter- suspects, Abdul Rahman Yasin, was interviewed rorism. War produces the warmth and direction of shortly after the bombing, provided useful infor- national unity behind national leaders. War brings mation, was released, took flight to Iraq, and has resources against terrorism that are difficult to not been seen since. He is still a wanted man, as justify or funnel through the criminal justice sys- the criminal justice response to the 1993 attack tem. War brings at least the perception that ev- grinds on. The war on terrorism that began after erything possible is being done to prevent future 9/11 also continues. It remains to be seen how terrorist attacks. In general, war has the status of a long this war can be maintained before competing heroic response to a mortal threat; criminal justice interests and values undermine its vigor. is government business as usual. War can reach directly and quickly to foreign bases and foreign support for terrorism that cannot be reached—or Conclusion only slowly reached—with the forces of criminal justice. It is time to summarize the implications of war and Unfortunately, no one today predicts that the justice with a view toward evaluating the relative war on terrorism will end anytime soon. The 64 The Psychology of Terrorism command and control capacity of al-Qaeda has Motassadeq was sentenced to seven years in prison been degraded as the leadership has been killed, as a member of a terrorist organization. And in captured, or driven into deep hiding places. The Spain, twenty-four Muslim men suspected of being current and continuing dangers of terrorist attack members of Al Qaeda went on trial in April 2005, are more a matter of local franchise operations in a three of them accused of providing support for the corporation that has lost its headquarters. Under 9/11 attacks. Prison terms were handed down in these conditions, some of the advantages of the September 2005, though charges related to 9/11 war on terrorism have begun to fade. The attention were not sustained. Zacarias Moussaoui, the only and priority given to the war on terrorism cannot person facing trial in the United States in connec- last indefinitely, military occupations in foreign tion with the 9/11 attacks, pleaded guilty to parti- lands cannot be maintained indefinitely, blank cipating in an al-Qaeda conspiracy. The penalty checks of support to foreign governments for at- phase of his trial is going on as this chapter goes to tacks on their own ‘‘terrorists’’ cannot be honored press in March 2006. indefinitely, and the government’s reach into the It appears, then, that the criminal justice sys- lives of U.S. citizens cannot deepen indefinitely. In tems of Western countries are capable of engaging sum, war is not an effective response to a chronic al-Qaeda’s terrorists. Criminal justice may be slower problem. than the war on terrorism, but it may be surer in This is a lesson that the United States has had reaching terrorist perpetrators. multiple opportunities to learn. Previous efforts For many, however, the crucial argument to harness the rhetoric and unity of war against against a criminal justice response to terrorism is chronic problems have been notably unsuccessful. that criminal justice failed miserably on 9/11. Pre- The U.S. war on poverty never came to victory or mise: Bringing the 1993 perpetrators to trial, con- even truce, and the gap between rich and poor viction, and incarceration did not save the United may even be growing. The U.S. war on drugs went States from the attacks of 9/11. Conclusion: The so far in military stylistics as to appoint a com- war on terrorism is the stronger medicine re- mander in chief or czar, but drug trafficking and quired. The answer to this argument is straightfor- drug abuse are not vanquished and perhaps not ward. Criminal justice has not failed when crime is even weakened. not eliminated; it fails only when crimes are not Against a chronic threat of terrorist attack, the solved and criminals are not put away. No one ar- U.S. response might usefully give increased sal- gues that the war on terrorism has failed because ience to the criminal justice frame. Criminal justice terrorist alerts continue. To a modern democratic does not glorify the terrorists and their cause. Cri- state, terrorist threat is not a mortal peril, not like a minal justice does not stereotype an ethnic or re- severe acute respiratory syndrome (SARS) epidemic ligious group as the enemy and avoids losing the but more like a recurring flu. Criminal justice can cooperation of the communities the terrorists claim be the treatment of choice for a chronic terrorist to represent. Criminal justice does not undermine threat. the balance of public security and civil rights in the United States and thus preserves a civil society Acknowledgments. I thank Gary LaFree for his care- worth defending from terrorism (Hirshon, 2002). ful reading of this chapter and suggestions for im- Perhaps most important, criminal justice does not proving it. I am grateful also for research opportunities lead to the collateral damages and foreign occu- provided by Bryn Mawr College and the Solomon Asch pations that are the lifeblood of terrorist mobili- Center for Study of Ethnopolitical Conflict at the zation against the United States. University of Pennsylvania. Preparation of this chapter Some movement in this direction may be vi- was supported by the United States Department of sible. In Germany, Mounir el Motassadeq was con- Homeland Security through the National Consortium victed in 2003 of involvement in the 9/11 plot, but for the Study of Terrorism and Responses to Terrorism his verdict was overturned when an appeals court (START), grant number N00140510629. However, the ruled that his trial was unfair because the United opinions expressed in this chapter are those of the States refused to produce testimony from terrorism author and do not necessarily reflect views of the U.S. suspects in U.S. custody. In August 2005, el Department of Homeland Security. War Versus Justice in Response to Terrorist Attacks 65

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The Staircase to Terrorism A Psychological Exploration Fathali M. Moghaddam

Despite notorious disagreements about the defini- specific psychological experiences—terror and help- tion of terrorism (Cooper, 2001) and claims that lessness (Moghaddam & Marsella, 2004); second, ‘‘one person’s terrorist is another person’s freedom terrorism often has harmful psychological conse- fighter,’’ there is general agreement that terrorism quences (Danieli, Engdahl, & Schlenger, 2004; has become a monstrous problem in many parts of Wessells, 2004); and third, subjectively inter- the world and that every effort must be made to end preted values and beliefs often serve as the most it. For the purposes of this discussion, terrorism important basis for terrorist action (Bernholz, is defined as politically motivated violence that is 2004). Psychologists are contributing in important perpetrated by individuals, groups, or state-sponsored ways to a better understanding of terrorism, as well agents and intended to bring about feelings of terror as more effective coping with its individual and and helplessness in a population in order to influence communal health consequences (Crenshaw, 2000; decision making and to change behavior. Terrorism is Danieli, Brom, & Waizer, in press; Galea, Ahern, depicted in this discussion as a problem, especially Resnick, Kilpatrick, Bucuvalas, et al., 2002; Hor- because many major international terrorist groups gan & Taylor, 2003; Moghaddam & Marsella, work to weaken rather than to strengthen democ- 2004; North, Nixon, Shariat, Mallonee, McMillen, racy and because terrorism distracts people and et al., 1999; North, Tivis, McMillen, Pfefferbaum, resources from paths blazed by growing grassroots Spitznagel, et al., 2002; North & Pfefferbaum, pro-peace, pro-democracy movements in different 2002; Pyszczynski, Solomon, & Greenberg, 2003; parts of the world. Contemporary terrorism is par- Robbins, 2002; Schlenger, Caddell, Ebert, Jordan, ticularly dangerous because terrorists might gain Rourke, et al., 2002; Schuster, Stein, Jaycox, Col- access to weapons of mass destruction (Gurr & lins, Marshall, et al., 2001; Silke, 2003; Silver, Cole, 2002). Terrorism is often strongly influenced Holman, McIntosh, Poulin, Gil-Rivas, 2002; Ste- by ideology, but it can also be carried out for ma- phenson, 2001; Stout, 2002). However, there is an terial gain (to benefit one’s family, for example). urgent need for greater attention to the social and Psychologists have a vitally important respon- psychological processes that lead to terrorist acts. sibility in combating terrorism because, first, the A better understanding of terrorism is essential actions of terrorists are intended to bring about for the development of more effective policies to

69 70 Terrorism combat this global problem. Critical assessments Two points need to be clarified at the outset of the available evidence suggest that there is little about the staircase metaphor. First, the metaphor validity in explanations of terrorism that assume is intended to provide a general framework within a high level of psychopathology among terrorists which to organize current psychological knowl- (Ruby, 2002) or that terrorists come from eco- edge and to help direct future research and policy; nomically deprived backgrounds or have little it is not intended as a formal model to be tested education (Atran, 2003). Clearly, explanations in- against alternatives. Metaphors have proven highly tended to reduce the causes of terrorism to dis- useful in psychological science (e.g., in concep- positional, intrapersonal factors are too simplistic, tualizing intelligence; see Sternberg, 1990) and can despite the serious efforts made to profile terrorists play a constructive role in better understanding the (e.g., Fields, Elbedour, & Hein, 2002), as are roots of terrorism. Second, the staircase metaphor explanations that are founded only on the mate- is intended to apply only to behavior encompassed rial conditions in which terrorism takes place, des- by terrorism as defined earlier in this discussion; it pite attempts to identify demographic and socio is not intended to apply to other types of minority economic factors associated with terrorism (e.g., influence tactics. Ehrlich & Liu, 2002). The present discussion is intended as a modest contribution toward a Ground Floor: Psychological Interpretation more dynamic, comprehensive account of the so- of Material Conditions cial and psychological processes leading to terrorism. A central proposition is that terrorism can best A puzzle arises when the economic and educa- be understood through a focus on the psychological tional backgrounds of terrorists are considered: interpretation of material conditions and the op- Poverty and lack of education become problematic tions seen to be available to overcome perceived as explanations for terrorist acts. In the West Bank injustices, particularly injustices in the procedures and Gaza, support for armed attacks against Israeli through which decisions are made (Tyler & Huo, targets tends to be greater among Palestinians with 2002). more years of education (Krueger & Maleckova, 2002). A British army document discussing the Provisional Irish Republican Army (PIRA) in 1978, The Stairway to the Terrorist Act at a time when armed attacks by the PIRA had reached a peak, stated that ‘‘there is a stratum of Toward a more in-depth understanding of terror- intelligent, astute and experienced terrorists who ism, it is useful to envisage a narrowing stairway provide the backbone of the organization. ...Our leading to a terrorist act at the top of a building. The evidence of the calibre of rank and file terrorists stairway leads to higher and higher floors, and does not support the view that they are mindless whether people remain on a particular floor de- hooligans drawn from the unemployed and un- pends on the doors and spaces that they imagine employable’’ (in Coogan, 2002, p. 468). Similarly, open to them on that floor. The fundamentally poverty and lack of education were not found to be important feature of the situation is not only the characteristic of captured terrorists associated with actual number of floors, stairs, rooms, and so on but al-Qaeda in Southeast Asia (Singapore Ministry of more importantly, in some contexts, how people Home Affairs, 2003) or of Osama bin Laden or the perceive the building and the doors they think are al-Qaeda members who perpetrated the tragedy of open to them. As people climb the stairway, they 9/11 (Bodansky, 2001). Clearly, absolute material see fewer and fewer choices, until the only possible conditions do not account for terrorism; otherwise, outcome is the destruction of others, or oneself, or acts of terrorism would be committed more by the both. This kind of ‘‘decision tree’’ conceptualization poorest people living in the poorest regions, and of behavior has proved to be a powerful tool in this is not the case. psychology. For example, Latane´ and Darley Psychological research points to the funda- (1970) conceptualized helping behavior as the mental importance of perceived deprivation. The outcome of five choice points that lead an in- seminal research of Stouffer and others on military dividual to either help or not help others in an personnel during World War II demonstrated that emergency. there is not necessarily an isomorphic relationship The Staircase to Terrorism 71 between material conditions and subjective ex- Revolution (Arjomand, 1988) and other collective perience: Members of the U.S. Army Air Corps uprisings in modern times, it is perceived and re- expressed less satisfaction with military life com- lative injustices rather than absolute deprivation pared to some other units, despite the higher rate that coincide with collective nonnormative action of promotions in that branch of the military (Miller, 2000). Perceptions of injustice may arise (Stouffer, Suchman, De Vinney, Star, & Williams, for a variety of reasons, including economic and 1949). Similarly puzzling was the fact that African political conditions and threats to personal or col- American soldiers stationed in the North often lective identity (Tajfel & Turner, 1986; Taylor, expressed less satisfaction than those stationed 2003). Perceived threat to identity is of central in the South. The concept of relative deprivation importance in the case of religious fundamenta- was introduced to explained such trends: The lists because of the unique ability of religion to higher rate of promotions in the air corps raised serve identity needs (Seul, 1999) and the feeling expectations and created more dissatisfaction for that increasing globalization, secularization, and those who were not promoted, and African Amer- Westernization are undermining traditional non- icans in the North had higher expectations about Western ways of life. Identity threat is also of deep equal treatment. Half a century of psychological concern to broader segments of non-Western po- research underlines the importance of subjective pulations, particularly the youth, who often grap- perceptions of feelings of deprivation (Collins, ple with the ‘‘good copy problem’’ (Moghaddam & 1996). Solliday, 1991), the feeling that the very best they Particularly relevant to terrorism is Runciman’s can achieve is to become a ‘‘good copy’’ of the (1966) distinction between egoistical deprivation, Western model of women and men propagated by in which individuals feel deprived because of their the international media—a ‘‘good copy’’ that can position within a group, and fraternal deprivation, never become as good as the original. which involves feelings of deprivation that arise Minority groups have different resources avail- because of the position of an individual’s group in able for meeting the challenge of the good copy comparison with other groups. Research evidence problem (for example, the development of alter- suggests that fraternal deprivation is under certain native media and educational systems, political conditions a better predictor of feelings of dis- opposition groups, or cultural institutions that content among minorities than is egoistical depri- allow for the evolution of alternative identities). vation (Dion, 1986; Guimond & Dube´-Simard, However, in most Islamic societies of the Near and 1983), and in some cases such feelings translate Middle East, local dictators have shut down all of to collective action (Martin, Brickman, & Murray, these possibilities, and the only remaining avenue 1984). Gurr’s (1970) theoretical formulation and for the development of alternative identities is the subsequent research (e.g., Crosby, 1982) suggest mosque. It is only in the mosque that alternative that fraternal deprivation is more likely to arise political and cultural voices, as well as religious when group members feel their path to a desired ones, can find an outlet, and it is only in the goal—one that their group deserves and others mosque that the young can meet the challenge of possess—has been blocked. For example, in the the good copy problem. case of terrorism, especially important could be a Radical elements have also been attracted to the perceived right to independence and the retention mosque, using the monopoly of the mosque to gain of indigenous cultures for a society, a perception privileged access to the young. Not surprisingly, that other societies have achieved this goal, and the source of the greatest number of terrorist at- a feeling that, under present conditions, the path tacks against the West are the two countries where to this goal has been obstructed (by Americans, the mosque has a monopoly and where national for example). Of course, such perceptions may be identity is most directly positioned as Islamic: influenced by deep prejudices (Moghaddam, Saudi Arabia, the home of Islam’s holiest sites, and 1998, ch. 10). Pakistan, which gained independence from India in The literature on collective mobilization also 1947 on the basis of its ‘‘Islamic character.’’ Thus, underlines the importance of subjective percep- in these societies particularly, the only institution tions (Taylor & Moghaddam, 1994). From the available for voicing dissatisfaction and trying to French Revolution (Schama, 1989) to the Iranian overcome the good copy problem is the mosque. 72 Terrorism

At the ‘‘foundational’’ ground floor, then, what formulations such as Brockner & Wiesenfeld, 1996). matters most is perceptions of fairness. Someone However, the equity tradition also underlines the may be living in extremely poor, crowded condi- vital role of psychological interpretations of justice tions in Bombay and not feel unjustly treated de- and the need for policy makers to understand local spite the opulent living conditions of others in the cultural practices and ideas—‘‘the native’s point of city; however, another person may be living in view’’—in justice. When local cultural interpreta- relatively comfortable conditions in Riyadh but feel tions lead to a view that the in-group is being very unjustly treated. A number of those who feel treated fairly, there is greater likelihood of support unjustly treated become motivated to search fur- for central authorities. ther for options to address their grievances. The availability of avenues for participating in decision making is a key factor in perceived jus- First Floor: Perceived Options tice and support for authorities (Tyler, 1994). In- to Fight Unfair Treatment dependent of the outcomes of judicial processes (distributive justice) and the explanations that People climb to the first floor and try different authorities provide for their decisions and the doors in search of solutions to what they perceive as considerations they show to the recipients of de- unjust treatment. Two psychological factors shape cisions (interactional justice), the research of Tyler their behavior on the first floor in major ways: first, (Tyler, 2001; Tyler & Huo, 2002) demonstrates perceived possibilities for personal mobility to im- that the major factor in perceived legitimacy and prove their situation (Taylor & Moghaddam, 1994) willingness to abide by government regulations and, second, perceptions of procedural justice is how fair people perceive the decision-making (Tyler, 1994). process to be (procedural justice). Although much A first key question is, are there doors that of the research on procedural justice has been could be opened by talented persons motivated to conducted in Western societies, there is solid evi- make progress up the societal hierarchy? Plato (The dence in support of basic universals in perceived Republic, book three, 415b–d) warned of the in- rights and duties (Doise, 2002; Moghaddam & evitable collapse of a society that does not allow Riley, in press) and strong reasons to believe that for the rise of talented people to the top of the so- procedural justice also plays a central role in many cial hierarchy and correspondingly the downward and perhaps all major non-Western societies. mobility of those who lack talent but are the off- A primary influence on procedural justice is spring of those in power. This idea received ela- participation in decision making (Tyler & Huo, boration in elite theory (Pareto, 1935) and is 2002). Opportunities for voice and participation in central to modern psychological theories of inter- decision making are lacking in many parts of the group relations (Taylor & Moghaddam, 1994). world, as evidenced by UN ‘‘human development’’ Evidence suggests that the survival of even ap- reports (e.g., ‘‘The spread of democratization apparently rigid hierarchical systems, such as the cast pears to have stalled, with many countries failing system of India, is aided by some level of social to consolidate and deepen the first steps toward mobility, albeit informal (Scrinivas, 1968). A democracy and several slipping back into author- variety of research evidence suggests that when itarianism. Some 73 countries—with 42% of the paths to individual mobility are seen to be open, world’s people—still do not hold free and fair there is far less tendency to attempt nonnormative elections, and 106 governments still restrict civil actions (e.g., Tyler, 1990; Wright, Taylor, & Mo- and political freedoms’’; United Nations Develop- ghaddam, 1990). ment Programme, 2002, p. 13). It is clear that low This is probably because of a strong human income is no obstacle to democracy and that a tendency to want to believe that the world is just region with an enormous deficit in democracy is and that one’s personal efforts will be rewarded the Middle East and North Africa. The democratic fairly (Lerner, 1980). Research on equity theory movements that have influenced the lives of hun- endorses the view that people strive for justice and dreds of millions of people in Latin America and feel distressed when they experience injustice (see parts of Africa and Asia have yet to have a serious the classic work of Adams, 1965, and Walster, impact on Islamic societies of the Middle East Walster & Berscheid, 1978, as well as more recent and North Africa. There is general agreement that The Staircase to Terrorism 73 options for voice, mobility, and participatory de- Carlson, & Miller, 2000; Miller, Pederson, Ear- mocracy are particularly lacking in Saudi Arabia, lywine, & Pollock, 2003). According to Freud, the the country of origin for many of the most influ- role of displaced aggression must be understood ential terrorist networks currently active on the in the larger context of intergroup processes. world stage (Schwartz, 2002). Freud’s account of displaced aggression in This is not, of course, a justification for at- intergroup relations gives particular importance to tempting the wholesale transplantation of Western- three factors, the first of which is the role of lea- style democracy to non-Western societies, but there ders. In Freud’s group psychology, leaders play is a need to support contextualized democracy, asocio- an important role in redirecting negative emotions political order that allows participation in decision within the group onto others outside the group. making and social mobility through the utilization He argued that it is always possible to ‘‘bind to- of local, culturally appropriate symbols and strate- gether a considerable number of people in love as gies. Contextualized democracy needs to proceed long as there are other people left over to receive with attention to the details of the cultural context the manifestations of their aggressiveness’’ (1930, in non-Western societies (see Moghaddam, 2002, p. 114). Second, Freud gives importance to the particularly Chapters 2 and 3), such as that of Shi’a targets of displacement. Such targets are not ran- Islam (Moghaddam, 2004). Contextualized democ- domly selected; rather, according to Freud, they racy should be given the highest priority in coun- are dissimilar outsiders. Third, Freud points to the tries such as Saudi Arabia, where a combination of in-group cohesion that results from out-group repression and corruption (see, for example, Abur- threat. By highlighting threats from dissimilar out- ish, 1995) leaves minimal options for any kind siders, leaders increase in-group cohesion and of public expression of dissatisfaction and partici- strengthen their own support base. pation in meaningful decision making. Psychologi- Related to Freud’s analysis, a strategy widely cal theories (Taylor & Moghaddam, 1994) suggest adopted by leaders for dealing with dissatisfactions that a range of possible interpretations will arise among populations in some part of the world is among people in this situation, including displace- anti-Americanism (e.g., see Atran, 2003, p. 1538). ment of aggression; those who vehemently blame For example, Rushdie (2002) has argued that anti- others (e.g., ‘‘America—the Great Satan’’) for their Americanism is serving to deflect criticism away perceived problems climb the stairs to the second from governments in the Middle East: floor. As always, anti-US radicalism feeds off the widespread anger over the plight of the Second Floor: Displacement of Aggression Palestinians. ...However ...anti-Americanism has become too useful a smokescreen for Mus- Terrorism involves acts of violence against civilians lim nations’ many defects—their corruption, and others who are only indirectly involved in the their incompetence, their oppression of their power struggle among the terrorists, governmental own citizens, their economic, scientific and authorities, and others. Attacks on civilians often cultural stagnation. involve displaced aggression. Of course, displaced aggression can be verbal and indirect. Most of the In such contexts, those who develop a readi- people who climb up to the second floor do not ness to physically displace aggression and actively undertake physical aggression; rather, they limit seek out opportunities to do so eventually climb themselves to verbal attacks. However, some of the stairs to the third floor in search of ways to take them go beyond verbal displacement of aggression, action. often through the influence of their leaders. Such displacement of aggression was discussed Third Floor: Moral Engagement extensively by Freud (1921, 1930) and has a uniquely important role in his account of intergroup Terrorist organizations arise as a parallel or sha- relations (see Taylor & Moghaddam, 1994, ch. 2). dow world, with a parallel morality that justifies The explanatory power and contemporary re- ‘‘the struggle’’ to achieve the ‘‘ideal’’ society by levance of displaced aggression are underlined by any means possible. From the perspective of the ongoing research (Marcus-Newhall, Pederson, mainstream, terrorists are ‘‘morally disengaged,’’ 74 Terrorism particularly because of their willingness to commit Fourth Floor: Categorical Thinking and acts of violence against civilians. However, from the Perceived Legitimacy of the the perspective of the morality that exists within Terrorist Organization terrorist organizations, terrorists are ‘‘morally engaged,’’ and it is the government and its agents After a person has climbed to the fourth floor and who are ‘‘morally disengaged.’’ The terrorist orga- entered the secret world of the terrorist organiza- nization becomes effective by mobilizing sufficient tion, there is little or no opportunity to leave alive. resources (McCarthy & Zald, 1977) to persuade In most cases new recruits in the first category, who recruits to become disengaged from morality as will be relatively long-term members, become part defined by governmental authorities (and often by of small cells, typically of four or five persons each, the majority in society) and morally engaged in the with access to information only about the other way morality is constructed by the terrorist orga- members in their own cell. In the second category, nization (for a related discussion, see Bandura, the foot soldiers who are recruited to carry out 2004). In the context of the Islamic world, terrorist violent attacks and to become suicide bombers, the organizations have fed on interpretations of Islam entire operation of recruitment, training, and im- that laud what outsiders see as acts of terrorism plementation of the terrorist act may take no more but terrorists depict as martyrdom (Davis, 2003; than 24 hours. Within those 24 hours, the re- Gold, 2003; Rashid, 2002). While the struggle for cruited member is typically given a great deal of control over the ‘‘correct’’ interpretation of Islam is positive attention and treated as a kind of celebrity, for the most part public (Donnan, 2002), the ter- particularly by the recruiter (who stays by his side rorist organizations that have evolved according constantly) and by a charismatic cell leader. to an ideology of martyrdom are secretive. The cell structure of terrorist organizations Recruits are persuaded to become committed may have first been widely adopted among guerilla to the morality of the terrorist organization through forces fighting dictatorships in Latin America in a number of tactics, the most important of which the mid-twentieth century and is designed to limit are isolation, affiliation, secrecy, and fear. Studies infiltration and discovery by antiterrorist agents. By of terrorist organizations and their networks the late 1960s and early 1970s, the cell structure (e.g., Alexander & Swetman, 2002; Coogan, 2002; was being copied by most terrorist organizations, Kaplan & Marshall, 1996; Rapoport, 2002; Sage- including those operating in Western societies man, 2004) reveal that, even when terrorists con- (e.g., Coogan, 2002, p. 466). Often it is informal tinue to live their ‘‘normal’’ lives as members of friendship networks and a need to belong that binds communities, their goal is to develop their parallel people to such cells (Sageman, 2004). Immersion lives in complete isolation and secrecy. Recruits in secret small-group activities leads to changes are trained to keep their parallel lives a secret even in perceptions among recruits: a legitimization of from their wives, parents, closest friends, and all the terrorist organization and its goals, a belief others around them. The illegal nature of their that the ends justify the means, and a strengthening organization, perceived harsh governmental mea- of the categorical ‘‘us versus them’’ view of the sures against them, and perceived lack of open- world. ness in society all contribute to their continued Social categorization is a powerful psycholo- isolation and the sense of affiliation with other gical process (McGarty, 1999) that can lead to in-group members. In essence, terrorist organiza- in-group favoritism and out-group discrimination tions become effective by positioning themselves even when the basis of categorization is trivial in at two levels: at the macrolevel, as the only option a real-world context (Taylor & Moghaddam, 1994, toward reforming society (they point to alleged Chapter 4). A categorical ‘‘us versus them’’ view government repression and dictatorship as proof of the world is one of the hallmarks of terrorist of their assertion), and at the microlevel, as a organizations and the people attracted to them ‘‘home’’ or in-group for disaffected individuals (Pearlstein, 1991; Taylor, 1988). Western psy- (mostly young, single males), some of whom are chological literature has identified right-wing recruited to carry out the most dangerous missions authoritarians as having a categorical viewpoint through programs that often have a very fast (Altemeyer, 1988a, 1988b), but in the world turnaround. context, religious fundamentalism may be more The Staircase to Terrorism 75 directly related to an ‘‘us versus them’’ viewpoint kill enemy soldiers (Grossman, 1995) and raise the among both Easterners (Alexander, 2002) and question as to how terrorist organizations train Westerners (Booth & Dunne, 2002). Just as Isla- their members to carry out the act that kills in- mic fundamentalists have labeled the United States nocent civilians. The answer is found in two psy- the ‘‘Great Satan,’’ leading evangelist Christians in chological processes that are central to intergroup the United States have backed the view that ‘‘Islam dynamics (Brown & Gaertner, 2001). The first was founded by ...a demon-possessed pedophile’’ involves social categorization (of civilians as part of (Cooperman, 2002). This ‘‘us versus them’’ think- the out-group), and the second involves psycho- ing from the West has played into the hands of logical distance (through exaggerating differences fundamentalists abroad, particularly Saudi Wah- between the in-group and the out-group). habism (Gold, 2003) and the radical form of Shi’i First, the categorization of civilians as part of the Islam, as represented by Hizballah in Iran and out-group matches the pattern of secrecy practiced Lebanon, for example (Shapira, 2000). Of course, by terrorist organizations; recruits to terrorist orga- a categorical ‘‘us versus them’’ viewpoint is not nizations are trained to treat everyone, including ci- sufficient to lead to terrorism; another important vilians, outside their tightly knit group as the enemy element is a belief in the terrorist organization as (Sageman, 2004). Newspaper headlines such as a just means to an ideal end. ‘‘terrorist blast kills three innocent bystanders’’ have Commitment to the terrorist cause strengthens little meaning from the perspective of terrorist or- as the new recruit is socialized into the traditions, ganizations because of the particular way in which methods, and goals of the organization. More than they have categorized the world into ‘‘us’’ and ‘‘them’’ a century of research on social influence (Mo- and because of their perception that anyone who is ghaddam, 1998, Chapters 6 and 7) suggests that not actively resisting the government is a legitimate conformity and obedience are very high in the cells target of violence. Besides, by attacking civilian tar- of terrorist organizations, where the cell leader re- gets, social order might be disrupted, and the ter- presents a strong authority figure and noncon- rorist act could serve as a spark to get people to formity, disobedience, and disloyalty receive the ‘‘recognize the truth’’ and revolt against authorities harshest punishments. The recruits at this stage (this was even assumed by the Oklahoma City face two uncompromising forces: From within the bombers; see Linenthal, 2001). Thus, from the point organization, they are pressured to conform and to of view of terrorist organizations, acts of violence obey in ways that will lead to violent acts against against civilians are justified because civilians are part civilians (and often against themselves); from out- of the enemy, and only when civilians actively op- side the organization, especially in regions such as pose the targeted ‘‘evil forces’’ will they no longer the Middle East and North Africa, they face gov- be the enemy. The perception of civilians as part ernments that do not allow even minimal voice and of the enemy helps explain how terrorists sidestep democratic participation in addressing perceived what Lorenz (1966) termed ‘‘inhibitory mechan- injustices. These dictatorial governments are seen isms.’’ as puppets of world powers, particularly the United Lorenz (1966) has argued that inhibitory me- States—a perception endorsed by a variety of in- chanisms serve to limit intraspecies killing. For ternational critics (Scranton, 2002). example, when two wolves fight, it usually be- During their stay on the fourth floor, then, comes clear fairly soon that one of them is stron- individuals find their options have narrowed ger, with the result that the weaker wolf signals considerably. They are now part of a tightly con- defeat by moving back and showing signs of sub- trolled group that they cannot exit from alive. mission. The aggression of the winner is inhibited by the signals of submission; thus the winner does Fifth Floor: The Terrorist Act and not continue to attack and attempt to seriously Sidestepping Inhibitory Mechanisms injure or kill the loser. Inhibitory mechanisms also evolved to influence human behavior; crime Terrorism involves acts of violence against civi- statistics (Federal Bureau of Investigation, 2002) lians, often resulting in numerous deaths. The ex- show that most killings of humans by humans take periences of professional military units demonstrate place through the use of guns and other weapons the intensive programs required to train soldiers to that allow killing from a distance and enable the 76 Terrorism sidestepping of inhibitory mechanisms potentially the aim of achieving a situation in which the triggered through eye contact, pleading, crying, and general population rightly feels that it lives in a just other means (also see discussion of weapons and society. This long-term policy should go hand in homicide in Smith & Zahn, 1999). Lorenz (1966) hand with short-term strategies to deal with the argued that among humans, inhibitory mecha- small number of individuals who have already nisms have been bypassed through modern weap- climbed to the top of the stairway and are active in ons, which allow an attacker to destroy a target from terrorist organizations. However, there needs to be a long distance away. a shift away from an almost complete preoccu- The case of terrorist attacks suggests that in- pation with secretive counterterrorism units and hibitory mechanisms can also be effectively cir- measures, away from a total concern with hunting cumvent by psychological distance, perhaps similar for the ‘‘bad apples,’’ and away from a naive re- to the distancing that takes place between a rapist liance on improved technology and superior mili- and the victim, particularly through the rapist’s tary might as the way to defeat terrorism. Such adoption of cultural myths about rape (see Burt, a policy shift may appear risky, but in practice 1980, and readings in Searles & Berger, 1995). it provides the best long-term safeguard against Terrorists often operate in tight physical proximity terrorism. to their human targets, particularly in the case of suicide bombers, so they could potentially be in- 2. Procedural Justice Toward fluenced by the kinds of pleading and other signals Contextualized Democracy that typically trigger inhibitory mechanisms. However, two key factors serve to sidestep these Psychological research clearly highlights the im- mechanisms during terrorist attacks. First, by portant role that procedural justice can play in categorizing the target, albeit civilians, as ‘‘the bringing about contextualized democracy. Local enemy’’ and exaggerating differences between in- cultural practices and symbolic systems need to be group and out-group, terrorists psychologically incorporated and used to enable more legal op- distance themselves from the other humans they portunities for voice and mobility, as well as to intend to destroy. Second, the victims seldom be- influence perceptions of these opportunities. Such come aware of the impending danger before the policies must include women and other minorities attack actually occurs, so they do not have an in the decision-making process. It is particularly in opportunity to behave in ways that might trigger this regard that support is needed for democratic inhibitory mechanisms. processes even when they contradict local traditions, such as a tradition of allowing only a very limited role for women in the public sphere (as is Some Policy Implications still the case in much of the Middle East and North Africa). In this regard, special attention must be In this final section I highlight four important given to the relationship between educational ave- policy implications arising from the stairway me- nues and opportunities for voice and mobility. taphor. 3. Educating Against Categorical 1. Prevention Must Come First ‘‘Us Versus Them’’ Thinking

The stairway metaphor has an overarching policy In order to help bring about greater voice and implication that is familiar to psychologists who mobility in societies such as those in the Middle are researching and practicing in mental health: East and North Africa, it is important to appro- Prevention is the long-term solution to terrorism. priately frame the fight against terrorism and par- This is in line with a model of mental health that is ticularly the way in which we categorize the social integral to a larger public health care system and world. As people climb up the stairway, their ca- that provides broad-based services. tegorization of the world into ‘‘us versus them,’’ Policies to combat terrorism should con- ‘‘the forces of good versus the forces of evil,’’ and centrate on changing conditions for people si- so on becomes more prominent and rigid. The tuated at the foundation level of the stairway, with challenge is to prevent such an inflexible style of The Staircase to Terrorism 77 categorization from becoming the norm at the by political needs rather than by scientific under- foundation level, where most of the people are standing. The focus of policies for the most part has situated. A starting point for implementing this been on people who have climbed all the way up policy is to avoid—and indeed to combat—a ca- the stairway and are already committed to carry- tegorization of the world into ‘‘us versus them’’ and ing out terrorist acts. Policies aimed at these in- ‘‘good versus evil.’’ Such categorization only en- dividuals do not address the foundational problem dorses the views of fundamentalists and increases at the bottom of the stairway, involving the vast the probability of more people climbing up the majority of people. Basic issues at the foundational stairway to commit terrorist acts. This requires a level need to be addressed by guiding principles, major policy shift in a number of countries. In the including how the majority perceive fairness, open- United States, despite assurances by some mem- ness, and voice opportunities in their societies and bers of the Bush administration that ‘‘there is no how they are influenced by leaders to see the source war against Islam,’’ the rhetoric of ‘‘you are either of their problems as external and to displace ag- with us or against us’’ has played into the hands gression onto out-group targets. As part of a policy of fundamentalists. shift, a categorization of the world into ‘‘us versus them’’ needs to be avoided. 4. Interobjectivity and Justice Acknowledgments. 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Scranton, P. (Ed.). (2002). Beyond September 11: An Stout, C. E. (Ed.). (2002). The psychology of terrorism. 4 anthology of dissent. London: Pluto Press. vols. Westport, CT: Praeger. Scrinivas, M. N. (1968). Mobility in the caste system. In Tajfel, H., & Turner, J. C. (1986). The social identity M. Singer & B. S. Cohen (Eds.), Structure and theory of intergroup behavior. In S. Worchel & G. change in Indian society (pp. 189–200). Chicago: Austin (Eds.), Psychology of intergroup relations (pp. Aldine. 2–24). Chicago: Nelson-Hall. Searles, P., & Berger, R. J. (Eds.). (1995). Rape and Taylor, D. M. (2003). The quest for identity. Westport, society: Readings on the problem of sexual assault. CT: Praeger. Boulder, CO: Westview Press. ———, & Moghaddam, F. M. (1994). Theories of Seul, J. R. (1999). ‘‘Ours is the way of God’’: Religion, intergroup relations: International social psychological identity, and intergroup conﬂict. Journal of Peace perspectives. Westport, CT: Praeger. Research, 36, 553–569. Taylor, M. (1988). The terrorist. London: Brassey’s Shapira, S. (2000). Hizballah between Iran and Lebanon. Defence Publishers. Tel Aviv: Kakibbutz Hameuchad. Tyler, T. R. (1990). Why people obey the law. New Silke, A. (Ed.). (2003). Terrorism, victims, and society: Haven: Yale University Press. Psychological perspectives on terrorism and its con- ———. (1994). Governing amid diversity: The effect sequences. Hoboken, NJ: Wiley. of fair decision-making procedures on the legiti- Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, macy of government. Law and Society Review, 28, M., & Gil-Rivas, V. (2002). Nationwide long- 809–831. itudinal study of psychological responses to ———. (2001). Trust and law abidingness: A September 11. Journal of the American Medical proactive model of social regulation. Boston Uni- Association, 288, 1235–1244. versity Law Review, 81, 361–406. Singapore Ministry of Home Affairs. (2003, January 9). ———, & Huo, Y. J. (2002). Trust in the law. New White paper: The Jemaah Islamiyah arrests and York: Russell Sage Foundation. the threat of terrorism. Retrieved April 19, 2006, United Nations Development Programme. (2002). from http://www2.mha.gov.sg/mha/detailed.jsp? Human development report 2002: Deepening democ- artid¼667&type¼4&root¼0&parent¼0&cat¼ racy in a fragmented world. New York: Oxford 0&mode¼arc. University Press. Smith, M. D., & Zahn, M. A. (Eds.). (1999). Studying Walster, E., Walster, G. W., & Berscheid, E. (1978). and preventing homicide: Issues and challenges. Equity: Theory and research. Boston: Allyn & Thousand Oaks, CA: Sage. Bacon. Stephenson, J. (2001). Medical, mental health com- Wessells, M. G. (2004). Terrorism and the mental munities mobilize to cope with terror’s psycholo- health and well-being of refugees and displaced gical aftermath. Journal of the American Medical people. In F. M. Moghaddam & A. J. Marsella Association, 286, 1823–1825. (Eds.), Understanding terrorism: Psychosocial roots, Sternberg, R. J. (1990). Metaphors of mind: Conceptions consequences, and interventions. Washington, DC: of the nature of intelligence. Cambridge: Cambridge American Psychological Association. University Press. Wright, S. C., Taylor, D. M., & Moghaddam, F. M. Stouffer, S. A., Suchman, E. A., De Vinney, L. C., Star, (1990). Responding to membership in a dis- S. A., & Williams, R. M. (1949). The American advantaged group: From acceptance to collective soldier: Adjustment during army life: Vol. 1. Prince- protest. Journal of Personality and Social Psychology, ton: Princeton University Press. 58, 994–1003. 6

Terrorism and the Media Joel N. Shurkin

The media find themselves in a dysfunctional po- The attack was planned on exactly that sition relative to terrorism. On the one hand, they premise—that the media would cover the story must report terrorist attacks as they happen. On the with the immediacy it deserved. That’s probably other, they are part of the reason these incidents why the attack was in two parts. The first plane occur in the first place. For members of the media, hitting the first building got everyone’s attention. the situation raises interesting, difficult, and com- When the second plane struck, the cameras were plex professional and ethical problems. The fact is on, and billions of people watched it live in their that the media are crucial in determining the ge- homes. While later replays of the event were neral community’s reaction to terrorism. Fortu- edited somewhat, those watching live saw bodies nately, the media seem to understand that. fall from the towers, people who had jumped or When the World Trade Centers were attacked been pushed, tumbling in space against the beau- on September 11, 2001, the common refrain among tiful autumn sky. No one knew how many people journalists was that nothing like this had hap- were still in the building when they so gracefully pened before and that the usual journalistic pro- and awfully collapsed. The sight could not have cedures and rules were inadequate. Undoubtedly, been more horrible. That, of course, was exactly like most Americans, they were stunned. The story what the terrorists wanted, but the television had astounding scope. A quick visit to an almanac networks could not turn off the cameras, photo- would show that on any business day as many graphers could not avert their lenses, and reporters as 20,000 people could be in the two buildings at could not turn away. Whatever else anyone can say one time. The number of casualties was beyond of the attacks, they were brilliantly conceived with imagination or more than the heart could bear, the media in mind. as the mayor of New York said. It was the first This dichotomy made the attacks perhaps the attack on U.S. soil since Pearl Harbor, but this most difficult reporting assignments in modern time it was not on a Hawaiian island but in Man- journalistic history. That the media did as well as hattan, the media center of the country—if not they did is a tribute to them—and a lesson. the Western world—and it was seen live—on Most of the media believed that what hap- television. pened that day had no precedent. In fact, it did

81 82 Terrorism have. Although the nuclear accident at Three Mile ‘‘freedom ﬁghter’’? Israelis view Palestinian bom- Island was not terrorism, many of the same issues bers as terrorists, while Palestinians point out that were raised then. And if journalists thought it Menachem Begin, a former prime minister of Israel would be a while before they were confronted with and something of a national hero, used a similar the same issue, they were mistaken. technique against the British to win Israel’s independence. The difference is who won and who got to write the history.1 Handmaiden to Terrorism

Without the media, there would likely be no Three Mile Island and the Precedent modern terrorism. Palestinian terrorists know that of Reporting the Threat of Disaster the Israeli and the world press will cover every bombing, particularly of civilian targets. If it did From a journalistic point of view, there was pre- not, there would be no political point in blowing cedent for 9/11, a huge story that could have been up a bus. Historically, the terrorists do not fancy made worse by the media if they had acted irre- themselves murders but martyrs for a cause, al- sponsibly. The precedent was set 33 years earlier at though with the rise of the new religious fanaticism Three Mile Island, a nuclear power plant in Penn- that may well be changing (Council on Foreign sylvania. No terrorism was involved, merely human Relations, 2004). In a free society that almost incompetence, but the media were placed in the guarantees that publicity, the dominant image re- awesome position of having to report a complex quires publicity and the media. story with insufficient information and having to Studies agree that a symbiotic relationship ex- get it right. ists between the terrorists and the media. In its most I was science editor of the Philadelphia Inquirer cynical form, the image is of terrorists using the at the time and faced the problem head on. The media as a conduit for their message and the media confusion we confronted easily matches the con- using the terrorists for dramatic stories (Lockyer, fusion reporters faced on 9/11—confusion that 2003). Terrorism has been called political ‘‘theater,’’ had been deliberately created. And, if we got the and that’s how terrorists view it. A nineteenth- story wrong, there might be unwarranted panic century anarchist called it ‘‘propaganda by deed’’ or people would be placed in danger that could (Council on Foreign Relations, 2004). If terrorism have been avoided. can be defined as violence that is designed to deliver Three Mile Island sits on an actual island in the a message, the media are the messenger. Experts are middle of the Susquehanna River, south of Harris- divided on whether the publicity always helps the burg, Pennsylvania. It was operated by a medium- terrorists’ cause, with some pointing out that their sized utility, Metropolitan Edison, which in retro- message plays differently to different audiences. spect was probably too small for the responsibility As the Palestinians have discovered, in public opi- of running a nuclear power plant. On March 28, nion the method overshadows the message after a 1979, because of operator error, the plant began a while. partial meltdown. It goes without saying that virtually all editors The Associated Press relayed the first word of and reporters would rather not have these stories the incident after the company reported a minor to cover, and all of them understand they are being radioactive release from the plant. Throughout used. They are aware that the language they em- the morning, news from the company continued to ploy in these stories is crucial—politicizing lan- portray the event as minor, but after a few hours it guage was not an idea invented by George Orwell. was clear that something unusual was happening. Words have meanings beyond those found in the The media, including the Inquirer, were un- dictionary. Janny de Graaf (Schmid and de Graaf, prepared for the event. Like many science reporters, 1982) has argued that, when journalists interview I had avoided writing about nuclear energy be- subjects, they are more inclined to use the subject’s cause, after a subconscious cost-benefit analysis, wording, whether it comes from a terrorist cell I had concluded that the aggravation created by or a government. For instance, when is a ‘‘terrorist’’ proponents and opponents of nuclear energy— a ‘‘guerilla’’? Who is a ‘‘murderer’’ and who a on the phone and in the mail—outweighed the Terrorism and the Media 83 benefits of doing the stories.2 Hence, although I blem that was facing the media at Three Mile had written about how these plants worked and Island. knew something of the technology, I was about to Richard Thornburg, then governor of Penn- be blindsided by a story well beyond my expertise. sylvania, called the president of the United States When I reported for work that morning and and demanded that someone produce informa- asked one of the editors whether he needed any tion that he could use—and, by extension, that help, I was told the political reporters at the state the press could use. The NRC sent a man named capital could handle the story. I was skeptical but Harold Denton to Middletown to act as a con- went back to my seat and waited. Within a few duit between the public and the government. hours, the reporters in Harrisburg were screaming The information—such as it was—finally began for help. They had no idea what was happening at to flow.4 the plant and were getting no information from the Still, reporters faced serious questions. The company. I was sent to Middletown, Pennsylvania, extent of the danger from the radiation was con- the community nearest to the plant. When I got troversial in the extreme in the scientific com- there, I found that every other newspaper was munity, one of the reasons the stories were so going through a similar process, with editors as- contentious. Some reputable scientists held that suming the story was a simple one, requiring no any radiation at all imposed a danger of cancer on expertise and only later shipping out their science the public; others said that only a certain level was writers. dangerous. As a competent reporter, you could The most serious problem was a lack of reli- predict the answers you would get by knowing able and creditable information. At first, Metro- whom to call. So, whom do you call? politan Edison simply refused to be of any help, at Several days into the accident, a bubble of least in part because the officials there had no clue hydrogen built up in the reactor and threatened to what was happening within the containment ves- explode—a calamity in the making, one that could sels of the reactors. Then the lawyers apparently indeed have endangered most of central Pennsyl- took over, and the company’s small information vania. No one could predict what would then machinery simply shut it down. The Inquirer even happen. What do you say? If you report that the tape-recorded a conversation that took place be- reactor is likely to explode, you will set off a panic. tween the company and the employees of a public And what if it didn’t explode? If you say everything relations firm, Hill and Knowlton, which had been is under control or the danger is minimal and it brought in to help them with the emergency, as then blows up, a lot of people who could have fled they conspired to prevent information from leak- would be in the path of the radiation. ing. They produced a press kit that contained no- The general, unspoken consensus was that we thing useful and set up a telephone number that had to play it straight and with moderation, giving was specifically designed to be eternally busy. the information we had clearly and calmly and with Even the federal government played along. as much context as possible, and let people decide The Nuclear Regulatory Commission (NRC) set up for themselves what to do. I called experts on ra- a trailer outside the press center, and the infor- diation I knew to be moderates who would give mation officer set up a system so he would not have me unruffled, measured responses. This in itself to give out information. Not only was the press was a problem. Readers, who apparently expected excluded from information, but so was the state experts to have answers, began flooding the news- government, which had the final responsibility for paper editors with complaints about our less-than- the public’s safety. specific information. They wanted experts who told In one of history’s great ironies, 13 days before them whether something was dangerous; they did the incident at Three Mile Island, Hollywood not want stories that straddled the fence. In 35 had released a film starring Jane Fonda, The China years of journalism, it was the most profound Syndrome, in which a reactor goes wild and threat- professional decision I ever had to make. We ac- ens everything around it.3 The movie was play- tually sat, discussed the matter, and decided how ing in Middletown at the time. In the film, a cha- to write the stories (Sandman & Paden, 1979a, racter says the meltdown could wipe out most of 1979b). That almost never actually happens in the central Pennsylvania. And that is exactly the pro- field. Reporters usually act on instinct. 84 Terrorism

I suspect that similar discussions occurred in Once the disease was identified, all of the in- newsrooms all over the country on 9/11 and for formation was shut down. NBC’s Robert Bazell the same reasons. Because information was scarce said, ‘‘all the government agencies including NIH and unreliable, it was difficult for everyone to com- and CDC were told not to talk. They were trying to prehend exactly what was happening, only that it develop a model where all the information came was gigantic and the potential enormous. What from a central source (Thomas, 2003). Meanwhile, other buildings were being attacked and by whom? of course, no information was getting out. Rick Word came quickly of the attack at the Pentagon, Weiss of the Washington Post was less kind. He but rumors of another at the State Department described the policy as ‘‘One department, one voice. proved untrue even after they were reported in But that one voice is busy right now, so please the major media. How many planes were still in leave a message’’ (quoted in Thomas, 2003). The the sky carrying terrorists? The FAA had reports process was similar to that adopted by the NRC of dozens; in fact, there was only one. Was the and Metropolitan Edison: Pretend you are giving United States under a general attack, or were out information when in fact you are doing noth- New York and Washington the only targets? ing of the sort. Should people panic? Were they safe? With bil- Information was the first casualty. Confusion lions of viewers—including a vast proportion of reigned. The Bush administration urged Americans the American public—watching, reporters had to to go about their business; meanwhile, the FBI was think before they wrote in ways they had not often predicting new attacks. done before. Journalists had ‘‘no precedent, no strategy to deal with rapid-fire breaking news of infection by killer germs, no ready-made pool of experts’’ Anthrax and the Media as the Target (Ricchiardi, 2001,). Part of the problem was a lack of personnel, with one public relations person It happened again quickly. This time the media initially assigned to answer questions. That person were the target, and it was terrorism. Again ob- recorded more than 135 messages a day, and there structions were placed between reporters and the likely were still more calls that were simply not information they needed. As with Three Mile Is- logged. Between October 4 and October 18, the land, this new development became a primer for media office reported 2,229 calls. Many more (an the government on how not to handle terrorism average of 230 calls a day) went unreported. By (Ricchiardi, 2001). October 14, five more public information officers Within weeks of 9/11, a terrorist struck again. (PIOs) had been brought in to handle the load. To this day, no one knows who the perpetrator Getting one of the PIOs on the phone did was, but the first victim was Robert Stevens, 63, a not solve reporters’ problems, however. They photo editor at a supermarket tabloid published by were usually referred elsewhere and then to CDC in American Media in Florida. The official response Atlanta—an unproductive circle. Meanwhile, as the only fueled the panic, especially after Stevens died. attacks spread by mail to other news media, in- Part of the difficulty was that the weapon of choice cluding the office of NBC’s Tom Brokaw, and as the was anthrax, a disease so obscure that virtually U.S. Postal Service gradually shut down, coverage no one knew much about it. exploded. Some of the cable news channels went ‘‘all That most of the targets were in the media was anthrax all the time’’ (Thomas, 2003). At this junc- a cunning ploy. As Ricchiardi wrote, ‘‘If you want ture, another plague erupted, just as it had on 9/11, to scare the wits out of America, scare journalists and many instant experts appeared, many (if not first.’’ The attacks were brought by the U.S. mail most) of whom had no idea what they were talking right into newsrooms. about. One channel produced an ‘‘expert’’ who re- ‘‘If you were a terrorist with only a small peatedly referred to the anthrax ‘‘virus,’’ when a ba- amount of anthrax, you want to send it to the cillus in spore form is actually what causes anthrax. people who would get you on the evening news— By October 15 it was obvious to everyone that people at the news tabloid, a news anchor, a po- the public needed more information—and needed litician,’’ said Kyle Olson, a terrorism expert it accurately and quickly. CDC brought in another (quoted in Ricchardi, 2001). 10 PIOs. By October 18 it was able to produce an Terrorism and the Media 85 extensive, multipurpose press release confirming nalists and reporters help society solve its problems, that a postal worker in New Jersey had contracted and half felt the media get in the way. the disease. Information went up on the Web and The study also found that the public could not in Spanish. Real information began to replace bad; get enough of the news. Gresham’s Law of Journalism had been reversed. Another effect of 9/11 was that the media, in The next time we might not be so lucky. An- some regard, sobered up. Before the attack, with thrax is a disease that is relatively hard to spread. news coverage sliding inexorably toward trivia, ce- Had it been variola, the smallpox virus, we would lebrity news, and junk medicine at the cost of re- not have had several weeks to get our act in order. porting serious news—particularly international The anthrax attack killed 5 of the 11 people who news—one result was a reversal of that trend, at became infected. More than 2,000 hoaxes and false least for a while. reports emptied government buildings and shut Rosenstiel reported that, right after the attack, down post offices. Most of the terrorism experts ‘‘the war on terrorism has caused a colossal shift feared that the worst could come at any moment. in the news people see on network television’’ ‘‘I think the press has been prudently cautious (Rosenstiel, 2001). The networks were producing in reporting the story and therefore helped the more traditional hard news than they had in dec- country understand that there is no need to be ades. The news agenda on the networks was more panic-stricken about this,’’ said Robert Giles, cura- reminiscent of the 1970s than the 1990s, but that tor of the Nieman Foundation, when the scare was expansion was limited. The new interest was in the over (quoted in Ricchiardi, 2001). war on terrorism, not in the broad world beyond that subject. Even Rosenstiel admitted, however, that the sobering up might be just a temporary re- How Did the Media Do? action. A year later, Althaus reported that everything was unfortunately back to normal (Althaus, 2002). In these difficult episodes, the American media did surprisingly well. Even the most free swinging sobered up. The main problem they had was not Notes of their making; rather, it was bureaucracies— government and industrial—that were keeping in- 1. Part of the problem may be the lack of neutral formation they needed from them. Of course, in the words to describe these acts. The Israeli govern- case of 9/11, reporters were confronting a situation ment and many Zionists have been in a decades- that was so gigantic that useful information was long battle with the British Broadcasting Company impossible to ascertain. over the terminology the BBC uses to describe events in the Middle East (Honest Reporting, 2004) Thirty A study by the Pew Research Center for the years ago in New York I had a similar battle as news People and the Press, made after 9/11, showed that editor for Reuters, when the London office removed the press’s image was improved by the coverage it the word ‘‘terrorist’’ from every story about airplane provided of the attacks (Pew Research Center for hijackers, claiming it was politically charged and the People and the Press, 2001). However, there was inappropriate for customers in the area. some unhappiness with a number of the practices 2. That there are stories like that is one of the the press had engaged in, and the somewhat mel- great secrets of journalism. Abortion is another ex- low attitude of the public has probably wafted ample. All that printing stories does is excite the away (Pew Research Center for the People and the readers and viewers who care passionately one way Press, 2002). According to the 2001 study, the or the other. They do not change anyone’s mind. Pew Center reported that, after the attack, 47% of Hence, many reporters do the stories only when they have to. respondents thought news organizations were po- 3. The ‘‘China syndrome’’ is an engineering litically biased, compared with 59% in early Sep- construct in which a nuclear reactor melts tember. Additionally, more people thought the down through the floor of the containment vessel media tried not to be biased (26% after the attack and keeps going. It would, in theory, eventually versus 35% in early September). More than half still hit groundwater and explode. But, taken to the thought the media had tried to cover up their mis- extreme, it would then keep going—all the takes, however. More than a third believed jour- way to China. 86 Terrorism

4. Thornburg eventually recommended that preg- news media’s image. Retrieved April 19, 2006, nant women leave the area. from http://people-press.org/dataarchive/. ———. (2002, August 4). News media’s improved image proves short lived. Retrieved April 19, 2004, References from http://people-press.org/reports/display .php3?ReportID¼159. Althaus, S. (2002, September). American news con- Ricchiardi, S. (2001, December). The anthrax enigma. sumption during times of national crisis. PS: American Journalism Review, 23(10), 18–23. Political Science and Politics, 35(3), 517–521. Rosenstiel, T. (2001, November). Before and after: Council on Foreign Relations. (2004). Islam in a How the war on terrorism has changed the news changing world. Retrieved April 19, 2006, from agenda, network television, June to October 2001. http://www.cfr.org/publication/7533/islam_in_a_ Retrieved January 8, 2006, from http://www changing _world.html. .journalism.org/resources/research/reports/ Honest Reporting. (2004, January 14). BBC’s selective agenda/default.asp. sensitivity. Retrieved April 19, 2006, from http:// Sandman, P., & Paden, M. (1979a, July–August). At Three www.honestreporting.com/articles/45884734/ Mile Island. Columbia Journalism Review, 43–58. critiques/BBCs_Selective_Sensitivity.asp. ———. (1979b, July–August). The ‘‘Inquirer’’ goes for Lockyer, A. (2003, August 18). The relationship broke. Columbia Journalism Review (sidebar), 48–49. between media and terrorism. Canberra: Austra- Schmid, A. P., & de Graaf, J. (1982). Violence as lian National University. Retrieved April 19, communication: Insurgent terrorism and the Western 2006, from http://rspas.anu.edu.au/papers/sdsc/ news media. London: Sage. viewpoint/paper_030818.pdf. Thomas, P. (2003, Spring). The anthrax attacks: A Pew Research Center for the People and the Press. journalist assesses what went wrong in coverage (2001, November 28). Terror coverage boosts of this story. Nieman Reports, 11–14. 7

What Is Terrorism? Key Elements and History Scott Gerwehr Kirk Hubbard

Laqueur (1987) defines terrorism as the illegiti- rorism can therefore be seen as a form of social mate or extranormal use of violence against non- influence, employing acts of extranormal violence combatants to achieve political ends. Although there (instead of leaflets or loudspeakers, for example) to are innumerable definitions of terrorism, they all influence a target population’s emotions, motives, bear some resemblance to Laqueur’s definition, and objective reasoning, perceptions, and ultimately, particularly this notion that the ends cannot be behavior. Social influence is normally instantia- reached directly by the means. Indeed, a key dif- ted in tools and techniques such as rumor, social ference between military activities (e.g., guerrilla or proof, radio and television broadcasts, posters, and special operations) and acts of terror is that ter- graffiti. However, violence itself can be a dramatic rorism takes place ‘‘on a stage’’ with an audience in medium for changing attitudes and perceptions. mind (Rubin & Friedland, 1986; Jenkins, 1975). Nothing in the definition of social influence pro- Unlike most guerrilla attacks or special operations, hibits the consideration of extranormal violence as an act of terrorism is usually of little military value a tool of attitude and behavioral change. Thus a but instead ‘‘sends a message’’ to the target audi- well-timed bit of sabotage that disables a banking ence, for example, in drawing attention to a his- system may bolster an effort to worsen an already torical grievance or discrediting hated authorities shaky economic situation. Similarly, direct action (Schmid, Jongman, & Stohl, 1988). Even the most that prevents police or fire-fighting personnel from horrific of recent terrorist acts—Kenya and Tan- responding to an explosion may help discredit zania in 1998, Washington and New York in 2001, those two agencies. In sum, virtually any form of Madrid in March 2004—are insignificant in mili- violence may be pressed into the service of social tary terms. They are, however, powerful and vivid influence so long as the goal is to manipulate a messages from terrorist groups writ in blood and target audience’s perceptions, cognitions, and ac- carnage.1 tions. Terrorism fits the description. Hoffman Delivering such a message in a shocking, (1998) states: sensational fashion is meant to catalyze political change, and it is inarguable that dramatic politi- Terrorism is specifically designed to have far- cal change has been spawned by these acts. Ter- reaching psychological effects beyond the

87 88 Terrorism

immediate victim(s) or object of the terrorist The communications from A to B are purpo- attack. It is meant to instill fear within, and sive: They are meant to galvanize specific thereby intimidate, a wider ‘‘target audience’’ changes in attitudes and behaviors. That said, that might include a rival ethnic or religious they may operate directly or indirectly (i.e., group, an entire country, a national government propagated in some fashion through a third or political party, or public opinion in party or mediated through another cognitive general. ...Through the publicity generated by process). their violence, terrorists seek to obtain the The communications from A to B are discrete leverage, influence and power they otherwise and finite and can be characterized by a lack to effect political change on either a local or channel or medium of communication. an international scale. Although widespread understanding and ap- Sudden, shocking acts of extranormal violence preciation of the importance of social influence are the medium for producing these psychologi- campaigns spans the historical record, their scien- cal effects, and this is a potent means of commu- tific study dates from the pioneering work of Carl nicating. There is ample historical precedent to Hovland and his colleagues during and after World support this assertion (Bell, 1978; Downes-Le War II (the famous ‘‘Yale model’’ of persuasion, Guin & Hoffman, 1993). For example, the Reagan based on learning theory). Since that time much administration felt compelled to facilitate the re- excellent work has been done, and we draw on it lease of more than 700 Shiite prisoners from Israeli in examining the particulars of historical terrorism. prisons in exchange for the 39 Americans aboard The Yale model of social influence can serve at least TWA 847, which was hijacked in 1985. Why? as a broad-strokes description of the structure of a After more than 2 weeks of intense coverage by the large-scale persuasion attempt (for how an audience news media, there was widespread support among internalizes and processes it, we incorporate more the American public for a nonviolent quid pro quo recent scientific work, such as Petty and Cacioppo’s ending. This domestic pressure (a deliberate and Elaboration Likelihood Model). As the following explicit goal of the hijackers) proved irresistible to discussion points out, many terrorist campaigns can the Reagan administration. be usefully thought of in these terms, and specific There are many such historical examples of acts of terrorism can be thought of as the individual terrorism producing political change through so- communications in the course of a social influence cial influence, and these examples will inelucta- campaign. A noteworthy qualifier to this character- bly lead to future imitators. The presence of so ization is the fact that these communications have many potential targets, civilians, and news media decidedly different intentions and are meant to is a powerful attractant to would-be terrorists, reach multiple populations. and they are virtually guaranteed a wide audience There are two broad dimensions of the Yale both domestically and internationally for their model: the process of persuasion and the variables message. of persuasion. As the Yale model suggests (Hov- land, Janis, & Kelley, 1953; many subsequent reports), a look at the process of any social influence Social Influence Campaigns attempt will reveal six stages (exposure, attention, comprehension, acceptance, retention, and trans- Four hostile newspapers are more to be feared than lation) that must be navigated to successfully per- a thousand bayonets. suade a target audience. When examining the out- General Burnod, Military Maxims of Napoleon comes of the persuasion attempt, there will be four types of independent variable (source, message, For our purposes, we may state that a social target, and channel). influence campaign is generally characterized by the following features: A Process View of Social Influence One individual, group, or government (A) communicates with another person, group, or Exposure. The first stage required to translate government (B) on multiple occasions. influence into desired action is exposure. In What Is Terrorism? 89

general, exposure requires that the message which in turn leads to quick and decisive re- reach the audience; for example, an elaborate jection of the message. This stage is perhaps radio campaign is useless if the target audience the single most important obstacle in the way does not listen to the station that broadcasts of terrorism as a vector of social influence. the communication. To achieve the intended Retention. Even an influential message must psychological objectives, a communicator must have a durable effect on the target audiences; transmit the persuasive message through the ‘‘durable’’ here means that the audience re- correct channel to the appropriate audience members the persuasive message long enough (by appropriate, we mean the audience that for the desired behavior to emerge at a propi- can directly or indirectly produce the desired tious time (Hovland, Lumsdaine, & Sheffield, response). 1949). Notably, the retention requirements of Attention. Even if the message is transmitted an influence campaign depend on its objec- through the correct channels, the appropriate tives. A few minutes may be long enough to audience still might not notice it. Attention can galvanize the surrender of a hostage taker sometimes be difficult to achieve. The world is holed up in a barricaded house, but a few years a noisy place: New messages compete with may be needed to reduce monetary support to contradictory information and sheer back- a government or a popular social movement. ground noise, which can drown out an In the context of terrorism, a clear example of otherwise persuasive communication.2 The success in navigating the retention stage is the message should be crafted to pierce this sur- train bombings in Madrid in March 2004. This rounding noise and suit the channel through act of terror took place 3 days before a national which it is transmitted (Klapper, 1960). election and utterly eclipsed all other issues in Comprehension. An influence campaign must the race for the following 3 days. The shocking ensure that the intended audience understands and horrific acts, which the public interpreted the persuasive communication. This requires as a punishment for Spanish support of the the communicator to craft and deliver the U.S. invasion of Iraq, indisputably affected the message in a culturally appropriate manner, outcome of the election. employing syntax, images, words, concepts, Translation. Translation entails cognitive and intentions that are tailored to the audi- change leading to behavioral change or the ence. Notably, a message that is linguistically translation of perception into action. For or idiomatically ill suited will likely fail and translation to occur, an unobstructed path may even be counterproductive (Eagly, 1974). must exist for a changed attitude to result in This stage poses a significant hurdle for ter- altered behavior (see, for example, Darley & rorism in terms of social influence. Batson, 1973). The target audience may truly Acceptance. The target audience must not only experience a change in attitude, yet be re- comprehend the message but also accept it. strained by repressive societies and/or author- Indeed, a well-crafted message can be trans- itarian leaders. The literature on social mitted, noticed, and comprehended but still psychology indicates that circumstances trigger instant rejection by audiences if it is not strongly influence actual decision making.4 articulated to gain their acceptance (Chaiken, Thus, influence attempts have a greater possi- 1987; Chaiken, Liberman, & Eagly, 1989; bility of success if they are conducted in an Petty and Cacioppo, 1986). One example of environment that facilitates the translation of how this rejection might occur involves the changes in attitude into changed behavior. inappropriate use of schemas.3 A widely disseminated message advertising a bounty on a This sequence represents a view of the process wanted fugitive might seem entirely reasonable of a social influence campaign. Another view of to the sender, but to a target audience the very social influence comes from Smith, Lasswell, and notion of a bounty (i.e., the ‘‘bounty’’ schema) Casey (1946), who state that the outcomes of any may invoke all manner of negative—even persuasion attempt are dependent upon the char- taboo—associations relating to hospitality acteristics of four types of independent variable: norms, kinship ties, and group affiliation, source, recipient, message, and medium. There is 90 Terrorism significant interplay between these categories and Terrorism as Social Influence the particulars of the process described earlier. Source. The apparent origin of a message can Kill one, warn a thousand. Chinese proverb matter significantly in how it is received by an audience. Relevant data about the originator of It is not possible to adequately treat all histori- the communication include factors such as cal terrorism within a single section of a single chap- credibility (Kelman & Hovland, 1953; Husek, ter. Moreover, the very word terrorism was coined 1965), authority (McGuire, 1969; Bochner & by Edmund Burke to describe state terror: the Insko, 1966), likeability and attractiveness government’s ‘‘reign of terror’’ in revolutionary (Chaiken, 1979), similarity to the recipient France (1793–1794). In fact, Robespierre opined (Byrne, 1971; Goethals & Nelson, 1973), that ‘‘Terror is nothing other than justice, prompt, trustworthiness (Andreoli & Worchel, 1978), severe, inflexible; it is therefore an emanation of and perceived profit motive (Hovland & Man- virtue.’’ These views clearly differ quite markedly dell, 1952). from how the word is commonly used today Recipient. Several characteristics of a target (to denote a criminal atrocity perpetrated against audience can weigh heavily in how the mes- noncombatants for political and/or ideological sage is perceived and processed. These vari- ends). In this chapter we do not embrace either ables include motivation (Petty, Harkins, & view of terrorism. Instead we examine terrorism as Williams, 1980), issue involvement (Petty & a persuasive instrument of marginal, revolutionary, Cacioppo, 1979), and culture (Eagly & War- or nonstate groups seeking significant political ren, 1976). change (not perpetuating the status quo). We Message. As many of these sequential steps sample the space of historical terrorism for illus- imply, the content and nature of a message will trations of the violence-as-social-influence theme, figure prominently in its ultimate effect. The and we argue that this perspective on terrorism is relevant qualities of a message can include applicable and fruitful in helping us to understand salience and vividness (Taylor & Fiske, the rise and fall of terrorist campaigns in all times 1975), emotional content (e.g., fear; see Janis and places. & Feshbach, 1953; Leventhal, 1970), the Terrorist acts by definition include some key number of arguments (Calder, Insko, & aspects of persuasive communication, as we have Yandell, 1974; Norman, 1976), and already outlined: others. Transmission and propagation. The nature of the Medium. The medium plays an important role international news media virtually guarantees in delivering and mediating the effects of the that target audiences will be exposed to the actual message. Some media are particularly terrorists’ message (step 1 of the Yale model). effective vectors of persuasive communica- The proliferation of and competition among tions, while others lend themselves less to this news outlets has created a 24-hour news cycle function. Among the characteristics that matter in order to satisfy the public’s appetite for in the choice of medium are style (e.g., audio sensational news and competitive advantage versus video; see Chaiken & Eagly, 1976), (i.e., items not possessed by competitors). This setting (e.g., one on one versus group; see means that, day or night, virtually anywhere in Burnstein & Vinokur, 1977), and nonverbal the world, there will be a near-instantaneous accompaniment (Harper, Weins, & Matarazzo, transmission of news of terrorist acts to mil- 1978). lions of viewers, listeners, and readers—with a In the following sections we highlight social subsequent multiplication as coverage con- influence variables in historical cases of terrorism tinues or is rebroadcast. to help us understand when and how terrorism is Vividness. By their shocking nature, terrorist effective. Our argument is that the requirements acts capitalize on the salience effect (Nisbett & for effective social influence are virtually identical Ross, 1980), ensuring that target audiences pay to those for successful terrorism (in the sense of attention to the message (step 2 of the Yale achieving the stated political aims). model). What Is Terrorism? 91

Fear Content. Horrifying acts of murder and agent of the people they purport to represent), mayhem are exemplars of fear-based commu- while those same governments or authorities nication. A fear-based message can be very would like to depict the terrorists as criminal persuasive when calibrated correctly (Le- lunatics at the fringes of society, representing venthal, 1970; Rogers & Mewborn, 1976; Ro- no one. This is not an idle struggle: With a gers, 1983): It must clearly depict the possible perception of authority comes very real power consequences of not heeding the message and to persuade (Hofling, Brotzman, Dalrymple, the likely avoidance of those consequences if Graves, & Pierce, 1966; Milgram, 1974; Peters the message is heeded; moreover, the audience & Ceci, 1982; Blass, 1991, 1999). must perceive itself as able to act upon the Stoking ‘‘avoidant’’ motivation. To the target message. Terrorists can often raise or lower the audience among whom political change is to level of fear at will (e.g., by phoning or not be catalyzed, the message of terrorism is one phoning in a threat before setting off a bomb), that emphasizes loss and suffering (e.g., obey which gives them control over most of these us, or we will wreak more havoc and carnage factors. upon you). Persuasion attempts that empha- Dual processing. Terrorist acts are both simple size loss are more effective than those highlight and complex messages: The violence is usually gain (Meyerowitz & Chaiken, 1987). Seeking accompanied by lengthy manifestos or state- to prevent losses—‘‘avoidant motivation’’—is a ments advocating the terrorist group’s ideology powerful force for attitude change and action. (e.g., Osama bin Laden’s 1996 declaration of jihad against the United States). The terrorist act and any accompanying statement may be The Means of Communication: processed both by peripheral and central Bullets, Not Ballots routes (the Elaboration Likelihood Model of Petty and Cacioppo [1996]). By this we mean Not all violent acts constitute terrorism. For ex- that an act of terrorism can be a persuasive ample, neither armed robbery nor mercenary communication whether it is thought about activity would typically qualify as terrorism. The systematically (e.g., reading a terrorist mani- key element in defining an act as terrorist or not festo and evaluating its merits) or heuristically is its instrumentality. Is the violence meant to ex- (e.g., witnessing an act of terror on TV and press an idea or serve a political/social/theological interpreting it as evidence of the current gov- movement, and does it do so by harming civilians? ernment’s fragility and illegitimacy). This If so, then, by most definitions, it is terrorism. greatly furthers the goal of communicating When terrorist groups are deciding on a violent with multiple audiences through a single discourse of action, they always calculate the ex- crete act. pressive or instrumental value of the violence. Credibility and power. Terrorism usually occurs Among the types of violent actions that can at the initiative of a terrorist group. By this we be considered terrorist are assassinations, bomb- mean that the terrorist group can turn the ings, kidnapping, torture, and intimidatory vio- violence on or off and choose the timing, place, lence (e.g., kneecapping), arson, lynchings, and and manner of attacks. This is probably suffi- virtually any use of weapons of mass destruction cient to establish the group as a credible source (WMD) against a civilian populace. Aside from and thus an important contributor to the per- considering how the audience might receive the suasiveness of its message among those who ‘‘message’’ of a violent act, terrorist groups are are processing it peripherally.5 greatly interested in the milieu and how it might Authority and legitimacy. Wielding the power of affect the processing of the meaning. This is not an life and death can place the terrorist group in idle concern. Much scientific work has been done the same cognitive frame as the government it on environmental factors and how they mitigate opposes, a goal uppermost in the minds of the transmission and impact of persuasive mes- many terrorist groups. They would like to be sages. This can include cognitive load and ambient seen as an authority equivalent-but-adversary noise (Bru¨ nken, Steinbacher, Plass, & Leutner, to the organization they oppose (and thus the 2002), countermessages (Papageorgis & McGuire, 92 Terrorism

1961; McGuire, 1964), social proof and con- time and propel the revolutionary movement from formity (Latane´ & Darley, 1970; Latane´ & Nida, the margins of power to the center. This large 1981; Tesser, Campbell, & Mickler, 1983; Wooten population is perceived as the constituency of any & Reed, 1998), and time pressure (Petty, Wells, & terrorist group, which desires that the constituency Brock, 1976).6 Terrorist groups go to great lengths view the acts of terror in a positive way. Indeed, to exert control over the environment in which the acts of terror are intended to be seen as blows their message is transmitted and received; for ex- struck on behalf of the constituency, in its name ample, they provide journalists with firsthand vi- and for its betterment. For the Liberation Tigers of deotapes of attacks in order to ensure that their Tamil Elaam, the constituency is the 3–4 million version—not the government’s version—of events Tamils chafing under Sinhalese rule on the island dominates the airwaves. All in all, with regard to of Sri Lanka. For the Provisional Irish Republican other forms of social influence, it is the variables Army, the constituency is the Catholic majority associated with the target audience that matter living in Northern Ireland. For al-Qaeda, the con- most in the psychological effect of terrorism. stituency is Muslims around the world, particularly Sunnis. Examples of simple messages aimed at the constituency in acts of terror are the fol- The Target Audiences: At Whom lowing: Is Terrorism Aimed? Only through violent resistance can we ac- There will always be multiple audiences for any act complish our ends. Negotiation is capitulation of terrorism. In broad theoretical terms, these can to tyranny. be thought of in two distinct categories: the group Witness that our enemies are not invulnerable on whose behalf the act is carried out (the con- and that we are capable of injuring them. stituency) and the group against whom the act is directed (the enemy). In practice, there will be Terrorist groups usually live or die based upon some nuances and third-party effects, which is to how well they communicate with their constituency; say that some audiences may be proxies for others it would be fair to state that the power and resilience (e.g., attacking McDonald’s as a symbol of the of any terrorist group greatly reflects the effective- United States) or mediate the message in some way ness of the social influence campaign used on its (e.g., attacking the UN to intimidate a wide array constituency. As Martha Crenshaw has pointed out of international actors). That said, the effectiveness (1981, 1991), when terrorist groups alienate, fail of a terrorist campaign—as is the case in any social to motivate, or misread the mandate of the con- influence campaign—is directly related to how well stituency, they are very likely to wither and dissolve. the author of the violent communication knows For example, alienation can occur when the acts of the target audience. Specifically, the critical knowl- terror are excessively or wantonly brutal (such as a edge is the way in which the target audience white supremacist shooting up a Jewish preschool processes information and acts upon it. and killing several children). Failure to motivate might take the form of simply receiving insufficient The Constituency: The Group or Population for money or recruits from the constituency: The appeal Whom the Terrorism Is Conducted for support is falling on deaf ears, as has been the case for Communist terrorist groups in Europe in Virtually every group engaged in a campaign of recent years. Misreading the mandate of the con- terror draws support from a broad base of active stituency is a classic mistake; since the acts of and passive supporters; this is Fraserand Fulton’s terror are vicarious blows struck on behalf of the pyramidal model (1984). The number of full-time constituency, they must be aimed where the constit- operatives (the acme of the pyramid) is quite small uency would like them to fall. Bombings that kill the compared to the number of people needed to constituency’s children are obviously in danger of provide money, intelligence, safe haven, forged misreading the mandate of the constituency (parti- documents, munitions, transportation, and the like cularly among secular groups). (the base of the pyramid). Moreover, beyond the active supporters are the vast numbers of like- The Enemy: The Group or Population Against minded people necessary to sustain the group over Whom the Terrorism Is Conducted What Is Terrorism? 93

Since terrorist groups are almost always incapable influence campaign aimed at the enemy. This of achieving the military defeat of their adversaries, seems obvious, but it is often eclipsed by other the acts of terror must aim at one of Clausewitz’s concerns: technology, criminality, rationality, body ‘‘centers of gravity,’’ namely, the political will of the counts, and so forth. These elements are import- opposition. In practice this means creating suffi- ant, but they do not determine the outcome of cient pain, aversion, or disincentive on the part of terrorist campaigns. the decision makers in the enemy authority to elicit political change and even revolution. This is clearly a tall order, though not at all impossible. In fact, Historical Terrorism there are many cases of campaigns of terror accomplishing this very thing (e.g., in Palestine In the following historical survey we highlight [1948], Algeria [1962], Lebanon [2000], Sri Lanka some of the key elements identified in the previous [2001], and Spain [2004]). For two reasons it is section, specifically those that are critical to the usually easier to accomplish this goal in democratic outcomes of terrorist campaigns. For a more com- societies than in authoritarian ones. First, it is easier prehensive and detailed view of terrorism, there are to inflict harm on a population than on its leader- excellent textbooks and monographs covering ship. Second, the leadership of democratic socie- all aspects of historical terrorism, and interested ties is more responsive and subject to the will of readers will find some suggested readings in the the population than authoritarian societies. Thus, bibliography. when terrorism occurs and the population is injured, it is democratic leaders who generally must Terrorism From Antiquity to World War II concern themselves most with the consequences. A cunning terrorist group uses acts of violence Terrorism as acts of violence by marginal or to create or exploit fault lines between enemy de- revolutionary movements has ancient roots, and, cision makers and the population they control. though the particulars—the weapons and the This form of social influence campaign is almost causes—have changed, the fundamental nature of the exact inverse of the campaign aimed at the ter- terrorism has not. rorist group’s constituency: In the former, the A group that would certainly be considered group is attempting to fracture and fragment terrorist by today’s prevailing standards were the support for the ruling authority and its political Zealots of first-century Judea. They opposed Ro- positions (e.g., maintaining a colonial outpost in a man rule and conspired to topple it. Extreme ele- distant land), while in the latter case the group is ments among the Zealots assassinated Romans trying to draw support from and unify often di- and Roman collaborators in order to catalyze both verse groups and interests (e.g., to eject a colonial a reluctance among the indigenous populace to power from native territory). Examples of simple work for or with the Romans and to effect a Roman messages aimed at the enemy in acts of terror may withdrawal in the long run. What makes these include the following: assassinations terrorist acts and social influence as we have defined them is the choice of location: The colonial government is weak and cannot densely populated public areas, such as market- control its possessions. places. Without a printing press (much less radio, You can expect more of this. The resistance TV, the Internet, and the like), the only sure way of will continue to kill colonial representatives quickly communicating a shocking act of violence until they depart. to a large number of people was to carry them out Since you have placed us all under your yoke, in crowded public spaces. The Zealots knew that all of the members of the colonial empire will their assassinations would never amount to a tell- be made targets. ing or even a painful military blow to the Roman As we mentioned earlier, the durability and occupation, but they hoped the acts would capability of terrorist groups is often based directly nevertheless bring about the desired political upon the social influence campaign aimed at their change. constituency. The success or failure of the terror- As we have already stated, there is often more ism depends upon the effectiveness of the social than one audience for terrorist action; that is, 94 Terrorism terrorists usually attempt to influence more than persuasive communication. It is ‘‘propaganda by one group at a time with a single violent action. the deed,’’ as nineteenth-century revolutionary Zealot violence was a medium of communicating Paule Brousse termed it in an 1877 article of the with distinct target audiences—Romans, their ac- same name. This communication is no less than a tual and potential Jewish collaborators, and other campaign of social influence. Jews yearning to be relieved of the imperial yoke. For the Romans, the message was a statement of Proxy, Anticolonial, and International dedicated resistance and defiance; for actual and Terrorism: World War II to 1980 potential collaborators it was a frightening warning; for other Jews it was an invitation to rally and a Terrorism became commonplace in the decades vicarious act of insurrection. The simplicity and following World War II. The major forces driving ardor of the message, delivered in a violent and this evolution were the Cold War, anticolonialism, shocking manner, elevated the status of the Zealots and the growth of international, televised media. from fringe group to leading element of the revolt As a result of the Cold War, direct confronta- against Rome (A.D. 66–70). tion between the competing superpowers of the The prototype for modern terrorism and ter- East Bloc and the West was avoided for the ob- rorists is found in the Narodnaya Volya (People’s vious reason of preventing a battle that might es- Will) movement of Tsarist Russia in the latter part calate to a nuclear conflict. This led to a booming of the nineteenth century. The Narodnaya Volya market in proxy battles around the globe, replete was composed of anarchists who followed in the with a massive flow of monies and weaponry. footsteps of prominent antitsarist revolutionaries Besides installing and equipping murderous des- such as Mikhail Bakunin and Sergey Nechaev. pots with the means to engage in state terror (e.g., While many socialists and anarchists believed U.S. support to the shah of Iran), it also led in (peaceful) revolutionary change, Bakunin and to the establishment of insurgent armed groups those who followed him felt that violence was the throughout Latin America, Africa, Europe, and key to beginning a powerful wave of political chaos Asia (e.g., Red Army Faction, Red Brigades). Many that would shatter the government. of these groups engaged in a full range of terrorist The Narodnaya Volya carried out numerous actions in the course of their struggles as they assassinations (including that of Tsar Alexander II) sought to sever the existing government’s re- to produce such an effect among the masses and lationship with its supporters in the general po- state agencies; it was not the violence, but rather its pulation while building their own base of support psychological effect, that was their objective. How and legitimacy. As proxies for the United States was such an outcome to be produced? Just as a key and the Soviets, these groups were able to generate instrument of terrorism—dynamite—was a pro- international shock waves and gain political ground duct of the late nineteenth century, so too was among the larger populace as a sure means of the second requisite component of terrorism: the gaining continued support from their sponsor (key rotary press and the ability to mass-produce in- constituency). expensive pamphlets and newspapers for public Closely linked to the advent of the Cold War consumption. As Schmid and de Graaf have noted was the dissolution of colonial empires and the (1982), for marginal groups bent on catalyzing founding of nationalist groups seeking to expel political change, the debut of mass media created foreign masters. In colonial outposts in Latin an opportunity for ‘‘expressive violence,’’ in which America, Africa, the Middle East, and Asia, the the savagery and its immediate consequences were French, English, German, Japanese, and other the instrument to an end. In the case of terrorism, empire-building nations suddenly found the the end is always an extreme form of social influ- natives restless. In the case of the Germans and ence: radical change in attitudes and behaviors. the Japanese, the issue was who would devour the From the Zealots to the Narodnaya Volya, pieces of their dismembered dominions. For na- what makes the terrorist is the terrorism: This is tionalist, anticolonial groups seeking to restore not an attempt at glibness but rather a recognition sovereignty or seize power in their own countries, that it is the ‘‘expressive’’ component of ‘‘expressive the time was ripe, but their resources were limited, violence’’ that transforms terrorism into an act of and conventional warfare against the countries that What Is Terrorism? 95 had survived World War II was out of the ques- nale (FLN) against their French colonial masters tion. Hence the resort to terrorism. Terrorist acts (1954–1962) and by the Viet Cong against U.S. would be used to force the colonial powers to re- invaders during the Vietnam War (1962–1975). In think the price of ownership while rallying in- both cases, small cells of insurgents planted bombs digenous support to the cause. and threw grenades into areas crowded with com- The final ingredient to the rise of terrorism batants and noncombatants alike in order to exact in the Cold War/post–World War II period was a heavy human toll on the foreign occupiers. This the explosion in international media. In the early price would never grow to an amount that the nineteenth century, the fastest a message could be military decision makers could ill afford, but they carried depended on the speed of a horse, and its were not the population targeted for influence. reach was constrained by the number and range of Rather, the cost in human lives brought about by the riders. By the late nineteenth century, messages the terrorism would be transmitted by the inter- were propagated instantaneously by wireless. With national media to the French and U.S. populations the advent of mass radio and then television broad- respectively, who in turn would exert pressure casting in the twentieth century came the ability to on their leaders to forego further loss. inform large numbers of people quickly. Moreover, the driving force behind much of the new mass The Rise of Religious Terror: media was a profit motive—and with it a need to 1980 to the Present grab and hold audiences. As the journalistic adage goes, ‘‘Bad news is good news, good news is bad Conventional terrorism is violent communication news, and no news is also bad news.’’ Terrorist acts aimed at a constituent population as well as an are sensational and decidedly bad news and thus enemy population, but religious terrorism adds perfect fodder for media outlets seeking sales, another audience: God. Under this model, terrorist readers, listeners, and viewers. acts are considered holy acts that are performed A prime example of terrorism in this period in the name of religious devotion, often to fulfill is that used by the Zionist groups in Palestine. sacred edicts or bring about apocalyptic scenarios. As Menachem Begin has recounted in his auto- This changes the calculus of terrorism signif- biography, The Revolt (1972), Zionist groups stu- icantly: Many of the constraints or earthly concerns died the British government’s decision-making that attempted to match the deed to the audience’s process in the battle against Irish separatism and perceptions and cognitions are removed, eclipsed decided that a campaign of terror in the post– by the absolutism of religious piety. As Hoffman World War II environment would weaken do- has noted (1995), secular or nationalist terrorist mestic British support for a colonial presence in groups act within the prevailing international po- Palestine. Further, these acts of terror would both litical framework and wish to replace the existing galvanize the Jewish population in the quest for order with another one. Since earthly audiences a sovereign Jewish state and drive fearful Arab are involved, secular terror necessitates some de- residents (Palestinians) into exile. The Zionist gree of adherence to international norms relating groups reasoned that a campaign of terror would to proportionality and precision of violence. Not be broadcast to a British public that was weary so for religious terror. ‘‘Winning’’ is not measured of conflict and war and eager to be relieved of a in earthly (political, social, or economic) terms distant colonial outpost of little obvious value to but rather in theological terms, which tend to be the nation. The Zionists believed that the public absolute, uncompromising, and not subject to would ultimately pressure the government to pull normative constraints.7 To religious terrorists, out. Indeed, British authorities turned to the UN killing is a sacred act, not a political act. for a solution that would relieve them of the in- Terrorism of the religious sort still very much creasing human costs of colonial control and thus includes a social influence component, but be- became midwife to the civil war that brought about cause the objective of political or social change the state of Israel. is reduced and the element of religious change Other examples of terrorist tactics in the post– (martyrdom, apocalypse) is introduced, the aspect World War II period include the urban warfare of social influence is generally narrowed to polar- fought by the Algerian Front de Libe´ration Natio- ization and rallying. That is, the rhetoric of 96 Terrorism religious terrorism is uncompromising and divi- Prophet’s Banner’’ (2001). An example of this lan- sive, resulting in faith-based, simplistic, good- guage from bin Laden’s 1998 fatwa (an opinion versus-evil arguments. For the faithful or potential issued by a Muslim scholar) suffices to illustrate recruits this is an opportunity to join the forces of the principles outlined earlier, namely, that earthly good; for those not swayed by the appeal, there is audiences and norms no longer establish the ap- only confrontation or acquiescence—compromise propriate guidelines for action: is not possible. Consider, for example, the differ- The ruling to kill Americans and their allies— ence between two large, accomplished terrorist civilians and military—is an individual duty for groups: the Liberation Tigers of Tamil Eelam (LTTE) every Muslim who can do it in every country in and Hamas. As a predominately secular, ethnona- which it is possible to do it. ...We—with God’s tionalist group, the LTTE is willing to negotiate with help—call on every Muslim who believes in the Sri Lankan government; as a strictly religious God and wishes to be rewarded to comply with and anti-Zionist group, Hamas is rarely able or in- God’s order to kill the Americans and plunder clined to find common ground with the Israeli their money wherever and whenever you can government. find them. One superb example of religious terrorism today is Aum Shinrikyo¯. Between 1989 and 1995, There is clearly little room for empathy, ne- this Japanese group murdered roughly 100 people gotiation, compromise, or hesitation in bin Laden’s and injured thousands, with the explicit intention message. Al-Qaeda and its affiliates use sacred vio- of starting an apocalyptic war that would kill lence as an instrument of social influence, but the millions. Their goal was to usher in a new era that message and its parameters are inflexible and di- would see existing civilization destroyed, creating visive. This means the constituency is limited to a blank slate that Aum could then use to create Muslims who accept bin Laden’s authority and a utopian successor society. By the time Japanese reasoning; the enemy population will be everyone authorities bestirred themselves to act against Aum, else (most of whom are demonized or devalued it had acquired thousands of zealous members, under al-Qaeda’s ideology). The third audience— finances in excess of $100 million, extensive media the divine—is characterized by al-Qaeda’s theol- operations, as well as businesses and land holdings ogy as sanctioning exactly this sort of dichotomous in numerous countries. Aum scientists and en- worldview and the unfettered violence that springs gineers had developed, weaponized, and attacked from it. civilians with anthrax bacillus, botulinum bacillus, and several types of nerve gas, poisons, and mind- altering drugs. Moreover, they had avidly been Conclusion: The ‘‘Persuasiveness’’ pursuing nuclear weaponry in the former republics of Terrorist Acts of the Soviet Union. The leader and founder of Aum Shinrikyo¯ was Shoko Asahara (born Chizuo Terrorism works. It works the way advertising and Matsumoto), an undisputed and all-powerful guru, marketing work; when an effective social influence a self-styled prophet and messiah with an escha- campaign is well designed and well executed and tological worldview and an unshakable grip on his when externalities do not interfere with or supersede followers. The acts of terror conducted by Aum the persuasion attempt, audiences react as desired. members were constrained only by the will and From the constituency audience, terrorist groups approbation of God (as interpreted and related by receive recruits, money, and a wide variety of logis- Asahara). tical support. From the enemy audience, terrorist Of course, no discussion of contemporary re- groups can directly or indirectly wrest political ligious terrorism can or should avoid al-Qaeda and change, ranging from legitimacy and negotiation to its affiliates. To understand the polarizing ideol- utter revolution. So, outside of hoping that terrorists ogy, language, and actions of al-Qaeda, one should will undo their own cause by overreaching or be examine the lengthy treatises and polemics issued hindered by an environment that disrupts their by Osama bin Laden and others, including his campaign, is there anything else that can be done? ‘‘declaration of jihad against the United States’’ The answer is ‘‘yes.’’ Terrorism and terrorist (1996), and Ayman Zawahiri’s ‘‘Knight Under the groups are vulnerable the way other forms of social What Is Terrorism? 97 influence campaigns and their originators are (e.g., the Marlboro Man) but with reversed vulnerable. Consider the hundreds of billions of messages. dollars that are spent each year on advertising reduce the credibility and likeability of the and marketing campaigns within the United States cigarette companies and, by association, their alone; some campaigns are poorly constructed, and products (Goldman & Glantz, 1998). some are lost in the noise of the marketplace, but others are mitigated or effectively neutralized by These are just a few examples of counter- competition and countercampaigns. For example, campaigns that can be employed against the jug- the six largest cigarette manufacturers together gernaut of cigarette advertising. They are made spent more than $11 billion on domestic adver- possible by a careful analysis of the social influence tising in 2001 (‘‘FTC Cigarette Report for 2001,’’ elements manipulated by cigarette advertising and 2003). While they clearly do not employ violence marketing campaigns, followed by the subsequent as an instrument of social influence, their goals are crafting of disruptive countermeasures suited to not unlike those of terrorist groups in that they the analysis. We contend that a careful analysis of both perceive an enemy audience and a constitu- terrorism as social influence campaigns will yield a ency audience. Blum (1989) has aptly summarized foundation for psychological countermeasures that these goals of the cigarette manufacturers’ adver- can mitigate or thwart the psychological effects of tising (social influence) campaigns: terror as they propagate through the population and the media. These countermeasures can take Recruit new smokers (constituency) the form of more effective risk communication by Sustain existing smoking ‘‘membership’’ (con- governmental agencies, better reporting by jour- stituency) nalists, increased resilience in the population as a Obtain protection and facilitation from legis- whole, better education of opinion leaders, a dis- lators and opinion leaders (constituency) crediting of terrorist groups, and many others. Associate smoking with positive values and To illustrate these principles with an example social goods such as personal independence from successful counterterrorism campaigns, con- and self-sufficiency (constituency) sider the last bullet point above on potential coun- Pull former smokers back in (constituency), or tercampaigns: reducing the credibility and likeability neutralize them as adversaries (enemy) of the adversary and, by extension, its activities and Neutralize antismoking forces such as jour- products. This tactic has been used, albeit somewhat nalists and hostile legislators (enemy) crudely and nonscientifically, in the past against As powerful and pervasive as cigarette com- terrorist groups: panies’ social influence campaigns are, they can be undone by countercampaigns and milieu control Emilio Aguinaldo, who headed an insurrection (e.g., legislative action). These countermeasures against occupying U.S. forces in the Phi- can work at every step of the Yale process model lippines at the start of the twentieth century, (exposure, attention, comprehension, acceptance, was captured and induced to sign an oath of retention, and translation) and each of the Yale in- loyalty to the United States. This greatly dependent variables (source, target, message, and reduced his stature among his constituents, medium). For example, countercampaigns can and the insurrection sputtered soon thereafter. Abdullah Ocalan, who led the Kurdistan use fear-based messages (regarding health) to Workers Party (Partiya Karkeran Kurdistan get smokers to quit and nonsmokers to never [PKK]; 1984–1999) in terrorist acts against start (Insko, Arkoff, & Insko, 1965) Turkey in order to create an autonomous affect the baseline social norms to prevent pro- Kurdish state, was captured. Turkish autho- smoking campaigns from controlling the mili- rities induced him to publicly plead for a eu (Worden & Flynn, 2002) ceasefire and for his own life, which dimin- parasitize pro-smoking ads to reduce their ef- ished his stature and credibility. As a result, fectiveness (Cialdini, Demaine, Barrett, Sagar- the PKK’s campaign soon ground to a halt. in, & Rhoads, in preparation). By ‘‘parasitize,’’ Abimael Guzmań, who, during the 1980s, was we mean employ similar motifs and formats the leader of the powerful Sendero Luminoso 98 Terrorism

(Shining Path) group of Peru, was captured in References 1992. Paraded before the public in a cage and induced by the authorities into publicly Andreoli, V., & Worchel, S. (1978). Effects of media, pleading for his life and a ceasefire, Guzmań communicator, and position of message on suffered a tremendous loss of authority and attitude change. Public Opinion Quarterly, 42(1), 59–70. credibility among his constituency. Within 2 Asch, S. (1953). Effects of group pressure upon the years of his arrest, thousands of Shining Path modification and distortion of judgments. In D. guerrillas had turned themselves in under a Cartwright & A. Zander (Eds.), Group dynamics: government amnesty program. Research and theory (pp. 607–623). Evanston, IL: Peterson. Begin, M. (1972). The revolt. Los Angeles: Nash. Notes Bell, J. B. (1978). A time of terror: How democratic societies respond to revolutionary violence. New York: 1. We use the term ‘‘terrorist group’’ to mean Basic Books. simply any group or institution that carries out acts bin Laden, Osama. (1998, February 23). ‘‘Fatwa.’’ Al of terrorism as we have defined them here. It is Quds al ‘Arabi. n. p. the act and not the ideology that makes terrorists. Blass, T. (1991). Understanding behavior in the Moreover, terrorist acts are aimed at noncomba- Milgram obedience experiment. Journal of Person- tants alone. Many governments label assaults against ality and Social Psychology, 60, 398–413. them or their militaries as ‘‘terrorism,’’ but this is in- ———. (1999). The Milgram paradigm after 35 years: accurate and propagandistic: Attacks on govern- Some things we know about obedience to mental or military targets are guerrilla warfare, not authority. Journal of Applied Social Psychology, 29, terrorism. 955–978. 2. For more information, see Drolet and Aaker Blum, A. (1989). The targeting of minority groups by (2002). the tobacco industry. In L. A. Jones (Ed.), 3. Schemas are mental arrays of associated Minorities and cancer (pp. 153–163). New York: ideas, characteristics, and perceptions. They are used Springer. as cognitive shortcuts to reduce the burden of deep Bochner, S., & Insko, C. (1966). Communicator thinking and to quicken reactions. This periph- discrepancy, source credibility, and opinion eral (versus central) processing of information change. Journal of Personality and Social Psychology, can have great utility—quickly associating smoke 4, 614–621. with fire has survival value—but can also be prob- Bru¨ nken, R., Steinbacher, S., Plass, J. L., & Leutner, D. lematic (Hass, 1981). Racial or ethnic stereotypes (2002). Assessment of cognitive load in multi- are common examples of harmful schemas. media learning using dual-task methodology. 4. For more information on the how the envi- Experimental Psychology, 49, 109–119. ronment affects decision making, see Asch (1953); Burnstein, E., & Vinokur, A. (1977). Persuasive Lasswell (1948); Janis (1982); and Petty and argumentation and social comparison as determi- Cacioppo (1986). nants of attitude polarization. Journal of Experi- 5. Source credibility is among the most complex mental Social Psychology, 13, 315–332. variables that figure in the outcome of persuasion Byrne, D. (1971). The attraction paradigm. New York: attempts. A careful summary of the issues and re- Academic Press. search can be found in Petty and Cacioppo Calder, B., Insko, C., & Yandell, B. (1974). The (1996). relation of cognitive and memorial processes to 6. ‘‘Cognitive load’’ is the significant encum- persuasion in a simulated jury trial. Journal of brance of an individual’s working memory. Applied Social Psychology, 4, 62–93. ‘‘Ambient noise’’ refers to a low signal-to-noise Chaiken, S. (1979). Communicator physical attrac- ratio. tiveness and persuasion. Journal of Personality and 7. In an excellent example of this point, Social Psychology, 3, 1387–1397. White (2002) points to the lesson taught by the ———. (1987). The heuristic model of persuasion. In biblical story of Joshua in the siege of Ai M. P. Zanna, J. M. Olson, & C. P. Herman (Eds.), (Joshua 8:24–28). God orders Joshua to kill Social influence: The Ontario symposium: Vol. 5 (pp. first the warriors of Ai and then every inhabi- 3–39). Hillsdale, NJ: Erlbaum. tant of the city—young and old, male and ———, & Eagly, A. (1976). Communication modality female. as a determinant of message persuasiveness and What Is Terrorism? 99

message comprehensibility. Journal of Personality Hoffman, B. (1995). Holy terror: The implications of and Social Psychology, 34, 605–614. terrorism motivated by a religious imperative. Chaiken, S., Liberman, A., & Eagly, A. (1989). Studies in Conflict and Terrorism, 18, 271–284. Heuristic and systematic information processing ———. (1998). Inside terrorism. New York: Colombia within and beyond the persuasion context. In J. S. University Press. Uleman & J. A. Bargh (Eds.), Unintended thought Hofling, C., Brotzman, E., Dalrymple, S., Graves, N., & (pp. 212–252). New York: Guilford Press. Pierce, C. (1966). An experimental study of nurse- Cialdini, R. (1993). Influence: Science and practice (3d physician relationships. Journal of Nervous and ed.). New York: HarperCollinsCollegePublishers. Mental Disease, 143, 171–180. ———, Demaine, L. J., Barrett, D. W., Sagarin, B. J., & Hovland, C., Janis, I., & Kelley, H. (1953). Commu- Rhoads, K. (in preparation). The poison parasite nication and persuasion. New Haven, CT: Yale defense: A strategy for sapping a stronger oppo- University Press. nent’s persuasive strength. Hovland, C., Lumsdaine, A., & Sheffield, F. (1949). Crenshaw, M. (1981). The causes of terrorism. Experiments on mass communication. Princeton, NJ: Comparative Politics, 13(4), 379–399. Princeton University Press. ———. (1991). How terrorism declines. Terrorism and Hovland, C., & Mandell, W. (1952). An experi- Political Violence, 3(1), 69–87. mental comparison of conclusion-drawing Darley, J. M., & Batson, C. D. (1973). From Jerusalem by the communicator and by the audience. to Jericho: A study of situational and dispositional Journal of Abnormal and Social Psychology, 47, variables in helping behavior. Journal of Personality 581–588. and Social Psychology, 27(1), 100–108. Hovland, C., & Weiss, W. (1951). The influence of Downes-Le Guin, T., & Hoffman, B. (1993). The impact source credibility on communication effectiveness. of terrorism on public opinion, 1988–1989. Santa Public Opinion Quarterly, 15, 635–650. Monica: RAND. Husek, T. (1965). Persuasive impacts on early, late, or Drolet, A., & Aaker, J. L. (2002). Off target? Changing no mention of a negative source. Journal of cognitive-based attitudes. Journal of Consumer Personality and Social Psychology, 2, 125–128. Research, 12(1), 59–68. Insko, C. A., Arkoff, A., & Insko, V. M. (1965). Effects Eagly, A. (1974). Comprehensibility of persuasive argu- of high and low fear-arousing communications ments as a determinant of opinion change. Journal of upon opinions toward smoking. Journal of Experi- Personality and Social Psychology, 29, 758 –773. mental Social Psychology, 1, 256–266. ———, & Warren, R. (1976). Intelligence, compre- Janis, I. (1982). Groupthink: Psychological studies of hension, and opinion change. Journal of Personality, policy decision. Boston: Houghton Mifflin. 44, 226–242. ———, & Feshbach, S. (1953). Effects of fear-arousing Federal Trade Commission Cigarette Report for 2001. communications. Journal of Abnormal and Social (2003). Washington, DC: Federal Trade Commis- Psychology, 48, 78–92. sion. Retrieved February 21, 2006, from http:// Jenkins, B. (1975). International terrorism: A new mode www.ftc.gov/os/2003/06/2001cigreport.pdf. of conflict. Los Angeles: Crescent. Fraser, J., & Fulton, I. (1984). Terrorism counter- Kelman, H., & Hovland, C. (1953). ‘‘Reinstatement’’ of action. FC-100–37. Fort Leavenworth, KS: U.S. the communicator in delayed measurement of Army Command and General Staff College. opinion change. Journal of Abnormal and Social Goethals, G., & Nelson, R. (1973). Similarity in the Psychology, 48, 327–335. influence process: The belief-value distinction. Klapper, J. (1960). The effects of mass communication. Journal of Personality and Social Psychology, 25, Glencoe, IL: Free Press. 117–122. Laqueur, W. (1987). The age of terrorism. Boston: Little, Goldman, L., & Glantz, S. (1998). Evaluation of anti- Brown. smoking advertising campaigns. Journal of the Lasswell, H. (1948). The structure and function of American Medical Association, 279(10), 772– communication in society. In L. Bryson (Ed.), The 777. communication of ideas (pp. 32–51). New York: Harper, R., Weins, A., & Matarazzo, J. (1978). Nonverbal Harper & Row. communication: The state of the art. New York: Wiley. Latane´, B., & Darley, J. (1970). The unresponsive Hass, R. G. (1981). Effects of source characteristics on bystander: Why doesn’t he help? New York: Apple- cognitive response and persuasion. In R. E. Petty, ton-Century-Crofts. T. M. Ostrom, & T. C. Brock (Eds.), Cognitive Latane´, B., & Nida, S. (1981). Ten years of research on responses in persuasion (pp. 141–172). Hillsdale, group size and helping. Psychological Bulletin, 89, NJ: Erlbaum. 308–324. 100 Terrorism

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Psychological Aspects of Suicide Terrorism Ariel Merari

By a strict definition, a suicide terrorist attack is Suicide terrorist attacks attract much public an assault that is intended to achieve a political interest and concern. This phenomenon has al- objective and is performed outside the context of ways been surrounded by mystery and fear. The a conventional war, in which the assailant inten- fact that, unlike ordinary self-immolation, terrorist tionally commits suicide while killing others. The suicide has been murderous and often directed self-immolation element makes this form of ter- against the random public, naturally augments the rorism substantially different in both its psycholo- feeling of cryptic danger and the need to under- gical foundations and potential consequences from stand it. In the absence of empirical research other terrorist attacks that involve high risk for the on this phenomenon, the explanations offered perpetrators. have been quite speculative. The most common Suicide terrorism constitutes a political and explanations have emphasized cultural factors. strategic problem of considerable import. This ob- Islamic religious fanaticism has been particularly servation seems obvious after the September 11, popular in this context (Taylor, 1988; Israeli, 2001, attacks in the United States. Yet even prior 1997; Hoffman, 1998). Taylor, for example, typi- to the attacks in New York and Washington, sui- cally included the analysis of suicidal terrorism in a cide attacks had, on some occasions, far-reaching chapter titled ‘‘fanaticism.’’ He finds the roots of political consequences. In 1983, attacks against this behavior in the tradition of the Assassins and U.S. and French forces and diplomatic missions in attributes suicidal terrorism to Shiite fanaticism in Lebanon resulted in the evacuation of the Multi- particular: ‘‘The forces that gave rise to the Assas- national Force from that country. This step en- sins remain and influence the Shi’ites today’’ (p. abled the Syrian de facto takeover of the country 109). Similarly, ‘‘the behaviours which we find so and, in the following years, had a vast influence on difficult to understand (suicide bombing, for ex- Lebanese domestic and international politics. In ample) have their origins in the kind of religious another arena, Palestinian suicidal terrorist attacks practice which characterises Islamic fundamental- in Israel in 1996 resulted in a change of govern- ism, and especially shi’iteism’’ (p. 110). ment and had a major deleterious impact on the Taylor, however, extends his account to in- Middle Eastern peace process. clude political suicides of other societies, notably

101 102 Terrorism

Western, such as those by members of the German Prevalence Red Army Faction in prison in the 1970s, the Irish hunger strikes in Maze Prison in 1980 and 1981, Several writers have maintained that suicide ter- and the Jonestown mass suicide in 1978. His rorism is an ancient phenomenon, claiming that it broader explanation attributes this phenomenon to was used by groups such as the Jewish Sicarii of the social pressure and conformity that characterize first century and the Muslim hashashin (Order of certain societies: ‘‘Both contemporary Shi’ite so- Assassins) of the eleventh through the thirteenth ciety, and the Japanese society of the time, show centuries (Sprinzak, 2000; Schweitzer, 2001; Atran, many attributes of intense control, with restric- 2003). This claim is erroneous since these groups tions on extra-societal influences. In many respects carried out attacks that involved great risk for the they are as ‘psychologically’ closed as the prisons perpetrators, sometimes their almost sure death, which sustained both the Baader-Meinhof and the but they were not suicide in the strict sense of IRA suicides’’ (p. 120). self-immolation. As much as recorded evidence is Raphael Israeli (1997) finds the basic ex- concerned, true suicide terrorist attacks, in which planation of this phenomenon in the Islamic frame the attackers kill themselves while killing others, of mind: ‘‘Turning to an Islamic frame of reference are a modern phenomenon. The first recorded case for a definition, and perhaps a diagnosis, would of a suicide terrorist attack was the car bombing of then appear imperative if we are to comprehend the Iraqi embassy in Beirut on December 15, 1981, the underlying motives of this sort of unparal- although as a methodical terrorist tactic, they were leled mode of self-sacrifice’’ (p. 107). However, he first used in Lebanon in 1983 by radical Islamic maintains (with no empirical evidence to support groups that later formed Hizballah. his claim) that personality factors also play a role A simple count of suicide attacks around the in the making of a suicide terrorist. Specifically, he globe shows an alarming rise in recent years (see speculates that suicide bombers share three com- Figure 8.1). Of the 583 suicide attacks that were mon characteristics: They are young and have few carried out around the world from 1981 to 2004, life responsibilities; they are unsuccessful or are 435 of them (75%) took place between 2000 and shunned by their family and society, so that they 2004. feel isolated; and they have low self-esteem. Sui- Indeed, since the first wave of suicide attacks cide terrorists, according to Israeli, ‘‘may be some- carried out in Lebanon by Hizballah in 1983, this what depressed and in search of easy solu- tactic has been espoused by many other groups tions to their problems. Unsuccessful, perhaps around the globe. These include eight groups in self-despising, they find solace in becoming mar- Lebanon (six of them Lebanese and two Palesti- tyrs, thus almost instantly and mythically trans- nian), four Palestinian groups in Israel’s occupied forming frustration into glory, failure into victory territories, two Egyptian groups, the Kurdish La- and self-depreciation into public adoration’’ bor Party (PKK), the Turkish Revolutionary Peo- (p. 106). ple’s Liberation Front (a left-wing group), Chechen Other explanations ascribed the phenomenon rebels, the Tamil Tigers (LTTE), Islamic militant to indoctrination, even brainwashing, in the sense groups in Kashmir, al-Qaeda, a militant Islamic of persuading ‘‘uninformed youth’’ to commit group in Morocco, and anti-American groups in suicide in the service of their advocated cause Iraq. Most of these have carried out only a small (Post, 2001). In an earlier study (Merari, 1990) I number of suicide assaults. Only a few have em- attributed politically motivated suicide, particu- barked on a systematic campaign of suicide attacks larly cases of group suicide such as Massada (AD as a central method in their armed struggle. Table 73) and the Irish chain suicide of 1980 and 1981, 8.1 shows the number of suicide attacks by to situational factors, notably group pressure, country from 1981 through April 2005. The table group commitment, and the influence of a char- also shows the number of people who committed ismatic leader, as well as to personality factors. terrorist suicide, as some attacks have involved These explanations are not entirely compatible multiple suicide attackers. with factual evidence that has accumulated on So far, suicide attacks have taken place in 30 suicide terrorism. countries. However, the great majority—nearly Psychological Aspects of Suicide Terrorism 103

200 179 180

160

140

120

100 94 Attacks

80 68

No. of attacks 61 60

40 33 18 18 16 20 20 15 6 6 10 9 8 11 2 3 2 5 33 2 0

1 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 200 2003 year

Figure 8.1. Suicide attacks by year.

88%—have been carried out in only 6 countries: lity to acquire and use a large quantity of ex- Lebanon, Sri Lanka, Israel, Turkey, Russia, and Iraq. plosives (or other means of causing mass casual- In fact, 73% of the world’s tally have taken place in ties), the selection of densely populated targets, only 3 countries, namely Sri Lanka, Israel, and Iraq, and smart planning that makes it possible for the and Israel and Iraq alone account for 63% of the group to devise original modes of attack and cir- world’s total. These facts highlight an important cumvent defenses. characteristic of the nature of the spread of suicide terrorism as a terrorist tactic. Although the overall frequency of suicide attacks has been on the rise The Profile of Suicide Terrorists since this tactic first appeared in Lebanon in the 1980s, suicide terrorism does not spread in a fashion Descriptions of the profiles of suicide terrorists similar to the growth rate of the use of new tech- relate to two types of data: demographic details and nologies, such as the Internet or cellular phones. psychological characteristics. Whereas the demo- Rather, it is restricted to places where acute, violent graphic descriptors, such as age and gender, are conflicts are being waged, and in these places, it is relatively easy to obtain, psychological features, limited to the duration of the acute struggle. It is true, notably personality traits and motivations, are not however, that the likelihood that suicide attacks will readily accessible. be adopted as a tactic in an insurgent struggle is The numerous descriptions of the psycholo- greater today than ever before. In this sense it seems gical (as distinguished from demographic) char- that this tactic has become a trend, especially (but acteristics of suicide bombers offered so far have not exclusively) among militant Islamic groups. by and large been speculative, conjecturing from Nevertheless, as demonstrated by the 9/11 biographical details (e.g., Hudson, 1999; Wein- events, the frequency of attacks is not the most berg, Pedahzur, & Canetti-Nisim (2003); Cronin, important factor in creating the impact of suicide 2003; Kimhi & Even, 2004; Holmes, 2005; Ricolfi, terrorism. Extremely large numbers of casualties 2005). Very few of the reports have been based result when the suicide method is coupled with on interviews with would-be suicide bombers or other characteristics of the group, namely, the abi- with their families (Andoni, 1997; Hassan, 2001). 104 Terrorism

Table 8.1. Number of suicide attacks and attackers by country and period, as of April 30, 2005

Country Period No. of Suicide Attacks No. of Suicide Attackers

Afghanistan 2001–2004 6 7 Argentina 1992–1994 2 2 Bangladesh 2001 2 4 Bolivia 2004 1 1 China 1998–2002 3 3 Croatia 1995 1 1 Egypt 1993–2005 5 6 India 1991–2001 9 9 Indonesia 2002–2004 4 5 Iraq 1988–2005 256 291 Israel 1988–2005 175 195 Kenya 1998–2002 2 4 Kuwait 1983–1985 2 2 Lebanon 1981–1999 41 41 Morocco 1995–2003 6 13 Pakistan 1995–2004 15 20 Philippines 2003 1 1 Portugal 1983 1 5 Qatar 2005 1 1 Russia/Chechnya 2000–2004 33 40 Saudi Arabia 2001–2004 8 15 Spain 2004 1 7 Sri Lanka 1987–2004 68 113 Tanzania 1998 1 1 Tunisia 2002 1 1 Turkey 1996–2004 25 26 Uganda 1998 1 1 USA 2001 5 20 Uzbekistan 2004 4 6 Yemen 2000–2002 2 4 Total 1981–2005 682 845

Note: Counts of the number of suicide attacks in Sri Lanka vary considerably, presumably because of differences in the deﬁnition of a suicide attack.

Interviews with would-be suicide bombers were Psychological data on suicide terrorists of most conducted by nonpsychologists and have not uti- groups have not been published. Since 1983 I lized psychological tests. The common conclusion have collected data on suicide terrorism around that suicide bombers are psychologically ‘‘normal’’ the globe from a variety of sources, mainly media should be treated with caution. Whereas acute reports that included demographic and biographi- psychosis (e.g., schizophrenia or depression) would cal details of suicides, sometimes based on in- probably be detected by a layperson, diagnosing terviews with the suicides’ families. Valuable in- more subtle personality disorders requires thorough formation was gained from interviews with jailed clinical interviews and personality tests. The pre- would-be suicides. Particularly useful as a basis sence of these kinds of disorders is not likely to for psychological autopsy was a systematic set of be revealed in an interview by nonprofessionals. data on 34 of the 36 Palestinian suicide terrorists Psychological Aspects of Suicide Terrorism 105 from 1993 to 1998. These data were based on persons are more willing to volunteer for suicide interviews with family members (parents and sib- missions. lings) of the suicides. Other data included inter- However, in the Palestinian case, it has also been views with people who attempted to carry out the policy of the organizations to refrain from re- suicide attacks but failed and with Hamas and cruiting married people for such missions. In a study Palestinian Islamic Jihad (PIJ) trainers of suicide of the demographic characteristics of Hizballah bombers. Data on suicide terrorists in Israel after members killed in action (most of them were not 1998 and on suicide attackers in Lebanon from suicides), Hurwitz (1999) found that, of those whose 1983 to 1989 (almost all of the suicide attacks in marital status was known, only 45% were single. Lebanon took place within this time frame) are Hurwitz notes, however, that Hizballah’s leadership based mainly on media sources (and include some preferred to recruit unmarried youth, but this policy demographic characteristics), as well as on inter- was incongruent with the Lebanese Shiite custom views with jailed would-be suicides. of marrying young. Martin Kramer (1991) has also noted that Hizballah’s ‘‘window of opportunity’’ for recruiting a youngster for military activity was rather Demographic Characteristics narrow because the Lebanese custom of marrying Age young allows the organization only a few years for training and participation in operations. Thus, al- The mean age of the Lebanese suicide bombers though the willingness to embark on suicide mis- was 21, and the age range was 16–28. The mean sions is presumably higher among young, unmarried age of the Palestinian suicides prior to the second people, both marital status and age of the suicides intifada was 22, with a range of 18–38. The age seem to reﬂect Hizballah’s policy. range of the Palestinian suicides in the current intifada was somewhat broader (17–53), but the Gender average remained the same: 22. Two-thirds of In the Lebanese case, 38 of the suicides were males, them were between 18 and 23 years old. Pape and 7 were females (all of the latter were sent by (2005:208) reported that the average age of the secular groups). All of the Palestinian suicides LTTE suicides was 21.9. The age range of the fe- prior to the second intifada were males. This, male PKK suicides was 17–27, and the males were however, was a result of the fact that, until re- 18–40 years old. The mean age of the actual and cently, the Palestinian organizations that used would-be male suicides combined was 27 (Ergil, suicide attacks were religious groups, which ob- 2001). The age range of the al-Qaeda 9/11 suicides jected to the use of women in combat missions. was reported as 20–33 (Schweitzer and Shay, During the second intifada the secular groups of 2002). Fatah and the Popular Front for the Liberation of Palestine (PFLP) also espoused suicide attacks. Marital Status After Fatah started using women (as well as men) Data for the Lebanese sample are lacking, but for suicide missions, the religious PIJ and Hamas clearly almost all of the suicides were single. In followed suit in a few cases. Nevertheless, the the 1993–1998 Palestinian sample, 31 (91%) were percentage of females among Palestinian suicide single (moreover, none of them was engaged to bombers remained very small, less than 4%. It is be married), and three were married (only one of noteworthy that left-wing Turkish and Kurdish them had children). During the second intifada groups, as well as the Tamil Tigers, have used (which started on September 29, 2000, and is women as often as men for suicide attacks. In the still going on at the time of this writing), the PKK, 11 of the 15 terrorist suicides between 1995 proportion of married suicide bombers remained and 1999 were women (Ergil, 2001). In the LTTE below 10%. By the 1997 Palestinian Authority there is a special women’s suicide unit, called (PA) census, the median age at ﬁrst marriage ‘‘Birds of Freedom’’ (Joshi, 2000), and about one- was 23 (Palestinian Central Bureau of Statistics, third of the suicide attacks have been carried out 1997). The fact that almost all of the suicides by women (Schweitzer, 2001; Chandran, 2001). have been single may suggest that unmarried Thus, the greater number of male suicides in the 106 Terrorism

Lebanese and Palestinian cases reflects only the al population. Because no relationship has been preference of religious Islamic groups. found between economic status and participation in suicide attacks, the influence of being a refugee Socioeconomic Status is presumably not due to the greater economic Reliable data are available only for the 1993–1998 hardship associated with the refugee status. Ra- Palestinian sample. In this study, the economic ther, it probably reflects the greater militancy of level of the suicides’ families was assessed by the refugees’ descendents and the greater support for interviewer on the basis of her extensive acquain- Hamas and Islamic Jihad among them. tance with the living conditions of the Palestinians in the West Bank and the Gaza Strip. In general, Religion the economic status of the Palestinian suicides’ families represents a cross-section of the Palesti- Suicide attacks in Lebanon were initially carried nian society in the Palestinian Occupied Terri- out by the radical Shiite groups, which eventually tories. In the 1993–1998 sample, the 34 families formed Hizballah. For this reason the phenomen- were distributed as follows: very poor, 12%; poor, on of suicide terrorism, especially the Middle 21%; lower middle class, 26%; middle class, 32%; Eastern brand, has been associated in public per- upper class, 9%. ception with religious fanaticism. This notion has also permeated academic writings. However, by 1986 it became clear that nearly two-thirds of the Education suicide attacks in Lebanon were carried out by The education level of the suicides at the time of secular groups (Merari, 1990). their suicidal attack was higher than that of the Prior to the second intifada, suicide attacks by general Palestinian society. Of the suicides studied, Palestinians were carried out only by militant re- 26% had at least a partial university education. In ligious groups (two-thirds of them by Hamas comparison, according to the Palestinian Central and one-third by the Palestinian Islamic Jihad). In Bureau of Statistics (2002) data, 11.9% of the the second intifada (‘‘al-Aqsa intifada’’), two se- general Palestinian population had some education cular groups—Fatah and the PFLP—have also re- beyond high school. Table 8.2 shows the dis- sorted to suicide attacks. By April 2005, these two tribution of the suicides’ education level. secular groups combined had been responsible for 27% of the suicide attacks in the second intifada. Refugees Versus Nonrefugees The conclusion that religious fanaticism is Whereas 21% of the Palestinian population in the neither a necessary nor a sufficient factor in suicide Territories live in refugee camps (Arzt, 1997, p. terrorist attacks gains further support from the 60; Shavit and Banna, 2001), prior to the second fact that several other nonreligious groups have intifada they were responsible for 56% of the sui- resorted to this tactic. Thus, the Tamil Tigers cides, more than twice their proportion in the (LTTE), a group that has carried out numerous population. Thus, living in a refugee camp should suicide attacks, is composed of Hindus and moti- be regarded as an important contributing factor to vated by nationalist-separatist sentiments rather the likelihood of committing a suicide attack. This than by religious fanaticism (Hopgood, 2005:47– phenomenon is true for both the West Bank and 48). Suicide attacks have also been carried out by the Gaza Strip: In each of these regions, refugee Marxist (and therefore clearly nonreligious) groups camps’ residents are represented among the sui- such as the Kurdish PKK and the Turkish Re- cides at more than twice their share of the gener- volutionary People’s Liberation Front.

Table 8.2. Education level of Palestinian suicides and of the general Palestinian population (percentage)

Education No schooling Partial elementary Elementary High school Partial university Full university

Suicides 0 2.9 8.8 62 23.5 2.9 General Population 10.5 29.2 25.3 23.0 11.9 Psychological Aspects of Suicide Terrorism 107

Revenge for Personal Suffering Personality Factors and Psychopathology Some observers have suggested that the suicides have been motivated by the wish to inflict revenge In none of the cases did interviews with would-be for suffering that they had personally experienced suicides or parents and siblings’ descriptions of their (Joshi, 2000; Fisk, 2001). Whereas this explana- personality and behavior (for complete suicides) tion is clearly incorrect in the case of the Sep- suggest the existence of a major psychopathology. tember 11 attackers, it may still be true with regard No evidence was found for hospitalization in a men- to suicide attacks in most other places, such as tal institution or outpatient psychological treatment. Lebanon, Israel, Turkey, and Sri Lanka. This ques- Furthermore, the descriptions did not reveal a com- tion was directly examined in the study of the mon personality type for all or most of the suicides 1993–1998 Palestinian suicides. In that study, the (however, relying solely on family descriptions was suicides’ families were asked about events that not a sufficiently sensitive method for characterizing could presumably provide a reason for a personal personality types). Still, significantly, no evidence grudge. These included the killing of a close family was found for the existence of risk factors for suicide. member by Israeli forces, the killing of a friend, the Three main risk factors are generally recognized in wounding or beating of the suicide in clashes with psychiatry and psychology: the existence of affective Israeli soldiers, and the arrest of the suicide. disorders (especially depression), substance abuse, Analysis of the results suggests that a personal and a history of suicide attempts (Lester & Lester grudge has not been a necessary factor and appar- 1971; Barraclough & Hughes, 1987; Klerman, 1987; ently not even a major one in initiating the wish to World Health Organization, 1993; Jacobs, Brewer, embark on a suicide mission, although in all prob- & Klein-Benheim, 1999; Linehan, 1999; Miller & ability it was a contributing factor in some of the Paulsen, 1999; Moscicki, 1999). None of these was cases. Thus, in only 1 of the 34 cases, a close family present among the Palestinian suicides of the 1993– member of the suicide had been killed by Israeli 1998 period. It is, of course, possible that more forces; however, in 15 cases the interviewees men- sensitive techniques would have revealed more tioned that a friend of the suicide had been killed subtle suicidal ideation in at least some of the ter- prior to the suicide mission. In 7 cases a close family rorist suicides. member (a father or a brother) had been jailed. With Furthermore, existing sociological and psy- regard to the suicide’s personal encounters, in 16 of chological theories of suicide seem to be inap- the cases the suicide had been beaten or wounded in propriate for explaining suicidal terrorism. A full clashes with Israeli forces during demonstrations. survey of the compatibility of suicide theories with Eighteen of the suicides had been jailed, most of the phenomenon of terrorist suicide is beyond the them for short periods of time for minor charges, scope of this chapter, and I therefore address this such as participation in violent demonstrations. issue rather succinctly. Of the sociological theories, In assessing these findings as indicative of the one that comes closest to explaining this phe- personal trauma, one should remember that most nomenon is Durkheim’s concept of altruistic sui- of the Palestinian youth were involved in vari- cide, more specifically, his subcategory of ‘‘optional’’ ous aspects of the intifada in activities such as altruistic suicide (Durkheim, 1951). Optional al- stone throwing, demonstrating, distributing leaf- truistic suicide comprises cases in which suicide is lets, painting graffiti, and enforcing strikes. In considered a merit by society but is not obligatory, other words, this part of the suicides’ personal such as the Japanese Samurai custom of seppuku, history does not distinguish them from the average or hara-kiri. Palestinian youngster in the period under consid- However, the suitability of Durkheim’s con- eration. Indeed, 19 of the suicides were described cept to the phenomenon of terrorist suicide is by their families as ‘‘very active’’ during the in- questionable on several grounds. Durkheim used tifada, and 8 were described as ‘‘active.’’ In most the concept of altruistic suicide to characterize cases, therefore, a high level of militancy preceded societies, not individuals. He explained the dif- a personal trauma, although such trauma might ferences in the suicide rates of various societies later add to the already existing hatred and desire by the attributes of these societies. He inferred for revenge. the motivation for committing suicide from the 108 Terrorism characteristics of the society to which the suicides Thus it becomes possible to treat oneself, or some belonged. Thus, he characterized suicides in the part of oneself (typically one’s disavowed body), as military as ‘‘altruistic’’ because of the characteristics an alien and an enemy’’ (Maltsberger, 1999, p. 73). that he attributed to the army, such as obedience While my study did not provide tools for ex- and a sense of duty. He perceived altruistic suicide amining the suicides’ unconscious processes, no as a stable rather than a situational characteristic external supportive evidence of this theoretical of the society in question. Altruistic suicide char- explanation of suicide was found either. A more acterizes societies that are highly ‘‘integrated,’’ in specific form of this approach was offered by Zil- Durkheim’s terms (i.e., very cohesive) and there- boorg (1996), who has stressed the importance of fore exert much influence on their members. identification with an important person who died Hence, to apply Durkheim’s concept of altruistic when the suicide was a child. The data do not suicide to the phenomenon of terrorist suicide is to support this theory. In the Palestinian sample, for attribute these suicides to the traits of the societies instance, only 6 (out of 34) of the suicides lost a in which they occurred—a religious group, an parent prior to carrying out the attack (at ages that ethnic community, a caste, or a social organization ranged from 2 to 10). It is unlikely, although such as the army. theoretically possible, though, that the suicides lost Terrorist suicide, however, has taken place in other psychologically important persons in child- very diverse societies. In addition to the Lebanese hood. But these theories would find it hard to Shi’ites, Lebanese Sunnis, secular Lebanese, Pa- explain the waves of suicide terrorism in the Le- lestinians, Egyptians, Armenians, Marxist Kurds, banese, Palestinian, and Sri Lankan cases, as well and Tamil Hindus, suicide for a political cause as the episodes of cluster suicides, such as the has also been committed by communist Germans, September 11, 2001, attacks in the United States, Catholic Irish, and Protestant Americans (John the Irish hunger strikers in 1981, and the cases Wilkes Booth, who assassinated President Lincoln, of Palestinian suicide attacks in duo or trio. committed suicide after the murder). It can be Whereas psychoanalytical theories have basi- argued that the important factor is not the larger cally viewed suicide as aggression (directed in- social unit—the ethnic group, religious group, or ternally), other psychological theories emphasize nation—but the microsociety of a terrorist group the element of despair. In this view, the wish to itself that provides the social milieu amenable to commit suicide is almost always caused by intense generating self-sacrificial suicide, in accordance psychological pain that is generated by frustrated with Durkheim’s altruistic variety. psychological needs. Suicide is committed by Highly cohesive and rigorous, they create rules those who view it as the best way to stop the pain. of conduct and behavior ethics that members are The prevailing emotion of suicides is the feeling expected to abide and live by. Yet, the great ma- of hopelessness-helplessness (Shneidman, 1985, jority of the terrorist groups, regardless of their 1999). Several other researchers (e.g., Farber, 1968; structure, have not resorted to suicide attacks at Beck, Kovacs, & Weissman, 1996) also under- all. Furthermore, there is no evidence that terrorist scored the role of hopelessness in generating the groups, which maintain a particularly strict dis- wish to commit suicide. The greater the feeling cipline and a tight structure, have resorted to of hope, the less the likelihood of suicide. Hope is suicide tactics more than the looser groups. On the the perceived ability to influence and to be sa- contrary: Among the Palestinian groups, the Pop- tisfied by the world. This concept of hope, how- ular Front for the Liberation of Palestine (PFLP) ever, relates to people’s expected ability to function has a much tighter structure and discipline than within their own social milieu, rather than to a Hamas. Yet, the PFLP has generated only a few general communal situation, such as being under suicide attacks, whereas Hamas has carried out occupation. Lester and Lester (1971, p. 45) noted many. in this regard that suicidal people tend to see not Psychological theories of suicide cannot read- only the present but also the future as gloomy, ily explain the phenomenon of terrorist suicide expecting to be socially isolated in the future. With either. Psychoanalytic theories view suicide as a regard to terrorist suicide, however, whereas it can result of an ‘‘unconscious identification of the self be argued that at least in some cases the suicide with another person who is both loved and hated. attacks are motivated by despair that exists at the Psychological Aspects of Suicide Terrorism 109 national or community level and is associated with Although this event does not qualify as an act of frustrated national needs, the families’ interviews suicidal terrorism because the hunger strikers did revealed no evidence that those who carried out not kill anyone but themselves, it was an act of self- the suicide attacks suffered from despair at the destruction for a political cause and, as such, can individual level (although it is possible that the teach us much about the psychological mechanisms interviews failed to discover more subtle person- involved in suicide terrorism. ality characteristics and motivations that would Self-starvation is an extremely demanding way have surfaced in psychological interviews and tests to die, much more difficult than the instantaneous administered to the suicides themselves). It is no- death caused by a self-inflicted explosion. It took teworthy in this respect that, in times of war, when the hunger strikers from 50 to more than 70 days the whole community is under duress, suicide to die. During that time mothers, wives, and priests rates tend to go down (Lester & Lester, 1971, pp. begged at least some of the hunger strikers to stop 109–110). their self-destruction (Beresford, 1987). The force The profiles of the terrorist suicides gleaned that led them to continue their strike to the very from the interviews did not resemble typical sui- end, ignoring all pressures, must have been very cide candidates, as described in the literature. By strong. What was this force that sustained their their family members’ accounts, 47% of the 1993– determination? The assumption that all ten were 1998 Palestinian suicides occasionally said that suicidal persons who happened to be in jail at the they wished to carry out an act of martyrdom, and same time is rather implausible. It is also unlikely 44% used to talk about paradise. However, the that they were motivated by religious fanaticism young people who eventually committed suicide and the promise of a place in paradise. had no record of earlier attempts of self-immola- The only way to understand this frightening tion and were not at odds with their family and demonstration of human readiness for self-sacrifice friends, and most of them expressed no feelings is to look at the group’s influence on its individual of being fed up with life. In the suicides’ notes members. The suicide was a product of a group and last messages, the act of self-destruction was contract that one could not break. The group presented as a form of struggle rather than as an pressure in that situation was as strong as the escape. There was no sense of helplessness or group pressure that led hundreds of thousands of hopelessness. On the contrary, the suicide was soldiers in World War I to charge against enemy presented as an act of projecting power rather than machine gun fire and artillery to almost sure death. expressing weakness. It thus seems that most ter- And it was even stronger once the first hunger rorist suicides in the Palestinian sample were not striker died. From that point on, the contract to die ‘‘suicidal’’ in the usual psychological sense. could no longer be broken because the person who could release the next person in line from his commitment was already dead. Terrorist Groups as Suicide A more comprehensive picture of the process Production Lines of making suicide bombers was gained from data collected on Palestinian suicide terrorists, includ- The preceding sections suggest that neither demo- ing interviews with trainers for these missions and graphic nor individual psychological characteristics surviving would-be suicides. The findings of these can in themselves explain the phenomenon of ter- data are supported by circumstantial evidence rorist suicide. from suicide terrorism in other countries. The data An important clue to understanding the phe- suggest that there are three main elements in the nomenon of terrorist suicide can be found in the preparation of a suicide bomber by an organiza- hunger strike of 10 Irish Republican Army (IRA) and tion, namely, indoctrination, group commitment, Irish National Liberation Army (INLA) members in and a personal pledge. Belfast’s Maze Prison in 1981. These Irish nationalists, led by Bobby Sands, starved themselves to death Indoctrination one after the other when their demand to be re- Throughout the preparation for a suicide mission, cognized as political (rather than common criminal) the candidates are subjected to indoctrination by prisoners was rejected by the British government. authoritative members of the group. Although the 110 Terrorism candidates are presumably convinced from start of operation, the organization usually presents these the justification of the cause for which they are tapes to the suicide’s family as a farewell message. willing to die, the indoctrination is intended to Typically, in this tape the suicide is seen with rifle further strengthen their motivation and to keep in hand (and, in Islamic groups, a Koran in the it from dwindling. Indoctrination in the religious other hand), declaring his intention to go on the Palestinian groups (Hamas and PIJ) included na- suicide mission. This act is not only meant for tionalist themes (Palestinian humiliation by Israel, propaganda. It is primarily a ceremony intended stories of Arab glory in the days of Mohammad and to establish the candidate’s irrevocable personal the Caliphate, examples of heroic acts during the commitment to carry out the suicide attack. This Islamic wars) and religious themes (the act of self- ritual constitutes a point of no return. sacrifice is Allah’s will, and the description of Having committed himself in front of a tele- the rewards guaranteed a place in paradise for vision camera (the candidate is also asked at that shahids—martyrs). time to write farewell letters to his family and friends, which are kept by the group along with Group Commitment the videotape for release after the completion of The mutual commitment of candidates for suicide the mission), the candidate cannot possibly renege operations to carry out a self-sacrificial attack is a on his promise. In fact, in both Hamas and PIJ, very powerful motivation to stick to the mission from that point on, the candidate is formally re- despite hesitations and second thoughts. The chain ferred to as ‘‘the living martyr’’ (al-shahid al-hai). suicide of the Irish hunger strikers in 1981 is an This title is often used by the candidates them- example of this social contract, which is extremely selves in the opening sentence of the video state- hard to break (Merari, 1990). A similar situation ment, which routinely starts this way: ‘‘I am [the exists when several members of a terrorist cell candidate’s name], the living martyr.’’ At this stage, prepare together for carrying out suicide attacks, the candidate is seemingly in a mental state of a such as the September 11, 2001, attacks in the living dead person and has already resigned from U.S., the multiple attacks in Morocco on May 16, life. 2003, and the London suicide attacks of July 7, 2005. Palestinian suicides are usually recruited and Public Support prepared individually for their mission. Some- times, however, two or three youngsters decide The magnitude of public support for suicide op- jointly to carry out a suicide attack and undergo erations seems to affect both the terrorist group’s the preparations together. willingness to use this tactic and the number of In the LTTE, both male and female suicides volunteers for suicide missions. Most, if not all, have been trained in special ‘‘Black Tigers’’ units. terrorist groups that have used suicide attacks are Most likely they are also bonded in a social con- not indifferent to the opinions and attitudes of tract to carry out the suicidal mission. In fact, the what they view as their constituency—the popu- power of the group commitment and the inability lation whose interests they claim to serve and to break it formed the basis of the willingness of from which they recruit their members. In the Japanese pilots in World War II to fly on ka- choosing tactics and targets, the groups tend to act mikaze missions. The last letters of the kamikazes within the boundaries of their constituency’s ap- to their families, written shortly before they took proval. During the last 6 months of 1995, for ex- off for their last flight, indicated that, although ample, Hamas refrained from carrying out suicide some of them went on their suicidal attack en- attacks because its leadership realized that such thusiastically, others regarded it as a duty that they actions would not be supported by the Palestinian could not evade (Inoguchi & Nakajima, 1958, pp. population at that time and would thus have had 196–208). an adverse effect on the organization’s popularity. In the Palestinian case, public support for terrorist Personal Commitment attacks against Israel in general and for suicide Many Middle Eastern groups have adopted a rou- attacks in particular has waxed and waned since tine of releasing a videotape to the media shortly the Oslo agreement of 1993, ranging from as low after a suicide attack. In addition, after the as 20% support in May 1996 to more than 70% in Psychological Aspects of Suicide Terrorism 111

May 2002 (Center for Palestine Research and deleterious impact on the economy. This final sec- Studies, 2000; Jerusalem Media and Communica- tion, however, deals only with their individual tion Centre, 2002; Palestinian Center for Policy psychological effects and the ways that Israel has and Survey Research, 2002). coped with them. The great increase in the frequency of suicide Terrorist events are known to be a source of attacks during the second intifada, al-Aqsa inti- psychological trauma. In addition to acute stress fada, reflects the greater willingness of Palestinian disorder, which appears immediately following youth to volunteer or to be recruited for what the such an event, a longer-term posttraumatic stress community generally regards as acts of ultimate disorder (PTSD) emerges in some of those exposed patriotism and heroism. Songs praising the shahids to the traumatic event. In a review of several studies are the greatest hits, the walls in the streets and of PTSD among people in various countries who alleys of Palestinian towns in the West Bank and witnessed a terrorist attack, Gidron (2002) found the Gaza Strip are covered with graffiti applauding an average PTSD rate of 28.2%. Symptoms of them, and their actions are mimicked in children’s posttraumatic stress disorder may appear not only games. In this atmosphere, not only do the ter- among those present at the site of an attack but also rorist groups perceive a public license to continue among some of those who consider themselves as the suicide attacks, but they also have a constant potential victims or who are exposed to the event flow of youngsters ready to become human bombs. through the mass media or personal accounts by The role of the preparation of the suicide candidate relatives and friends. Studies conducted after the is to make sure that the youngsters who, because 9/11/ attacks in New York found PTSD symptoms of social pressure, have said ‘‘yes’’ to an offer to among people who had not personally witnessed become a shahid (or even an enthusiastic volun- the attack (Cohen Silver, Holman, McIntosh, Pou- teer) would not have second thoughts and change lin, & Gil-Rivas, 2002; Galea et al., 2002). PTSD their mind. rates were higher among people who lived in The importance of public attitude notwith- proximity to the site of the attack and therefore felt standing, it should be emphasized that so far there a greater direct danger. has not been even a single case of a person who Although psychological trauma of civilian vic- carried out a true terrorist suicide attack for a po- tims of terrorism in Israel has been studied since litical cause on an independent, personal whim. In the 1970s, interest in this problem has grown since every case it was an organization that decided to the 1990s, when suicide attacks became a frequent use this tactic, chose the target and the time, pre- occurrence. These attacks intensified in the second pared the explosive charge, and arranged the lo- intifada, which started on September 29, 2000. gistics necessary for getting the human bomb to the The nearly 6 years of the intifada (as of this writ- target. Evidently, therefore, the terrorist group’s ing) have been marked by suicide attacks, which decision to use suicide attacks as a tactic and the have been the most deadly form of terrorism by group’s influence on the candidates are the key far. Although suicide attacks in this period have elements in this phenomenon. constituted only about 0.5% of the total number of terrorist attacks, they have accounted for 59% of the civilian fatalities (Israel Defense Forces, Coping With the Psychological 2003). Suicide attacks are more frightening than Effects of Suicide Terrorism other forms of terrorism not only because they generate a larger number of victims but also be- Terrorism in general and suicide attacks in parti- cause these incomprehensible acts of self-sacrifice cular constitute a major source of stress. This sec- seem unstoppable. They create a sense of in- tion deals with the ways that potential targets have security and lack of control. An explosive charge adopted to deal with this stress. As Israel has faced hidden in an innocent-looking package or a a continuous series of suicide terrorist attacks since shopping bag can be detected and rendered 1993, it is an appropriate case in point. Suicide harmless, but most of the suicides activate their attacks have exacerbated the Israeli-Palestinian con- charge upon detection. People avoid public places, flict and have had a significant adverse political such as shopping centers, coffee shops, and buses effect on the peace process. They have also had a because these are the targets of suicide attacks. 112 Terrorism

Surveys conducted in Israel during the recent Warnings that are based on intelligence in- quarter century have consistently found a very high formation and concern an actual or intended rate of expressed worry of terrorism. Since 1979, launching of a terrorist attack in a certain area are in most of the surveys, more than 70% of repre- followed by a massive effort to dissuade or stop the sentative samples of the adult Israeli population perpetrator by police and military roadblocks and have said that they were ‘‘very worried’’ or ‘‘wor- searches. This effort is often successful and helps ried’’ that they or members of their families would to reduce the feeling of uncertainty and give the be hurt in a terrorist attack. The rate of worry public a sense of control over the situation. The cre- was high even when the intensity of terrorism dibility of the warnings is highly important for was much lower than during the second intifada establishing public trust in the authorities. In the (Merari and Friedland, 1980; Arian, 2003, p. 19). absence of trust, public responses might have re- Nevertheless, this high rate of worry is not sulted in a paralysis of economic and social activ- necessarily associated with stress disorder. A 2003 ities. As the suicide bombers target public places, survey by Bleich, Gelkopf, and Solomon de- guards are stationed at the entrances to cafes, termined the occurrence of PTSD among Israelis. shopping malls, theaters, and schools. These guards The survey was conducted in April and May 2002, constitute the last line of defense, and some of at a time when Israeli civilians were exposed to them have been killed as they prevented the sui- frequent suicide attacks. Although more than 60% cide attacker from getting inside the target build- expressed a low sense of safety for themselves and ing, thus saving the lives of many people. their relatives, the authors found that only 9.4% Intervention after the attack necessitates the met the symptom criteria for PTSD. This low rate coordinated action of many organizations. Police, is especially surprising because more than 16% of fire fighters, medical corps, and victim identifica- the sample reported that they had been directly tion teams are the first responders on the scene. exposed to a terrorist attack, and 37.3% had a Concurrently, hospitals in the area of attack are family member or friend who had been exposed. alerted and get ready with medical and mental In comparison, in the United States, various sur- health teams to take in a large number of casual- veys found that 10%–20% suffered from several ties. At the same time, the municipalities activate PTSD symptoms a couple of months after 9/11 teams whose task is to inform victims’ families and (Schlenger et al., 2002; Cohen Silver et al., 2002). provide psychological and social support. Several The difference may be explained not only by studies suggest that social support (by the family methodological variations (e.g., in the length of or community) is negatively correlated with post- time since the exposure to the traumatic event) traumatic stress (e.g., Solomon, Mikulincer, & but also by a habituation process that has taken Flum, 1988; Cohen Silver et al., 2002). The ac- place in the Israeli population. Another possible tivity of social services and volunteer organizations explanation is that the Israeli mental health system is important mainly in the days and months fol- is more adept at handling the psychological effects lowing the attack. of terrorist attacks. Persons who suffer acute stress reaction as Coping with the psychological effects of ter- well as PTSD patients are entitled to social security rorism in general and suicide attacks in particular compensation for their loss of ability to work comprises two general categories: (1) preparatory and to financing for psychological treatment. Fol- measures, and (2) intervention after the attack. Pre- lowing an incident, social security personnel con- paratory measures include the training of organi- tact psychological patients and invite them to zations and units involved in responding to actual attend support groups that start a week after the or threatened suicide attacks (police, military units incident. Those who suffer long-range psycholo- of the homeland command, medical corps, pub- gical incapacitation get a permanent social security lic information, etc.). Public knowledge of the allowance commensurate with the degree of in- existence of an effective response system and trust capacitation. in its committed and professional performance In conclusion, the Israeli experience suggests reduce anxiety and create some sense of control of that even a protracted campaign of suicide terror- a situation that is inherently surprising and un- ism does not necessarily cause widespread psy- certain. chological trauma. A credible warning system and Psychological Aspects of Suicide Terrorism 113 trust in the authorities’ effectiveness reduce anxi- Durkheim, E. (1951). Suicide: A study in sociology. New ety. Mental health and social support services may York: Free Press. effectively reduce and limit the psychological Ergil, D. (2001). Suicide terrorism in Turkey: The trauma associated with direct or indirect exposure Workers’ Party of Kurdistan. In Countering suicide to terrorist attacks. terrorism: An international conference (pp. 105– 128). 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The Strategy of Terrorism and the Psychology of Mass-Mediated Fear James N. Breckenridge Philip G. Zimbardo

Throughout the history of violent conflict, ad- terrorist strategy, few discuss the relevant psy- versaries have resorted to terrorism when their chological science in any detail. In this chapter we opponents’ superior material and military assets examine the psychological basis of terrorism and prohibited a direct struggle for strategic goals. Acts the important ways in which public reactions dif- of terror, especially suicide terrorism, represent a fer from responses to other tragic and disastrous growing transnational threat due specifically to the events. People’s reactions are more complex than psychological advantages terrorism possesses a mere visceral sense of personal danger, and the in modern asymmetrical warfare. Modern terrorism multifaceted aspects of their fears can strongly derives this tactical advantage from its reliable abi- influence the public’s trust in and support for lity to evoke disproportionate fear and to create an government policy. Disproportionate reactions to enduring, pervasive apprehension of threat. Ter- the threat of terrorism, we argue, result from emo- rorists appear to have a keen, intuitive appreciation tionally driven biases associated with appraising of psychological mechanisms that spread the effects risks and making decisions with uncertain of terror well beyond their primary victims and prospects. The threat of terrorism is further aug- amplify the perception of risk and vulnerability far mented by a variety of sociopsychological pro- out of proportion to reasonable probabilities. Mod- cesses, especially the priority that human attention ern terrorism is necessarily mass-mediated political assigns to negative information and the narrative violence, and the media play a critical role in fa- frames with which the mass media surround re- cilitating the psychological processes that intensify ports of terrorist actions. Finally, we maintain that the public’s fears and apprehensions. the threat of terrorism is made more menacing Countering terrorists’ intuitive use of the tac- by stereotypical, dispositional explanations of evil- tics of mass-mediated fear demands an appre- doers, characterizations that are also central to the ciation of the underlying psychology and requires terrorists’ own view of the enemies they seek to strategies that exploit scientific progress in under- harm. standing the nature of emotionally biased judgment Acts of terrorism can serve many goals from and perception. Although scholarly works routi- simply injuring an enemy to venting longstanding nely acknowledge the psychological nature of hostilities and frustration. Inciting widespread fear

116 The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 117 and vulnerability, however, may represent the (United Nations, 1987) asserts that ‘‘the distin- terrorists’ most important objective. guishing feature of terrorism is fear and this fear is stimulated by threats of indiscriminate and horrifying forms of violence directed against ordinary Fear: The Critical Element people everywhere.’’ Because terrorists lack the of Terrorist Strategy military prowess, political power, and material resources of their adversary, their strategy is critically Although newspaper, magazine, and television dependent upon the strategic benefits of inciting a accounts have often focused on the potential use perception of vulnerability that far exceeds realistic of chemical, biological, radiological, or nuclear dangers, an aim that depends heavily upon mass- weapons to inflict mass casualties or severe damage media publicity. The threat of terrorism should to critical infrastructure, experts have long ques- thus bear ‘‘no relation to the actual statistical pro- tioned whether such objectives are essential or bability of one’s being killed or injured in a terror perhaps even counterproductive to the strategy of attack, or even of a terror attack taking place terrorism. A few months prior to September 11 at all,’’ (Ganor, 2004). The strategy of terrorism some experts questioned whether objective data aims to undermine the public’s sense of security, supported ‘‘media-hyped’’ concerns about a grow- disrupt everyday life, and sway public opinion by ing threat of high-casualty terrorism ( Johnson, ‘‘creating an unremitting, paralyzing sensation 2001). Despite the enormity of September 11, of fear’’ (Ganor, 2004). Terrorists strive to pro- subsequent dramatic bombings in Madrid and Bali voke a pervasive feeling of threat that comes to and the increase in terrorist attacks internationally assume priority over all other social and political following U.S. wars in Iraq and Afghanistan, the concerns. ‘‘new terrorism’’ may yet continue a conservative A heightened sense of crisis can lead to poli- approach to high-technology weapons of mass tical disaffection and diminished confidence in destruction (Crenshaw, 2000; Hoffman, 2001a, government. For example, the terrorist bombings 2001b; Lesser et al., 1999; Tucker, 2001). It has in Madrid just prior to the 2004 elections in Spain been argued that terrorists can carry out less costly, appear to have significantly influenced both elec- more restrained acts of terror that nevertheless toral outcomes and subsequent foreign policy. To ‘‘could have disproportionately enormous con- maximize discontent and crisis, terrorists typically sequences, generating fear and alarm and thus target civilian noncombatants to heighten the sense serving the terrorists’ purpose just as well as a lar- of public threat. Reports suggest, for instance, that ger weapon or more ambitious attack with massive recent suicide attacks by insurgents in Iraq, hoping casualties’’ (Hoffman, 2001a, p. 8). to foment a breakdown of social trust and co- Terrorists choose terrorist tactics—even sui- operation, have shifted priorities from attacks on cide terrorism—because historically the under- military and government targets to high-casualty lying logic has realized some success. Suicide suicide bombings in civilian settings (Bunker & terrorist tactics, for instance, apparently produced Sullivan, 2005). incremental gains for the terrorists’ side in Leba- Mass-mediated acts of terror can also strength- non in the 1980s and the Gaza Strip and the en popular support for a more militant counter- West Bank in the 1990s; they have also resulted terrorism policy and for bold restrictions on civil in progress for the position of the Kurds in Turkey liberty, as well as encourage public acceptance of and for the Tamils in Sri Lanka (Pape, 2003). potentially misplaced priorities. A national survey These gains, however, have not been a conse- conducted soon after September 11, 2001, for in- quence of the number of people harmed or the stance, found that the greater the public’s sense of magnitude of damage to critical infrastructure but threat, the greater the willingness to place restric- resulted from the political impact of public fear tions on civil liberties to increase safety and security and the perception of personal vulnerability mul- (Davis & Silver, 2004). Another post–September tiplied throughout the victimized society. 11 New York Times poll found widespread sup- The critical role fear plays in the terrorist port for military action against terrorism even if strategy has been acknowledged by leading secu- ‘‘many thousands of innocent people’’ were killed rity experts. The Geneva Declaration on Terrorism (Berke & Elder, 2001). A longitudinal review of 118 Terrorism national polling data found that public support for It is not surprising that fear and apprehension restricting civil liberties to combat terrorism peaked can have considerable political consequence. The in the early days following September 11, and al- role of emotions in most matters of political interest though support diminished over the next year, is powerful and pervasive because emotions bias a majority of Americans continued to support re- judgments, frame perceptions, prime supporting strictions on their civil liberties if personal costs memories, and influence agenda setting (Marcus, were relatively low (Kuzma, 2004). 2000, 2003). Precisely these psychological con- Trust in government is a significant, albeit structs also characterize the basis of the media’s occasionally overstated, moderator of public threat influence on public opinion. Affective influences perceptions (Viklund, 2003). Public trust in gov- on attention, memory, and judgment contribute ernment and support for counterterrorism policy to the widespread experience of disproportio- expenditures increased significantly following Sep- nate vulnerability and looming threat appraisal that tember 11, in sharp contrast to a long period of make terrorism a more psychologically complex public cynicism regarding government capabi- phenomenon than mere ‘‘scare tactics.’’ lities (Chanley, 2002). However, a year later, public confidence in government was almost evenly divided between optimistic and pessimistic ap- More Than Personal Fear praisals (Kuzma, 2004). Fear mixed with cynical and Different From Responses distrust can also undermine compliance with public to Other Types of Disasters safety and other security instructions during a crisis. Several studies have observed a troubling percen- Reactions to an act of terror and to the threat of tage of Americans who report that they would ig- future attacks are more complicated than mere nore or disobey the recommendations of authori- visceral experiences of personal danger. Emotions ties during a terrorist attack (Boscarino, Figley, & can range from a mix of sadness, fear, anger, and Adams, et al., 2003; Fischhoff, Gonza´lez, Small, & even positive emotions, such as gratitude for lives Lerner, et a12003; Lasker, 2004).1 spared and increased affiliation and social con- Mass-mediated attention to acts of terror nectedness. A predominantly fearful response can can also encourage public acceptance of misguided produce an effect on the perception of future ter- policy priorities. The public’s political attention is rorist threat that is opposite to what an angry re- highly selective and ultimately emotionally driven. action may evoke (Lerner & Keltner, 2001). Fear In addition, the consensus among political scien- stimulates a pessimistic estimate of risk, whereas tists is that sustained public awareness of the de- anger is associated with a more optimistic outlook. tails of current events, politics, and public policy Fearful versus angry emotional responses can also is limited at best. It is no coincidence that gov- differentially influence support for public policy. ernment leadership is often eager to focus public For example, a post–September 11 national study attention on decisions and programs that are con- using video stimuli to experimentally manipulate sistent with opinion polls. If people’s perceptions emotional reactions found that angry respondents are shaped by mass-mediated accounts of recent had more optimistic future risk appraisals but fa- acts of terror, public concerns may focus on ‘‘yes- vored more vengeful government actions than did terday’s threat.’’ For example, the public’s support fearful respondents (Lerner, Gonzales, Small, & for the national airline passenger-screening pro- Fischhoff, 2003). gram may reflect the indelible impact of the Individuals’ perceptions of fear of harm to (mediated) events of September 11, coupled with themselves do not automatically determine their limited public knowledge of the deficiencies in perceptions of sociotropic fear, that is, their esti- the screening of airline cargo. The potential for mation of danger or risk to society. Sociotropic fears misplaced threat-related priorities may represent following terrorist acts appear more common and a particularly daunting challenge for the United more strongly related to public policy views than States, which can anticipate a vast array of possible do perceptions of personal threat. The separation terrorist targets and methods, but relative to many of personal and sociotropic fears is consistent with areas of conflict, it has had little historical experi- a widely observed positive bias in self-perceptions. ence with terrorist attacks.2 That is, on the average, each of us tends to view The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 119 our own prospects and circumstances as superior Fear, especially sociotropic fear, is widespread to that of others (Mezulis, Abramson, Hyde, & in the aftermath of terrorist acts, but mass hysteria Hankin, 2004). Personal threats violate ordinary or panic is rare. Panic is highly situation specific. expectations and may be especially likely to pro- Studies of natural and technological disasters in- mote anxiety and traumatic responses. dicate that only on some occasions, when there is This is precisely what was observed in a na- a perception of immediate, severe danger coupled tional survey of reactions in the 6 months follow- with the appearance of narrowing opportunities ing September 11, 2001: Heightened perceptions for escape, has mass panic been observed (Perry & of personal threat were associated with increased Lindell, 2003). Even in such circumstances, panic rates of fear, anxiety, and somatic features of af- is not inevitable. fective distress (Huddy, Feldman, Lahav, & Taber, 2003). Personal self-interest (e.g., fear of personal Contrasting Terror to Other Catastrophes harm) had relatively little relationship, however, to support for government policy or with expecta- How comparable psychologically are natural dis- tions for risk to the nation. On the contrary, fear asters or unintentional human-made catastrophes for the community and the nation was predictive to acts of terrorism? Prior experience with natural of stronger support for military intervention and disasters has much to inform the development of government counterterrorism policy. Similarly, per- programs to prepare for acts of terrorism, espe- ceptions of personal threat were not correlated with cially with regard to organizing, coordinating, and participants’ predictions of future threats of ter- deploying resources. Can we borrow from disaster rorism in a study of New York residents following management experience as we attempt to under- September 11 (Huddy et al., 2002). Perceptions of stand and counter the terrorist strategy of fear? personal and national threat are distinct but clearly We believe that natural disasters and accidental related, nevertheless; those who expect little risk to human-made catastrophes provide only an incom- the nation, for example, typically do not anticipate plete comparison with acts of terror. Just as dis- personal risk. asters present problems quite unlike routine emer- Although well beyond the scope of this chap- gencies, acts of terror pose unique challenges that ter, it should also be noted that people vary greatly differ distinctly from other traumatic catastrophes. in terms of their vulnerability to trauma. For a In stark contrast to natural disasters, terrorism significant portion of the public, especially persons intentionally targets basic social infrastructure in a with current or past psychiatric disorders or those manner that inspires lingering fear throughout who have been exposed to prior trauma, the psy- society (Fullerton, Ursano, Norwood, & Holloway, chological consequences can include depressive, 2003). Public consciousness of the deliberate, in- traumatic, or other mental health disorders (for a tentional nature of acts of terror is a critical emo- review, see Chapter 3 in this volume and Danieli, tional distinction. Despite the traumatic impact of Engdahl, & Schlenger, 2004). Traumatic conse- natural disasters, quences can be especially severe for young chil- the resulting psychological fallout is not as de- dren and older adults (F. H. Norris, Byrne, & vastating because these events are understood to Dıáz, 2002). Certain fortunate individuals, how- be the result of circumstances beyond human ever, exhibit an overall positive emotional response responsibility, and therefore unpreventable. to calamities, and, regardless of whatever anger, These acts of God or nature or human error are fear, sadness, and other negative emotions they also seen as unusual circumstances not attri- experience, demonstrate a resistance to traumatic butable to malevolence. (Ditzler, 2004) psychological injury and more resilient coping in the aftermath of crisis. For example, a small study Actions with obvious malevolent intent have of college students begun before September 11 much more powerful emotional impact. Thus, in found that students who reported feelings of gra- a review of studies of 102 disasters, more than titude and increased social affiliation appeared to two-thirds of victims of mass violence catastrophes have superior resistance to depression in the weeks incurred severe impairment as opposed to 34% of following the catastrophe (Fredrickson, Tugade, those who were subject to natural disasters (F. H. Waugh, & Larkin, 2003). Norris et al., 2002). Paul Slovic, a pioneer in the 120 Terrorism psychology of risk perception, dubs terrorism a ‘‘new mortality rates (Slovic, Finucane, Peters, & Mac- species of trouble’’ because it entails calculated mal- Gregor, 2004). Rationale analyses strive to conform evolent intent (Slovic, Fischhoff, & Lichtenstein, to the laws of probability, using new data to revise 2000). expectations in a Bayesian fashion. Classical deci- Malevolent intent targets a society or a nation. sion theory comes to conclusions by weighting ex- While there are inevitable costs to the nation, nat- pectations by some estimate of the utility of each ural disasters victimize localities (e.g., hurricanes possible factor. Thus, the probability of success and strike coastal residents, and tornados ravage the failure are weighted by some quantified valuation of Midwest). Most importantly, society recognizes the cost and benefits of each alternative. ‘‘Correct’’ that every citizen is a potential target of future decisions optimize the combination. Most people, malevolence. It is this perception of lingering however, do not make risky decisions in this way. threat that best distinguishes terrorism from other Whereas expert risk appraisals are bounded by calamities. The psychological strategy of terrorism probabilities, public worries about extreme threats is to ensure that no matter what defensive actions typically dwarf any ‘‘rational’’ or statistical assess- are taken, the next act of terror seems inevitable ment of risk. In an opinion piece for the AEI- and likely to occur sooner rather than later, Brookings Joint Center, Michael Rothschild sum- threatening each of us personally. marizes the paradoxical nature of disproportionate The temporal boundaries of natural disasters risk appraisals assigned to acts of terror following are defined by a return to normality, a pattern of September 11: recovery socially constructed in terms of memories The odds of dying in an automobile accident of past disasters. Psychologically, normality does each year are about one in 7,000, yet we con- not return after an act of terrorism. A ‘‘new nor- tinue to drive. The odds of dying from heart mality’’ begins and brings unexpected concerns and disease in any given year are one in 400 and of new threats (Hills, 2002). While scientists develop dying from cancer one in 600, yet many of us uncertain, but comfortably distant, predictions fail to exercise or maintain a healthy diet. We of future natural disasters, security officials worry have learned to live with these common threats immediately about copycat responses and hoaxes to our health. Yet we are afraid to return to in the aftermath of terrorism. It is unusual for malls and the skies. (Rothschild, 2001, p. 1) natural disasters to reoccur soon; thus, survivors of natural calamities such as earthquakes and tsuna- Rothschild further calculates that, even if air mis do not expect to be victimized again in the near travel resumed at normal rates and one plane per future. In contrast to second-guessing natural dis- month were attacked, the odds of flyers encounter- asters, intelligence officials are told their greatest ing terrorists were more than 500,000 to 1. Even failure has been a failure of imagination, a failure to more striking, the odds of dying in a terrorist anticipate a new or an unusual form of terrorist bombing at a shopping mall are approximately 1.5 attack (Peters, 2004). Yet, there are so many targets, million to 1, even if it is assumed that terrorists so many citizens, so many methods. If we recognize totally destroy one mall per week. that we cannot defend ourselves against every Indeed, the public perceives that these risks possible threat, can we ever feel safe?3 pose a much greater threat than Rothschild’s ap- The perception of continuing threat is therefore praisal indicates they actually present, with enor- the crucial distinction between terrorism and other mous consequence to U.S. society. The economic traumatic calamities. Lay threat perceptions typically costs of avoiding airline travel in the aftermath of differ dramatically from professional risk appraisals, September 11 are staggering. The volume of U.S. and this considerable difference favors the terrorist. commercial airline traffic did not return to pre– September 11 levels until February 2005. The economic damage to the national and international Why Do We Feel So Vulnerable? airline industry and to tourism—more than $57 Public Fears Versus Statistical Odds billion for the U.S. travel industry alone—has been enormous (Frey, Luechinger, & Stutzer, 2004). Expert risk appraisals tend to correlate well with Terrorism is not society’s only exaggerated statistical evidence of potential harm, especially fear. Social scientists have long recognized that The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 121 many public fears are often grossly inconsistent set of heuristics—mental shortcuts—that most of with objective data. In his popular pre–September use to predict risk and make decisions under un- 11 book, The Culture of Fear, sociologist Barry certainty. Glassner (1999) questions why American fear the ‘‘wrong’’ things and are obsessed with apprehensions about crime, drugs, health risks, and other Perceived Risk and Negativity Bias threats that are either unsupported or completely contradicted by empirical evidence. Dispropor- Judgment and Heuristics tionate fears of crime, for example, have endured in the face of many years of well-publicized de- Risk perceptions and many other judgments are clining crime rates. The public’s misplaced worries guided by heuristics, implicit and intuitive short- about crime, however, present an alluring oppor- cuts, which often contrast dramatically with the tunity for media outlets seeking readers or viewers. logical, probability-based analytical process em- A longitudinal study of public perceptions of crime ployed by professional experts. Although the range in the early 1990s, for example, revealed a dra- of processes identified by advances in psychology matic 52% increase in the number of Americans and cognitive neuroscience is beyond the scope of who rated crime as the most important problem this brief chapter, two such cognitive biases exert a facing the country despite widely published FBI critical role in the public’s evaluation of the threat statistics to the contrary (Lowry, Nio, & Leitner, of terrorism: the availability heuristic and the affect 2003). Television news coverage was identified as heuristic. the primary source of the public’s distorted per- Under conditions of uncertainty, emotionally ception of crime. Clearly, disproportionate appre- evocative events are more easily imagined and more hensions about crime also represent an attractive readily available for cognitive processing. This en- opportunity for the ‘‘politics of fear’’ (Baer, 1997).4 hanced availability—our ability to easily imagine Despite the ‘‘irrational’’ excesses of public risk images of the event—influences our judgment perceptions, homeland security professionals can- about the likelihood of similar events. The avail- not ignore public opinion. Response and pre- ability heuristic refers to a widely observed tendency paredness efforts to counter terrorism will involve of people to assign a higher perceived probability large numbers of the lay public, many more than (or risk) to vivid, easily imagined (available) events the growing number of trained professionals. It (Teversky & Kahneman, 1974). In the aftermath of can also be argued that, in a democracy, inter- a terrorist act, powerfully facilitated by mass media ventions that address the misguided fears of a reporting, the event is highly available, thus ele- majority, or at least a large number of citizens, are vating disproportionately the perception that an- legitimate even if only anxiety is reduced and other act is likely. The availability heuristic is objective threat reduction is negligible (Sunstein, exploited strategically by many ‘‘availability en- 2003). Parenthetically, such reasoning raises cri- trepreneurs’’ (Kuran & Sunstein, 1999), including tical questions about the value of government ac- terrorists, who capitalize on intense, elevated per- tions such as the Homeland Security Advisory ceptions of danger by creating and publicizing System, which elevates fears with alerts but offers threatening events. citizens no tangible actions to foster even the il- People also rely upon an affect heuristic to make lusion of control or preparedness. judgments (Finucane, Alhakami, Slovic, & John- The public’s perceptions of threat can escalate son, 2000), tacitly employing feeling states to fa- rapidly, outpacing rational analysis. Because hu- cilitate decision making and risk appraisals. Simply man beings do not weigh negatively and positively put, ordinary people use their feelings to estimate valenced information evenly, the perception of ter- risk. In general, the public’s assessment of risk rorist threat, like other public fears, can intensify utilizes an intuitive, emotional process that deems in the face of compelling empirical disconfirmation highly dreaded, unusual, or uncontrolled events as and contrary probabilities. Negativity bias impacts more probable. Psychometric studies have shown a wide range of psychological processes, including that at least two qualitative characteristics of threats attention, memory, decision making, and impres- underlie people’s risk perceptions (Slovic et al., sion formation. Negativity works in concert with a 2004; Slovic et al., 2000). A diverse array of threats 122 Terrorism or hazards can be differentiated in terms of indicating the presence of risk are evaluated as perceived ‘‘dread,’’ the most important factor, and more trustworthy than positive messages commu- the degree to which they are viewed as unfamiliar nicating the absence of risk (Siegrist & Cvetkovich, or new. Thus, those threats that are most feared 2001). Furthermore, with respect to political con- (i.e., evaluated as the most dreadful and unfamiliar) text, voters lend greater weight to negative in- are actually perceived as greater risks. Acts of terror formation about candidates (Klein, 1991). Simi- were second only to warfare and the use of nuclear larly, negativity bias can play a powerful role in weapons in one psychometric risk perception study shaping public trust. Negative events appear to (Slovic et al., 2000). have a greater impact on damaging public trust The influence of both heuristics is compoun- than positive events have on bolstering trust ded by the difficulty most people experience in (Poortinga & Pidgeon, 2004; Slovic, 1993). Slovic contrasting rare events and comparing quantitative (1993) dubs this imbalance the ‘‘asymmetry prin- outcomes in different contexts or frames. Studies ciple’’ (i.e., that it is easier to destroy than to build have demonstrated, for instance, that people will public trust in the capacity of government to mi- judge interventions to save the same absolute tigate risks). number of lives quite differently if the different Negativity bias is also associated with observa- outcomes represent different relative proportions. tions of prospect theory (Kahneman & Tversky, Thus, if one intervention saves 50 people out of a 1979). For example, people exhibit a pronounced possible 100, it will be seen as much more effective risk aversion when decisions about uncertain out- than an intervention that saves 50 out of 1,000. comes are framed in terms of negative results. Dubbed ‘‘psychophysical numbing,’’ this is a highly Thus, if the risks of a medical procedure are pre- ingrained, robust example of our struggles to com- sented to a patient in terms of the odds of death, the pare tragic or catastrophic outcomes (Fether- patient will respond very differently than if the stonhaugh, Slovic, Johnson, & Friedrich, 2000). same risks are presented in terms of the chances of The dramatic, emotionally charged, and dreadful survival. Even though the odds of death and survival context that frames terrorist casualties produces a are necessarily codetermined, patients are less likely converse effect, belying the relative odds of actual to consent to statistically equivalent risks when personal threat. framed in terms of the negative outcome. In addition, people tend to overreact to small chances Negativity Bias of bad outcomes. Furthermore, they subjectively overestimate the probability of highly undesirable Human beings are much more powerfully influ- but objectively rare outcomes. When intense ne- enced by negative than by positive information. gative emotions are involved, as in the case of all Judgments concerning valence—the positive versus terrorist threats, our attention is captured by the negative evaluative aspect of information—are dreaded outcome, and we overlook the relatively ubiquitous, automatic, and largely outside con- small chance of the threat actually occurring. Such scious awareness (Slovic et al., 2004). The greater ‘‘probability neglect’’ (Sunstein, 2003) is an im- emotional force of negatively valenced material portant contributor to sustaining disproportionate results in a negativity bias that pervades human per- fears of terrorism. ception, impression formation, attention, judg- Because negativity biases and the emotional ment, and decision making, frequently in ways basis of risk perception are fundamental aspects of that appear irrational (Baumeister, Bratslavsky, the psychology we all share, perceptions of threat Finkenauer, & Vole, 2001; Rozin & Royzman, can easily ripple through society. The propensity 2001; Skowronski & Carlston, 1989). Negative for social amplification further bolsters terrorist information tends to be construed as more in- threats. formative and influential than positive data, and when positive and negative information are both presented together, the emphasis on the negative is Social Amplification greater than would be predicted for an equally weighted, emotionally balanced combination. For These fears and apprehensions that can rip- example, research suggests that negative messages ple through society are compounded by social The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 123 amplification. Social amplification is especially began only after the first television satellite was common when there is ambiguity, doubt, or mis- launched in the late 1960s (Hoffman, 1998). The information, which promote fear and instigate ru- terrorists’ aim to maximize their audience and mor. Social amplification, for example, deeply commercial journalism’s competition for readers exacerbated perceptions of risk and stigmatization and viewers have spawned a symbiotic terrorist- of British beef following the identification of ‘‘mad media relationship. cow disease’’ and contributed to the ultimate long- The Geneva Declaration on Terrorism (United lasting collapse of the British beef market in 1996. Nations, 1987) recognized that the media could Similarly, technological or product stigmatization play a direct role in terrorism by ‘‘uncritically dis- (Gregory, Flynn, & Slovic, 1995) is a likely and seminating disinformation’’ and playing an indirect potentially severely destructive consequence of role through a pattern of selective coverage. Twenty- a biochemical terrorist attack on the agricultural first-century terrorists are no longer dependent system. Parallel consequences are likely to char- upon formal media outlets to disseminate their acterize public reactions to terrorists’ use of in- message. Most national and international media fectious disease agents or radiological weapons. outlets exercise disciplined restraint with respect to The consequences of socially amplified fears obvious terrorist propaganda and avoid replaying are not simply psychological. For example, the mad terrorist announcements or communique´s. Unfor- cow crisis costs to the European Union were at tunately, terrorists can readily circumvent jour- least $2.8 billion and more than 4 billion pounds nalistic censorship. Recorded instructions and to the United Kingdom (Powell, 2001). Ex- coded communications, as well as videos of exaggerated fears destroyed public confidence ecutions, beheadings, hostage pleadings, and ‘‘doc- in British regulatory authorities and forced the umentaries’’ of suicide bombings are now easily creation of a new food standards agency (Food distributed over the Internet and nonmainstream safety: Experiences of four countries in con- sources. solidating their food safety systems, 1999). A While terrorists are likely to continue to ex- deliberate attack on the food supply could have ploit the publicity potential of the Internet, the similar economic impact in the United States, psychology of risk perception dictates that me- where one out of every eight people is employed dia coverage, especially television journalism, will in a food-related occupation (Risk assessment for continue to play a crucial role in fueling public food terrorism and other food safety concerns, fears. Vivid, repetitive coverage of acts and threats 2003). American travel, tourism, and the airline of terror prime the cognitive and emotional pro- and dining industries in metropolitan areas fol- cesses that help create a disproportionate sense of lowing September 11 are estimated to have lost risk and vulnerability. Images of terror become more than one million jobs in 2002 due to public more readily available and underscore the sense of trepidations over the threat of terrorism ( Joint emotional dread. Dramatic media accounts of ter- Committee on Economics, 2002). Strong public rorism capture public attention, and the percep- fears represent a powerful disincentive to partici- tion of a greater risk of future attacks is heightened pate in industries marked by the threat of terror- by the availability and affect heuristics. ism, as well as a costly incentive to accelerate the Televised reporting of acts of terror appears to pace of resource diversion to antiterrorist security have stronger emotional impact than print news measures. Disproportionate fears can easily result (Cho et al., 2003). Clearly, all of the tools of the in proportionate cuts in commerce. modern film industry are available to television journalism, and only professional ethics and convention restrain the exploitation of high-production The Role of the Media sound, music, graphics, animation, and video to deliver the maximum emotional impact. Compelling A primary strategic goal of terrorism is to com- dramatic images of victims and their suffering per- municate its message via violent acts (Hoffman, sonalize the implicit threat of terrorism, tacitly 2002). Consequently, the mass media have been conveying a persuasive implication of the viewers’ called the essential ‘‘oxygen’’ of terrorism (Dettmer, vulnerability: This has happened to people like us; 2004). It has been suggested that modern terrorism therefore it could happen to us. The importance of 124 Terrorism television is underscored in studies of reactions to Negativity bias is a fundamental factor in the the September 11 terrorist attacks. For instance, media’s selection and framing of news events and greater monitoring of television reports was asso- the public’s trust in media analysis and reporting, ciated with adverse reactions (Huddy et al., 2003), and studies reveal a powerful bias toward coverage and increased media reliance before September 11 of negative events and outcomes (Niven, 2001). In was associated with greater threat perceptions after their recent comprehensive review of the intersection the attacks (Lowry et al., 2003). Even in countries of media, communication, and psychology, Byron with prolonged exposure to terrorism and emo- Reeves and Clifford Nass (2003) conclude that tionally hardened populations, media exposure has people relate to mediated events in ways that reflect a significant impact. Prior to the war in Iraq, Israelis fundamental psychological processes that underlie represented a major portion of terrorist casualties. human information processing. In particular, they A recent Israeli study (Keinan, Sadeh, & Rosen, note that human attention and memory—supported 2003) has demonstrated that exposure to media by ‘‘hardwired’’ neuropsychophysical processes— coverage of terrorist attacks was correlated with an assign priority to negatively valenced, high-arousal increase in traumatic symptoms even in this sea- stimuli. The underlying processes occur automa- soned population. tically and without conscious awareness and are Contemporary trends in terrorist tactics further probably the result of evolutionary adaptational call attention to the media’s critical role, with iro- advantages accrued from increased vigilance to po- nic, but terrible, consequences for working mem- tential threats. Memory for events following negative bers of the press. Three developments characterize and high-arousal stimuli is proactively enhanced, recent acts of terrorism (Pfefferbaum, 2003). First, and prior material is retroactively inhibited. there has been a substantial increase in the lethality Interestingly, the effects of arousal are cumula- and brutality of terrorist acts, which may speak to tive. Reeves and Nass argue, citing substantial sup- the greater publicity value and inherently terrifying porting evidence, that mediated events are processed qualities associated with more dramatic violence psychologically in much the same manner as ‘‘real (Stern, 1999). world’’ events. Thus, it is not surprising that tele- In contrast to earlier policies employed by vision networks, perpetually engaged in fierce European terrorist groups (e.g., IRA and Basque competition for ratings and viewers, would feature ETA), which minimized casualties but maximized reports with qualities that grab people’s attention publicity by alerting police or journalists of plan- and stick in their memories: those that are nega- ned bombings with sufficient time to allow eva- tive and arousing. These qualities govern the selec- cuation, terrorists in Iraq and Afghanistan prepare tion and prominence assigned to stories that ulti- their own videos documenting the extent of death mately make it to the television screen, as well as and damage of their efforts for distribution after shape their ‘‘packaging,’’ that is, the editorial em- attacks to maximize media exposure. The grow- phasis, the images selected, the music, the accom- ing technical proficiency of international television panying graphics, and all the other subtle nuances journalism creates an expanding market that may that set the emotional tone. have provided such excesses with an unintended Thus, psychological processes give priority to encouragement. In addition, the use of Web-based negative, arousing material, and the news media streaming video clips of beheadings and pleading act in accordance with the psychology of their hostages are often described, if not replayed, by audience. The media create a wider audience of professional media outlets. Second, anonymous spectators to terrorist acts while intensifying their acts of terrorism have increased but would have emotional reactions, which engenders a greater limited tactical value without media dissemination. sense of threat. If the availability and affect heur- Dramatic, graphic media coverage of anonym- istics contribute to a disproportionate perception ous, unattributed acts of terror—such as suicide of risk and vulnerability, the media—especially bombings—nevertheless incites fear and appre- television—augment and exacerbate the under- hension among the public. Third, there has been lying psychology. an increase in terrorist attacks on journalists, a In addition to serving as a source of intense tragic indicator of the media’s indispensable role in emotional stimuli, the media play a crucial role in the strategy of terrorism. profoundly shaping the public’s understanding of The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 125 terrorism. In fact, almost all areas of political in- devoted to the September 11 attack continued for terests are influenced by the media’s powerful many months, the number of alternative reasons, ability to set agendas and frame our understanding explanations, or motives considered diminished of events (Kinder, 1998). The media’s influence dramatically within just a few weeks (Traugott & lies not so much with its potential to persuade or Brader, 2003). Another study of editorials for the to propagandize but rather with its reliable capa- ten largest U.S. newspapers during the year after city to determine the facts, data, arguments, ex- September 11 concluded that editors quickly— planations, and theories to which its audience within the first month—arrived at a consistent, attends. The media tend not so much to persuade consensus narrative frame of the ‘‘war on terrorism’’ us but to dictate the facts, choices, or questions with little disagreement or dissent (Ryan, 2004). we should consider, evaluate, or debate. Risk Even the decision to characterize an act of perceptions are not exclusively emotional. Indeed, political violence as ‘‘terrorism’’ is subject to im- risk appraisals also depend on our ability to pro- plicit editorial biases. For instance, many studies ject future implications on the basis of our indicate that regional media tend to report in- understanding of present circumstances. With re- cidents of political violence against their own ci- spect to terrorism, our understanding of present tizens as acts of terror but use other terms for circumstances is heavily dependent upon the news similar acts against foreigners elsewhere (Nacos, media’s determination of what to report and how 2002). Subtle variations in the use of descriptive to report it, and this determination begins with terms can have very different psychological and how reports are framed. political implications. Our own preliminary results Framing is a potent, yet inescapable, influence in an ongoing study of terrorist media coverage on the interpretation of reported events (Scheufele, reveal interesting variations in reports of a suicide 1999). In its simplest form, framing refers to the bombing attack after a recent truce agreement central organizing story. The frame simplifies the with the new Palestinian government. While most report and cues the audience to the report’s ‘‘place’’ countries explicitly described the attack as a sui- in a familiar, shared social construction of every- cide bombing, most Israeli sources consistently day reality. Tacitly, the frame signals another in- omitted the term ‘‘suicide,’’ perhaps choosing stance of a familiar theme (e.g., another report of to stress the damage to civilians over terms that wasteful government spending, another example convey the sense of martyrdom the terrorists seek of political corruption, another instance of gang to emphasize. In addition, we found considerable violence). Sometimes a single image establishes variation among the framing of this event among the frame. For instance, the images of Muhammed U.S. newspapers. We observed that front-page Dura, a Palestinian boy supposedly killed in his headlines describing the incident were split be- father’s arms, ‘‘clinches the ‘larger narrative’’’ tween those framing it as a major threat to a fragile linking the event to ‘‘a chain of iconic images truce and those emphasizing the act of suicide which (rightly or wrongly) signify historical events bombing. Nearly a third of the newspapers chose in public memory’’ (Liebes & First, 2003, p. 59). not to put the story on the front page, implicitly Why one frame rather than another is chosen reframing the incident below front-page priority and mains an object of intense debate and study (P. importance. Norris, Kern, & Just, 2003). Clearly, the process is As discussed earlier, people often experience immune to neither political partisanship (Niven, great difficulty in estimating risks using prob- 2001) nor the influence of social power or material abilities and percentages and instead fall back on sponsorship (Carragee & Roefs, 2004). psychological shortcuts or heuristics. The media Studies suggest that news coverage of terror- must make parallel choices between reporting base ism, after the initial focus on the details of the act rate data and statistical analyses or relying pri- and the government’s early response during the marily on illustrative examples or case histories. aftermath, rapidly (often in only a few weeks) re- Although news reports commonly employ examples stricts consideration of alternative explanations and of ‘‘typical cases,’’ which are frequently chosen for motives for the attack. One study of terrorist re- their sensational qualities, base rate data are often porting in a prominent national newspaper, for omitted. If examples are exaggerated, they can be instance, found that, while the volume of coverage perceived as more broadly representative than 126 Terrorism actually borne out by facts. For example, in an theories of terrorism offered hypothetical support experimental study (Gibson & Zillmann, 1994) for dispositional explanations, attributing the choice that manipulated levels of exemplar distortion, of the terrorist path to narcissistic rage, ‘‘hostile readers of news reports featuring highly ex- neuroses,’’ paranoia, and other intrapsychic factors aggerated examples of carjacking considered car- (Hudson, 1999). jacking to be a much more serious national In fact, however, comprehensive reviews of problem than readers of reports with less distorted both classified and unclassified data regarding exemplars. This effect was not mitigated by the psychological features of known terrorists con- presentation of accurate base rate data, a result sistently conclude that the distribution of psy- consistent with the consensus of literature in this chopathology among terrorist groups is similar to area, which concludes that base rate information that of other groups (Atran, 2003; Crenshaw, ‘‘fails to exert a strong effect on news consumers’ 2000; Hoffman, 2002; Horgan, 2003; Hudson, perceptions’’ (Gibson & Zillman, 1994, p. 608). 1999; Silke, 2003; Victoroff, 2005). In contrast to Thus, the implied threat of terrorism is likely to be popular dispositional accounts, much current magnified by vivid, evocative examples of terrorist research and analysis emphasizes the powerful attacks despite efforts to balance conclusions by influence of situational factors in explaining the including precise statistical data about objective origins and motivations of terrorists. For example, relative risk. situationally based explanations have greater va- Although threats to public welfare are more lidity in explorations of the development and in- likely to capture the attention of mass media than fluence of terrorist networks (Sageman, 2004), the less negative and arousing events, not all risks influence of the decision-making process under become headline news. In an analysis of risk re- clandestine circumstances (McCormick, 2003), the porting for three very different well-publicized effects of social relationships and religious factors events in Great Britain, the authors conclude that (Strenski, 2003), and the social and psychological risks will be reported when ‘‘there are decisive processes that facilitate the recruitment and moral scientific statements, major disasters, fresh human disengagement of those who choose the terrorist interest stories, official reactions and/or when path (Moghaddam, 2005). Why, then, do disposi- major organizations or governments come into tional characterizations of mentally deranged ter- conflict over the extent of the danger’’ (Kitzinger & rorists persist and in fact flourish in popular and Reilly, 1997, p. 344). They further conclude, how- professional accounts? ever, that the media are poorly equipped to sustain The fundamental attribution error (Ross, 1977), ‘‘high level coverage for long-term threats’’ beyond that is, the tendency of people to explain behavior the immediate controversies of the day. in terms of internal, dispositional causes and to Not only can mass media’s preference for overlook or ignore situational factors clearly un- controversy over scientific subtleties and careful derlies the intuitive appeal of the deranged ter- exposition of risks elevate the public’s sense of rorists portrayed as victims of pathology or character danger and vulnerability, but it can also limit the flaws (Atran, 2003). Moreover, in stark contrast to public’s understanding of the enemy. This is clear dispositional explanations of ‘‘bad’’ actions, social with respect to an understanding of the mind of psychologists have demonstrated that even among the terrorist, a distortion that has potential to otherwise ‘‘good’’ people, evil can readily arise further exacerbate public fears. from situational factors (Zimbardo, 1995, 2004). The influence of social factors such as obedience to authority (Milgram, 1974) and the structure of Dispositional Stereotypes Versus social roles (Haney, Banks, & Zimbardo, 1973) Situational Explanations of Terrorists can interact with ordinary psychological processes common to most people to disengage or diffuse Popular characterizations in many countries and their natural moral restraints (Bandura, 1999). political contexts typically portray terrorists as Situational factors may have explanatory applica- mentally deranged, homicidal madmen who are tion to understanding evil ranging from petty driven by severe psychopathology and antisocial crimes to horrendous atrocities, yet the funda- personalities (Ruby, 2002). Early psychological mental attribution error regularly obscures the The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 127 situationist perspective. It is not surprising, then, more easily utilized politically because it avoids the to witness a popular but misplaced focus on the complicated examination of situational factors, ‘‘mind’’ of the terrorist. some of which may include policies and behaviors Attributional errors can have important and on both sides of the conflict. destructive consequences. Political psychologists Therefore, although terrorists are clearly evil, it have observed that attributional bias can lead to is important to recognize all of the systemic factors flawed threat assessments in international politics that support and facilitate terrorism. Despite the because adversaries are understood in disposi- power of situational explanations, they are some- tional terms, while behavior on the part of one’s times mistaken as excuses: ‘‘Social circumstances own country is explained by situational factors compelled terrorists’ violent, evil actions.’’ The (Levy, 2003). Thus, because situational factors, validity of situational contributions does not ex- including threatening policies and actions of one’s onerate terrorists, who remain culpable for their own country, are often discounted in favor of a crimes in any case. Situational explanations of focus on the adversary’s perceived hostile inten- terrorist behavior do not imply situational ethics. tions, the adversary is seen as more dangerous and In his discussion of the origins of the Rwandan malevolent. Actions on the part of one’s own genocide, Diamond (2005) reminds us that ex- country are viewed as forced by situational factors planations of misconduct can be misconstrued as (perceived threats). Thus, ‘‘if we take security mea- excuses, but sures because we have no choice, presumably whether we arrive at an over-simplified one- others recognize this and understand that we are factor explanation or an excessively complex no threat to them, so that if they buy arms or mo- 71-factor explanation for genocide doesn’t bilize forces it must be because they have hostile alter the personal responsibility of the per- intentions’’ (Levy, 2003, p. 266). The cycle of at- petrators ...for their actions. This is a mis- tributing malevolent intent to the adversary and understanding that arises regularly in discussion overlooking the provocative interpretation of our of the origins of evil; people recoil at any ex- own well-intentioned reactions can spiral out of planation, because they confuse explanation control. with excuses. But it is important that we un- Parallel patterns can occur with popular per- derstand the origins of Rwandan genocide—not ceptions of terrorists. Certainly, the terrorists’ in- so that we can exonerate the killers, but so tention is indeed hostile and malevolent, but a that we can use that knowledge to decrease the focus on disposition can both increase the sense of risk of such things happening again in threat and obscure appropriate counterresponses. Rwanda or elsewhere. (pp. 326–327) Portrayals of terrorists as madmen fit well with the psychological processes we have argued create a A preoccupation with intrapsychic, disposi- disproportionate sense of threat and, to that extent, tional factors not only helps make terrorists more may further the terrorists’ agenda. ‘‘Deranged, cra- frightening, which is to their strategic advantage, zed terrorists’’ are simultaneously unfamiliar and but can also result in a failure to fully scrutinize dreadful—extreme on both psychometric dimen- the recruitment processes, group decision-making sions associated with elevated risk perceptions. structures, and various societal influences that Negativity bias furthers bolsters the intuitive appeal support the evil of terrorism (see Chapter 8 in this of dispositional characterizations of evildoers be- volume). The same cognitive and emotional pro- cause, as we noted earlier, negative descriptors cesses that facilitate the disproportionate sense of are perceived as more credible and more trait in- danger and vulnerability, however, present a ser- formative. The primarily dispositional portrayal of ious challenge to the public’s appreciation of si- terrorists is quite compatible with the media’s bias tuational explanations. toward negatively valenced and high-arousal content, while exploration of situational factors challenges the media’s reluctance to take on complex Recommendations stories that unfold only after sustained analysis. Furthermore, terrorism is always understood within It is essential that government leadership make a political context. The dispositional portrayal is every effort to ‘‘take the terror out of terrorism’’ by 128 Terrorism deploying programs to address the psychosocial the vicinity of Ground Zero or the strain on public processes that underlie public perceptions before, health resources caused by a flood of ‘‘worried well’’ during, and after a terrorist emergency. Fear man- urgently seeking medical evaluations. agement programs are unlikely to achieve success Stress Preparation and Training. Preevent or- without strong executive leadership. Because ganized activities can have enormous impact on public reactions are complex, they cut across the public trust, and perceptions of trust can mitigate province of medical, law enforcement, and other the impact of negativity bias and heightened feel- disaster-response stakeholders and entail sensitive ings of fear and vulnerability. Simulations and attention to the priorities and concerns of diverse exercises to educate the public, practice respond- ethnic, cultural, and religious segments within ing, enlist the cooperation of civic organizations, states. Moreover, the economic, political, and social and disseminate accurate and authoritative in- consequences of failure are so substantial that the formation regarding best practices in response to intricacies of managing public fear in an era of various terrorist actions are absolutely essential. terrorism must not be ignored. Simulations and other exercises can contribute Several factors are key to successfully re- to public perceptions of government competence sponding to human-made attempts to exploit the and bolster public trust. Such activities may psychology of fear: also help develop valuable relations with media Provide Full Information That Speaks to Local representatives. Public and government leaders Concerns. Fear management efforts must recog- should insist upon adequate support for state nize that psychological reactions to acts of terror programs, as well as advocate for comprehensive are actually composed of a diverse, complex array integration with nongovernmental organizations, of emotions and perceptions that can have very including private medical facilities, the American different effects on traumatic outcomes, public Red Cross, charitable organizations, and healthcare trust, and support for government policy. The professional organizations that provide voluntary public must have ready access to accurate in- disaster relief services. formation concerning threat assessment and pre- Regular preevent simulations and exercises are paredness, as well as to developments and pro- valuable opportunities to ensure the optimal use of tective governmental responses, following acts influential social networks within the structure of a of terror. Risk alerts or warnings should stress state’s communities. Preparedness efforts should realistic probabilities rather than dramatize cata- ensure that fear managers capitalize on opportu- strophic possibilities. In addition, neither federal nities to integrate resources well in advance of government public affairs efforts nor national terrorist threats rather than relegate integration media communications are likely to adequately to belated attempts to introduce leadership and address public concerns at state and local levels. ‘‘trade business cards’’ at the site of the disaster. Fears of tainted or contaminated products follow- Finally, preevent training provides opportunities ing an act or threat of agroterrorism, for instance, for leadership to rehearse its decision-making present different concerns and challenges for food process governing the release of information. production than for recipient communities. Gov- Within reasonable bounds, full public disclosure ernments should consider investing in the de- is critical to rebutting rumor, misinformation, velopment and field testing of risk communications and distrust. Homeland security leadership should tailored specifically to local concerns, priorities, exploit every opportunity, including preevent and cultural norms and attitudes. Of course, simulations, to develop, practice, and evaluate materials and information should be made avail- policy and methods for determining the reasonable able in languages other than English where boundaries on information management. appropriate. Use Scientifically Credible Risk Communica- Plan for Realistic Psychological Reactions. Fear tion. Risk communication about acts of terror management programs must avoid focusing on the should be informed by social scientists who relatively unlikely probability of public panic and are familiar with the psychological challenges hysteria. Fear management plans should emphasize that characterize public response. Effective fear more probable scenarios, for example, the mass management requires a well-considered, practiced convergence of spectators, volunteers, and media on media strategy. Public relations specialists can The Strategy of Terrorism and the Psychology of Mass-Mediated Fear 129 make an important contribution. Public trust in develop an emergency plan for themselves but the sincerity and competence of government, how- will respond to their children’s interest. Governors ever, is critical and will be undermined by any should also actively recruit cultural, ethnic, and appearance of political spin or misguided efforts to religious leaders to serve as advisors and consultants calm public reactions by obscuring or strategically in building and implementing fear management reframing information. Preparedness and response programs, as well as to serve as communication programs should encourage media access and facilitators and spokespersons within diverse com- build local media relationships with the clear re- munities during crises. cognition, however, that media coverage during Take Advantage of Technological Communication a crisis will likely be dominated by out-of-state, Resources. Internet-based information resources national outlets whose priorities will often trump can effectively supplement fear management ef- local relationships and media guidelines. forts. Web-based resources to rebut urban legends Unmask the Anonymous Perpetrator. The un- and potentially destructive product misinforma- known is inherently more frightening than tion and rumor may serve as useful examples the known. Even if data are limited, providing the (Kimmel, 2004). public with information about specific terrorists, It is the quintessential nature of terrorism that especially information that highlights their fallibi- perceptions of vulnerability, fear, and apprehension, lity and pedestrian qualities, is preferable to however exaggerated or unrealistic, will inevitably inviting the public to project an unwarranted sense represent the shared concerns of a large majority of capability onto the absence of information. of citizens. Therefore, during an era of terrorism Exercise Particular Care With Warnings. Given a democratic society has every right to expect the the power of negative information to aggravate highest standards in fear management. Despite public fear and vulnerability, public alerts or much progress, extensive research and development warnings of potential terrorist threats should be is needed to optimally mitigate our enemies’ efforts reconsidered if available information is vague and to promote public terror. no specific public actions can be recommended. Public policy for managing responses to ter- All warnings should stress the low magnitude of rorism should be guided by attention to three relative risk, perhaps by comparison with ordinary factors: education, resource integration, and scien- familiar hazards, such as car accidents, lightning tific credibility. Government must invest in exec- strikes, and so on. Official warnings should be utive education that is designed specifically for coupled with detailed information regarding gov- homeland security leaders and managers. Executive ernment preparedness actions, preferably including education should include a comprehensive but a clearly prescribed role for concerned citizens. (It pragmatic review of risk perception and commu- should be noted that research, albeit limited, on nication, as well as the psychology of fear manage- warnings and response allocation suggests that ment. Leadership and their staff must be well scant political cover is likely to be provided by trained in practical psychological principles and vague, seemingly gratuitous warnings that happen effective communication and media strategies. to precede actual attacks.) Resource integration is critical, and people are a Anticipate the Needs of Special Populations. critical human capital resource. Effective fear man- Fear management plans should strive to identify agement depends upon well-managed collaboration in advance populations with particular vulner- among many government and nongovernmental ability to the traumatic impact of terrorists’ actions constituencies. Government leadership should ad- (e.g., children) and also anticipate ethnic or cul- vocate and fund state-tailored programs to reach tural groups at risk for retribution or backlash out to government and community leaders, to following actions apparently linked to particular provide continuous training, and to monitor pro- cultural or religious origins. Homeland security gress and revise programs. The aim should be to leadership should encourage school systems to develop an integrated community of stakeholders develop disaster plans and implement routine age- that can provide a valuable forum for discussion and appropriate training and drills. Preparatory efforts public education. that target students may have a productive impact The range of possible terrorist threats is daunt- on otherwise apathetic parents, who might fail to ing. In the long run, the most important advances in 130 Terrorism fear management will result from a better-educated important, therefore, to get the complexities of (and hardened) public. Government should lead a evil right and not settle for emotionally biased and continuing dialogue—one that is carefully and re- perhaps politically expedient simplifications. This peatedly presented in the mass media—about concern is elevated to even greater importance if realistic limitations on our true capacities to protect recent assertions that the use of fear as a political justification has become a more favored against any threat. pragmatic political method in democracies as Finally, in too many ways, fear management faith in political principles fades (Robin, threatens to become a cottage industry fueled by the 2004). economics of fear. Many popular fear management interventions have not stood up to rigorous evaluation. It is essential that fear management References programs be scientifically validated. Expert opinion Atran, S. (2003). Genesis of suicide terrorism. Science, is simply no substitute for empirical evidence. A 299(5612), 1534–1539. large body of scientific work exists to inform future Baer, J. (1997). Generating fear: The politics of crime program development, and the safety of citizens reporting. 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The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism Timothy A. Kelly

On September 11, 2001, the world changed, and, fact, a full 90% reported turning to prayer, re- like it or not, civilization is now enduring an age of ligion, or spiritual feelings. That is slightly more terrorism. On that clear Fall morning, the world than the 85% of Americans who report that re- watched in horror as the Twin Towers collapsed, ligion is ‘‘fairly or very important’’ in their lives and thousands of innocent lives were lost. The (Gallup, 2003). In a similar vein, survivors of television footage was horrendous, showing some the Oklahoma City bombing were found to con- plunging to their death from the flames, others sistently use ‘‘positive religious coping strategies’’ fleeing monstrous clouds of dust in panic, and still as a means of working through the trauma of others exhausted and covered in ghastly soot from that attack (Harrison, Koenig, Hays, Eme-Akwari, top to toe. On average, adults watched more than 8 & Pargament, 2001, p. 88). hours of coverage that day (Schuster et al., 2001), Shortly after 9/11, the Department of Justice enough to see the towers come down dozens of distributed the Office for Victims of Crime Hand- times, enough to traumatize the hapless viewer. book for Coping after Terrorism (U.S. Department Acts of terrorism are of course designed to do just of Justice, 2001). The handbook refers several that—to traumatize a population into submission times to the fact that victims of terrorism may need (Linley, Joseph, Cooper, Harris, & Meyer, 2003). to consider ‘‘professional or spiritual’’ counseling, The United States has not submitted, but it has meaning help from a counselor or minister.1 Re- been traumatized by the terror of 9/11. cognizing this fact, the city of New York gene- Where do people turn in times of trauma? rously provided for the thousands of workers Where is help to be found when the very infra- charged with the grisly task of sorting through the structure of society collapses as it did in New York rubble of the Twin Towers. Dozens of mental City? A RAND survey conducted less than a week health professionals and clergy were brought in after 9/11 discovered that people relied primarily to make themselves available for the workers as on two resources—one another and their under- needed. To whom does one turn when you have standing of God. As the survey authors state, ‘‘most just recovered a coworker’s body or perhaps the turned to religion, and also to one another for arm of a child from the wreckage? Mental health social support’’ (Schuster et al., 2001, p. 1511). In professionals can help rescue workers process

137 138 Consequences of Terrorism their thoughts and feelings in a manner that is with a discussion of practical recommendations for certainly helpful in many instances. But for many emergency mental health professionals, individ- trauma victims, clergy can offer more: a level of uals, and faith-based communities in drawing on comfort, a means of grace, a touch of the divine spirituality and religion to help those affected cope in the midst of the struggle to cope with in- with the trauma of a terrorist attack. comprehensible tragedy. So it has been found that, in times of cataclysmic trauma, people turn first to clergy for emotional support and only later, if at Key Concepts and Terms all, to mental health workers (Everly, 2003). On the other hand, religiously oriented per- Religion, Spirituality, and Faith-Based sons experiencing a life trauma may find that their Community religious beliefs do not necessarily help. They may struggle endlessly with the age-old question of Wars have long been fought (and are still being theodicy—how to reconcile the reality of evil with fought) over which concept of God and which the concept of an all-powerful and all-good God. definition of religion will stand. In fact, the ter- This is most poignantly expressed as a syllogism: rorism the world faces today—primarily that of militant Islam—is often justified by the perpe- A good and omnipotent God must be willing trators as necessary in order to protect and expand and able to prevent evil. a way of life based on strict religious beliefs. It is Evil exists. both ironic and tragic to note that militant Islamic Therefore, God is either not omnipotent or not terrorists kill in the name of God, while at the same good. time many victims of their attacks turn to God in For example, a study of Vietnam veterans suffering order to cope with the inflicted trauma. It is not from posttraumatic stress disorder (PTSD) found surprising, then, that no precise definition of re- that 74% have difficulty reconciling their religious ligion can be offered with which all theologians beliefs with the trauma they experienced in Viet- and policymakers would agree. Instead, this chap- nam. Slightly more than half (51%) stated that they ter offers a dictionary definition that is generic abandoned their religious faith in Vietnam (Dre- enough to reflect a pluralistic approach, yet spe- scher & Foy, 1995). For these veterans, religion cific enough to be meaningful: and spirituality did not help them to cope with the Religion: belief in a divine power to be wor- horror of warfare. shipped and obeyed as the creator and ruler of What is to be made of the fact that those the universe, expressed in conduct and ritual. who were traumatized by a terrorist attack turned (Webster, 1979) in large numbers to religion and spirituality, yet many Vietnam veterans abandoned their faith? Do ‘‘Spirituality,’’ too, is a word with variable religion and spirituality provide a critical resource usage and meanings. Currently in postmodern in times of national trauma, or is this a false hope? America the term is frequently used to refer to a If it is indeed an important resource, precisely more personal, subjective, psychological, and less what aspect of religion or spirituality helps one to formalized type of religious orientation. Thus, a cope in times of trauma? This chapter addresses person can be spiritual without necessarily being these and related questions as they pertain to in- religious. To some, it is more authentic to be spi- dividual and community preparedness for terrorist ritual in one’s own way than to be religious by attack. Since there is some confusion as to the following the directives of an organization such definitions of basic concepts such as ‘‘religion’’ as a church, synagogue, or mosque. However, this and‘‘spirituality,’’ the chapter begins by introdu- dichotomized view of religion and spirituality is cing and defining key terms: spirituality, religion, problematic. After all, many traditionally religious faith-based community, posttraumatic stress dis- people place a high value on spirituality as well order, posttraumatic depression, and posttraumatic and hold that these are not mutually exclusive growth. Next current research on trauma care concepts. Perhaps it is more helpful to suggest that and on the role of religion and spirituality in co- spirituality and religion are overlapping concepts ping with trauma is reviewed. The chapter closes with a difference in focus. Spirituality focuses The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 139 more on individual and psychological expression, Posttraumatic Stress Disorder whereas religion focuses more on corporate and sociological expression. It is possible to experience The concept of psychological trauma following in one without the other, but many would say that the wake of physical trauma is generally well ac- they function best as two sides of one coin. A re- cepted by professionals and the general public alike. ligious person who lacks spirituality may be seen The central idea, as presented in Chapter 13, is that as superficial, and an antireligious spiritual person people who have experienced an overwhelming may be seen as simply self-indulgent. In contrast, a trauma may find afterward that they are simply un- person who is both spiritual and religious can be able to cope well with life’s stressors. Instead, they seen as demonstrating a credible maturity of faith experience debilitating symptoms that may continue and practice. unabated unless treated. During and after the world Consider, for example, notable religious lea- wars of the twentieth century, for example, many ders such as Mother Teresa and Inamullah Khan, servicemen were found to suffer from shell shock Christian and Muslim recipients of the Templeton and to need hospitalization. The need for treatment Prize, or Lord Jakobovits, former chief rabbi of for postcombat servicemen helped drive the ex- Great Britain. Each of these remarkable people can pansion of Veterans Administration hospitals and be said to have demonstrated a life that was both sped the growth of clinical psychology. religious and spiritual. Acknowledging, then, that Not until after the Vietnam War was the term these concepts are distinct yet complementary, we ‘‘posttraumatic stress disorder’’ (PTSD) coined as a may define spirituality as follows: way to capture the disabling experiences that many combat veterans endured. PTSD is defined for men- Spirituality: the individual’s personal, sub- tal health professionals in the Diagnostic and Statis- jective expression of their search for trans- tical Manual of Mental Disorders (American Psychiatric cendent meaning and purpose, which may or Association, 2000). The condition can occur after may not involve organized religion. exposure to a life-threatening stressor that induces fear, helplessness, and/or horror (e.g., combat, With these definitions in mind, it is possible to sexual assault, torture, terrorist attack). Exposure state with some clarity what ‘‘faith-based commu- may involve being present at and experiencing a nity’’ means. Since religious beliefs are not subject direct threat of death or injury, as was the case for to empirical verification and concepts of the divine those in the Twin Towers on 9/11, or it may involve are not subject to standard scientific tests, faith is a witnessing such an event either close at hand or via prominent component in both religion and spiri- media coverage (Linley et al., 2003). The result is tuality. (Of course, even the hardest science re- an array of difficult symptoms such as feelings of quires faith in the empirical method and scientific extreme anxiety or panic, recurrent nightmares or interpretation, but that is another discussion.) flashbacks, a mental and emotional reliving of the Thus, religiously or spiritually oriented people are event, ceaseless hyperactivity, and significant dys- often described as ‘‘people of faith,’’ and many function at home or work. consider themselves part of a community of those Results of a national survey in the mid-1990s who believe as they do (though some are more showed that PTSD was fairly widespread in the individualistic and idiosyncratic in their faith and United States even before 9/11 (Kessler, Sonnega, do not associate with any religious organization). Bromet, Hughes, & Nelson, 1996), and rates The faith community typically revolves around a appear to rise after major disasters. For instance, parish, church, synagogue, mosque, or some other nations that have experienced extreme conflict anchor point for like-minded believers: show extremely high rates of this disorder: Algeria (37%), Cambodia (28%), and Gaza (18%) (de Jong Faith-based community: that group of like- et al., 2001). minded believers with whom the individual In sum, PTSD is a well-recognized emotional participates and identifies regarding religious/ disorder, triggered by a traumatic event, that seri- spiritual beliefs and practices. It is to such ously impairs one’s quality of life. If untreated, PTSD communities that survivors of terrorist attacks can result in permanent mental disability involv- invariably turn for help. ing intense psychological suffering, social alienation, 140 Consequences of Terrorism disorganization, decreased productivity in the work- more recently identified another possible after- place, and ongoing medical and legal expenses. Since effect of trauma that is only beginning to be a terrorist attack is by definition a potentially over- understood—posttraumatic growth. Actually, the whelming traumatic event, survivors of such attacks possibility of positive change resulting from ne- are at high risk for PTSD. This is confirmed by re- gative events has been recognized through the ages search that was completed 6 months after 9/11 in in philosophy, literature, and religion. Consider, New York City, which found that 36.7% of those for example, the mythological story of the Egyptian who were in the World Trade Center met the criteria phoenix—a great bird that was destroyed, only to for PTSD (Galea et al., 2003). rise again from the ashes. Or consider the actual story of Lance Armstrong, multiple winner of the Posttraumatic Depression Tour de France after surviving cancer. In his au- and Other Disorders tobiography Armstrong discusses how the trauma of cancer and chemotherapy led to his resolve to Survivors of a terrorist attack are clearly at risk for become a world champion: ‘‘[The] truth is that PTSD. They are also at risk for other emotio- cancer is the best thing that ever happened to me’’ nal disorders that may be either related to PTSD or (Armstrong, 2001, p. 4). Of course, this does not totally distinct but triggered by the same trauma mean that Armstrong welcomed the scourge of (Flannery, 1999). For instance, posttraumatic de- cancer; rather, it means that even the worst expression can occur as a survivor finds that, fol- perience can lead to remarkable benefit. Thus the lowing a trauma, a profound sense of hopelessness concept of new birth or growth resulting from and sadness becomes overwhelming and debili- trauma and suffering is not new. tating. Such depression may include loss of sleep For the past 10 years a growing number of and appetite, loss of motivation and energy, feel- researchers have been studying this intriguing con- ings of guilt or anxiety, and suicidal thoughts. cept. Although various terms are used, the concept Unless treated, posttraumatic depression may be- is the same—long-term positive outcome following come chronic and even lead to suicide attempts. crisis (e.g., ‘‘stress-related growth,’’ ‘‘adversarial Other emotional disorders may also be triggered growth’’). As a result, a growing body of literature by trauma, though PTSD and posttraumatic de- has found that a significant number of those who pression are the most common. Trauma survivors have been victimized by trauma experience post- may experience panic attacks, agoraphobia (fear of traumatic growth (Affleck & Tennen, 1996; Ar- leaving the safety of one’s home), or psychosomatic nold, Calhoun, Tedeschi, & Cann, 2005; Calhoun pains such as stomach cramps or headaches. Sur- & Tedeshi, 2006; Linley & Joseph, 2004; McMil- vivors may also find that, for the first time, they len, 1999; Tedeschi & Calhoun, 1995; Tedeschi, struggle with drug and alcohol abuse or other high- Park, & Calhoun, 1998; Woodward & Joseph, risk behaviors. After 9/11, surveys found that the 2003). trauma of terrorist attack led large numbers of It is possible to experience growth after illness, Americans to seek help for substance abuse (Na- bereavement, and other major life stressors. It is tional Center of Addiction and Substance Abuse, also possible to experience growth after the severe 2001). It is not known why the same trauma evokes trauma of a terrorist attack. But just what does post- different disorders in different people, but it is clear traumatic growth mean, and how is it best un- that these disorders call for timely and effective help. derstood? Most researchers suggest that it consists If no help is available, these disorders may result in of positive changes in interpersonal relationships, intense psychological pain, an increase in accidents positive changes in life philosophy, and /or a sense or illness, lost productivity in the workplace, per- of peace and optimism in the face of adversity. As a manent disability, or suicide (Flannery, 1999). result, the posttraumatic individual ends up at a significantly higher level of functioning at home, at Posttraumatic Growth work, and with others. This positive change is labeled ‘‘posttraumatic growth.’’ Whereas the fairly common experience of PTSD It is important to note that posttraumatic and related emotional disorders is well studied and growth is not the same thing as resilience or re- well accepted, clinicians and researchers have covery (e.g., Bonanno, 2004, 2005), topics that The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 141 are addressed in Chapters 12 and 21. It is certainly The most widely recognized treatment approach true that many people are able to recover from even is known as critical incident stress management a disastrous trauma and carry on, especially with (CISM; Everly & Mitchell, 1999), which provides a the support of friends and family. These are emo- paradigm for postcrisis care. CISM is designed to tionally strong people who have the ability to re- reduce the acute psychological distress suffered by turn to normal functioning with little help and who victims of a trauma such as a terrorist attack and to will likely not experience PTSD. However, post- reduce the incidence of emotional disorders such traumatic growth means more than just recovering as PTSD that may be triggered by that trauma. one’s normal state of functioning, as important as CISM necessarily requires planning and pre- that is. It also means that the trauma victims actu- paration on the part of emergency care agencies, ally end up surpassing their pretrauma state of such as selecting and training EMH professionals functioning and report being significantly better off and developing area strategies. Once these are im- for having suffered the event. This does not at all plemented, there are four primary treatment com- suggest that the trauma is therefore welcomed or ponents that can be helpful both for the residents trivialized, nor does it mean that there is no nega- of an affected area and for disaster workers at- tive impact from the trauma. It is possible for a tending them: survivor to go through periods of severe anxiety Individual acute crisis counseling, consisting and grief on the way to posttraumatic growth. of one-on-one sessions, with or without med- Nevertheless, it does mean that the final outcome ications. This is typically offered as soon as is actually superior to the starting point. possible to those who are severely traumatized In sum, there are three possible outcomes to and who may have difficulty with daily life trauma: PTSD, recovery, and posttraumatic growth. functioning. Not only do these outcomes yield different experi- Brief small-group debriefings. These discussions ences for the victims of trauma, but they also require are designed to reduce acute symptoms such as different treatment responses, as trauma care re- high anxiety levels and grief by working through searchers are now recognizing. such feelings. The goal is to offer this service early on so as to defuse what could otherwise become debilitating emotional trauma. Trauma Care and the Role of Religion Longer-term small-group discussions known and Spirituality as critical incident stress debriefing (Mitchell & Everly, 1996). The goal of long-term de- Critical Incident Stress Management: briefing is to work through traumatic events A Trauma Care Standard and achieve a sense of closure so that victims can move on with their lives without difficulty. Every major metropolitan area across the United This may take weeks or months of focused States has designated resources for meeting a effort, especially for those who have difficulty community’s needs after a disaster, whether that expressing negative thoughts and feelings. involves food and housing, physical healthcare, Family crisis intervention procedures. Living or mental healthcare. Emergency mental health with traumatized individuals can be hard on a (EMH) services are designed to meet the mental family unit or on others who live or work health needs of individuals and communities after closely with thevictim. In this intervention, a major disaster such as a terrorist attack (Flan- EMH professionals go into the neighborhoods nery, 1999). These services are typically coor- and homes of trauma victims and offer family dinated from a central crisis-response center and therapy and other supportive and problem- involve those who have been selected and trained solving services that may be called for. to serve the community as EMH professionals in times of crisis. Thus in any given area there should The goal of these interventions is to reduce be a team of psychiatrists, psychologists, social pathological symptoms, build caring networks of workers, and/or other mental health practitioners friends and family for ongoing support, and restore who are ready to serve when called upon. What a sense of mastery and purpose in life. If the guides the services that EMH professionals offer? interventions do not adequately meet the needs of 142 Consequences of Terrorism those impacted by the trauma, CISM calls for re- approach to posttraumatic treatment, as well as the ferrals for psychological assessment and treatment unique relevance of spiritual and religious re- on an as-needed basis. CISM is supported by empi- sources. rical evidence (Everly, Flannery, & Mitchell, 2000; Everly & Mitchell, 1999) and is considered by The Role of Religion and Spirituality many as an international standard of trauma care in Coping With Trauma for mental health needs (Mitchell & Everly, 2000). For this reason it was widely offered as a standard Terrorism demoralizes a population with fear, ‘‘blanket’’ intervention after 9/11 for those who anger, paranoia, and grief. Those who have lost were exposed to the trauma of the World Trade loved ones are devastated, and witnesses (even via Center attack (Miller, 2002). media) are horrified. Trust in one’s community and government may fail, and the very fabric of Research on the Effectiveness of Trauma Care society may seem to be crumbling. Saathoff and Until recently CISM and related approaches were Everly point out that these feelings have the po- assumed to constitute state-of-the-art effective tential to spread by contagion, in that the popu- treatment for all trauma victims. The assumption lation inadvertently spreads the intended impact of was that all those who were exposed to life- a terrorist attack by losing perspective and resolve threatening stressors would benefit from the de- (Saathoff & Everly, 2002). We thus further ter- scribed services. After all, common sense suggests rorize ourselves. If CISM is not capable of neu- that it is helpful to work through grief and anxiety tralizing such trauma sequelae for all victims, what following trauma and loss and that the alternative is recourse is there? to deny emotions at one’s own risk. Surprisingly, One recourse is to draw on the near-universal a growing literature demonstrates that that is not human experience of faith, spirituality, and re- the case (e.g., Bonanno & Kaltman, 1999; Stroebe ligion. These resources have been historically & Stroebe, 1991; Wortman & Silver, 1989). As it neglected by the field of psychology for various turns out, not only is CISM sometimes ineffective, reasons, yet are now recognized as strongly related but in some cases it may actually be harmful. One to mental health (Hill & Pargament, 2003; Kelly & review of grief therapies, which overlap con- Strupp, 1992; Miller & Thoresen, 2003). Perhaps siderably with CISM strategies, found that 38% one could add that this rediscovery is coming in of those who received treatment actually got worse the nick of time, as the United States faces an (Niemeyer, 2000). CISM is most likely helpful for enemy capable of destruction on the order of a some trauma victims who are spiraling downward nuclear war, yet without the predictability of the emotionally and need help to process their negative cold war. Thankfully, because of the rediscovery of feelings and thoughts, but it is not necessarily ap- the role of spirituality in mental health, there is a propriate for those who have a different experience growing literature on the topic of spirituality and in reaction to trauma (Bonanno, 2004). trauma—sometimes referred to as ‘‘religious cop- Thus, it seems increasingly clear that there ing.’’ Researchers have found that positive religious are differential treatment needs among survivors coping is associated with lower rates of depression of a terrorist attack. Some may benefit from CISM and with fewer symptoms of psychological dis- and related approaches, as detailed in Chapter 16. tress such as those found in PTSD (e.g., Calhoun, However, according to George Everly, who heads Cann, Tedeschi, & McMillan, 2000; Drescher & up the International Critical Incident Stress Foun- Foy, 1995; Everly, 2003; Harrison et al., 2001; dation, many people need what might be called Meisenhelder, 2002; Overcash, Calhoun, Cann, & ‘‘pastoral crisis intervention.’’ Everly defines this as Tedeschi, 1996; Pargament, Tarkeshwar, Ellison, ‘‘the use of traditional pastoral interventions ap- & Wulff, 2001; Pargament et al., 1990; Sowell plied within a context of sound emergency mental et al., 2000). More specifically, research points health skills.’’ He states that pastoral crisis inter- toward three key resources that religion and spir- vention is ‘‘nowhere ...more useful than in re- ituality provide for victims coping with the trauma sponse to real or threatened terrorism’’ (Everly, of a terrorist attack: openness to religious growth, 2003, p. 1). Thus a well-recognized proponent of engagement in spiritual reflection, and involve- CISM acknowledges the limitations of that ment in a faith-based community. The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 143

trauma but is also related to posttraumatic growth. Openness to Religious Growth Calhoun et al. (2000) tested 54 students who had In earthquake-prone California, much has been experienced a major traumatic event within the learned about the type of building construction that past 3 years. They measured posttraumatic growth can withstand a major earthquake. Standard build- with the Posttraumatic Growth Inventory (Te- ing practices produce rigid structures that are un- deschi & Calhoun, 1996) and openness with the able to flex or sway in response to a tremor, and Quest Scale (Batson, Schoenrade, & Ventis, 1993), these buildings are much more likely to suffer da- which includes a subscale on openness to religious mage or even collapse. Earthquake-resistant struc- change (e.g., ‘‘there are many religious issues on tures are built with flexibility so that they may give which my views are still changing’’). Five other and sway during a quake. Although the swaying variables thought to be related to posttraumatic can be unnerving for those inside, it protects them growth were also measured, including ‘‘early event from harm. In like manner, those who experience rumination.’’ When they ran a simultaneous mul- a major trauma are going to discover whether tipleregression equation,with posttraumatic growth their faith and spirituality are rigid or flexible. as the dependent measure, only two of the vari- A rigid approach to religion means that sim- ables were significantly predictive of growth— plistic concepts are maintained at all costs, such as openness to change and early event rumination. ‘‘a faithful person will not suffer tragedy.’’ Those Thus, openness to religious change is found to be with this (or a similar) rigidly held religious belief an important factor in the very desirable outcome are left with only three options after experiencing a of posttraumatic growth. This suggests that a major trauma. They may attempt to deny that the willingness to learn and grow, coupled with a fo- trauma was as bad as it seems, thus maintaining cus on one’s understanding of God, function to- their belief that they are not subject to life’s tra- gether as a powerful coping mechanism after a gedies despite evidence to the contrary. They may trauma-inducing event. draw the depressogenic conclusion that the tragedy The research therefore seems to suggest that proves they lack faith. Or they may abandon their there are two possible responses to trauma relevant religious beliefs altogether since the trauma ex- to personal growth. One response focuses inward perience was not consistent with their unrealistic on self, holds rigidly to grievances, and increases and rigid theology. Needless to say, none of these the misery of posttraumatic stress. The other fo- options are desirable. Neither a life in denial nor cuses outward on one’s understanding of God, depression nor a life shorn of faith will help a is open to learning new things in the midst of victim cope with the trauma of a terrorist attack. suffering, and leads to posttraumatic growth. For The alternative is to be flexible in response to some the latter may be very difficult, for a variety the trauma and open to change and growth as a of reasons. Thus it is never appropriate to blame person of faith. This means holding onto one’s core trauma victims for the anguish of their posttrau- religious beliefs even while searching for answers, matic stress. The only correct response is com- and turning to one’s understanding of God in a passion. At the same time, it is important that heartfelt manner for help and direction. Where trauma victims be made aware of the potential better to turn in time of overwhelming trauma? benefits of openness to religious growth. In that After the 9/11 terrorist attacks, 90% of New York way, those who are so inclined will be encouraged City residents turned to prayer, religion, or spiri- to access this important resource and experience tual feelings (Gallup, 2003). In short, they turned its benefits. to God as a source of comfort, strength, and understanding. For a person of faith, only in God Engagement in Spiritual Reflection can ultimate meaning and purpose be found— If being open to religious growth is a significant especially in the face of death and terror. This help when coping with trauma, by what mechan- means trusting that God exists and is greater than ism does that help occur? After all, ‘‘openness’’ all traumas and being open to spiritual growth and is a fairly static concept, seemingly more attitudinal change even in the midst of pain and suffering. than behavioral. Just what does a person do who is Empirical evidence suggests that openness to turning to God and open to posttraumatic growth? religious growth is not only helpful in coping with Among other things, they think carefully about 144 Consequences of Terrorism what happened and all that it means for them. on concepts found in cognitive psychotherapy but An appropriate visual metaphor would perhaps be incorporates a positive focus such as Seligman’s Rodin’s Thinker, sitting with elbow on knee and work discusses. chin on fist while contemplating. After experien- Here too, empirical evidence suggests that cing a traumatic event such as a terrorist attack, spiritual reflection is not only helpful in coping with numerous questions inevitably press in on the trauma but also related to posttraumatic growth. mind. What should I conclude from this terrifying Calhoun and colleagues used a ‘‘rumination’’ scale, experience? How do I make sense of it? Why did it defined as ‘‘recurrent [event-related] thinking, in- happen? Where was God? What must I do now to cluding making sense, problem solving, reminis- be safe? These and related questions flow through cence, and anticipation’’ (Calhoun et al., 2000, p. the victim’s consciousness, and it is easy to become 522). The scale covers the following items: preoccupied with the search for answers. If such deliberately thinking about the event to try to thinking leads nowhere and no answers are found, understand it discouragement follows and adds to the weight deliberately trying to make something good of posttraumatic distress. But if reflection leads to come out of the struggle with the event new realizations and conclusions that help explain deliberately trying to see benefits in the event not only the event but also deeper questions rethinking about the meaning or purpose of life garding life’s ultimate meanings, that is another (p. 524) matter. Productive, positive spiritual reflection is a significant help for victims struggling to cope Using a multiple regression equation, the re- with trauma. searchers found that early event-related rumina- It should not be surprising that constructive tion was related not just to coping with trauma but cognitive processes constitute a significant coping also to posttraumatic growth. Calhoun et al. note mechanism for dealing with trauma. Since the rise that there is a negative, intrusive, unabated type of cognitive therapy in the 1970s and 1980s (e.g., of rumination (negative cognitive process) that is Beck, 1976; Ellis, 1987; Meichenbaum, 1977), it unhelpful. Thus, simply obsessing over worries has been clear that negative cognitive processes in a circular manner does not help. However, are related to many forms of psychopathology. constructive reflection does help and contributes Changing those negative cognitions thus leads to significantly to posttraumatic growth. This means improvement. In fact, in the long run, cognitive that the trauma victim takes the time to reflect on therapy and related cognitive-behavior therapy, the event (what to make of it, what it really means, which target specific negative cognitions, have been etc.) in a positive manner that leads at least in part found to be more effective than medication in to satisfactory answers. treating anxiety disorders (Gould, Otto, Pollack, & In this way spiritual reflection, functioning Yap, 1997). Additionally, most therapists currently as a mechanism for openness to change, leads to declare themselves to be cognitive-behavioral in positive outcomes in trauma victims. According to orientation (Craighead, 1990; Prochaska & Nor- the research, it needs to occur early on, and it must cross, 2003). lead at least in part to satisfactory conclusions that Although the focus has traditionally been on help the victim make sense of the trauma. A criti- diminishing negative thought processes in order to cal discrimination is between positive spiritual relieve pathology, ongoing work by Martin Selig- reflection (which is productive) and pointless ru- man adds a complementary positive point of view. mination (which continues endlessly without Seligman points out that psychology as a field has conclusion). The latter simply adds to the agony of tended toward a negative focus on psychopathol- the trauma, but the former constitutes a powerful ogy and argues for a more positive and optimistic tool for coping with it. Moreover, it adds to the mental health focus to include concepts such as a likelihood that the victim will experience post- person’s strengths, values, and life goals (Seligman, traumatic growth. 1990). For spiritual reflection, it is this broader view of the importance of cognitive processes— Involvement in a Faith-Based Community including both positive and negative cognitions— A trauma victim engaging in spiritual reflection that is most relevant. Spiritual reflection thus draws and open to religious growth is more likely to cope The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 145 well with posttraumatic stress and to experience Each of these three responses to trauma is posttraumatic growth. Nevertheless, an individ- helpful for coping with the enormous stressors a ual’s efforts can go only so far, and most victims victim experiences. Even more than that, the three turn to family and friends as well—a healthy in- together constitute a comprehensive strategy for stinct given the universal need for community and survival and growth that is hard to match with support. For those who are already part of a standard treatment plans. Trauma victims do well to local faith community, that community constitutes adopt an attitude of openness to religious growth, to a third resource that is not to be overlooked. A think through concerns in constructive spiritual mosque, church, or synagogue can play a unique reflection, and to link up with their faith-based role in coping with trauma since it can provide community. Such a strategy provides powerful help both social support and a shared belief system that in coping with trauma and increases the likelihood together offer effective help. This social support of eventually experiencing posttraumatic growth ra- reminds victims they are not alone and encourages ther than PTSD. Perhaps this is why almost half of them to rely on others who are struggling to work Americans surveyed after 9/11 reported that their through similar trauma. The shared belief system faith was actually stronger after the terrorist attack provides a meaningful theological and philosoph- (Wagner, 2001). ical framework for thinking through what has occurred and helps the victim to avoid extreme and counterproductive conclusions. This is not so, Recommendations and Next Steps however, if the religious culture is one of rigidity, punishment, and harsh theological teachings (such It is clear that spirituality, religion, and faith-based as ‘‘God is punishing you because of your lack communities can play a key role in coping with the of faith [or your disobedience]’’). A punitive faith trauma of a terrorist attack. Although the mental community only adds to the burden of posttrau- health profession has historically neglected these matic stress, but one that offers love and accep- resources, the recognition of their importance for tance, as well as a reasoned and wholesome the- mental health services is growing (Kelly, 2003; ology, constitutes a critical resource for the victim Miller & Thoresen, 2003). In fact, this is precisely of trauma. where many turn in times of crisis. More im- There is a growing literature that recognizes portantly, research shows that the help that trauma the importance of local faith-based organizations victims find there sometimes surpasses what is in times of personal or community trauma. Har- available via standard mental health care. Such rison et al. have found that, although punitive re- comfort not only provides a resource for coping with ligious reframing is counterproductive, ‘‘it appears trauma but also increases a victim’s likelihood of that seeking congregational support and reframing experiencing posttraumatic growth. A nation locked the event in benevolent terms have positive health in combat with terrorism cannot afford to overlook benefits’’ (2001, p. 86). Meisenhelder states that such a resource. ‘‘attending religious services brings people together Practically speaking, what does this mean in a supportive environment, where pain can be for the emergency mental health professionals, acknowledged and comforted. The shared belief individuals, and faith-based communities? What system in itself decreases the sense of isolation steps can they take in preparation for and in re- accompanying crisis or trauma. ...People who use sponse to terrorist attack? Furthermore, what ad- positive religious coping see their life as part of a ditional research is needed in order to better larger spiritual force and try to find the lesson for understand this important resource? them in the crisis’’ (2002, p. 775). That lesson may refer to, for example, a new appreciation for the For Emergency Mental Health sanctity and beauty of life, and the importance of Professionals being more other-oriented. These researchers seem to support what is generally well recognized—that The standard protocol for emergency mental participation in a local faith-based community health care—critical incident stress management— can be good for body and soul, especially in times needs major modification. CISM is likely help- of crisis. ful for some trauma victims who are spiraling 146 Consequences of Terrorism downward emotionally and need help to process ready to provide CISM when clearly indicated, their negative thoughts and feelings but not for refer to cognitive-behavioral or other treatment others who react differently to trauma. Emergency modalities as needed, encourage all victims to turn mental health professionals must be trained to dif- to family and friends, and encourage people of ferentiate between those who might benefit from faith to draw on their spiritual and religious re- CISM and those who might not, especially since sources, including their faith-based community. the misapplication of CISM can be harmful. Dif- ferentiation may involve using an assessment instrument capable of clearly identifying appropriate For the Individual candidates for CISM versus other treatments or According to the Department of Homeland Se- strategies. Those in need of treatment but not curity there are several ways that an individual can likely to respond well to CISM could be referred prepare for times of crisis, including purchasing to other modalities such as cognitive-behavioral needed items (emergency food, radio, flashlight; therapy or exposure therapy. Those not in need of duct tape and plastic for creating a ‘‘safe room,’’ treatment should be encouraged to turn to other etc.) and developing plans for meeting and com- sources of help such as family, friends, or spiritual/ municating with loved ones. But how is one to pre- religious resources. pare to draw on spiritual and religious resources at Since the field is advancing so rapidly, EMH these times? Here are recommendations for in- professionals must not rely on traditional, out- dividuals who are preparing for and possibly re- dated protocols for emergency mental health care. sponding to trauma such as a terrorist attack: Instead, it is critical to keep up with the literature, conferences, and training opportunities. Increas- ingly, researchers are turning their attention to Preparation for Crisis developing strategies for working with survivors of 1. Do not be satisfied with religious or spiritual terrorism (e.g., Gil-Rivas, Holman, & Silver, 2004; beliefs that are rigid and unrealistic and that Kelly, 2004, 2005). One of the findings is that cannot flexibly respond to your needs during a some members of a community are predictably crisis. For example, if your belief system leads more at risk than others for being negatively im- you to expect that no harm can come to you or pacted by trauma. For instance, a recent study your loved ones (as long as you are faithful, found that adolescents with a history of mental obedient, etc.), you are less likely to cope illness or learning difficulties were more at risk for well with trauma. It may be helpful to expand difficulties following 9/11 than the general popu- your theological understanding so that it can lation (Gil-Rivas, Holman, & Silver, 2004). Ac- assimilate the reality of tragedies that some- cordingly, EMH professionals should be trained to times afflict good and faithful people. At that assess for these and other risk factors among the point you will be better prepared to weather a target population before prescribing care. They crisis. can then tailor services and supports to meet in- 2. Regularly practice productive spiritual reflection dividual needs rather than automatically offering as a natural part of life during times of peace them to all comers. so that, when crisis comes, this resource will It is important to note that a person of faith not be foreign to you. This may involve prayer (one for whom spiritual and/or religious matters and meditation, the study of religious writings, are very important) may benefit from CISM or keeping a spiritual journal, or discussing key other treatment modalities as well as from faith- theological issues with others. Such practices based resources. It is not an either-or scenario, so prepare you for crisis by familiarizing you with whether or not a person of faith receives profes- positive spiritual reflection and making it less sional care, they should also be encouraged to likely that you will fall into fruitless rumination access the full spectrum of spiritual/religious rein the aftermath of a trauma. sources available to them. For this reason, EMH 3. Align yourself with a faith-based community professionals need to be trained to understand the that is capable of providing interpersonal importance of spirituality and religion as coping support during times of crisis. The faith resources in times of trauma. In sum, they must be community must have a belief system you are The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 147

comfortable with and that can account for life’s fullest in a godly manner.’’). It is a time for tragedies in a realistic and meaningful manner. growth. A faith-based community built primarily upon 4. Become fully engaged with your faith-based superficial interactions, whose members are community, whether synagogue, church, smiling and friendly but seldom wrestle with mosque, or other organization. Remember that life’s difficulties, will not do. Only a commu- this will not help if that group is rigid and nity whose members support one another in harsh, perhaps with a focus on punishment. meaningful ways and who share a wholesome However, if it is a community of compassion and realistic theology will be a helpful resource and sound shared beliefs, it will serve as a during a tragedy. tremendous resource for all of its members. Attend functions, volunteer for programs and activities, and become as involved as possible. Posttraumatic Response This will not only provide needed support for 1. Remember the importance of your faith, your you, but it will also allow your support to be spirituality, and your religion because these given to others, which is healing for both resources can make all the difference as you parties. Moreover, it will allow for discussion struggle to cope with tragedy and loss. Re- of core existential and theological questions member who you are spiritually and where that are the natural sequelae to major trauma to turn for help. events. 2. Be open to religious change and deliberately 5. Expect not only that these resources will help avoid rigid attitudes and unrealistic expecta- you to cope with posttraumatic stress but tions. Instead of focusing inward on yourself, that you may also experience posttraumatic focus outward on your understanding of God growth. and on seeking God. Expect that some of your 6. Do not hesitate to access standard mental assumptions will be challenged, and be willing health resources as needed—such as mainline to let them be modified or expanded. Expect psychotherapy and medication or CISM—for that managing the trauma may change your emotional needs that persist. To do so does not spiritual and religious understanding in sig- negate the value of your spirituality, religion, nificant and helpful ways, and be open to that. or faith, as it is not an either-or matter. Expect that posttraumatic suffering will hurt but that it will also create new things in your For the Faith-Based Community life that will come to have deep and satisfying spiritual significance. Unfortunately, not all faith-based communities rise 3. Embrace spiritual reflection early on as a key to the occasion when crisis hits. It was reported resource for handling crises. This does not that in Manhattan, after 9/11, some of the local mean to engage in pointless rumination but to church pastors immediately left to stay with family invest time and energy into productive prayer and friends in other areas (A. D. Hart, personal and meditation, discussion, and so on, as you communication, Oct. 3, 2003). This seems akin to search for answers. Remember that it is ap- dereliction of duty, as the faith-based community propriate and necessary to do so and that has a critical role to play in times of disaster. consequently you may not be as focused as Following are several recommendations for faith- usual on life’s daily tasks for some time. Record based communities that desire to prepare for crises your thoughts and prayers in a journal, and and to be ready to help their members in an ef- share them with loved ones and members of fective and compassionate manner. your faith community. Do not be afraid to draw conclusions that might have seemed quite Preparation for Crisis foreign to you before the trauma (e.g., ‘‘There 1. The governing body of a faith-based organi- is a struggle in this broken world between zation, especially those located in large good and evil, with real consequences and metropolitan areas or near high-value terrorist innocent casualties. Therefore it is best to targets, should recognize the importance of actively support the good and to live life to the preparation for terrorist attack. This should 148 Consequences of Terrorism

include discussion among the membership, as 3. Utilizing these resources, the faith-based orwell as with national representatives (if ap- ganization needs to put in place a plan of ac- plicable). Making an effort to be prepared for tion to be followed in times of crisis. This may potential disaster is consistent with most involve stipulating which staff or members theological traditions and is one example of cover which function, how members will be caring for the faith community. A clear deci- contacted and communication maintained, sion should be made to allocate the time what resources (housing, emotional support, and resources necessary for planning and etc.) will be offered, how to liaison with local preparation. emergency services, and so on. In this way, the 2. Once the decision to move ahead with plan- faith-based community becomes prepared to ning and preparation has been made, the take a major role in time of posttraumatic re- governing body (or those tasked) should locate covery. This will of course dramatically benefit and appropriate any and all available re- the faith-based community’s members, and it sources. There are at least three sources to also positions the organization to be of help to consider: the wider community. a. Faith-based communities with a national leadership organization should look to that group for help with plans and resources. If Posttraumatic Response such help is not yet available, the national 1. Remember the critical importance of the organization should be strongly encouraged ‘‘faith’’ part of your faith-based community and to move in that direction. There is no excuse where your help ultimately comes from. for any national faith-based organization to 2. Make sure that all organizational staff and re- ignore critical current issues, and this one is presentatives stay local, remain engaged, and of primary import. make themselves available as necessary. b. Local government disaster relief agencies 3. Implement the faith-based community’s plan should be contacted so that their emergency of emergency action with courage and com- plans may be coordinated with those of the passion, knowing that to do so is to provide a faith community in a mutually helpful tremendous resource both to members and to manner. It may be helpful for a re- the wider community. presentative of the faith community to begin 4. To the extent possible, ensure that all com- attending emergency preparation meetings, munity members are accounted for and that which are generally open to the public. they feel accepted, supported, and encouraged Such interest and help would likely be throughout the posttrauma period. welcomed by the relief agency. 5. Focus on the importance of talking through all c. Federal government agency websites should that has occurred in the context of the faith be accessed so that available plans and re- community’s shared beliefs. Make sure that sources there may be had. There are many multiple, ongoing opportunities are provided government-sponsored websites filled with for such discussion and that all questions are relevant and helpful information for in- taken seriously. dividuals and communities wanting to pre- 6. Encourage members to help one another to pare for terrorist attack (e.g., Centers for cope with the extreme stress of a terrorist at- Disease Control and Prevention, Department tack, to be open to religious growth, to engage of Homeland Security, Federal Emergency in productive spiritual reflection, and to par- Management Agency, National Institute on ticipate in as many faith-community activities Mental Health, and the Substance Abuse and and programs as possible. Encourage them to Mental Health Services Agency). One or expect that they will find strength for coping more faith community members could be and to be open to posttraumatic growth. tasked with downloading relevant informa- 7. Be ready to refer members with ongoing tion and presenting it to the governing body emotional needs to standard mental health (see websites listed in Chapter 27). resources such as mainline psychotherapy, The Role of Religion, Spirituality, and Faith-Based Community in Coping With Acts of Terrorism 149

medication, and CISM. This must not be seen erate firm conclusions statistically would add as a sign of failure any more than would to the growing literature on this important visiting a doctor for penicillin to treat an topic. Especially significant would be research infection. that addresses the facilitation of posttraumatic 8. Expect the unexpected, and be ready to im- growth and explores its course and clinical provise or change the plan of action quickly, importance. creatively, and as often as needed. 4. The three spiritual and religious resources so far identified in trauma research are of critical importance. Openness to religious growth, Research Recommendations engagement in spiritual reflection, and involvement in a faith-based community all have Although much is known about the importance of very practical and clinically significant appli- the three spiritual and religious resources discussed cations for victims of trauma such as a terrorist earlier in responding to trauma, the research lit- attack. Additional research that replicates these erature is still nascent on these and related topics. findings and also identifies other spiritual and There is a pressing need, made more so by the religious resources would help expand our threat of terrorist attack, to push ahead with com- current understanding, as well as our present prehensive and programmatic research to build on strategies for coping with disaster. Eventually, the foundation that has been laid. Here are some of an array of evidence-supported spiritual re- the areas that warrant priority attention: sources and strategies could be identified and 1. Emergency mental health professionals must incorporated in EMH trauma care protocol. be able to accurately differentiate between those trauma victims who would benefit from CISM and those who would not. Reliable and Conclusion valid assessment instruments and protocols must be developed for this purpose. For in- The world changed on 9/11, and for a long time to stance, a brief, psychometrically sound survey come, life in the United States is not likely to be as with high discriminant validity (few false po- secure as it once was. We cannot ignore the ever- sitives regarding the need for CISM) would be present threat of a suicidal/homicidal religious ter- of tremendous help. rorist breaking through the nation’s security appa- 2. In a similar fashion, emergency mental health ratus. It is only prudent, therefore, for the nation to professionals must be able to clearly identify begin preparing for the next 9/11, even as we fer- those who are likely to benefit from their vently hope it will never occur and do all that can be personal spiritual and religious resources in a done to prevent it. Furthermore, the next 9/11 may posttrauma period. A brief survey or interview be significantly worse than the first, especially if it protocol addressing this topic would be of involves biochemical or radioactive weapons de- great help in identifying people of faith or signed to kill large numbers of unsuspecting citi- others who would want to be referred to those zens. resources and would benefit from them (e.g., In such a scenario society would by necessity the Religious Commitment Inventory devel- turn to binding up the wounds of the survivors oped by Worthington et al., 2003). and rebuilding what was destroyed. Since some of 3. The concept and clinical reality of posttrau- the most grievous wounds are psychological rather matic growth is clearly relevant to trauma care. than physical, attending to psychological post- Several psychometrically sound measures of trauma needs becomes a top priority. This chapter posttraumatic growth are now available (e.g., has explored a topic that policymakers and mental the Posttraumatic Growth Inventory developed health professionals alike have historically over- by Tedeschi & Calhoun, 1996). Research that looked—spiritual and religious resources that can applies these measures to different populations help in times of crisis. As we have seen, these in different trauma scenarios and with suffi- resources can be as healing as standard mental ciently large numbers of participants to gen- health services and, in many cases, are more 150 Consequences of Terrorism readily desired by trauma victims. Such resources of us are perhaps recognizing that the effort to create cannot be ignored in this time of potential peril. It a ‘‘naked public square’’ (Neuhaus, 1984) devoid of is of utmost importance that federal, state, and all things religious and spiritual was in large measure local agencies charged with emergency prepared- mistaken. In a pluralistic society that champions ness and care (including but not limited to the freedom of religion (among other basic rights), what newly created Department of Homeland Security) is needed is not a naked public square but simply an take note. The once-neglected spiritual factor must open public square where all ideas—theological, be included in policy deliberation, research prio- philosophical, governmental, policy related, and rities, and treatment considerations. Why? Because so on—are welcomed in the marketplace of public survivors almost universally perceive it as having opinion and debate. Let individuals, not govern- the utmost importance as a help in times of need. mental or religious authorities, decide which ideas On a more philosophical and theological note, to adopt. one cannot reflect on the importance of spirituality This chapter exemplifies an open public square and religion in times of crisis without coming face approach in that it recognizes the importance of to face with some of the most enduring and per- religion, spirituality, and faith in response to the plexing questions ever to face humankind. Does disaster of a terrorist attack. When crisis strikes, God exist? If so, how do we know? Either way, when the next 9/11 occurs, give surviving victims how do we explain the reality of what appears at permission to draw on their own spiritual and re- times to be a very broken world filled with un- ligious resources, and help them to do so by fol- warranted tragedies? How can it be that life is at lowing these recommendations. This will help a times wonderful beyond words and at other times stricken community to find strength and prevail hellish beyond belief? In light of that, just what is even in the face of terror. the purpose of life? These questions may seem irrelevant to public Acknowledgments. The author deeply appreciates policy and crisis care, but they are not, for people’s the contribution made by research assistants Elizabeth ability to productively address such questions de- A. Secrist and Sherry M. Walling to this chapter. termines to some extent how well they will be able to cope with the trauma of a terrorist attack. It would of course be inappropriate in a pluralistic Note society for any government agency to promote a given set of answers to these fundamental life- 1. Here the term ‘‘minister’’ is used broadly to in- questions. The strength of a free and democratic dicate ‘‘one who ministers to others in the name of society is that it allows citizens to reach their own a given religious or spiritual perspective.’’ Thus, the religious and philosophical conclusions and pur- term would apply to pastors, priests, rabbis, imams, sue their own destiny as they see fit, as long as they and others who represent faith traditions. respect social and legal norms. This is in marked contrast with cultures that demand allegiance to a given set of philosophical or theological proposi- References tions, such as is the case with militant Islam. In fact, were militant Islam to spread, one of the first Affleck, G., & Tennen, H. (1996). Construing benefits rights to be lost would be that of religious freedom. from adversity: Adaptational significance and However, it is not inappropriate for the plur- dispositional underpinnings. Journal of Personality, alistic agencies of the U. S. government to recognize 64, 899–922. 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Psychological Consequences of Actual or Threatened CBRNE Terrorism Glenn R. Sullivan Bruce Bongar

The acquisition of chemical, biological, radiological, War I, ballistic missile attacks on Tehran and Israel, a nuclear, and high-yield explosive (CBRNE) weapons radiological accident in Brazil, an outbreak of plague remains a priority of several terrorist organizations, in India, and a chemical attack on the Tokyo sub- including al-Qaeda. The extreme lethality and dis- way. We describe the potential psychological impact ruptive effect of CBRNE weapons make them highly of various CBRNE weapons and present evidence attractive to these groups, who conceive that their that argues against the likelihood of mass panic in use will help them to achieve their strategic goals. the aftermath of a CBRNE attack. We discuss the CBRNE weapons could be said to be true ‘‘terror phenomenon of mass psychogenic illness and offer weapons’’ because their psychological impact usually recommendations for treatment and planning. exceeds the extent of their physical destructiveness, The majority of victims of CBRNE terrorism will however massive. be psychological, not physical, casualties. In the Terrorism is psychological warfare, and the aftermath of a CBRNE attack, public health autho- civilian population is the primary target. Terrorist rities should expect that for every person actually groups do not, and will never, possess the means to exposed to radiation or chemical or biological agents, limit or even reduce the strategic capabilities of a many (perhaps hundreds) more will seek medical nation such as the United States. Their only hope is screening. A significant percentage of nonexposed to inflict sufficient psychological trauma on civilians, individuals seeking screening will present with who will in turn pressure their governments to effect psychosomatic symptoms that mimic those of vic- policy changes that favor the terrorists’ interests. tims who were actually exposed. Enormous numbers Promoting psychological resilience and minimizing of people will present with symptoms of fear that psychological trauma in the wake of terrorist attacks will need to be managed by overtaxed medical per- has therefore become a matter not only of individual sonnel. health but also of national security. The threat of chemical attack or an outbreak This chapter presents several historical models of a highly contagious and lethal disease could that illustrate critical psychological aspects of this result in a mass exodus of civilians from popu- threat. In addition to the psychological reactions to lation centers. This demonstrated loss of faith in the 9/11 attacks, we examine gas exposure in World the government’s ability to protect its citizens can

153 154 Consequences of Terrorism compel a nation’s leaders to effect drastic policy without specialized equipment or medical tests changes. The economic losses following such an (at least during the physiologically asymptomatic event could be catastrophic. Effective preparation stage of exposure). The possibility of person-to- and official communication are critical to pre- person transmission magnifies our natural fear of venting unplanned evacuations. contagion. When people fear infection from others Fortunately, a reasonably well-prepared civi- or infecting those close to them, social support lian population can withstand prolonged terrorist networks disintegrate. CBRNE events evoke the campaigns, even those marked by the realistic primal human fear of being permanently dis- threat of CBRNE attack. The rate of psychological figured or disabled. Years after an attack, there will casualties will decline precipitously as people ha- be residual fears of subsequent birth defects or the bituate to the attacks, which they tend to do ra- delayed appearance of cancers, and so on. pidly. Understanding these nightmarish weapons External factors also serve as ‘‘terror multipliers’’ as instruments of psychological warfare and not as during CBRNE events. Inconsistent or incomplete weapons of mass (physical) destruction is critical information from the media and authorities can to planning and executing an effective response. heighten anxiety and deplete trust. Perceived contradictions regarding preventative measures, prognosis, and treatment effectiveness among public The Psychological Impact health officials and kibitzers appearing on 24-hour of CBRNE Weapons news channels can contribute to anxiety. Stress and anxiety are compounded when treatments (e.g., This modality of terrorism is exceptionally well Cipro) are identified but availability is perceived to suited to the apparent objectives of contemporary be limited. Witnessing large numbers of dead or terrorist organizations. CBRNE attacks spread fear, injured people can demoralize or shock even those foster uncertainty, and undermine confidence in not directly exposed to the attack. This effect is government and leadership. They elicit irrational maximized when images of dead or injured chil- and repressive countermeasures, including, poten- dren are broadcast. tially, a nuclear response demanded by an incensed The novelty of CBRNE weapons is perhaps American public. They have the potential to rend their most potent aspect: Human beings dread ‘‘the fabric of trust that bonds society’’ (Hoffman, most that with which they are unfamiliar. For- 2002, p. 313). Potential individual psychological tunately, habituation to frightening stimuli occurs reactions to CBRNE terrorism include numbness; rapidly (Rachman, 1990). The first offensive use of anxiety and fear; horror and disgust; anger and gas in World War I produced panic among the scapegoating; paranoia; loss of trust; demoraliza- defenders, but subsequent attacks did not (Mo- tion, hopelessness, and helplessness; and survivor scrop, 2001). Similarly, all other factors remaining guilt (Holloway, Norwood, Fullerton, Engel, & constant, if an airliner were flown into the Empire Ursano, 1997). State Building tomorrow, the psychological reac- Survivors of mass violence (e.g., terrorism or tion would be less intense than the reactions shooting rampage) are more likely to suffer sub- observed on September 11, 2001. sequent psychiatric illness than are survivors of natural or technological disasters (Norris et al., 2002). One reason for this is that intentional attacks Credibility of the Threat ‘‘might happen again at any moment,’’ whereas re- spites are expected after natural disasters. Further, In 1975 terrorism analyst Brian Jenkins said fa- mass violence reveals a degree of human malevo- mously, ‘‘Terrorists want a lot of people watching lence that most people cannot integrate into their and a lot of people listening and not a lot of people worldview. dead’’ (p. 15). Over the ensuing 30 years, a new The very nature of chemical, biological, and paradigm has emerged, which Jenkins (1999) radiological agents inspires terror. People are un- himself has acknowledged: able to see or feel the agent and in most cases are unable to smell or taste it. Because of this intang- A number of America’s foes and potential foes ibility, direct exposure is impossible to detect are actively conducting research on chemical, Psychological Consequences of Actual or Threatened CBRNE Terrorism 155

biological, or nuclear weapons. As motives not apply to nonstate actors.3 Groups such as al- change and their self-imposed constraints erode, Qaeda already know that the United States is com- today’s terrorists seem more interested in run- mitted to its absolute destruction; therefore, they do ning up high body counts than in advancing a not fear additional retaliation. Indeed, al-Qaeda’s political agenda. strategic intent has been described as deliberately provocative of massive retaliation (McCauley, CBRNE terrorism is a low-probability/high- 2002). Jihadist terror organizations do not feel an consequence event. To date, the airliner attacks of ethical obligation to limit civilian casualties. More- September 11, 2001, remain the sole example of over, they do not fear alienating anyone with the mass casualty CBRNE terrorism on U.S. soil.1 The nature of their outrages because (unlike the IRA) best evidence that terrorist groups do not yet their funding and manpower do not rely on broad- possess the biologic, chemical, or nuclear means to based public support. inflict hundreds of thousands of civilian casualties Former chief U.S. weapons inspector David is that there have been no such attacks to date. Kay (2001) has noted that even nation-states may Security concerns, particularly the fear of inter- be tempted to engage in CBRNE terrorism because ception before delivery, would compel any ter- they perceive no alternatives to U.S. ascendancy. rorist organization committed to megacasualty Kay has stated that, as the power of the United operations to launch such attacks almost im- States increases, the probability that its strategic mediately upon acquiring the means to do so competitors will employ CBRNE weapons through (Friedman, 2004). indirect means (or proxies) will increase as well: The desire of terrorist masterminds to commit Nations will seek courses of action that will al- murder on an apocalyptic scale is well docu- low them operational freedom from U.S. con- mented. Jessica Stern (1999) observed that re- ventional attack or, at least, the ability to inflict ligious militants conceive of weapons of mass significant losses on the United States if it does destruction (WMD) as the perfect means to ‘‘con- attempt to frustrate their ambitions with mili- jure a sense of divine retribution’’ (p. 8).2 Osama tary actions. Terrorism, and particularly mass bin Laden has proclaimed the acquisition of WMD casualty terrorism, is a logical counter for such a ‘‘religious duty’’ and has diligently curried cle- states. Chemical, biological, and radiological rical support in order to justify future mass killings terrorism offers tremendous difficulties of (Scheuer, 2005). It should be remembered that the attribution—that is, proving who really carried intention of Ramzi Yousef, architect of the 1993 out an attack. Biological terrorism even has World Trade Center bombing, was to topple one the added difficulty of determining or proving of the Twin Towers into the next, sending both that one is really under attack and not simply crashing lengthwise onto lower Manhattan, killing seeing a natural disease outbreak. perhaps 250,000 people (Friedman, 1999). The technical challenges involved in developing On the individual level, people who ascribe to CBRNE weapons remain formidable (Steinhausler, apocalyptic ideologies or religious fanaticism may 2003). Even Aum Shinrikyo¯, an apocalyptic cult be more likely to engage in CBRNE terrorism be- with vast economic and intellectual resources, failed cause they may be less concerned about the need in its extensive efforts to develop effective CBRNE for self-protection while handling deadly agents in weapons. However, concerns persist regarding both preparation for an attack (Moores, 2002). A com- the security of nuclear materials in the former So- monly cited bioterrorism scenario involves mar- viet states and the willingness of some scientists tyrdom teams infecting themselves with smallpox (e.g., Pakistan’s A. Q. Khan) to share their expertise and then boarding as many commercial airline with terrorist groups or states that support terror. flights as possible before they are overcome. Due to technical obstacles, it is more likely that terrorists will obtain CBRNE weapons by indirect means. Mass Panic It is especially worrying that the ‘‘calculus of deterrence’’ that helped prevent a nuclear ex- Mass panic is defined as an ‘‘acute fear reaction change between the Cold War superpowers does marked by loss of self-control which is followed by 156 Consequences of Terrorism nonsocial and nonrational flight’’ (Quarantelli, ing, but the ‘‘practice effect’’ of that experience and 1954, p. 265). It is important to differentiate mass of half-hearted fire drills during the intervening panic from ‘‘mass anxiety,’’ a classic example of years is dubious. Far more important is that people which is the public’s reaction to Orson Welles’s tended to make the long descent among friends ‘‘War of the Worlds’’ broadcast. Those who were and coworkers after the decision to evacuate was listening to their radios on Halloween night 1938 made by individual office groups. This familiarity may have been nervous and uncertain, but they not only provided social support but also enforced were not running for their lives. An example of socially appropriate behavior. mass panic is the 1942 Cocoanut Grove nightclub Individual heroism played a large role as well. fire in Boston. A total of 492 people died in 15 The head of security for Morgan Stanley’s Individual minutes in large part because panic prevented the Investor Group, Silver Star–decorated Vietnam ve- crowd from using the revolving doors at the main teran Rick Rescorla, is credited with saving the lives entrance or other exits in a socially appropriate of almost 2,700 of that company’s employees manner (Thomas, 1992). (Stewart, 2003). During the evacuation, he sang It is a commonly held opinion among emer- patriotic songs through a bullhorn in order to calm gency planners that the public responds to disaster people’s nerves. He was last seen walking back up with either passivity or panic (Perry & Lindell, the stairs, searching for stragglers, shortly before the 2003). However, public responses to a variety of towers collapsed. actual disasters do not support this view. Mass Multiple factors may contribute to an outbreak panic, in particular, appears to be quite rare in the of panic behavior: (1) perceiving oneself at high historical record. Panicked flight did not occur risk of illness or injury; (2) limited availability during the bombings of British, German, or Japa- of resources that are apportioned on a first-come, nese cities during World War II. Mass panic did first-served basis; (3) perceived lack of effective not break out in the wake of the 1995 Tokyo management of the catastrophe; and (4) loss of subway sarin attack, despite the horrifying in- credibility by the authorities (Hall et al., 2003). visibility of the debilitating agent and the fears of Perhaps most relevant to the situation in the upper contamination and mutation that have affected stories of the burning Twin Towers is this com- Japanese society since the 1945 atomic bombings. bination of contributing factors: any situation in The repeated Scud missile raids on Israel dur- which a mortal threat is present and there are ing the Gulf War did not provoke a mass exodus limited escape routes (Pastel, 2001). from the cities, despite a rational expectation of chemical attack. There was no mass panic by civilians after the Oklahoma City Federal Building Mass Psychogenic Illness bombing, although the circumstances of the attack were highly ambiguous and no one could be sure The phenomenon of mass psychogenic illness, in that other office buildings would not be next. other times and contexts, has gone by other names, Perhaps the most compelling example of non- including epidemic hysteria, conversion hysteria, panic in response to disaster is that of the 1993 mass sociogenic illness, mass hysteria, somatiza- and 2001 World Trade Center attacks. Orderly tion, and, most recently, outbreaks of medically evacuations were executed after both incidents. unexplained physical symptoms (MUPS). Mass Former New York mayor Rudolph Giuliani esti- psychogenic illness (MPI) has been defined as ‘‘a mated that 20,000 people were safely evacuated constellation of symptoms suggestive of organic before the Twin Towers collapsed on September illness, with no identifiable cause and little clinical 11, 2001 (Giuliani, 2004). Giuliani attributes this or laboratory evidence of disease, which occurs remarkable feat to both the courage of first re- among persons who share beliefs regarding their sponders and to the calmness of the civilians: symptoms’’ (Jones, 2000, p. 2650). ‘‘People exited this building carefully, they exited Ironically, vigorous emergency response to this building quickly, they exited this building suspected or actual CBRNE terrorism (and con- without harming or hurting each other’’ (p. 15). sequent intense media attention) may facilitate the Some of the evacuees on 9/11 had walked emergence of mass psychogenic illness. The emer- down those same stairwells after the 1993 bomb- gence, maintenance, and resolution of physical Psychological Consequences of Actual or Threatened CBRNE Terrorism 157 symptoms occurs completely outside the bounds of 5. Do not label MPI patients as psychiatrically ill conscious awareness; people suffering from MPI or identify members of the treatment team as are not consciously malingering or feigning illness. psychiatrists or psychologists. CBRNE attacks will likely trigger epic outbreaks of 6. As soon as possible, have patients engage in mass psychogenic illness that could easily over- useful work. whelm medical and government institutions and 7. Quickly return patients to their social network. threaten civil order (DiGiovanni, 1999). 8. Remember that a ‘‘skeptical attitude may in- Direct exposure to an agent is not required to duce efforts by patients to prove their symp- develop somatic symptoms (in fact, no agent is toms are real’’ (Engel, 2001, p. 47). required at all). The literature contains countless 9. Remember that nonphysical origin does not examples of people in schools, military bases, rule out real distress. churches, and so on falling ill due to a purported 10. Remember that psychological distress is often gas leak or toxic exposure, and upon investigation comorbid with physical exposure. no such exposure was found (e.g., Jones et al., Individual differences may determine a per- 2000). If medical care is perceived to be a scarce son’s susceptibility to MPI. These differences in- resource, more people will develop symptoms of clude preexisting anxiety levels, suggestibility, exposure, and somatic symptoms will become personal belief systems, and connection to social more severe. Rumor, irresponsible media coverage, networks (Bartholomew & Victor, 2004). MPI may or inconsistent official announcements could in- disproportionately affect more females than males crease the prevalence of psychogenic cases. Within and frequently involves adolescents and children the context of a CBRNE event, it is highly probable (Jones, 2000). MPI is more common among pa- that large numbers of unaffected persons will tients suffering from preexisting psychological dis- inaccurately attribute physical stress reactions orders, severe stress, or perceived lack of social (headache, shortness of breath, diaphoresis, etc.) support (Jones, 2000). to lethal agents (Alexander & Klein, 2003). The most commonly presented symptoms of MPI are headache; dizziness or lightheadedness; nausea; abdominal cramps or pain; cough; fatigue; Post-9/11 Incidence of Mass drowsiness or weakness; sore or burning throat; Psychogenic Illness hyperventilation or breathing difficulties; and watery or irritated eyes ( Jones, 2000). Causal factors The anthrax mailings of October 2001 were a prime may include hyperventilation or syncope ( Jones, opportunity for a widespread outbreak of mass 2000). ‘‘Symptom sharing’’ and ‘‘line-of-sight’’ trans- psychogenic illness. Letters containing the weapo- mission (in which an individual becomes ill upon nized form of this bacteriological agent were mailed witnessing others becoming ill is common (Jones, to prominent media and government figures. In all, 2000). 5 people died, and 22 became ill, many of them Drawing from the experience of military med- postal workers who handled the letters. Moreover, ical personnel charged with treating psychiatric ‘‘[m]illions of people were made anxious and the casualties and the work of contemporary re- routine act of opening the mail became dangerous’’ searchers in the field (e.g., Engel, 2001; Holloway, (Hall et al., 2003, p. 139). The publicized symp- Norwood, Fullerton, Engel, & Ursano, 1997; Jones, toms of anthrax exposure were dismayingly similar 2000), we offer the following treatment recom- to those of influenza or a severe cold: fever, chills, mendations and guidelines: chest pain, cough, nausea, vomiting, and labored breathing. In describing the effects of the anthrax 1. Keep suspected MPI patients separate from attacks, Bruce Hoffman (2002) has noted that patients with known exposure. ‘‘[t]errorists do not have to kill 3,000 people to 2. Off-site treatment is preferable, whenever create panic and foment fear and insecurity: five possible. persons dying in mysterious circumstances is quite 3. Identify and manage symptoms of hyperar- effective at unnerving an entire nation’’ (p. 313). ousal. Nevertheless, no reports have been published 4. Encourage patients to hydrate, eat, and sleep. of medical facilities being overwhelmed or overly 158 Consequences of Terrorism burdened by a sudden influx of people who were in neighboring regions refused to go outside or eat concerned that they had been exposed to the an- anything but canned food (Salter, 2001). thrax bacillus. Perhaps those who were worried The 1987 radiation accident in Goiania, Brazil, about possible exposure sought assistance from serves as a useful model for public response to a their primary care providers and not from local dirty bomb attack. A radiotherapy machine was emergency departments. If there was a large-scale stolen from an abandoned medical clinic and sold outbreak of MPI directly related to the 2001 an- for scrap metal. When the machine was dis- thrax attacks, it has escaped our review of the re- mantled, a curious powder that glowed in the dark search literature. was discovered inside. This powder (the radioactive A handful of localized, small-scale, bioterrorism- isotope cesium 137) was played with and shared related MPI scares did occur in the immediate among the family and friends of the machine’s ap- aftermath of 9/11 (for a review, see Wessely, Hyams, propriators. Soon after, many people who were & Bartholomew, 2001). However, MPI events occur directly exposed to the radioactive powder devel- with regularity, especially in schools and other re- oped flulike symptoms (e.g., anorexia, nausea, gimented social contexts such as military training vomiting, and diarrhea). posts. There is no evidence that the events of Sep- The extent of the exposure—and the cause— tember 11, 2001, prompted an increase in these eventually came to the attention of local public events. health authorities. Any residents who thought they might have been exposed to the stolen radioactive substance were invited to come to the city’s soccer Radiation Hysteria: Goiania, stadium for a free radiological screening. More Brazil, 1987 than 10% of Goiania’s 1.2 million residents presented themselves for screening (Pastel, 2001). The detonation of a radiological dispersion device The actual number of people who were found (RDD)—or ‘‘dirty bomb’’—could immediately kill to have been contaminated with radiation was dozens to hundreds of victims, sicken thousands of 249; of these, 20 required hospitalization, and 4 others, and make a large section of a major city eventually died from their exposure (Pastel, 2001). uninhabitable for many years. Clean-up costs from Therefore, the ratio of ‘‘concerned’’ to ‘‘conta- a single RDD have been estimated at more than minated’’ people in this event was greater than $100 billion (Stern, 1999). Yet the primary impact 500 to 1. of a dirty bomb lies not so much in its lethality or A significant portion of Goiania’s citizens economic cost but in the psychological terror it demonstrated their apprehension by traveling could engender. to a central location and standing in long lines Although we have been living in the ‘‘nuclear for many hours before undergoing screening age’’ for more than 60 years, the general public with Geiger-type radiation detectors. Undoubtedly, remains both ignorant and highly fearful of ra- many more residents were passively concerned or diation (Slovic, Fischhoff, & Lichtenstein, 1980). anxious about possible exposure, but other factors The regular outpouring of concerns regarding the (the need to work, inability to travel, or fear of potentially harmful effects of radiation (e.g., the medical authorities) kept them away from the agricultural irradiation of apples) often bears strik- screening center. ing resemblance to mass hysteria. The psychol- Of the 125,800 people screened at Goiania, ogical effects of the Chernobyl nuclear disaster 8.3% presented with psychosomatic reactions that (depression, anxiety, and stress reactions) are far mimicked the symptoms of radiation exposure more prevalent and range farther from the focal (Pettersen, 1988). People fainted and vomited while point of the incident than the physical effects (e.g., they waited to be screened; many complained of increased risk of developing thyroid cancer). Re- diarrhea, and most were visibly fearful (Pastel, ports from Chernobyl suggest that some people 2001). Using the experience of Goiania as a guide, who thought they might have been exposed to we might reasonably expect that for every person fallout committed suicide rather than face the terror actually exposed to radiation in the aftermath of a of death by radiation sickness (Salter, 2001). For dirty bomb attack, more than 500 will seek medical months after the Chernobyl accident, many people screening for possible contamination, and more Psychological Consequences of Actual or Threatened CBRNE Terrorism 159 than 40 will exhibit fear-related physical symptoms Saddam was planning a major chemical attack on that mimic the symptoms of radiation exposure. the capital city (Findley, 1991). This threat was not unfounded, as Iraq had employed chemical weapons on the frontlines beginning in 1984. Plague: Surat, India, 1994 Between February 29 and April 20, 1988, in response to missile attacks against Baghdad, Iraq A potential analogue to a widespread bioterrorism launched 190 conventional Scud-B missiles at attack is the 1994 outbreak of pneumonic plague Tehran and other major Iranian cities (Findley, in Surat, India. A total of 5,150 suspected cases 1991). No chemical weapons were deployed (per- of plague were identified by health officials; 49 haps only because Saddam did not possess the residents eventually died of the disease (Rama- capability to deploy such weapons in that manner lingaswami, 2001). Fear of contagion was so great at that time). Nevertheless, in the wake of this 6- that approximately 600,000 people (almost 33% of week-long aerial assault, at least 100,000 civilians the city’s population) fled the city by any means fled Tehran (some estimates put the figure as at their disposal—and on foot if necessary (Rama- high as 1.5 million—25% of the city’s population) lingaswami, 2001). Even medical doctors fled the (Martin, 2002). city and left their patients unattended. In Calcutta— An estimated 2,000 people were killed dur- more than 1,500 kilometers away—people stayed ing these attacks, and an additional 6,000 were indoors and off the streets. Tetracycline and wounded (Martin, 2002). In terms of the amount other drugs were hoarded and quickly became of destruction inflicted as a ratio of ordnance ex- unavailable. pended, the ballistic missile attacks during the so- This medical crisis is estimated to have cost called War of the Cities were roughly equivalent to billions of dollars. The tourism industry for the the V1 and V2 rocket attacks on London during entire subcontinent virtually shut down for a time. World War II (Fetter, Lewis, & Gronlund, 1993). There were widespread cancellations of existing However, the Nazi rocket attacks did not prompt a orders for Indian exports. Economic activity in the mass exodus of the civilian population from the affected areas dropped to nearly nothing. targeted capital city. The government’s mishandling of this emer- The variable of interest here is the realistic gency contributed to its magnitude. Initially, the threat of chemical warfare, which multiplied the Indian government attempted to minimize the scale psychological impact of the attacks many times. of the outbreak and play down the risk of contagion Indeed, the threat of chemical warheads delivered (Ramalingaswami, 2001). Official communications via ballistic missile not only depopulated Tehran were dilatory, often inaccurate, conflicting, and and weakened support for the revolutionary re- sometimes intentionally misleading (Ramalinga- gime but also pushed Iran’s leaders to accept a swami, 2001). Government attempts to obfuscate or disadvantageous UN peace resolution. minimize the disease outbreak and the flight of health care personnel from the affected area were major factors in the unplanned evacuation. Scud Missile Attacks on Israel, 1991

The psychological impact of ballistic missile attacks The ‘‘War of the Cities,’’ 1987–1988 on Israeli civilians during the 1990–1991 Gulf War did not nearly approach the regime-threatening Toward the end of the brutal and protracted war magnitude of the War of the Cities. From January 17 between Iran and Iraq (1980–1988), both nations to February 25, 1991, 39 Scud missiles were laun- attempted to break civilian morale and end popular ched at Israeli cities in 18 separate attacks (Bleich, support for the opposing regime by targeting the Dycian, Koslowsky, Solomon, & Weiner, 1992). As public at large with intermediate-range ballistic during the Iran-Iraq War, expectations of chemical missiles. In 1987 Saddam Hussein ordered 150 attack were high among both civilians and govern- Scud missiles fired at Tehran, but these attacks ment officials. Saddam Hussein’s prior use of che- achieved little strategic or tactical effect. One year mical weapons and his strategic interest in drawing later, rumors began to circulate in Tehran that Israeli forces into hostilities heightened the fear of 160 Consequences of Terrorism impending chemical attack. Memories of the Holo- system. The cult had been under increasing pres- caust, in which poison gas was used to kill millions sure and scrutiny from Japanese security forces, of Jews, maximized the psychological impact. which fed their leader’s already paranoid world- A total of eight people were killed as a result view (Lifton, 2000). One of the reasons for the of the missile attacks. Only two of those deaths increased scrutiny was the group’s suspected in- were directly caused by missile-related injuries. volvement in a sarin gas attack the previous year in Six deaths were attributed to suffocation resulting Matsumoto that killed seven people. In Shoko from the improper use of gas masks (Bleich et al., Asahara’s rush to ‘‘strike first,’’ his followers pro- 1992). Even though they were choking, these peo- duced and disseminated a relatively low-lethality ple refused to remove their masks because they version of the deadly chemical (Lifton, 2000). were convinced that poison gas was filling the While much has been made of Aum Shinrikyo¯’s room (Bleich et al., 1992). It can be fairly said that vast financial and intellectual resources, the mem- these people died of fear. bers who dispersed the cult’s chemical weapons A total of 773 war casualties were hospitalized were not trained microbiologists but rather ‘‘gifted during this 4-week period. Nearly 30% of the hos- amateurs’’ with professional experience in chem- pitalizations were due to missile-related physical istry or medicine. injuries (Bleich et al., 1992). These were broadly On the chaotic day of the attack, more than defined to include falls taken while running to 5,000 civilians and first responders were rushed to shelter, injuries sustained in car accidents that Tokyo emergency rooms for treatment of suspected occurred during air raids, and so on. A majority of exposure to the deadly nerve agent (Pangi, 2002). the hospitalizations were for either psychological Almost all of these people displayed signs of psy- stress reactions (43%) or unjustified atropine re- chological reactions to the event, including severe actions (27%) (Bleich et al., 1992). The unjustified anxiety or shock (Hall et al., 2003). Nearly 80% of atropine injections are a symptom of anxiety, those who were brought to emergency rooms that specifically the unfounded belief that poison gas is day were examined and discharged. Of the 5,081 present in the environment and must be counter- people who received medical attention in the after- acted. math of the attack, 19% were hospitalized for sarin As civilians became habituated to the air raids, exposure (n ¼ 984), 1.2% were severely injured (n ¼ the number of stress-related hospital admissions 62), and 12 died (Asukai & Maekawa, 2002). fell. Ambulance crews adapted to the raids as well Many researchers (Ohbu et al., 1997; Asukai & and became less likely to transport psychological Maekawa, 2002; Pangi, 2002) have suggested that casualties to the hospital (Bleich et al., 1992). No an unknown but significant percentage of the mass exodus from Tel Aviv or any other Israeli city people examined and discharged on the day of the was reported. The resilience of the Israeli people to sarin attack had never actually been exposed to air attack may have been bolstered by the gov- the gas. On the patients’ initial arrival at an emer- ernment’s policy of outfitting all of its citizens with gency room, the combination of shock, emotional modern gas masks. (Israeli citizens who do not distress, and fear-related physical symptoms (e.g., maintain their masks in good working order are shortness of breath, nausea, rapid heartbeat) would subject to fines.) In addition, universal military make those who have actually experienced low- training may increase this population’s confidence level exposure to a nerve agent virtually indistin- that they ‘‘know what to do in case of an emer- guishable from those who merely believe they were gency.’’ In addition, public trust in the government exposed. However, it is important to emphasize and the media was very high. that patients suffering from actual exposure to nerve agents are also likely to exhibit signs of intense fear, anxiety, and emotional distress. Sarin Gas Attack in Tokyo Subway, 1995 Gas Mania in World War I On March 20, 1995, members of the apocalyptic religious cult Aum Shinrikyo¯ dispersed deadly Modern understanding of mass psychogenic illness sarin gas within the confines of the Tokyo subway in the context of actual or threatened exposure to Psychological Consequences of Actual or Threatened CBRNE Terrorism 161 chemical weapons began during World War I. marshal their personal resources in order to arm Exposure to gas, whether to blister agents such as themselves against the psychological onslaught of mustard gas or choking agents such as phosgene or terrorism. We offer the following guidelines and chlorine, had a relatively low mortality rate. About recommendations to inform terrorism response 2% of soldiers exposed to gas died (Shepard, planning and preparation: 2001). Therefore, chemical warfare during World War I was primarily concerned with disrupting 1. In any CBRNE attack, psychological casualties enemy operations, denying territory to the enemy, will exceed physical casualties. For every and disabling (usually temporarily) enemy person- physical injury, expect 10–100 times as many nel. Chemical weapons were not employed simply psychological casualties. All simulations, table- in order to kill swathes upon swathes of enemy top or real life, should include a realistic soldiers. number of psychological casualties. For each soldier who was exposed to gas on the 2. When planning, assume higher than normal Western Front, 2 applied for medical care, without absenteeism among first responders and hos- any evidence of exposure (Pastel, 2001). Put an- pital staff. Healthcare and emergency workers other way, 2 out of 3 soldiers seeking medical care will fear contamination and also feel com- for gas exposure during World War I had not pelled to help their families first. actually been exposed to gas. Soldiers commonly 3. The symptoms of anxiety prompted by a presented with symptoms that mimicked exposure CBRNE attack can easily mimic the effects of to gas (e.g., fatigue, chest pain, difficulty breathing, exposure to chemical, biological, or radi- coughing, tingling or burning in the throat, watery ological weapons. or itchy eyes, blurred vision). In a famous incident, 4. Large numbers of trained people will be re- 500 soldiers of the U.S. 3rd Division became dis- quired to perform initial assessment and triage. abled with symptoms of gas exposure even though Develop a simple charting system to handle their unit was not in an area in which gas had been large numbers of patients. If possible, screen deployed by either side (Pastel, 2001). for ‘‘actual exposure versus MPI’’ off-site (in This phenomenon became known as ‘‘gas churches, schools, etc.) to prevent hospitals mania,’’ and victims were treated much like other from being overwhelmed. Automated tele- psychological casualties during that conflict. Sol- phone or web-based screening tools may re- diers were treated as close to the front as possible, duce the number of nonexposed individuals usually ‘‘within the sound of the guns.’’ They were seeking medical care. fed and encouraged to sleep. The expectation of 5. Create a informative, nonsensational, easy-to- a rapid return to one’s fighting unit was empha- understand public education campaign about sized. Simple treatment approaches (e.g., proximity, terrorist use of CBRNE weapons. Officials can immediacy, expectancy) minimized the disruption reduce fear by providing the public with spe- caused by fear of chemical attack. cific, relevant information regarding the scope and nature of threatening situations. The perception that information is being withheld or Summary and Recommendations that necessary actions are not being taken will only increase the public’s anxiety. In the Age of Terrorism, civilians are both the tar- 6. People will take steps to protect themselves gets of direct violence and the intended audience from threat, so officials should provide the for violent outrages. The strategic intent of terrorist public with clear instructions regarding the groups is to inflict psychological trauma on civilian most effective actions to take and the reasons populations and thereby undermine popular sup- for those actions. Should necessary responses port for the current policies of democratic gov- go beyond the scope of individual action, then ernments. Seen through this strategic prism, governments should explain what protective civilians are not merely the potential victims or actions are being carried out and why (Perry & indirect agents of terrorists but also combatants in Lindell, 2003). the war against terrorism. Mental health profes- 7. Civilian resilience has been chronically un- sionals have an important duty to help citizens derestimated by government planners and 162 Consequences of Terrorism

public health officials. Fear and anxiety are Bartholomew, R., & Victor, J. (2004). A social- normal human reactions to threat and should psychological theory of collective anxiety attacks: not be confused with psychiatric illness. Dur- The ‘‘Mad Gasser’’ reexamined. Sociological Quar- ing World War II, mental health experts in terly, 45(2), 229–248. Britain before the blitz predicted that three to Bleich, A., Dycian, A., Koslowsky, M., Solomon, Z., & Weiner, M. (1992). Psychiatric implications of four million cases of ‘‘acute panic, hysteria and missile attacks on a civilian population: Israeli other neurotic conditions’’ would require lessons from the Persian Gulf War. Journal of psychiatric care during the first 6 months of air the American Medical Association, 268(5), raids (Shepard, 2001, p. 175). The actual 613–615. number of psychiatric casualties during the DiGiovanni, C. (1999). Domestic terrorism with blitz was ‘‘astonishingly small’’ (p. 178). chemical and biological agents: Psychiatric aspects. 8. A significant minority of the affected popula- American Journal of Psychiatry, 156, 1500–1505. tion will suffer long-term psychological con- Engel, C. C. (2001). Outbreaks of medically unex- sequences that require professional care. At plained symptoms after military action, terrorist highest risk are those with preexisting psy- threat, or technological disaster. Military Medicine, chiatric illnesses or poor social support sys- 166(12), 47–48. Fetter, S., Lewis, G. N., & Gronlund, L. (1993). Why tems. Also at increased risk are those who were casualties so low? Nature, 361, 293–296. suffered physical injuries, lost family in the Findley, T. (1991). Chemical weapons and missile event, directly witnessed the deaths of others, proliferation. Boulder: Lynee Rienner. handled dead bodies, or experienced sig- Friedman, G. (2004). America’s secret war: Inside the nificant loss of property or economic reversal. hidden worldwide struggle between America and its enemies. New York: Doubleday. Friedman, T. L. (1999). The Lexus and the olive tree. Notes New York: Farrar, Straus, & Giroux. Giuliani, R. (2004). Testimony before the National Com- 1. The high-yield explosive employed was the hi- mission on Terrorist Attacks upon the United States. jacked airliners’ aviation fuel. Examples of high-yield Retrieved March 15, 2005, from http://www explosive attacks include those on Oklahoma City’s .9–11commission.gov/archive/hearing11/ federal building (April 19, 1995); Russian and Dages- 9–11Commission_Hearing_2004–05–19.pdf tani apartment buildings (August–September, 1999); Hall, M. J., Norwood, A. E., Ursano, R. J., & Fullerton, and the World Trade Center and Pentagon (September C. S. (2003). The psychological impacts of 11, 2001). bioterrorism. Biosecurity and Bioterrorism: Biode- 2. The terms ‘‘WMD’’ and ‘‘CBRNE’’ are used here fense Strategy, Practice, and Science, 1(2), 139–144. interchangeably. ———, & Levinson, C. J. (2002). Psychological and 3. Hitler did not use chemical weapons against the behavioral impacts of bioterrorism. PTSD Research Allies during World War II because he believed that Quarterly, 13(4), 1–7. the United States possessed a more deadly stockpile Hoffman, B. (2000). Change and continuity in terrorism. than Germany’s. Saddam Hussein refrained from using Address delivered at the conference on ‘‘Terrorism WMD in Gulf War I because he feared nuclear re- and Beyond: The Twenty-first Century,’’ Oklaho- taliation by the United States. ma City, OK, April 17. Retrieved March 15, 2005, from http://www.mipt.org/hoffman-ctb.asp ———. (2002). Rethinking terrorism and counter- References terrorism since 9/11. Studies in Conflict and Terrorism, 25, 303–316. Alexander, D., & Klein, S. (2003). Biochemical Holloway, H. C., Norwood, A. E., Fullerton, C. S., terrorism: Too awful to contemplate, too serious to Engel, C. C., & Ursano, R. J. (1997). The threat of ignore. British Journal of Psychiatry, 183, 491–497. biological weapons: Prophylaxis and mitigation Asukai, N., & Maekawa, K. (2002). Psychological and of psychological and social consequences. Journal of physical health effects of the 1995 sarin attack in the American Medical Association, 278(5), 425–427. the Tokyo subway system. In J. Havenaar & J. Jenkins, B. M. (1975). International terrorism: A new Cwikel (Eds.), Toxic turmoil: Psychological and mode of conflict. In D. Carlton & C. Schaef (Eds.), societal consequences of ecological disasters (pp. International terrorism and world security 149–162). New York: Kluwer Academic/Plenum. (pp. 13–49 ). New York: Wiley. Psychological Consequences of Actual or Threatened CBRNE Terrorism 163

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Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning Dennis D. Embry

Danger requires response. When a hurricane nears terrorists have raised the specter of sustained vig- the U.S. shore, all manner of warnings and pre- ilance and made apparent the need for planned parations follow, depending on the magnitude and responses by government (at all levels), law en- path of the threat. Similarly, when meteorologists forcement, health professionals, the private sector, spot a tornado, warnings sirens signal the depth of and private citizens. It is equally clear the military’s the emergency, and broadcast media immediately defeat of the Taliban and al-Qaeda or the capture inform those who should seek shelter. of leading terrorists will not end future risk. Dangers differ. For some, people have advance The greatest danger of terrorism is not to be knowledge, but others, like earthquakes, strike found in the typical territorial acquisition, body suddenly and without warning. Some are chronic counts, or target destruction of historical wars. The dangers and some are acute, and they vary in the essential danger—and objective—of terrorism is type of response they require. Tobacco, alcohol, the creation of terror—a state of mind and its re- and other drugs have a chronic, adverse impact on sultant behavioral responses. Terrorism applies the safety and health. Health promotion psychology science and practice of psychology for political has tested any number of strategies to reduce or purposes in much the same way that thermonuclear prevent the hazard they pose. In the past few weapons apply the science of physics for military decades exposure to violent offenses such as rape, purposes. More powerful, plentiful, technologically assaults, and homicides have caused a rush of other sophisticated weapons and military strategies are strategies that utilize community policing, preven- the common response to promote security in the tion, and security systems. face of conventional warfare threats. An essential Terrorism is a newly acknowledged danger in policy, strategic, and tactical question now is, how the United States, although its threats have been might we achieve those same levels of safety and apparent for some time, and it has substantial security when the threat is psychological? history in many other parts of the world. The at- Multiple areas of psychological research offer tacks of September 11, the anthrax letters, shoe guidance to help shape policy and practice for bombs, other actions, and threats of action by homeland security. Failure to make use of lessons

164 Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning 165 from these sources could seriously increase real risks Asymmetric Strategy One: Condition for future acts of terrorism or slow recovery from Fear and Anxiety such events. Effective use of psychological research and technology could substantially improve the com- Terrorism aims not just at any fear. Terrorism petence, resilience, and protection of U.S. citizens. works best from a strategic perspective if the very This chapter explores several approaches for using symbols of everyday life become classically con- psychology in the defense of the United States. ditioned fear and anxiety stimuli, which then render your stronger opponent (if you are the weaker player in the asymmetric war) strategically The New Type of War Using the wounded. Psychology of Mind and Behavior Classical conditioning especially affects either aversive- or approach-type behaviors and specifi- In the United States, we are equipped and trained cally emotionally laden behaviors or thoughts (e.g., to fight large conventional wars. We make more Carlson, 1994). Here I am concerned with aversive tanks, more ships, more airplanes, and more of or emotional conditioning. The mechanism is everything to overwhelm an enemy. Regardless of fundamental in behavioral sciences and has been who the enemy is, they are matched tank for tank, well studied for nearly a hundred years. Classical plane for plane, or weapon for weapon. Military conditioning is a form of learning in which a strategists call this a symmetric war, and the United previously unimportant stimulus (visual, auditory, States has excelled in symmetric wars. They have tactical, or internal body event) acquires the prop- typically worked well and ensured security for the erty of an important stimulus. For example, your country and its citizens. new baby sees a balloon for the first time. Another Some wars in recent history, such as the Gulf child pops the balloon, and the baby is startled by War, have been disymmetric: Iraq was a weak force the loud noise (important, unconditioned stimu- facing a strong force. Iraq fought conventionally lus) and cries from the fright (unconditioned re- against an immensely stronger opponent. sponse to fear in babies). Thereafter, balloons evoke The current situation, however, is asymmetric, fear in the baby. The conditioning often becomes not disymmetric like Iraq. Presently, the United much more complicated. For example, what if ex- States has unquestioned hegemony in world affairs posure to the balloons were paired with birthday and conventional warfare. It is the remaining world paraphernalia such as signs, hats, and noisemakers? superpower. Asymmetric war dictates that any op- Subsequently, sheer exposure to any of those sti- ponent of the United States, representing the su- muli might trigger the fear or anxious response— perior force, needs to avoid the strengths of the especially if the fearful events were relatively sin- United States and concentrate on its vulnerabilities. gular or potent. A simple map of classical con- U.S. military strategies have for some time warned ditioning is shown in Figure 12.1. that the United States is (as the 911 attacks and the The power of classical conditioning in creating anthrax letters demonstrably proved) vulnerable to fear and anxiety was obviously not lost in the asymmetric strategies of warfare. planning of the terrorist attacks of 9/11. The entire Asymmetry is about the qualitative difference event resembled a large-scale Pavlovian con- in the means, values, and styles of the new ene- ditioning experiment: mies. Once a power like the United States achieves military superiority and singular influence in 1. Strong iconic symbols were chosen with mat- world affairs, its disadvantaged enemies resort ched visual and auditory cues—the Twin to unconventional asymmetrical means to fight it, Towers, the Pentagon, and perhaps the White avoiding its strengths and concentrating on its House or Capitol, had the fourth plane found vulnerabilities. The greatest vulnerability is the its target. This alone increased the chances of mind of its citizens, who use perceived safety as conditioned fear and anxiety. The image of the the behavioral foundation to maintaining the very Twin Towers and the words describing that fabric of the U.S. productivity system and the image are the same, which is also true of the global economy. Pentagon. 166 Consequences of Terrorism

Unconditioned Unconditioned Stimulus Response • Pain • Freezing • Threat • Fight • See others • Flee or withdrawal die or hurt • Sick behaviors • Unpleasant body or immune sensations reactions

Conditioned Unconditioned Unconditioned Stimulus Stimulus Response • Visual • Pain • Freezing • Sound • Threat • Fight • Tactical • See others • Flee or withdrawal • Social die or hurt • Sick behaviors • Internal body • Unpleasant body or immune sensations sensations reactions

Conditioned Conditioned Stimulus Response • Visual • Freezing • Sound • Fight • Tactical • Flee or withdrawal • Social • Sick behaviors • Internal body or immune sensations reactions

Conditioned Conditioned Stimuli Response Sights • Freezing • Fight Place Sounds • Flee or withdrawal Body • Sick behaviors or immune reactions Figure 12.1. Classical conditioning sequence.

2. The instruments of violence or trauma were tary forces in the world. Had the White House verbally associated with the country’s name— or Capitol building been hit, the prime sym- United and American Airlines. This would bols of our form of government would have mean that the very words and colors associated been destroyed. with the United States could have fear-evoking 4. The timing ensured that live news coverage properties. would show the attacks, guaranteeing that 3. The attacks injured or destroyed symbols almost every citizen would watch the scenes that were associated with high efﬁcacy and over and over and over again, which further power—Wall Street (in fact, world capitalism), guaranteed that news networks and the acro- the largest dollar exporter and symbol of U.S. nyms (CNN, NBC, CBS, etc.) associated with technology (Boeing), and the U.S. Defense them would become paired with fear and Department, representing the strongest mili- anxiety. Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning 167

5. Facial expressions of fear or terror, weeping Whereas conventional warfare may seek to cause from loss, fleeing from danger, and probably surrender by shock and awe, asymmetric war raging fire are unconditioned stimuli in seeks to cause fear, freezing, and withdrawal. humans—evoking visceral reactions of fear Classically conditioned fear serves the strategist and anxiety. well in an asymmetric war. First, it undermines the authority of the government of the stronger party. All of these items contain the basic components of By choosing to attack the very symbols of the the classic conditioned fear and anxiety paradigm, United States, this fear made leaders look weak, yet this author could find no references in any further enhancing fear conditioning in many seg- popular commentary to this fact. The responses by ments of the population. Second, conditioned fear the public were rather predictable. These also meet severely weakens the productive capacity of the the requirements of stimulus equivalence based on stronger party. Fear and anxiety are well docu- relational frame theory (Barnes, 1994; Hall, 1996; mented to cause significant reductions in task Hayes & Wilson, 1993, 1995; Peoples, Tierney, performance—even in less vulnerable, highly Bracken, & McKay, 1998). trained groups. This can translate into major losses Consider the evidence for classical conditioning of productivity or market performance. responses. First, the popular media have universally Few would conceive of simple classical con- reported visceral responses such as ‘‘I felt sick,’’ ditioning as a ‘‘weapon of mass disruption.’’ In- ‘‘My head hurt,’’ or ‘‘I couldn’t concentrate.’’ Sec- deed, when teaching the principles of classical ond, ‘‘freezing’’ and withdrawal responses quickly conditioning to students, educators, business lea- followed. People stayed put in settings they deemed ders, or policy makers, many will say, ‘‘Oh, that historically safe, and many adults whisked their applies only to lower animals—certainly not to children out of school. Other multiple conditioned humans.’’ Those who understand the role of clas- responses then tended to emerge. For the most part, sical conditioning in modern society are presently these responses were all across the United States, two groups outside of researchers on human be- only mediated by watching TV or listening to the havior: (1) Advertising and marketing companies radio. routinely pair unimportant stimuli (a new product) Military objectives for conditioned fear in an with an important stimulus (e.g., sex appeal) asymmetric war are quite potent. A major aim is to to evoke desired behaviors toward their product; disrupt normal business and economic transac- (2) terrorists have proven the immense power tions that sustain the infrastructure of the enemy. of classical conditioning of fear and anxiety as a The attacks of 9/11 did that brilliantly. While one weapon. The loss of business in the financial mar- would have forecast attacks against people of Mid- kets and travel industry in the few months after the dle Eastern descent or appearance in the aftermath, attacks is estimated to have exceeded hundreds of the real secondary shock wave of the attack was billions of dollars, which is primarily the result of near universal fear and avoidance of travel (or classically conditioned fear and anxiety. anything remotely connected with travel symboli- cally), big buildings, consumer spending, and im- Asymmetric Strategy Two: Increase paired stock trading for anything related to Wall Long-Term Prevalence Rates of Fear, Street and the ‘‘center of world finance.’’ Anxiety, and Mental Depression These fear and anxiety responses hurt the country greatly. Because uncertainty strengthens Depression is epidemic in Western culture. The the fear conditioning toward U.S. icons, the mili- U.S. National Comorbidity Survey (e.g., Kessler, tary objectives of the attacks were further served by Berglund et al. 2005) reveals a striking rise in the al-Qaeda’s not taking credit for the attacks; taking lifetime prevalence of depression (Figure 12.2). A credit would have diluted the psychological fac- similar pairing can be seen in the increased num- tors. A cardinal precept of asymmetric war is to ber of prescriptions for depression paid for by maximize fear and anxiety conditioning, not ne- Medicaid and private insurance companies, shown cessarily to maximize loss of life or property— in the related graph. Both of these sets of data have a very big difference from symmetric warfare. implications for homeland security. 168 Consequences of Terrorism

$985.4 $1,000 25 Years born: $762.1 $800 1966–75 20 $629.5 $600 15 $502.5 % 10 $400 1956–65

5 1946–55 $200

1936–45 Expenditures (Millions) Total 0 $0 10 12 14 16 18 20 22 24 1995 1996 1997 1998 Age of onset Figure 12.2. Depression prevalence data and Medicaid expenditures. Source: The Lewin Group analysis of HCFA Medicaid Drug Rebate Program data, 1995–1998. 46 states reporting, 1995–1997, 45 states reporting, 1998.

At first blush, depression would seem to have What some pundits may not appreciate is the nothing to do with an asymmetric war against huge impact of all of these aggregate outcomes on the United States. If your purpose is, however, to state and local budgets. An increased prevalence of wreck havoc in a country by capitalizing on its depression will substantially drive up health costs, vulnerabilities, then increasing the prevalence rates unemployment benefits, and family service costs of depression or the severity of the condition suits in the United States during a time in which the the purpose well as a target of opportunity for nation’s governors report that a majority of states terrorism. Active depression has a number of no- will experience at least a 10% shortfall in revenue table symptoms: (Associated Press, 2002). The current vulnerability to depression in Western society has thus been lowered cognitive function and diminished used as a ‘‘weapon of mass destruction.’’ performance on tasks Further, a seminal study by Zullow (1991) has decreased energy and motivation demonstrated, quite amazingly, that national eco- increased physical illnesses, irritability, and nomic trends are predicted by pessimistic rumi- pessimistic ruminations nations and/or headlines in popular music or news In clinical psychology, these symptoms are magazines. One need only pick up these publica- seen in the context of an individual, not in their tions to grasp the frequency of negative rumina- broader social impact. However, hundreds of tions after September 11. The abstract of Zullow’s thousands of people with depressive symptoms study foreshadows current events: can have a major adverse impact on the larger society, with corresponding economic and political Content analyzed lyrics of the top 40 US songs reverberations. Increased prevalence of depression of each year from 1955 to 1989 for 2 depressive can have manifold adverse societal-level effects, the psychological traits: rumination about bad most prevalent of which are the following: events and pessimistic explanatory style. Cover story captions of Time magazine for those years decreased consumer confidence and spending were also analyzed for rumination. Increased decreased work productivity and satisfaction pessimistic ruminations (PRs) in popular music decreased participation in everyday life, which predicted: (1) changes in the American media in turn is associated with and public’s view of real world events with a increased social isolation and withdrawal 1- to 2-yr lead-time, (2) increased rumination increased rates of domestic violence and in- about bad events in Time magazine, and stability (3) increased pessimism about the economy in Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning 169

nationwide consumer surveys. PR in songs and Why would the creators of terrorist strategy rumination in Time predicted changes in even think about increasing substance abuse or consumer optimism, which in turn predicted misuse among their enemies? There are several personal consumption expenditures and GNP reasons that have military significance. First, sub- growth. Although PR in songs was an indirect stance abuse or misuse has obvious adverse con- predictor of GNP growth, it may provide early sequences on productivity, health, law enforcement, warning of recessions, since its 2-yr moving and government operations. These harmful con- average correlated highly with the moving sequences are extremely well documented by a average of GNP change in the subsequent two variety of reports such as Shoveling Up! The Cost of years. (p. 501) Substance to States (Center on Substance Abuse and Addictions, 2001). Second, zealots need cash: The illegal drug trade has been linked to the funding of Asymmetric Strategy Three: Stimulate terrorism—even the funding of likely al-Qaeda ac- the Prevalence of Substance Abuse tivities in the United States (Wannenburg, 2003). and Misuse Third, the illegal drug trade provides a powerful cover to overwhelm the mechanisms that detect the According to a wide variety of research reports smuggling of items or people who might be used in a (e.g., Kosten, Rounsaville, & Kleber, 1986), per- terrorist attack—even though early surveillance of ceived stress (e.g., danger, fear, worry, depression, drug smuggling might increase, as happened at both anxiety) among humans increases the rate of sub- Mexican and Canadian border crossings (Kelleher, stance abuse. Increased substance abuse or misuse 2001). is an obvious likely outcome from psychological, Thus, organized terrorism of the kind that physiological, and sociological events such as ter- occurs in an asymmetric conflict has many solid rorist attacks. Such information is freely available. strategic reasons to seek to increase substance For example, in testimony in 1991, I reported that abuse and misuse among the population of its en- alcohol sales at U.S. military base exchanges in emy. Is there any evidence of increased substance Germany stayed the same in the month of January abuse yet? I am not aware of any organized studies, 1991 even though some 100,000 troops had been but there are already some indices and evidence of deployed from these bases while their dependents the awareness of the strategy’s utility and emerging remained and were exposed—via television—to outcomes in the wake of September 11: threats of terrorism and potential casualties. For most people, the pain of terrorism is vicar- The New York Times has variously reported ious classical conditioning, and substantial research (e.g., Mcfadden, & Moynihan, 2005) that al- shows that a whole array of substances short-circuit Qaeda had elaborate plans to produce and sell a the felt pain from classical conditioning (e.g., Davis, very high-grade heroin for export to the United 1992). For example, opiates, benzodiazepines, mar- States and Western Europe. The Speaker of the ijuana, and alcohol can affect the potency of classical U.S. House of Representatives formed a special conditioning, although the mechanism may differ by committee to investigate the way in which the type of drug. For example, opiates and benzodia- illegal drug trade is being used to fund terror- zepines directly affect the learning of the pairing of ism (Associated Press, 2001a). stimulus and response. Alcohol may increase per- Bar sales of alcohol have increased substantially ceived safety through serotonergic and opiate rein airports, despite fewer fliers (Reel, 2001). ceptor mechanisms, yet still affect conditioned States are substantially cutting treatment dol- fear responses (e.g., Chung, Yoon, & Park, 1998; lars for substance abuse and related disorders Stromberg, 1992). Further, the pain- or fear- in the aftermath of September 11 (Alcoholism reduction properties, however, are typically achieved and Drug Abuse Weekly, 2002), which further only if the substance use state is maintained. Noyes enhances the military goals of the terrorist and Baram (1974) report that cannabis may work as attacks. a mild analgesic, which would be potentially de- The illegal drug trade increased by 25% in the sirable for those who experience perceived pain as a Caribbean area following the terrorist attacks result of terrorism. in the United States (Associated Press, 2001b). 170 Consequences of Terrorism

A survey of all states showed an increase in advantage to the weaker force in an asymmetric treatment seeking in 23 in the wake of the war. Poor detection or nondetection aids actual attacks (The COMPA Bulletin, 2002). terrorist attacks, and false positives undermine appeals for homeland security. Increasing substance abuse and misuse is a Mass appeals to increase vigilance to potential powerful strategy that organized terrorist groups threat may also have some serious, unintended utilize to harm a more powerful opponent and an consequences for mortality and morbidity from equally potent strategy for funding those attacks. various diseases. For example, sustained attention The principles for increasing likely substance abuse to potential threat increases the risk of cardio- or misuse are available to anyone who can use the vascular disease (e.g., Gump & Matthews, 1998; Internet (e.g., http://www.nida.nih.gov/) and un- Winters, McCabe, Green, & Schneiderman, 2000). derstands basic psychological research. It is possible that more people could die from sustained vigilance than from terrorist attacks. For Asymmetric Strategy Four: Increase the theoreticians of asymmetric war, this is simply Errors in Detecting Threats a bonus from a military strategy perspective.

Successful terrorist attacks depend on normal ci- Vigilance by Security Personnel tizens not noticing things—losing the ability to Homeland security involves thousands of persons process potential threats or increasing responses to hired to engage in vigilant behavior—airport per- ‘‘false positives’’ for the sake of disruption. Noti- sonnel, law enforcement officers, immigration of- cing potential threats requires sustained vigilance. ficials, post office employees, military personnel, Vigilance is a well-studied cognitive skill in psy- intelligence officers, and many more. Part of the chology, going back to research on radar operators military strategy of terrorists is to increase the in World War II. Homeland security involves failure of such personnel, both to create opportu- vigilance by average citizens and by paid employ- nity for attacks and to disrupt government. The ees at airports, immigration offices, and other lo- mechanisms for both are easy to manipulate with cations vulnerable to acts of terrorism. a modicum of knowledge from psychological research that is easily available. Vigilance by Private Citizens The first tactic is to foster all sorts of stress and Increasing the vigilance of private citizens poses a anxiety among those who are doing the screening. paradox. Pressure to maintain or increase vigilance Too much stress and anxiety reduces the accuracy can have an adverse consequence on the behavior of their vigilance tasks. It is easy to make such of citizens in the market place, increasing the stress and anxiety happen. For example, mass chance that the economy will suffer, thus creating media reports regularly chastise airports and air- a military victory in the context of an asymmetric lines for failures, and the jobs of security personnel war. Maintaining vigilance, however, is poten- have regularly been challenged as a way to ‘‘shape tially aversive for citizens, who are likely to have up behavior.’’ This type of pressure to be more heightened fear or anxiety as a result of constant vigilant as a result of threats to job security (e.g., ‘‘If cajoling to pay increased attention to potential you don’t find more security violations, you’ll get threats. Under such conditions, psychologists fired’’) has already been shown to decrease vigi- predict several outcomes: (1) Some people will lance (e.g., Singh and Singh, 1985). Emotional dis- make many errors in failing to distinguish real tress alone is sufficient to impair the performance threat from the mere pressure to perform; (2) some of even the most highly trained people (e.g., Si- will detect too many perceived threats that are not monov, Frolov, & Ivanov, 1980). Vigilance can be real; and (3) some people will opt not to engage in sustained with accuracy for only a short period of sustained attention because they may perceive it as time without significant training, positive reinfor- too aversive—creating an incentive for avoidance cement, and support. (e.g., Krohne, 1993). Perceived control also inter- Decision making in emergency situations has acts with vigilance accuracy in that lower perceived been studied and is relevant here. For example, control reduces accuracy (e.g., Lawler & Schmied, Janis and Mann (1977) detailed how defensive 1987). All of these errors provide some military avoidance or hypervigilance can become dominant Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning 171 in some disaster detection settings, which generally This ploy was then copied by others—with de- leads to maladaptive actions. For example, many vastating effects on the Israeli economy (Khan, people may become nonsensitive to cues while Swerdlow, & Juranek, 2001). others become oversensitive, meaning too many false positives or false negatives in the detection of Asymmetric Strategy Six: Undermine threats. Empirical evidence (e.g., Trivizas & Smith, Perceived Authority by Role Rigidity 1997) indicates that the attack strategies of terrorists seem well primed to evoke maladaptive In a classic study, Haney, Banks, and Zimbardo behaviors by supervisors and line personnel asso- (1973) had college students pretend to be inmates ciated with homeland security, with only short- or guards in the basement of the psychology de- lived effects of actual events on both employees partment of Stanford University. Soon the ‘‘guards’’ and the general public. began to evidence the behaviors that typically lead to the excesses often documented in prison settings. The ‘‘inmates’’ complied for the most part, subject to Asymmetric Strategy Five: Foster their roles. Few people aside from research psy- Piggyback Events chologists and military force-management person- An old saying exists in war: ‘‘An enemy of your nel know how much people assume the behaviors enemy is your friend.’’ Terrorism strategy seeks of their structured role. Thus, it would be reason- therefore to increase the likelihood that others will able to predict that many of those who ‘‘don the commit copycat or piggyback attacks. The ratio- uniform’’ of homeland security might come to en- nale ought to be obvious. The more copycats or gage in overzealous behaviors in the name of re- piggyback actions there are, the greater the impact ducing terrorism. This would increase as a function will be of vicarious classical conditioning because of perceived job stress and the pressure to be vigi- of perceived helplessness and lack of control. Fur- lant against the nefarious plots of terrorists. In the ther, the threat will be perceived as even more famous Stanford experiment, it took only days for diffuse and unpredictable. It would seem quite these behaviors to unfold. likely that any well-educated person involved in Role stereotypy and role ‘‘freezing’’ naturally planning terrorist attacks that are grounded in create an adverse reaction to the behavior of those psychological research would be likely to know in authority by others who are not part of the uni- of the probability of imitation following highly visi- form ‘‘script’’ or context. To some extent this effect ble crimes. There are several reasons to believe this is clearly an outcome of the Arab-Israeli conflict, theoretically: wherein public support for the Israeli position has eroded in many countries—precisely the goal of 1. Suicidal behavior is clearly more likely to fol- many of the Arab tacticians who fought against the low a high-profile suicide or suicidally moti- overwhelming military power of Israel. This dis- vated homicide, especially when accompanied satisfaction has even been voiced by academics and by extended media coverage in an apparent scholars within Israel (Shalhoub-Kevorkian, 2004). dose-response relationship (Etzersdorfer, Vor- To the extent that others come to see the exercise of acek, & Sonneck, 2001; Phillips & Hensley, authority as illegal or immoral, terrorist strategies 1984; Sonneck, Etzersdorfer, & Nagel-Kuess, begin to work. 1994; Stack, 2000). 2. Retributive violence may be copied more as a function of ensuing military action (Bebber, Using Psychological Theory to 1994; Diefenbach & West, 2001). Guide the Prediction of Targets of Mass Disruption The piggyback events, whether using the same targets as the original terrorists, are not material As I reflected on the attacks of September 11, it to the impact on affected communities. In 1978 a became more and more clear that the targets, dozen children in Holland and West Germany methods, and processes were very carefully thought were hospitalized after terrorists deliberately con- out from a psychological perspective, just as they taminated citrus fruit from Israel with mercury. were considered from a structural and logistical 172 Consequences of Terrorism point of view. When I have voiced this opinion, yoked to an audio source. The sheer simplicity of some people have seemed angry that one could give vicarious classical conditioning and the strong the terrorists credit for being intelligent or knowl- relationship of classical conditioning to issues of edgeable. To ignore their intelligence risks grave consumer behavior, addictive behaviors, mental danger and disruption. One rule exists in the mili- disorders, and cognitive competence under stress tary and intelligence operations: If you can think of make classical conditioning one of the most pow- it, your enemy already has. erful and low-cost strategies of an asymmetric war. Can psychological theory be used to predict Vicarious classical conditioning, as in the case of likely targets of terrorism in the United States or September 11, caused a crippling blow to the other countries? I believe so, and I suggest the United States. The question is, can we learn to following hypotheses: design a preventative strategy short of engaging the very purposes of strategists of terrorism? Hypothesis 1 Targets or conditioned stimuli that have high visual and iconic salience with related auditory Author’s Postscript cues will be preferentially selected for attack. For example, the Twin Towers are a better vicarious At the time of final editing, the Dubai Ports con- classical conditioning stimulus for fear than a troversy had just surfaced, and the deal was scut- building like the Sears Tower or the Empire State tled before sending back the final manuscript. Building. The visual image and verbal labels are Arabic nationality, terrorism risk, and serious not as strong in the latter cases, and this assertion threat had become so conditioned in the public could be tested in rather simple classical con- mind that a political firestorm emerged, resulting in ditioning experiments in which the stimulus is a cancellation of the deal. While the merits of the embedded in brief presentations associated with issue can be debated in honest ways, the vicarious unconditioned stimuli. classical conditioning effect set in motion on Hypothesis 2 September 11th continued to achieve rippling asymmetric military effects, as predicted. That is, Targets or conditioned stimuli that are associated perceived prejudice multiplied between the United with projections of power, potency, and univer- States and Arabic peoples, setting fertile ground for sality in the United States will be preferentially se- terrorism recruitment; public trust in leaders (e.g., lected for attack. Thus, terrorist operations would the President and its backers) was further eroded be far more likely to involve Federal Express, Uni- as witnessed by spot polls and pundits; and eco- ted Parcel Service, or the dollar currency than U- nomic commerce is set back now with threats of Haul trucks, DHL, or bank checks. United and commercial boycotts of United States products by American Airlines are far more likely to be selected key Arabic trading partners. While the specifics as a delivery mechanism than Delta or Southwest could not be predicted theoretically, the general Airlines. trajectory of a culture of posttraumatic condition- Hypothesis 3 ing could. Targets or conditioned stimuli that convey everyday connotations of safety, happiness, productivity, and/or pleasure are more likely to be selected. References Thus, something like Coca-Cola, fire trucks, or school buses would be a better vehicle for the Alcoholism and Drug Abuse Weekly (2002, January 7). delivery of terrorism than a bottled water com- Treatment Dollars Cut After 9/11. Armfield, J. M., & Mattiske, J. K. (1996). Vulnerability pany, a regular truck, or a tour bus. representation: The role of perceived dangerous- Vicarious classical conditioning is testable by ness, uncontrollability, unpredictability, and dis- rather simple laboratory experiments that were gustingness in spider fear. Behaviour Research and first pioneered more than 50 years ago. A com- Therapy, 34(11–12), 899–909. puter or slide projector could be used to present Associated Press. (2001a, September 21). ‘‘Hastert the visual stimuli, and either one could easily be forms task force on drugs.’’ Psychological Weapons of Mass Disruption Through Vicarious Classical Conditioning 173

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Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks Susan E. Brandon Andrew P. Silke

Newspapers mentioned that a recent survey showed that seven out of every ten Americans suffer psychological problems following the attacks on New York and Washington. Osama bin Laden to Mullah Omar, quoted in Cullison (2004)

Humans show an extraordinary and local and national histories, not because these capacity to survive in adverse situations. Although are not important but because we want to consider there are tragic instances of people who are per- the most frequently occurring behaviors and the manently scarred by trauma, these are relatively most general behavioral trends. While there is re- few; the majority of those who are involved in vio- latively little empirical analysis of terrorism or lent or life-threatening events do not exhibit long- terrorists’ behaviors (Silke, 2003, 2004)—despite term symptoms of distress. On the whole, they re- the plethora of materials published since 9/11— cover and may even exhibit resilience (Bonanno, there is a significant body of scientific investigation 2004). When terrorists strike neighborhoods, what on how people respond to trauma. It is that do- people most often do is wash the blood off the main of science that we draw on to understand and streets and continue on. How and when such re- predict how people are most likely to respond to covery occurs is the theme of this chapter. terrorist attacks. Here we consider the possibility that the survival, recovery, and occasional resilience seen after terrorist incidents or other disasters reflect pro- Powerful Forces for Normalcy cesses of dissipation, adaptation, habituation, and sensitization that are ubiquitous to biological or- Dissipation, Adaptation and Habituation, ganisms. We also consider that many instances and Sensitization of human survival—including thriving—are the result of broad cognitive and affective reappraisal Common patterns of responses to single or re- processes that mediate the impacts of our inter- peated aversive events have been well documented actions with the world and of normative tenden- in the psychological literature. However, the ap- cies to seek out others under conditions of stress. parent robustness and ubiquity of these responses We describe the near- and long-term psycho- across many organisms and circumstances suggest logical effects of exposure to terrorist attacks and that a typology of such responses may help us to the threats of terrorist attacks here, largely ignor- understand what kinds of behaviors are likely to ing important differences in location, type of strife, ensue when an organism confronts a potentially

175 176 Consequences of Terrorism

(a) (b) (c) (d) (e)

Dissipation decay Adaptation Habituation Sensitization Intensity

Time

Figure 13.1. A likely immediate reaction to a threatening or harmful event. The Y-axis represents the intensity of the response, and the X-axis represents the passage of time. Discrete traumatic events are represented by the black squares below the X-axis. (a) A single response to a single event. (b) A more salient event evokes a stronger response. (c) Adaptation, observed following longer-term exposure to a single event. (d) Habituation, observed as a decreasing response to a traumatic event that occurs repeatedly across time in an otherwise stable context. (e) Sensitization, observed as an invigorated response elicited when the organism is in a heightened state of anxiety, fear, or vigilance. harmful event. How well these patterns predict re- longer-term exposure to an event (if the spider sits on sponses to events as complex as natural or tech- the person’s arm), adaptation is the likely outcome, nological disasters is an empirical issue. We offer illustrated in (c). Although some decay occurs after the patterns here to serve as a heuristic and to help the initial response, the system does not return to organize the discussion. baseline but settles at some intermediate level, above A single exposure to a threatening or harmful baseline. This adaptation to the change in status quo event is likely to provide an immediate reaction occurs via the expenditure of the psychological, (see Figure 13.1).1 The y-axis represents the in- neural, neuroendocrine, and neuroimmune systems’ tensity of the response, and the x-axis represents protective mechanisms. This expenditure, however, the passage of time. Discrete traumatic events are is likely to result in the depletion of the ability to represented by the black squares below the x-axis. respond to further assault or need (McEwen, 1998; A single response to a single event, shown in (a), McEwen & Mendelson, 1993). reaches its peak quickly and then dissipates. For When a traumatic event occurs repeatedly in an purposes of explanation, we might assume that the otherwise stable context, as shown in (d), the re- aversive event is a spider crawling up the arm of a sponse to the event decreases in vigor, a phenom- spiderphobic person. The response, which might enon called habituation (Thompson & Spencer, be fear, could be assessed by measuring an in- 1966). Thus, if a person is repeatedly exposed to a crease in heart rate or respiration, by recording spider crawling up his arm, even the phobic will how vigorously the person shakes his arm to get begin to show a decreased fear response. Habitua- rid of the spider, or by asking this person how tion has three characteristics that are relevant here. afraid he feels. In the absence of repeated or con- First, it is relatively specific to the eliciting event: tinued exposure to the event (if the spider is re- Habituation to a spider is not likely to transfer to moved), psychological and biological systems another fearful insect or event (e.g., a snake) and typically show the simple return to baseline shown even less to a fear of elevators or public speak- in (a). The simplest explanation for the return to ing. Second, habituation itself may dissipate under baseline is the decay or dissipation of these ‘‘high conditions in which the aversive event does alert’’ response systems. not reoccur for a significant period of time. Third, If the event is more salient—more frightening, habituation is sensitive to the context in which it more intense, more catastrophic (a huge tarantula)— occurs, where the term context refers to the external the response is stronger, as shown in (b). With physical environment and internal psychological Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 177 and physical states of the organism. The ability of the history of psychiatric problems and the avail- most habituated responses to generalize across ability of helping resources (Breslau et al., 1991; contexts—to be elicited within a different context— Norris et al., 2001a, 2001b; North et al., 1999; is fickle, and habituation that occurs or is acquired Shalev, Peri, Canetti, & Schreiber, 1996). in one context does not often transfer to a novel con- Currently, the most common measure of psy- text. Thus, acquiring a robust habituated response chological impairment following trauma such as a to a spider in the doctor’s office may not be of much car accident, rape, victimization in a violent crime, use when the spider is found at home in bed. or exposure to terrorist attack and other techno- What appears in some ways to work against logical or natural disasters is the assessment of habituation is sensitization. Many response sys- a relatively complex cluster of factors that, when tems show increased vigor when they are elicited they occur together, provide a diagnosis of post- while the organism is in a heightened state of an- traumatic stress disorder (PTSD). PTSD descri- xiety, fear, or vigilance, a phenomenon referred to bes the condition of someone who has been ex- as sensitization (Borszcz, Cranney, & Leaton, 1989; posed to a traumatic event; experiences at least one Cacioppo et al., 2002; Connolly & Firth, 1978; recurrent symptom related to the event (such as Davis, 1972; Hammond, 1967). Imagine walking intrusive, repeated recollections or dreams of the alone in a dark forest, fearful of what is all around: incident); persistently avoids people, activities, or A spider landing ever so lightly on one’s arm is places associated with the event; and cannot recall likely, in this context, to elicit an especially fearful important aspects of the trauma. This person also response. This pattern of invigorated responding is shows disinterest in the usual daily activities and a illustrated in a comparison of Figure 13.1(d) with restricted range of affect or a sense of foreboding Figure 13.1(e). As can be seen, habituation is in about the future to the extent that they no longer effect attenuated. expect to have a normal life. These symptoms, in The temporal characteristics of these processes conjunction with hyperarousal (difficulty in fall- appear to be a function of the intensity of the in- ing or staying asleep, outbursts of anger, hyper- itial, impacting event: Very strong events provoke vigilance, inability to concentrate, or exaggerated a stronger initial response and a slower return to startle responses), may lead to significant impair- baseline in the absence of further stimulation. ment in social, occupational, or other important These responses are also modified by experience— areas of the person’s life. To the extent that such that is, they involve significant learning—so that dysfunction is present, the individual exhibits PTSD how someone reacts changes across time: People (American Psychiatric Association, 1996). It has are likely to vary in the intensity and duration of been estimated that baseline rates of PTSD among these various responses as a result of their own Americans is about 3%–4% (National Institute of unique life experiences. Mental Health, 2004). Exposure to psychological trauma has con- Baseline: Normal Levels of Emotion sequences for physical as well as psychological and Stress health. To the extent that such trauma disrupts home, family, and community life, as well as the Epidemiological studies within the past decade ability to work and play, it will have profound have found that the risk for exposure to a sig- effects on everyday behavior—including those nificant aversive event or trauma in the general everyday social and individual behaviors that are population of the United States is as high as 50%– related to half of all causes of morbidity and 60% (Breslau, Davis, Andreski, & Peterson, 1991; mortality in the United States (National Center McFarlane, 1986; Norris, 1992; Ozer & Weiss, for Health Statistics, 2003). Psychosocial variables 2004), but the large majority of victims of trauma have also been shown to be significant risk factors do not develop chronic posttraumatic mental for chronic disease risk and recovery (Barefoot health problems (Breslau et al., 1991; Kessler, et al., 2000; Leserman et al., 1999). For example, Sonnega, Bromet, & Hughes, 1995; Ozer & Weiss, stress may contribute directly to heart disease by 2004). The degree of vulnerability correlates with narrowing the blood vessels, leading to athero- the magnitude and severity of the trauma as well as sclerosis (Rutledge et al., 2003). Blascovich and 178 Consequences of Terrorism

Tomaka (1996) report that extreme levels of upset, being bothered by disturbing memories, or arousal, such as terror, rage, lust, and ecstasy, are having difficulty concentrating or falling asleep likely to play a role in stress and stress manage- (Schuster et al., 2001). The impacts of the attacks ment, and dysfunctional arousal plays a role in were even felt far beyond New York and Washing- coronary heart disease (Blascovich & Katkin, 1993) ton: Almost 20% of Americans across the country and immunosuppression (O’Leary, 1990). Negative reported symptoms of distress (Silver, Holman, emotions have been linked to enhanced suscept- McIntosh, Poulin, & Gil-Rivas, 2002). ibility to infection (Herbert & Cohen, 1993), As might be expected, the degree of exposure poorer response to an influenza vaccine (Kiecolt- to an attack mediates responses to it. People who Glaser, Glaser, Gravenstein, Malarkey, & Sheridan, are close to the site experience more salient events; 1996; Rosenkranz et al., 2003), and impaired furthermore, they are subsequently reminded of wound healing (Kiecolt-Glaser et al., 1996). Alter- the attack more often by seeing, hearing, and natively, positive emotions are correlated with good smelling disaster-related cues. Disaster relief work- health: A longitudinal study of Catholic nuns found ers, firefighters, police, and emergency personnel that those who expressed the most positive emo- show the highest rates of PTSD, particularly when tions when they were young lived up to 10 years the disaster is of human origin (North et al., 2002). longer than those who had expressed less positive Data collected after 9/11 show that 10% of adults emotions earlier (Danner, Snowdon, & Friesen, who lived south of 110th Street in Manhattan 2001). (roughly the bottom two-thirds of the island) re- It is important to recognize that expectations ported symptoms consistent with a diagnosis of and perceptions mediate the impact of many current PTSD after the attacks, while south of stressors and that an event has a stressful impact Canal Street, only blocks from the site of the de- to the extent that it is appraised as taxing or ex- vastation, the incidence was 20% (Galea et al., ceeding one’s resources and endangering a person’s 2002; Galea et al., 2003). In general, the pre- well-being (Lazarus & Folkman, 1986; McEwen & valence of probable PTSD was higher in New York Mendelson, 1993). Antonovsky (1985) has argued City (11%) than in Washington, DC (3%), and the that stress can be health enhancing when stressful rest of the country (4%). People in the New York situations are perceived as challenges and when City metropolitan region were about three times these challenges are subsequently perceived as more likely to have a probable case of PTSD than being met; that is, he argued for the salutogenic, as those who were elsewhere that day (Schlenger well as the pathogenic, effects of stress (Durkheim, et al., 2002). Similar data were reported following 1951; Selye, 1991; Suedfeld, 1997). the 1995 Oklahoma City bombing of the Murrah Building: Seven weeks after the violence, a clini- Coping With Large-Scale Single Events cal needs assessment of more than 3,000 sixth- through twelfth-grade students in Oklahoma City A Lexis/Nexus search of all major English news- showed posttraumatic stress symptoms (15% re- papers and TV news in the last week of August 2001 ported that they did not feel safe, and 34% said showed approximately 50 news stories [that] were devoted to public health scares or crises. During the that they worried about themselves and their fa- week of October 23–30 (the height of the anthrax milies) (Pfefferbaum et al., 1999). These symptoms events in the U.S. in the Fall of 2001), there were were the highest among those who had experi- 558. About 1 month later, the rate dropped to ap- enced a personal loss. Two hundred fifty-five proximately 120. survivors of the direct blast showed a high in- Osterholm (2001) cidence of postdisaster stress (45%) and PTSD (34%) 6 months after the bombing (North et al., Dissipation 1999). (The fatality rate inside the Murrah Build- The attacks of September 11, 2001, on New York ing was 46%, and 93% of those in the building and Washington, DC, produced widespread reac- were injured [North et al., 1999].) tions among residents of those cities, as well as The effective intensity and the temporal char- across the country and the world. Three to five acteristics of such attacks are also mediated by days after the attacks, about 90% of the residents victim characteristics that, in some instances, may of New York City and Washington reported feeling override proximity effects (Galea et al., in press). Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 179

After the Oklahoma City bombing, women re- making such actions the most common coping ported about twice the rate of PTSD symptoms behavior (Schuster et al., 2001). In retrospect, ci- of men, and more than half of the victims with vilian and emergency response personnel report bombing-related PTSD had a predisaster lifetime that, when under attack, their most urgent need is history of psychiatric illness (North et al., 1999). to find out whether their family and friends are all In New York City after 9/11, Hispanics, African right. The most frequent coping activities among Americans, and those with poor general health, Israelis, after more than 2 years of exposure to less education, and lower income were more repeated violence directed at civilians, was to stressed than others (Galea et al., 2003; Rasinski, check on the location and safety of friends and Berktold, Smith, & Albertson, 2002). family after an attack; the second most common For most people, the distress produced by was to seek social support (Bleich, Gelkopf, & exposure to a single incident does not persist for Solomon, 2003).2 very long. With some exceptions, responses to the The most frequently reported emotional re- attacks on 9/11 dissipated with the simple passage sponses among Americans to the attacks on 9/11 of time and the absence of any additional attacks were anger, sadness, and disbelief (NBC News/Wall on U.S. soil. Surveys of adults in New York City 1 Street Journal, September 12, 2001). Sadness was month, 4 months, and 6 months after the attacks the most frequent reaction among New Yorkers, showed that the prevalence of probable PTSD re- followed by anxiety and fear (Felton, 2002). Sixty lated to the violence in Manhattan had declined to percent of Americans said that they cried, 50% that 9.5% after 1 month, to 1.7% after 4 months and they were tense or nervous, and more than 45% to 0.6% after 6 months (Galea et al., 2003). The reported feeling ‘‘sort of dazed and numb.’’ This distress was transitory for the rest of the United pattern of responses is similar to that found among States as well (Schlenger et al., 2002); a nationwide Americans after the Kennedy assassination in 1963 probability sample indicated that distress symp- (Rasinski et al., 2002). toms fell from 17% after 2 months to 6% after 6 Sadness fosters reflection, resignation, and months (Silver et al., 2002). acceptance and evokes sympathy and helping responses in others (Izard, 1992, 1993). Preliminary Adaptive Behavior: Seeking Others data on the initial reaction to 9/11 among some Stress and uncertainty produce social behaviors: 90,000 service recipients of New York City’s Pro- People seek out others, perhaps to enhance social ject Liberty (a consortium of New York State Of- support (Cohen & Willis, 1985; Mehl & Penne- fice of Mental Health, county and New York City baker, 2003) or to help to affirm their cultural mental health departments) showed that people view of the world and the threat (Pyszczynski, did many things in response to the attacks, but Solomon, & Greenberg, 2002). Almost 100% of what they did not do was withdraw from others Americans surveyed after 9/11 reported that what (Felton, 2002). Donations of bottled water, food, they did that day was to talk with others about clothing, and dog food for the animals helping the attacks (Schuster et al., 2001). Passengers on in the search around the World Trade Center Flight 93, which crashed in the Pennsylvania swamped the capabilities of food banks and local countryside, and as many as 353 workers in the Salvation Army posts so that some of it had to be World Trade Center towers, called family and shipped to warehouses 90 miles from New York friends when they realized that what was hap- City (Dwyer, 2001). A national survey found 36% pening around them was likely to be catastrophic of Americans making donations to relief services (Glanz, 2002). The calls were to say good-bye, (Schuster et al., 2001). A large-scale survey of send love, and, in at least one instance, to confirm more than 50,000 people in various disaster si- their location so that their family would know of tuations found that social continuity and access to their certain death and not wonder what had substantial personal and community resources happened (9/11 Commission Report, 2004). Al- mitigate impact. Disasters with more dire effects, most 30% of Americans polled said that they had such as Hurricane Andrew in 1992 and the 1989 called or emailed a friend or relative in New York Exxon Valdez oil spill in Alaska, involved not or Washington on 9/11, and 75% of Americans only destruction and threat to life but also pro- checked on the safety of close family members, longed social and financial disruption and loss of 180 Consequences of Terrorism resources (Norris, Watson, Hamblen, & Pfeffer- circulating brain dopamine, which is also asso- baum, 2003). ciated with rewarding events (Ashby, Isen, & Turken, 1999). It has been suggested that positive Adaptation: Compensatory Responses and emotions are part of resilient individuals’ reactions Positive Emotions to adversity (Bonanno, Papa, & O’Neill, 2002; The New York Times series ‘‘Portraits of Grief,’’ Keltner & Bonanno, 1997). Positive emotions can which ran from September 2001 to December 31, help reduce distress both by distracting from and 2002, offered a small photo and paragraph about undoing the effects of negative emotions (Freder- each of some 1,800 of the 2,937 people who died ickson & Levinson, 1998; Keltner & Bonanno, in the World Trade Center on 9/11. Unlike the 1997). Importantly, positive emotions may work usual obituary, these ‘‘portraits’’ offered joyful and by increasing contact with a social support net- humorous anecdotes that family and friends re- work. To the extent that groups or communi- membered about those who died that day. Lazarus, ties lose loved ones and members, remedial social Kanner, and Folkman (1980) have suggested that processes and social bonding are likely to coun- positive emotions serve as breathers (temporarily teract the devastating effects of loss due to vio- freeing a person from the stress of an experience lence. An interesting possibility is that the human and allowing pleasurable diversions), as sustainers tendency to seek out and engage in social beha- (fostering the persistence of coping efforts), and as viors that are elicited and exacerbated by the threat restorers (replenishing damaged or depleted re- of an attack is sufficient not only to help people to sources or fostering the development of new re- cope with that immediate challenge but serves a sources). Nonpathological grief, which occurs in broader healing function as well (Curran, 1988). the majority of instances of loss, is known to in- The supportive role of others has been shown volve the recognition of positive outcomes, such as to buffer cardiovascular reactivity to psychologi- happy thoughts, beliefs, and appraisals, positive cal stress (Uchino, Cacioppo, & Kielcolt-Glaser, emotion, and laughter (Bonanno, 2004). 1996). Two weeks after the 9/11 attacks, almost 70% Social psychologists have discovered a peculiar of Americans reported positive emotions, such as human tendency to recover better and faster to being excited about and interested in life; feeling major trauma than to minor trauma. This pattern proud, pleased, or accomplished; and ‘‘on top of may be part of what Gilbert, Lieberman, Mor- the world’’ and as if ‘‘things were going their way.’’ ewedge, and Wilson (2003) call the region-beta Less than 35% reported negative emotions, such as paradox, where the time to recovery from a minor feeling restless, lonely, bored, depressed, or upset. insult is longer than the time to recovery from a By the end of 2003, 70% of Americans claimed major one. The notion is that, in the instance of a that the threat of terrorism had had a positive im- major assault, psychological attenuation processes pact on their lives, either by making them evaluate are more likely to come into play (cf. Aronson & what is important in their lives or by making them Mills, 1958; Zimbardo, 1966). Wilson and Cairns stronger and more resilient. At the same time, (1992) reported that residents of Enniskillen, the number of Americans who thought that others Northern Ireland, where a bomb killed 11 people were helpful was higher than it had been since and injured 60 others, exhibited more active and the 1970s, a view that remained consistent in the fewer passive coping behaviors than residents of subsequent year (Rasinski et al., 2002). Similarly communities less under attack. Rather than en- positive outcomes were reported among Americans gaging in denial or distancing mechanisms, the after the Cuban missile crisis in 1962 (Smith, residents of Enniskillen accurately recalled the 2002). violent event and actively sought social support, Positive emotions appear to have a ‘‘broad- often via church attendance and religiosity. Simi- ening’’ effect (Frederickson, 1998, 2001), which larly, among Americans who knew someone hurt is to produce flexible, creative, and open-minded or killed in the 9/11 attacks, the high levels of thinking (Frederickson & Branigan, 2001; Fre- stress reported immediately after the attacks had derickson, Tugade, Waugh, & Larken, 2003), an returned to normal within less than a year, and outcome that may be correlated with an increase in those who knew someone hurt or killed in the Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 181 attacks had some of the highest levels of recovery Once an unexpected event occurs and people of any subgroup, reporting nearly three fewer have an intense emotional response to it, they are symptoms (Rasinski et al., 2002). able and likely to make sense of the event quickly, even without realizing that they are doing so Adaptation: Compensatory Responses (Heider, 1958; Piaget, 1952). Post hoc analysis of and Affective Reappraisal an event makes it understandable, and to the ex- An event is stressful to the extent that it is ap- tent that this is so, people will think less about it, praised as taxing or exceeding one’s resources and and the intensity of the emotional response is endangering one’s well-being (Lazarus & Folkman, likely to decrease (Wilson & Gilbert, 2003). With- 1986). What appears to matter most is what we in 1–2 days, Americans went from thinking such expect about the world. These expectations shape an attack would not happen on domestic soil our perceptions, and our perceptions shape our to expecting another assault. On September 13, emotional, cognitive, and physiological reactions 2001, a Time/CNN Poll found that 64% of their to stressful events. Wilson and Cairns (1992) found national sample had thought that an attack as that residents of Northern Ireland who were living serious as those that had occurred would never in towns with a greater incidence of civil violence happen; an NBC News/Wall Street Journal poll at were more likely to exhibit psychological disorders the same time found that 66% of respondents only if they perceived a high level of violence; thought that another attack in Washington and those who perceived little or no violence exhib- New York was likely. A Gallup poll on September ited no more psychological distress than did re- 11, 2001, found that the assaults were interpreted sidents of towns with a lower incidence of civil as ‘‘an act of war’’ by 86% of their sample, and 78% violence. identified Osama bin Laden as ‘‘very likely’’ to have In the instance of both the Japanese attack on been personally involved in the violence; another Pearl Harbor on December 7, 1941, and the attacks poll 2 days later showed that 83% of the sample on New York and Washington on September 11, blamed bin Laden (Pew research survey, Septem- 2001, the events were unanticipated by the Amer- ber 13–17, 2001), and a majority interpreted the ican public. The immediate response to 9/11 was attacks as a result of U.S. foreign policy in the comparable to or greater than that to Pearl Harbor Middle East (Pew, 2001). in terms of surprise and dismay (CBS news poll, One might wonder why Americans were so September 12, 2001; NBC News/Wall Street Journal surprised. Terrorism was not new to the United poll, September 12, 2001). In one national poll, States. However, previous attacks could be de- more than 85% thought that the attacks on 9/11 scribed as not only distant but also increasing comprised ‘‘the most tragic news’’ in their life- gradually in intensity, allowing for habituation and time (CNN/USA Today/Gallup poll, September 11, adaptive processes to mute reactions. Until the 2001). Moreover, although the attackers targeted 1960s, international terrorism focused on indi- Washington, DC, and New York City, the events viduals and occurred primarily via assassination; were viewed as attacks on the nation at large, and random attacks and the killing of innocent by- people across the country reported intense emo- standers began in the late 1960s. Hostage taking tional responses. Decreased heart rate variability—a and airplane hijacking began in the early 1970s, characteristic associated with increased cardiovas- and embassy attacks began in the late 1970s. Ca- cular and sudden death in patients with and with- sualties began to number in the hundreds by the out heart disease—was reported for the week 1980s, with car bombs among military person- following 9/11 among 12 patients in the Yale New nel and civilians and the downing—rather than Haven Hospital, located some 90 miles northeast of hijacking—of airplanes. In the United States, the New York City (Lampert, Baron, Craig, McPherson first successful attack by international terrorists was & Lee, 2002). Because the more unexpected an the 1993 bombing of the World Trade Center, event, the greater the emotion it provokes (Kamin, which killed 6 (and wounded more than 1,000). 1968; Ortony, 1988), the robust emotional re- The 1995 bombing of the Murrah Building in Ok- sponses to the attacks on 9/11 were in many respects lahoma City, which killed 167, was not character- predictable. ized as an attack by an organized, international 182 Consequences of Terrorism terrorist network but as the behavior of one or two wail readily frightened people, and, at nights, the individuals, which probably marginalized its sig- noises of automobile or tramcar gears were con- nificance as a threat for most Americans (Hoffman, tinually mistaken for warnings. Before the end of 1940, Londoners were general taking no notice 1998; Stern, 1999). In some respects, this pattern of of sirens at all ...unless accompanied by the noise gradual increases in the ferocity of the attacks, with a of planes, gunfire, or bombs. ...In some areas [it] is concomitant rise in the number of deaths, made it a social faux pas to mention the fact that they have highly likely that the next terrorist assault would go sounded. They provoke irritation and boredom.’’ largely unnoticed by the American and perhaps the Vernon (1941, p. 459) Western European public, unless the perception of State and local responders in Israel, where suicide the attacks was that they were significantly beyond bombers have killed more than 300 Israelis and accommodation ranges. injured more than 3900 others since the 2000 start of the al-Aqsa intifada, have developed an impact- Adaptation: Compensatory Responses and mitigation strategy by removing as much evidence of the attack as quickly as possible. After immedi- Cognitive Reappraisal ate medical aid, teams come to pick up body parts Stressful life events are more likely to cause long- and wash off blood from the streets and buildings term difficulties if they shatter a person’s view of where a blast occurred, and structural damage to the world (Davis & Nolen-Hoeksema, 2001; those streets and buildings is repaired as quickly as possible. Parkes, 1971). Religion is known to foster recovery Hoffman (2004) during bereavement, perhaps by affording a way of understanding how the loss is consistent within a larger, stable belief system and by providing so- Habituation and Sensitization cial support from a religious community (McIn- In the past 10 years, more than 210,000 Americans tosh, Cohen Silver, & Wortman, 1993; Stroebe & have been the victims of criminal murder, more Stroebe, 1993). Finding meaning and an acceptable than 300,000 people have taken their own lives worldview is a core component of the grieving in suicide, 420,000 people have been killed in process (Davis & Nolen-Hoeksema, 2001; Parkes, car accidents, 5,400,000 have died of cancer, and 1971). People under stress often exhibit more re- nearly 7,500,000 have died as a result of heart ligious behaviors than they do when not under disease (Anderson, 2001; Fox & Zawitz, 2001). In stress: The Centers for Disease Control’s ongoing the same 10 years, some 3,300 Americans have lost Behavioral Risk Factor Surveillance System found their lives as a result of terrorism. Relatively few that about 50% of the residents of Connecticut, Americans know someone who was directly af- New Jersey, and New York had participated in fected by a terrorist attack, whereas many of us religious or community memorial services within know people who have died as a result of murder, 1–2 months after 9/11, and more than 10% had suicide, car accidents, cancer, or heart disease. We attended a funeral or memorial service for an ac- might consider that part of what makes terrorism quaintance, relative, or community member (Mor- so frightening is that it is unfamiliar. bidity and Mortality Weekly Report, 2002). A More than 30 years of violence in Northern nationwide survey found that 90% of Americans Ireland have offered an opportunity to study the had religious thoughts or engaged in religions ac- effects of long-term exposure to civil violence and tions and that 60% had participated in memorial or terrorist attacks. The violence, which began in the commemorative group activities (Schuster et al., late 1960s, peaked in 1972 with more than 10,500 2001). shooting incidents in that year alone (Curran, 1988). Records from more than 1,500 bomb vic- Coping With Instances tims seen in emergency departments between of Repeated Attacks 1969 and 1972 indicate that about 50% showed psychological disturbances. A study of civilians An early anecdotal report of civilian behavior during injured between 1979 and 1984 found more than the air raids in England recalled that reactions to the 20% with diagnosable PSTD, primarily overarousal air raids seemed to be a function of how much experience the populace had with them: Early in the (startle and sleep disturbances) (Loughrey, Bell, war, ‘‘the mere sounding of sirens was enough to Kee, Roddy, & Curran, 1988). These people ex- send large numbers to shelters. ...Their gruesome hibited varying symptom thresholds—the longer Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 183 they were exposed to the violence, the more likely as they enter adulthood, such as educational they were to exhibit the PTSD symptoms initially— disruptions and a shortage of jobs (Cairns, 1987; but there was some apparent habituation as well Thabet, Abed, & Vostanis, 2002). High rates of because only half of the victims had emotional PSTD were found among Kuwaiti and Kurdish reactions lasting longer than 3 months (Kee, Bell, children after the 1991 Gulf War, as well as among Loughrey, Roddy, & Curran, 1987; see Bleich, children in Croatia and Bosnia, especially if they Dycian, Koslowsky, Solomon, & Wiener, 1992, for were displaced from their homes and communities evidence of apparent habituation during the First (Thabet, Abed & Vostanis, 2002; see also Freud & Persian Gulf war [1991]). An in-depth analysis of Burlingham, 1943, for similar observations about psychiatric morbidity in Derry, which has a social children who experienced the bombings of Lon- deprivation among the worst in Northern Ire- don in World War II). Thabet & Vostanis reported land as well as a 30-year history of civil conflict, in 1999 that more than 40% of Palestinian chil- found 1-month and 1-year prevalences of psy- dren showed moderate to severe PTSD reactions, chiatric disorder not different from those of a de- and more than 20% showed high rates of anxiety prived inner-city section of London (McConnell, and behavioral problems, presumably as a function Bebbington, McClelland, Gillespie, & Houghton, of the longstanding, armed intifada conflict be- 2002). tween 1987 and 1993. These compared with an In Israel, since the 2000 start of the al-Aqsa overall prevalence of 1%–15% for emotional and intifada, suicide bombers have killed more than behavioral disorders of children in the population 300 people and injured more than 3,900 others. In as a whole. As the conflict subsided, evidence of 2002, a nationally representative sample of about children’s PTSD decreased to about 10% (a 1-year 500 Israelis queried by a telephone survey after 19 follow-up; Thabet & Vostanis, 1999), although the months of attacks that had occurred with in- rate of general emotional and behavioral disorders creasing frequency showed that about 10% ex- was as high as 20%, as rated by parents. hibited symptom criteria for PTSD, 77% reported There is some evidence of sensitization effects at least one traumatic stress–related symptom, and (heightened arousal after repeated exposure to 59% reported feeling depressed (Bleich, Gelkopf, trauma) among children who are exposed to re- & Solomon, 2003). A significant portion of the peated threats of violence. The more recent al-Aqsa respondents in this survey had experienced earlier intifada in Palestine has been characterized not only traumatic attacks such as previous wars, terrorist by civil violence and armed conflict but also by attacks, or the Holocaust. Despite these histories bombardment and home demolition. Thabet, Abed, and the fact that almost half of the participants in and Vostanis (2002) found severe to very severe the sample had been exposed to civilian violence PSTD among children who had lost their homes. either personally or through a friend or family These rates were significantly higher than among member (with 60% reporting that they felt their children who had also lived in the Gaza Strip but lives were in danger), the emotional impact ap- had not been directly bombarded or lost their peared to be moderate. The rate of PTSD found homes (although they had likely been exposed to among Israelis after 19 months of repeated attacks bombardment by helicopters, mutilated bodies on was lower than the rates reported for people in the TV, and media coverage of the conflict). The most immediate vicinity of the World Trade Center frequent symptoms were difficulty concentrating, towers 2 months after 9/11, which might be in- sleep disturbances, and avoidance of reminders; terpreted as habituation among Israelis to the re- these children also had higher total fear scores than peated attacks. did the comparison children. However, a reverse There is evidence that habituation and resi- trend—perhaps an instance of the region-beta lience processes might be different among chil- paradox referred to earlier (Wilson & Gilbert, dren and that they need to be assessed differently. 2003)—was observed for anxiety problems: These Children who are exposed to civil violence some- were higher in the group not directly bombarded times exhibit exaggerated levels of antisocial be- than in the group that was. This same trend was havior, although this is complicated by the fact observed among children involved in the Bosnian that the same civil violence is likely to result in conflicts (Smith, Perrin, Yule, & Rabe-Hesketh, other disadvantages for these children, especially 2001). As the authors noted, this divergence may 184 Consequences of Terrorism also have occurred because the more severe PTSD to normal functioning, which had ceased tem- masked the anxiety in the exposed children. porarily. Functioning returns to preevent levels, whereas resilience is viewed as the ability to Adaptation: Compensatory Responses maintain equilibrium (Bonanno, 2004). In addition, Lead to Resilience resilience is more than the absence of psycho- It has been suggested that, in England during pathology; resilient people may show transient per- World War II, there was a ‘‘Britain can take it turbations in functioning (for several weeks) but mood’’ for much of the period from 1940 to 1941, demonstrate a stable trajectory of healthy func- and prewar hysteria about mass casualties was tioning over time and ‘‘the capacity for generative replaced by a new myth of universal resilience. experiences and positive emotions’’ (Bonanno, Investigators were unable to describe a significant 2004, p. 2). increase in ‘‘neurotic disturbances,’’ even though On the individual level, resilience differs from there was an apparent increase in functional so- optimism in that resilient people recognize the ef- matic disorders (headache, fatigue, dyspepsia, joint fects of stressful situations, yet still experience and muscle pain, indigestion) (Jones, Woolven, positive outcomes (Masten, 2001; Tugade & Fre- Durodie, & Wessely, 2004, 2006). derickson, 2002). These people are likely to elicit A telephone survey of Israeli residents con- positive emotions though humor, relaxation, and ducted in 2002, some 2 years after the beginning of optimistic thinking. Factors related to resilience the al-Aqsa intifada in Israel—and after the deaths include hardiness (Kobasa, Maddi, & Kahn, 1982), of 318 Israeli civilians by knife or gun attacks, which is defined as the capability of finding drive-by shootings, or suicide bombings—showed meaningful purpose in life, the belief that one can that although symptom criteria for PTSD were met influence one’s surroundings and the outcome of by 9.4% of the sample, the majority of the partici- events, and the belief that one can learn from both pants felt optimistic about their personal future positive and negative experiences; a kind of self- (82%) and the future of Israel (66%) (Bleich, enhancement (Greenwald, 1980). Bonanno et al. Gelkopf, & Solomon, 2003). The construct of re- (2005) found that ‘‘self-enhancing’’ individuals silience was developed on the basis of observations who were in or near the World Trade Center at the of people who not only survive but also thrive in time of the 9/11 attacks reported better adjustment situations of extreme adversity. The notion comes and more active social networks and were rated from early investigations of atypical schizophrenic more positively by their friends. Physiological as- patients who had premorbid histories of relative sessments of resilient people indicate that they competence at work, good social relations, mar- experience less stress as indicated via salivary cor- riage, and capacity to fulfill responsibilities (Gar- tisol measures (Brindley & Rolland, 1989). These mezy, 1991). It was posited that such disordered people apparently regulate their emotions more patients, who had the least severe course of illness, effectively (Lazarus, 1993; Masten, 2001; Rutter, were less dysfunctional because of these relatively 1987), perhaps via repressive coping (Weinberger resilient trajectories. & Davidson, 1979), which is the tendency to re- Similarly, children of schizophrenic mothers press or avoid unpleasant thoughts, emotions, and sometimes have thrived despite their high-risk memories (Weinberger & Schwartz, 1990). status, which has led to a characterization of the children as resilient (Garmezy & Masten, 1991): It Adaptation: Compensatory Responses Enable was thought that attributes of the children them- Victims to Thrive selves, their families, and their wider social en- Civil unrest and violence do not always result in a vironments were critical to this resilience (Masten, damaged populace. Sometimes just the opposite Best, & Garmezy, 1990). (There is evidence that, appears to occur, where such strife is accompanied for children, resilience may be inconsistent: Al- by a suspension or decrease in the use and perhaps though some at-risk children excel at a particular need for psychological and physical remediation. point in time, they may falter subsequently [Lu- One of the outcomes of civil violence may be im- thar, Cecchetti, & Becker, 2000].) Notably, resi- proved psychological health (Fogelson, 1970; lience is more than recovery: Recovery is a return Greenley, Gillespie, & Lindenthal, 1975; Mira, Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 185

1939), perhaps because of the increased social large part, principled. This view begs the question, cohesion shown in response to a common threat or what should we expect for the future? enemy (Durkheim, 1951). Lyons (1972) observed that, in areas closely associated with violence, male depression and suicide rates drop, whereas in areas Habituation Versus Sensitization less directly exposed, the reverse is true. In England of Emotional Reactions and Wales, the number of suicides reported in the We should expect, at least for the majority of month of September 2001 was significantly lower people, adaptation and accommodation to living than in other months for every September of the with terrorist attacks and with the threats of ter- previous 27 years (Salib, 2003). During and after rorist attacks. This has already been noted for the 1975–1976 civil war in Lebanon, admissions communities in Northern Ireland, Israel, and Pa- to psychiatric hospitals decreased, and outpatient lestine. Similar habituation could be claimed for the treatment fell more than what might have been public in the United States before 9/11, which was expected on the basis of transportation or commu- affected by terrorist attacks only incrementally until nication disruptions. When the hostilities ceased, 2001. outpatient treatment appeared to rebound (Nasr, The attacks on 9/11 killed 3,063 people. Al- Racy, & Flaherty, 1983). though there were multiple sites, similar methods Curran (1988) points to data from racial rioting were used: Each involved airplanes and suicide in U.S. cities in 1968 and in Kuala Lumpur in terrorists. From what we know about habituation 1969, as well as to earlier data from the Algerian and adaptation, we might expect one of the foll- civil war, the Spanish civil war, and World War II, owing scenarios: (1) For a subsequent attack to as showing no increase in demand for psychiatric significantly increase public perceptions of vulner- services and, in some cases, decreased demands for ability, fear, and stress, it will likely have to be of such services during the period when the violence larger perceived intensity than those that occurred was ongoing, with some evidence of a rebound on 9/11, unless a significant period of time elapses effect after the violence had peaked. Bleich et al. before the next attack; or (2) in the near term, (1992) reported that, during the Scud missile at- repeated, similar attacks will generate less disrup- tacks on Israel in 1991, there was an inverse relation due to habituation and adaptation effects. tionship between the number of physical casualties However, (3) a series of smaller attacks that vary in and the number of psychological stress casualties location, method, and target—that is, that do not reporting to hospitals. As Curran (1988) noted, entail habituation or adaptation because of the vari- there may be multiple reasons for such outcomes, ance in the nature of the attacks, such as the bomb- including the failures of people to report distress ing of shopping malls, schools, and hospitals— and seek help, the migration out of the area of those can be expected to be as effective (or more so) than who are most distressed, the fact that people are a single, large-scale attack, even in the near term. distracted by the more immediate demands of ex- It may be instructive to consider the impact of ternal stressors (Ierodiakonous, 1970), or the ten- the Washington, DC, sniper attacks in 2002 in dency of people to engage in active denial or view of this notion that Americans might ‘‘habi- reappraisal (Gross, 1998). tuate to terrorist attacks.’’ Few systematic data are yet available about the impacts of these incidents What to Expect for the Future (although studies are in progress). Public perception is that, rather than exhibit habituation or Although one must carefully qualify such a state- adaptation as a function of the previous exposure ment, what we have observed for most people in to the attacks on the Pentagon on 9/11 and the instances of terrorist attacks in the United States, anthrax events the following fall, residents in the Northern Ireland, and Israel is the dissipation of greater Washington metropolitan area showed a the effects of isolated attacks and habituated and sensitization effect: They exhibited hypervigilance, adaptive behaviors to repeated attacks. Dissipation, that is, behavior that could be described as in- habituation, and adaptation are behaviors that can appropriate given the statistically low level of being be predicted on the premise that behavior is, in a victim, which actually put people in positions of 186 Consequences of Terrorism greater likelihood of injury from other sources. ever, when events were perceived as highly likely (Examples of such behavior were driving long or even certain, people engaged in more antici- distances in order to avoid neighborhood gas sta- patory reconstrual, making sense of the event tions or shopping malls, keeping school children ahead of time. To the extent, then, that a popula- indoors during recess and after school, and can- tion perceives a terrorist attack to be an inevitable celing sporting events in numerous schools for part of its future, it is more likely to adjust its many weeks.) understanding of an attack ahead of time on the One way to understand this pattern of beha- basis of its current knowledge and understand- vior is to grasp the fact that habituation is context ing of such an event. These views and attitudes and event specific and occurs with repeated ex- are likely to be difficult to change, even in the posure to a traumatic event under otherwise stable face of additional information or contradictory conditions; thus the event can be anticipated on evidence. the basis of the context in which it occurs. Habi- On the basis of what is known about affective tuation does not generalize to different contexts or forecasting—our abilities to predict how we will to a substantial change in the nature of the fearful feel about an event that will happen in the event. When events change over time—such as future—we can surmise that we expect we will be planes smashing into buildings, then anthrax being more distressed about future attacks than we ac- sent in the mail, and finally, snipers cropping up at tually will be (e.g., Read & Loewenstein, 1995). shopping malls—the outcome is the opposite of We will also misconstrue and misremember im- habituation or sensitization—the increase, rather portant aspects of the event in hindsight (e.g., than decrease, in anxiety or fear as a function of Kaplan, 1978), especially the intensity and fre- repeated exposure to fearful events. This leads to quency of our emotions about it (Christianson & the expectation that, should the public be exposed Safer, 1996). Further, our initial understanding of to a series of different types of attacks (the third an attack will largely determine our long-term un- scenario just listed), sensitization may exaggerate derstanding of it, even when provided with sub- the effects of any one of the attacks, even though sequent information to correct for errors (Tversky any one as a single instance would have had a & Kahneman, 1974). In short, we will work hard small effect. to transform the meanings of the attacks so as to mitigate their negative impacts, all the while Cognitive and Affective Reappraisal remaining curiously unaware of this tendency (Loewenstein & Adler, 1995). This kind of ‘‘mis- The American public has been encouraged to be- forecasting,’’ while probably resulting in more po- lieve that it is vulnerable to future terrorist at- sitive emotions than would otherwise accrue, will tacks. Affective and cognitive reappraisals can be nonetheless make people vulnerable to decision expected to occur in the context of such expecta- errors because people act in accordance with how tions because we try to make sense of the world they expect to feel about that action. To the extent around us. It is likely that this psychological pre- that our affective forecasting is inaccurate, these paration will depend, to some extent, on our as- decisions will be unsound. sessment of the likelihood of such an assault. When people expect an event to occur in a future over Preparation Strategies which they perceive themselves as having little or no control, they tend to engage in anticipatory How might we take advantage of these guesses reconstrual, that is, they get a head start on in- about the future to inform response and recovery terpreting its meaning. Wilson and his colleagues preparations? There are several implications, all of found that, when events that had either positive which are extrapolations from assumptions about or negative connotations were probable but not basic mechanisms but need empirical validation. certain, people engaged in little anticipatory re- We offer them here as food for thought. First, a construal (e.g., Wilson, Wheatley, Kurtz, Dunn, & preparedness strategy that focuses on fear is likely Gilbert, 2004). Instead, they adopted a ‘‘wait and to produce either habituation to alerts and threats see’’ strategy, postponing their interpretation of the or adaptation and a chronic state of anxiety that meaning of an event until after it occurred. How- depletes individual and community resources. A Near- and Long-Term Psychological Effects of Exposure to Terrorist Attacks 187 strategy that highlights our strengths and capacity expected scenarios into a more familiar context, for recovery would not only save resources but may which would lessen anxiety and increase response even help create them (Durodie, 2002, 2004). capacity. For example, chemical toxins could be Public participation in dealing with community described within the context of advice about which disasters has repeatedly been shown to bolster pub- protective and palliative behaviors are likely to lic morale and ameliorate psychological stress— be useful. If the similarity between the chemical from the bombings in London during World War II weapons of terrorists and the chemicals that sit ( Jones et al., in press) to the modern-day Israeli/ under our own kitchen sinks is pointed out, we Palestinian conflict (Bleich et al., 2003). might take advantage of the habituated emotional Second, if we try to ‘‘expect the unexpected’’ response we have already learned to paint thinners and then incorporate the unexpected within the and drain cleaners and of the knowledge we al- context of normal as much as possible, we will ready have about what to do when exposed to harm react less vigorously to a novel attack event. Our from such agents. expectations are based on what we have experi- Finally, we reflect, talk, and listen so that we enced and already know, and we are most likely to can understand the world around us, especially be disrupted by what we do not expect. It is likely when feeling threatened or experiencing loss. that Americans expect future attacks, should they Might anxiety be alleviated, strengths encouraged, occur, to involve airlines, large buildings, suicide and wisdom engendered to the extent that the na- terrorists, and New York or Washington. These tion engages in learning about the people and ideas expectations are probably encouraged by the most that motivate the terrorists that attack us (Ilardi, obvious change—greatly enhanced airport secur- 2004; McNamara & Blight, 2003)? This, too, is an ity. There is remarkably little national dialogue empirical issue worth pursuing (Fischhoff, perso- about alternatives to that scenario. A national dis- nal communication, June 29, 2004). cussion of alternative attacks would not only allow for realistic and detailed descriptions of what might happen but also engage the public so that Conclusion the views and practices of communities and their possible responses could inform response and re- The quote at the beginning of this chapter reflects a covery strategies (cf. Lasker, 2004), as well as edu- common belief that Americans and other victims of cation and preparedness strategies (Vineburgh, terrorism remain vulnerable to the trauma that ter- 2004). To the extent that Americans begin to view rorist attacks evoke. It implies that fear and anxiety, terrorist attacks in other countries as occurring, once aroused, do not dissipate, adapt, or habituate. in some sense, also to ourselves, our expectations But humans, like all animal organisms, have evolved should begin to change so that even the unim- to deal with changing environments, especially those aginable, such as a school bombing, is perceived as that threaten us. Perhaps what we know about how ‘‘experienced,’’ if only vicariously. One might argue we respond can be used to protect us. that such anticipatory preparation is appropriate to the fact that the current threats come from loosely organized, international networks of terrorists, Notes which are likely to employ a variety of methods against a variety of targets (Burke, 2003). 1. This graph is from a real-time, computational Such a discussion would also engage some de- theory of conditioning that describes the modulation gree of adaptation to the fear responses that might of learned and unlearned behaviors by fear (Wagner & be provoked; obviously, such dialogue would be of Brandon, 1989; Brandon & Wagner, 1998). This theory assumes that the nature and strength of respon- most benefit if it were conducted in the context of ses to discrete events are predictable, based on the understanding what people fear, what they would learning history of the responding organism and the be likely to do in such scenarios, and how we might nature of the eliciting event. Most of the data upon adapt risk communications and recovery strategies which this theory is based come from reduced or to those behaviors (Fischhoff, 2002; Fischhoff, simple learning preparations with nonhuman animals. Gonzales, Small, & Lerner, 2003). This sort of dis- However, the theoretical processes are known to map cussion might also help to put particularly un- onto many aspects of the biological systems that the 188 Consequences of Terrorism theory embraces and may well be ubiquitous to Bleich, A., Dycian, A., Koslowsky, M., Solomon, A., the fundamental processes of learning and emotion & Wiener, M. (1992). Psychiatric implications of in all vertebrate systems. The SOP model is used here, missile attacks on a civilian population. Journal however, because it offers a straightforward, albeit of the American Medical Association, 268, 613–615. theoretical, picture of these fundamental processes, Bleich, A., Gelkopf, M., & Solomon, A. (2003). which we believe can be used to describe the behaviors Exposure to terrorism, stress-related mental health of humans in both mundane and extraordinary cir- symptoms, and coping behaviors among a na- cumstances. tionally representative sample in Israel. Journal 2. 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The Response of Relief Organizations to Terrorist Attacks An Overview of How the Red Cross and Other Relief Organizations Work in Conjunction With Other Agencies John A. Clizbe Susan Hamilton

Ironically, on September 10–11, 2001, emergency meet face to face to talk it out. This was true among management leaders from around the country were the not-for-profits, government agencies, busi- meeting in Montana. Their agenda was to discuss nesses, and just about everyone who was working ways in which they could work together when to respond to the disaster. When these interac- faced with terrorist events. Included in the group tions happened, problems were solved. Frequently were senior leaders from the American Red Cross the problems, challenges, and misunderstandings and emergency managers from many of the areas persisted, however, when the communication was directly impacted by the terror of September 11. indirect or through the media or other sources. While everyone obviously felt an urgent need to return home, in retrospect there were some short- term unforeseen advantages to being stranded Context together in Montana. It was possible, for example, to work through some of the issues requiring Although the acts of terror on September 11 were coordination that would have been impossible to generally unexpected and unpredicted, they hap- do back home, given the chaos within the com- pened in the context of decades of relationship munication systems. For example, a quick face-to- building in the emergency management and non- face meeting between a Red Cross leader and the profit community. At the local, state, and national emergency management group from the Com- levels, a number of organizations had been meet- monwealth of Virginia resolved some challenges ing, planning, and working together in a variety of with Red Cross access to the Pentagon. Everyone situations. The participants at these events in- agreed it would have been extremely difficult to cluded not only the relief organizations themselves track each other down through the turmoil on the but also a number of partner agencies in govern- eastern seaboard. ment and business (American Red Cross, 2002). A longer-term implication and lesson emerged Some of the leaders from the nonprofit orga- from this experience as well. Over the subsequent nizations also had long-standing relationships months, problem solving and communication with other agencies through their participation in clarification occurred best when key people could the National Emergency Management Agency, the

194 The Response of Relief Organizations to Terrorist Attacks 195

National Hurricane Conference, the Natural Ha- organizations. By the year 2000, the Clara Barton zards Institute, and other organizations. As the Center for Domestic Preparedness Training had association officially responsible for Emergency been established in Pine Bluff, Arkansas, and Support Function #8 in the Federal Emergency Re- trainers and trainees again included representa- sponse Plan, the American Red Cross was a regular tives from a range of organizations. attendee at planning meetings involving all of the At the national, state, and local levels, often federal agencies involved in emergency preparation working in conjunction with emergency manage- and response. ment, voluntary relief organizations participated in The National Voluntary Organizations Active a variety of planning and training sessions and in Disaster (NVOAD) is, as the name suggests, a exercises. They were, for example, involved in all of consortium of nonprofit organizations who parti- these phases with the federally sponsored, multi- cipate in disaster relief nationally and often locally. state TOPOFF 1 (named for the involvement of top At annual meetings and smaller gatherings, mem- officials), which was intended to test the abilities bers of the organization had been reviewing ways in of the entire disaster system to handle serious si- which they could work together more effectively in multaneous disasters across the country. Red Cross a wide range of potential emergencies, including chapters in New York City, Washington, DC, and acts of terrorism. Most of the member groups and elsewhere participated with other organizations in their representatives had been working with each similar experiences (American Red Cross, 2002). other for a number of years. They had also been An additional context predating 9/11 was discussing the niches each group preferred to the strong emphasis placed on an ‘‘all hazards’’ fill—often in a deliberately complementary fash- approach by the entire emergency management ion. Included in almost all of their events had community. It became quite clear that the experi- been representatives from the Federal Emergency ences relief organizations had in working together Management Agency and other government orga- and with other agencies on natural disasters were nizations. directly applicable in both preparation and po- At the local level, American Red Cross chapters tential responses to acts of terrorism. Many of the had also spent a number of years planning and same services would need to be delivered, the same responding with their colleagues in NVOAD, other working relationships would function, and the nonprofit organizations, and government agencies. same stresses and strains would occur. Thus, dis- In New York City and Washington, DC—as well as cussion in NVOAD and other settings explored locations in Massachusetts, Rhode Island, Con- ways in which these experiences might translate necticut, New York State, New Jersey, Pennsyl- into situations involving terrorism. vania, Maryland, Virginia, and elsewhere around There were, of course, some clear differences the country—Red Cross chapters had solidly es- between acts of terrorism and natural disasters. tablished relationships, often based on formal The fact that an act of terrorism was a crime meant statements or memoranda of understanding. These that law enforcement would be more directly in- declarations typically spelled out the general terms volved in the planning and response. Research of the working relationship as well as specific de- seemed to suggest that acts of terrorism would tails applicable to exactly how and when the or- have different psychological and sociological im- ganizations would work together. pacts than natural disasters. The scale and scope Several voluntary relief organizations had also of the impact was likely to be greater, expanding initiated, well before 9/11, new programs in an- far beyond the place where the event took place. ticipation of possible weapons of mass destruction These and other differences proved to be especially or terrorist events. Starting in 1998, for example, problematic for relief organizations as the days the Red Cross established a special task force to following 9/11 unfolded. address ways in which that organization and its The events of September 11, 2001, did not, partners could prepare for and respond to these then, occur in a vacuum. Advance planning, think- kinds of events. Various subgroups were set up, ing, relationship building, and theorizing had all ranging from training to community education to taken place. Some of it proved to be well founded, logistics, and they all included members from and some of it erroneous. Some new players en- throughout emergency management and relief tered the field with different perspectives. Several 196 Consequences of Terrorism organizations with experience in natural disasters sistance, which was not always in direct propor- struggled to find their niche in this new environ- tion to the resources available to them. Some ment. Some of those with no previous disaster- required help from their often far-flung families. related experiences found ways in which they Many needed someone to simply listen as they could substantially contribute. The established talked about what they had experienced; others background and context was sometimes helpful were looking for someone to tell them what to do, but sometimes constraining. if that was at all possible. Some had to have physical support near the site of the disaster, whereas others needed to move away from the site. In a The Need number of respects, the hierarchy of requirements espoused by Abraham Maslow often seemed to As the horror of September 11 developed, two reflect the ways in which people looked for assis- different sets of needs quickly emerged. Most im- tance, with safety, survival, and a sense of security portant, of course, were those of the survivors, but taking clear precedence over more ‘‘actualizing’’ the definition of just who was a ‘‘survivor’’ ex- needs. Much of this complexity was consistent panded exponentially. For example, survivors with the findings published in a National Institute came to be viewed as not just those who physically of Mental Health (2002) report on mental health walked away from the specific disaster sites but and mass violence. also colleagues and extended family members and For many, support was a direct reflection of residents in the affected communities. Ultimately, their personal circumstances. Elderly people who people across the country came to view themselves were stranded in high rises needed physical as- as attempting to ‘‘survive’’ the disasters. A second sistance and sustenance. Those with pets required set of needs related to the institutions attempting care for their animals. Those in dust-contaminated to help the survivors and the institutions also be- apartments lacked a place to stay and a way to clean came a rapidly expanding pool. up. Injured people sought physical care and emotional support. Those who were primarily impacted The Survivors economically were faced with earning a living, finding a new job, or surviving while their em- For the survivors, however they were defined, a ployers regrouped. Employers themselves searched number of needs were apparent. This was true for ways to aid their employees. whether they were people who physically survived Perhaps especially striking was the degree to at the point of devastation, family members related which people throughout the country and around to those who had been injured or had lost their the world were affected—and called for support. lives, rescue workers or relief organization work- The tens of thousands of requests the American ers, or those who were located physically far from Red Cross call-in center received underscored the site of impact but were nevertheless pro- these needs: A mother in Iowa wondered how foundly affected. to deal with her anxious 6-year-old. A couple in Houston struggled to cope with a layoff attrib- The Need for Support uted to 9/11. Korean tourists were stranded in the One such need was the requirement for quick Midwest without hard-to-find prescribed medica- support. The exact nature of the support was some- tion. Thousands of people felt driven to do sometimes obvious and sometimes not to either the thing to help all those who were expressing a need seeker or the provider, but a wide range of people for some kind of support. clearly felt they had to have some kind of help. For the families of those who lost their lives, The Need for Linkages the required support was often quite complex. It The relief agencies also quickly realized the need was assumed (not always correctly) that emotional for linkages between family and community. First, help was crucial, but other kinds of support were of course, were those who were desperate to find often expressed both directly and indirectly. Some a loved one they feared was lost in the disasters. If families had an immediate need for financial as- they lived together, the hour-by-hour trauma of The Response of Relief Organizations to Terrorist Attacks 197 trying to make contact was profound. Many tried transportation routes were available? How can I get to reach the physical site in hopes of establishing there (or how can I get away from there)? contact. Others stayed by the phone. Still others Second, people required information about had strong reason to believe their loved one had available services, which they often sought before not survived. the services were established. Who will help me Agencies seeking to help faced the huge chal- find out about a loved one? Who can tell me what lenge of trying to reestablish these contacts, often in I should do now? Who can get food to the emer- the face of sparse and inaccurate information. Some gency responders? Who can help me financially of the initial estimates of lives lost approached right now? What kind of services do you offer? 50,000, then paused for weeks at around 6,000, A third kind of information was education and ultimately reached about 3,000. This meant about what was going to happen next. Who can that, for a while, it was not possible to account for help me find a job? Who can tell me how to talk tens of thousands of people—almost all of whom with my children? Who can offer child care ser- had someone hoping to reestablish contact with vices? Who will bring my family together? Who them. will help with burials? Who offers counseling? As time dragged on, those who seemed to have Who will help me find another place to live? Who lost loved ones needed linkages with other family can help look after my long-term financial con- members and friends in the community. These cerns? connections, which often had to be arranged, In a related vein, people asked questions about provided some of the most important senses of how to prepare for another attack or for some support for those directly impacted. Family mem- comparable emergency. What kind of planning bers who lived around the country also searched should families do? What should be stockpiled in for connection. As many as twenty or thirty family a family survival kit? What kind of preventative members from a single family often came to New health care actions should I take? What can com- York, Washington, or Pennsylvania to be together munities do to be better prepared? with family members living in those areas. Others sought information about how they People in the broader community sought com- could help. Thousands of spontaneous volunteers parable linkages. Preestablished, newly formed, and arrived at or near the disaster sites wanting to help. spontaneous community groups provided their Hundred of thousands of others wanted to know members with these connections. A wealth of re- how their financial contributions would be put to ports filtered into the Red Cross, for example, de- use. Teachers sought information about how to scribing special church services and meetings at talk to their students. Children were unsure of established organizations that focused on the events how to talk to each other. Agencies were often of September 11, newly formed citizen discussion overwhelmed with people who wanted to be of and action groups, and neighbors bonding in ways assistance. All of these requests reflected a need for they never had before. another kind of information—how to help others. People also required information on how to The Need for Information cope. Should I go back to work immediately? Information often became the most important kind Should my children go back to school? Should I of support. Both people who were located in the sell our home and move? Should I go to the banker impacted areas and others around the world de- or the lawyer first? How do I get my life back manded in-depth news of the events. First, they together? Workers in relief agencies listed hun- wanted to know about the situation ‘‘on the dreds of such questions they were asked. ground’’ and looked to the relief organizations and Survivors, at a minimum, needed multiple their contacts in government to provide it. What kinds of support—help in establishing connec- had happened? How had it happened? How many tions with family and friends and lots of informa- people were injured or killed? Who were the viction. The relief organizations had to address these tims? What was being done, and what else could challenges quickly because the needs were press- be done? A myriad of smaller questions followed. ing. Doing so would require extensive collabora- What streets and building were impacted? What tion with each other and with other agencies. 198 Consequences of Terrorism

The Institutions mately to be impacted economically, a different clientele would emerge. Should the relief services The institutions quickly discovered the needs they be provided only in the localities directly im- themselves faced if they wished to serve and in fact pacted, or did the data suggest a wider need? What survive. No organization was truly prepared for would be the pattern of the emerging needs— an event of this nature. People were in desperate emotional? financial? educational? straits, but the relief organization often did not The institutions also needed to assess them- have the capacity to immediately deliver the re- selves. How did their strengths fit with present quired services. They thus had to balance the needs? How would their shortcomings be ex- difficulty of quickly serving people with the si- acerbated by the existing situation? In order to multaneous challenge of providing those sought- evaluate both their current capacity and their ca- after services. pacity for growth, they had to determine their staffs’ strengths and capabilities This self-assessment also The Need for Assessment needed to include an appraisal of the network of While challenged to quickly provide assistance, potential services and service deliverers. How did the relief organizations also had to attempt to their capabilities fit with the community’s other understand and assess what was happening, what resources? What programs would be available was needed, what would happen next, and what through governmental agencies? Did they need to would be needed in a rapidly changing environ- invent a new program, or would they be reinvent- ment. If they were to be able to go beyond simply ing the proverbial wheel? reacting to the latest piece of accurate or inaccurate information, they had to find ways to understand The Need for Coordination the full nature of the situation. If they were to plan If they did not wish to reinvent the wheel, the for and predict demands for services and re- relief organizations would have to coordinate with sources, they had to be able to undertake a broad- one another and with other agencies. On the one ranging assessment. hand, they presumably did not want to duplicate This assessment was actually twofold. Much services. On the other hand, they also did not like the survivors, the institutions needed an as- want people’s needs to go unmet because of gaps sessment of the situation. How many people had in service. These objectives were not always suc- been directly affected? Were there many people cessfully met. Sometimes services were duplicated, in the impacted buildings who were able to walk and sometimes gaps in services meant that needs away? How many were injured? Were the directly were left unfulfilled. To minimize these possibi- affected people from the immediate area or from lities, extra coordination was going to be required. somewhere else? Who was already delivering what As the situation evolved, it became even clearer services? They also had to undertake a healthy self- that coordination was key. Government officials assessment. What was their capacity? What kinds and those who were directly impacted were out- of human and financial resources did they have spoken in their criticism of the lack of coordina- and still need? tion. At times this was easier to point out than to The perplexing nature of the situation on the resolve. Not only was it necessary for people in the ground presented an immediate test to the relief organizations to talk, but their systems also had to organizations. If there were 6,000 victims, they work together. This called for an entirely new level needed to be ready at one level; if there were of coordination. 3,000, a different level of response was required. Thousands versus hundreds of injuries carried The Need to Share Information different implications. The events surrounding 9/11 raised the question of Who were the immediate clients? Who would whether relief organizations should share in- or should be secondary clients? If the primary formation they had traditionally seen as only their needs were those of people who had lost loved own. This issue was not simply a matter of pro- ones, then the focus had to be in that direction. prietary self-interest; it also involved assumptions However, if hundreds or thousands were ulti- (and sometimes promises) made concerning client The Response of Relief Organizations to Terrorist Attacks 199 confidentiality—for example, could such informa- The Need to Work With and Strengthen tion be passed from one organization to another? Local Resources Various groups had different information available It was immediately clear to many inside observers to them that could potentially lead to better and that New York City and the Pentagon, for example, more efficient service delivery. They might know, had some outstanding resource specialists in place. for example, that a new walk-in clinic had been They knew their community and the people in it. established in a particular neighborhood. One or- They knew local needs and neighborhood assets. ganization might learn of a pocket of unmet needs, Furthermore, they were very likely to be there while another might develop a new service (fi- when others would be long gone. The relief or- nancial planning, for example) that would be of ganizations thus had to quickly identify, work interest and use to many. Examples occurred of with, and strengthen those local, on-the-ground one relief group saying that another organization authorities. would provide a specific service when that was The requirement was twofold. The larger or- not, in fact, what was planned. ganizations responding to September 11 needed to Coordination of Communication strengthen both their own local affiliates and the other existing local service agencies. In fact, it The relief organizations also found they had to appeared that many services could be effectively coordinate their communications to the public. delivered and sustained only if the local resources Sometimes inconsistent and even conflicting in- were primary. Obviously, those local assets were formation was disseminated by different parties. often overwhelmed and welcomed the arrival of The confusing nature of the available information help. Yet the long-term need had to be for all of was, of course, one of the contributing factors, but them to be reinforced rather than weakened, taken when various organizations or people were pub- over, or supplanted. licizing conflicting information, the confusion was Smaller organizations moving into the areas only heightened. At the same time, the prospect found a somewhat different challenge. Lacking ex- of coordinating public statements was, for many isting local affiliates, these new arrivals had to find groups, a new and challenging concept. local resources they could help to shore up. Some While it did not usually appear necessary for called it the ‘‘swoop-in factor’’—the temptation for the organizations to speak with only one voice, organizations outside the impacted area to step in they had to at least be aware of what their collea- and save the day by delivering services. Clearly, for gues had said or were going to say. Two different all, the fundamental principle was the long-term organizations might spend time and resources enhancement of existing resources. developing similar communication vehicles (brochures for identical audiences, for example). Or- ganizations working virtually side by side might Risk Management announce different hours of operation. The need for risk management also emerges in a Sometimes a single voice was called for. For crisis environment. Virtually every relief organi- example, the issue of confidentiality of records was zation had to confront the risks they were tak- relevant to almost all of the organizations, as was ing with their services and their members. While advocacy and appreciation of the work being done many of them were accustomed to this challenge in by the relief groups. In these instances the relief natural disasters, certain dimensions of September organizations had to stand together in their mes- 11 were different. For example, there was the early saging. temptation for some relief organization workers Communicating in a high risk environment is and volunteers to rush to the disaster site, which an acknowledged art and science. As Joshua Got- was still laden with physical risk. There was also baum, former chief executive officer of the Sep- the danger of possible follow-up acts of terrorism tember 11 Fund, said, ‘‘When in the spotlight, use and the question of just where it was safe to be. it—or else’’ (Gotbaum, 2003). The relief organi- Moreover, it was unclear whether acts of terrorism zations needed to clearly appreciate the complexity were covered by the same policies that covered of the communication challenges. workers in natural disasters. 200 Consequences of Terrorism

With the wealth of spontaneous volunteers and the sole nonprofit agency that has been assigned the demands of many workers, additional risks specific responsibilities in the Federal Response included the degree to which traditional standards Plan (FRP), which describes federal assistance in and credentials needed to be maintained. For ex- any federally declared major disaster or emer- ample, the Red Cross had a long-standing policy gency. Under the Robert T. Stafford Disaster Relief of using only mental health professionals whose and Emergency Assistance Act, the Red Cross was credentials had been closely examined in advance. required to provide emergency shelter, food, emer- Could and should these same standards be main- gency first aid, disaster welfare information, and tained? Could the standards be better maintained the bulk distribution of emergency relief items and by changing the on-the-job requirements—for to support information dissemination, planning, example, requiring workers to work for shorter health and medical services, and the bulk acqui- lengths of time compared with more typical dis- sition of food. asters, thereby making it possible for more peo- Previously established relationships and formal ple with appropriate credentials to work? Did statements of understanding and letters of agree- we even know for certain what kinds of interven- ment were very quickly activated by the nonprofit tions were the most appropriate in this catastrophic organizations and the federal, state, and county event? agencies. Because these agreements were estab- Because of the intense demand for services, it lished in advance and described the parameters and was sometimes necessary to balance a desire to do method of cooperation, it was much easier to im- what seemed like the right thing with the risks of mediately set up liaisons, working relationships, actually doing it—perhaps ineffectively. For ex- and information sharing. This cooperation helped ample, should workers reach out and solicit an bring some order to the complex and chaotic cir- opportunity to help by going door-to-door look- cumstances occurring in New York, Washington, ing for ‘‘victims’’? Was this professionally appro- and Pennsylvania. priate, and did it place the organization at risk? As one example of multiagency activation, Importantly, the Red Cross center was receiving at Boston Logan International Airport, the Logan phone calls that indicated that people wanted Massport Authority officials activated their aviation help but were unable to come to Red Cross super- response plan while the Red Cross Mass Bay chapter vised sites. set up a family assistance center at the Logan Hilton for approximately 78 Massachusetts families directly impacted by the crashes. Among the other The Response responding agencies were the state police, FBI, Massachusetts Corps of Fire Chaplains, the Mas- The events of September 11 brought to the fore- sachusetts Department of Health, the Trauma front a multitude of organizations. Some were well Center, the American Psychological Association established, while others were newly formed. Al- Disaster Response Network, the American Psy- most all of them genuinely sought to help; a few chiatric Association Disaster Network, area hospi- were purely opportunistic. Given the extensive tals, and the Department of Veterans Affairs. needs that were immediately apparent and emer- Part of the success of the response in Boston ging, both traditional and new methods of response was due to the Logan Airport aviation incident needed to be implemented by the relief organiza- planning initiative and drill exercise sponsored tions. the previous year by Massport. Ten Red Cross The American Red Cross had a unique posi- chapters had taken part in the exercise, nurturing tion and set of obligations. Its congressional relationships with state agencies and private-sector charter mandates that it provide relief to disaster professional groups and providing an operational victims and help people prevent, prepare for, and context for mobilizing almost immediately. These respond to emergencies. It is the agency selected relationships also facilitated the necessary flex- by the National Transportation and Safety Board ibility to make changes as needed. (NTSB) to provide assistance at aviation, trans- Well-established connections were expanded, portation, and mass casualty incidents—obviously and new ones were created, ranging from the applicable on September 11. The Red Cross is also National Organization for Victims of Crime and The Response of Relief Organizations to Terrorist Attacks 201 the New York Port Authority to long-term agree- Dulles Airport in Washington, DC) and destina- ments between the Red Cross and the Southern tions (Los Angeles and San Francisco). Baptist and Church of the Brethren response networks. Early in the development of Red Cross Family Assistance Centers mental health services, the national mental health associations had developed statements of under- Within 72 hours of the time the planes hit the standing with the organization and had set up World Trade Center, New York Mayor Rudolph networks whose members were able to be alerted Giuliani authorized the opening of a family assis- to respond to Red Cross requests for mental health tance center (FAC). The objective was to establish volunteers. a center where families and individuals who had The 9/11 United Services Group (USG) ori- lost loved ones or whose loved ones were hospi- ginally consisted of a consortium of 13 New York talized (or if they themselves had been hospita- City human services organizations working on the lized) could meet with the relief agencies. It was to front lines of the recovery efforts. On December be an accessible, one-stop location where multiple 14, 2001, they came together to oversee assistance agencies could meet multiple needs. The first FAC to the victims. Their joint mission was to ensure opened at the Lexington Avenue Armory. Four that everyone needing assistance received it in weeks later it was relocated to Pier 94, a 20,000- an effective, timely, and supportive manner, while foot warehouse that remained open until March at the same time ensuring accountability and 22, 2002. Buses transported families to and from strengthening confidence in the delivery of chari- three locations: the Armory, Penn Station, and table aid and social services. They formed and Chambers Street. maintained a comprehensive tracking service using Initially, the FAC served as a place where data provided by the participating groups. In this people could file missing-person reports, obtain way they were able to identify service gaps and information, and bring DNA samples for later potential duplication of services. identification. It later expanded to assist those who Integrated services through the USG included had lost their jobs and homes. Because of the high financial assistance, training, and help with case security and the facilities and services it provided, management. A case manager was assigned to all the FAC evolved into a safe haven for families and those who received assistance, helping them ne- friends and provided waiting rooms, child care, gotiate the system. The USG also served as a liaison telephones, Internet access, and meals. The center to the community-at-large by providing requested was open 7 days a week from 8:00 A.M. until reports that would inform the public on how ser- midnight. Areas were set aside for emotional vices were provided and how clients were helped. support and spiritual care, for the Federal Emer- A hotline was developed that operated 24 hours a gency Management Agency (FEMA), representa- day, 7 days a week for people with questions or tives from the mayor’s office, insurance companies, requesting a service coordinator. Immediate crisis the New York State Crime Victims Board/Safe counseling was available, and referrals could be Horizon, the New York Police Department Com- made to mental health or substance abuse practi- mand Center, Department of Veterans Affairs, la- tioners or programs. Within a year, 67,000 people bor leaders, the FBI Crime Victims Assistance, had received aid, and the number of participating foreign governments, the American Red Cross, agencies had grown considerably. the Salvation Army, and other community re- The agencies were also required to rapidly sources. A separate dining area served meals to adapt their usual responses to the exceptional the center staff and to workers returning from needs of the moment. Two cities were experien- Ground Zero. cing mass casualties on the ground, a plane had Additional centers were later set up at Liberty crashed in rural Pennsylvania, and bereft families State Park in Jersey City, New Jersey, and at the and travelers were stranded by grounded planes Crystal City Sheraton in Arlington, Virginia, for around the country. Shelters had to be opened the families affected by the Pentagon tragedy. As throughout the country for travelers. Family as- the days progressed and the needs became clearer, sistance centers were being established at the more and more services were provided. In Virgi- planes’ points of origin (Boston Logan Airport and nia, for example, trained dogs were brought into 202 Consequences of Terrorism the center to help create an emotionally supportive indicated that as many as two-thirds of U.S. climate. Family assistance centers became the vital households had donated money to the charitable ingredient in service delivery. organizations. Yet, despite all of the available dollars and all Respite Centers of the effort, the needs of some groups of people remained unmet. The difficulty was not a lack of The purpose of the three respite centers near money but uncertainty about how to best channel Ground Zero was to provide support services for those resources. Focused, special kinds of needs rescue personnel and recovery animals working at (e.g., for financial planning) emerged. In addition, the site. Their aim was to reduce the psychologi- particular groups (e.g., undocumented workers, cal and physical stress caused by the demanding people whose livelihood was disrupted, those liv- work of rescue and recovery. These centers became ing outside a designated area) still required assis- multifunctional sites in partnership with agencies tance. As had usually been the case with natural providing specialized services. The key collabor- disasters, it was important to establish mechanisms ating agencies in New York were the Office of for addressing these unfulfilled needs. Emergency Management, the Red Cross, the Sal- It became apparent that some people whose vation Army, the food banks, the New York Health family members had died on September 11 would Department, the Hotel and Restaurant Association, not receive compensation or assistance from some local clergy, and veterinary services for the care programs either because they were ineligible or of the search-and-rescue dogs. The centers pro- because they simply fell through the cracks. For vided meals, a place to sleep and relax, clothes, example, in New York City, a Spanish family work gear, articles for personal hygiene, emotional was unable to claim government assistance because and spiritual support, and physical health care. the business that had employed the victim would When the three centers downsized to a ‘‘big white not confirm the person’s employment since it was tent,’’ the Salvation Army assumed overall direc- ‘‘off the record.’’ Michelle Archer, a program co- tion, while the Red Cross provided mental health ordinator for the 9/11 fund at the New Jersey Im- services. migration and Policy Network, disclosed the fact that a number of people who worked at the World Service Centers and Cross-Training Trade Center had held H-I visas (legal work permits), but their spouses and children were un- The Red Cross established three service centers in documented, which made the task of seeking aid Manhattan and several outside the Manhattan area daunting. Archer, with other relief groups in New to provide direct financial assistance to displaced Jersey, set up immigrant centers where translators, families and others. Originally designed as a place attorneys, and interpreters assisted these immi- for the delivery of Red Cross services, they ulti- grants and informed other service providers of mately housed a number of agencies that worked their needs. Church World Services (CWS) funded together cooperatively. As the casework increased, Tepeyac, a New York–based group that helped fam- the Red Cross, the Salvation Army, and Safe Hor- ilies of immigrants who died. izon cross-trained their volunteer workers at these Specific ethnic groups were also struggling. centers. This not only helped use staff members New Life Center was created to assist the Fujia- more efficiently but also enabled clients to receive nese, an ethnic group from the Fujian province of services from multiple agencies and the agencies China, who did not qualify for assistance because to coordinate some of their service delivery. they lived beyond the strict geographical guidelines that many agencies used but whose homes Unmet Needs Groups and workplaces were impacted. Their problem was confounded because most of the 9/11 lan- By November 2001, the September 11 Fund guage assistance was available only in Cantonese stopped soliciting donations and in January 2002 and other major Chinese languages. asked the public to stop sending contributions. In Emerging psychological needs also stimulated much less than a year, well in excess of a billion additional programs and support. At the time of dollars had been donated to the charities. Surveys the tragedies, many national mental health and The Response of Relief Organizations to Terrorist Attacks 203 humanitarian organizations quickly published in- of September 11 were felt immediately, and some formation for the public. The American Psycho- people came forward only when they absolutely logical Association, the National Center for Victims had to, which, unfortunately, was occasionally of Crime, the Institute of Mental Health, the Na- after other resources had lapsed. Eligibility for the tional Mental Health Association, the New York federal program of financial assistance continued University Child Study Center, and the Red Cross for an extended time as families struggled to all published material to help people cope and choose between receiving a cash grant or pursuing recover. The National Center on Post Traumatic legal action against the airlines and others. Stress Disorder published ‘‘Dealing with the After- Some professionals projected that unmet needs math of Terror’’ and ‘‘Facts about PTSD.’’ The Red might well emerge over a period of years, rather Cross had its materials translated into many lan- than just months. A number of organizations, such guages and posted them on its website. as the American Red Cross, with the substantial Others were victims of secondary economic donations it received, expect to continue with as- effects. In April 2002 the United Methodist Com- sistance for a number of years. While some of mittee on Relief (UMCOR) allotted monies for a 3- those needs are predictable from previous experi- year program that focused on secondary victims in ences (such as long-term mental health require- New York. John Scibilia, director of the September ments for some rescue workers), others may yet 11 response for Lutheran Disaster Relief in the arise. New York area told the Board of Global Ministries that there was a major shortfall in meeting the needs of the impacted. Some people who lost their The Challenges jobs because of the terrorist attacks soon exhausted their savings and other funds and began to use As the relief organizations worked in conjunction their retirement funds. Members of the New Jersey with other agencies to develop methods of re- Interfaith Partnership for Disaster Recovery set up sponding to communities’ needs, new and more an ‘‘unmet needs table’’ to address this problem effective means of collaboration and service deliv- and help clients with expenses, encouraging them ery emerged. A great deal was done right, and a to become self-supporting through retraining and great deal of assistance was delivered. However, significant changes in lifestyle. although the background of pre-9/11 cooperative On July 17, 2002, the New York Regional efforts certainly helped, challenges persisted. Many Associations of Grantmakers, the Twenty-first of those remain as important considerations for Century Foundation, and the Rockefeller Foun- whatever future difficulties these organizations may dation had decided to cosponsor a program called confront. Unmet Needs: A Special Post-9/11 Session. In February 2003 caseworkers from UMCOR and Making It Easier for Those Who other major agencies, including the Salvation Were Affected Army, Catholic Charities, and El Centro, were continuing to bring cases to the New Jersey unmet An extraordinary number of relief organizations needs table. Their clients had grown to include responded at an unprecedented level, especially laid-off airline personnel and people with delayed in the large metropolitan area in and around New psychological reactions. CWS also funded a num- York City and, to a slightly lesser extent, Wash- ber of interfaith programs to assist people who ington, D.C. Families who lost loved ones lived were still hurting. These included the New York around the country and world, although most lived Disaster Recovery Interfaith, the New Jersey Part- in the suburbs of New York, New Jersey, and nership for Disaster Recovery, the Long Island Connecticut. For those families who sought face- Council of Churches Disaster Taskforce, and the to-face contact with the relief organizations, the New York City September 11 Unmet Needs logistics were a challenge at best. Roundtable. Often those who sought assistance from sev- Despite all of these efforts, some people con- eral organizations had to negotiate their way be- tinued to need assistance after the initial programs tween multiple sites. Once there, they frequently were discontinued. Not all of the economic effects had to fill out different forms asking for much of 204 Consequences of Terrorism the same information again and again. These were have to be faced. A model of institutional triage issues not unique to the nonprofit community; may need to be developed and implemented. they certainly also included government programs. A range of possible solutions began to appear. Sharing Information Some were never fully actualized, however, and some are still under discussion. Barriers included There was increasing pressure both to share and simply a lack of time and staff, the need to work not share information. Much of this debate proved through risk and liability issues, problems of phys- to be a forerunner of current concerns about ical logistics, special requirements by some orga- patient/client privacy. As questions about eligibility nizations to be consistent with their standard for assistance escalated, so did the topic of whether practices, and sometimes cultural resistance within organizations should and could share the informa- associations. Constructively, some groups began tion they had. Sometimes this was an issue between to merge their sites—initially at large centers and governmental and nongovernmental agencies, with then at smaller drop-in locations. Staff from dif- the clients of the latter expressing concern about ferent organizations were even cross-trained in each their personal information (for example, residency other’s forms and procedures so that clients could and immigration status) being given to the govern- do ‘‘one-stop-shopping.’’ Still under intense dis- ment. On other occasions, it was a matter for discussion (and strongly advocated by some govern- cussion even between nongovernmental agencies. ment officials and clients) are the ways in which the Aggressive efforts were made to develop a relief organizations can use common forms, there- system of sharing appropriate information using by allowing clients to fill out only one form and outside database consultants in hopes of protecting eliminate duplication of effort. some kinds of confidential data. Other organiza- Other challenges include the application of tions went through extensive processes of obtain- technology to allow people to be assisted without ing release-of-information permission. This area is physically coming to a site. The Red Cross, for ex- a major challenge confronting the relief commu- ample, established a massive call-in center for just nity and does not lend itself to quick and easy such a purpose. The relief organizations must also solutions. Virtually all of the organizations re- deal with the problem of getting their technology cognized the need for at least some basic sharing of systems to interface. Some of them have already information. Perhaps a starting point would be the found ways in which they can link up with national, determination of what is confidential and what is state, or local government databases and programs. not. At the very least, relief groups will need to adopt strategies to address this problem. Determining the Nature of the Assistance Understanding Those Who September 11 changed the ways many organiza- Wanted to Help tions thought about the nature of the assistance they offer. Most have historically worked on a There were at least three categories of people who clearly defined needs-based approach. The defi- expressed a desire to help: donors of time, donors nition of ‘‘needs,’’ however, altered on 9/11. For of goods, and donors of money. All three re- some organizations this not only presented sig- presented significant challenges, and although this nificant challenges internally but also impacted has historically been the case, the challenges be- the collaboration among organizations. If one used came even greater on 9/11. The very nature of the strict financial criteria and another applied a more event stimulated new donors, new expectations, liberal interpretation of need, confusion could reign and new frustrations. and misunderstanding increase. It was not imme- Tens of thousands of people arrived at various diately clear what criteria government programs locations volunteering to help. This required a would use in the future. massive process of volunteer management. Here, Most of the relief groups ultimately chose to too, was an area where information sharing could use their own criteria, although a few attempted be helpful. Were some organizations looking for to agree on some common definitions. If similar people with certain kinds of skills? Were there events happen in the future, this challenge will places where people could be utilized later? The Response of Relief Organizations to Terrorist Attacks 205

Unfortunately, some potential volunteers left angry gaps were not so much in technical know-how but because they were not given an opportunity to more in the decision making and flexibility. help. The relief organizations will have to address Arguably, some of these concerns cannot be this challenge of volunteers (including how to cre- addressed only with training, and good selection dential them), and this may require a higher level is therefore essential. The relief organizations real- of collaboration. ized the necessity of doing more advance work in Those who donated goods also posed an un- identifying those who are best suited for these kinds paralleled challenge. Countless truckloads of un- of disasters and providing them with the training solicited goods arrived hourly. The simple logistics and systems that enable them to do their jobs. of where to unload them became a daunting task. The process of sorting, organizing, distributing, Safety and Security Issues and/or destroying unusable materials occupied numerous hours. Although the emergency man- One common problem faced by most of the relief agement community has tried in the past to com- organizations was the safety and security of their municate the disadvantages of these kinds of members. Particularly with the influx of so many donations, the message still needs to be delivered groups and volunteers, the task became substantial. more effectively. It was also a challenge for the law enforcement September 11 was an event that triggered an community to understand and meet these needs of enormous outpouring of financial support from the nonprofits. around the country and the world. What dis- One issue was identification. Many sites ne- tinguished this outpouring from that after other cessarily had restricted access. Identifying who disasters (in addition to the sheer number of dol- should have admittance was difficult. Identification lars donated) was perhaps the quantity of com- badges were forged, and uniforms were mimicked. paratively small spontaneous donations made in Most of the traditional identification processes used a wide variety of settings—retail establishments, by the nonprofits were unsophisticated. The relief street-corner collections, at-home coffee hours, organizations, working with the law enforcement and so on. These donors in particular, perhaps community, must find ways of effectively and effi- donating for the first time, had very strong feelings ciently identifying their people. about how their dollars should be used—almost Sometimes the safety of staff and clients was always a direct and full pass through to victims’ also a challenge at the relief sites. Even issues families. Most notably the Red Cross, but other such as protecting lines of clients from inclement organizations as well, faced a major challenge in weather became difficult. Most of the nonprofit or- understanding these donors’ intentions and de- ganizations have not felt it necessary to have se- termining how best to respond. How to handle curity experts on their staffs, but the challenges similar situations in the future remains an issue related to September 11 predict that such expertise to be resolved. A related challenge for the relief will be required in similar events in the future. community is to find ways of communicating the legitimacy of associated expenses, the need for Handling Turf infamous ‘‘infrastructure,’’ and the costs of readiness. We hope that the relief organizations will Issues of turf arise despite the best of intentions. be able to do this without embarrassment. Relief organizations, like all other groups, take pride in their special skills and mission. Under- Improving Selection and Training standably, most of them believe they are very good at what they do. Although not often acknowl- The enormous complexity of the events sur- edged, competition sometimes arises between re- rounding September 11 highlight the critical need lief associations just as it does elsewhere. for training people—whether paid or volunteer. The task for relief organizations is to keep this Fortunately, many relief organizations had already phenomenon from detracting from the ultimate invested significantly in training—some of it even good of the people they are seeking to serve. Some focused on terrorism. Yet very few were adequately lessons have emerged in the wake of 9/11. First, it trained for what they experienced. The training is important to respect the need of each association 206 Consequences of Terrorism to fulfill its fundamental mission. Most groups Conclusion with a history have evolved a clear sense of their mission. The challenge, while collaborating, is to The relief organizations that responded to the let them—even help them—do it. events of September 11, 2001, did an amazing job. Second, the relief organizations needed to stick More people were served faster with more direct to their strengths. When these groups begin to assistance than at perhaps any other time in history. move away from what they are good at doing, In addition, this occurred in a high-stress, first- then they experience both internal and external time-ever climate with substantial ambiguity, con- problems. Relief organizations must respect each fusion, and escalating expectations. other’s turf and also manage their own with respect Before 9/11, relationships within the relief for their compatriots. organization community and between the community and other agencies certainly facilitated Supporting One Another these efforts. The fact that these groups had numerous formal and informal agreements and ex- The task of supporting one another derives from periences provided a context in which they could the challenge of turf management. Joshua Got- work together. The needs they attempted to serve baum, in the commentary cited earlier, noted in in some ways paralleled earlier experiences but in particular the failure of much of the nonprofit other ways were very different. Whole new ways of community (unlike the business community, he thinking about the needs of clients, donors, and says) to pull together when some parts of it were communities emerged. A wealth of new programs under siege (Gotbaum, 2003). When specific relief and services evolved. New kinds of controversies organizations were criticized for certain practices, arose. Demands for effective collaboration esca- very few members of the broader community of lated. relief groups came to their defense—even though The lessons learned from these experiences are the practices were often common to many of them. also still coming to light as more and more retro- As a result, the image of the entire relief commu- spective analyses are published. There seem to nity suffered to some extent. be, however, some clear challenges—mostly quite As Gotbaum suggests, the nonprofit commu- manageable—requiring the attention of relief or- nity has traditionally failed to see itself as a unified ganizations both independently and collectively. group, instead leaving each organization to fend These require new ways of thinking about the for itself. Many groups may even have preferred ‘‘industry,’’ new ways of working with each other this model. Recent history suggests, however, that and other agencies, and even new ways of en- these associations have a stake in each other’s visioning who is to be served and how they are to success and face the job of finding ways to ap- be aided. propriately support each other.

References Political Pressures American Red Cross. (2002). September 11, 2001: Relief organizations may find one of the best op- Unprecedented events, unprecedented response. portunities to support each other in the political Internal document. arena. Granted the concerns about lobbying (an Gotbaum, J. (2003, February 6,). Lessons learned after issue that is often misunderstood by nonprofits), September 11. Chronicle of Philanthropy, 15(8), there are often political issues of common concern 37–39. to many nonprofits. With September 11, some National Institute of Mental Health. (2002). Mental of these issues (such as sharing information) arose. health and mass violence: Evidence-based early These provided the organizations with the chal- psychological interventions for victims/survivors of lenge and the opportunity to discover common mass violence. A workshop to reach consensus. purposes and needs and to perhaps work together NIH Publication no. 02–5138, Washington, DC.: in the political sphere. U.S. Government Printing Office. 15

Understanding How Organizational Bias Inﬂuenced First Responders at the World Trade Center Joseph W. Pfeifer

At 9:59 A.M., the South Tower collapsed. What the world saw on television, we could not see. Our world in the lobby of the North Tower went black. In darkness, I radioed to the firefighters above. ‘‘Command to all units in Tower 1, evacuate the building!’’ While many of the firefighters assisting people heard the message, they were already dozens of floors above ground level. Little did we know that time was running out. Author’s recollection of 9/11

To fully understand the 9/11 response, this chapter this chapter provides a unified command model for will examine how organizational bias influenced overcoming organizational bias—something vital the evacuation of first responders from the World for effective Homeland Security and the command Trade Center. Regardless of any prior history of of complex incidents of terrorism. power struggles among first responders, it is in- In trying to understand critical aspects of the conceivable that any commander on 9/11 would response of New York City agencies to the crisis at ever deliberately withhold vital information that the World Trade Center (WTC) on September 11, could potentially save lives. Then why did organi- 2001, many observers overlook the effects of years zations not think to share critical reports about the of interagency fighting for sole command power. signs of collapse of World Trade Center towers? The following analysis explores the impact that The answer lies in years of organizational bias social group behavior has on information sharing within the emergency response community, where under conditions of stress and uncertainty. organizations generally act independently of each The action aim of this chapter is to demon- other. strate that the likelihood of sharing vital informa- One would expect that these organizational tion at critical times during complex incidents biases would be abandoned during times of crises; becomes greater when groups that ordinarily are however, the events of 9/11 in New York illus- competing or acting independently are organized trate a strong systematic bias towards group self- to act as an integrated group under a unified com- interest. The analysis of the World Trade Center mand, where all members are equally responsible for response illustrates the negative effect organiza- command-coordinated action. However, to achieve tional bias has on commanding complex incidents. this level of integration, organizational biases need These organizational biases are seen under three to be overcome. command conditions: (1) resistance to a single in- Social identity that promotes the power of one cident commander, (2) development of blind spots organization over another produces two social in command capacity, and (3) a diffusion of per- outcomes during complex incidents. First, it creates sonal command responsibility. Most importantly, a positive in-group bias toward those who are part

207 208 Consequences of Terrorism of the same group and a negative out-group bias sponders according to each organization’s intra- against those who are part of an alternate group agency protocol. No messages were transmitted by (Deaux, 1996; Zimbardo, 2004). When providing radio, computer, or face-to-face contact between information across groups, people are prone to give the two primary response agencies. This created a more information to members of their own group stovepipe situational awareness that resulted in and less to members outside it. Second, when under separate and divergent operational pictures of the stress, people feel little obligation to share valuable fires on the upper floors, information with those outside their group since the responsibility for acting is diffused within their NYPD Rapid Evacuation in-group. This phenomenon excludes the out- group from receiving information that may be vital When the South Tower of the World Trade Center to their operation. collapsed, the Emergency Service Unit (ESU) teams To fully understand the power of organiza- of the New York Police Department (NYPD) in the tional (systematic) bias, one must examine how North Tower, like the firefighters, had no idea information sharing within and outside groups what had just occurred. After witnessing this col- influenced the evacuation of first responders from lapse from the air, the NYPD aviation units im- the North Tower of the World Trade Center. This mediately radioed a report, and the ESU dispatcher chapter illustrates that the most accurate and timely made five emergency transmissions, ordering all information reported by police aviation produced a of the emergency service officers to get out of the rapid evacuation with a sense of urgency. However, North Tower (Dwyer & Flynn, 2005, p. 214). the majority of the first responders, including At 10:01 A.M., an ESU detective at the NYPD firefighters within the North Tower, did not re- command post on Church and Vesey streets saw ceive the same situational-awareness report. That the South Tower fall and ordered the evacuation information-transmission failure was responsible of all ESU units from the WTC complex (9/11 for an unhurried evacuation without any apparent Commission Report, 2004, p. 309). An ESU officer sense of urgency. inside the North Tower clearly heard the message Comparing these two cases demonstrates the but could not comprehend how a 110-story severe consequences of keeping critical informa- building could collapse, so he asked for the mes- tion within an organization. This lack of informa- sage to be repeated. It was then explained that tion sharing is referred to as ‘‘stovepipe situational the South Tower was gone and that the North awareness.’’ Analogous to a stovepipe, information Tower building, which they were in, was in im- travels only within a single organization. As a re- minent danger of also coming down (9/11 Com- sult, one agency had superior situational aware- mission Staff Report #13, 2004, pp. 24–25). That ness regarding the fire on the upper floors of the message was an alarm for all of the ESU units to towers, while the fire department had little or no immediately begin their evacuation. information. This inequity greatly affected the de- These officers now understood why they needed cision-making capacity of emergency responders. to leave rapidly. But it was the additional helicopter It also raises the more important question regard- radio transmissions of observed fire conditions and ing the reason commanders did not communicate building instability that made it more apparent that this vital information to each other. they were not simply to evacuate the building but to leave rapidly in order to escape its inevitable collapse. The transmissions from the police helicopter Escape From the North Tower were made on an NYPD Special Operation Division (SOD) frequency that was monitored by ESU officers This case study compares two separate situational- inside and outside the North Tower.1 awareness pictures given to first responders. The analysis looks at the radio transmissions on 9/11 10:00 A.M. ‘‘A member of the NYPD aviation unit between the time the South Tower collapsed at radioed that the South Tower had collapsed immediately after it happened and further 9:59 A.M. and the collapse of the North Tower at advised that all people in the WTC complex 10:28 A.M. Messages transmitted during those 29 and nearby area should be evacuated.’’ (9/11 minutes were given by radio to emergency re- Commission Report, 2004, p. 309). Understanding How Organizational Bias Influenced First Responders at the World Trade Center 209

10:07 A.M. The pilot of Aviation 14 radioed: ‘‘Advise needed to rapidly leave the building. For these offi- everyone to evacuate the area in vicinity of cers, the situational-awareness reports they received ... Battery Park City. About fifteen floors from NYPD Aviation and fellow officers outside the down from the top, it looks like it’s glowing red. It’s inevitable’’ (Dwyer & building were critical to their escape from the North Flynn, 2005, p. 223).‘‘To be certain that the Tower and most likely saved their lives. message was delivered, the dispatcher repeated it, practically word by word, so that all the police officers on the air heard FDNY Unhurried Evacuation the warning. ‘All right, he said from the 15th floor down, it looked like the building The situational-awareness picture for the Fire De- was going to collapse and we need to partment of the City of New York (FDNY) was vastly evacuate everyone’’’ (Dwyer & Flynn, 2005, different from that of the police department. When p. 223). the South Tower came down at 9:59 A.M., rescuers on 10:08 A.M. A moment later, the pilot of Aviation 6 the upper floors of the North Tower felt the building reported, ‘‘I don’t think this has too much longer to go, I would evacuate all people shake, similar to what is felt when a small earthquake within the area of the second building’’ occurs. Simultaneously, operational commanders in (Dwyer and Flynn, 2005, p. 223; supported the lobby had debris dust fill their location, forcing by 9/11 Commission Report, 2004, p.309 them to move to a passageway between the North and 9/11 Commission Staff Report #13, Tower and 6 World Trade Center (the adjacent 2004, p. 25). building). As the South Tower disintegrated in front 10:20 A.M. ‘‘NYPD aviation unit reports that the top of the tower might be leaning’’ (National of them, the Chief of Department and his command Institute of Standards and Technology staff, located on the far side of West Street, aban- [NIST], 2005, p. 37). doned their command post and took shelter in a 10:21 A.M. ‘‘NYPD aviation unit reports that the parking garage under the World Financial Center. North Tower is buckling on the southwest Throughout the incident, there was an absence of corner and leaning to the south’’ (NIST, any NYPD commanders at both the incident com- 2005, p. 37).‘‘NYPD officer advises that all personnel close to the building pull back mand post and the operations section. These facts three blocks in every direction’’ (NIST, set the stage for operational stovepipe situational 2005, p. 37). awareness and the looming disaster. 10:27 A.M. ‘‘NYPD aviation unit reports that the roof is going to come down very shortly’’ (NIST, 10:00 A.M. ‘‘The South Tower total collapse was 2005, p. 37). immediately communicated on the Man- hattan dispatch channel by an FDNY [fire] ... These reports make it clear that NYPD officers boat but no one at the site received this information, because every FDNY command had a comprehensive situational awareness not post had been abandoned’’ (9/11 Commis- only of the collapse of the South Tower but also sion Report, 2004, p. 306).‘‘Despite the lack the imminent danger of collapse to the building of knowledge of what had happened to the they were occupying. The McKinsey Report states South Tower, a chief in the process of that NYPD Aviation warned the police department evacuating the North Tower lobby sent out an order within a minute of the collapse: ‘‘that WTC 1 collapse is likely and advises im- ‘Command to all units in Tower 1, evacuate mediate evacuation’’ (2002, p. 50). The officers the building’’’ (9/11 Commission Report, who received these messages were able to correctly 2004, p. 306). Within minutes, some of the interpret the information they received and quickly firefighters heard leave the building. Each subsequent message had a the evacuation order. ‘‘At least two battal- ion chiefs on the upper floors of the cumulative effect of added urgency, plus multiple North Tower ...heard the evacuation validations of the original report. instruction ...and repeated it to everyone Eyewitness reports indicate that ESU officers did they came across’’ (9/11 Commission not remain and, at one point, were jumping from Report, 2004, p. 307). landing to landing by sliding down the stair banis- 10:10 A.M. Another chief (after moving from the lobby ters. These reports confirm the importance of the of the North Tower to the North Bridge) ‘‘soon followed with an additional evacua- helicopter messages for understanding that the tion order’’ (9/11 Commission Report, building was about to buckle and that the officers 2004, p. 306). 210 Consequences of Terrorism

10:15 A.M. The Chief of Department issued a radio tion about the collapse of the South Tower, the order for all units to evacuate the North spread of the fire, and the potential collapse of the Tower (9/11 Commission Report, 2004, North Tower provided the police department with p. 308). enough data to precipitate a rapid escape, while the lack of similar information for the fire depart- Of the 100 interviews conducted by the 9/11 ment translated into an unhurried evacuation—and Commission and its review of 500 internal oral its lethal consequences. These facts illustrate how histories from members of the FDNY, only three information sharing—and the lack of it—affected firefighters mentioned hearing any possibility of the emergency responders’ interpretation of the ‘‘imminent collapse’’ (2004, p. 550). Indeed, most evacuation orders. of the firefighters in the North Tower had little The strongest statement about the dangers of idea that the South Tower had fallen and did not stovepipe situational awareness comes from an receive warning messages from police aviation investigation conducted by the National Institute predicting the collapse of the North Tower (9/11 of Standards and Technology (NIST). The study Commission Report, 2004, p. 554). The FDNY, as concludes that ‘‘a preponderance of evidence in- well as the Port Authority police, were never pro- dicates that emergency responder lives were likely vided with the critical information that the NYPD lost at the WTC resulting from the lack of timely possessed. information-sharing and inadequate communication capabilities’’ (2005, p. 174). This is further clarified by the 9/11 Commission Report that any The Importance of Sharing radio failure, while important, ‘‘was not the pri- Information mary cause of many firefighters’ deaths in the North Tower’’ (2004, p. 323). The reason so many Although the 9/11 Commission shied away from firefighters died in the North Tower was that com- using the term stovepipe situational awareness to manders who received vital messages from their describe interagency communication, it did re- helicopters never shared that information with the cognize that critical information was not shared FDNY, resulting in an uneven distribution of crit- among agencies and that FDNY chiefs would have ical information. benefited greatly had they been able to receive the An unhurried evacuation made perfect sense same situational-awareness picture as the NYPD to those who lacked situational awareness in the (2004, p. 321). The situational-awareness picture North Tower. A rapid evacuation made equally for the fire department members inside the North perfect sense to those police officers who heard the Tower was limited to a rumbling sound and orders repeated warnings of the North Tower’s possible to evacuate the building. The fire department re- collapse. ‘‘If events are noticed, people make sense ceived no updates about the spreading fire or the of them, and if events are not noticed, they are not deterioration of the building. They were given no available for sensemaking’’ (Starbuck & Milliken, warnings from the helicopters of the building’s 1988, p. 60). Those emergency responders who possible collapse, which would have reinforced the had the power of situational awareness were able absolute necessity for a rapid mass departure. to avoid being trapped in the collapse of the North Essential to situational awareness is the need Tower; those without it did not stand a chance. to make sense of the information one receives. Effective incident command is dependant Organizational psychologist Karl Weick has de- upon strengthening information sharing to main- scribed the basic human process of ‘‘sensemaking’’ tain common situational awareness. When an or- as a ‘‘search for context within which small details ganization possesses critical information, it must fit together and make sense’’ (1995, p. 133). The be immediately shared with other commanders and more detailed the information, the better the all emergency responders operating at an incident. sense-making capability of the receiver. Only then can emergency responders make sense The NYPD and FDNY case studies dramati- of and react quickly to new messages. The single cally portray how emergency responders reacted to most important safety lesson learned by emergency different levels of situational awareness. Informa- responders on 9/11 is simply to share information. Understanding How Organizational Bias Influenced First Responders at the World Trade Center 211

Understanding Organizational Bias This intergroup competition is illustrated by an absence of cooperation, duplication of effort, These case studies reveal the vital role that in- and strict control of information that might benefit formation sharing or lack of it played in the deci- other groups. One frequently wishes to exclude the sions that were made at the World Trade Center. It is others from an operation or is not forthcoming shocking to think that critical information was not with information simply to demonstrate its per- shared among the first responders from these New ceived power. This bias not only gives one group York City agencies. Some observers would like to an advantage over another but also systematically conclude that a technological problem with portable conditions groups to think only of themselves. radios was to blame, but the 9/11 Commission Re- One would expect that these social biases port confirms that the evacuation messages were would be abandoned during times of crises; indeed heard (2004, p. 554). Furthermore, the however, the WTC case studies illustrate a stronger NIST investigation concludes that the WTC repeater partiality for an individual group’s self-interest, (a system to boost radio signals) was incapable of which in this case proved to be a fatal flaw for the working after the South Tower collapsed and would first responders. Even with thousands of police not have assisted in the evacuation of firefighters officers and firefighters at the scene and many only from the North Tower (2005, p. 138). a few feet from each other, reports from the police Inadequate radio interoperability is another helicopter never reached any of the fire chiefs. theory that may help to account for the commu- During the 9/11 World Trade Center attack, the nication gap among the agencies. However, agen- first responders were unable to overcome their cies, commanders, and personnel were within a organizational biases, thus causing a fragmented short distance of each other (NIST, 2005, p. 162). command structure. One can observe the ramifi- Regardless of any history of infighting between cation of these biases under three different com- the police and the fire department, it is inconceiv- mand conditions: able that any commander would ever deliberately resistance to a single incident commander withhold vital information that could save the lives development of blind spots in command of personnel from other organizations. With that capacity in mind, a critical question arises: Why did police diffusion of personal command responsibility commanders—over the course of 29 minutes— remove their members from the vicinity of the The first command condition is the failure of towers and fail to inform the fire department of the preincident planners to recognize that, at ter- the dangers observed by police aviation? One an- rorism incidents with multiple agencies present, swer lies in years of organizational biases within social biases cause organizations to resist the con- the first responder community, whose organiza- trol wielded by a single incident commander. The tions are generally autonomous. This is not a con- WTC response depicted a refusal by certain agen- scious bias but rather a long-standing bias on a cies to operate under the authority of the fire systematic level. department’s incident commander. Even though Organizational bias stems from the desire to both WTC Towers were on fire, ‘‘there is no record belong to an omnipotent group that is capable of that the ICP [Incident Command Post] had any excluding those who are not part of the group. In senior NYPD personnel assigned to it to provide government, it is usually demonstrated through liaison or assist with operations’’ (NIST, 2005, command power and the authority to control in- pp.161–162). Agencies implicitly think of them- formation. The turf battles between the NYPD and selves as being the most important, and, as a the FDNY mirror those of CIA and the FBI, which group, their natural tendency is to resist deferring was made public during the 9/11 Commission to another organization. This is especially true for investigation (Staff Report #9, 2004). In both in- police and fire departments whose organizational stances, the key to understanding the failure to development reinforces a sense of belonging to an share information for command of incidents or important group. These organizations call them- operations is ultimately a quest for the superiority selves the ‘‘Finest’’ and ‘‘Bravest,’’ and each one has of one agency over the other. significant roles to play during a terrorist incident. 212 Consequences of Terrorism

During large, complex incidents, agencies must did not also ensure that firefighters were quickly change this perception by viewing themselves as withdrawn. The only rationale they gave was, ‘‘I part of a unified command, whose members are thought the fire department was evacuating, too.’’ equally important and necessary to the operation. Indeed a few of the firefighters and police officers Doing so will eliminate the tendency to withhold together in the North Tower felt individually re- information in the quest for retaining or acquiring sponsible to tell each other to evacuate the build- power. Organizational social biases will engender ing, but there is no evidence that detailed messages considerable resistance to accepting the authority from the helicopters were ever relayed to the fire of a single incident commander who is not ‘‘one of personnel. Most disconcerting of all is the fact that their own’’ when the group believes its right to police commanders did not feel individually re- command is equally important to the outcome of sponsible for ensuring that the fire department the incident. understood that it was vital to evacuate the North The second command condition is the devel- Tower (Figure 15.1). opment of blind spots in command capacity. These Similar group dynamics played out in 1964, develop as part of a group prejudice toward mem- when 38 people could not explain why they did bers of the same group and against those who do not phone police as they witnessed the stabbing not belong to the group. This was evident in the death of Kitty Genovese in Forest Hills (Gladwell, case studies of instances in which information was 2000, p. 27). In these cases, ‘‘the presence of provided within one group but not shared across others diffused the sense of personal responsibility groups. It has also been found that, as the stress and of any individual’’ (Zimbardo, 2004, p. 42). When complexity of a crisis increase, people tend to nar- people are in a group, they assume that someone row their focus on aspects judged most important to else will make the notification, or, since no one is them (Weick, 1995, p. 102). acting, there is not really an urgent problem. As the intensity of the WTC crisis mounted, On 9/11, it was assumed that a police com- commanders became so focused on central orga- mander had to have told the fire department about nizational tasks that they neglected to perform the the messages from police aviation. Or it was as- critical task of sharing information. Their com- sumed that it was not a problem if the fire demand capacity became so myopic that they failed partment did not receive this exclusive information to recognize the fact that the reports from heli- about the fire on the upper floors because they were copters would be of crucial importance to the fire evacuating their members anyway. To this day, department. Critical messages were never passed there has not been a public statement of a sense of from the police to the firefighters or their com- personal responsibility by any police commander manders, nor did the fire commanders ever re- for not sharing information with the fire depart- quest information from the police on conditions as ment. That absence of acknowledgement supports seen from the helicopters. Both organizations were the theory that people feel less responsible for their so preoccupied with performing their own opera- behavior when their focus is narrowed by an in- tions that they developed blind spots that reduced group mentality. Ironically, if there had been a their own command capacity. These agencies never unified command at the WTC with one fire de- crossed group boundaries to consider the welfare partment incident commander and one police de- of the other, nor did they consider how the other partment incident commander, there would have could have contributed to the welfare of their own been a sense of responsibility not only for one’s organization. own organization but also for the other’s. As a re- The third command condition is organiza- sult, many more firefighters and other emergency tional diffusion of responsibility away from the responders would be alive today. individual and toward the group. Hearing reports from police aviation warning of structural failure, many ranking police officers in the street acted Unified Command quickly to move their members to safety, yet they never considered telling the fire department. When Evaluating the events of 9/11 and the effects of asked to account for this oversight, they could not systematic social bias is not intended to assign explain why they pulled back police officers but blame or exonerate any first responder. It is in- Understanding How Organizational Bias Influenced First Responders at the World Trade Center 213

SITUATIONAL AWARENESS Inside the North Tower “Evacuate the Building”

SENSEMAKING based on In-group and Out-group information

Organizational NYPD Bias FDNY

South Tower Collapsed Social identity Numerous emergency evacuation resists single messages by dispatcher command 15 floors glowing red. It’s inevitable Building Development Looks like the building is going to collapse evacuation of blindspots Does not have too much longer to go ordered by limiting Top of the tower is leaning chief officers The North Tower is buckling on the command southwest corner and leaning to the south capacity

Diffusion of responsibility away from Decision: individuals and Decision: Rapid toward the Unhurried Evacuation group Evacuation

Figure 15.1. Organizational bias blocks information sharing and reduces sense making. Routine use of uniﬁed command removes organizational biases.

tended to help develop a command system that is Each incident commander will take individual re- resilient enough to overcome these organizational sponsibility for jointly sharing information and biases in future crises. The World Trade Center developing operational objectives. Incident com- responses demonstrate the shortcomings of ad- manders in this unified structure will have prior vocating a single incident commander or separate training and a new sense of control and will be parallel commands. After completing its invest- personally responsible to one another for all of the igation, the 9/11 Commission Report strongly actions taken at an incident. recommended that ‘‘when multiple agencies or Today’s homeland security efforts of joint ex- multiple jurisdictions are involved, they should ercises under a unified command provide a good adopt a unified command’’ (2004, p. 397). first step. However, it may not be enough to over- To overcome organizational bias, agencies with come these ingrained social biases. It is docu- a major role at terrorist events must not seek to mented that, as stress increases, people tend to control each other but instead work equally in abandon recently learned responses and fall back synergistic fashion to command the responses of on overlearned systematic responses (Barthol & their members. A unified command allows agen- Ku, 1959; Weick, 1995). Public service organiza- cies with different functional responsibilities to tions need to repeatedly practice systematically work effectively together without affecting their depending on each other at small incidents, as well individual authority (National Incident Manage- as at large-scale terrorist events. During these in- ment System, 2004, pp. 11–12). Incident com- cidents, it is necessary to develop a network of manders in a unified command structure will organizations that uses common language and eliminate organizational blind spots by combining participate in everyday social interaction (Walsh & their knowledge to build a more robust authority. Ungson, 1991, p. 60). Organizations that seek 214 Consequences of Terrorism power over others through their endorsement of a may place emergency responders at even greater single commander at interagency incidents will risk at the next incident. revert to an individual group bias during a terrorist Commanding complex incidents is directly event. Only through daily practice of unified connected to the systematic development of a command and organizational interdependency can unified command at everyday incidents and the agencies hope to prevail over systematic social construction of a mutual system of respectful in- biases, thereby enabling organizations to coordi- teraction. Unless our public service organizations nate their strengths in effectively dealing with the can be integrated into a unified command group, next terrorist incident. where decisions are made with full awareness of the Effective commanding during a crisis is de- capabilities and capacities of each of the relevant pendant upon overcoming organizational biases groups, we are doomed to be governed by our or- and strengthening information sharing to main- ganizational biases and repeat the mistakes of lim- tain a common situational-awareness picture of the iting command capacity at the most important times crisis venue. When organizations possess critical in the lives of the communities we have pledged to information, members must feel responsible for serve. sharing it with other emergency responders operating at an incident. Information sharing provides emergency responders with an opportunity to Note make sense of any emergent ambiguity and to act quickly in response to new messages. 1. The 9/11 Commission Report, the WTC in- Finally, there is the need for building a sy- vestigation carried out by the National Institute of Standards and Technology (NIST), the NYPD McKinsey nergistic response network for preparedness. This Report, and New York Times authors Dwyer and Flynn point cannot be overstated. The term network im- have noted slightly different times for each NYPD heli- plies interconnection into a cohesive fabric. In the copter report. However, they agree on content. context of incident response, this cohesion is possible only through a thorough familiarity with the capabilities and limitations of each member of References the network and a willingness to overcome organizational bias to ensure a free flow of information The 9/11 Commission Report, (2004). Final Report of among all of the members. the National Commission on Terrorist Attacks Upon the United States. New York: Norton. The 9/11 Commission Staff Report #13 (2004, May Conclusion 18). Emergency preparedness and response. Retrieved January 18, 2006, from http://9–11commission. gov/staff_statements/staff_statement_13.pdf. The actions taken inside and outside the Twin Barthol, R. P., & Ku, N. D. (1959). Regression under Towers were analyzed for systematic insight on stress to first learned behavior. Journal of Abnormal crisis management. It is not my intent to single out and Social Psychology, 59, 134–136. the successes and failures of individuals or even Deaux, K. (1996). Social identification. In E. T. Higgins particular organizations but rather to use the events & A. W. Kruglanski (Eds.), Social psychology: of 9/11 to examine emergency response as a whole Handbook of basic principles (pp. 777–798). New and determine what is needed to build an in- York: Guilford. tegrated response system that will foster future Dwyer, J., & Flynn, K. (2005). 102 minutes: The untold preparedness. story of the fight to survive inside the Twin Towers. This glimpse of duty at the World Trade New York: Times Books. Gladwell, M. (2002). The tipping point: How little Center may give us the greatest opportunity for things can make a big difference. New York: Little, saving lives in the future. This chapter centers on Brown. understanding how organizational biases affect in- McKinsey & Company. (2002). Improving NYPD formation sharing and decision making when res- emergency preparedness and response. New York: cue personnel are stretched beyond their capacity New York City Police Department. by the shock and cumulative stress of a terrorist National Incident Management System. (2004). Depart- attack. Failure to carefully examine these issues ment of Homeland Security. Washington, D.C. Understanding How Organizational Bias Influenced First Responders at the World Trade Center 215

Retrieved January 18, 2006, from http:// effect: Concepts and methods for studying top www.dhs.gov/interweb/assetlibrary/NIMS-90- managers (pp. 35–65). Greenwich, CT: web.pdf. JAI Press. National Institute of Standards and Technology (NIST). Walsh, J. P., & Ungson, G. R. (1991). Organizational (2005). Federal building and ﬁre safety investigation memory. Academy of Management Review, 16, of the World Trade Center disaster: The emergency 57–91. response operation. Retrieved January 18, 2006, Weick, K. E. (1995). Sensemaking in organizations. from http://wtc.nist.gov/pubs/NISTNCSTAR1–8 Thousand Oaks, CA: Sage. .pdf. Zimbardo, P. G. (2004). A situationist perspective on Starbuck, W. H., & Milliken, F. J. (1988). Executives’ the psychology of evil. In A. Miller (Ed.), The social perceptual ﬁlters: What they notice and how they psychology of good and evil (pp. 21–50). New York: make sense. In D. C. Hambrick (Ed.), The executive Guilford. 16

Warfare, Terrorism, and Psychology L. Morgan Banks Larry C. James

The history of our species is one of almost con- point is that the underlying goal is usually not one tinual conflict interspersed with brief periods of of simple destruction or extermination. peace. Competition, initially between individuals, There are some very logical reasons for this. Once then tribal units, and finally nation-states and a people or a country believe that extermination groups of nation-states, is a fundamental theme of is the real purpose of a conflict, they will ordinarily our existence. In its most intense and modern form, fight for survival with fierce determination—not we refer to this competition as warfare. The pur- something any enemy usually desires.1 If simple pose of this conflict—of war—is almost never the destruction or killing of the enemy were sufficient, physical destruction of an opposing group. The real then wars would generally be won or lost based on purpose, most often, is for one group to get the casualties. As even a brief glimpse of history shows, other to do something it would not ordinarily do. that is not the case. In fact, it is not uncommon for In military terminology, we say that our purpose is the victor to accept greater casualties than the side to impose our will on the enemy (Clausewitz, 1993, that is defeated (Figure 16.2). p. 83). Of course, what we are really talking about In the U.S. Civil War the North had many is behavior modification. Very rarely has the over- more casualties than the South. Now, it is true that all purpose of conflict been to annihilate another since they had larger armies, their disease numbers group of people (Figure 16.1). were higher, even though the rate of disease was There are certainly exceptions, and the twen- actually lower. However, even when looking at tieth century had some notable ones, but more battle casualties alone, the number of casualties the often than not, there is a clear political purpose North suffered was about 17% greater than what that transcends the military defeat of an enemy. the South endured (Figure 16.3). Access to resources is perhaps the most common The numbers from World War I are equally objective. Be it lebensraum, access to oil, or room startling. Although the statistics in Figure 16.4 are for westward expansion, the underlying reason not as accurate as we might hope, nevertheless the today is usually economic. In one sense this is contrast is stark. a circular statement since almost everything that In perhaps the most remarkable case of all— affects a country is essentially economic, but the Vietnam—the numbers look like this: The total of

216 Warfare, Terrorism, and Psychology 217

Military Threat: Conventional vs. Unconventional Psychological Terror (to include biological warfare

The Psychology of Terrorism

Psychological Resiliency Media Based Threat/Terror

Figure 16.1. Psychology of terrorism model. all U.S. allied deaths was about one-quarter that ex- the garrison. Ironically, when the British surren- perienced by the North Vietnamese/Vietcong (Fig- dered, the Japanese had enough ammunition for ure 16.5). And this was a case in which the United only 3 more days of fighting (Perrett, 1993, p. 272). States had a tremendous technological advantage. Contrast that with the Japanese attack on Wake Of course, there are plenty of examples of Island in December of 1941. A very small island, the opposite situation, also. With that in mind, we isolated and with no chance of reinforcements or assert that the psychological hardiness—morale, relief, had about 400 marine infantry, 12 fighter esprit de corps—of a military force is often what planes, and about 1,100 civilian construction will win the day, in spite of fighting a larger foe. workers. The first Japanese attack consisted of 1 In Singapore in February 1942, Japanese light cruiser, 2 older cruisers, 6 destroyers, 2 des- Lieutenant General Yamashita led an attack against troyer transports, 2 transports, 2 submarines, and the British garrison commanded by Lieutenant a 450-man naval infantry landing force. The Japa- General Percival. Yamashita had approximately nese were repulsed on their first attempt and came 40,000 troops, while Percival had more than back a week later with 2 fleet carriers, 6 heavy 107,000. The Japanese troops had very high mor- cruisers, 6 destroyers, and a 1,000-man naval land- ale, whereas Percival’s troops did not. The British ing force, with a 500-man reserve. The resulting made a number of poor decisions, and after only a casualty numbers were 49 marines, 3 seamen, and few days of fighting, Percival decided to surrender

American Civil War The best thing of all is to take the enemy’s North South country whole and intact; to shatter Battle Deaths 112,000 Battle Deaths 94,000 and destroy it is not so good. ...It is better Disease, etc. 227,500 Disease, etc. 164,000 to capture an entire army than to destroy it. Total Deaths 339,500 Total Deaths 258,000 Sun Tzu, 490 BC Figure 16.3. American Civil War casualties. Figure 16.2. Source: J. Wintle (Ed.), The Dictionary of Source: A. R. Millet & P. Maslowski, For the Common War Quotations (New York: Free Press, 1989), Defense: A Military History of the United States of America p. 19. (New York: Free Press, 1984), 229. 218 Consequences of Terrorism

The Great War Supreme excellence consists in Allies Central Powers breaking the enemy’s resistance Russia 1,700 K Germany 1,774 K without fighting. France 1,376 K Austria- 1,200 K Sun Tzu, 490 BC Hungary British Empire 908 K Turkey 325 K Figure 16.6. Source: J. Wintle (Ed.), The Dictionary Italy 650 K Bulgaria 88 K of War Quotations (New York: Free Press, 1989), Romania 336 K p. 19. United States 126 K Serbia 45 K Belgium 14 K Rather, the point is that most warfare is es- Others* 12 K sentially psychological in nature. That may sound Total 5,167 K Total 3,387 K like an absurd statement since there are usually *Portugal, Greece, and Japan more than a few nonpsychological injuries that occur on the battlefield. Why then do we cause Figure 16.4. World War I casualties. so much destruction while conducting warfare? Source: S. Everett, The Two World Wars, Vol. I. World We maintain that we ordinarily conduct warfare in War I (Greenwich, CT: Bison Books, 1980). Quoted at the manner we do because of its psychological http://www.worldwar1.com/tlcrates.htm. effects (Figure 16.6). In other words, we cause destruction because 70 construction workers killed, versus 4 destroyers, of the psychological effect that it has or that we 1 destroyer transport, 1 submarine sunk, and at expect it to have on an opponent. Again, there are least 900 Japanese killed (Perrett, 1993, p. 308). some rather well-used (but used for good reason) We are not suggesting that morale and psy- examples of this. chological hardiness can win every battle. For example, at the battle of the Little Bighorn, Custer Japan—Hiroshima, Nagasaki, Tokyo lost all 250 members of his attacking element, compared to 50 lost by Chiefs Sitting Bull and When the Germans began the bombing of London Crazy Horse. Having said that, the historical record in World War II, they believed it would cause a makes it clear that Custer was not able to maintain great sag in the morale of British citizens. The appropriate command and control over his forces, people of London endured continuous bombing nor was he able to effectively use his better dis- and watched as their modern city was destroyed ciplined soldiers against the less disciplined, but block by block. There was little of military sig- overwhelming, enemy force. nificance that was destroyed, however. The same argument applies to the U.S. decision to begin its firebombing campaign in Japan, Vietnam War although it is true that Japan’s manufacturing Killed in Action Estimates capability was spread throughout its cities. The United States 47,400 NVA/VC 1,100,000 firebombing of Tokyo on March 9, 1945, killed ARVN 224,000 83,793 men, women, and children, injured an- Other Allies 5,000 other 40,918, and left more than a million people Total 276,400 1,100,000 homeless (Weigley, 1977, p. 364). In neither case did the bombing have the desired effect. In London, the citizens rallied, and the Figure 16.5. Vietnam War casualties. country appeared to intensify both its opposition to Source: Compiled from U.S. National Archives and Germany and its determination to win the war. Al- Records Administration (2002), Retrieved April 24, 2005, from http://www.archives.gov/research_room/ though today great controversy still surrounds the research_topics/vietnam_war_casualty_lists/statistics Tokyo bombing and the subsequent use of atomic .html; also at Wikipedia, retrieved February 4, weapons on Hiroshima and Nagasaki, the Tokyo 2006, from http://en.wikipedia.org/wiki/Vietnam_ firebombing did not immediately end the war with War#casualties. Japan. Warfare, Terrorism, and Psychology 219

On the other hand, the use of atomic weapons did accomplish that objective. In Hiroshima, To place any dependence upon 70,000–80,000 people died instantly, and an equal militia is assuredly resting upon a number were injured. In Nagasaki, about 35,000 broken staff. people died at once (Weigley, 1977, p. 365). Why George Washington, letter to Congress, did one cause immediate capitulation and not the September 1776 other? Speaking militarily, if the purpose of warfare is Figure 16.7. Source: J. Wintle (Ed.), The Dictionary of to impose our will on the enemy, then we must War Quotations (New York: Free Press, 1989), p. 65. defeat our adversary. The point, however, is not that we must kill, maim, and destroy the enemy of a line of British soldiers charging with bayonets but only that we must defeat our foe. The implied would make anyone run. In modern warfare, the term here is psychological defeat. tank often provokes the same type of response. If any country wishes to impose its will on an- Military training teaches soldiers that ‘‘perception is other, then it must devise a way to psychologically reality.’’ Our perception of the threat, rather than defeat it. One can do this through bloodshed and the threat itself, is the power of terrorism. starvation, as in the U.S. Civil War, or by convincing the enemy that ‘‘resistance is futile.’’ In the Gulf war, Terrorism the United States dropped many bombs on the Iraqi soldiers in the trenches. Although some members of How does this concept relate to terrorism? Figure the U.S. Air Force may contest this, the truth is that 16.8 presents the army’s definition of terrorism, the bombing killed relatively few Iraqi soldiers. and it is probably as good as most. However, the constant bombing and the inability of As McCauley has pointed out, the distinction the Iraqi forces to take any effective action against us between combatants and noncombatants—built produced a response many of us would call learned up over the centuries—began to erode in the helplessness. When the ground war began, Iraqi sol- early 1800s with the Grande Armie of Napoleon diers surrendered by the thousands, and, although (McCauley, n.d.). Since then, few wars have been there were exceptions, very few put up a stubborn fought only by the military. resistance. The purpose of terrorism is essentially the In truth, then, defeat—like terrorism—is a psy- same as more conventionally oriented warfare, that chological concept. Germany was militarily beaten is, to get governments or societies to do what the in World War I, but was it defeated? Enemy forces terrorist wants. One real difference is that it is con- never really set foot in Germany. The people were ducted by an opponent who does not have the certainly beginning to feel the effects of the war, military strength to fight directly. We contend that but most of them believed they were somehow this type of warfare relies most heavily on the use cheated. The imposed reparations simply added to the buildup of animosity against Britain and France. At the end of the Vietnam War, the United States was not militarily defeated. We had basically Terrorism The calculated use of unlawful won every battle. Nevertheless, we were psycho- violence or threat of unlawful logically defeated by a strategy that outsmarted us. violence to inculcate fear; intended George Washington was not a fan of the to coerce or to intimidate militia. He believed that it did not have the ne- governments or societies in the cessary discipline to fight in a tough battle and pursuit of goals that are generally would run at the first opportunity (Figure 16.7). political, religious, or ideological Washington felt that way in part because the militia would not stand up to the British soldiers’ Figure 16.8. Definition of terrorism. bayonet charge. The militia’s rifles took a long time Source: Joint Publication 1-02, Department of Defense to reload and lacked bayonets. Once the militia had Dictionary of Military and Associated Terms. Retrieved fired, the British would charge and be on them with February 4, 2006, from http://www.dtic.mil/doctrine/ bayonets before they could reload. The very image jel/doddict/data/t/05394.html. 220 Consequences of Terrorism of psychology. We also believe that Osama bin deal of time studying the effects of traumatic stress. Laden wanted, as one of his goals, to get the United As one might expect, our focus is not usually on the States out of the Middle East. He calculated that positive aspects of humans under stress but instead we, as a country, would psychologically run away is on the negative results of stress and ways to re- from the horror he was inflicting on us. (He re- mediate them. (We are certainly not saying that this ceived bad advice on that.) is a bad thing. One could easily argue that this is the In our opinion, there is no better recent example foundation of our science.) of how one side wished to psychologically defeat The county in which one of us lives recently another than the overall strategy that bin Laden at- went through a severe drought. Mandatory con- tempted in his war against us. First, he would de- servation efforts were put into effect, including the monstrate our vulnerability in what we consider the use of disposable tableware at restaurants and an safest of refuges. He would shock us by killing in- appeal to citizens to refrain from watering lawns discriminately. In other words, not that he would and washing cars. The most significant request, use this term, he would try to induce learned though, was for voluntary reductions in household helplessness in us. Consequently, we would be water use. As a result of people’s response, the rate forced to take some action against him. Then, when of water use went from 6.1 million gallons per day we attacked him on his territory, he would maul to 1.9 million gallons, and most of the decrease was us—causing many Americans to come home in body credited to the reductions in household use. This bags. His view of the Russian invasion and sub- small community pulled together, with neighbor sequent departure from Afghanistan was that he and helping neighbor. As Seneca once said, ‘‘the good his Mujahedeen had defeated the Russians, and he things which belong to prosperity are to be wished, viewed the Russian military as stronger than the but the good things that belong to adversity are to be United States. Once we as a country had experi- admired’’ (Lucius Annaeus Seneca Quotes, 2005). enced the horror of war in Afghanistan, he believed Much has been said concerning psychology’s that we, too, would leave in defeat—again, just as focus on pathology. Seligman (1991) has made a he had seen in Somalia and just as he believed strong case that we should review the way in which happened in Vietnam. Because he believed his side we address strength and virtue—his work on po- was founded on stronger principles—a strong and sitive psychology (Seligman, 1991). For 20 years, abiding Islamic faith—there could be no other out- one of us has been deeply involved in helping sol- come than the routing of the decadent Western diers survive the rigors of warfare. As a friend of forces. Said another way, bin Laden’s goal was not to ours is fond of saying, the goal is to have soldiers conquer our military forces (although he actually moderately aroused while under stresses that would believed he could do that) but rather to defeat the seem to most of us to be unmanageable—such as country psychologically. being in combat. It is not just that we should study strength and virtue. Rather, how do we manage to get men and women to do incredible things under Psychology and Psychologists very high levels of stress? How do we resist the forces of terrorism? We maintain that focusing What does any of this have to do with psychology? on treating people who have been exposed to this As we mentioned earlier, we believe that bin Laden horror as victims is the wrong way to resist. predicted that the United States would recoil from Unfortunately, over the years we have had to the horror of 9/11. And if we actually sent in talk to a fair number of people following tragedy. ground troops, he would maul us, and we would What has always amazed us is the incredible run away—just as he had seen us do in Somalia and strength that people have. Yes, we know there is a as he had heard we responded in Vietnam. price to be paid. Nothing is free. People who have There is a great deal that would have supported undergone great tragedy will always carry that with his expectation, especially if one performs a quick them. However, as Eric Maria Remarque said in his review of our psychology literature. For a variety of book about a physician living through the Nazi very good reasons, we focus our energy, research, occupation of Paris, ‘‘Human beings can stand a and treatment on the understanding and remedia- great deal’’ (Remarque, 1945, p. 455). We maintain tion of illness. In this context, we have spent a great that it is critical to treat people as though they have Warfare, Terrorism, and Psychology 221 resources, not as though they lack them. We must other words, terrorists will use the media (usually instill competence and confidence to survive an- in the form of television or radio news reports) to other tragedy. provide a community, region, or nation with a Strength of character, steadfastness in the face perceived threat of attack with car bombs, hostage of adversity, physical bravery—not just the type taking, suicide bombers, and so on. Even though that soldiers discuss but that of firefighters and the actual military threat to national security may everyday Americans on 9/11—we believe that these be minimal, the perception is that the threat is real. are subjects for us to ponder, study, and encour- Modern-day terrorists may not possess as many age. We continue to expand our knowledge of tanks as the United States during the Cold War, the negative effects of stress. At the same time, but their threats appear real due to their use of we need to expand our knowledge of the value of the media in shaping a nation’s perception. stress and the factors that help develop bravery, courage, and integrity under stress. People are victims only when they decide they have no control Psychological Threat and Terror over their lives. We are not a nation of victims. We are the most powerful, free, creative, and generous In many of the third-world regions, military threat nation on earth because we are doing something may in fact be less fear provoking than that of the right. conventional forces of Western society. However, these units from third-world regions employ psychological terror to manipulate and shape the be- A Model for Understanding havior of others. Let us use some recent examples the Psychology of Terrorism of the application of psychological terror. Shortly after 9/11, anthrax was mailed to a major Wash- Understanding the psychology of terrorism can be ington, D.C., post office building, one of the Senate a daunting task because the act of (as well as the office buildings, and the post offices at Walter Reed psychology of) terrorism is a complicated process. Army Medical Center. A few people died as a result, Those who want to employ psychological terror compared to the thousands of people killed in the against us have many ways to enhance our sense of World Trade Center bombings. Yet, the psycholo- psychological vulnerability and to psychologically gical terror instilled by the anthrax attack in Wash- attack us. One way to conceptualize this involves ington, D.C., paralleled the horror experienced in a paradigm that examines the dynamics of the New York on September 11. In many cases, the military and the psychological threat, perhaps en- psychological threat of biological and chemical hanced by a media-influenced perception and our weapons can be just as devastating psychologically psychological resilience. as an actual attack with major military weapons. Sustained fear rather than death is the goal of psychological threat. When death and physical Military Threat injuries are objectives as well, terrorists tend to select types of attacks that will kill, as well as pro- Earlier in this chapter we explained how the per- vide lingering psychological terror in a particular ception of success or failure, sometimes in direct population. contradiction to actual success or failure, can be the major determining factor of a battle. The power of this perception has even served to psychologically The Role of Psychological Resilience deter actions of other nations. For example, the United States, during the military buildup of the Expose two people to the same traumatic event, and Cold War era, deterred Eastern bloc countries from they may have very different psychological experi- attacking with the psychological threat of our over- ences. Why? One answer appears to have to do with whelming force and technology—without firing the level of individual resilience. This capability may a single missile. very well shape not only how people perceive an Frequently, the perception of military threat is event but also how they respond at the time and how shaped via a media-based perception of peril. In they physically and psychologically recover from 222 Consequences of Terrorism the incident. A resilient person focuses on healthy Department of Defense. (2004). Joint Publication 1–02, coping strategies rather than on the event itself and Department of Defense Dictionary of Military and the pathological responses it provokes. Associated Terms. Department of Defense, April How is resilience related to the psychology of 12, 2001 (as amended through November 30, terrorism? As the level of internal flexibility in- 2004). Lucius Annaeus Seneca Quotes. (2005). Retrieved creases, the level of reported ongoing trauma de- January 19, 2006, from http://www.brainyquote creases. Thus, it would serve communities well to .com/quotes/quotes/1/luciusanna154988.html. develop programs that promote and teach resi- McCauley, C. R. (n.d.). The psychology of terrorism. lience training as a response to acts of terrorism. Retrieved January 19, 2006, from http://www One can argue that such an intervention may very .ssrc.org/sept11/essays/mccauley_text_only well aid a community in its ability to recover from .htm. acts of psychological terror. Millet, A. R., & Maslowski, P. (1984). For the common defense: A military history of the United States of America. New York: Free Press, p. 229. Notes Perrett, B. (1993). The battle book: Crucial conflicts in history from 1469 BC to the present. London: Arms The opinions expressed in this article are those and Armour Press. of the authors and do not reflect official policy of either Remarque, E. M. (1945). Arch of triumph (W. Sorell & the Department of Defense nor the U.S. Army. D. Lindley, Trans.). New York: Appleton-Century. 1. For example, some historians have argued that, Seligman, M. E. P. (1991). Learned optimism. New York: because the Japanese people believed that the allied Knopf. forces in World War II wished to completely destroy U.S. National Archives and Records Administration. their culture, the entire country was prepared to fight (2002). Retrieved April 24, 2005, from http:// to the death (Weigley, 1977, p. 310). Certainly, the www.archives.gov/research_room/research_ United States’ experience on the islands of Tarawa and topics/vietnam_war_casualty_lists/statistics Okinawa would support this view. Out of a total of .html. 4,836 Japanese forces, only 146 were captured. The Weigley, R. F. (1977). The American way of war: A rest died in combat (Perrett, 1993, p. 288). history of United States Military strategy and policy. Bloomington: Indiana University Press. Wikipedia. (2005). Retrieved January 19, 2006, References from http://en.wikipedia.org/wiki/Vietnam_ War#casualties. Clausewitz, Carl von. (1993). On war. New York: Wintle, J. (Ed.). (1989). The dictionary of war quotations. Knopf. New York: Free Press. IV Assessment and Treatment This page intentionally left blank 17

Terrorism Stress Risk Assessment and Management Douglas Paton John M. Violanti

Acts of terrorism represent a significant risk to are these demands more pronounced than in mental health. When the World Trade Center the context of responding to acts of terrorism and Pentagon were attacked on September 11, (Grant, Hoover, Scarisbrick-Hauser, & Muffet 2001, some 100,000 people witnessed the event 2003; Jackson, Baker, Ridgely, Bartis, & Linn, directly, and millions more through the media. The 2003; Kendra & Wachtendorf, 2003; Simpson & consequent potential for psychological trauma was Stehr, 2003). immense (Galea et al., 2002; Shuster et al., 2001; Recognition of the risk faced by protective Yehuda, 2002). The protective services profes- services officers who confront the consequences of sionals and disaster mental health workers who terrorist acts is reflected in the development of respond to the needs of a community as a result specific resources to assist them by the American of acts of terrorism are not immune from these Psychological Association (Carlson, James, Hobfoll, consequences (Brown, Mulhern, & Joseph, 2002; & Leskin, 2004; Leskin, Morland, Whealin, Everly, Creamer & Liddle, 2005; Gorski, 2002; North et al., Litz, & Keane, 2004), and others (Cloak & Ed- 2002), and the manner in which the risk to their wards, 2004; Gorski, 2002). However, the foun- mental health is conceptualized has acquired a dation upon which these resources are based does significant new dimension since 9/11. not represent a comprehensive account of the psy- Protective service professionals (e.g., law en- chological consequences of response to terrorist forcement officers, firefighters, military personnel) events. For example, following the Oklahoma City are in the front line for exposure to acts of ter- bombing, North et al. (2002) noted that 77% of the rorism that show no sign of abating. Managing firefighters self-appraised their post–Oklahoma the psychological consequences associated with bombing work performance as satisfactory or bet- experiencing these events has implications beyond ter. Furthermore, 39% endorsed positive changes safeguarding well-being. Stress adversely affects from their work compared with 12% who endorsed performance in circumstances that demand high negative changes (ibid.). The fact that traumatic levels of attention and creative solutions to emer- experiences can be resolved as positive or negative gent problems (Paton & Flin, 1999). Nowhere outcomes begs the question of whether it is possible

225 226 Assessment and Treatment to influence this outcome. The risk management professional role. A combination of these factors paradigm provides a framework within which we arising from sources over which they have little can answer this question. control and the very nature of emergency work precludes preventing exposure to terrorist events as a mitigation strategy. This does not, however, The Risk Management Paradigm preclude seeking to manage this risk by altering the consequences of exposure to such events. If it While usually associated only with loss or deficit is possible to exercise control over the factors that outcomes (e.g., PTSD), the risk management para- mediate the relationship between this exposure digm was developed to encapsulate both growth/ and its psychological consequences, it will be pos- adaptation outcomes and deficit/loss outcomes sible to manage stress risk in a proactive manner. (Dake, 1992; Hood & Jones, 1996). The risk man- There are several ways in which this might be agement approach is built on the premise that, if we achieved. can identify the factors that predict positive and One approach would be to use stress in- negative outcomes, we may be able to manipulate oculation and other training strategies to develop them in ways that enable us to make informed the interpretive mechanisms and competencies choices regarding the psychological consequences (e.g., understand the nature and consequences of of responding to challenging events. According to critical incident work, decision making) required this conceptualization, we can use our knowledge to accommodate the psychological implications of of these factors and how they interact to estimate working in challenging operational environments. stress risk and inform the development of risk These strategies can help protect officers’ well- management policies and practices. We can then being by providing them with a capacity to render implement these guidelines to increase personal, threatening experiences meaningful. They can group, and organizational capacity to adapt to these also facilitate the effective performance of their demands (Creamer & Liddle, 2005; Paton, Vio- response role by providing the competencies re- lanti, Dunning, & Smith, 2004). That is, by de- quired to deal with atypical operating demands fining event demands and characteristics as risk (Dunning, 2003; Flin, 1996; Paton, 1994). An- factors, we can reduce a priori assumptions of an other approach involves developing organizational automatic link between adverse events and distress practices (e.g., incident management protocols, outcomes and provide a more neutral content within performance expectations, interagency coopera- which to consider the relationship between people tion) and an organizational culture (e.g., regarding and acts of terrorism. However, to manage this risk, emotional disclosure, reviewing response out- there must exist a capability to make choices re- comes as sources of blame versus learning oppor- garding outcomes by exercising control over the tunities) that can help mitigate stress risk (Jackson causes of adverse stress reactions or the factors that et al., 2003; Paton, 1997; Paton & Jackson, 2002). influence the way in which people interpret these Once articulated, knowledge of these processes experiences. provides a framework within which we can de- While the process of attempting to compre- velop and implement stress risk management hend the scale and nature of the consequences of strategies. terrorist acts can represent a significant psychological challenge, terrorist stress risk factors can rarely be identified from the event (e.g., detonating Managing Stress Risk From a weapon of mass destruction, flying a plane into a Threatening Events building) per se. Stress risk factors can be more readily discerned in the hazardous event char- Risk can be managed before (primary and sec- acteristics (e.g., threat to health, physical danger, ondary prevention) or after (tertiary intervention) working in protective clothing, confronting bio- exposure. While several personal (e.g., individual hazardous agents, dealing with human remains, competence can be enhanced through selection handling infectious materials, making complex and and training) and organizational (e.g., managing urgent decisions under conditions of uncertainty) the demands of a multiagency response using in- that officers encounter when performing their teragency team development and decision making) Terrorism Stress Risk Assessment and Management 227 factors are amenable to change prior to exposure, Personal Factors the complexity of terrorist events makes it impossible to mitigate all of the risks, and tertiary The concept of vulnerability has been evoked to strategies are required to manage residual mental explain the range of reactions that accompany health issues (Violanti & Paton, 2006). However, exposure to traumatic events (Violanti & Paton, the manner in which tertiary intervention is 2006). Blaikie, Cannon, Davis, and Wisner (1994) conceptualized should expand to accommodate have defined vulnerability as the combination of the role of social and organizational factors characteristics of a person or group in terms of (Paton & Stephens, 1996). Consequently, effective their capacity to anticipate, cope with, resist, and stress risk management will require a comprehen- recover from hazardous impacts that threaten their sive approach, one that integrates all three per- life, well-being, and livelihood. The personal pre- spectives. dictors of vulnerability reflect experiential, dis- While postevent strategies (e.g., debriefing) are positional, and interpretive factors. routinely provided, the benefits of primary pre- Officers’ stress vulnerability is influenced by vention are less well known (Carafano, 2003; Pa- their history of traumatic experience prior to their ton, 1994; Paton, Violanti, & Smith, 2003). The employment (Violanti & Paton, 2006), as well as fact that protective services officers will be called transient factors such as health status, fatigue, and upon repeatedly to deal with terrorist events and psychological fitness. In their comprehensive ac- may experience prolonged periods of involvement count of posttrauma vulnerability, Scotti, Beach, under hazardous conditions makes a proactive Northrop, Rode, and Forsyth (1995) have identi- approach particularly important. The importance fied three categories. The first concerns biologi- of primary and secondary prevention is also cal factors and genetically based predispositions heightened by the fact that any training and or- (e.g., heightened autonomic and physiological re- ganizational development activities required to activity) and changes in physiological reactivity mitigate stress risk are not amenable to change as a consequence of earlier traumatic exposure. through current postevent, tertiary prevention Second, historical antecedents such as learning practices (e.g., debriefing). It can be provided history, experience of child abuse, preexisting psy- only before officers’ involvement, making it an chopathology, and repetitive exposure to traumatic essential component of an effective risk manage- events also influence vulnerability. Finally, psy- ment strategy. chological factors such as learned avoidance of In this chapter, the development and im- threat situations, social skills deficits that limit use plementation of primary prevention strategies is of social support, hypervigilance of threat-relevant discussed in relation to the choices available at cues, and inadequate problem-solving behavior individual and organizational levels. With regard are identified for their potential to influence sus- to the former, discussion focuses on the personal ceptibility to experiencing adverse posttrauma out- competencies and interpretive mechanisms re- comes. However, the diverse nature of disposi- quired to render atypical and physically and psy- tional influences on vulnerability renders their chologically threatening aspects of the experience organization in ways that can assist risk manage- (e.g., the nature of terrorism and its goals, dealing ment problematic. One way in which vulnerabil- with human remains, exposure to biohazards) ity data from these different sources can be meaningful and coherent. The second line of in- quantified and incorporated into the risk assess- quiry focuses on identifying the organizational ment process involves using a vulnerability coef- practices (e.g., degree to which authority is de- ficient that is estimated as a constant across a volved, empowerment, interagency collaboration) group of individuals (Violanti, 1990; Violanti & that reflect sources of risk emanating from the Paton, 2006). response management paradigm (e.g., command While dispositional and personality factors can and control, standard operating procedures), inform primary prevention through the recruit- which defines how an agency responds to a crisis ment and selection processes, the assessment of event. In the next section, the rationale for the risk from this quarter has a more prominent role inclusion of these perspectives within risk man- to play in informing the development and de- agement is discussed. ployment of tertiary intervention resources (e.g., 228 Assessment and Treatment peer support). For example, it can be used to as- fear is an important factor in the etiology of PTSD. sess likely needs and residual risk (that portion of The Diagnostic and Statistical Manual of Mental risk that cannot be reduced through primary and Disorders (DSM-IV; American Psychiatric Associa- secondary intervention) (Violanti & Paton, 2006). tion, 1994) lists fear in ‘‘criteriion A’’ for PTSD. It is not discussed further here. There is, however, Brewin, Andrews, and Rose’s (2000) longitudinal another individual difference factor capable of in- analysis of criterion A confirmed its validity. Sixty- fluencing stress risk for terrorist events. Risk is one percent of those diagnosed with PTSD re- influenced by the fact that the mental models ported ‘‘intense’’ trauma-related emotions of fear 6 or mind-sets that underpin the manner in which months after the event. Feelings of vulnerability people interpret and organize experiences and and fear that result from terrorist acts may be make predictions about their future (Paton, 1994) persistent and thus have the potential to pose a have been rendered less applicable by the growing much higher risk for PTSD than most other dis- threat of terrorism (Daw, 2001). asters, which are temporary in nature. In addition, unlike natural disasters, the fear and feelings of Shattered Assumptions of Safety vulnerability generated by terrorism have the capability to spread to general as well as local Despite a long-held belief that their home soil was populations and persist for considerably longer relatively safe from foreign attack, Americans lost periods of time. this perception of safety on 9/11. Zimbardo (2001) Managing risk involves first identifying the has stated that the fear generated by terrorism threatening elements of terrorist events that con- undercuts the sense of trust, stability, and contribute to this fear. The importance of this activity fidence in one’s personal world. Moreover, this lost is emphasized by Cooper’s (2001) conclusion that sense of safety and security may be accompanied the incidence and destructiveness of acts of ter- by feelings of helplessness and anxiety (Figley, rorism will increase in the future. The ability of the 1985). The relationship between exposure to ter- media to instantaneously bring the horrible details rorist events and psychological trauma could thus of a terrorist event directly into people’s homes will be mediated by individual vulnerabilities as they no doubt increase not only indirect exposure to apply to fear. Fear becomes anxiety when it gen- terror but also perceived personal vulnerability to eralizes to become a more pervasive feeling of its impact, perpetuating this climate of fear. Once personal vulnerability. one is victimized, it is relatively easy to see oneself The fact that the 9/11 attacks were deliberate in the role again; the experience is now ‘‘available,’’ human acts made them particularly distressing and one sees oneself as ‘‘representative’’ of those for Americans and compounded their loss of per- who were actually victimized (Maercker & Muller, ceived safety and security. The accuracy of this 2004; Kahneman & Tversky, 1973; Lasker, 2004; statement is reflected in the fact that a huge de- North et al., 2005). crease in airline use and travel occurred im- Consequently, the United States now sees itself mediately after the attack. Myers (2001) has stated as seriously challenged. The assumptions that had that the terrorists made progress in their fear war formerly enabled it to function effectively can no by diverting our anxieties from big risks toward longer be relied on as guides for behavior (Janoff- smaller ones. Thus, Americans’ illusion of in- Bulman & Freize, 1983). As a result, Americans vulnerability was shattered at both the macrolevel must explore a new way of being (Daw, 2001). and the microlevel of everyday existence. To Samuel Karson (quoted in Murray, 2001), a psy- Americans, the world is now a threatening place— chologist for the Federal Aviation Administration, terrorism has come home and is no longer deni- commented that feelings of vulnerability can be able. The fear instilled by terrorism works by assuaged if we deal with our weakness of not breaking down the walls of psychological in- knowing our enemies’ intention. Massive informa- vulnerability and introducing a new mind-set tion is thus needed on the terrorists, their culture, dominated by preoccupation with the fear of re- language, and psychology, and this knowledge occurrence. must be encapsulated in new mind-sets or inter- Posttraumatic stress reactions can result from a pretive mechanisms that can assist us in adjusting variety of exposures. In the context of these events, to this new reality. Terrorism Stress Risk Assessment and Management 229

The development of these interpretive me- most significant predictor of posttrauma risk for chanisms will be particularly important for pro- this group (Era¨nen, Millar, & Paton, 2000; Paton, tective services officers who may have to repeatedly Smith, Violanti, & Era¨nen (2000). Compared with confront the consequences of terrorism and re- dispositional (hardiness), social support, and for- spond to the challenges it poses to themselves and mal support (debriefing) factors, it was three times the communities they serve. Before discussing how more influential as a predictor of traumatic stress this might be accomplished, it is important to outcomes (Figure 17.1). According to this analysis, consider the fact that protective services officers organizational culture (beta ¼0.3) and family experience terrorist events and develop their in- dynamics (beta ¼0.2) represent the two most terpretive mechanisms within an organizational significant predictors of stress risk. context. It is thus pertinent to ask whether this Using data from a longitudinal study of police context influences risk. In the next section, this officers, Paton (in press) has demonstrated that not issue is introduced in the context of a brief dis- only can this relationship be primarily attributed cussion of the relationship between organizational to the negative elements of organizational culture factors and posttrauma outcomes. In so doing, it (e.g., lack of consultation, poor communication, also demonstrates the validity of including organi- red tape), but these negative elements (beta ¼ zational intervention as the second element in the 0.23) were also more significant predictors of primary prevention strategy introduced earlier. posttraumatic stress reactions than the traumatic experiences (e.g., shooting incidents, body re- ¼ Stress Risk From Organizational Sources covery, dealing with child abuse) (beta 0.16) per se. Furthermore, he has demonstrated that the Analyses of protective services officers’ experience negative elements of organizational culture do not of terrorist events have highlighted the fact that their predict well-being. In contrast, the positive ele- stress risk does not emanate solely from the nature ments of organizational climate (e.g., empower- and scale of these events and their horrific content. ment, devolving and delegating responsibility for It is also influenced by organizational and opera- crisis decision making) do predict positive out- tional factors (Brake, 2001; Carafano, 2003; Federal comes (Paton, in press). This means that the or- Emergency Management Agency [FEMA], 2004; ganization of risk management strategies requires Grant et al., 2003; Jackson et al., 2003; Kendra & two components. One manages the negative cul- Wachtendorf, 2003; McKinsey Report, 2002). What tural elements in ways that contribute to mitigating evidence supports a role for organizational factors as acute stress and posttraumatic stress risk. Another predictors of posttraumatic stress risk? develops those positive cultural elements necessary Analysis of the experience of rescue workers to promote well-being. Paton et al. (2000) have following the sinking of an Estonian ferry reveals also identified family dynamics as a significant that perception of organizational culture was the predictor of posttraumatic outcomes (Figure 17.1)

Hardiness −.10 Post Trauma Organizational Climate Stress −.30 R2 = .45 −.22

Perceptions of Social Support Family Life Debriefing (Quality) Change Effectiveness .33 .29

Figure 17.1. The relative contributions of organizational, dispositional, debriefing, social support, and family variables to posttrauma stress outcomes. Source: Adapted from Era¨nen et al. (2000) and Paton et al. (2000). 230 Assessment and Treatment but in ways that are linked to other support re- quences of acts of terrorism to contribute to stress sources. In so doing, they also suggest a need for risk, the fact that organizations can make choices a more comprehensive approach to the provision about their relationship with families (e.g., family of tertiary intervention. friendly policies and support groups, involving Structural equation analysis reveals that, al- family members in recovery planning) provides though perceptions of organizational culture had organizations with the potential to contribute to a direct effect on posttraumatic stress scores, the the proactive management of stress risk. influence of a commonly occurring tertiary inter- Overall, the studies discussed in this section vention (psychological debriefing) did not (Figure demonstrate the value of including organizational 17.1). Rather, the influence of the latter was and family factors within stress risk assessment and mediated by social support and changes in family management strategies. The prominence of orga- functioning (Figure 17.1). This suggests that, for nizational factors as stressors within the terrorist those who found debriefing to be effective, it was event response environment (Carafano, 2003; because, first, it enhanced social support quality, Grant et al., 2003; Kendra & Wachtendorf, 2003) which, in turn, enriched the quality of family func- makes it imperative that variables relating to orga- tioning. The latter had a direct influence on the nizational culture and practices be included in the posttrauma outcome (Figure 17.1). From this we risk assessment and management process. Rec- can infer that additional emphasis on developing ognition of the influential nature of these factors the quality of social support and family functioning and of the fact that they describe variables under could have beneficial mental health consequences the control of the emergency organization also infor officers and their family members alike. While creases the choices available to emergency organi- this study demonstrates the influence of this change zations regarding primary intervention. By making during a 6-month postevent period, organizations choices about these variables and developing pol- have it within their power to develop social support icies and procedures accordingly, organizations can and family functioning resources within the con- develop strategies that ensure more effective stress text of a primary prevention program. Indeed, the risk management (Creamer & Liddle, 2005; Paton benefits of the latter can be discerned in other as- et al., 2004). In the sections that follow, discussion pects of the work-family relationship. centers on the nature of the processes and com- Shift work, a common component of emer- petencies that can be harnessed in pursuit of this gency service work, has a well-documented history goal. There is, however, one additional variable that as a predictor of the quality of family functioning must be taken into consideration if a comprehen- and provides a good example of an organizational sive overview of terrorism-related stress is to ensue. practice capable of influencing family stress risk This additional variable describes changes in offi- (Shakespeare-Finch, Paton, & Violanti, 2003). The cers’ involvement over time. number and timing of hours worked outside the Officers’ experience of terrorist events evolves home significantly influence workers’ ability to over time as they progress through a series of participate in and enjoy family life. While it is stages, each with its own unique demands and often assumed that the traumatic nature of officers’ characteristics and thus implications for stress risk. experiences has a greater influence on this re- These stages are the alarm/warning and mobiliza- lationship than organizational factors such as shift tion phase, the response phase, and the process work (Wraith, 1994), this assumption is incorrect. of reintegration into routine work following the Shakespeare-Finch and colleagues have discussed termination of their deployment (Hartsough & how, when shift work was controlled for, there Myers, 1985). was no difference in family functioning between an emergency services shift work group and a control group composed of nonemergency shift workers. Managing Stress Risk During the This suggests that shift work, rather than officers’ Alarm and Mobilization Phase traumatic experience per se, contributes to family problems. While this position is not intended to The alarm phase is the period of comprehending deny the potential for the psychological conse- and adjusting to the occurrence of a terrorist event. Terrorism Stress Risk Assessment and Management 231

The demands that typify this phase include, for Homeland Security, 2003; Paton & Hannan, example, accessing intelligence about what has 2004). occurred, differentiating fact from inference, mak- Irrespective of the quality of planning for tering sense of the confusing and often ambiguous rorist events, the translation of plans into opera- information presented by such events, and nego- tional reality remains a contentious issue (Brake, tiating operational arrangements with other agen- 2001; Department of Homeland Security, 2003; cies and jurisdictions (FEMA, 2004; Grant et al., Grant et al., 2003; HBWMD, 2001; McKinsey 2003; Paton & Hannan, 2004). The potential of Report, 2002). The different statutory and reg- previous experiences to influence predispositions ulatory frameworks that prescribe how agencies to interpret accidents (e.g., the New York power (e.g., law enforcement, military) define and engage outage) as terrorist events can add to the com- in the response are prominent contributors to this plexity of the response environment for protective discrepancy (Brake, 2001). Factors such as these services officers. complicate the mobilization and coordination of The final report of the Human Behavior and a multiagency response and increase the risk of Weapons of Mass Destruction (HBWMD) Crisis/ acute stress reactions for those officers who are Risk Communication Workshop (2001) concluded involved (Paton, 2003). The TOPOFF 3 exercise that, for those in command or coordination roles, (April 2005) examined ways of dealing with this terrorist events pose several challenges during this issue. The evaluation of this exercise may provide initial phase. The stress of responding under these valuable insights into how these complex issues circumstances can be traced to several factors. In can be managed. Strategies that can be employed addition to their emanating from the direct effect to manage other aspects of a multiagency response of experiencing a terrorist attack, acute stress re- are discussed later in the chapter. actions can also be attributed to the demands as- Another prominent source of stress risk during sociated with adapting plans to deal with ur- the alarm and mobilization phase of terrorist events gent, emergent, and evolving emergency demands is their implicit unpredictability (HBWMD, 2001). (Brake, 2001; HBWMD, 2001), the need for For example, a terrorist attack that involves the creative responses to emergent demands (Kendra detonation of a conventional bomb will create an & Wachtendorf, 2003), and the need for responses event with a clearly defined location, a clear be- to accommodate and integrate the efforts of several ginning and end, and a finite period of impact. It agencies across multiple jurisdictions (Brake, poses demands that can be accommodated by de- 2001; Department of Homeland Security, 2003, ployment strategies similar to those used to manage 2004; Grant et al., 2003; Paton & Hannan, 2004). more ‘‘routine’’ emergencies. In contrast, a bioha- A crucial competence in this context is the ability zard attack (e.g., pollution of water supplies, release to extract salient cues that assist in adapting of a biohazard such as smallpox) may have com- plans and response actions to fit unpredictable menced before its existence has been identified, situational demands. This is situational awareness present more diffuse beginnings and ends, spread (Endsley & Garland, 2000), and it is essential to in ways dictated by local conditions such as build- understanding mobilization stress risk (Carafano, ing density, topography, and prevailing weather, 2003; Flin & Arbuthnot, 2002; Paton & Hannan, and create relatively prolonged periods of impact 2004). Another facet of situation awareness, the (Fisher, 2000; HBWMD, 2001; Lasker, 2004). The capacity to anticipate future demands, has been alarm may be raised some time after the event has identified as an important competence for terrorist actually begun, thus creating greater uncertainty events (Department of Homeland Security, 2003). during mobilization. For example, the immediate High situational awareness facilitates the capability effects of a disease-causing agent could be dismissed of emergency responders to minimize their ex- as flu, and its true nature might not become clear posure to risks, allows more effective use of re- until some time after initial contact. This time lag sources, and enables better command and control means that protective services professionals will by addressing issues such as managing conver- face considerable uncertainty with regard to the gence and coordinating operations controlled by nature and magnitude of the problem they face, as multiple agencies (Carafano, 2003; Department of well as their own status (particularly if they have 232 Assessment and Treatment come into contact with those affected), and they The organizational role is to facilitate this capacity will, as a result, respond within a more complex to impose meaning on threatening and challenging societal context (Lasker, 2004; North et al., 2005). demands to limit the likelihood that officers will be For example, planning for such events assumes overwhelmed by the scale or the horror of the si- that people comply with recommenced actions tuation they must contend with (Alexander & (e.g., staying where they are until authorities in- Wells, 1991; Paton, 1994). To accommodate dif- form them that it is safe to move, going to a vac- fering agency definitions of terrorism and their in- cination center). The reality may be quite different vestigative objectives (Brake, 2001), this would (Lasker, 2004). Lasker has discussed how the ac- have to be done for each organization. In so doing, tions that people take are dictated by how they this strategy could ameliorate stress in each pro- resolve the contradictory demands they experience fession, but it could also contribute to coordination (e.g., placing a desire to reunite with their children stress in multiagency response environments, em- immediately above advice to remain in situ, re- phasizing the need to develop a superordinate team fusing to go a vaccination center for fear of coming structure that accommodates these multiple roles. into contact with those already infected). A dis- For protective services officers, factors such as crepancy between plan assumptions and actual uncertain dispersal patterns and the possibility of behavior creates an additional source of un- further attacks in unpredictable locations means certainty for protective services officers and further that the alarm (and subsequent) phase of a terrorist contributes to their stress risk. Response planning event will be accompanied by significant concerns should thus be based on more realistic estimates for their family members (HBWMD, 2001). This of what people will actually do (Lasker, 2004). marks a significant departure from other emer- Biohazardous weapons can also generate highly gency events and makes a substantial contribution dynamic response scenarios. For example, aerosol to the stress risk associated with acts of terrorism. dispersion creates a physical hazard whose dis- Programs designed to help officers develop a ca- tribution is a function of both prevailing and pacity to adapt should also be extended to their changing meteorological conditions. In addition to family members. These should include ensuring its direct effects, stress risk is increased by diffi- regular and informative communication between culties in knowing where and when to deploy and agency and families, providing information, offer- what protective equipment to take (Department of ing training that addresses ways to manage their Homeland Security, 2003). People’s uncertainty reactions, suggesting ways in which they can as- regarding what they should do to protect them- sist their partner’s recovery, developing support selves can increase their reliance on protective groups, and facilitating their access to, for example, services for information. However, under these cir- vaccines and mental health resources (HBWMD, cumstances, officers would not have recourse to 2001; Shakespeare-Finch, Paton, & Violanti, 2003; the normal means of reassuring citizens (Fisher, Violanti & Paton, 2006). 2000; Lasker, 2004). Stress risk during mobilization is greater when Stress risk is increased if deployment precedes officers respond at the end of a shift or when a full appreciation of the nature or implications they are affected by transient factors (e.g., illness, of a terrorist event. For example, police officers occupational stress). The personal and transient who were immediately deployed to the site of the nature of these factors renders them difficult to Lockerbie disaster found it difficult to comprehend control. Risk management programs that enhance the carnage and death they encountered (Mitchell, awareness of these limiting factors, their implica- 1991). While performing similar duties in a similar tions for performance, and the need to adopt ap- environment, officers deployed after the cause of propriate response strategies (e.g., increased need the event had been identified (a terrorist bombing) for teamwork) can reduce the likelihood of adverse reported significantly lower levels of stress. Being mobilization reactions (Flin, 1996). able to define their situation as a criminal in- It therefore follows that strategies designed vestigation allowed them to apply professional to mitigate terrorist stress risk during mobilization schema (e.g., conceptualizing the work of handling must not be based on assumptions derived from human remains as an evidence-gathering proce- routine emergencies or on unrealistic or untested dure) to render the experience more meaningful. plans (Carafano, 2003; Department of Homeland Terrorism Stress Risk Assessment and Management 233

Security, 2003; Lasker, 2004; Paton, 1997). Ra- Kendra & Wachtendorf, 2003; Paton & Hannan, ther, they must be derived from accurate analyses 2004; Simpson & Stehr, 2003). of community (e.g., accommodate the need to reconcile different actions) and professional (e.g., Event Characteristics consider concerns for self and family, adapt plans to accommodate emergent issues) response needs Event causation is a risk factor for terrorist events. and expectations and accommodate the unique de- Because the causes of terrorist acts can always be mands likely to be encountered. Developing ef- attributed to deliberate human action intended to fective stress management plans also requires an cause harm, they threaten perceived control, a pro- understanding of these issues as they arise during minent stressor in emergency responders whose the response. training is designed to promote control (MacLeod & Paton, 1999; Myers, 2001). The magnitude of the death and injury they Managing Stress Risk During encounter, which is coupled in many cases with a Response to Terrorism uncertainty regarding the cause of death or whether those they come into contact with are infec- Despite having a long and effective history of re- tious, provides a further source of stress (Jackson sponding to emergency events, protective services et al., 2003). For large-scale events, such as those officers face psychological contexts (e.g., vulner- presented by the aftermath of the World Trade ability and assumptions of safety) and demands Center collapse, the time frame for body recov- associated with terrorist events that present them ery can be prolonged (Simpson & Stehr, 2003). with a unique set of problems (Carafano, 2003; Working in proximity to dead or seriously injured Fisher, 2000; Grant et al., 2003; Jackson et al., victims, particularly if coupled with a perceived 2003; Simpson & Stehr, 2003). For example, lack of opportunity for effective action, results in greater uncertainty surrounds the timing, duration, officers facing constant reminders of their per- and distribution of the consequences of terrorist ceived inability to deal with this loss and suffering. events, which possess a unique capacity to create The ensuing reduction in officers’ sensitivity to the a sustained climate of fear. They can also involve needs of others as they attempt to shut out these hazardous agents (e.g., biohazard and radiological signals can reduce their willingness to utilize agents) that are difficult to detect, can create sig- support resources (Paton & Stephens, 1996; Ra- nificant acute and chronic health problems, and phael, 1986) and increase their risk of experien- generate consequences that may persist for quite cing posttraumatic stress reactions. Insufficient, some time. These factors, coupled with the possi- inadequate, or inappropriate resources to perform bility of large-scale destruction and loss of life from response tasks can fuel a sense of inadequacy the use of weapons of mass destruction (WMD), and increase stress vulnerability (Carafano, 2003; create a response context whose characteristics dif- Paton, 1994). fer substantially from those normally encountered. Uncertainty regarding the duration of their Furthermore, the nature of the threats means that involvement or additional attacks, for example, protective services professions are not just pro- heightens officers’ stress risk, as does their expo- tecting the public. They must also protect them- sure to personal danger. Officers who respond to selves; thus the need to reconcile the safety of both the devastation associated with a terrorist bombing protective services officers and the public becomes would encounter hazards from disrupted sewerage a significant stressor in this context (Department of systems, threats associated with working in un- Homeland Security, 2003). stable buildings, exposure to contaminated blood During the response phase, risk factors ema- products or infectious diseases, and increased nate from the characteristics of the terrorist in- health risks from dust, ash, and asbestos in dam- cident. However, the psychological consequences aged buildings. of the exposure to these characteristics will be in- With regard to sources of danger, exposure to fluenced by the personal and organizational com- events that pose unseen threats (e.g., highly toxic petences brought to bear to manage the response chemical, biological, or radiation hazards) con- (Alper & Kupferman, 2003; Grant et al., 2003; tributes substantially to stress risk by making it 234 Assessment and Treatment more difficult for emergency responders to directly between these expectations and what they en- observe what they need to be aware of in order counter is a significant indicator of stress risk to take protective actions. Separation from family (Paton, 1994). According to this conceptualiza- members, if accompanied by continuing concern tion, stress risk will be a function of the degree to for their safety, would also constitute a hazard, as which the prevailing mental model or mind-set, would the demands associated with safeguarding derived from socialization, training, and experi- the public from threatening circumstances. Ter- ence in routine contexts, can accommodate these rorist attacks involving weapons of mass destruc- atypical experiences. tion can impact over a large and often ill-defined geographical area (e.g., meteorological factors in- Changing the Mind-Set fluence the distribution of radioactive plumes) and generate rapidly evolving demands. The scale of The events of 9/11 highlighted the fact that, for destruction increases the risk of death in emer- terrorist events, emergency responders need to gency response personnel. Death or serious injury make substantive changes to the mind-set or in- to a colleague can amplify stress risk associated terpretive frameworks they use if they are to de- with an already hazardous environment (Paton & velop and implement an effective response to these Stephens, 1996). incidents (Brake, 2001; Kendra & Wachtendorf, Environmental factors such as heat, noise, or 2003). Responders’ needs have been underes- poor visibility affect stress risk (Vrij, van der Steen, timated because expectations have been based & Koppelaar, 1994), as can the sights, sounds, and largely on the experience of responding to routine especially the smells encountered (Paton, Cox, & events or disasters of natural and human origins, Andrew, 1989). The demands associated with en- which may not be accurate predictors of the con- vironmental factors such as heat may be significant ditions that protective services professionals may and unexpected as a result of the need to wear encounter in a determined, protracted terrorist protective suits and breathing apparatus as pro- campaign (Carafano, 2003; HBWMD, 2001; Paton, tection from biohazardous agents or toxic dust, for 1994). example. Because this need is similar to those that The schema or mental models that guide the arise in relation to many routine response scenar- response to terrorist events reflect officers’ socia- ios, the use of protective clothing and breathing lization into their profession and organization, apparatus may be less demanding for fire person- their training, the experiences they accumulate nel. It can, however, represent a significant stressor over time, and the operating practices that pre- for those (e.g., police, EMT personnel) for whom scribe their response to routine emergencies. These this would represent a highly novel demand. The become implicit (or taken for granted) aspects of need for protective clothing contributes to stress the mental models officers use to make predictions risk both directly (e.g., its use is necessitated by about future events, organize experiences, and the use of biological or chemical contaminants) make sense of the consequences of events and their and indirectly (e.g., increased heat stress from reactions to them. However, their importance wearing protective clothing and from additional as determinants of well-being and performance problems with operating equipment (Carafano, effectiveness tends to remain unrealized until offi- 2003). cers encounter incidents that challenge these im- This discussion represents a brief summary of plicit assumptions (Paton, 1994). Consequently, event-related stress risk factors. A more compre- training for terrorist events must confront these hensive account can be found in Paton (1997). A assumptions and facilitate the development of in- key issue here concerns the fact that the demands terpretative competences, or mind-sets, appropri- encountered when responding to terrorist events ate for the demands likely to be encountered (Flin, are qualitatively different from those that charac- 1996; Paton, 1994; Paton & Jackson, 2002). In terize routine work. The importance of recognizing addition, they must accommodate the legacy (e.g., this distinction derives from the fact that officers increased levels of fear in the community, changes develop mental models from their routine training in security precautions, perceptions of the world as and experience that prescribe their expectations of increasingly threatening) of terrorism into their how they will respond to events. The degree of fit thinking. Terrorism Stress Risk Assessment and Management 235

Changes in mind-set are required to accom- event). This process has been labeled performance modate the implications of more complex operat- guilt (Raphael, 1986). However, training that de- ing environments (e.g., the response environment velops realistic outcome expectations, an ability to could simultaneously be a disaster area, a crime differentiate personal and situational constraints, scene, and a mass grave). New ways of con- and interpretive processes that review experiences ceptualizing the world may be required in order to as learning opportunities that enhance future com- accommodate the consequences of attacks on ele- petence increases adaptive capacity (Dunning, 2003; ments of strong symbolic value (e.g., the Twin Paton, 1994; Paton & Jackson, 2002). Towers) whose loss can amplify the sense of Stress risk is particularly pronounced when societal loss associated with acts of terrorism performing body recovery and identification du- (Simpson & Stehr, 2003). ties. Following the Oklahoma bombing, firefighters A combination of the legacy of fear that acts of reported being upset by contact with body parts terrorism leave in their wake and the speed with (54%) and body fluids (36%), but encounters with which information regarding subsequent events is children’s remains (72%) were associated with the disseminated by media coverage can substantially highest levels of distress (North et al., 2002). expand the ripple effect. For example, when many The 9/11 attacks on the World Trade Center in- people witness such events both directly and introduced an additional dimension to risk in this directly through the media, as on 9/11 (Shuster context. Search and rescue personnel had to work et al., 2001; Yehuda, 2002), this additional factor in a context defined by considerable diversity with can create contingent demands in areas that may regard to cultural practices associated with the re- be peripheral to the targeted area or even at some trieval and treatment of human remains (Simpson distance from the event (Pfefferbaum et al., 2000), & Stehr, 2003). necessitating that officers expand their concep- Positive interpretation (e.g., interpreting body tualization of the social dimensions of a given recovery duties in terms of their role in assisting event relative to that associated with expectations families to begin the grieving process and not derived from their routine experiences. as performance failure on their part) can facilitate New interpretive frameworks are needed to adaptation to the demands encountered under manage events that fall outside the realm of ‘‘rou- these circumstances (Paton, 1994; Thompson, tine’’ emergencies. For example, they will be re- 1993). Training and experience in handling body quired to accommodate demands associated with remains lessens stress in those exposed to this agricultural emergencies that threaten the food activity for prolonged periods but less so for those supply or represent a source of human infectious exposed for relatively short periods (Alexander & disease (Carafano, 2003). Officers’ mental models Wells, 1991; Deahl, Gillham, Thomas, Searle, & must also accommodate the fact that, when re- Srinivasan, 1994; Mitchell, 1991; Thompson, sponding to terrorist events, the scene could 1993). This difference may reflect the time it takes become an intentionally hostile environment for to invoke coping strategies such as imagery. While them (Department of Homeland Security, 2003; imagery can be an effective coping strategy during FEMA, 2004; Maniscalco & Christen, 2002). body recovery duties, it can constitute a source of Several terrorist attacks, such as the Bali bombing, stress following the termination of these duties as used one bomb to attract responders and evacuees personnel review their actions and thoughts (Paton to the location of secondary devices in a manner et al., 1989). This highlights the importance of in- intended to inflict maximum death and injury cluding both positive and negative aspects of ex- on those fulfilling a response role. perience in postevent reviews. Interpretive processes can influence outcome In general, training that is designed to develop in other ways. For example, the scale or nature of the capability of operational mental models (es- terrorist impact can limit opportunities for effec- sential to response planning and organizing action) tive action. Stress risk increases if these limitations to impose coherence upon atypical and challenging are perceived as a failure attributed to personal experiences and to accommodate the demands inadequacy rather than to environmental con- encountered should be an essential component of straints beyond an individual’s control (e.g., as a stress risk management (Dunning, 2003; Paton, result of the sheer scale or complexity of the 1994; Paton & Hannan, 2004). A capacity for 236 Assessment and Treatment reframing can be developed using simulations. Si- internal conflicts regarding responsibility (which mulations provide opportunities to conceptualize can constrain officers’ response to emergent de- and review response activities, construct realistic mands), and a predisposition to protect the orga- performance expectations, increase awareness of nization from criticism or blame (Gist & Woodall, stress reactions, and rehearse strategies to deal 2000; Paton, 1997). Organizational culture can with stressful circumstances and reactions (Crego also exercise a pervasive influence on stress risk & Spinks, 1997; Paton, 1994; Paton & Jackson, through the procedures it prescribes, such as in- 2002). They can also identify areas for personal and adequate consultation, poor communication, and organizational development. excessive red tape. Developing these more sophisticated psycho- However, organizational culture that supports logical structures requires that simulations be autonomous response systems, a flexible, con- constructed using information derived from two sultative leadership style, and practices that ensure sources. One concerns the systematic analysis of that role and task assignments reflect incident de- the competencies required for effective response mands can reduce the risk of adverse stress out- to terrorist events. The second involves designing comes (Gist &Woodall, 2000; McKinsey Report, simulations capable of reconciling event character- 2002; Paton, 1999). Similarly, managerial practices istics (e.g., exposure to biohazards, personal dan- such as recognizing the value of work in traum- ger, recovery of human remains, and encounters atic contexts and delegating responsibility increase with cross-cultural aspects of death and loss) with adaptive capacity (Dunning, 2003; Paton, in press). the capabilities required to manage them (e.g., Furthermore, because the organization defines hazard identification and interpretation; adaptation the operational paradigm it uses (e.g., command of plans; team and multiagency operations; in- structure, level of autocracy, degree of devolved formation and decision management) in ways that authority, level of training), stress risk is influenced promote adaptive capacity (Paton, 1994; Paton et by the degree to which these polices and practices, al., 1999; Pollock, Paton, Smith, & Violanti, 2003). which are often extrapolated from those used for The degree to which the choices made within the routine work, are appropriate for managing the risk management process are effective in reducing atypical consequences of terrorist events (Cara- adverse outcomes will influence the quality of of- fano, 2003; McKinsey Report, 2002; Kendra & ficers’ adaptation during the postevent, reintegra- Wachtendorf, 2003; Paton & Hannan, 2004). This tion period. supports earlier conclusions regarding the organi- Discussion in this section has focused on the zational contribution to response effectiveness and sources of stress risk. Traditionally, the causes of stress risk when an organization’s members are traumatic stress reactions have been attributed involved in dealing with the consequences of ter- predominantly to the horrific, threatening, or rorist acts. challenging event characteristics (e.g., handling Recognition of the organizational role is im- human remains) to which officers are exposed. portant in two respects. First, the role of organi- While this aspect of a terrorist event will remain zational factors as predictors of traumatic stress a prominent predictor of traumatic stress risk, it is outcomes has been underrepresented. Second, they not the only one. Organizational factors and the define predictors of stress risk over which emer- response protocols they prescribe also play a sig- gency organizations have more control. They thus nificant role as predictors of stress risk. provide the principle means by which emergency organizations can make choices regarding stress Organizational Factors risk. These issues are illustrated here by considering communication, decision making, and inter- When responding to terrorist events, protective agency teamwork. services officers do so within a context defined by their organizational membership and culture. For Information and Decision Management example, bureaucratic organizations increase stress risk through the persistent use of established op- Communication among agencies responsible for erational and decision procedures (even when re- responding to a terrorist attack can be rendered sponding to different and urgent crisis demands), problematic by the loss of infrastructure from their Terrorism Stress Risk Assessment and Management 237 being deliberately targeted or as the result of Given that responding to events involving WMD secondary loss from explosion or contamination and biohazardous weapons can create rapidly (Brake, 2001; Department of Homeland Security, changing demands, skill in naturalistic decision 2003; Carafano, 2003; FEMA, 2004; HBWMD, making is essential for protecting well-being and 2001; McKinsey Report, 2002). Response man- facilitating effective responses in those managing agement is also affected by the quality of infor- the consequences of terrorist acts. Because success mation management, that is, the degree to which in naturalistic decision making is a function of the collaborating agencies can access, interpret, collate, ability to match current and past situations, deci- and use information to manage complex events sion effectiveness is enhanced by having more (Alper & Kupferman, 2003; FEMA, 2004; Grant options to match. This ability can be developed et al., 2003; Jackson et al., 2003; McKinsey Report, through experience or simulation. The latter style, 2002; Paton, 2001; Paton et al., 1999). A capacity however, remains important where time allows. to make decisions using this nonroutine informa- Terrorist events also increase the need for decision tion is also required. making to take place in a multiagency response Terrorist events involve making decisions in a context. context defined by urgent, emergent (i.e., unique, unexpected, or unpredictable) demands (Brake, Team and Interagency Operations 2001; Grant et al., 2003; Kendra & Wachtendorf, 2003; Simpson & Stehr, 2003) and using non- A central characteristic of the response to terrorist routine data and information from a variety of acts is the need for a multiagency and multi- novel sources to do so. The dynamic and complex jurisdictional response (Brake, 2001; Department nature of terrorist events also generates a need for of Homeland Security, 2003; FEMA, 2004; Grant a level of creative decision making that exceeds et al., 2003; Jackson et al., 2003; Kendra & that required for response to ‘‘routine’’ emergencies Wachtendorf, 2003). Analysis of the interagency ( Jackson et al., 2003; Kendra & Wachtendorf, activities in Shanksville following the crash of 2003). Stress risk is also heightened by having to United flight 93 in September 2001 illustrates the deviate from the standard operational procedures benefits of effective coordination of emergency associated with routine work and producing con- mutual aid assignments (Grant et al., 2003). The tingent solutions to novel problems. The capacity possibility that the effectiveness of this activity to do so can be facilitated by the associated stress, resulted from the quality of relationships and in- particularly if officers are trained in crisis decision teragency collaboration that reflect its provincial making. location cannot be discounted. That is, an equally For trained personnel, crises enhance alertness effective response may not occur so smoothly in and thinking skills (Flin, 1996). However, putting large urban settings (McKinsey Report, 2002), and this to good use requires an ability to operate in the capacity for interagency communication and environments characterized by information over- decision making operations must be specifically load. Situational awareness—the capability to ex- targeted within planning and training processes tract or operate on limited cues within a complex (Department of Homeland Security, 2003; FEMA, environment and use them to construct mental 2004). models of complex events that allows appropriate The potential scale of terrorist attacks makes decisions to be made—is a key adaptive capacity this an important issue and one whose implica- (Carafano, 2003; Endsley & Garland, 2000) and tions have been accepted as requiring detailed one that contributes to reducing stress risk (Paton consideration (Department of Homeland Security, & Hannan, 2004). The decision process that is 2003, 2004). Exercises such TOPOFF (1–3) pro- used must also be tailored to this circumstance. vide good models of the kind of realistic, real-time Naturalistic decision making, in which a per- simulations that are necessary for the develop- son recognizes the type of situation at hand and, ment and critical evaluation of a multidisciplinary, from previous experience, selects an appropriate multijurisdictional response to complex, large- course of action, is highly adaptive in events scale terrorist attacks. The review of the TOPOFF 2 characterized by substantial time pressure and exercise (Department of Homeland Security, 2003) high risk (Flin, Salas, Strub, & Martin, 1997). has demonstrated a capacity for the successful 238 Assessment and Treatment integration of agency communications and action hoc arrangements are more likely to increase in- relative to the principle federal officials who pro- teragency conflict, result in a blurring of roles and vided the unified command structure. It also, responsibilities, and fuel frustration and feelings of however, identified a need for improved informa- inadequacy and helplessness (McKinsey Report, tion management and coordination with regard to 2002; Paton, 1994). Thus, irrespective of the qual- making nonroutine decisions such as those asso- ity of the planning that precedes a disaster response, ciated with the radiological dispersion component a capacity for cohesive action should not be as- of the exercise. A crucial issue here is recognizing sumed (Department of Homeland Security, 2003). that planning for a coordinated response does not It can be developed using liaison mechanisms and guarantee its translation into an effective opera- the integration of respective agency roles through tional capacity (Department of Homeland Security, interagency team development (Flin & Arbuthnot, 2003). Even in Shanksville, the diverse perspec- 2002). tives applied by different agencies to make sense This developmental process must take several of the situation generated conflict (Grant et al., factors into account. One concerns the way in 2003). This was often related to the need for which each agency defines interagency collabora- protective service agencies to collaborate with non- tion. For example, turf protection increases inter- routine agencies (e.g., the American Red Cross, agency competition and consequently stress risk in Salvation Army). situations that require active collaboration (Paton The complex nature of terrorist events brings et al., 1999). Organizations must accept the value together agencies that rarely interact or collaborate of collaboration (e.g., the need for diverse per- with one another under routine circumstances, spectives) if they are to understand and manage reducing opportunities to allow shared under- complex problems. A second factor concerns the standing of their respective roles to develop. For patterns of interaction among group members example, the multiagency response to terrorist in relation to institutional policies, structures and events could include hazardous materials response culture, and the language and terminology they teams, urban search and rescue assets, community use (Brake, 2001). This would mean concep- emergency response teams, antiterrorism units, tualizing terror response as involving a series of special weapons and tactics teams, bomb squads, superordinate groups whose membership is pre- emergency management officials, municipal agen- scribed by their collective role in managing specific cies, and private organizations responsible for facets of the overall operation, including the de- transportation, communications, medical services, velopment of mechanisms for meaningful (e.g., public health, disaster assistance, public works, that supports decision making) communication and construction workers (Carafano, 2003). To among them. A third factor involves contextual this list could be added experts in radiological factors such as the level of understanding of plume characteristics and dispersal (Department integrated emergency management policies and of Homeland Security, 2003). Given the potential practices, the status and power accorded to dif- for role conflict and ambiguity under these cir- ferent members, and resource constraints. A fourth cumstances, understanding and managing inter- issue is the level of trust between partners (Brake, agency and team issues becomes an important 2001; FEMA, 2004; Grant et al. 2003; Paton et al., component of the stress risk management process. 2003). For large-scale terrorist events, a cohesive in- At one level, these issues reflect the need to teragency team and a capacity for multijurisdic- match the structural integration between agencies tional management is essential to the effective with a corresponding procedural or operational supervision of events that require coordinated in- capacity to act in concert during a crisis (Paton put from several agencies if effective decisions are to et al., 1999). However, it also encompasses parti- be made (Brake, 2001; FEMA, 2004; Grant et al., cipants’ understanding of their respective con- 2003; Jackson et al., 2003; Kendra & Wachtendorf, tributions to the same plan and their shared 2003). However, simply bringing together repre- understanding of each member’s role in the re- sentatives of agencies who have little contact with sponse (Brake, 2001; FEMA, 2004; Paton & Flin, one another under normal circumstances will not 1999). This contributes to their ability to share a guarantee a coordinated response. Rather, such ad common understanding of evolving events, to work Terrorism Stress Risk Assessment and Management 239 toward mutual goals over time, and, importantly, to planning and training are essential components of anticipate the needs of those with whom they are stress risk management programs. While exercises collaborating (Department of Homeland Security, such as TOPOFF 2 and 3 represent simulations 2003; Flin, 1996; Pollock et al., 2003). that are capable of testing the effectiveness of inter- Extensive joint planning in conjunction with agency and multijurisdictional abilities, an alter- teamwork activity involving collaborating agencies native approach is required to develop them in the can reduce the risk of experiencing adverse stress first place (Paton et al, 1999; Paton, 2001). outcomes, particularly when responding in a mul- Several factors, including pragmatic issues as- tiagency context (Brannick, Salas & Prince, 1997; sociated with multiagency exercises and the di- Flin, 1996; Paton et al., 1999; Pollock et al., versity of collaborative relationships (e.g., agencies 2003). The TOPOFF 2 and 3 exercises illustrate can be differentiated with regard to those with this process in practice. A key factor underpinning whom they will collaborate) that will compose the the benefits that can accrue from these collabora- overall response makes developing this capacity a tive activities concerns good information sharing complex task. In an attempt to circumvent these (Department of Homeland Security, 2003; Paton, problems, Paton (2001) has proposed a method 2003). for accomplishing this by defining decision mak- In effective teams, members provide more ing and informational needs. unprompted information, increasing a capability Using realistic decision making scenarios that for proactive response management through better require input from diverse sources (agencies) to decision making and resource allocation when define and resolve problems, it first calls for de- responding to complex acts of terrorism (Depart- fining the decisions required to manage antici- ment of Homeland Security, 2003; Entin & Ser- pated demands. The second stage involves each faty, 1999). For this to occur effectively, team agency identifying the information it requires to members must share a ‘‘team mental model’’ that make these decisions. Agency identification of the facilitates the provision of goal-related information data and information it needs to acquire (and then required by decision makers at critical periods to assimilate and translate) to make nonroutine (Cooke, Salas, Cannon-Bowers, & Stout, 2000). decisions provides a foundation for conceptualiz- As the level of teamwork and planning activity ing the need for and benefits of a coordinated increases, officers develop progressively similar multiagency response and understanding how they mental models of response environments and the will relate to other agencies during a crisis if they roles and tasks performed within them. This, in are to perform effectively. turn, increases implicit information sharing during Building this competence is essential given the high workload periods, enhancing team capacity complexity of terrorist events. For example, the for adaptive response (Paton & Jackson, 2002; effective performance of search and rescue opera- Stout, Canon-Bowers, Salas, & Milanovich, 1999). tions requires cooperation from biohazard, crime The concept of distributed decision making scene security, and quarantine experts. The com- acknowledges the need for contributions from plexity of the scenario supplies a context within people who differ with respect to their professions, which agencies can develop a model of the re- functions, roles, and expertise and who may be in lationship between their input and that of other different locations or involved in different levels agencies and provides a foundation for developing (e.g., operational vs. tactical) of decision making team mental models whose efficacy can be tested (FEMA, 2004; Paton & Flin, 1999). The quality of in simulations. A similar approach for managing shared understanding and procedural integration distributed operations (in which decision makers thus determines the capability of the multiagency must coordinate their actions from geographically team to utilize its collective expertise, even if dis- dispersed locations) when dealing with nonroutine, persed or contributing different perspectives, to multiagency response has been proposed by van manage the response. It also increases the like- der Lee and van Vugt (2004). Other models have lihood of their operating with a shared mental also been proposed. model of the situation that facilitates the effective Burghardt (2004) has proposed the combined and efficient allocation and use of limited re- systems model. According to this model, effective sources. Consequently, high levels of interagency response to complex crises can be facilitated by 240 Assessment and Treatment

first delegating well-structured tasks to artificial portant both for their own sake and with regard to systems, which leaves more time for human de- their role as a recovery resource. A comprehensive cision makers to deal with emergent demands. discussion of family intervention can be found in Second, it argues for employing decentralization Shakespeare-Finch et al. (2003). Emergency orga- mechanisms that delegate control to self-organizing nizations must accept their role in this process and subsystems (e.g., those dealing with radioactive implement resources (e.g., family friendly policies, fallout, performing search and rescue role, or family support groups, family recovery planning) managing inoculation centers) who are closer to that contribute to the proactive management of the scene. Finally, the model advocates the use of family stress risk. decision support systems developed to accommodate the complex psychological, cultural, and Managing Stress Risk During Reintegration political interactions that characterize multiagency response environments. With regard to the latter, The period of transition from responding to an act Burghardt suggests several mechanisms that can be of terrorism back into routine work and family life used to visualize the relationships between evidence poses a unique set of demands. Vulnerability is not and courses of action and the clarification of ter- restricted to those who had negative event experi- minology within these contexts. ences. Positive response experiences can become a To summarize this section, stress risk during risk factor for posttraumatic stress reactions during response can be managed by developing the inter- reintegration if, for example, officers experience a pretative, team, and information and decision- conflict between a period of rewarding personal or making abilities required to impose a sense of professional performance and readjusting to rou- coherence on atypical experiences and to deal with tine duties and catching up with any backlog them effectively. It is also important to ensure that of work, dealing with reporting pressures, and these competences are activated within an organi- handling any legal and sociolegal aspects of the zational culture that supports and protects officers’ response. well-being and that establishes response protocols During the postevent period, the complex that do likewise. While facilitating the proactive nature of terrorist acts, their causation, and the mitigation of stress risk during response, it is, how- emergency response may come under intense ever, important to note that termination of involve- public and media scrutiny. Sociolegal processes ment in a specific event does not eliminate risk. and media coverage can substantially extend the period of event experience and thus stress risk. During this time, officers may have to contend with Stress Risk During Reintegration blame (e.g., media accounts regarding event preventability, response effectiveness) being directed The unique nature of terrorist events requires new toward them or coming to terms with self-blame as approaches to postevent stress risk management they reflect on their role in the response. There are (Carafano, 2003). During reintegration, stress risk several ways in which risk can be managed during management involves managing the emotional the reintegration phase, with social support playing correlates of involvement in a terrorist event and a prominent role. providing a framework within which officers can render atypical, threatening experiences meaning- Interpersonal Support and Cohesion ful. With regard to the former, support practices that assist positive resolution and growth are dis- While generally considered to ameliorate stress cussed elsewhere (Dunning, 2003; Tedeschi & reactions, the fact that support provision occurs Calhoun, 2003). While the management of stress within a social context introduces several factors reactions associated with the event experience itself capable of influencing stress risk (Paton & Ste- has dominated postevent practice (e.g., debriefing), phens, 1996; Solomon & Smith, 1994). Solomon stress from this source may, as discussed earlier, and Smith discuss ways in which the demands on represent a less significant source than that ema- a social network for support occur at a time when nating from the organizational culture and from all of the members may have support needs, family dynamics. Attention to family issues is im- making support provision a highly stressful event Terrorism Stress Risk Assessment and Management 241 in itself, potentially reducing both its availabil- future preparedness play an important role in ity and quality. This is particularly likely in the mitigating stress and in developing future stress aftermath of terrorist events that create substantial resilience. It should, however, be borne in mind ripple effects from the pervasive climate of fear that that recovery, reintegration, and support practices can affect whole communities and the manner in occur within an organizational context. The in- which events are interpreted or reported. Recovery fluence of the latter must thus be included in re- can be assisted by providing coworker and peer integration risk management. support resources (Paton, 1997; Williams, 1993) capable of managing the diverse issues (e.g., mental The Organizational Context health issues, rumination, counterfactual thinking) that characterize the reintegration experience Stress risk is increased if reintegration is ex- (Gist & Woodall, 2000; MacLeod & Paton, 1999; perienced within an organizational culture that Paton & Stephens, 1996). discourages emotional disclosure, focuses on attri- While cohesive teams can constitute a natural buting blame to officers, or minimizes the signif- protective resource (Park, 1998), team cohesive- icance of members’ reactions or feelings (Paton & ness can, ironically, contribute to vulnerability if Stephens, 1996; MacLeod & Paton, 1999). Positive situational constraints result in a response being reintegration experiences are more likely if the or- perceived as less effective than anticipated. Some ganizational culture encourages managers to ac- level of failure, relative to expectations derived from tively promote reintegration. This is particularly routine experience, is likely given the unpredict- important if it takes place in a context of critical ability of terrorist events and their potential to public and media scrutiny regarding event causa- create large-scale destruction. This threat to team tion (e.g., beliefs that police were less vigilant than integrity may be compounded by the fear and un- they should have been) and response management certainty that call assumptions of future capability (e.g., beliefs that response could have been faster or into question. Officers may find it difficult to per- that it involved inadequate resources). ceive the positive characteristics in the group ne- Managers can assist adaptation by helping cessary to maintain a positive social identity. Under officers comprehend that they performed to the these circumstances, support networks break down best of their ability and by reducing performance (Hartsough & Myers, 1985), a negative social guilt by realistically reviewing the ways that situa- identity develops (Paton & Stephens, 1996; Solo- tional factors constrained performance (Alexander mon & Smith, 1994), and the risk of acute stress & Wells, 1991; MacLeod & Paton, 1999; Paton, reactions increases. Countering this possibility re- 1997). Managers can also facilitate positive resolu- quires team processes that facilitate the realistic tion by assisting staff in identifying the strengths interpretation of circumstances, including con- that helped them deal with the terrorist emergency fronting the psychological implications of, for ex- and building on this to plan how to deal with ample, the fear that is an explicit goal of terrorist future events more effectively. If these actions are acts and cultural predispositions to martyrdom. It not taken, risk management programs should re- should also involve actively differentiating perso- view the climate of relationships between man- nal and situational response factors and focus on agers and staff (e.g., trust) and seek ways to build learning from the experience (Gist & Woodall, this capacity (Gist & Woodall, 2000; Paton et al., 2000; Lyons, Mickelson, Sullivan, & Coyne, 1998; 2003). Such analyses can promote future response Park, 1998; Paton & Stephens, 1996). effectiveness and contribute to the development Lyons et al. (1998) describe team resilience as and maintenance of a resilient organizational cli- a function of its ability to engage in ‘‘communal mate. Pursuing this objective may require some coping.’’ This is characterized by the members’ organizational change. collective acceptance of responsibility for event- related problems and the existence of mechanisms Organizational Learning and Future by which they can cooperate to resolve problems. Capability Acknowledging and building on effective collaboration during the crisis and working together Terrorism will not only increase in the coming afterward to develop understanding and enhance years but also become more deadly (Cooper, 242 Assessment and Treatment

2001). Under these circumstances, it is impor- predictable and dynamic terrorist events. A failure tant that emergency organizations learn from ex- to learn from experience increases the likelihood perience (both their own and that of others) and that response to future events will occur in an ad commit to developing a capacity to manage the hoc manner, with effective response occurring demands associated with acts of terrorism (FEMA, more by chance than by sound planning and good 2004; Jackson et al., 2003; Kendra & Wachten- judgment. dorf, 2003). What does this mean for organiza- To enhance the adaptive capacity to deal with tional learning? complex terrorist events, organizations must learn The development of a capacity to effectively from past failures and learn to think ‘‘outside the manage terrorist events requires that people and square’’ (Berkes et al., 2003; Kendra & Wachten- organizations confront the assumptions derived dorf, 2003; Paton, 1994; Paton & Jackson, 2002). from a long history of effective response to routine Not only must the organizations learn to live with emergency events and accept the fact of their ex- risk, they must also develop a culture that is ap- istence within a changed reality. At the same time, propriate for a contemporary operating environ- organizations must also accept the influence of ment within which terrorist acts are a fact of life. organizational culture, procedures, and managerial Recognition of the importance of institutional learn- attitudes, whose nature and influence are directly ing thus becomes an important precursor of cul- under their control, on stress risk. Finally, it must tural change. According to Berkes et al. (2003), this use this understanding to make choices regarding involves first ensuring that the memory of prior these factors in ways that reduce stress risk. terrorist events and the lessons learned, whether A capability to learn from experience should positive or negative, are incorporated into institu- not be taken for granted (Berkes, Colding, & tional memory and accepted as an enduring fact of Folke, 2003; Harrison & Shirom, 1999; Mitroff & emergency organizational life. Second, realistic risk Anagnos, 2001; Paton, 1997). For example, bu- estimates should be derived from comprehensive reaucratic inertia, vested political interests, and reviews of potential events and accurate audits of centralized power and authority conspire to block competence (Jackson et al., 2003). These risk esti- change. Change is also unlikely if organizations mates must form the basis for future officer and underestimate the consequences for them or as- organizational development. Finally, recognition sume that their size and existing resources will of the risk posed by terrorist events and the im- safeguard them from significant disruption and al- portance of learning from them must be consoli- low prompt recovery. Change can also be thwarted dated into a culture that espouses the policies, by managerial expectations regarding operating procedures, practices, and attitudes required to conditions and outcomes that have become en- facilitate a capacity for adaptive response to an trenched and insulated from environmental change uncertain future (Berkes et al., 2003; Brake, 2001; (Carafano, 2003). Under these circumstances, FEMA, 2004; Jackson et al., 2003; Kendra & emergency organizations may underestimate or Wachtendorf, 2003; Paton & Jackson, 2002). overlook threats or initiate inadequate actions, thereby reducing their ability to match their capabilities to a changing hazardscape that now in- Conclusion cludes highly unpredictable acts of terrorism whose occurrence will be a significant predictor of stress Terrorism adds a new, unique, and challenging risk for their officers. A failure to take appropriate dimension to the hazards faced by contemporary steps to mitigate stress risk not only constrains the protective services organizations and their mem- exercise of duty of care regarding officers’ mental bers and consequently contributes substantially to health but also reduces their response effectiveness. the risk of acute stress and posttraumatic stress Organizational cultures that embody these faced by officers. It is possible, however, to develop characteristics will attempt to render the con- a proactive approach to managing this risk. The sequences of terrorist acts understandable by application of the risk management paradigm to making them fit in with previous experience, which managing stress associated with terrorist events only makes it difficult for managers to consider, far affords an opportunity to confront a priori as- less confront, the demands associated with un- sumptions regarding posttraumatic stress out- Terrorism Stress Risk Assessment and Management 243 comes. That is, the neutral starting point afforded Blaikie, P., Cannon, T., Davis, I., & Wisner, B. (1994). by the risk paradigm can provide a framework At risk: Natural hazards, people’s vulnerability, and within which emergency organizations can identify disaster. London: Routledge. options that inform their risk management choices. Brake, J. D. (2001). Terrorism and the military’s role in Knowledge of the relationship between the psy- domestic crisis management: Background and issues for congress. Washington, DC: Congressional chologically challenging characteristics of acts of Research Service, Library of Congress. terrorism and the individual and organizational Brannick, M., Salas, E., & Prince, C. (Eds.). (1997). resources mobilized to deal with them can be used Team performance, assessment, and measurement. to identify those aspects of this relationship about Mahwah, NJ: Erlbaum. which choices can be made. This constitutes the Brewin, C. R., Andrews, B., & Rose, S. (2000). Fear, basis of the risk assessment process. Acting on helplessness, and horror in posttraumatic stress these choices is risk management. disorder: Investigating DSM-IV criterion A2 in We have argued here that choices can be made victims of violent crime. Journal of Traumatic Stress, regarding how threatening and challenging ex- 13, 499–509. periences and significant operational demands are Brown, J., Mulhern, G., & Joseph, S. (2002). Incident- rendered meaningful. 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Evidence-Based Interventions for Survivors of Terrorism Josef I. Ruzek Shira Maguen Brett T. Litz

Although profoundly changed as a result of terrorist acute stress disorder (ASD) and PTSD in terms of acts, most survivors of mass violence or those who their implications for postterrorism intervention. have lost loved ones as a result of terrorism do not We also discuss prevention and treatment research develop significant mental health problems or dis- related to the management of traumatic bereave- ability. As is the case with any trauma, a relatively ment and alcohol problems. Moreover, we review small but salient percentage of survivors of terror current thinking about disaster mental health care will develop chronic mental health problems, such and suggest ways of improving care. Attention is as posttraumatic stress disorder (PTSD). Any mental given to individual, group, and community-scale health strategy or plan needs to take into account interventions during the emergency, early, and later the number of affected individuals, the available periods of the terrorist event. Special challenges of treatment resources, and the research literature. If service delivery in the postterrorism environment resources were unlimited, we would attempt to are also explained. hasten recovery and promote adaptive functioning Although mental health practitioners generally in every survivor of terrorism. However, in most agree about the need to use empirically supported mass violence contexts, too many affected indivi- intervention methods, to date the outcome research duals exist, typically coupled with a lack of well- examining services for terrorism and disaster sur- trained professionals. As a result, secondary pre- vivors is limited. Few of the components of disaster vention of chronic mental health problems and mental health services have been evaluated, and the functional disability in those most at risk is the methodological base of much of the existing re- priority. In addition, resources should be devoted to search is not sufficiently strong to support clear providing evidence-based tertiary prevention for recommendations. Therefore, in this chapter we those terror survivors who develop chronic psy- discuss and extrapolate from evidence-based in- chiatric problems. terventions that have been applied to trauma- A range of interventions may be useful to pre- related psychological problems in contexts other vent or address the negative psychological impact of than terrorism and disaster and emphasize inter- exposure to terrorist incidents. In the following vention methods that, if not evidence based, are at sections we examine findings from the literature on least consistent with current evidence and theory.

247 248 Assessment and Treatment

Evidence-Based Interventions for group trauma–focused interventions, although only Trauma-Related Problems two known studies were randomized controlled trials. Zlotnick et al. (1997) randomly assigned 48 Evidence-Based Treatment for female survivors of childhood sexual abuse with Posttraumatic Stress Disorder PTSD to either a 15-week affect-management group or a wait-list control condition. Participants re- A considerable body of evidence from randomized ceived individual therapy and psychotropic medi- controlled trials supports the efficacy of cognitive- cation beginning 1 month before and throughout behavioral therapy (CBT) for acute and chronic the study. Those who completed the group re- PTSD. CBT entails a package of interventions de- ported significantly fewer PTSD symptoms com- signed to promote stress and affect management, pared to those in the control condition. Schnurr assimilation and accommodation of the meaning et al. (2003) conducted a multisite randomized and of traumatic experiences, and processing of the controlled trial of group therapy for PTSD in Viet- emotional residue of trauma. CBT entails prolonged nam veterans (n ¼ 360). Veterans were assigned to exposure to trauma memories and various forms of either trauma-focused group therapy or to present- cognitive restructuring, which involves challenging centered group treatment, in which participants maladaptive cognitions related to the trauma and were explicitly instructed not to discuss their trau- replacing these with healthier alternative thoughts. ma. Weekly groups were held for 30 weeks, fol- Prolonged-exposure therapy, which involves a re- lowed by a tapered treatment of one session per peated therapeutic reliving of traumatic experiences month for 5 months. Results indicate that PTSD to facilitate emotional processing, is often con- symptoms improved from baseline, with 40% sidered the sine qua non of any effective treatment. of participants demonstrating significant changes However, stress inoculation (applied stress man- in symptoms; however, there was no significant agement) and cognitive therapy alone have been difference between the trauma-focused and the shown to be as effective (e.g., Ehlers & Clark, 2003; present-centered groups. When excluding partici- Foa et al., 1999). pants who did not attend a sufficient number of Prolonged-exposure CBT treatments have been treatment sessions, results indicate that avoidance found to significantly decrease PTSD symptoms in and numbing symptoms were reduced more in a range of survivor populations, including Vietnam trauma-focused group participants, although drop- veterans (Cooper & Clum, 1989; Keane, Fairbank, out rates were higher in this group. Caddell, & Zimering, 1989; Boudewyns & Hyer, 1990; Glynn et al., 1999), female sexual assault Applications to Terrorism survivors (Foa, Rothbaum, Riggs, & Murdock, CBT is the prescriptive treatment for PTSD. It is 1991; Foa et al., 1999; Resick, Nishith, Weaver, important to note that not everyone is helped by Astin, & Feuer, 2002), and survivors of varied CBT and that positive symptoms (e.g., intrusive traumas (Marks, Lovell, Noshirvani, Livanou, & thoughts) are more likely to improve than negative Thrasher, 1998). Cognitive restructuring has been symptoms (e.g., avoidance). Furthermore, because demonstrated to be effective in studies of survivors PTSD is a chronic problem for many, we should not of mixed traumas (Marks et al., 1998; Tarrier, Pil- assume that people necessarily regain their pre- grim, et al., 1999), and stress inoculation training trauma functioning completely. Given these quali- (i.e., an anxiety management treatment that makes fiers, for those who are traumatized as a result of use of techniques such as breathing, muscle re- their exposure to a terrorist attack and develop laxation, and calming self-talk) has performed well PTSD, some variant of CBT would arguably be with female sexual assault survivors (Foa et al., useful. Future randomized controlled trials should 1991; Foa et al., 1999). Resick et al. (2002) have confirm this expectation. demonstrated significant improvements in female Studies are needed to demonstrate the efficacy rape survivors using cognitive processing therapy, of group treatment following a terrorist attack. The a manualized form of CBT in which elements of existing studies demonstrate symptom improve- exposure and cognitive therapies are combined. ment regardless of the modality of therapy. One While these studies evaluated individual treat- possibility is that the crucial ingredient in symptom ment, there have also been several investigations of improvement is the support that group therapy Evidence-Based Interventions for Survivors of Terrorism 249 offers, given the absence of other forms of treat- and report three of the following four symptoms: ment. However, in at least one of the group studies, intrusive thoughts about the deceased, yearning for participants were receiving concurrent individual the deceased, searching for the deceased, and/or and psychopharmacological interventions. Overall, loneliness as a result of the death. Additionally, the group therapy seems to be better than no treatment person experiences a host of other possible symp- and in and of itself is a cost-effective intervention; toms (e.g., purposelessness, numbness, difficulty however, in the best-case scenario, group therapy acknowledging the death), with symptoms lasting should perhaps be utilized in conjunction with at least 2 months, and the disturbance needs to individual treatment. cause significant impairment in functioning. Clin- To date, there is only one study of a group ically, many of the symptoms and problems of intervention for survivors of a terrorist attack. This traumatic grief are conflated with PTSD symptoms, was conducted in Israel following an attempt to but clinicians may mistake traumatic bereavement use a Palestinian vehicle filled with explosives to for PTSD, which is inappropriate because the latter blow up an Israeli bus (Amir et al., 1998). The 15 disorder fails to capture the unique problems that women participating in group debriefing plus brief result from loss (e.g., Neria & Litz, in press; Ra- group psychotherapy were not injured in the at- phael, Minkov, & Dobson, 2001). Because of the tack and participated in six group sessions in the 2 possible sheer magnitude and the horrific nature of months following the attack. The group included deaths due to terrorism, traumatic grief is impor- psychological debriefing (i.e., each woman spoke tant to examine as a separate clinical problem in about her memories of the trauma in a safe en- relation to coping with loss in the context of ter- vironment), normalization of feelings, discussion rorist events. of coping strategies, cognitive restructuring, and There are few systematic and specialized treat- a focus on return to pretrauma functioning. ments for traumatic grief. Shear et al. (2001) have Symptoms were assessed 2 days, 2 months, and developed a treatment that is a combination of 6 months after the terrorist event. PTSD symptoms interpersonal therapy for depression and CBT for improved at 2 and 6 months when compared to 2 PTSD. These researchers conducted an uncon- days after the event. At the 6-month follow-up, 27% trolled, 16-session pilot study of their treatment of participants met all of the criteria for a PTSD with people suffering from traumatic grief. Imaginal diagnosis. Due to the lack of a control group and and in vivo exposure were the primary strategies for nonrandomized design, it is difficult to ascertain grief reduction (e.g., listening to audiotaped per- whether improvements in symptoms were due to sonal accounts of trauma, in vivo hierarchies of the natural course of recovery or to the intervention. painful contexts). Additionally, Shear et al. (2001) While this intervention employed a combination of used interpersonal therapy techniques to help psychological debriefing and group psychotherapy victims reengage with others. After 4 months of immediately following exposure to a terrorist event, treatment, reduction of grief, depression, and an- there is emerging consensus that psychological xiety symptoms was reported; however, the authors debriefing is contraindicated on empirical and have not reported follow-up data, thus the long- conceptual grounds directly following exposure to term efficacy of this treatment is unknown. trauma (e.g., Litz & Gray, 2004). The large dropout rate of those who lost loved ones as a result of a traumatic incident is worri- Evidence-Based Treatment some; as a result, it is unclear whether this treat- for Traumatic Grief ment is appropriate for people who may lose a loved one to an act of terror. Additional limitations Prigerson et al. (1999) have proposed that trau- include the older age of completers, the length of matic grief is a distinct disorder (i.e., separate from time since the death of the loved one (i.e., the PTSD, depression, or other anxiety disorders) and mean was 3 years), and assumptions that partici- offered a classification system by which clinical pants experience avoidance as a hallmark symp- problems with traumatic grief or complicated be- tom of traumatic grief, as demonstrated by the reavement can be identified. According to this decision to employ in vivo hierarchies (i.e., the taxonomy, to receive a diagnosis of traumatic grief, opposite may be true; people may be constantly a person must experience the death of a loved one thinking about the deceased and/or have intrusive 250 Assessment and Treatment thoughts of the deceased). It is also unclear whe- feelings), and self-care. In the second hour, they ther this treatment generalizes to younger people shared death-related experiences and received who have unexpectedly lost a loved one as a result emotional support and assistance in reframing the of a senseless act of terror rather than losing a death and its consequences. The intervention re- spouse or parent to old age. sulted in differential effects for mothers and fathers, Two randomized, noncontrolled trials of gui- with mothers improving on 80% of mental distress ded mourning for ‘‘morbid grief’’ (i.e., grief result- measures, including depression, anxiety, and fear. ing from the loss of a significant other in which Conversely, fathers improved on fewer than 50% symptoms persist for more than a year) resulted in of the measures. Additionally, higher self-efficacy, grief symptom improvement for the intervention self-esteem, and positive reinterpretation of events and control groups, suggesting no differential im- at baseline predicted lower mental distress up to 2 pact of treatment (Mawson, Marks, Ramm, & Stern, years later for both mothers and fathers. 1981; Sireling, Cohen, & Marks, 1988). Partici- Furthermore, repressive coping predicted pants received six sessions of either a guided greater mental distress for fathers, and Murphy mourning or antiexposure intervention. Those in et al. (1998) postulate that repression of feelings in the guided mourning group were instructed to fathers may be difficult to reduce because of gender participate in tasks involving exposure to avoided socialization and may contribute to some of these cognitive, affective, and behavioral cues (e.g., view- gender differences. Although mothers seemed to ing pictures of loved ones, writing letters to the improve, when compared to the control group, deceased). Conversely, the antiexposure group was there were no significant differences for either encouraged to focus on the future rather than parent on any of the outcome measures (i.e., mental thinking about the past and to avoid all reminders distress, trauma, loss accommodation, physical of the deceased. Participants in both groups were health, and marital satisfaction). When the results assigned between-session tasks and were en- were parsed by level of distress, the intervention couraged to engage in new activities. Results in- was beneficial for mothers with higher mental dis- dicate that individuals in both groups demonstrated tress and grief at baseline. However, this may be a improvement on a number of variables at several case of regression to the mean. Conversely, fathers intervals, up to 9 months posttreatment (Sireling et with higher levels of PTSD at baseline did worse al., 1988). Overall, the exposure group performed than control group fathers, which is of concern and significantly better than the antiexposure group may demonstrate that intervention should vary by only on a bereavement-avoidance task, as well as gender. some measures of distress to bereavement cues (out Several potential moderators of treatment out- of a total of 29 outcome measures). One possible come were examined in a trial of complicated grief conclusion is that support and encouragement to treatment among inpatients (n ¼ 139) that were engage in new daily activities are the critical ther- randomized into either interpretive (i.e., explora- apeutic ingredients that facilitated improvement. tion of interpersonal and/or intrapersonal conflicts) Limitations include failure to report modes of death or supportive (i.e., sharing of coping strategies) of loved ones and the assumption that bereaved short-term group therapy (Ogrodniczuk & Joyce, people avoid thoughts of the deceased (similar to 2004; Piper, McCallum, Joyce, Rosie, & Ogrod- Shear et al., 2001). niczuk, 2001). Similar to Murphy et al. (1998), There have also been group interventions for Ogrodniczuk & Joyce (2004) found that women those who may experience traumatic grief. For ex- had better outcomes than men following treatment. ample, Murphy et al. (1998) conducted a 10-week, They report that men were less committed to their randomized, controlled trial for parents who lost therapy groups and perceived by other group a child to homicide, suicide, or accident. Parents members as less compatible than women (Ogrod- participated in 2-hour treatment sessions. In the niczuk et al., 2004), which may suggest that men first hour of each group, parents learned skills need different types of treatment or that separate pertaining to actively confronting problems (e.g., gender groups may be most beneficial. ways to release anger), respecting differences in Several other factors contributed to improve- mourning, closure (e.g., writing down thoughts and ment in symptoms following group including Evidence-Based Interventions for Survivors of Terrorism 251 personality factors (Ogrodniczuk, Piper, Joyce, what can be gleaned from this literature. Some McCallum, & Rosie, 2003), perceived social sup- promising treatment approaches have been devel- port from friends (Ogrodniczuk, Piper, Joyce, oped (e.g., Shear et al., 2001), but rigorous tests of McCallum, & Rosie, 2002), interpersonal factors these approaches are necessary before they can be (Ogrodniczuk, Piper, McCallum, Joyce, & Rosie, recommended. Furthermore, given that individual 2002), and level of engagement in the group or group treatment studies have not been con- (Ogrodniczuk & Piper, 2003). More specifically, ducted with people who have lost a loved one due extraversion, conscientiousness, openness, secure to terrorism, the generalizability to such events attachment to the deceased, and recent social role is questionable. The one treatment study that in- functioning were positively associated with symp- cluded people who suffered loss from traumatic tom improvement, and neuroticism was negatively means reported the highest dropout rates (Shear associated with symptom improvement (Ogrodnic- et al., 2001). One possibility is that timing is a zuk, Piper, McCallum, et al., 2002; Ogrodniczuk crucial aspect of these interventions and the most et al., 2003). optimal timing of delivery is simply unknown; Two group studies were conducted with another is that existing individual treatments for grieving adolescents. The first included African traumatic grief do not generalize to those who have American adolescents exposed to homicide and lost a loved one due to traumatic means. consisted of a 10-week group therapy intervention Another possibility is that loss due to traumatic aimed at reducing PTSD symptoms (Salloum, events represents a syndrome that is different from Avery, & McClain, 2001). Participants received what has been traditionally defined as complicated psychoeducation about grief and trauma and were bereavement, which can be associated with any type encouraged to share their thoughts and feelings of loss (many studies of complicated bereavement about death. They were also taught about normative include large numbers of widows and widowers grief reactions, healthy coping techniques, safety, who lost a loved one due to illness and/or old age). anger management, and ways to access support, For example, when someone loses a loved one by utilize spirituality, and focus on future goals. Fol- traumatic means such as terrorism, the person is lowing the intervention, group members reported likely to experience excruciating intrusive thoughts decreased reexperiencing and avoidance symp- about the deceased and, as a result, is likely to avoid toms; however, there were no improvements in reminders or triggers of these painful memories. In level of arousal. Interpretation of this study is greatly the case of terrorism, the intrusive thoughts will limited because of the lack of a control group and likely involve the means by which the loved one was the absence of randomization. This study was also killed. Thus, arguably, when someone dies as a limited due to a large range of time since death result of terrorism, the clinical picture of the sur- (1–10 years). Rynearson, Favell, Gold, and Pri- vivor is an amalgam of traumatic grief and PTSD, gerson (2002) conducted a similar 10-session ado- with both avoidance of images and reminders and lescent group study with incarcerated youths who intrusive thoughts of the loved one, especially if the had experienced the violent death of a friend or deceased person was horrifically injured in the family member. They surveyed a wider range process. of outcome variables (e.g., depression, grief, and Murphy et al. (1998) conducted groups with PTSD symptoms), all of which significantly de- parents who had lost their children, who most creased following intervention. Major limitations closely represent people who have lost a loved one include lack of a control group and random as- due to traumatic means such as terrorism. Un- signment to condition as well as a small sample size. fortunately, compared to controls, the parents who Additionally, Rynearson et al. (2002) failed to received the intervention did not improve on any describe the type of treatment provided, although of the outcome measures. One possibility is that a treatment manual is available upon request. the support they received and the skills they were taught through the group were useful, but being Applications to Terrorism exposed to stories of how other children died may Treatment research for traumatic grief is in its in- have been retraumatizing. Future studies should fancy, and major methodological problems limit investigate which treatment modality works best 252 Assessment and Treatment for which group following the loss of a loved one with those who have lost loved ones due to ter- due to terrorism. rorism are necessary to evaluate their efficacy (see Interventions that attempt to create or foster Litz & Gibson, in press). the use of social supports (e.g., support groups of similarly bereaved people) may be especially Evidence-Based Treatments helpful given that social support is inversely related for Alcohol Abuse to symptoms of traumatic grief (Spooren, Hender- ick, & Jannes, 2000). However, women may ben- Research has established a link between trauma efit from group interventions to a greater extent exposure, chronic PTSD, and alcohol consumption than men, and these gender differences should be (Ouimette & Brown, 2002). Some evidence also examined. indicates that alcohol consumption may increase Arguably, exposure-based interventions may following exposure to trauma (e.g., Burnam et al., facilitate recovery for those traumatically bereaved 1988; Kilpatrick, Acierno, Resnick, Saunders, & individuals who avoid thinking about the deceased, Best, 1997) and disaster/terrorism events (North et the mode of death, or other reminders of the death al., 2002; Vlahov et al., 2002; Grieger, Fullerton, (as compared to those who are nonavoidant). & Ursano, 2003; Vlahov, Galea, Ahern, Resnick, & However, not everyone who suffers from traumatic Kilpatrick, 2004). For example, increases in alco- grief experiences may exhibit avoidance as a pre- hol consumption were reported by 25% of a dominant symptom pattern, so this should be sample of Manhattan residents 5–8 eight weeks carefully assessed, and treatment should be tailored following the 9/11 attacks (Vlahov et al., 2002), accordingly. In addition, it should not be assumed and increased drinking remained in evidence at 6 that avoidance and suppression are necessarily months (Vlahov et al., 2004). Grieger, Fullerton, signs of psychopathology. There is emerging con- and Ursano (2003) also reported increased use of sensus in the bereavement literature that evasion of alcohol in survivors of the 9/11 terrorist attack on painful affect can lead to positive outcomes from the Pentagon. loss (e.g., Bonnano, 2004). It is likely that tradi- In the context of terrorism and disaster, mental tional CBT methods of reducing avoidance, such as health providers may be confronted by survivors imaginal and in vivo exposure, need to be carefully who have increased their consumption of alcohol. reconsidered. There may be cases that require ex- For those whose drinking increases to problem le- posure-based interventions because the functional vels, it is important for alcohol consumption to be impairments entail gross restrictions in functioning. explicitly addressed. In fact, a large literature sup- Intense forms of emptiness, numbness, and despair ports the effectiveness of relatively brief treatments may be addressable by behavioral activation strain reducing consumption (e.g., Moyer, Finney, tegies that promote active engagement with plea- Swearingen, & Vergun, 2002; Dunn, 2003). Not surable activities. much is yet known about how trauma survivors The optimal timing of delivery of interventions generally or terrorism survivors in particular will for loss by terrorism is entirely unclear. Indeed, the respond to these approaches. One study has de- timing of interventions with a bereaved population monstrated that a single 30-minute interview with has been noted as a confounding variable in sev- patients admitted to a trauma center for treatment eral studies (see Schut, Stroebe, van den Bout, & of injury who screen positive for excessive alcohol Terheggen, 2001). Some studies highlight the im- use can reduce alcohol consumption in those with portance of allowing the grieving process to unfold existing alcohol problems (Gentilello et al., 1999). naturally so that the bereaved can heal with time This intervention consisted of a motivational in- and find sources of support independently of terview that explored personalized feedback about receiving treatment; however, the dearth of con- a patient’s drinking habits. Quantity and frequency trolled studies limits the ability to draw firm con- of consumption were compared to national norms, clusions about intervention timing. Although there level of intoxication at admission was related to are clearly significant challenges inherent in con- injury risk, negative consequences of alcohol as ducting randomized clinical trials with this popu- indicated on the screening tools were discussed, lation, more rigorous tests of these approaches and negative physical consequences based on Evidence-Based Interventions for Survivors of Terrorism 253 abnormal laboratory test results and level of alcohol to terrorism-related PTSD (Gillespie, Duffy, Hack- dependence based on questionnaire assessment mann, & Clark, 2002), these approaches should were reviewed. The interviewer also stressed in- perhaps be offered to terrorism survivors who have dividual responsibility for reducing drinking, of- developed PTSD. Traumatic grief interventions are fered a menu of strategies for change, and provided in the early phase of development and should be a list of treatment resources in the local community. regarded as exploratory in the context of terrorism. While this array of individual assessment informa- However, given the need to offer help to those who tion would not be available in crisis counseling experience traumatic grief in that context, there situations, the general principles of review of in- may be sufficient anecdotal evidence from the dividual drinking habits and consideration of op- manualized treatment of survivors of 9/11 to war- tions could be applied. rant consideration. Finally, brief alcohol reduction It is not known how best to provide such interventions conducted in a hospital trauma cen- education following terrorist attacks. Possibly, brief ter have been effective, suggesting the possible education to reduce consumption can be supplied utility of such interventions among survivors of by media. A study conducted by Acierno, Resnick, terrorism and disaster. Flood, and Holmes (2003) suggests that a 17- Most of the research on the treatment of PTSD minute educational video delivered shortly fol- is for survivors whose problems have existed for lowing rape may be capable of reducing postrape some time. Thus, the current evidence base largely substance abuse. The low-cost, easily administered fails to speak to the real world of delivery of ter- educational intervention reduced the likelihood of rorism and disaster services, in which services may marijuana abuse at 6 weeks, and there was a trend be provided immediately after an event and in the for the video to be associated with less alcohol first weeks and months after a trauma. In the next abuse among women with a prior history of alcohol section, we describe more comprehensively the or marijuana use. Single-occasion interventions, range of interventions that should be considered whether provided via media or face-to-face contact, and comment on them from the standpoint of can be expected to have limited impact for some, current research and theory. and additional follow-up contacts may increase the impact of helping efforts. In another study of an intervention based on motivational enhancement Toward an Integrated (Miller & Rollnick, 2002), Longabaugh et al. Intervention System (2001) reported that a 40–60 minute intervention plus a booster session was more effective in redu- Features of a System of Care cing alcohol-related negative consequences in patients seeking emergency medical care than Stepped Care standard care or a single-session intervention. During and after terrorist attacks and in situations Disaster responders will also see those who of ongoing threat of attack, people’s need for as- may be at elevated risk for relapse into preexisting sistance will vary widely, depending on aspects problems following exposure to a terrorist attack. of their exposure, history, biology, personal re- Those who are in recovery from substance abuse sources, and the recovery environment. While it is problems, especially those recently abstinent, may expected that most people will continue to function benefit from monitoring and intervention to pre- well without intervention or will experience initial vent relapse. Those who relapse should be referred acute stress reactions but will recover without for- for evidence-based treatment. mal help, some will not. The challenge is to find better ways of matching people to services based on the nature and degree of their needs. Conclusions Many current postterrorism contacts between survivor and helper take place in a relatively in- Given the considerable body of evidence support- formal meeting, on-scene, at an emergency shelter, ing the use of CBT methods in treating PTSD, with or in the context of a community outreach visit. some evidence of generalizability of these methods In these meetings, the helper offers support, 254 Assessment and Treatment psychological first aid, and brief educational infor- To date, terrorism and disaster-specific group mation. In fact, a one- or two-session brief coun- interventions require additional development and seling approach characterizes much of current-day evaluation. The primary model of early group in- disaster crisis counseling. tervention to reduce the impact of trauma is group For those who have developed significant pro- stress debriefing (Raphael & Wilson, 2000), but blems, it is likely that multiple-session interventions there is no evidence that this approach prevents will be more helpful than a single contact. Some PTSD (e.g., McNally, Bryant, & Ehlers, 2003), and problems may require only two to five sessions. For in our view this approach is inappropriate because those who do not improve following this level of it is a single-session intervention that does not help, sustained expert mental health care is indi- screen participants in any way for risk or need and cated. This ‘‘stepped-care’’ approach matches people there is no systematic vehicle to stepped care (Litz, to a level of care in part based upon response to Bryant, & Adler, 2002). Other group approaches earlier steps and reduces the likelihood of unneces- for early disaster care (e.g., Ruzek, 2002b), dis- sary and inappropriate treatment (cf. Haaga, 2000). aster-related PTSD (e.g., Young, Ruzek, & Ford, 1999), and disaster-related sleep difficulties (Kra- Individual and Group Interventions kow et al., 2002) have been described. Interventions to prevent postterrorism problems A special case of group-related social support is must be delivered in a variety of interpersonal the self-help or mutual aid group. When survivors contexts. Most education and support will likely be join together to help one another, they can do much provided in the context of individual contacts be- to provide mutual emotional support. For example, tween disaster mental health workers or other after the events of 9/11, families who lost loved ones community providers and survivors, and, to date, in the World Trade Center attacks linked with fa- most of the efforts to develop trauma-related milies who experienced losses due to the bomb- interventions have focused on individual care. How- ing of the Oklahoma City federal building. Mutual ever, in many postterrorism environments, indi- aid groups can help members reestablish a sense vidual care may be difficult to deliver (e.g., due of control over events and sometimes go beyond to large numbers of affected persons, insufficient support functions to address political or legisla- availability of mental health providers, or cost tive issues affecting themselves and their com- constraints), and group interventions provide a munity. potentially cost-effective alternative. Generally, in communities affected by terror- Groups may be used soon after a terrorist ism, efforts should be made to restore a sense of attack or disaster to provide education, mobilize so- control to survivors by helping them to take prag- cial support, and teach skills for coping with stress matic action to improve their situation, strengthen reactions and other posttrauma challenges. Com- perceived safety, and rebuild their community. pared with one-on-one services, they may be able to Glass and Schoch-Spana (2002. p. 219) have sug- more effectively harness some important helping gested that naturally occurring civic, occupational, processes, including social support and social mod- or information networks should be seen as ‘‘a po- eling. When terrorism survivors arepart of an existing tential conduit for organizing or facilitating public group that will continue functioning as a unit (e.g., responses that are beneficial,’’ related to informa- work colleagues), the group will effectively act as part tion dissemination, outbreak monitoring, resource of the ongoing recovery environment, and members distribution, and survivor care. For example, var- can be encouraged to support one another. In such ious community networks could be mobilized to a circumstance, group cohesion may serve a protec- distribute antibiotics, convene vaccination gather- tive function and so may be useful as a target for ings, or organize home visits. A potentially im- helping efforts. When group structures permit mul- portant role for mental health providers is to help tisession contact, educational messages can be re- facilitate the development of self-help activities by peated, supportive relationships among members can survivor groups. Depending on the situation and be strengthened, and recovery behaviors and skills the receptivity of the survivors, mental health can be shaped and reinforced. At a later time, group providers could educate them about reactions to psychotherapies may represent an effective means terrorism and ways of coping and provide advice of treating chronic PTSD (Foy et al., 2000). on group structure and function. Evidence-Based Interventions for Survivors of Terrorism 255

Phase-Specific Care help to provide more formal mental health inter- Service delivery needs will evolve over time as on- ventions in the first days following exposure. Ex- scene support moves toward acute helping re- ceptions include providing treatment to those who sponses, then to the provision of early mental are in danger (e.g., psychotic, suicidal) and those health services, and finally to the detection and whose initial responses are extreme (e.g., intense delivery of care to those who develop enduring panic) and who may benefit from short-term medi- problems as a result of their exposure to terrorism. cations. However, with regard to most survivors, Services delivered immediately after the act of no single-session interventions that can be ad- terrorism or other disaster, those organized in the ministered very soon after trauma have yet been first weeks and months after the event, and those shown to be effective in preventing later problems made available in the longer term will differ (Bisson, 2003). greatly. The earliest efforts will focus on psycho- Screening, Triage, and Referral logical first aid appropriate for most survivors. If problems appear severe or disabling or if they In the immediate aftermath of terrorist events, persist past the initial postevent period, brief crisis helping resources are likely to be very limited; thus counseling is an option. If brief several-session more intensive psychological care must be re- help is insufficient to resolve problems, referral served for those most in need. Initial triage efforts for mental health treatment may be warranted. depend on the ability to differentiate between Changes in service delivery over time reflect the those whose problems require immediate help and changing needs of survivor populations and the those who may not require urgent care. When fact that early posttrauma support may be useful terrorist events involve biological or chemical at- for many survivors, while more intensive help at tacks, the identification of those in need of more later times will be required by fewer persons. intensive care will be especially difficult. Emer- gency medical facilities may be overwhelmed by large numbers of help seekers. For example, fol- Components of Care lowing the Aum Shinrikyo¯ cult sarin attacks in 15 Tokyo subway stations, approximately 5,000 peo- Psychological First Aid ple sought emergency care; almost 75% of those There is widespread agreement on the importance who were seen had not been exposed to sarin of ‘‘psychological first aid’’ (PFA) in the immediate (Bowler, Murai, & True, 2001). Also, reactions to aftermath of terrorist events (National Institute of various biological or chemical agents may mimic Mental Health, 2002). PFA is an umbrella term for stress reactions or psychiatric problems (Ursano, a variety of helping activities designed to contain Norwood, Fullerton, Holloway, & Hall, 2003), distress and reduce acute stress responses. It in- making differential diagnosis difficult. cludes restoration of sleep, reconnection of survi- In addition to initial triage efforts, some ap- vors with loved ones, and direction to helping proaches to early posttrauma intervention include resources (Litz et al., 2002). Figure 18.1 shows a an effort to identify those who are expected to be at list of early steps to provide for basic needs and risk for development of chronic problems so that PFA (Veterans Health Administration, 2003). preventive interventions can be delivered (Ruzek, These activities, although difficult to study em- in press). There is, however, a limited current pirically, are believed to be helpful and are widely ability to accurately differentiate in the first weeks judged as unlikely to cause additional harm. Some between those whose distress and traumatic stress may lend themselves to more systematic develop- reactions will improve without help and those ment and delivery. For example, efforts to reduce whose symptoms are unlikely to remit. After sev- immediate anxiety may benefit from the applica- eral months have passed, accuracy improves. tion of methods of anxiety management, such as Nonetheless, identification of those who may simple training in deep breathing, which may be be in need of mental health intervention occurs at useful to offer more systematically to disaster all stages of response. Gross indicators of risk may survivors experiencing hyperarousal. be sufficient in some circumstances. These include For a variety of reasons, there is a growing severe direct exposure to the aftermath of violence, reluctance to go beyond this kind of pragmatic destruction, and traumatic loss. For example, in 256 Assessment and Treatment the aftermath of 9/11, such groups included be- mental health services. Wessely (2003) maintains reaved families, those evacuated from workplaces, that screening that is intended to facilitate the and those involved in the recovery of remains. In prevention of posttrauma psychological disorders the context of face-to-face interactions, outreach should meet a variety of conditions, including that workers and mental health counselors routinely spontaneous recovery is unlikely, that those who make judgments about whom to refer for coun- are screened would not have presented for care in seling. In current disaster mental health practice, the absence of screening efforts, that there is a people who are using FEMA-funded crisis coun- proven intervention for those detected, that the seling services typically receive brief counseling anticipated benefits of screening outweigh the neg- (e.g., 1–3 sessions), and if they determine the ative consequences, that screening and treatment need, crisis counselors refer these help seekers to are acceptable to those screened, that a validated more intensive mental health counseling. How- screening tool is available, and that evidence in- ever, most disaster mental health training materials dicates that early treatment will lead to better out- devote relatively little attention to evidence-based comes than late treatment. criteria for referral (Young, Ruzek, & Pivar, 2001), At present, these questions cannot be answered and little is known about how these determina- in the affirmative for early screening. Our ability to tions of need for referral are actually made. accurately identify those who are at risk for chronic While triage decisions are necessitated in many problems is limited. Early symptom levels are not postdisaster environments, there is ongoing debate necessarily indicative of risk, and predictors of about the application of systematic screening to PTSD may vary significantly across trauma popu- identify those who may need more intensive lations (Brewin, Andrews, & Valentine, 2000); moreover, the challenge is to predict other problems in addition to PTSD, including other anx- Provide for basic survival needs and comfort iety, substance use, and mood disorders (Yehuda, Help survivors achieve restful, restorative sleep McFarlane, & Shalev, 1998). Bryant (2003) has sug- Preserve an interpersonal safety zone protect- gested that it may be premature to identify people ing basic personal space (privacy, quiet, perfor intervention before 2 weeks posttrauma, that sonal effects) active cognitive-behavioral intervention should not Provide nonintrusive ordinary social contact be offered earlier than 2 weeks, and that delay in Address immediate physical health problems intervention may be recommended in part because or exacerbations of prior illnesses it may allow time for survivors to marshal resources Assist in locating separated loved ones and and deal with practical problems. friends and verifying their safety With regard to posttraumatic stress symptoms, Reconnect survivors with loved ones, friends, screening is possibly most effective several months trusted others posttrauma. In this context, validated screening Help survivors take practical steps to resume tools and evidence-based treatment for PTSD have day-to-day life been developed. Following the World Trade Help them take practical steps to resolve Center attacks in New York, Project Liberty created pressing problems caused by the trauma (e.g., a range of services intended to help the commu- housing, finances) nity; in its second year of operation, a paper-and- Facilitate resumption of normal family, com- pencil screening tool was used to identify those munity, school, and work roles who might benefit from a referral for more ad- Provide opportunities for grieving vanced services. Also in New York, Difede, Ro- Help them reduce problematic tension or an- berts, Jaysinghe, & Leck (n.d.) have developed a xiety to manageable levels screening program for emergency relief workers Support helpers with training in common re- who responded to the attacks. They used a battery actions and stress management techniques of well-validated measures to screen for PTSD and Source:VeteransHealthAdministration(2003). other mental health disorders. There is a need for systematic evaluation of both early and later Figure 18.1. Some elements of management screening initiatives, related to their predictive va- of acute stress reaction lidity, impact, and cost-effectiveness. Evidence-Based Interventions for Survivors of Terrorism 257

Selected Follow-Up With Survivors to increase adaptive ways of coping with the One approach worth considering is the delivery of trauma and its effects and decrease proble- routine telephone follow-up monitoring of survi- matic forms of coping (e.g., alcohol con- vors who appear to be at risk for continuing sumption, social isolation) posttrauma problems on the basis of known risk to increase survivors’ ability to help family factors. This ‘‘screen and treat’’ (Brewin, 2003) members cope (e.g., information about how to approach has several potential benefits. It would talk to children about what happened) and, in identify those who should be monitored, not those some cases, include entire families in educa- who require early intervention. A simple request tional efforts for permission to recontact a survivor at a later to help survivors recognize the circumstances date may be less stigmatizing or less likely to en- under which they should consider seeking gender negative responses from oneself and others. counseling and to reduce obstacles to seeking It is probable that such a follow-up opportunity therapeutic help (e.g., misperceptions of will be welcomed and seen as a sign of significant helping services, perceived stigma) interest and commitment on the part of the prac- to inform survivors where they can obtain titioner and parent organization. Those who do additional help, including mental health not wish to be followed up can simply deny per- counseling mission. People will differ in their receptivity An important early goal of educational inter- to offers of counseling at different points in time, vention is the normalization of stress reactions, and this approach may provide the survivor with and research is needed to examine the normal- multiple opportunities to seek services. If a survi- ization process and our ability to influence it; vor continues to report mental health problems 3 indeed, the emphasis on reducing fear and mis- months after the terrorist event, counselors may interpretation of acute stress responses is con- have more confidence in the person’s need for sistent with some current theories of PTSD (e.g., more formal help. Ehlers & Clark, 2003). It is important that mental health responders ask about survivors’ perceptions Survivor Education of their own reactions and help them better un- One practice that remains widely supported at all derstand and manage them. Efforts should be stages of terrorism and disaster response is edu- made to reduce shame or embarrassment at seek- cation for survivors and the community at large. ing help, and mental health services should be However, it is important to note that this practice described as commonsense and practical oppor- has not been empirically validated. Nonetheless, tunities for support. brief educational efforts are relatively nonstigmat- A challenge will be to combine education about izing and generally appreciated by survivors; they stress and coping with information about the are low-cost forms of care that may be delivered aftermath of the event. In bioterrorist incidents, through informal conversations or in structured mental health providers will need to work with formal presentations. After terrorist events that medical educators to provide accurate and timely affect large numbers of people, such educational information about issues such as the biological information will need to be delivered via cost- agents, infection control, the care of seriously ill effective public media presentations, written ma- persons, and the unfolding situation itself in ways terials, and group educational activities. Generally, that are consistent with media-delivered public educational content is selected for the following health messages. Another challenge will be to pro- reasons: vide care for families, who in some cases may need the information conveyed at several different de- to help survivors better understand a range of velopmental levels. posttrauma responses to normalize responses so that survivors come to view their posttrauma reactions as typical Enhancement of Social Support (e.g., not as reactions to be feared, signs of Postterrorism care should include significant efforts personal weakness, or signs of mental illness) to increase social support for survivors. Although to increase survivors’ use of social support the ways in which support can help or hinder 258 Assessment and Treatment recovery are not well understood, research does simple low-intensity element of stepped care that indicate that perceived social support is related to reaches large numbers of survivors. When disaster posttrauma and postdisaster outcomes. Lack of mental health counseling settings provide oppor- social support after a trauma is a risk factor for tunity for multiple contacts with survivors who are PTSD (Brewin, Andrews, & Valentine, 2000), and experiencing significant postevent problems, it is greater received and perceived social support has possible to go beyond the simple sharing of in- been associated with less distress among disaster formation to provide coping skills training. Such survivors (Norris, Friedman, Watson, Byrne, Dıáz, guidance can help survivors learn how to do the et al., 2002). Declines in social support account things that will support their recovery by delivering for a large share of disaster victims’ subsequent a cycle of instruction that includes education, mod- declines in mental health (Norris et al., 2002). eling, coaching, repeated practice, and feedback. Rather than seeking out mental health profes- It can also include between-session task assign- sionals, those affected by terrorist events primarily ments with diary self-monitoring and real-world turn for help to nonprofessional sources such as practice of these coping mechanisms. Skills taught family, friends, and colleagues (Luce & Firth- in this way can include anxiety management Cozens, 2002). As a result, mental health profes- (breathing retraining and relaxation), challenging sionals must work with natural helping networks to maladaptive thoughts, emotional ‘‘grounding’’ increase support over time. In the immediate (Najavits, 2002), anger management, and problem- aftermath of a terrorist event, it is standard practice solving skills. As noted previously, stress inoc- to make efforts to reestablish contact between dis- ulation training (anxiety management) has been aster and terrorism survivors and their loved ones. effective as a treatment for chronic PTSD (e.g., Foa Disaster workers also advise survivors to spend time et al., 1999). with family and friends and to seek and offer sup- To date, attempts to train survivors in these port. Support groups are often established by skills have not been systematically undertaken or helping professionals, and self-help groups some- evaluated in the context of disaster and terrorism. times provide significant opportunities for mutual However, a single session of telephone-delivered helping. anxiety management training has been shown to In addition to the routine enhancement of decrease anxiety among Israeli citizens who were social support with affected people, families, and worried about the possibility of a Scud attack communities, mental health providers should un- (Somer, Tamir, Maguen, & Litz, 2005). When ci- dertake to identify those who are socially isolated tizens called a hotline as a result of Scud-related or lacking in social support and, if judged ap- distress, they were randomized to either cognitive- propriate, take steps to increase their access to behavioral intervention or a standard hotline support. They should also routinely assess the counseling (unconditional positive regard, em- interpersonal functioning of survivors and make pathic listening, validation, social support) control efforts to maintain interpersonal functioning in group. The intervention lasted around 15 minutes those whose relationships are suffering as a result and included normalization of stress responses, of exposure to the terrorism or disaster stressors. instruction in diaphragmatic breathing and cog- Exposure to terrorism and the development of nitive restructuring, phone practice of the latter PTSD and other problems may impair the survi- techniques, and assignments to practice at home. vors’ relationships with significant others, includ- Compared with standard hotline practice, the ex- ing spouses or partners (North et al., 1999). This perimental intervention was associated with sig- impairment may be common, for example, among nificantly less distress, anxiety, and worry about emergency workers and their spouses. missile attack 3 days after the counseling. In addition to its innovative telephone delivery system, Coping Skills Training this project is significant for its demonstration of Disaster mental health responders routinely pro- the utility of anxiety management skills training vide written materials about coping and review for those affected by disasters and terrorism. Also ways of coping with survivors. This instruction is important is the fact that paraprofessional hot- primarily conveyed through brief advice and is a line counselors were trained in the anxiety Evidence-Based Interventions for Survivors of Terrorism 259 reduction intervention via a single 5-hour training the survivors were treated in 5 or fewer sessions. workshop. Seventy-eight patients demonstrated significant pre-post improvement on standardized measures Interventions for Survivors Experiencing of symptoms from the treatment, with an effect Significant Problems size for improvement in PTSD symptoms of 2.47 (a As noted in the context of coping skills, some magnitude of change comparable to or larger people whose problems do not respond to simple than controlled trials of CBT for PTSD). In this advice or education may benefit from multiple- demonstration study, intensity of care (i.e., num- session or intermediate-intensity interventions. For ber of sessions) was determined by response to example, ASD has been established as a relatively intervention and varied from a few sessions to strong predictor of development of chronic PTSD, many. and a cognitive-behavioral approach that includes A cognitive-behavioral intervention was also education, anxiety management training, imaginal delivered to some of the survivors of the New York exposure therapy, in vivo exposure, and cognitive City World Trade Center attacks, beginning ap- restructuring (cognitive therapy) has been shown to proximately 18 months after 9/11, as part of an be significantly more effective in preventing PTSD ‘‘enhanced’’ service offered under the auspices of and in decreasing depressive symptoms than simple Project Liberty crisis counseling programs. Com- education and support. To date, this approach has posed of psychoeducation, coping skills training, been tested with individual survivors of motor ve- and cognitive restructuring delivered in 9–12 ses- hicle accidents, industrial accidents, and nonsexual sions, it was provided to users of crisis counseling assault that meet criteria for a diagnosis of ASD services who screened positive on a paper-and- (Bryant, Harvey, Dang, Sackville, & Basten, 1998; pencil selection tool and was well received by Bryant, Sackville, Dang, Moulds, & Guthrie, 1999). providers and survivors (Norris et al., in press). It has been delivered over the course of four to five Clinicians reported that this intervention was well individual therapy sessions and initiated about 2 received by clients, but no formal outcome as- weeks after the trauma. In a long-term follow-up of sessment has been conducted to date. those receiving their intervention, Bryant, Moulds, In the years following an event affecting large and Nixon (2003) reported that, 4 years after being numbers of survivors, many can be expected to helped, participants who had received the CBT develop chronic problems, including PTSD, despite intervention showed a lower intensity of PTSD the availability of crisis counseling services. Af- symptoms than those receiving education and fected communities should continue to detect and support. treat PTSD in survivors who have not sought or Intermediate intensity services may hold pro- benefited from access to these services. Postterror- mise for incorporating effective behavior-change ism mental health response must therefore be ex- methods (e.g., cognitive restructuring, anxiety man- tended in time and incorporate the implementation agement, therapeutic exposure, skills training, of screening programs in key community settings self-monitoring, social reinforcement) while re- where survivors may present for help (e.g., primary quiring fewer resources than full mental health care) and training of mental health providers in the treatment, but they have not been tested with mass evidence-based treatments discussed earlier. Such violence or disaster survivors as an early phase screening and treatment practices do not currently postdisaster intervention. However, Gillespie et al. represent standard care in medicine and mental (2002) conducted an open trial of a cognitive- health. behavioral therapy delivered between 1 and 34 months (median 10 months) postattack with sur- Toward Terrorism-Related, vivors of the 1998 Omagh terrorist bombing in Situation-Specific Interventions Northern Ireland who had developed PTSD. Ninety-one patients who met the criteria for PTSD Those who provide mental health services in the resulting from the bombing received 2–78 sessions wake of terrorist attacks may be challenged to (with a mean of 8) of a treatment that combined extend conventional disaster mental health ap- imaginal exposure with cognitive therapy; 37% of proaches to meet the challenges associated with 260 Assessment and Treatment specific postterrorism situations. For example, Coping With the Continuing Threat of Terrorism specific interventions for people who have experi- Although some interventions exist to help in- enced actual and perceived toxic exposure are not dividuals cope with the aftermath of trauma and part of conventional disaster mental health training terrorism, there is scarce information about how to and require more development. In fact, the physical help people deal with the ongoing and potential interventions that may be needed in terrorism threat of terrorism, especially in communities at environments—barrier environments, quarantine, risk. In order to better understand how to inter- restricted travel, mass immunization, use of gas vene in these communities, it is important to un- masks, decontamination, and destruction of per- derstand which types of coping styles produce the sonal clothing and property—may increase stress best mental health outcomes, especially in those levels among survivors (Holloway, Norwood, who demonstrate resilience amid the threat of Fullerton, Engel, & Ursano, 1997; Norwood, terror. 2001), and mental health activities may need to Following the tragedies of 9/11, the possibility focus on assisting survivors in coping with these of another terrorist attack in the United States was a interventions. For example, in situations involving looming threat, and U.S. citizens were warned to be the delivery of vaccinations (or other medical pro- on constant alert for suspicious activity. In this phylaxis), survivors may benefit from interventions context, Silver, Holman, McIntosh, Poulin, and Gil- that include assistance with decision making or Rivas (2002) examined coping styles in a national address adherence to a physician’s instructions. The sample and reported that, 6 months after the at- wearing of gas masks has been associated with tacks, active coping (e.g., taking action to improve anxiety and panic in some people (e.g., Carmeli, the situation) was inversely associated with distress Liberman, & Mevorach, 1991; Rivkind et al., and general anxiety. Conversely, denial, self-blame, 1999), and mental health providers may be called and behavioral disengagement (i.e., giving up) upon to assist people in adapting to this equipment. predicted higher levels of distress. Furthermore, Those who are evacuated due to environmental risk PTSD symptom severity 6 months after 9/11 was may represent a high-risk group and may benefit predicted by acceptance (e.g., learning to live from support and training before, during, and after with the situation), behavioral disengagement, de- their move. nial, seeking social support, self-blame, and self- Terrorist events can also involve ongoing ex- distraction (e.g., turning to work to take one’s mind posure to legal proceedings, and mental health off of the situation). Overall, active coping seemed providers may need to help survivors manage trial- to lead to the best adaptation to the ongoing ter- related stressors and exacerbation of distress. For rorist threat. example, following the bombing of Pan Am Flight Given that most people will indeed cope well 103 over Lockerbie, Scotland, those affected were with the threat of ongoing terror and prove to be provided with a Lockerbie trial handbook, oppor- resilient, understanding the conditions that pro- tunity to observe the trial proceedings via remote mote adaptation is a key ingredient in intervening closed-circuit viewing, and funds to enable victims’ appropriately with those who are not able to cope family members to receive mental health counseling effectively. In the context of the attacks on 9/11, a throughout the trial process (Smith, Kilpatrick, prospective study was conducted in which people Falsetti, & Best, 2002). In some postterrorism en- were surveyed prior to the terrorist attacks and vironments, the risk of community violence can be again after they had occurred. Fredrickson, Tugade, expected to increase. This may be due to a break- Waugh, and Larkin (2003) determined that re- down in societal order or may affect particular silient individuals were able to find positive mean- segments of the community. For example, after the ing in daily hassles and stressors and also reported attacks of 9/11, violence and threats of violence more positive emotions and fewer negative ones against Arab Americans increased, meaning that following the attacks. Furthermore, there was an mental health response was charged both with at- inverse relationship between resilience and de- tempting to prevent or reduce anger and perpetra- pression symptoms, and this relationship, as well as tion of violence and with helping Islamic families that between resilience and growth in psychological cope with situations of increased risk of harm. resources, was mediated by positive emotions. Evidence-Based Interventions for Survivors of Terrorism 261

Positive emotions seem to be an important com- victims of the bombing attack 6 and 18 months ponent in coping with the ongoing threat of ter- later and found that emotion-focused coping was rorism and serve as a protective factor against positively associated and problem-focused coping negative psychological symptoms and distress. was negatively associated with PTSD symptoms. There have also been a number of studies Both of these studies surveyed individuals about 6 conducted internationally that help shed light on months after the attacks and occurred in countries effective coping amid the threat of terror. Israel is a that do not have to confront chronic terrorist at- country in which the threat of terrorism is a tacks (i.e., these horrific situations were novel). chronic concern; it is an environment that is quite These results are similar to those of Silver et al. different from the United States, where overt ter- (2002). rorist acts are still a rarity. Consequently, Israelis The need to focus on promoting positive have been living with the threat much longer than emotionality in the context of coping with the citizens in many other countries, which provides a threat of terrorism is an important intervention unique perspective on how people cope with on- method that emerges from existing research. In- going threat. In two studies, both adults and deed, positive emotionality has been demonstrated children who employed problem-focused coping, to be a resilience factor in several recent studies as compared to emotion-focused coping, did worse involving people who have been exposed to in the long run. Weisenberg, Schwarzwald, Ways- stressful events (e.g., Tugade & Fredrickson, man, Solomon, and Klingman (1993) surveyed 2004), and positive emotionality is consistently children who were at risk for Scud attacks, and associated with growth following trauma (Liney & Gidron, Gal, and Zahavi (1999) surveyed adults Joseph, 2004). Therefore, promoting positive who were at risk of transportation explosions. emotionality in the context of coping with the Measurement limitations (i.e., unstandardized mea- threat of terror will perhaps allow people to be sures of coping), administration timing (i.e., mea- more resilient in the context of ongoing threat. suring coping directly following a terrorist event With regard to optimal types of coping, study re- that obfuscates whether the types of coping mea- sults are challenging to disentangle, given the di- sured are beneficial in acute versus chronically versity of environments and situations in which threatening situations), and specificity of coping the studies were conducted. Many more studies reaction (i.e., whether ways of coping were eval- should also be conducted before firmly drawing uated generally versus encompassing methods any conclusions about coping with an ongoing specific to the terrorist events that preceded the threat of terrorism. Nonetheless, one possibility surveys) were among some of the limitations of is that emotion-focused coping may promote bet- these studies. ter health in chronically terror-ridden environ- Researchers have also measured coping in ments immediately following a terrorist event. Ireland and France. In Northern Ireland, Cairns Conversely, problem-focused coping may be more and Wilson (1989) found that those who were helpful in environments where terrorism is rarer in living in higher-violence areas used more distan- order to cope with the threat many months after a cing. Regardless of the actual violence in their terrorist event. neighborhood, people who appraised the violence Given the scarcity of studies that examine as more severe used more social support seeking coping with the threat of potential terror, con- and less distancing (i.e., these were the two types clusive recommendations are difficult to make; of coping examined in this study). Therefore, those however, at least one study has demonstrated that, living in areas with greater potential for violence although most people will have adequate resources tended to distance themselves from the situation in and support to cope with the threat of terrorism on order to cope. Limitations of the study included their own, cognitive-behavioral techniques such as failure to test for association with mental health relaxation training and modifying irrational beliefs outcomes and failure to include a wider variety of about the threat may be helpful to people who ways of coping. In France, following a terrorist require further assistance (Somer et al., 2005). attack in a Parisian subway, Jehel, Duchet, Pa- Even for the average person who is not unduly terniti, Consoli, and Guelfi (2001) surveyed burdened with the threat of potential terror, 262 Assessment and Treatment challenging occasional maladaptive thoughts and reduce the burden of preventable admissions. relaxation techniques may be helpful. Benedek, Holloway, and Becker (2002) contend that lucid, consistent, easily available, dependable, Actual and Perceived Toxic Exposure and redundant information that is distributed from Biological terrorism is a serious threat that may be reliable sources will curtail uncertainty and fear especially frightening for affected populations. Noy about the cause of a symptom and that the absence (2002) maintains that a primary prevention proof such information is likely to be associated gram is the most important component in the with unnecessary treatment and use of resources. protection of citizens against biological warfare Particular attention should be given to special and that failure to implement such a program will populations, such as patients with preexisting an- result in maladaptive coping and an unnecessary xiety disorders who may have difficulty following increase in somatic and psychological casualties. instructions that would ensure their survival. As Previous studies have suggested the importance of was the case in Israel, individuals with preexisting not only educating the masses about how to re- anxiety disorders may develop anxiety attacks cognize the signs of a biological attack, which is an when faced with taking steps to ensure their safety, important goal in and of itself, but also preparing such as utilizing a gas mask during a possible psychologically for such an attack (i.e., how to attack (e.g., Rivkind et al., 1999). regulate anxiety about the threat of an attack). For Education also should be provided concerning example, during the Scud attacks in 1992, Israelis which types of samples to submit for further test- were taught how to use gas masks in preparation ing, given that public health laboratories may for biological warfare, given instructions on pre- otherwise be overburdened with samples, thus paring sealed rooms, and provided with guidance taxing existing resources. For example, following about when to self-administer antidote injections. the deaths due to anthrax, one state public health When Scud missiles were eventually launched, laboratory received 1,496 environmental submis- they did not contain biological warheads as feared. sions of anthrax, all of which tested negative for Nonetheless, the missiles caused widespread de- bioterrorism agents (Dworkin, Ma, & Golash, struction, in some cases resulting in death. A study 2003). Education is important not only to prevent reviewing the medical records of patients who putting an unnecessary burden on the public were hospitalized as a result of the attacks de- health system but also to ensure that suspected termined that 43% of these cases resulted from outbreaks are reported in a timely and efficient the victims’ psychological response to the assault manner. For example, Ashford et al. (2003) have (Bleich, Dycian, Koslowsky, Solomon, & Wiener, reported that, for six outbreaks in which bio- 1992). Furthermore, 27% of those who were terrorism or intentional contamination was possi- hospitalized had mistakenly injected themselves ble, reporting was delayed for up to 26 days, with an antidote, and there was a great deal of arguing that education and frontline work by overlap between mistaken antidote injections and healthcare professionals and local health depart- individuals classified as psychological casualties. ments are crucial to the dissemination of critical Given these high rates of psychological hos- information. pitalization, one specific intervention recommendation would be to systematically educate Health citizens about psychological reactions to the threat Many of those affected by terrorist events will of terrorism. This could be done in conjunction complain of health or somatic symptoms, especially with education about different biological agents, in connection with events involving possible ex- how to recognize signs of a biological attack, and posure to chemical, biological, or radiological tox- specific behavioral steps that should be taken in ins. Both medical professionals and mental health the event of such an attack. Educating the public professionals will face the challenge of distin- about psychological responses and how to coun- guishing symptoms of actual exposure from stress- teract them (e.g., challenging irrational thoughts, related somatic symptoms, and the relationships relaxation training) is arguably an important step between stress and health difficulties will be diffi- toward minimizing psychological casualties in the cult to interpret in many cases. Having the best event that such an attack should occur and may possible information is important if mental and Evidence-Based Interventions for Survivors of Terrorism 263 medical health providers are to help reduce anxiety- blems and increased rates of referral for men- eliciting misinformation and rumor (Hyams, Mur- tal health care (cf. Leskin, Ruzek, Friedman, & phy, & Wessely, 2002). Gusman, 1999). For those with inexplicable health problems, Fischoff and Wessely (2003) have outlined some simple principles of patient management that may Service Delivery Challenges in the be useful in the context of terrorist attacks: Focus Postterrorism Environment communication around patients’ concerns; organize information coherently; give risks as numbers; The Context of Ongoing Threat acknowledge scientific uncertainty; use universally understood language; and focus on relieving As mentioned earlier, many terrorism situations symptoms. Although relatively little is known present a continuing possibility of additional at- about treating these problems, a recent clinical trial tacks. Circumstances of ongoing threat may create comparing treatments for Gulf War illness may anticipatory fears (Piotrowski & Brannon, 2002; have some relevance to similar complaints asso- Silver et al., 2002), sustain anxiety, and potentially ciated with terrorist incidents. Donata et al. (2003) interfere with recovery in those who have survived have reported that both cognitive-behavioral group a previous attack. Some evidence suggests that the therapy (CBGT) and exercise were effective; CBGT disrupted daily routines created by these circum- improved physical function, whereas exercise led stances may be associated with PTSD symptoma- to improvement in many of the symptoms of Gulf tology (Shalev, Tuval-Mashiach, Frenkiel, & Hadar, War veterans’ illnesses. Both treatments improved 2004). Because interventions that are designed for cognitive symptoms and mental health functioning, the treatment of PTSD have been applied primarily but neither improved pain. In this study, CBGT under conditions of relative safety (i.e., threat of was specifically targeted at physical functioning continued harm is minimal), questions can be and included time-contingent activity pacing, raised about their generalizability to some terrorist- pleasant activity scheduling, sleep hygiene, asser- threat environments. If realistic ongoing exposure tiveness skills, confrontation of negative thinking to continued attacks is part of the environment in and affect, and structured problem-solving skills. which traumatic stress reactions must be managed, The low-intensity aerobic exercise intervention was this may have implications for mental health ser- designed to increase activity level by having veter- vices. Shalev et al. (2003) have described mod- ans exercise once per week for 1 hour in the pre- ifications in the delivery of cognitive-behavioral sence of an exercise therapist and independently treatment for PTSD related to terrorist attacks in two to three times per week. Israel, designed to reflect a terror-ridden environ- It is likely that most of those who seek help ment. During in vivo exposure assignments, sur- for stress-related complaints will focus on physical vivors were encouraged to expose themselves to symptoms and present in emergency medicine situations that were clearly safe but not to those (Ruzek, Young, Cordova, & Flynn, 2004) and widely considered dangerous and avoided by most primary care medical settings rather than to crisis of the populace (e.g., city centers where repeated counseling services. This can be expected both bombings had occurred). immediately following possible exposure, when They also noted that differences in cognitions large numbers of people have begun to worry even underlying avoidance by the general population before the extent of actual community and in- compared with avoidance by those with PTSD. dividual exposure is known, and in the months and Members of the latter group were thinking, ‘‘if I go, years postdisaster, when people visit their physi- there will definitely be another attack, and this cians with stress-related health concerns (e.g., time I will definitely die,’’ whereas those without headaches, sleep difficulties). For the primary care PTSD were thinking, ‘‘the risk is very small, but I provider, this means that patients will require really don’t need to go and buy a book—it is not screening for exposure to traumatic events and worth the risk’’ (Shalev et al., 2004, p. 182). posttraumatic symptomatology. In the months and Cognitive therapy was applied to help the mem- years following an event, systematic screening can bers of the PTSD group modify their beliefs. Fi- lead to better identification of stress-related pro- nally, terror survivors in treatment were frequently 264 Assessment and Treatment exposed to additional traumatic events during methods of care after an event has taken place, as therapy. They were advised to limit indirect media well as their potential for reducing PTSD symp- exposure by not watching detailed news reports, toms. They also suggest that such efforts will their appropriate avoidance was characterized as require workshop-style training, ongoing super- ‘‘positive safety behaviors,’’ and their goal was vision and consultation, and the development of achieving ‘‘normal fear.’’ It can be anticipated that strategies to maintain delivery of services (cf. such pragmatic flexibility in the modification of Young, Ruzek, Wong, Salzer, Naturale, et al., in interventions will be needed to provide care in the press). In the New York City training program midst of continuing danger and other challenging mentioned earlier, clinicians perceived clinical case aspects of the postterrorism environment. demonstration as the most valuable training mode; they also considered role plays as very useful, and Availability of Evidence-Based Services lectures were rated as the least valuable (although they were seen as useful in giving theoretical in- A second contextual constraint in the postdisaster formation). Generally, the selection, training, and environment is the likelihood of limited availability support of providers are critical parts of post- of evidence-based care for PTSD. Most mental terrorism response. Preplanned, systematic proce- health providers have not been trained in evidence- dures can be expected not only to improve the based treatments, and in most affected commu- quality of care but also to help in answering nities, the demand is likely to outstrip the supply. common service-delivery questions: how to ensure However, recent evidence suggests that mental that the large numbers of volunteers who show up health professionals can rapidly be trained in the after disaster events are competent to offer help; delivery of these treatments. how to incorporate important local systems re- In an important first demonstration of the fea- sources (e.g., local clergy) who do not possess sibility of training indigenous mental health provi- standard disaster training or credentials; and how ders in evidence-based treatments, Gillespie et al. to decide which volunteers to turn away. (2002) conducted an open trial of cognitive therapy with survivors of the 1998 Omagh terrorist bomb- Obstacles to Mental Health Providers’ ing in Northern Ireland. Therapists were National Access to Survivors Health Service mental health providers with no previous experience in treating trauma. The study Reluctance of Survivors to Seek Available Mental suggests that this intervention can easily be dis- Health Care seminated and effectively implemented and is pro- In most disasters, many of those who are affected mising for the potential delivery of CBT inter- do not use the available crisis counseling programs ventions by a range of mental health professionals or the more conventional mental health services. and paraprofessionals following disasters. For example, 3–6 months after the World Trade Following the attacks of 9/11, several efforts Center attacks in New York City, only 27% of to train mental health providers in evidence- those reporting severe psychiatric symptoms had based treatments were undertaken. Neria, Suh, and obtained mental health treatment (Delisi et al., Marshall (2003) described their efforts to provide 2003). Following the terrorist bombing of Pan Am systematic training and supervision in PTSD 103 over Lockerbie, Scotland, relatively few family prolonged-exposure treatment for New York City members of those who perished sought counseling therapists (Foa & Rothbaum, 1998). Training was despite significant levels of distress (Smith et al., initiated approximately 2 months after the attacks, 2002). This reluctance to use mental health ser- and over a 12-month period, more than 500 local vices appears to extend to emergency workers clinicians were trained. This project is notable for (e.g., North et al., 2002) and medical staff (e.g., its use of a theory of behavior change to guide the Luce & Firth-Cozens, 2002). design of dissemination efforts and its evaluation Some of this reluctance to use services may of the impact of training activities on changes in represent an acceptance of posttraumatic distress provider attitudes, behaviors, and self-efficacy. that reflects an awareness that some stress symp- Together, these efforts demonstrate the feasi- toms are to be expected and that life can go on bility of the dissemination of evidence-based nonetheless. Some people who endorse high levels Evidence-Based Interventions for Survivors of Terrorism 265 of PTSD symptoms may not label themselves as who responded to the World Trade Center collapse, significantly distressed or disabled, as has been distress at trauma reminders was seen as a normal found with Israeli citizens exposed to continuous reaction to the events and not a reason to seek terror (Shalev et al., 2004). As Shalev and col- treatment. Rather, anger, irritability, and sleep prob- leagues have noted, PTSD symptoms are to be lems were seen as reasons to seek help. expected in communities that are subjected to A better understanding of what motivates peo- ongoing terrorist attacks and may not represent ple who need help to actually seek it might be useful maladaptive reactions. However, stigma and other in marketing these services, increasing engagement obstacles likely play an important role as well. For in counseling, and widening acceptance of mental those who lost family members in the Lockerbie health referral. Since many disaster and terrorism bombing, the most frequent reasons given for not survivors will talk to their primary care practi- using counseling included thinking that they could tioners, ways of addressing mental health in these handle it with help from family, friends, and their settings will be important. Others will seek assis- religious faith; that mental health counseling is a tance in emergency rooms. More generally, efforts to sign of weakness and felt stigmatizing; that they destigmatize help seeking are in need of creative could not afford it financially; or that they could not development. One possibility involves having a admit to having a problem (Smith et al., 2002). mental health worker available at the emergency It is important to recognize that not everyone room or within a medical practice to help patients needs mental health treatment and that, for some, struggling with issues that are more psychological in seeking help from one’s family, friends, and/or nature (i.e., a ‘‘one-stop shopping’’ model of care). religious faith is adequate and offers sufficient The idea is that, once the patient meets with the support. However, those who attempt to offer mental health professional and rapport is estab- evidence-based terrorism and disaster interven- lished, transition to short-term problem-focused tions must acknowledge this underutilization of therapy will occur with greater ease. services and take steps to reduce any obstacles to appropriate utilization by those in need. Disaster Restrictions on Physical Access to Survivors mental health practice has evolved to address this In some events, it may be difficult for mental health reality by including significant outreach compo- providers to establish face-to-face contact with nents. Much help is provided at places where survivors. This may be due to restrictions on travel survivors congregate as mental health responders by authorities, perceptions of ongoing environ- offer ‘‘therapy while walking around.’’ Outreach mental danger (e.g., continuing risk for terrorist workers seek out survivors in shopping malls, on attack or toxic exposure), or, possibly, quarantine. doorsteps, in workplaces, and at religious gather- In situations of ongoing risk of exposure to biolo- ings. At large events, the mass media are harnessed gical toxins, providers themselves may be reluctant to market crisis counseling programs; in New to work with possibly infected survivors. Tele- York, the services of Project Liberty were advertised phone- or Internet-delivered services may be useful via major public education campaigns that in- in these circumstances. Both cognitive-behavioral volved television spots in which well-known celeb- telephone (Greist et al., 2000; Mohr et al., 2000; rities appeared. Somer et al., 2005) and Internet interventions Relatively little is know about how to encourage (Gega, Marks, & Mataix-Cols, 2004) have proven the use of services and how survivors make deci- helpful with a variety of mental health problems. sions about self-referral. In much postterrorism/ Future research should focus on testing these disaster education, information is presented to help modalities of help following a terror event, espe- survivors differentiate between normal reactions to cially given their ability to provide a convenient the event and those that may warrant counseling. and stigma-reducing vehicle to promote self- These efforts are appropriate, but it is not known management (Gega, Marks, & Mataix-Cols, 2004). whether they are effective in encouraging appropriate self-referral. More efforts should be made to Providers as Survivors understand the perspectives of survivors themselves. For example, Difede et al. (n.d.) have re- Especially in large-scale terrorist attacks, many of ported that, among emergency services workers those who are called upon to provide mental health 266 Assessment and Treatment services will themselves be affected by the event. groups conflicts with an evident need to view af- For example, following the 9/11 terrorist attack, fected people and communities as survivors and to many employees of the Pentagon’s Family Assis- emphasize capacity and commitment to resist ef- tance Center were in the building when it was hit or forts at intimidation and to overcome adversity lost friends and colleagues (Huleatt, LaDue, Leskin, (Hyams et al., 2002). Ruzek, & Gusman, 2002). In some events, mental On the other hand, in the aftermath of the health workers may be concerned about the well- events of 9/11, there was considerable questioning being of their loved ones. The fact that, in some of the fit between the disaster mental health crisis scenarios, workers will have been exposed to the counseling program model (with its emphasis on terrorist event and will themselves be experiencing normalization and low-level interventions for stress reactions may affect their ability to respond many people) and the significant mental health and provide care. For example, in a simulation of impact of such a high-magnitude terrorist event a biological outbreak, some responders and their (Norris et al., in press). Much concern was ex- spouses disagreed about reporting for duty (Di- pressed about the adequacy of such brief inter- Giovanni Jr., Reynolds, Harwell, Stonecipher, & ventions for survivors who were the most severely Burkle Jr., 2003). In the 1994 outbreak of plague in affected. The inclusion of enhanced, moderate- Surat, India (Ramalingaswami, 2001), doctors were intensity services is part of an ongoing evolution of among the estimated 600,000 people who fled the disaster mental health practice to meet the needs city, believing that nothing could be done to ef- of such groups (Gibson et al., in press). fectively treat the outbreak. In designing mental Many of the procedures that have been devel- health response postterrorism, it will be important oped as mental health interventions are based on to anticipate that staff will experience conflict be- an educational, skills-training model. Cognitive- tween their work and personal/family roles. Sys- behavioral interventions for posttraumatic stress in tematic staff care procedures should be developed, particular are based on a model that stresses that and steps should be taken to minimize the extent posttrauma problems are the outcomes of normal to which staff members may be distracted by con- adaptive learning processes (Follette & Ruzek, in cerns about their family and/or community (e.g., by press) and interventions derived from the model establishing systems to enable staff contact with are often relatively brief, pragmatic, and goal di- loved ones). rected, features that lend themselves to application following disasters and terrorism.

Future of Mental Health Response Technology and Terrorism Response in Terrorism Communication technologies will be increasingly Changing Models of Disaster Mental harnessed to provide interventions for individuals Health Service Delivery and groups in future terrorist attacks and disasters. The Project Liberty 800-number hotline operating Psychological research on prevention of PTSD and in New York was widely hailed as a major source other posttrauma problems has implications for of support and referral information for survivors delivery of postterrorism care. Potentially valuable and a key useful feature of 9/11 response (Norris is an effort to synthesize lessons learned from et al., in press), and it can be assumed that similar different groups of trauma survivors, for whom efforts will be widely implemented in the future. early intervention services have often evolved in- The demonstration that anxiety management may dependently with resulting differential strengths be effectively undertaken via telephone will only (Ruzek, in press). However, ways of integrating accelerate exploration of phone services. Similarly, psychological treatment and disaster mental health the Internet saw significant use during 9/11 that ‘‘resilience’’ perspectives requires development and prefigures wider application. The Project Lib- experimentation. In the context of terrorism and erty website (http://www.projectliberty.state.ny.us/) other community disasters, emphasis on the iden- provided information and other services to crisis tification of vulnerable or high-risk individuals and counselors and terrorism survivors alike, and the Evidence-Based Interventions for Survivors of Terrorism 267

National Center for PTSD site (http://www Ashford, D. A., Kaiser, R. M., Bales, M. E., Shutt, K., .ncptsd.org) attracted a heavy volume of traffic. Be- Patrawalla, A., McShan, A., et al. (2003). Planning cause of their capacity to reach large numbers of against biological terrorism: Lessons from outbreak affected individuals and their relative ease of use and investigations. Emerging Infectious Diseases, 9, circumvention of concerns about stigma and con- 515–519. Benedek, D. M., Holloway, H. C., & Becker, S.M. fidentiality, these technologies have significant po- (2002). Emergency mental health management in tential to become a key element of stepped care, bioterrorism events. Emergency Medicine Clinics of supplement face-to-face care, and improve post- North America, 20, 393–407. disaster response (Ruzek, 2002a). Bisson, J. I. (2003). Single-session early psychological interventions following traumatic events. Clinical Psychology Review, 23, 481–499. Summary Bleich, A., Dycian, A., Koslowsky, M., Solomon, Z., & Wiener, M. (1992). Psychiatric implications of No individual victims, groups of victims, or com- missile attacks on a civilian population: Israeli munities victimized by terrorism escape unscathed. lessons from the Persian Gulf War. Journal of However, most people will not develop formal the American Medical Association, 268, long-term mental health disturbances. The key 613–615. practical, ethical, logistic, clinical, and adminis- Bonanno, G. A. (2004). Loss, trauma, and human trative challenge in the aftermath of mass violence resilience: Have we underestimated the human capacity to thrive after extremely aversive events? is to identify those who are most at risk for chronic American Psychologist, 59, 20–28. posttraumatic mental health problems and func- Boudewyns, P. A., & Hyer, L. (1990). Physiological tional impairments. Secondary prevention of these response to combat memories and preliminary problems is critical because the life-course impact treatment outcome in Vietnam veteran PTSD of trauma for those most at risk is pernicious and patients with direct therapeutic exposure. Behavior disabling. Unfortunately, risk and resilience re- Therapy, 21, 63–87. search is in its infancy. However, there are rules of Bowler, R. M., Murai, K., & True, R. H. (2001, January/ thumb to guide efforts at devoting resources to February). Update and long-term sequelae of the those most at risk following a terrorist attack; the sarin attack in the Tokyo, Japan subway. Chemical most important risk factors are, in order of im- Health and Safety, 1–3. portance, degree of life threat and loss of life, Brewin, C. R. (2003). Post-traumatic stress disorder: Malady or myth? London: Yale University Press. traumatic loss, direct exposure to the aftermath of ———, Andrews, B., & Valentine, J. D. (2000). violence (e.g., seeing the dead and dying), and loss Meta-analysis of risk factors for posttraumatic of personal and social resources as a result of the stress disorder in trauma-exposed adults. Journal terrorist event. In this chapter we have described of Consulting and Clinical Psychology, 68, the evidence to support various clinical interven- 748–766. tions and strategies to address those most in need. Bryant, R. A. (2003). Cognitive behaviour therapy of When there was no evidence to address a given acute stress disorder. In R. Orner & U. Schnyder problem, we offered a set of practical and least re- (Eds.), Reconstructing early intervention after trauma: strictive options for treating survivors of terror. Innovations in the care of survivors (pp. 159–168). Oxford: Oxford University Press. Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., References & Basten, C. (1998). Treatment of acute stress disorder: A comparison of cognitive-behavioral Acierno, R., Resnick, H. S., Flood, A., & Holmes, M. therapy and supportive counseling. Journal of (2003). An acute post-rape intervention to prevent Consulting and Clinical Psychology, 66, 862–866. substance use and abuse. Addictive Behaviors, 28, Bryant, R. A., Moulds, M. L., & Nixon, R. D. V. (2003). 1701–1715. Cognitive behaviour therapy of acute stress Amir, M., Weil, G., Kaplan, Z., Tocker, T., & Witztum, disorder: A four-year follow-up. Behaviour Research E. (1998). Debriefing with brief group psycho- and Therapy, 41, 489–494. therapy in a homogenous group of non-injured Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., victims of a terrorist attack: A prospective study. and Guthrie, R. (1999). Treating acute stress Acta Psychiatrica Scandinavica, 98, 237–242. disorder: An evaluation of cognitive behavior 268 Assessment and Treatment

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Neurobiological and Behavioral Consequences of Terrorism Distinguishing Normal From Pathological Responses, Risk Proﬁling, and Optimizing Resilience Rachel Yehuda Richard Bryant Joseph Zohar Charles R. Marmar

Some people are vulnerable to the development of On the other hand, terrorism is not only about psychopathology following exposure to events that life threat to individuals or even a small group of elicit terror and helplessness, but the majority ex- people but is also designed to instill fear in society at perience transient symptoms that for the most part large. Those who are not in immediate proximity to resolve within weeks or months. One of the major the attack or who were not directly affected by the gaps in our knowledge is the difficulty in predicting loss of someone important to them can also be af- long-term responses to trauma on the basis of the fected, in part because terrorist attacks receive nature and time course of the acute response to any repeated coverage in the media. Terrorism can traumatic event—particularly for any given person. threaten the sense of safety and security of everyone This chapter summarizes current knowledge about in the society attacked because they are aware that differentiating normal from pathological responses terrorists may strike again in unpredictable loca- and predicting psychopathologic responses fol- tions. The mental health consequences in those lowing exposure to terrorism and highlights pro- who are indirectly exposed but show symptoms mising areas for future research. may be qualitatively or quantitatively different from It is important to determine the generalizability those of people who have suffered direct exposure of findings on the effects of trauma exposure arising and also different from those of people who ex- from other contexts to terrorism and mass violence. perienced near misses. The cumulative effect of In one sense terrorism is a prototypic traumatic anticipatory anxiety of future incidents in those event, particularly for those who directly experi- who have been directly exposed is also not known. ence a threat to their lives or physical integrity or The real threat of imminent attack may be related experience traumatic loss. Those directly exposed to how quickly they can recover from its effects. to terrorism are candidates for the development of A critical issue in differentiating normal from acute stress disorder (ASD) or posttraumatic stress pathological responses is the passage of time. This disorder (PTSD), and knowledge about the impact is particularly true in considering outcomes such of other traumatic events may be helpful in defining as PTSD, a diagnosis that requires symptoms and their psychological outcomes. functional disturbances to have persisted for at least

273 274 Assessment and Treatment a month following trauma exposure. However, situation in which the individual is functioning terrorist acts usually initiate anxiety about future (Wakefield, 1996). attacks. If a terrorist event represents the beginning A longitudinal perspective provides insight into or continuation of a situation or threat—as it often the pathological nature of acute responses to ter- does—the timetable for recovery may be shifted. rorism. It is now clear that most people recover Thus, in considering whether the effects of ter- from early posttraumatic symptoms. This phe- rorism are pathological, it may be appropriate to nomenon can be illustrated by results of surveys conceptualize normal responses to be present for conducted by the New York Academy of Medicine more than 30 days after the initial trauma. In the following the attacks of September 11 in New York context of ongoing terrorist threat, identifying City. Five to eight weeks after the attacks, 7.5% of persistent disorder may be more accurately defined randomly sampled subjects living south of 110th only after the immediate threat is substantially Street had reportedly developed PTSD (Galea et al., reduced. This caveat does not suggest that people 2002), with those who experienced the most severe do not have mental health needs that should be exposure or personal loss at higher risk than others. met within this timeframe. Instead, it acknowl- When another randomly sampled group was stu- edges that a normative response may involve strong died 6 months after the attacks, only 0.6% of those and persistent symptomatic reactions if actual living south of 110th Street met all of the diagnostic threat persists. criteria for PTSD, and an additional 4.7% met the In trying to delineate the mental health con- criteria for subsyndromal PTSD (Galea, Boscarino, sequences of terrorism, researchers have generally Resnik, & Vlahov, 2003). As a whole, the Man- conducted surveys or interviews in which they in- hattan community recovered substantially from the quire about expectable emotional reactions. These initial effects of the September 11 attacks. However, include difficulties in sleeping and concentrating, an important question raised by these findings is irritability, nightmares, distressing thoughts about whether the initial estimates of PTSD based on early the event, or distress at reminders of the event symptoms constituted a real clinical syndrome re- (Schuster et al., 2001), that is, symptoms suggestive quiring treatment or rather was simply a reflection of PTSD. In the immediate aftermath of terrorism of temporary distress. Obviously, in those who did most people will exhibit these symptoms. The not recover or had persistent features of PTSD even question becomes whether having time-limited high if they partially recovered, these symptoms may levels of symptoms at a time when most of those have been the earliest manifestations of psycho- directly exposed also have them constitutes, let pathology, raising a second important question of alone predicts, pathology. the extent to which early symptoms of postterror- Although hypervigilance to future attacks or ism are predictive of later ones. persistent worry about exposure to anthrax may have been widely present following the attacks of 9/11, is it best to consider these symptoms as in- Predictors of Pathological Responses dicative of a pathological or normative response in a terrorist environment? Most mental health Those with minimal symptoms in the immediate models regard acute stress reactions as a mental aftermath of a traumatic event are at low risk for the disorder, but it may be erroneous to attribute development of subsequent PTSD or other forms of symptoms of anxiety to a mental disorder when psychopathology (Shalev, 1992). Greater symptom the context suggests that such reactions are war- severity from 1–2 weeks posttrauma and beyond ranted. The question of how to think about such is positively associated with subsequent symptom symptoms is important from a public health per- severity (Harvey and Bryant, 1998, Murray, Ehlers, spective since it raises the even greater issue of & Mayou, 2002; Shalev et al., 1997). Those who do whether the presence of early symptoms requires show high-magnitude PTSD symptoms in the days intervention. The question resonates with com- immediately posttrauma represent two distinct mentators who have noted that a definition of subgroups: those in whom symptoms will abate disorder should recognize the extent to which a within days to weeks and those in whom symptoms condition is dysfunctional in the context of the will persist (McFarlane, 1989; Shalev, 1992). These Neurobiological and Behavioral Consequences of Terrorism 275

findings support the idea that the ‘‘pathologic immediately after trauma exposure. There is evi- process’’ involved in PTSD and possibly other dence that such panic attacks occur in 53%–90% posttraumatic mental health reactions are in part a of trauma survivors who experience severely trau- reflection of a failure to recover from early symp- matic events (Bryant & Panasetis, 2001). More toms. Yet because high levels of PTSD symptoms in than half of those who meet the criteria for ASD the first days after a trauma predict failure to re- report peritraumatic as well as subsequent panic cover in some but not other trauma victims, the attacks (Nixon & Bryant, 2003). Galea et al. found findings point to the importance of identifying peritraumatic panic to be the best predictor of additional early markers of longer-term pathology. PTSD in the post-9/11 survey of 1,008 residents One possible predictor of long-term psycho- living south of 110th Street in Manhattan. This pathology may be peritraumatic dissociation. Nu- observation is consistent with recent observations merous studies have found an association between from a study of 747 police officers, in which panic peritraumatic dissociation and the subsequent de- reactions and related emotional distress during velopment of PTSD (e.g., Marmar et al., 1994; Eh- exposure were highly predictive of pre-9/11 PTSD lers, Mayou, & Bryant, 1998; Koopman, Classen, & symptoms (Brunet et al., 2001) and in a pro- Spiegel, 1994; Marmar, Weiss, Metzler, Delucchi, spective study of 311 NYPD officers also predictive & Best, 1999; Murray et al., 2002; Shalev et al., of post-9/11 symptoms (Marmar et al., 2005). 1998; Marmar, Metzler, & Otte, 2004; Marmar McNally has suggested that both peritraumatic et al., 2005). Peritraumatic dissociation refers to a dissociation and peritraumatic panic can result in a dissociative experience that occurs at the actual catastrophic interpretation of the event and or the time of the traumatic event and includes features of erroneous conclusion that the symptoms are har- depersonalization, derealization, and altered time bingers of more serious problems (McNally, 2003). sense. A meta-analysis by Ozer, Best, Lipsey, and Indeed, some investigators have demonstrated the Weiss (2003) indicates that peritraumatic dis- power of negatively appraising any aspect of the sociation was the single best predictor (r ¼ .35) of event in the peritraumatic period to predict long- PTSD among trauma-exposed individuals, but this term pathology. For example, having a negative view has not been unanimously supported in pro- perception of other people’s responses (e.g., ‘‘I feel spective studies (e.g., Dancu, Riggs, Hearst-Ikeda, that other people are ashamed of me now’’) predicts Shoyer, & Foa, 1996; Marshall & Schell, 2002). PTSD beyond what can be predicted from initial In 2003, McNally asserted that findings of the symptom levels (Dunmore, Clark, & Ehlers, 2001). predictive power of peritraumatic dissociation are People with ASD show enhanced anxiety sensitiv- difficult to interpret because many studies do not ity. For example, they are prone to catastrophize adequately distinguish between true peritraumatic about somatic cues (Smith & Bryant, 2000) and dissociation and subsequent depersonalization and also respond to a hyperventilation challenge test by derealization in the first weeks after exposure, engaging in more dysfunctional thoughts about which are required for a diagnosis of ASD, and somatic responses (Nixon & Bryant, in press). Si- which do not appear to be predictive of PTSD over milarly, attributions of exaggerated responsibility and above the acute reexperiencing, and presence for a trauma in the acute posttrauma phase predicts of avoidance and arousal symptoms. Studies of PTSD (Andrews, Brewin, Rose, & Kirk, 2000; De- peritraumatic dissociation usually do not covary lahanty et al., 1997). In the context of terrorism, the for cognitive ability, which in itself is a risk factor presence of these attributions provides a way of for PTSD that is linked with dissociation (McNally, distinguishing between being external events that 2003). Thus, it may be that peritraumatic dis- attempt to terrorize and internal reactions of actu- sociation predicts PTSD because it is highly linked ally being terrified. Those who are exposed to a with other risk factors for this disorder, in parti- traumatic event are not traumatized unless they are cular peritraumatic panic (Brunet et al., 2001; deeply distraught at the time of the event and then Marmar et al., 2005). make ongoing catastrophic interpretations. Another potentially important predictor of Peritraumatic panic may favor the develop- pathological outcomes following trauma exposure ment of PTSD for neurobiological reasons as well is the presence of a panic attack during and/or as cognitive misattributions. Basic science research 276 Assessment and Treatment on memory consolidation and fear conditioning likely to appraise a situation as more immediately have demonstrated that heightened adrenergic ac- dangerous. On the other hand, it may be that tivation can promote the consolidation and retrie- preexisting cognitive factors or exaggerated threat val of fear-provoking memories (Bohus & Lissak, appraisals at the time of exposure drive the ca- 1968). Building on this preclinical work, condition- techolaminergic response to the trauma that leads ing models of trauma response propose that PTSD to the panic. These preexisting cognitive factors, in is the result of strong associative learning whereby turn, may or may not be the cause, result, or people who will go on to develop PTSD initially correlate of a preexisting biological alteration that react to a traumatic event (unconditioned stimulus) sets the stage for an extreme response. with high levels of sustained arousal and fear, as In summary, those who are exposed to ter- occurs in peritraumatic panic reactions (uncondi- rorism or other catastrophic events, do not panic tioned response). People with PTSD then continue or dissociate during the event and in the first to show arousal (conditioned response) when hours afterward, and have low levels of PTSD-like confronted with trauma-related cues (conditioned symptoms in the first days and weeks after ex- stimuli). posure are most likely to have a normal stress re- It has been hypothesized that extreme sympa- action and not to develop PTSD. Among those who thetic arousal at the time of a traumatic event may experience high levels of symptoms in the first result in the release of stress-related neurochemicals days or weeks, some will recover and some will (including norepinephrine and epinephrine) in not. Prolonged and sustained peritraumatic panic the cortex, mediating an overconsolidation of (Brunet et al., 2001; Galea et al., 2002; Marmar trauma memories (Pitman, Shalev, & Orr, 2000). et al., 2005), as well as peritraumatic dissociation The majority of trauma survivors will engage in (Ozer et al., 2003; Marmar, Metzler, and Otte, extinction learning in the weeks after trauma ex- 2004), are strong predictors of those who will not posure, in which they associate the conditioned recover. stimuli with safe consequences and thereby actively Clarifying the causes of high levels of im- inhibit the fear response through new learning. In mediate and long-term symptoms will no doubt contrast, the minority of people who will develop lead to ideas about potential preventative treat- PTSD have impaired extinction learning and over- ments. For example, to the extent that panic reac- consolidated memories of the trauma. Both dis- tions are associated with increased catecholamine sociation (Simeon, Guralnik, Knutelska, Yehuda, & responses at the time of trauma, aggressive inter- Schmeidler, 2003) and panic reactions (Charney, vention with adrenergic blocking agents such as Deutch, Krystal, Southwick, & Davis, 1993; propranolol (Pitman et al., 2002; Vaiva et al., 2003) Southwick et al., 1997) have been associated with or cognitive behavioral stress management techni- increased catecholamine states. It is plausible that ques emphasizing anxiety management rather than people who experience panic, dissociation, or other emotional catharsis or retelling (i.e., reexposure, as forms of intense emotional distress during and in some forms of debriefing) may be the most ap- immediately after a traumatic event have higher propriate immediate interventions for those who levels of catecholamines than those who do not panic at the time of exposure and in the hours respond in this manner. An enhanced elevation of immediately following a traumatic experience. For catecholamines in the immediate aftermath of a those who are not in a position to receive inter- traumatic event may increase the probability of in- vention within several hours or days posttrauma, trusive recollections in the first few days and weeks it will be necessary to determine the impact of posttrauma (Pitman, 1989; Charney et al., 1993). posttraumatic risk factors such as lack of social One of the major gaps in our knowledge support and subsequent adverse life events on the concerns the interplay of biologic responses at the longitudinal course of pathologic responses to time of a traumatic event and cognitive factors. trauma. Indeed, it is easy to see how an increased ca- It is important to note that there is not a per- techolaminergic response to trauma could be the fect one-to-one correspondence between the level proximal cause of intense panic. Furthermore, it of acute stress reactions and longer-term adjust- seems plausible that those who find themselves ment. A small proportion of people can apparently in a more intense biologic state of fear might be develop PTSD or other disorders after a delayed Neurobiological and Behavioral Consequences of Terrorism 277 period of time following the traumatic event. The velop chronic PTSD (Koopman, Classen, Cardena, Diagnostic and Statistical Manual of Mental Disorders & Spiegel, 1995). The ASD diagnosis attempts to (DSM-IV) identified delayed-onset PTSD when the differentiate between the majority of trauma sur- disorder becomes apparent at least 6 months after vivors who display a transient stress reaction and the precipitating event (American Psychiatric As- recover within a few weeks to months and those sociation, 1994). Large-scale studies of civilian who are in the initial phase of a chronic disorder. trauma have reported delayed-onset PTSD in a The ASD diagnosis was strongly influenced by small minority of cases (around 5%; Bryant & the perspective that dissociative reactions are a Harvey, 2002; Buckley, Blanchard, & Hickling, crucial mechanism in posttraumatic adjustment 1996; Ehlers et al., 1998; Mayou, Bryant, & Du- (Spiegel, Classen, & Cardena, 2000). The argu- thrie, 1993). Evidence indicates that people who ment that ASD reflects a ‘‘disorder’’ is based in part develop delayed-onset PTSD experience more on the belief that dissociative responses after persistent stressors after the initial trauma, which trauma lead to psychopathological responses be- may contribute to PTSD development (Ehlers et al., cause they impede access to and processing of 1998; Solomon, Kotler, Shalev, & Lin, 1989; traumatic memories. Dissociative reactions in the Green et al., 1990). acute aftermath of trauma exposure are predicted It is possible that ongoing stressors in the to limit or disorganize emotional processing of the aftermath of an initial terrorist attack (for example, traumatic memories, leading to psychically un- the ongoing threat of terrorist attacks and later metabolized traumatic memories and chronic terrorist acts of violence elsewhere in the world) symptoms. may contribute to the development of delayed- There are now 12 longitudinal cohort studies of onset PTSD. Alternately, fear-conditioning models adults that have addressed the extent to which ASD posit that initial conditioning may persist in a within the initial month after trauma exposure latent form, restrained by new fear extinction predicts subsequent PTSD (Brewin, Andrews, Rose, learning, until sufficient cues or increased stressors & Kirk, 1999; Bryant & Harvey, 1998; Creamer perhaps elicit a conditioned response in the form et al., 2004; Difede et al., 2002; Harvey & Bryant, of PTSD (Charney et al., 1993). Fear-conditioning 1998, 1999, 2000b; Holeva, Tarrier, & Wells, models suggest that some form of fear reaction 2001; Kangas, Henry, & Bryant, in press; Murray should occur in the acute phase and that this et al., 2002; Schnyder, Moergeli, Klaghofer, & Bud- should be exacerbated under certain circumstances deberg, 2001; Staab, Grieger, Fullerton, & Ursano, that reinstate the initial fear-related cues. This 1996). Most of these studies demonstrate that the proposal is supported by evidence that most peo- majority of trauma survivors who display ASD— ple who develop delayed-onset PTSD do display approximately 75% across studies—subsequently elevated stress reactions and higher resting heart develop PTSD. However, only a minority of people rates in the acute phase after trauma exposure who eventually developed PTSD initially met the (Bryant & Harvey, 2002). criteria for ASD. It appears that a major reason the ASD diagnosis does not adequately identify the majority of people who develop PTSD is the Differentiating Normal From requirement that three dissociative symptoms be Pathological Responses in the First displayed (Bryant, 2003). Evidence suggests that Weeks Following Exposure there are multiple pathways to developing PTSD that may or may not involve dissociation (Harvey & One of the formal attempts to recognize initial pa- Bryant, 2002). thological responses to trauma was the introduction of the ASD diagnosis in DSM-IV (American Psychiatric Association, 1994). This diagnosis was Identifying Those at Greater Risk intended to fill what was considered to be a diagnostic gap because the PTSD diagnosis requires Although being able to predict long-term pathology that symptoms be present for at least a month. A from the acute response, such as peritraumatic second purpose of the diagnosis was to identify panic, is of paramount importance, understanding acutely traumatized people who were likely to de- the development of pathologic responses will also 278 Assessment and Treatment necessitate understanding the risk factors for those and eyeblink (electromyographic [EMG]) startle early responses. The finding that only a percentage responses before trauma exposure in a cohort of of those exposed to trauma develop short-term firefighter trainees predicted acute stress reactions symptoms and that only a minority of those with after subsequent trauma exposure. Further, slower high levels of acute symptoms will develop a extinction learning after aversive conditioning be- chronic severe form of PTSD justifies a search fore trauma exposure strongly predicted chronic for individual differences in resilience and vulner- posttraumatic stress after trauma exposure (Gu- ability. A wide variety of risk factors, including thrie & Bryant, manuscript submitted for pub- developmental, familial, situational, and even ge- lication). Collectively, these findings point to the netic risk factors for PTSD, have now been identi- importance of psychophysiological reactivity prior fied (McFarlane, 1989; Yehuda, 1997; Brewin, to trauma exposure as a risk factor for subsequent Andrews, & Valentine, 2000; Ozer et al., 2003). fear conditioning and development of posttrau- Retrospective studies suggest that those who matic stress. are at greatest risk for developing PTSD following Family and genetic studies are pointing toward a traumatic event are people with a personal or the role of genetic contributions to posttraumatic family history of psychopathology (Breslau, Davis, stress reactions. Compared to adult children of Andreski, & Peterson, 1991), prior exposure to Holocaust survivors without PTSD, adult children trauma, especially during childhood (Nishith, of Holocaust survivors with PTSD show a greater Mechanic, & Resick, 2000; Breslau, Chilcoat, prevalence of PTSD to their own traumatic events Kessler, & Davis, 1999), cognitive factors, such as (Yehuda, Schmeidler, Wainberg, Binder-Brynes, & lower IQ (Silva et al., 2000), female gender (Bre- Duvdevani, 1998). It is difficult to know to what slau et al., 1999), stressful life events in the year extent that increased vulnerability to PTSD in fa- preceding the traumatic event, and certain pre- mily members of trauma survivors with PTSD can existing personality traits, such as proneness to be attributed to being raised by a parent with this experiencing negative emotions and having poor disorder (Yehuda, Halligan, & Bierer, 2001), to social supports (Brewin et al., 2000). To a large exposure of the fetus to the mother’s stress hor- extent, prospective studies have supported these mones during pregnancy, or to genetic factors. findings, in that individuals with greater initial Several studies on twins support the role distress and less recovery over time had more of of genetic contribution, given the increased pre- these risk factors than those with less distress. valence of PTSD in monozygotic compared with However, when such risk factors have been used dizygotic twins (True et al., 1993). Further, a study in discriminant function analyses to predict sub- by Orr et al. (2003) compared startle responses sequent PTSD in prospective studies, no single in pairs of Vietnam combat veterans and their variable emerged as a strong predictor. This may monozygotic twins who were not exposed to reflect the fact that retrospective studies use a battle. They found evidence of more slowly habi- narrower range of subjects that are classified based tuating skin conductance startle responses in vet- on the dichotomy of presence or absence of PTSD, erans with PTSD and their non-combat-exposed whereas prospective studies usually include a twins, compared to veterans without PTSD and broader range of people with generally lower levels their non-combat-exposed twins. This finding of PTSD symptoms, reducing the power of such suggests that more slowly habituating skin con- predictions. ductance responses to acoustic startle stimuli may Recent work has begun to identify risk factors represent a pretrauma vulnerability factor for by assessing populations that are likely to be ex- PTSD (Orr et al., 2003). This model is supported posed to trauma before and after such exposure by the prospective findings of greater skin con- actually occurs. A prospective study by Marmar ductance and eyeblink EMG startle responses be- et al. (2005) of New York police officers has found fore trauma exposure in firefighter trainees with that elevated symptoms of PTSD assessed several greater acute stress reactions after duty-related years before 9/11 predicted greater 9/11-related traumatic exposure (Guthrie & Bryant, 2005). PTSD symptoms several years after the WTC at- The issue these risk factors raise is whether tacks. A study by Guthrie & Bryant (2005) of they need to be part of an initial assessment in startle responses has found that skin conductance the immediate aftermath of a trauma, and this is Neurobiological and Behavioral Consequences of Terrorism 279 currently an open question. Studies have clearly of a trauma (Resnick, Yehuda, Foy, & Pitman, demonstrated that people with both high PTSD 1995; Delahanty, Riamonde, & Spoonster, 2000). symptoms in the first week and additional risk Moreover, those who develop PTSD show higher factors—childhood trauma, low educational at- heart rates in the emergency room and at 1 week tainment, personal or family history of anxiety or posttrauma compared to those who ultimately re- mood disorders, history of heavy alcohol use in the cover (Bryant, Guthrie, & Moulds, 2000; Shalev months prior to an incident, poor social supports et al., 1998, Zatzick et al., 2005), suggesting a in the posttraumatic period, and greater levels of greater degree of sympathetic nervous system ac- exposure during the incident—are less likely to tivation. These findings imply that biologic re- recover than those who do not. However, if the sponse to acute trauma are distinct in those who panic and related emotional distress at the time of do and do not go on to develop PTSD. the traumatic event—or if a high level of PTSD Further supporting the distinction between symptoms that substantially interfere with occu- normal and pathological responses to trauma are pational and relationship functioning within the sensitization models of PTSD. Post, Weiss, and first few weeks after an event—are sufficiently Smith (1995) have proposed that, with chronic predictive of longer-term symptoms, it may not be repeated stimulation by trauma reminder cues, necessary to assess pretraumatic risk factors for the the reexperiencing of symptoms begins to occur purpose of triage and timely intervention. Rather, spontaneously, rather than requiring triggering, those risk factors might prove important in unin a kindling-like process. Consistent with this derstanding and possibly differentiating among model, Shalev and colleagues (2000) have reported various types of acute reactions and in providing that elevated heart rate and more slowly habitu- stress inoculation training as a prophylaxis. ating skin conductance and EMG responses to startle stimuli were observed at 1 and 4 months following trauma but not at 1 week after trauma in Biological Markers Differentiating those who subsequently developed PTSD. These Normal From Pathological results suggest a progressive neuronal sensitization Responses to Trauma associated with heightened physiological reactivity underlying PTSD development. There appears to be a distinct set of biological The precise origin and onset of any of the markers of PTSD. These markers have been found biologic alterations associated with PTSD have to differentiate those with PTSD from trauma- not been elucidated. Recent findings suggest that at exposed individuals without PTSD and from psy- least some of the biologic alterations observed chiatric controls. These findings suggest that the (e.g., low cortisol levels, smaller hippocampal vo- biology of PTSD is not simply a reflection of a lumes) may represent a genetic or early develop- normative stress response but rather a distinct pa- mental risk factor for the disorder rather than thologic condition (Yehuda and McFarlane, 1995). either a consequence of trauma exposure or de- In concert with observations of the phenom- velopment of PTSD (Yehuda et al., 2000; Gilbert- enology and psychology of PTSD, neurobiological son et al., 2002). It is important to first develop examinations of trauma survivors also support the models and then testable hypotheses for how such possibility that the development of PTSD is fa- preexisting risk factors might explain the devel- cilitated by a runaway stress response at the time opment of PTSD. Low cortisol may favor the de- of the trauma, resulting in a cascade of biological velopment of PTSD for several reasons. Cortisol alterations that lead to intrusive, avoidance, and inhibits its own release through negative feedback hyperarousal symptoms. In contrast to the normal at the level of the pituitary and the hypothalamus. fear response, which is characterized by a series of Lower levels of cortisol at the time of a traumatic biological reactions that help the body cope with, event would disrupt the process of stress recovery and gradually recover from, stress (e.g., high cor- by failing to inhibit the activation of the pituitary, tisol levels), some recent prospective biologic stu- resulting in increased hypothalamic corticotropin- dies have demonstrated that people who develop releasing factor (CRF) stimulation in synergy with PTSD or greater PTSD symptoms appear to have other neuropeptides, such as arginine vasopressin, attenuated cortisol increases in the acute aftermath resulting in a higher magnitude ACTH response, 280 Assessment and Treatment which might further stimulate the sympathetic architecture (Neylan et al., 2003). Structural and nervous system (Holsboer, 2001). Further, gluco- functional neuroimaging studies of PTSD have corticoid release inhibits norepinephrine secretion demonstrated changes in brain volume, neuronal from the sympathetic nerve terminals; as a result, metabolism, and/or activation in regions such as lower cortisol levels may have the consequence of the hippocampus and the amygdala (Rausch, Shin, prolonging norepinephrine availability to synapses & Pitman, 1997; Schuff et al., 2001). One model both in the periphery and in the brain (Pacak, proposes that PTSD is influenced by excessive Palkovitz, Kopin, & Goldstein, 1995). Ultimately, amygdale activation resulting from diminished in- low cortisol levels might result in an upregulation hibitory regulation of the central nucleus of the or increased sensitivity of glucocorticoid receptors amygdala by the rostral anterior cingulate (Bush, in response to the detection of a greater internal Luu, & Posner, 2000; Shin et al., 2001). Hippo- demand by the pituitary, which would further campal abnormalities may also preexist trauma strengthen negative feedback inhibition. Alter- exposure and serve as risk factors (Gilbertson et al., natively, an enhanced negative feedback inhibition 2002). It is also possible that there are important may be present at the time of the trauma and may individual differences in biologic systems in PTSD. contribute to the premature suppression of ACTH In support of individual differences in biologi- and cortisol, leading to undermodulated catecho- cal responses, Southwick and colleagues demon- lamines responses (Yehuda, 2002). strated that in certain PTSD patients, panic attacks There may be consequences of increased ca- and flashbacks were elicited by the manipulation techolamine levels in the acute aftermath of the of the noradrenergic system with yohimbine, trauma for promoting the consolidation of the whereas in others they were elicited by the ma- traumatic memory. Indeed, adrenergic activation nipulation of serotonergic neurotransmission with in the face of a low cortisol level has been shown to m-chlorophenylpiperazine (mCPP) (Southwick facilitate learning in animals (Cahill, Prins, Weber, et al., 1997). & McGaugh, 1994). If this were also occurring in Low GABA plasma levels immediately after trauma survivors, the memory of the event would trauma are also predictive of subsequent PTSD not only be strongly encoded but also associated (Vaiva et al., 2003). GABA agonists reduce fear re- with extreme subjective distress. The distress, in actions (Zangrossi, Viana, & Graeff, 1999). Lower turn, could facilitate the development of altered GABA levels shortly after trauma may suppress perceptions and thoughts in the aftermath of the glutamatergic functioning, and thereby lead to event, particularly those associated with one’s own PTSD. This interpretation is consistent with the perception of danger or ability to cope with threat. finding that intoxication at the time of trauma can These altered beliefs could serve to further delay reduce the risk for PTSD (Maes, Delmeire, Mylle, & recovery by leading to a failure to modulate fearful Altamura, 2001). responses, which would further serve to strengthen, It remains to be determined which of these are rather than reduce, both maladaptive cognitions in risk factors and which evolve with exposure to response to trauma and fear responses, thus per- traumatic stressors or with the development acute petuating the intrusive, avoidance, and hyperar- and chronic PTSD. It is conceivable that any one of ousal symptoms described earlier. In this context, a number of biologic risk factors would have the there is evidence that, in the initial month after effect of facilitating a biological sensitization to trauma, survivors with ASD display greater theta subsequent traumatic events by allowing for greater EEG activity than non-ASD trauma survivors (Fel- physiologic arousal, greater terror during exposure, mingham, Bryant, & Gordon, in press). Theta EEG and, as a result, greater fear conditioning and activity has been associated with overconsolidation memory consolidation. Biological characteristics of of memories (Klimesch, Doppelmayr, Russegger, & those at risk for developing PTSD appear to po- Pachinger, 1996). tentially involve preexisting alterations that might PTSD has been associated with numerous compromise adaptive cognitive processing at the other biologic alterations, including immune (Maes time of the event (e.g., lower IQ, prior trauma) and/ and colleagues, 1999), catecholaminergic (South- or preexisting alterations that might impede con- wick et al., 1997), and psychophysiologic (Orr, tainment of the biologic response to fear (e.g., lower 1997) alterations, as well as changes in sleep cortisol or additional neuropeptides that might fail Neurobiological and Behavioral Consequences of Terrorism 281 to contain sympathetic nervous system arousal). It risk factors and levels of posttraumatic symptoms is not known whether these biologic risk factors are is currently unknown. Those with greater PTSD related to biologic factors, such as increased ca- symptoms following a terrorist attack may be more techolamines, that may be present in tandem with likely to withdraw from social support, disrupt and influence levels of peritraumatic panic or disclose relationships, and struggle to meet occupa- tress. It is now critical to determine in prospective tional demands leading to a domino progression of studies the relationships between biologic altera- losses. They may also become nihilistic (e.g., ‘‘Why tions in PTSD and symptoms and particularly drive with a seat belt when you can be wiped out between biologic alterations that may have been any time?’’) or counterphobic (e.g., ‘‘I survived the present before or during trauma exposure and the collapse of the towers, so I am immune to normal subsequent development of pathologic responses. dangers’’) and as a consequence engage in increased risk-taking behavior leading to subsequent retraumatization. Limitations in the Use of Behavioral The conclusion that PTSD is specifically and Biological Markers for Risk associated with neuroendocrine, neurotransmitter- Profiling, Diagnosis, and Prognosis related, and neuroanatomic alterations is war- of PTSD Following Terrorist Acts ranted, as there has been a good degree of replication across different groups of trauma survivors If the results of the World Trade Center attack at different phases of the chronic PTSD condition. studies are generalizable, most people who are However, no single biologic marker or even pattern distressed in the first few months will substantially of biologic markers have been demonstrated to be recover from the effects of terrorism, with estimates sufficiently sensitive and specific to constitute a of PTSD rates dropping from 7% at 2 months to reliable and valid diagnostic test of PTSD. Fur- 0.5% at 6 months (Galea, Ahern, & Resnick, 2002; thermore, it is not yet clear whether these biologic Galea, Boscarino, Resnik, & Vlahov, 2003; Galea, alterations constitute preexisting risk factors for Nandi, & Vlahov, 2005). At the same time among the disorder rather than consequences of trauma those who no longer met the criteria for PTSD, exposure or failure to recover from the biologic more than half manifested subsyndromal PTSD, responses to stress. Studies examining biologic al- suggesting caution about a long-term course. Those terations prospectively beginning soon after trauma with partial PTSD may be particularly susceptible exposure have produced reproducible, but not in the event of future attacks in New York or else- universal, results and primarily only in studies where in the United States. Those at risk for long- evaluating more homogenous groups of trauma term symptoms appear to have a more intense re- survivors (e.g., following the trauma of rape or action at the time of the trauma, for example, motor vehicle accidents). peritraumatic dissociation or peritraumatic panic, Indeed, biologic alterations in the peri- and associated with a more negative appraisal of dan- posttraumatic periods are likely to be highly in- ger. It is not clear whether and to what extent fluenced by many individual differences in both pretraumatic risk factors (e.g., preexisting psycho- stress exposure and personal characteristics. Dif- pathology, prior adversity, family history of psy- ficulties in recruiting subjects for detailed biologic chopathology including PTSD and panic disorder, studies in both the immediate aftermath of trauma low IQ and other cognitive risk factors, preexisting and more chronic PTSD studies can result in a personality traits such as avoidance and/or neuro- selection bias with respect to subjects both willing ticism) influence the intensity of peritraumatic re- and eligible to participate. Whether biologic al- sponses to trauma, but presumably these risk terations observed in other groups of subjects with factors are more relevant in situations where ex- PTSD would be similar to those observed in vic- posure is less severe. tims of terrorism with mental health symptoms is Posttraumatic risk factors, such as lack of so- not currently known and represents a critical cial support and newly occurring stressful life frontier. Certainly, to the extent that biologic al- events, also seem to be important predictors of terations represent either specific risk factors for psychopathology, but the extent to which these trauma exposure or PTSD, it is imperative to de- may be influenced by pre- or even peritraumatic termine whether pathologic responses to terrorism 282 Assessment and Treatment are similar, from a biologic perspective, to those panic in the development of chronic disorder may observed in other groups with PTSD related to be moderated by the relationship of these factors to combat, rape, accidents, or other forms of inter- pretrauma vulnerability factors, such as childhood personal violence. It is also important to determine abuse (Keane, Kaufman, & Kimble, 2001; Otte whether there are biologic alterations associated et al., 2005); (5) determine whether resilience is with the more nonspecific effects of terrorism, associated with biologic and behavioral mechan- such as anticipatory anxiety, that might contribute isms that are different from those involved in vul- to adverse psychological and medical outcomes. nerability to PTSD; (6) conduct research on novel There is also agreement about the predictive strategies for building resilience, including stress power of peritraumatic dissociation and peritrau- inoculation training; (7) differentiate between pa- matic panic attacks. What remains somewhat dis- thologic responses in those directly exposed and puted is whether peritraumatic dissociation and among those who become anxious and impaired panic are proxies for other PTSD risk factors such because they are frightened by eyewitness news as negative appraisal or cognitive performance or, coverage or secondhand reports of what happened alternatively, whether the experiences of dissocia- as told by survivors or because they are afraid of tion and panic during exposure characterize the subsequent attacks; (8) conduct studies address- state of being traumatized and drive subsequent ing the risks and benefits of the mass media, the negative appraisals regarding self-efficacy and Internet, and other public education tools; safety. Because these studies generally call for ret- (9) determine the characteristics of those most likely rospective analysis (usually within days or weeks to seek treatment; and (10) determine whether of the traumatic event, however), it is possible that chronic intrusion and avoidance in the absence of some bias is introduced. That is, very few studies hyperarousal and disability are pathological. report on actually observing peritraumatic disso- Without a coordinated intellectual framework ciation or panic occurring in real time since inves- for the effects of psychological trauma, public tigators are not generally at the scene of a traumatic policy makers cannot design effective public health event to witness this firsthand. Also, the majority responses to terrorism, and public education will of studies documenting peritraumatic dissociation result in the presentation of contradictory or in- and panic attacks have not been direct examina- complete information. The mental health response tions of survivors of terrorism. to the two main terrorist attacks in this country (the Oklahoma City bombing and the 9/11 attacks) was not guided by evidence-based medicine and Research Priorities in Mental Health psychology but largely by clinical lore and prior Consequences of Terrorism practices. Because almost no systematic research was done on the nature of those who needed or The following are pressing research priorities: received services, it is not even clear to what extent (1) Determine whether individual differences in ge the responses were successful or what should be netic, familial, cognitive, behavioral, and personality done differently next time. As many opinion lea- risk factors for the development of psychopathol- ders raised the possibility that some interventions, ogy following exposure to trauma require different including ‘‘hot debriefings’’ of those in acute dis- interventions or surveillance in the immediate tress, may have been contraindicated (McNally, aftermath of terrorism; (2) determine the role of 2003), it is clear that it is critical to obtain and to adverse outcomes other than PTSD including major disseminate the proper information to mental depression, panic disorder, generalized anxiety health response teams on a large scale. disorder, substance abuse, somatic symptoms, and What we currently know justifies that, at a physical illnesses, particularly hypertension, asth- minimum, public health agencies should ensure ma, chronic pain syndromes, and other psychoso- that the natural recovery process is not impaired matic illnesses (Boscarino, 1996); (3) determine the through any interventions provided in the initial interplay of biological and behavioral variables in stage. Although evidence is limited, it appears risk for PTSD, using prospective, longitudinal de- appropriate to provide educational information signs following terrorism; (4) determine whether that supports activities that enhance safety, security, the contribution of peritraumatic dissociation or and social support and promotes the reduction of Neurobiological and Behavioral Consequences of Terrorism 283 hyperarousal in the immediate phase. Often re- Brunet, A., Weiss, D. S., Metzler, T. S., Best, S. R., ferred to as ‘‘psychological first aid,’’ this approach Neylan, T. C., Rogers, C., et al. (2001). The does not presume that trauma survivors have a Peritraumatic Distress Inventory: A proposed mental disorder or in fact that a mental disorder Measure of PTSD Criterion A2. American Journal needs to be prevented; instead, it assumes that the of Psychiatry, 158, 1480–1485. Bryant, R. A. (2003). 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Older Adults and Terrorism Lisa M. Brown Donna Cohen Joy R. Kohlmaier

Within 24 hours following the 9/11 terrorist attacks, animal advocates were on the scene rescuing pets, yet abandoned older and disabled people waited for up to 7 days for an ad hoc medical team to rescue them. Nora O’Brian, Director of Partnerships, International Longevity Center

The importance of preparing our country to scribing psychological reactions to the terrorist counter and respond to terrorism has been para- events of 2001 (Chung, 2004; Strug, Mason, & mount since the 9/11 attack on the World Trade Heller, 2003). Only one study had pre-9/11 mea- Center, the Pentagon, and United Flight 93 in sures of depression to compare with postevent le- Pennsylvania. In contrast to the large body of em- vels in older adults living in Manhattan who were pirical studies describing the emotional and beha- participating in a research project examining the vioral consequences of natural and human-caused relationship between depression and vision loss disasters, the existing literature on the psychologi- (Brennan, Horowitz, & Reinhardt, 2004). cal consequences of terrorism is small. Likewise, Two important reports sponsored by the In- our knowledge about the differential impact of stitute of Medicine (Butler, Panzer, & Goldfrank, specific forms of terrorism (e.g., explosives; che- 2003; Hooke & Rogers, 2005) give scant attention mical, biological, radiological, or nuclear weap- to the special vulnerabilities and needs of older ons), which determine how long the effects of the populations. The 2003 report extensively reviews attack last, the number and distribution of victims, issues related to the prevention and treatment of the types of first responders, quarantine and de- emotional and behavioral consequences in chil- contamination requirements, and clinical inter- dren and adolescents, but it mentions older per- ventions, is almost nonexistent (Stein et al., 2004). sons only three times throughout the volume, ac- Therefore, it is not surprising that studies specific knowledging that they have special needs. The to the effects of terrorist attacks on the psycholo- 2005 report again mentions older adults only four gical health of older adults are even more limited in times, recognizing their vulnerability due to social scope and detail. The methods used include large- isolation and the special requirements for emer- scale epidemiological studies examining age effects gency responses to terrorism. between older and younger adults (Boscarino, The available literature on the aftermath of Adams, & Figley, 2004; Chen, Chung, Chen, Fang, terrorist attacks indicates that the ratio of people & Chen, 2003; Schlenger et al., 2002; Silver, Hol- who develop serious adverse psychological effects man, McIntosh, Poulin, & Gil-Rivas, 2002) and relative to those who sustain illness or physical in- small, exploratory, qualitative investigations de- juries ranges from 4–5:1. Therefore, it is imperative

288 Older Adults and Terrorism 289 that effective mental health interventions be devel- may be injured, ill, or dead. Lives are irrevocably oped that can readily be implemented by health altered. Mass catastrophes shatter core personal care professionals and trained volunteers from relief assumptions of individual control, safety, and the organizations to help restore psychological func- predictability of life (Parkes, 2002). tioning. Mental health intervention may be parti- The immediate deadly consequences of ter- cularly important for vulnerable populations of rorism cause a series of powerful emotional reac- older adults, including, but not limited to, those tions in adults of all ages: feelings of shock, horror, who are more socially isolated, frail, physical dis- and disbelief; concerns that other attacks will oc- abled, and cognitively impaired and have a history cur; intense personal emotions (e.g., anxiety, ap- of exposure to an extreme and prolonged traumatic prehension, fear, anger); and the need to find and stressor. help family, pets, neighbors, and friends. Whereas This chapter reviews empirical research and most healthy older persons will be able to react theoretical perspectives regarding psychological and cope with the immediate emergencies, there consequences of terrorist events on different po- are vulnerable older adult populations who are at pulations of older adults. It also examines the ef- high risk for immediate, short-term, and long-term fects of natural disasters on long-term health care negative consequences. These include but are not systems serving vulnerable older populations. Ad- limited to those who are socially isolated, frail, ditionally, we identify the challenges of responding chronically ill, and cognitively impaired and have a to the needs of older people and their families in history of exposure to an extreme and prolonged the community, describe strategies to assess the traumatic stressor (e.g., refugees from terrorist re- vulnerabilities and mental health risks of various gimes, holocaust survivors). older populations, and provide an overview of in- Although distinctions can be drawn between terventions that can be used at the personal, family, intentional acts of terrorism, human-caused dis- community, and health care system level. asters, and natural disasters, there are some commonalities in psychological consequences, social disruption, and destruction of personal and com- The Effects of Natural and Human- munity property (Fullerton et al., 2003; Butler, Made Disasters on Older Adults et al., 2003). However, ample research indicates that psychological symptom profiles in the popu- Natural and human-made disasters share char- lation following human-made disasters are different acteristics with terrorist attacks. Occurring with from those after natural disasters (Baum, Fleming, unexpected swiftness and overwhelming force, & Singer, 1982; Frederick, 1987; Green, 1990; they adversely affect ordinary people who happen Norris, Byrne, Diaz, & Kaniasty, 2002; Phifer & to be in the wrong place at the wrong time. In Norris, 1989). Norris, Byrne, Dıáz, and Kaniasty contrast to the experience of individual trauma (2001) have reported that the presence of at least (e.g., accidents or criminal acts), which affect one two of the following four conditions increased the person and intimate family members, the occur- negative mental health consequences of an event: rence and aftermath of a terrorist attack adversely the occurrence of a human-made disaster, wide- affect social structures and dynamics, which in turn spread damage to property and community, eco- threaten the existence and functioning of commu- nomic hardship, and high prevalence of threat to nities, cities, and larger geographic areas (Butler, life, injury, and loss of life. In general, disasters et al., 2003; Fullerton, Ursano, Norwood, & Hol- caused by malicious human intent are more dis- loway, 2003). When a large-scale traumatic event turbing than other human-made and natural dis- occurs, every aspect of community life is disrupted, asters (Beaton & Murphy, 2002; North et al., 1999; causing a breach in an individual’s emotional, so- Norris et al., 2001). In these circumstances there cial, physical, and environmental support system. may be a greater need for delivery of mental health Moreover, homes, worksites, health care facilities services to avoid lasting, severe, and pervasive across the continuum of care, schools and other psychological disturbances. Table 20.1 presents the educational institutions, as well as law enforce- similarities and differences among natural and hu- ment, fire fighting, and other emergency operations man-made disasters at each stage (i.e., pre-, during, may have been destroyed. Large numbers of people and postevent) in more detail. Limited—existing treatments may not work asviruses influenza have the ability to change No Some—Ongoing monitoring by public health officials andWorld the Health Organization to detect infection Uncertainty if infected Likely—Ongoing monitoring by public health officials andWorld the Health Organization to detect human infection Yes Yes Pandemic Flu Loss of life andcan psychological be distress reduced with advanced warning resilence/inoculation training fire, mudslides/avalanche No—earthquakes No—tsunami No Sometimes—variable Yes—only in affected area Oftentimes—tornadoes No—earthquakes No—mudslides/avalanche Sometimes—fire Sometimes—tsunami Sometimes; prior exposure to event Seasonal activity: hurricanes, tornadoes, Yes—hurricanes , human-made unintentional, and natural disasters Sometimes No Sometimes—with sufficient monitoring and training No No Rarely Act Human-Made Unintentional Natural Disaster Sometimes—elevated warning No Yes Yes monitoring and intervention No Sometimes—with sufficient No No Differences and similarities between human-made intentional Information stress from media coverage Uncertainty if exposure to toxin occurred High perceived threat toprior life to event Preventability of event Psychological preparedness of population Predictability Table 20.1. Timing and Event Characteristics Human-Made Intentional Pre-Event Advance Warning

290 may not work asviruses inﬂuenza have the ability to change Yes Yes Yes Yes Limited—existing treatments Likely Likely Yes No Yes Yes Yes Yes Yes Yes Yes Yes area area Likely Likely Yes No No Sometimes Sometimes Sometimes Likely Yes Sometimes Yes Sometimes Yes—only in affected area Yes—only in affected area Sometimes Yes—more so in affected area Yes—only in affected area No No Sometimes Yes Yes—more so in affected areaYes—more so in affected Yes—only area in affected area Yes—only in affected Sometimes Sometimes Sometimes Yes—only in affected area Yes—only in affected area area Yes—only in affected area Yes—only in affected area Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Sometimes National Fear Event Local fear Loss of life Information stress from media coverage Controllability Physical injury or harm Disruption of community Yes—more so in affected area Exposure to dead Disruption of social networks Yes—more so in affected Altered sense of safety Post-Event Information stress from media coverage Behavioral disturbance Psychological distress/illness Yes Healthcare systems overwhelmedLoss of Yes—more faith so in in institutions affected Likely National bereavement Loss of property

291 292 Assessment and Treatment

Green (1990) described several factors that only seriously mentally ill people receive treatment mediate negative psychological outcomes of dis- from mental health clinicians, fear that their reac- asters. People who report significantly more con- tion to the event is a sign that they are becoming cerns about being at risk for death or injury and demented, or perceive acceptance of psychological those who have a closer temporal or physical treatment as a sign of personal weakness. Finally, proximity to the event are at higher risk for adverse some may resist asking for help because they suppose psychological functioning. Personal injury and that others have fared far worse than they and physical harm, exposure to dead and mutilated therefore are less willing to actively pursue or accept bodies, and the violent, sudden death of family, available mental health intervention. A step in over- friends, and coworkers are potent mediators of coming a number of these barriers includes educating acute and long-term sequelae of traumatic stress. those at risk for adverse psychological outcomes Norris (2001), in a comprehensive review of the about typical reactions to disaster and providing in- literature, has also found a number of studies that formation about the nature of mental health inter- reported a proximity dose-relationship with men- vention. tal health status. However, two additional studies Along with directing survivors to available that have examined mental health functioning services such as water, food, shelter, and medical following the events of 9/11 and the Florida hur- care, triage for mental health problems should be ricanes found that the nature of the recovery included in the hierarchy of basic disaster re- phase, more so than actual proximity to the event, sponse. Older adults may be more willing to be was associated with adverse mental health con- assessed for potential mental health problems if the sequences (Brown, Schinka, Borenstein, & Morti- screening is conducted with a medial evaluation or mer, 2005; Silver, Poulin, et al., 2004). While the provided with other basic necessities. Early mental type and severity of catastrophic disasters influence health assessments should effectively screen those psychological outcomes, the premorbid existence of at greater risk for developing acute stress disorder, psychiatric symptoms or emotional distress is the PTSD, depression, and complicated bereavement. best overall predictor of long-term maladaptive Depending on timing, situation, and circum- psychological functioning (Kessler et al., 1999; stances, it may be appropriate for some individuals Knight, Gatz, Heller, & Bengston, 2000; Phifer & to receive group treatment. A more comprehensive Norris, 1989). discussion of treatment issues specific to older Although an extensive body of research sug- adults is presented later in this chapter. Never- gests that older adults typically fare better in terms theless, even without the onset of serious psy- of emotional and psychological functioning when chological impairment, many older adults will compared to younger adults, they still experience require assistance in preparing, responding, and decrements in mental health in the aftermath of a recovering from such events. disaster (Bolin & Klenow, 1983). However, for the majority of older adults, most untreated psycho- Theoretical Frameworks: Psychological logical distress that occurs shortly after a disaster Responses to Disasters and Mass will abate in time (Blanchard et al., 1995; Krause, Violence in Older Populations 1987; Raphael, 2003). For those who require more than psychological first aid following a terrorist Early work suggested that disasters would have a event, special efforts may be required to overcome disproportionate effect on older adults, who would personal and system barriers to treatment. For be more vulnerable to psychological distress than example, some older adults in the community younger adults. Friedsam (1960, 1961) concluded may be reluctant to admit they feel overwhelmed, from his review of the disaster literature that older confused, or distressed in the aftermath of a dis- adults were least likely to receive warning about aster because they fear that such an admission may impending disasters, more reluctant to evacuate, lead to loss of freedom or institutionalization in more disturbed by disruption in daily life, and a long-term care facility. Others may refuse to ask more likely to become physical casualties, thus for help because of the stigma associated with experiencing a greater sense of deprivation in re- mental health treatment. Some may believe that sponse to losses. In another review of the litera- Older Adults and Terrorism 293 ture, Kilijanek & Drabek (1979) reported that Dıáz, & Kaniasty, 2002). Resilience is defined as older disaster victims were at greater risk for in- the ability to adapt quickly or recover from illness, curring debt, economic losses, physical injury, and difficult life experiences, misfortune, and traumatic disrupted employment relative to younger adults. events (Rutter, 1987). Older adults have an ex- However, this and a later review of the literature tensive and varied accumulation of life experiences did not find sufficient support for the relative de- that affect short- and long-term vulnerability or privation hypothesis (Fields, 1996; Kilijanek & resilience following exposure to traumas. They Drabek, 1979). Since then, several theories have may adapt to certain life stressors with relative ease attempted to explain the response of older adults yet experience difficulty responding to and re- to traumatic events. We briefly describe a number covering from other types of traumatic events. of theories that have appeared in the literature. Although older adults may endure a more severe Age is one of many predisaster, within-disaster, exposure to disaster, have poorer health, and have and postdisaster risk factors that mediate the se- fewer social and economic resources, they have verity of adverse consequences (Norris et al., 2002). a lifetime of learning how to cope with stressful Analyses of the relationship of age and mass vio- events as well as fewer currently unresolved stressful lence have revealed that school-aged children are experiences, both of which promote adaptation to the most vulnerable to severe mental health pro- disasters (Phifer, 1990). blems throughout the world (Norris et al., 2002). In For older Americans, a lifetime of experience all of the published U.S. studies, middle-aged also provides many opportunities to make com- people (40–60 years) sustained the most adverse parisons between current and previous stressors effects, whereas individuals older than age 60 were and evaluate the effectiveness of different coping more resilient. Cross-cultural research has sug- strategies. Cognitive strategies facilitate the ability to gested that age effects are mediated by socio- maintain a perspective on goals and outcomes and political, economic, historical, and cohort effects manage negative emotions to prevent overreaction (Norris et al., 2002). In the aftermath of the 1995 to stressful situations. Active coping strategies are bombing of the Oklahoma City federal building, frequently used to avoid negative situations and posttraumatic stress disorder increased with age in maladaptive interactions under times of extreme Asian and Middle Eastern immigrants (Trautman stress (Folkman, Lazarus, Dunkel-Schetter, De- et al., 2002). At least one study of Bosnian refugees Longis, & Gruen, 1986; Janoff-Bulman, 1992). has shown that increased mortality rates in older Problem-focused coping focuses on altering the persons were associated with mass violence (Mol- person-environment transaction or managing the lica et al., 1990). source of stress, in contrast to emotion-focused Many theoretical frameworks, presented as coping centering on the regulation of emotional theories, models, or hypotheses, are useful in or- responses elicited by the situation (Folkman & ganizing the results of empirical studies that in- Lazarus, 1980). vestigate the relationship of advanced age to In a study of the frequency and impact of po- adaptive versus maladaptive emotional and beha- tentially traumatic events, Norris (1992) reported vioral outcomes: resilience and coping theories, not only that older adults were more resilient but inoculation theory, burden theory, the matura- also that younger adults had the highest rates of tional hypothesis, residual stress vulnerability, con- PTSD in response to 9 of 10 potentially traumatic servation of resources, and social deterioration events. Many older adults have learned that they can models. overcome difficult or challenging life events, adapt to adversity, and return to prior levels of psycholo- Resilience and Coping gical functioning. In describing the resilience of the old-old (i.e., those who are 75–84), Phifer (1990) A significant body of research indicates that age is noted several factors that could account for this age a protective factor and that older adults tend to be group’s ability to overcome adversity in the after- more resilient than younger adults in responding math of a natural disaster. The nature and severity to stressful events, including disasters and mass of the traumatic event, personal history and ex- violence (Huerta & Horton, 1978; Norris, Byrne, periences, and psychological characteristics affect 294 Assessment and Treatment individuals’ psychological outcomes (King, King, Although the inoculation hypothesis has re- Fairbank, Keane, & Adams, 1998). ceived substantial support, Thompson, Norris, and Hanacek (1993) noted that it failed to explain dif- Maturation Hypothesis ferences between middle-aged and older adults. The authors proposed that disaster impact and age were The maturation hypothesis is based on the premise not characterized by an inverse linear relationship that psychological maturation is protective (i.e., (that is, young adults are affected the most, and older more mature coping styles associated with advan- adults the least). Instead, a curvilinear relationship cing age protect older adults against the harmful applies, with middle-aged adults being affected the effects of stressors). Older adults are thought to be most by disasters, due to their responsibilities to less emotionally reactive to stressful events than children, parents, and employers. younger adults, and the maturation hypothesis helps to explain the lower levels of depressed mood in Burden Theory older adults following a traumatic event. The maturation theory was not supported by a study that The Burden theory posits that middle-aged adults examined the presence of depressed mood in adults have multiple roles and responsibilities as parents, before and after the 1994 Northridge earthquake caregivers, and employees and therefore feel more (Knight et al., 2000). Although Knight and collea- burden relative to younger and older persons with gues found support for the inoculation theory, age fewer responsibilities. The results of several studies did not moderate the relationship between rumi- have found that middle-aged adults showed more nation and damage exposure. distress in response to disasters than younger or older adults (Phifer, 1990; Verger et al., 2004). Inoculation Theory Verger and associates (2004) have reported that the risk of PTSD following the 1995–1996 bomb- The main premise of the inoculation hypothesis is ings in France was significantly higher among that prior experience with stressful circumstances, people aged 35–54 compared to younger and older including disasters, inoculates people against in- adults. Phifer (1990) reported that, following the tense emotional reactions to future disaster-related 1984 Kentucky flood, those aged 55–64 were at stressors. Therefore, the greater the exposure to di- greatest risk of experiencing psychological symp- sasters, the higher the level of protection to future toms compared to those age 65–74 and 75 years disasters (Knight et al., 2000). Since older persons and older. have had a lifetime of opportunities for stressful experiences, coping capacities should increase with Residual Stress Vulnerability advancing age. Support for the age relationship to an in- Although older adults tend to be resilient in the oculation effect is mixed. Knight et al. (2000) face of life challenges, including disasters, some found partial support for this hypothesis when older adults may be particularly vulnerable (e.g., they reported that prior earthquake experience Holocaust survivors, prisoners of war, persons was associated with lower levels of postearthquake exposed to interpersonal violence, persons abused depression in both young and old adults. Although as a child or adult) (Bremner et al., 1992; Breslau the results of a study of older adults following the et al., 1998; Eaton, Sigal, & Weinfeld, 1982; Green 1997 Red River flood showed no changes in psy- et al., 2000; Nishith, Mechanic, & Resnick, 2000; chological functioning (Ferraro, 2003), the authors Yehuda et al., 1995). Exposure to extreme, pro- interpreted the findings to reflect the constant longed stress may result in permanent develop- exposure of residents to many earlier floods in that mental effects that increase vulnerability to future location. Phifer and Norris (1989) reported that traumatic events throughout the lifespan. Dougall older adults’ reactions to the 1984 Kentucky flood and colleagues (2000) hypothesized that trauma were influenced by previous experience with a history sensitizes people to new stressors, thus flood in 1981 and that those with past exposure potentiating its effect. showed better psychological adaptation than their Several studies of survivors of the Nazi Holo- inexperienced counterparts. caust have helped elucidate the vulnerabilities of Older Adults and Terrorism 295 older persons. Yehuda and colleagues (1995) re- because older adults are in need of continued ported that the presence and severity of PTSD support from family, personal social networks, and symptoms were related to many factors, including the community at large after a cataclysmic event the immediate trauma, as well as current and life- and because interruption and breakdown in these time stressors. In a similar study, Holocaust survi- systems create distress. In particular, the percep- vors were more likely to have mild psychiatric tion of support from nonrelatives was found to symptoms than controls, and the levels of psychia- mediate the impact of disaster stress on depres- tric symptoms were greatly amplified in those sur- sion. For older adults, deeper and broader social vivors who had recently perceived an increase in support networks play a significant role in ameli- anti-Semitism in the community (Eaton, Sigal & orating the negative impact of traumatic life events Weinfeld, 1982). Port, Engdahl, Frazier, and Eberly (Tyler & Hoyt, 2000; Watanabe, Okumura, Chiu, (2002) have reported an increase in PTSD symptoms & Wakai, 2004). among older men who had been prisoners of war. These authors emphasized the importance of assessing for additional late-life stressors, including de- The Role of Social Support Networks creased social support, negative health changes, and lower death acceptance, which may impact trauma- Most social networks are composed of family, close related symptomatology. friends, neighbors, and community associates (Cantor, 1979). As it is not uncommon for families Conservation of Resources to provide 70%–80% of in-home care for older adults with chronic health conditions, informal According to the conservation of resources (COR) caregivers, such as family, neighbors, and friends, theory, psychological stress results when there is a are often first on the scene following a disaster and threat to or an actual loss of existing resources can be instrumental in securing shelter, medical (Hobfoll, 1989; Hobfoll, Dunahoo, & Monnier, care, food, and water and providing support. For 1995). Resources include physical possessions, older adults, these social connections typically play social roles, personal resources, and financial re- a role in buffering or mitigating the negative effects sources. The attendant losses from disasters tend of normal life stressors. During times of crisis, so- to be most closely related to survival, and they are cial support systems are critical to the psychological usually profound and numerous. This theory well-being of older adults. Several studies have suggests that the use of psychological interven- found that anticipated or perceived support, the tions immediately after a traumatic event is not belief that significant others care and will provide especially helpful. The focus should be on more assistance, if required, is predictive of better psy- pressing needs, such as the rapid replacement chological outcomes following a disaster than the of necessary resources (e.g., food, water, shelter) receipt of actual assistance (Cook & Bickman, (Hobfoll et al., 1995). When basic needs are met, 1990; Krause, 2001). Additionally, the degree of older adult disaster survivors have the potential for social embeddedness, that is the size, closeness, developing a new sense of self-efficacy and mastery and activeness of the older adult’s social network, is or learning new coping skills as they recover from also directly related to mental health functioning. a disaster. These socially protective resources are particularly vulnerable to disruption and decline following Social Deterioration Model a disaster. Significant deterioration of the social support system is likely to result in adverse short- Acts of terrorism and disasters result in social de- and long-term psychological consequences (Ka- terioration and pose a threat to the existing social niasty & Norris, 1993). order. Following a disaster, personal loss may re- To offset potential mental health problems, sult in an intense but short-term effect on older provisions for preparing for, responding to, and adults’ depressive symptomatology, but destruc- recovering from a disaster need to be adequate. tion of communities and loss of social support Social support can come from various sources, but networks produces long-term psychological dis- not every type of support may be available or ap- tress (Kaniasty & Norris, 1993). This is most likely propriate (Watanabe et al., 2004). It is not unusual 296 Assessment and Treatment for dysfunctional family interactions to worsen (Boscarino, 1995). Setting realistic expectations during stressful circumstances. Although family about the quantity or quality of family support members are more likely than friends to provide provided in the aftermath of a disaster may decrease instrumental support to older adults, in some in- the potential for interpersonal conflict and mini- stances family relational behaviors may have a mize negative interactions. To the extent possible, negative impact on perceived social support (Wright resuming normal daily activities and maintaining and Query, 2004). Sometimes members of an social connectedness help preserve social em- older adult’s family may feel obliged to assume a beddedness and foster recovery. supportive role because of relational ties as opposed to a true desire to provide care. Friendships, The Impact of Disasters and Terrorism because they tend to be formed voluntarily, are not on Older Adults as affected by a sense of familial obligation (Wright and Query, 2004). Friends and close neighbors are In the late summer and early fall of 2004, four often a source of assistance to older adults who major hurricanes devastated Florida in a period of need help in accomplishing disaster-related tasks 44 days, resulting in the deaths of 117 people and (Crohan & Antonucci, 1989). more than $60 billion in damages. Florida experi- Although social support is often mobilized enced more adverse effects from this series of when an older person’s life or health is threatened hurricanes than any other state had sustained from after a natural disaster, assistance is less available natural disasters in the same period of time. The when property is damaged or destroyed, electricity consequences of the hurricanes exceeded the state’s or phone communication is lost, or daily routines capabilities and resources because of insufficient are disrupted (Kaniasty and Norris, 1993). It is time for recovery between storms and because all probable that many members of an older adult’s 67 counties were severely impacted. Many areas social support network will also be victims of the faced extensive and continued loss of electrical same disaster. Social network members may be power, lack of food, and potable water. Homes, dead, have relocated, or be unable to assist because hospitals, nursing homes, hotels, businesses, and their immediate needs exceed their current re- airports were severely damaged from wind, flood- sources. Compounding the situation, disruption ing, and heavy rains. Indeed, entire communities and destruction of community services diminishes throughout the state were devastated. Voluntary the availability of other formal resources that pro- and mandatory evacuation forced thousands of vide social support, such as senior center activities people to evacuate several times, leaving their and Meals on Wheels. As a result, the need for homes and communities for extended periods to support and services for all of the disaster survivors live with family and friends and in hotels. may surpass the availability of existing resources, Systems that provide care and services to older leaving traditional networks unable to provide adults were significantly strained during this 6- much-needed support to older adults. week period. Among the many challenges were Even though social networks may be depleted, difficulties in securing transportation to evacuate crisis intervention workers can provide temporary older adults from areas that lay in the path of the support and assistance in rebuilding these systems. hurricanes and learning that buildings designated Steps to reestablish and strengthen the support to serve as shelters were severely damaged and networks include educating family members about unusable. The residents of many nursing homes the range of normal psychological reactions to dis- and assisted-living residents had to be evacuated aster, such as irritability, stress, and fatigue. Because many times during the 6 weeks, and patients in survivors accurately recognize the grave danger damaged hospitals had to be triaged and relocated they were exposed to during the disaster, mild to to other counties. Locating and assisting older re- moderate stress reactions during the postevent sidents who were living at home (many in trailer phase are not uncommon. If appropriate, family parks) was complicated. In the immediate after- members should be encouraged to talk about their math, these services included finding people, feelings and experiences. Contact with others locating sufficient temporary housing for them, who have undergone the same trauma can buffer recovering pets, identifying and treating medical the negative psychological effects of disaster problems, getting medications, providing food and Older Adults and Terrorism 297 water, protecting against the natural elements (e.g., emergency management services, inadequate city- heat, high humidity, and hornets that were re- wide coordinated community services, the absence leased from overturned trees), and assisting people of a system to identify and locate older adults, and with cleaning up and getting insurance payments, the lack of mechanisms to convey pertinent in- aid from the Federal Emergency Management formation before and after emergencies. Emergency Agency (FEMA), and other assistance. organizations such as FEMA and the American Red In the months to come, it became apparent Cross were not prepared to assist older and dis- that recovery from these four hurricanes was to be abled people living near Ground Zero. For 7 days measured in months and years, not days and or more after the attacks, older and disabled weeks. It also became painfully clear that state people were still unidentified and neglected in as well as city and county disaster assistance plans the surrounding residential buildings (O’Brien, were not adequately developed to deal with the 2003, p. 2). multiple direct hits throughout Florida or to deal In contrast to younger adults, older adults are with the special needs of vulnerable older popu- less likely to complain, ask for support, and relations. Numerous meetings and conferences were ceive services or resources following a disaster held by state authorities, local government and (Fields, 1996). Not surprisingly, after the events of nonprofit agencies, and long-term care providers 9/11 and the hurricanes, older adults who were to attempt to handle this challenge. Existing dis- not affiliated with a community service agency or aster preparation guidelines were reviewed, and registered with the county for special needs shel- the preparation and response capabilities of older ters were at risk for not receiving services from adults and care providers to deal with prolonged emergency providers. Many resisted preenrolling disruption were evaluated. in programs designed to identify vulnerable adults, Similar meetings were also held by various fearing they might be forced to move from their agencies in New York City shortly after the events of home to a long-term care facility. However, with 9/11, resulting in a report that described short- each passing hurricane, more people signed re- comings in the existing emergency response system gistries identifying themselves as requiring the and presented a disaster response plan to meet the services of a special needs shelter because they needs of older New York City residents more ef- increasingly recognized the benefit (Ott, 2005). fectively (O’Brien, 2003). Reviews of the proceed- Ideally, older adults in the community should ings from the meetings held in Florida and New have at least one person in their social support York reveal two conclusions: (1) Older adults in the network who will be willing and able to assist community, frail and homebound persons, and them during or after a terrorist event. For pre- older adults living in long-term care facilities often dictable events such as hurricane or tornado sea- had distinctively different needs, and (2) current son, many older adults will appreciate assistance emergency response plans did not adequately ad- with purchasing emergency supplies (food, water, dress those differences. The special disaster con- medication), preparing their home for the event siderations identified in long-term care or home (tarps, window protection, weather radio), re- health environments included but were not limited gistering with the county for housing at a special to the level of care and assistance needed by patients needs shelter, identifying evacuation routes and or residents, the resources and equipment required securing transportation, if needed, and cleaning to provide care, and the ability of patients and up, if the event occurs. The list of recommended residents to assist themselves or others during a items for an adequately stocked disaster supply kit disaster. Because these environments provide spe- is extensive. (Items recommended for a standard cialized care, they, in turn, require unique emer- emergency supply kit can be found at http:// gency preparedness plans. www.ready.gov/america/get_a_kit.html.) To facilitate contact with members of the social Older Adults in the Community support network and to secure medical treatment if needed, older adults should develop a list that Problems encountered in providing emergency provides contact and background information be- assistance to older New York City residents sub- fore a disaster occurs. At a minimum this list should sequent to 9/11 included a lack of appropriate include personal contacts (relatives, friends, and 298 Assessment and Treatment neighbors), health care providers (physician, phar- (approximately 11 million) are hard of hearing or macist, and mental health clinician), medical deaf (Holt & Hotto, 1994). Backup communica- conditions, disabilities, medications, treatments tion systems need to be developed to disseminate (e.g., dialysis, oxygen), allergies, and insurance in- emergency information to the entire population formation (health, home, car). Depending on the following a disaster. Communication systems were situation, duplicate copies of this list might be kept severely impacted by the destruction of the World by trusted family members or friends. A free form to Trade Towers. Cell phones, telephones, email, tele- create emergency reference cards is available at vision, and radio service was disrupted throughout http://www.ready.gov. Some individuals with cog- the city (O’Brien, 2003). Similarly, cell phone and nitive impairment, such as Alzheimer’s disease, may telephone service was interrupted in many com- have registered with the Safe Return program, wear munities that were hit by the hurricanes. an identification bracelet (similar to a medic alert Before a disaster occurs, emergency contact bracelet), or carry an identification card that notes numbers such as 911, the police department, fire their memory loss. In times of disaster, detailed station, hospital, as well as family and close friends, contact and medical information should be at- should be programmed into all phones. A com- tached to those who may not be able to commu- munications plan that utilizes family and friends nicate because of memory impairment or other should be in place so that contact can be made with condition, such as speech or hearing loss. a person outside the area, as well as with local fa- Many older adults, especially those age 85 and mily, friends, and neighbors. Following a disaster, a older, have chronic physical illnesses and dis- caller is more likely to connect with a long-distance abilities that affect their ability to prepare for a number outside the affected area than with a local disaster (Davis, 2004; Gignac, Cott, & Badley, phone number. Additionally, older adults should 2003). Approximately one-fifth of the U.S. popu- learn how to forward their home number to their lation has one or more disability (Davis, 2004). cell phone in the event of an evacuation. Chronically ill or disabled people of all ages may In the aftermath of a human-made or natural require help with emergency preparedness and disaster, survivors may experience a sense of un- assistance during and after a disaster (Orr & Pit- reality and dissociation, although the event is over man, 1999). Davis (2004) has reported that 61% and the area is calm. However, older adults are not of those with disabilities did not have a plan to in a position to benefit from psychological inter- evacuate from their home quickly and safely, and ventions in the period immediately succeeding a 58% admitted they did not know who to contact in disaster since most will have legitimate worries an emergency. People with service dogs may find about meeting basic needs. The ability of older that their animal is hurt or too frightened to work adults to adjust and cope after a disaster is miti- immediately following a disaster. Furthermore, it gated by their capacity to access tangible support. may be difficult to reach a veterinarian or purchase Obtaining water, food, and a safe place to stay are pet food. A disaster-planning kit for service ani- the initial concerns following a traumatic event: mals should be prepared and include collar, har- ‘‘Physical care is psychological care, and this is the ness, identification tags, vaccination records, prime and essential function of relief organiza- medications, and animal food. tions’’ (Kinston & Rosser, 1974, p. 450). Older adults who require assistance may be However, some older adults may be reluctant confused about whom to call for aid and unsure to accept assistance from government agencies, or about which organizations are available to provide they may find the task of completing the necessary help. Material providing information and tele- paperwork daunting. Some may be more willing phone numbers, describing how to prepare for a to receive assistance from the Salvation Army, Red disaster, and detailing steps to take in the event of Cross, or church groups than from government a disaster should be developed and widely dis- agencies. Penner (2003) has recommended that seminated by government and nonprofit agencies, mental health crisis workers be knowledgeable the media, and other community-based organiza- about existing service providers and provide older tions such as churches and synagogues. Emergency adults with assistance in identifying organizations directives should be available as print material that can help with disaster response and recovery. A since more than 29% of the older population useful reference for mental health providers is a Older Adults and Terrorism 299 comprehensive list of websites that provide in- responsibilities. Emergency workers believed formation and resources for older adults who have the buildings had all been evacuated, but dis- been exposed to terrorism (Cohen & Brown, 2004). abled people who were unable to leave their After the Florida hurricanes, stores that sup- apartments were left behind with no electricity plied medication, disposables to manage diabetes, (and therefore no television, radio, lights, ele- and incontinence supplies were damaged or de- vators, refrigerators, etc.), no running water, and stroyed. The results of a study conducted shortly no information about what was happening and after the first of the four destructive hurricanes, what they should do. Home health aides were Hurricane Charley, indicated that medical care unable to check on whether or not their patients was disrupted because of damaged or destroyed had been rescued. (O’Brien, 2003, p. 2) medical facilities, which resulted in the worsening In reviewing the events that followed the 2004 of medical conditions in about one-third of the hurricanes, people raised concerns about how some survey respondents (Little et al., 2004). Since communities had triaged frail, older persons and older adults may be forced to seek medical treat- moved them from shelter to shelter, creating re- ment, supplies, and medication outside the com- location anxiety in those who were already highly munity, programs need to be in place to coordinate stressed from the disaster (Ott, 2005). The literature services among agencies that provide care, identify on the relocation of older adults includes a number community residents who might be in need of of reports that describe the negative effects on such services, and assist with transportation needs. mental and physical health and social networks (Raid & Norris, 1996; Sanders, Bowie, & Bowie, Homebound Older Adults 2003). Relocated people were found to be more distressed than other survivors of the disaster (Bland In an ideal world, home health aides would con- et al., 1997; Gleser, Green, & Winget, 1981). For tinue to provide daily care during disaster evacua- vulnerable older adults who were sheltered without tions and accompany frail older adults to temporary home health aids, lack of physical mobility, con- or long-term shelters. However, the probability of finement to a wheelchair, and vision impairment service interruptions to the homebound is high, and further compounded disaster-related stresses. during the 2004 Florida hurricane season, there Other problems may arise during the recovery was a gap between what should have happened and phase of a disaster or terrorist event. Without as- what actually took place. A total of 29 home health sistance, vulnerable homebound adults may not agencies were damaged or destroyed during the have the ability to access public or private trans- hurricanes (Gregory, 2004), and many homebound portation. Lack of transportation and physical im- older adults found themselves alone at special pairments that restrict mobility may limit their needs shelters because their home health aide was opportunities to seek help from disaster assistance dealing with personal or family needs (Ott, 2005). centers and replenish food and water. Furthermore, A survey of New York City public health nurses people who are poorly educated, have limited fi- who were attending an emergency preparedness nancial resources, and have weak social networks program revealed that 90% of the attendees re- are unlikely to use community services (Rosenzweig, ported at least one barrier (e.g., family responsi- 1975). Outreach programs will need to locate older bilities, transportation problems, personal health adults who may not have the knowledge needed to issues) to their ability to report to duty in the event access services or the physical ability to leave their of an emergency (Qureshi, Merrill, Gershon, & homes and stand in line for assistance. Calero-Breckheimer, 2002). Other obstacles in providing continued care to this population were evident after 9/11: Institutionalized Older Adults

Service personnel lacked access to older and frail The ability of Florida’s long-term care providers to residents living in the ‘‘frozen areas.’’ Essential prepare for, respond to, and recover from disasters services, such as meals for the homebound and or acts of terrorism is critical since 18% of the home health care, were not delivered because population is 65 years of age and older and nur- staff had no ofﬁcial authorization to carry out sing homes and assisted-living facilities care for 300 Assessment and Treatment

70,000–77,000 residents, respectively. Facilities needs, staff shortages and extended work hours that were damaged or destroyed during the 2004 further strained the system. Cross-training the staff hurricanes included 114 of the 276 hospitals, 60 to provide services outside their daily routines of the 699 nursing homes, and 85 of the 2,287 before the hurricanes was helpful. For example, assisted-living facilities (Gregory, 2004). Many of nurses and physical therapists who had obtained these institutions were closed for an extended a license to drive buses were able to transport period of time, forcing residents to receive shelter residents and staff from the facility to the shelter. outside their community. Several facilities that were forced to evacuate at During the hurricanes, the difference in the night because of heat, heavy traffic, and changing level of assistance provided to those in nursing weather conditions required more time to move homes compared to those in assisted-living facil- their residents. One long-term care facility reported ities was pronounced. State regulations for nursing that rousing sleeping residents, who had taken homes specify staff duties and responsibilities, hypnotics or psychotropic medications with seda- evacuation procedures, and required resource re- tive effects, greatly slowed their evacuation during serves, whereas assisted-living facilities are not the first hurricane. However, staff were better pre- under the same obligation to assist residents with pared during the second hurricane strike and evacuation and care during the storms. Several moved residents who received sleep medication to special needs shelters were overwhelmed when locations that were close to emergency exits. assisted-living facilities dropped off residents with Not all counties were equally prepared to re- dementia or communication impairments, without spond to the hurricane. A survey of 670 nurs- accompanying staff to provide care or identifica- ing homes and 500 assisted-living providers was tion to relocate residents after the storms (Ott, conducted shortly after the 2004 Florida hurricane 2005). A number of older adults with cognitive season to understand their experiences in prepar- impairment were briefly lost in the system because ing for, responding to, and recovering from this they were unable to describe where they had been series of disasters (Hyer, Brown, Polivka-West, & living before they arrived at the shelter. Bond, 2005). Difficulties with evacuation and Emergency relocation of people with signifi- transportation, as well as extended power loss, were cant cognitive impairment presents a unique set of among the major problems the long-term care fa- challenges. Older adults with cognitive impairment cilities encountered. The buildings that housed the are more likely to require institutional care and emergency operating centers in Charlotte and Polk are especially vulnerable in disaster situations. Ap- counties were badly damaged, and this greatly im- proximately 4 million Americans are afflicted with peded their ability to assist in coordinating services. Alzheimer’s disease, and this number is expected to Moreover, emergency transport companies were exceed 16 million by the year 2050. Most people overwhelmed and unable to meet their agreements survive an average of 8–10 years after being diag- with nursing homes as hospitals had top priority for nosed with Alzheimer’s disease, and many will services. spend 5 of those years living in a skilled nursing The loss of electrical power was also a sig- facility (Hendrie, 1998). After the 2004 hurricanes, nificant problem for many long-term facilities that it was suggested that shelters be designated to pro- remained in operation. Not all of the facilities had vide the level of care required for this at-risk po- working generators, sufficient fuel to operate them pulation. Although nursing homes with transfer for extended periods of time, or adequate power agreements were able to move patients with Alz- to operate multiple areas within the facility. Those heimer’s disease to other facilities, the wander guard that lost electrical power were entitled to receive system used by the home facility was not always priority restoration of services, but not all parts compatible with the system used by the host facility. of the state recognized priority reconnection for This presented a problem for staff, already short in nursing homes, and a handful of facilities that were numbers, who had to monitor residents closely to providing skilled care to frail, vulnerable persons prevent elopement during and after the storm. went days without power. Since many long-term care staff were unable Despite many difficulties with the disaster re- to report to work because of family or personal sponse system, many dedicated people worked Older Adults and Terrorism 301 diligently with a number of agencies to provide population age 65 and older have absorbed the continued care to this vulnerable population. It is impact of the terrorist attacks with a perspective to their credit that, despite the severity of these that comes only from surviving a lifetime of ex- storms, there was no immediate loss of resident or periences, including living though World War II staff life directly related to the hurricanes. Before and the Korean War. Many displayed resilience as the 2004 hurricane strike, the Florida Health Care well as a historical and personal perspective on good Association had established a disaster preparedness and evil, love and hate, living and dying, and war committee and had widely disseminated published and peace. guidelines delineating steps to be taken in response Although older people as a population adapt to a variety of natural and human-made disasters. better than younger adults, there are certain vul- During the hurricanes, this organization sent out nerable subgroups, including but not limited to daily email alerts that contained information about the following: those who are very old and frail; past and pending storms, queried facilities about those who have multiple, disabling health pro- their needs for supplies and assistance, located blems; those who have grown old with develop- needed resources, and coordinated relief efforts. mental disabilities and mental retardation; those The experience of dealing with several hurri- with Alzheimer’s disease and related dementias; canes proved emotionally and physically stressful those who already have psychiatric problems; and for residents and staff alike, and the disruptions those who have endured a serious traumatic cir- contributed to the need for disaster mental health cumstance (e.g., Holocaust survivors). services. Long-term care facilities varied in their A sudden, threatening, traumatic event induces ability to provide mental health services to re- fear, helplessness, and a vulnerability in everyone sidents. Some had a social worker on staff, whereas affected, but when an older person already feels others had to refer residents elsewhere for mental increasingly susceptible because of impaired health, health services. Immediately after a serious disaster mobility, and declining sensory and cognitive or terrorist event, a multidisciplinary team that abilities, the feelings of powerlessness and help- includes psychologists, physicians, social workers, lessness may be overwhelming (Young, Ford, Ru- nurses, and other mental health paraprofessionals zek, Friedman, & Gusman, 1998). Unexpected is an ideal way to quickly identify high-risk groups evacuations from nursing homes, assisted-living to promote recovery from acute stress and decrease facilities, retirement communities, senior apart- the likelihood of long-term adverse effects. Mental ments, or trailer parks, as well as moves from one health clinicians that arrive from outside the fa- facility to another, can be frightening experiences cility benefit from working collaboratively with that cause disorientation, confusion, and anxiety. staff who can provide information about residents’ Cognitive and sensory impairments usually make it premorbid functioning and assist in screening. harder for older people to understand evacuation Those who provide relief and mental health ser- instructions or emergency assistance information, vices should possess basic knowledge about how cope with a chaotic environment, and respond to mental health problems manifest in older adults emergency workers and friends who want to assist (O’Brien, 2003). them (Massey, 1997). The untimely deaths of children or grand- Priority Issues in the Assessment children are among the most difficult situations for of Older Persons older persons, not only because of the unexpected, violent death of a loved one but also because of As noted earlier, the experiences that accumulate a sense of broken continuity within the family, over a lifetime provide most older people with the including its traditions, ceremonials, and legacies. knowledge and skills they need to cope with and Family support and contact for older relatives may adapt to the many changes, losses, and painful decrease in the immediate aftermath of a tragedy emotions associated with mass violence and dis- while everyone in the family and community is asters. Different cohorts of older persons have var- consumed with the struggle of dealing with im- ious characteristics and life experiences that shape mediate losses, injuries, and deaths. When family their vulnerability and resilience in the future. The support is less available, it is common for older 302 Assessment and Treatment people, especially those with health problems, partial or subthreshold PTSD). The existing litera- to fear being moved into an institution, which ture suggests that a small group of older people will prompts them to withhold their personal con- develop full-blown PTSD, but the prevalence of cerns, difficulties, and emotional reactions. subsyndromal PTSD could be a serious conse- Grandparents may find themselves taking on quence of mass disasters. parenting roles and responsibilities for their grand- The few studies that have examined the pre- children when adult children have been killed. valence of PTSD in older adults suggest that it either This increases emotional stress not only as older is often not identified or is incorrectly diagnosed adults grieve for an adult child and help grand- (Davidson, 2001; Port, Engdahl, & Frazier, 2001). children cope with the loss of a parent but also as Some researchers have hypothesized that older they significantly alter their lifestyles and routines adults go undiagnosed because they do not as- to integrate the needs of young grandchildren. sociate their posttrauma difficulties (e.g., sleep dis- Frailty, chronic illness, housing, and financial turbance, intrusive thoughts) as abnormal (e.g., insecurity are other factors that affect the ability friends and family are experiencing the same thing). of grandparents to deal with the aftermath of a Furthermore, because PTSD is often comorbid and disaster. a variety of mental illnesses can and do occur with Mass violence and terrorism in their many forms PTSD, it may also be that healthcare clinicians at- have profound effects on the immediate victims and tribute the symptoms that older adults experience communities, as well as on others removed from the and report as related solely to alcoholism, depres- event. There are many common emotional, cogni- sion, or anxiety disorders (Goenjian et al., 1994). tive, behavioral, and physical reactions following Within the spectrum of criteria defined in DSM-IV mass disaster and violence. Table 20.2 provides an there are a number of posttraumatic responses that overview of symptoms that may be expressed in fall short of meeting full PTSD diagnostic criteria. each of these domains. Even though a full PTSD syndrome may not be These are normal reactions in the face of present, older adults can and do experience sig- sudden mass violence caused by explosives and nificant functional impairment following traumatic chemical, biological, radiological, or nuclear wea- exposure (Bramsen & van der Ploeg, 1999; Spiro pons. Individuals may experience all or only a few et al., 1994). of these responses, but as time passes, these symptoms and difficulties should diminish as the nor- Assessment of Risk mal routines of daily life are restored. Because there are significant differences in people’s histories and Everyone should be screened for risk factors for in the way they express grief, fear, and anger, the developing PTSD. Certain factors (e.g., history of recovery time will vary across the population. significant traumatic stressors, psychiatric history, However, some vulnerable persons are at a greater and gender) place a person at greater risk for PTSD risk for manifesting symptoms of PTSD, other an- but are not mutable, whereas other factors (e.g., loss xiety disorders, depressive disorders, and substance of resources and social support) can be modified by abuse disorders. intervention. Knowledge of these modifiable factors The psychological effects of severe violence can be useful when developing future interven- and mass trauma have not been well studied in the tions. Given the high prevalence of psychiatric older population (Cook, Arean, Schnurr, & Sheikh, comorbidity, assessment for depression is also war- 2001). Older people who are geographically distant ranted. It is the responsibility of the mental health from the attack appear to recover faster than clinician to differentiate between normal and ab- younger adults, but the recovery rate for those in normal reactions to terrorism. Interviewing older affected areas will vary depending on the many persons to assess this complex set of issues requires circumstances discussed in the previous section. a careful process of therapeutic enjoining to develop Although older persons may not meet all of the the trust and rapport necessary to accurately assess diagnostic criteria for PTSD or other anxiety dis- mental health needs. Table 20.3 summarizes the orders, they may manifest clinical symptoms that information that should be included in a screen- interfere with biopsychosocial functioning (e.g., ing assessment. Table 20.2. Normal emotional, cognitive, behavioral, physiological, and interpersonal reactions to stress

Emotional Physiological

Anger Aches, pains, muscle soreness Anxiety Choking, smothering sensation, ‘‘lump’’ in throat Apathy Cold or hot spells/chills or sweating Blame Dizziness Denial or constriction of feelings Fatigue and weakness Depression Fine motor tremors Dissociation GI upset Fear about present and future Headaches Feeling overwhelmed Heart palpitations and chest pain Guilt Hyperventilation Helplessness and powerlessness Lightheadedness Irritability Nausea Rage Paresthesias (numbness, tingling sensation) Sadness or grief Reduced immune response/vulnerable to illness Shock and disbelief Tachycardia Terror Tics Cognitive Behavioral Calculation difficulties Crying easily or for no apparent reason Confusion Decreased libido Concentration problems Excessive alcohol or drug use Decision-making difficulties/slowness of thought Hyperactivity Difficulty with verbal expression Hyperarousal Disbelief Hypervigilance Disorientation Inappropriate humor Emotional numbing Inertia Intrusive thoughts/memories Insomnia Loss of pleasure Over- or undereating Memory problems/forgetfulness Nightmares Perseveration Pacing Reduced attention span Ritualistic behavior Self-blame Startle response Worry Interpersonal Alienation Distrust Externalization of blame Externalization of vulnerability Family problems Feelings of being abandoned Increased relational conflict /reduced intimacy Overprotectedness Social withdrawal

303 304 Assessment and Treatment

Table 20.3. Issues to Consider During the Screening complaints after disasters (Green, Epstein, Kru- Assessment pick, & Rowland, 1997).

Connection with individual Medical needs/health status /exposure to toxic Interventions After Terrorism contamination or Mass Violence Signs of traumatic stress/individual responsiveness Current or previous psychiatric illness Crisis intervention services are now widely re- Weather exposure/extreme fatigue cognized as an effective treatment modality for Frailty/disability/cognitive impairment emergency mental health care to individuals and Mobility groups. Guidelines published by the Centers for Cultural background/demographics Disease Control (CDC, n.d.) recommend that, fol- Living situation lowing a traumatic event, clinicians allow people to Proximity of family members talk when they are ready, validate their emotional Availability of other social supports reactions, avoid diagnostic and pathological lan- Determination of appropriate level of care guage, and communicate person to person rather Injury or death of family members as victims than expert to victim. The American Psychological Assessment of danger/safety of self and others Association (APA) has suggested several levels of Previous exposure to serious trauma intervention for older people after a terrorist attack. Availability of transportation and communication These include building resilience with psychosocial Extent of terrorism or disaster preparedness and behavioral support, performing therapeutic (e.g., food, water, medications) interventions for persons with psychopathology, Normalization of responses/psychoeducation and also using older people as community re- Perception of trauma sources to cope with community needs and restore Coping methods normalcy (APA, n.d.). The timely delivery of ap- Religious beliefs propriate treatment is imperative following the Drug/alcohol use acute crisis phase to mitigate the potential for psy- Suicide/homicide risk chopathology (e.g., acute stress disorder, PTSD, and other forms of anxiety and depression). Al- Note: Issues are not ranked in order of importance. though older people are at low risk for mental health problems, those who do develop serious Older adults may refuse mental health psychiatric distress may go unrecognized or un- screening and rarely make use of mental health treated or be inadequately treated following a ter- services following a disaster (Lindy, Grace, & rorist attack. Green, 1981). After 9/11, there was a surge in Several practical strategies and tactics that visits among patients who were in therapy before older persons can use to build their resilience in- the terrorist attacks, but there was no signiﬁcant clude the following: educating themselves about increase in mental health service use by younger normal reactions to terrorism; maintaining rou- and older adults who were not previously receiv- tines as much as possible; maximizing self-care ing mental health care, despite the availability of (e.g., sleeping, eating appropriately, exercising, fol- free services (Boscarino, Adams, & Figley, 2004). lowing good hygiene practices, engaging in plea- Older adults may turn to religious leaders, family surable activities, staying connected to family and members, informal social networks, or their friends, talking with others about feelings, writing personal physician for relief from their distress. a journal or diary, reaching out for help if needed, Somatic symptoms associated with PTSD, depres- prioritizing problems, developing a concrete plan sion, and anxiety may motivate some older adults of what needs to be done and taking action one to ask for medication from their physician. For step at a time, volunteering, examining personal those that seek care from a medical provider, this strengths, and ﬁnding personal meaning in the is encouraging in that it indicates a willingness to experience). All of these simple but critical ap- receive treatment. Primary care physicians have proaches are essential to work though during increased their efforts to screen for trauma among the immediate and short-term aftermath of mass older adults who seek medical care for somatic disasters. Older Adults and Terrorism 305

Secondary Exposure problems are responsive to psychotherapies, group therapies, counseling, and psychotropic medica- News broadcasts of the horrific events on 9/11 en- tions, when necessary (APA, 1998). However, older gendered considerable distress in most television people may be especially reluctant, ashamed, or viewers, and research that was conducted to ex- embarrassed to admit and discuss mental health amine the impact of the media in creating collective problems, given the mass devastation, injury, and traumatic stress in people who were not present at deaths in the aftermath of disaster. Education to the actual event revealed a dose-response effect; decrease the misattribution of somatic symptoms that is, those who watched the most television and increase the acceptance of mental health coverage reported the highest levels of distress treatment should be provided. Effective screening (Ahern et al., 2002; Schuster et al., 2001). People measures need to be validated with older adult who lost friends or family were found to be parti- populations so that those at risk for postdisaster cularly vulnerable to vicarious traumatization from psychopathology can be quickly and accurately frequent viewing of disturbing images (Ahern et al., identified. Programs to reduce stigma and enhance 2002). Older adults in institutional settings, as well the attractiveness of mental health interventions as those who were living in the community, were need to be developed. Following acts of terrorism, more likely to watch television coverage of trau- intervention should be focused on building a matic events for prolonged periods of time. Because recovery environment that returns people to intentional death and harm are considered espe- their usual sources of social support and restores cially heinous, they elicit strong reactions that ap- normalcy. pear to enhance the retention of information, even Although exposure to traumatic stressors can in those with Alzheimer’s disease (Budson et al., be potentially hazardous to one’s psychological 2004). well-being, times of crisis may lead to personal A study investigating memory and emotions growth (Tedeschi, Park, & Calhoun, 1998, p. 2). among older adults for the September 11, 2001, Gerald Caplan, the founder of modern crisis in- terrorist attacks showed that those with Alzheimer’s tervention, argued that crisis is a necessary pre- dementia were more likely to remember personal cursor to growth (1961, p. 19). The coping process, (e.g., how they heard the news) rather than factual a time when an individual strives for equilibrium information (e.g., details of the attack), compared or stability in response to a stressor, provides a to those with mild cognitive impairment or cogni- venue for achieving either a higher or lower level of tively intact older adults. Notably, people with functioning than the precrisis state and creates a Alzheimer’s disease did not differ from cognitively foundation for future development (Brown, Shiang, intact adults in their level of emotional intensity & Bongar, 2003). This appears to support the for six emotions (sadness, anger, fear, frustra- data on older persons exposed to mass violence tion, confusion, and shock) that were measured in and disasters who largely show greater resil- response to the terrorist attacks (Budson et al., ience and adaptation than middle-aged and younger 2004). adults. The older population is an underutilized community resource to assist with everything that Conclusion must be done to assist victims and families, restore normal routines, deliver basic necessities of life, Older adults appear to be more willing to accept cook, provide child care, and canvas neighbor- help on many levels from families or in familiar hoods. Thompson and colleagues have proffered settings, including senior centers and religious in- that ‘‘intervention efforts should be directed at stitutions. The challenge to mental health profes- shifting some of the burden towards older people’’ sionals and trained volunteers is to find a balance in (1993, p. 615). Older adults have significant responding to the special needs of vulnerable po- generative roles and responsibilities with which to pulations, as well as supporting the resilience of assist children and other adults in coping with others in the greater affected communities. Re- short- and long-term effects. Indeed, older people, sponding professionals need to be trained to un- by their very existence, are a symbol that life goes derstand that older adults with mental health on and that there are many ways to survive. 306 Assessment and Treatment

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Children and Terrorism A Family Psychoeducational Approach Maureen Underwood John Kalafat Nicci Spinazzola

Since the terrorist bombing of the Alfred P. Murrah country as measured by exposure to the event, Federal Building in Oklahoma City in 1995, there continuing media coverage, and loss of a family has been a growing body of mental health literature member (e.g., Galea, Ahern, & Resnick, 2002; emphasizing the critical importance of addressing Schlenger, Caddell, et al., 2002). Several northern the needs of families and children who were di- New Jersey communities that stretch along the rectly impacted by this type of traumatic event commuter rail line into New York City were par- (Webb, 2004; Gist & Lubin, 1999). Borrowing ticularly impacted. In one town, for example, 18 from interventions in countries such as Israel that residents, most of whom were the fathers of large, deal with chronic terrorism (e.g., Itzhaky & York, young families, lost their lives. Moreover, the im- 2005), the approaches utilized in the United pact of the attacks was felt in many ways unknown States have included both indicated interventions to the rest of the country, such as commuter lots for those exhibiting significant stress responses filled with unclaimed cars and smoke rising from (Saltzman, Layne, Steinberg, Arslanagic, & Pynoos, the ruins that lingered for weeks, creating a con- 2003) and selective interventions for those who are stant reminder. exhibiting subclinical reactions to exposure and As in most communities, there was a dearth of loss, which characterize the majority of responses trained mental health practitioners to address the to traumatic events (Kelly, Berman-Rossi, & Pa- challenging trauma recovery tasks presented by lombo, 2001). these families (Gurwitch, Sitterle, Young, & Pfef- The unprecedented events of 9/11 necessitated ferbaum, 2002). Well-intentioned practitioners at- the adaptation of these as well as a variety of other tempted to fill the breach in services, sometimes approaches in response to a myriad of complicated with uninformed interventions that made families mental health issues related to the massive num- question the wisdom of mental health services bers of deaths, the ongoing trauma exposure of the (Padgett, 2002). Examples from our experience first responders, and the continuing threat of fu- include one mother who reported that a therapist ture terrorist events. The impact on families in the had created towers of blocks for her 6- and 8-year- New York metropolitan area has been documented old children, then crashed a toy plane into them and as substantially greater than in other parts of the asked the children where they thought their father

311 312 Assessment and Treatment was located. Another told the story of a counselor terventions was informed by a consistent set of who asked her 3- and 5-year-olds which child relevant conceptual and empirical sources: missed their father more. crisis intervention, which emphasizes the Immediately after 9/11, Underwood, Milani, & provision of structure, mobilization of sup- Spinazzola (2004), who are practitioners in one ports, and the avoidance of pathologizing, of the most affected communities, provided deb- which were originally found to be effective riefings and consultations to local schools with during wartime (Butcher & Maudal, 1976, students who had experienced deaths of family p. 678) members to assist in both student management and community education, which applies adult the processing of staff responses. With a recognized learning principles such as collaborative, active expertise in crisis intervention and the impact of learning relevant to current issues in partici- traumatic death on children, they responded to pants’ lives (Knowles, Swanson, & Holton, requests for in-service training programs at schools 2005) and mental health agencies statewide and devel- ecological emphasis, which focuses on inter- oped written guidelines for crisis response that were actions between people and their environ- published on the University of Medicine and Den- ments, as opposed to strictly person-centered tistry of New Jersey website. Inundated with these approaches (Kelly, 2000) service requests, they joined with a third associate empowerment (Rappaport, 1981), which em- and approached colleagues to explore the possibi- phasizes the enabling of community (Iscoe, lity of designing and implementing a community- 1974), family (Dunst, Trivette, & Deal, 1988), based group intervention for these local families. and individual (Bonanno, 2004) competence In this chapter Underwood, Kalafat, & and resilience. In this context, Gitterman Spinazzola describe a psychoeducational approach (2001) has noted that resilience is an ecologi- for helping children and families cope with the cal concept reflecting complex person- 9/11 terrorist attacks in New York City that is environment transactions and not simply a based on ongoing work with children and families personal attribute. who lost a family member on that day. First, is a group approaches, which, in addition to mu- review of the conceptual framework that informed tual support (Lieberman & Borman, 1979), the intervention, followed by a description of the provide classic healing factors such as uni- program derived from these applied intervention versality, altruism, imitation learning, socia- principles. lizing techniques, information, feedback, and cohesiveness (Yalom, 1995). Additional group mediators have been posited for trauma Conceptual Framework groups, including reducing isolation and promoting reconnections to family and other In selecting the intervention approach, Underwood supports, validation of the trauma experience, & Kalafat drew on their experience in developing rebuilding trust, reality testing, and correcting community-based psychoeducational programs for distortions in one’s assumptive world created families living with cancer (Joannides, Underwood, by disasters, practice of nurturing (including & Kalafat, 1986), adults and children dealing with self-nurturing behaviors), and grieving (Dem- the impacts of divorce (Kalafat, Underwood, Fie- bert & Simmer, 2000; Buchele & Spitz, 2004). dler, & Neigher, 1990), those who had experienced traumatic events in schools (Kalafat & Underwood, Even in the face of the challenges presented by the 1989; Underwood & Dunne-Maxim, 1997), and unprecedented events of 9/11, we saw no reason to children exposed to natural disasters (Shepherd- abandon these established approaches, which had Levine, Underwood, & Cernak, 2000). The basic effectively informed our work to date. strategy for developing such programs consists of Our review of the literature on the current initially engaging and observing members of the status of responses to trauma and disasters af- affected population in order to inductively capture firmed these approaches and further informed our their experiences, issues, and needs. Following this family group interventions. There have been sev- grounded, qualitative approach, each of these in- eral reviews of the psychosocial impacts of 9/11 Children and Terrorism 313

(Galea et al.,2002; Groves, 2002; Schlenger et al., ment and children’s social milieu are among the 2002), as well as the impacts of disaster and trauma most stable predictors of resilience in youth ex- on children and families (Berkowitz, 2003; Cathe- posed to violence. Kumpfer and Alvarado (2003), in rall, 2004; Joshi & Lewin, 2004; Pynoos, Steinberg, their contribution to American Psychologist’s special & Wraith, 1995; Pynoos & Nader, 1988; Vernberg section on prevention, which deals with children & Vogel, 1993;Weingarten, 2004). These reviews and youth, report that family-focused prevention report sequelae such as risk factors for and the efforts have a greater impact than strategies that incidence of PTSD; the responses of children at focus only on parents or children. different ages; the fact that families can, in addition Finally, in a review of evidence-based early in- to giving support, transmit anxiety and transge- terventions for victims of mass violence, the Na- nerational effects of exposure to violence; the fact tional Institute of Mental Health (2002) identified that early coping responses predict later adjust- key intervention components: nurturing resilience ment; and the plasticity and, hence, vulnerability and recovery by fostering—but not forcing—social of children’s physical and psychological develop- interactions, providing coping skills training, pro- ment. These findings have led to recommenda- moting natural supports, and offering group and tions for early, family-focused interventions and family interventions. Several resources are now the ongoing monitoring of children and families’ available for implementing these recommendations responses. for enabling resilience through family and group At the same time, these reviews note that, even interventions (Underwood, 2004; Buchele & Spitz, in the face of events such as 9/11, while children 2004; Kelly et al., 2001; Klein & Schermer, 2000; and families may experience transitional perturba- Stoiber, Ribar, & Wass, 2004). tion in normal functioning, their resilience is so common as to constitute the norm rather than the exception (Bonanno, 2004; Padgett, 2002). The The Family GOALs Project implication of this is an emerging consensus for interventions that acknowledge and address fa- Sustained, visual media coverage of the events of milies’ crises, stress, and grief in a nonpathologizing 9/11 created a myopic preoccupation with the cir- way and focus on enabling family strength and re- cumstances of the trauma, and many families felt silience. Joshi et al. (2004) have warned against that life had stopped for them in those tragic ‘‘overmedicalizing normal reactions’’ (p. 715) and moments. The choice of a community-based inter- noted that not all children exposed to traumatic vention reflected the goal of reconnecting members events develop PTSD and can actually be resilient. of a traumatized community through shared heal- They contend that programs that effectively build ing activities, rather than through continued em- resilience focus either on protective factors or on phasis on the disaster. The use of community what works in children’s lives instead of risk factors resources was also a way to concretely engage the or what does not work. community in healing and provide an antidote to In their own review of evidence-based inter- the pervasive sense of helplessness initially reported ventions for trauma, Litz, Gray, Bryant, and Adler by the community at large (Van den Eynde & Veno, (2002) have concluded that the most appropriate 1999). early intervention should be ‘‘conceptualized as Underwood, Milani, & Spinazzola (2004) also supportive and non-interventionist, but definitely recognized that, because the postdisaster recovery not as therapy or treatment’’ (p. 128). They further environment exerts such a powerful effect on chil- conclude that this approach includes group sup- dren’s reactions to disasters, an essential component port that responds to the need that arises for people in long-term adjustment would be the augmenta- to share their experience while respecting those tion of the systemic connections with possible who do not wish to focus on what happened. Ber- protective and resilience effects. It was decided that kowitz (2003) notes that parental support is quite the focus of the interventions would be on the en- amenable to early intervention and salient in gagement of community resources in support of preventing poor functioning in children, while family life. The name of the project, Families Going O’Donnell, Schwab-Stone, and Muyeed (2002) On After Loss (GOALs), was chosen to reflect this have stated that factors related to family environ- intention. 314 Assessment and Treatment

Another objective of community healing was service delivery should focus on bringing together to situate the program in an accessible community all of the members of the nuclear family affected by location. The initial site selected was the local the loss. Research indicates that the existing family YMCA, although it was clear at the first meeting that structure is at least temporarily altered by a trau- there was a palpable contrast between the families matic loss event such as 9/11 (Berkowitz, 2003; attending the ‘‘Y’’ for fun events and those gathering Kissane & Bloch, 1994). Parents face multiple there in grief, which disturbed the leaders. A mul- communication challenges as they struggle to find tinational corporation, located in the same com- words to explain what happened to themselves munity, was approached and agreed to host the and to their children. The children must also find project at its corporate headquarters. The local ways to communicate at a time when their life mental health center was intentionally avoided be- experiences do not provide them with a frame of cause leaders were concerned that there might be an reference either for what has occurred or what they unspoken stigma attached to services provided in are feeling. Vital executive functions in the family a clinical location. They felt it would be easier to can also be disturbed as surviving parents strive to address mental health concerns and to make po- remain available for emotional nurturing, educa- tential referrals for clinical services in a neutral tion, and protection when they themselves are setting. Neighborhood schools were also not con- in great need of similar support and guidance sidered because leaders did not want children, (Cook & Dworkin, 1992; Curry, 2002; Vernberg & especially those who had become somewhat school Vogel,1993). phobic, to associate their grief with the school en- With this increase in the emotional and phy- vironment. sical demands on the surviving parent, supervision The community focus was evident not just in in the household often decreases or is delegated to the intervention’s location but also in the busi- surrogate caregivers. Because the family’s sense of nesses, organizations, and community groups that invulnerability has been shattered, the family may donated supplies and services. Community out- become fatalistic and expect the worst from life reach became the responsibility of one of the staff (Janoff-Bulman, 1985). As a result of these worries, members, and there was a generous outpouring of parents often become overprotective of their chil- support and assistance from sources as diverse as dren and impede the development of autonomy, the United Way and the local pizzeria for the which can create anxiety in their children. Because myriad of things that needed to be done to make each member of the family understandably deals the project really work. with the trauma and grief differently, the many good things the family shares can get lost in the sense of isolation and confusion created by the Phase 1 traumatic event The initial outpouring of support immediately following a traumatic incident is dis- Basic Considerations continued long before the family’s recovery is Consistent with the strength-based or resilience complete. People get back to the business of living paradigm, the initial goal was to acknowledge the their own lives, leaving families who have experi- families’ and children’s pain, fear, and loss and then enced the trauma feeling that there is a lack of to identify and emphasize strengths and effective understanding of the deeper meaning of the loss. coping methods. The latter consist of a positive and Project leaders felt strongly that creating an hopeful outlook and active rather than passive or intervention model that included all of the mem- avoidant coping strategies (Bonanno, 2004; Nation bers of the nuclear family, even the youngest chil- et al., 2003). In addition, a central issue for the dren, might moderate some of the more deleterious program was how to frame these approaches so that effects of the trauma on family life. Since families children could understand and apply them to their are often divided by each member’s unique style of concerns. grieving, Underwood, Milani, & Spinazzola (2004) Given that most of the existing program also felt that the intervention plan should contain models targeted children and adults either sepa- similar learning objectives for the entire family, al- rately or in individual family units, project leaders though the activities designed to accomplish these felt that one aspect of a more effective model of objectives needed to be developmentally relevant Children and Terrorism 315 for each member. This similarity would provide the knew that the 6-month anniversary of 9/11 would family with opportunities for joining together in present a barrage of trauma and loss reminders, some aspects of their grief. they wanted to have an intervention in place that The resulting psychoeducational support group would help the families both anticipate the chal- model included entire families that were combined lenges of that day and plan a family response that into multifamily groups, which addressed many of would contain their grief and honor the memory of the aforementioned concerns and enhanced several the deceased. The leaders also saw this as an op- other therapeutic factors of groups (Stoiber, Ribar, portunity to model for the families ways in which & Waas, 2004): the 1-year anniversary could be commemorated. The series was therefore scheduled to begin in late 1. Families that felt isolated and stigmatized by February 2002. Up to that time, most of the fa- the traumatic event could be reassured by the milies were still struggling to accept the reality of presence of other families who had undergone what had happened, adjust to the changes in fa- similar experiences (Curry, 2002). mily life precipitated by the loss, plan and carry 2. Groups would provide an opportunity for va- out private memorial services, and deal with the lidation and normalization of feelings through Thanksgiving and December holidays. In addition, comparison with others (Gordon, Farberow, & the families were invited to a plethora of public Maida, 1999). activities related to 9/11. Special concerts, sporting 3. In addition to active participation, groups events, meetings with local and national elected would provide an opportunity for vicarious officials, and plans for various public memorials learning (Bloch & Crouch, 1985). occupied their time and energies. Because mid- 4. Groups would expose children to age-mates winter schedules seemed more open, the leaders felt who might be at different stages in trauma that group intervention held at this time of the year resolution. would help families make their way into the busy 5. Youths might accept both support and shared spring. learning from peers that they would not accept Recognizing the competing demands of school, from adults (Terr, 1989). extracurricular events, and grief-related activities, 6. Family members would have an opportunity to the project leaders decided to employ a closed- help others in the group, which might coun- group format and limit the group series to six ses- teract some of the feelings of helplessness sions of 90 minutes each. Because the groups generated by the trauma (Bloch & Crouch, included a psychoeducational component with an 1985). assumption of accumulated learning, the closed 7. Families in need of additional services could format seemed to be better designed to achieve this be assessed and referred (Terr, 1989). objective. It also facilitated the development of co- 8. The use of a psychoeducational format could hesiveness and supportive connection among the help organize the tasks of recovery (Harkness families who reported feeling isolated and stigma- & Zador, 2001). tized in the community at large. The project leaders were also sensitive to the limitations of groups in situations of mass trauma Participants (Nader, 2004). They recognized that some aspects The participants for this intervention were drawn of the trauma experience, like specific discussions from a population that shared risk factors for post- about what type of remains had been recovered, traumatic stress identified by Gurwitch et al. (2002) might be very personal and private and thus in- in their review of the aftermath of terrorism. These appropriate topics for group discussion. They were include degree of exposure, television reexposure, also alert to the tendency of youth to be influenced relationship to the victim (with children most af- by their perceptions of others’ expectations, which fected by the loss of a parent), and bereavement (i.e., predisposed the leaders to exclude certain aspects trauma and grief interact with posttraumatic stress of trauma resolution such as the construction of to complicate the grieving process and interfere personal narratives from the curriculum. with children’s efforts to both address the loss and The timing of the intervention was also critical. adapt to subsequent life changes). Gurwitch et al. Because Underwood, Milani, & Spinazzola (2004) also found that the parents’ responses to the events 316 Assessment and Treatment affected the children’s reactions and, specifically, a family could not attend a session, the leaders that family support mitigated the development of would contact the family member who was in their PTSD symptoms. group to explain what had happened during the Considering these factors, recruitment focused missed session. This outreach served to reinforce on the population of families with school-aged group cohesion, and the younger children in par- children within three geographically contiguous ticular were usually surprised and pleased to get New Jersey communities that had been particularly such a call from the ‘‘grown-up’’ leaders. impacted by 9/11 casualties. Initial screening re- An aspect of group structure that is perhaps vealed that all of these families were Caucasian; the related to group composition (i.e., families strug- primary loss for these families had been the death gling to regain homeostasis after a devastating of the husband and father, which became the pri- event) was a need for continuing outreach. Many mary admission criteria. Thus, the need for services of the participating families had contact with the seemed particularly acute in families where the group leaders between sessions, especially during father had been lost, as has been documented in the first series. They brought questions related other disasters (Gurwitch et al., 2002). to their children’s’ adjustment, school-related di- Twenty families who met the criteria were lemmas, and the need for validation in the face of identified by individual therapists, schools, and the the continuing demands of the trauma. Although it agencies providing support services to 9/11 families. was not an intentional aspect of the initial group They were contacted by telephone in late January design, this outreach component seemed to be 2002 by one of the group’s leaders. She explained very helpful in maintaining the group’s continuity the purpose of the groups as providing information and in expanding the families’ support networks. and support to assist the family in managing its loss and inquired about the family’s level of interest. All Staff of the contacted families were receptive to the pro- Because there was no funding base for the initial gram, but three of them felt too overwhelmed with program, staffing was provided by volunteer mental the single parenting of very young children to take health practitioners who were recruited from a on another activity at the time the groups were being variety of settings, including schools, mental health offered. With the remaining families, the leader centers, hospitals, and private practice. The recruits ascertained the number and ages of the children, were, in general, well qualified and had some level whether the family was involved in any type of of prior experience with trauma and crisis inter- counseling or receiving formal support services, and vention with youth, as well as skill in leading how the children were performing in school. Al- groups. September 11, however, was a daunting though minimal information was obtained in these and unprecedented event that required an as yet phone conversations, most of these discussions unknown set of intervention skills. Thus the high lasted for more than an hour as each woman told the degree of experience and expertise in the recruit- leader her personal 9/11 story. An unintended po- ment criteria perhaps reflected the need to generate sitive consequence of this telephone outreach was confidence in the project through the combined that the leader was able to personally engage these experience base of the staff. Table 21.1 outlines the women. Thus, when they arrived at the first group, specific characteristics of staff members involved in they were already feeling some sense of connection. the first group series. Seventeen adults with 27 children, ages 5 to 15, Staff recruitment also considered the ideal lea- signed up for the first group series. dership paradigm for each group. A developmental Group membership was closed after the first perspective was utilized in selecting female leaders session, although preregistered families who were for the prekindergarten group to provide some of unable to attend that session were included in the maternal nurturing that may have been com- subsequent ones as long as they were able to at- promised by the mothers’ grief. The leaders used a tend session two. The leaders stressed the im- systemic perspective in selecting both a male and a portance of attendance at each session. Because of female leader for the elementary, middle, and high the sudden nature of the losses on 9/11, the lea- school groups. Because all of the participants had ders were sensitive to the impact of unexplained experienced the death of a father, the leaders felt a absences, especially on the younger children. If male presence was essential to counterbalance the Children and Terrorism 317

Table 21.1. Characteristics of staff: First group series

Years of Professional Group Role Training Age Sex Experience

Project coordinator MSW 50þ F35 Leader: adults Professional counselor, 50þ F10 hospice volunteer Leader: adolescents Professional counselor, 40þ F25 marriage & family therapist Coleader: adolescents Doctor of psychology 50þ M35 Leader: latency School psychologist, 40þ M20 professional counselor Coleader: latency Professional counselor 40þ F5 Leader: early kids Professional counselor 40þ M20 Coleader: early kids Professional counselor 40þ F3 Leader: pre-K MSW 30þ F12 Coleader: pre-K MSW 30þ F10 Interns Social work, professional 20þ F3,5 counseling Volunteers Education, business, 16–50 M (4); F (3) homemakers, high school students

father loss in the family system. In the adult group, Although the leaders preferred that the volun- which was composed of young widows, female teers maintain the same assignments each week, leaders were the choice to model the female para- reassignment was considered under some circum- digm shift from nurturer to nurturer/provider in stances. The leaders anticipated that the content of support of the reconstituted matriarchal, single- the adult group’s discussion would challenge the parent family. ability of the leaders and volunteers to remain open The project leaders also attempted to balance and empathic to the intensity of feelings expressed older staff with younger assistants, whom the chil- by group members without becoming personally dren would not view as parent figures. Volunteers overwhelmed. In pregroup interviews, potential who ranged in age from senior citizens to high members were quite clear about their frustration school students rounded out the staffing picture, when people to whom they told their stories began which modeled an extended family system. In the to cry or respond emotionally. This response made groups with the youngest children, each group them feel as if they had to take care of the other member would be paired with an assistant who was person’s feelings and that they could no longer talk available to help that child with activities, especially about themselves. ‘‘This is worse than unhelpful,’’ those that required writing or drawing. This assis- one woman stated. Unfortunately, during the first tant also helped with bathroom breaks or, if the session, one of the volunteers in the adult group had child experienced any separation anxiety at all, took trouble containing her feelings, getting tears in her the child on short trips to see the youngster’s mo- eyes as the group members told their stories. Un- ther. Because many of these families had children surprisingly, the group process became restrained below the age of three, staff members also had to be and stilted. In a private debriefing the leaders spoke available for babysitting. The most successful ba- with the volunteer and decided the group’s needs bysitters were high school boys, who seemed to would be best served if she were moved to one of the energetically manage the tired children at the end of children’s groups. The change was announced at the the day, and these youngest children would often next session. The explanation given was that, al- be the first members of their families to arrive in the though the tragedy had created lots of helping roles, group room each week, eagerly looking for their it sometimes took time to determine where a per- ‘‘sitters.’’ son could make the best contribution. The careful 318 Assessment and Treatment consideration of the timing of the group, the staff their roles as modeling self-disclosure by sharing members’ qualifications, and the participants’ de- their personal reactions in the debriefings, which velopmental needs also reflect evidence-based they hoped would encourage staff and volunteers to principles of effective prevention programs (Nation do the same. Staff members were also required to et al., 2003) and recommendations for support complete written reports of each session that in- groups after a community disaster (Dembert & cluded not just information about members’ parti- Simmer, 2000). cipation but also recorded their personal reflections on that group’s content and dynamics. The project Program Design leaders would review these notes and provide The initial planning meetings, held in a local school, feedback and consultation when necessary. Other began in January 2002. They focused on the staff’s simple touches, such as serving food at every project personal reactions to 9/11 and its sequelae before meeting and giving each leader and volunteer a exploring perceived needs for services. The project journal for personal reflection, were additional leaders felt that it was critical for staff members to techniques the project leaders employed to nurture recognize their reactions and feelings at every step the staff and acknowledge the emotional challenges of the process to mitigate against the ‘‘compassion inherent in this work. fatigue’’ so commonly associated with trauma work (Figley, 1999). To emphasize this point, strategies Group Design for self-care were discussed over a meal before the The project leaders provided the framework for the discussion about the needs of the targeted com- proposed psychoeducational support group inter- munity even began. Moreover, in this situation, in ventions, which included disaster mental health, which the leaders themselves were members of the grief theory, family systems work, group work pro- affected community, personal reflection and process and dynamics, and resilience, and then re- cessing were vital. There was a continued focus on viewed these theoretical bases to ensure that all of the feelings and reactions of the project staff at every the staff members held the same frame of reference step of the project development to ensure as much for intervention design. Using these theoretical objectivity as possible in responding to the parti- foundations, the leadership team and staff arrived cipants’ articulated needs. jointly at specific objectives for the project which When a myriad of opportunities arose for were then divided into topic-focused group ses- qualified mental health professionals to assist in sions that, addressed the following content areas: support activities at Ground Zero, the leaders made development of group cohesiveness; education a conscious choice to limit the scope of the project about grief and trauma responses; identification of to assisting survivor families in their natural com- and attention to individual and family needs related munity settings. The leaders felt that providing to the traumatic circumstances of the death; en- services at Ground Zero would compromise the couragement of personal and family problem sol- delicate degree of emotional distance that would be ving; enhanced recognition of personal and family needed in order to maintain the strategic posture resilience; and the development of coping skills. between empathy and disengagement that is ne- Activities to address each objective were then de- cessary for clinically sound trauma-related inter- signed in consideration of the developmental skills ventions. Finally, in recognition of the dangers of of the specific age groups: prekindergarten (4–5), compassion fatigue, the leaders felt that any suc- early childhood (6–8), latency (9–11), adolescents cessful intervention would need to incorporate staff (12 and older), and adults. support and debriefing into every aspect of the The groups used activities and discussions that project design. were grounded in cognitive-behavioral theory. From the beginning session, the leaders knew By utilizing these techniques, group leaders could that the groups’ needs would exact an extraordinary identify and foster relevant coping skills (Bryant, emotional demand on all of the staff members and Harvey, Dang, Sackville, & Basten, 1998). These volunteers, regardless of their previous training or techniques included writing, drawing, storytelling, experience. At the conclusion of each group session, and arts and crafts. Their aim was to provide the it was essential for leaders and volunteers to review participants with a concrete way to organize what had happened. The project leaders saw one of the ‘‘disorganized’’ experience of the trauma and Children and Terrorism 319 death, as well as allow them to maintain as much cally modeled the progression of the grief process emotional distance from the topic as they needed to and provided sharp contrast to the unstructured feel safe (Appleton, 2000). The language of meta- trauma experience. Sessions would begin with ri- phors, which speaks to the unconscious and stret- tualized, emotionally nonthreatening, introductory ches abstract reasoning skills, was the choice for activities that provided members with an oppor- most of the activities in order to provide a safe tunity to reengage in the group after the week’s approach to potentially threatening topics and to break between sessions. The youngest children invite each participant to decide on a personal recited a short reading called ‘‘Our Circle,’’ which meaning for content areas (Underwood & Clark, reminded them of the group’s goals. ‘‘We have come 2004; Barker, 1985). Especially after a traumatic together,’’ it began, ‘‘to listen to each other, to sup- event such as 9/11, which shattered people’s as- port each other, to care about each other, to un- sumptions about personal and family safety, the derstand each other because special people in our provision of group content that reinforced survi- lives have died and we need each other’’ (Under- vors’ emotional safety was of paramount concern wood, Milani, & Spinazzola, 2004). Latency-aged (Burrough & Mize, 2004). children and adolescents began their groups by For several reasons, the project leaders deci- randomly tossing a skein of yarn among the mem- ded to omit from curriculum activities a content bers to create a ‘‘web of connection.’’ Each week’s area that was particularly relevant to trauma in- toss was accompanied by a ‘‘question of the week,’’ terventions. That activity was the construction of a which was designed to increase group cohesiveness trauma narrative (Neimeyer & Levitt, 2000). The through self-disclosure. creation of such narratives would ultimately be Even the adult group had a ritualized begin- essential to helping participants integrate the ex- ning. Small, plastic garbage pails were placed in perience and receive social validation for their the center of each group circle, and the partici- account of their losses. Nevertheless, the story pants were given scraps of paper on which they of what had transpired on September 11 was still were instructed to write down all of the ‘‘junk’’ that evolving, and families were still learning new facts had happened to them during the past week. Each about what had happened to their loved one that participant would stuff her weekly ‘‘junk’’ into the day. In addition, most of the families had yet to garbage pail, and it was shredded ceremoniously at receive personal remains, which the leaders felt the last group session. This activity was also used was an essential element of their narratives. They with success in the prekindergarten group, where also did not want a member’s personal narrative to the personally decorated garbage can often occu- be influenced by what other group members might pied a place of honor in the child’s room. Several construct. Moreover, as members themselves of the months after the group’s conclusion, one mother affected communities, the project leaders—albeit reported she had observed her 4-year-old son ex- unconsciously at the time—had yet to complete plaining to a playmate that he used his garbage can their own narratives, which made it difficult for to ‘‘throw away all the sad and mad stuff that hap- them to help others in this essential task. They did pens.’’ These opening rituals were similar to those feel, though, that there were enough other aspects in a closed-membership trauma and grief group of the trauma recovery process that the project developed at the National Center for Child Trau- could address to make it both helpful and mean- matic Stress at UCLA (Saltzman, Layne, Steinberg, ingful for the participating families. Others have & Pynoos, in press). concurred with this decision. Berkowitz (2003) The middle portion of the session contained the contends that reexposing participants to the details material directly related to the trauma as it was of the event by asking them to review what oc- addressed in that week’s objectives. Personally re- curred is not appropriate for crisis models. Mayou, flective activities such as writing to the deceased or Ehlers, and Hobbs (2000) have noted that ex- illustrating difficult feelings were balanced by the posure to internal and external stimuli without inclusion of a less emotionally demanding activity clear and obvious symptomatology may interfere such as cookie decorating or a scavenger hunt with the natural recovery process. (Burrough & Mize, 2004). The content was infused Each session was carefully structured to have a with creative activities, which the leaders felt were beginning, a middle, and an end, which symboli- essential to approaching the emotionally difficult 320 Assessment and Treatment content in a nonthreatening manner (Barker, 1985). (demonstrated in the decoration of sugar cookies Providing an opportunity for the participants to es- that the participants gave to people who had been tablish emotional distance from the challenging helpful), they were carried out with a mixture of fun material would facilitate the containment of painful and seriousness that the leaders hoped would affect. Creative techniques also helped break down facilitate their replication by the family at home. complex issues and emotional responses into man- The ending of each group session was also ri- ageable pieces; they were selected to emphasize tualized to demonstrate how to contain the content strength and resilience, another of the project’s discussed in that session and to practice the use of themes. coping techniques and resiliency skills. All of the The thread of metaphor tied most of the group groups, regardless of age, made use of personal af- activities together. The leaders chose this frame of firmations to conclude the sessions with a positive reference because it facilitated individual inter- focus. For the youngest children, affirmations such pretation of the same material in ways that reflec- as ‘‘All of my feelings are okay’’ or ‘‘I am special’’ ted the emotional tolerance and understanding of were often combined with scavenger hunts or individual participants. Because specific stories that written on pieces of colorful paper and wrapped addressed the challenges of trauma recovery around lollipop sticks. The adults were provided through metaphor were not readily accessible for with a list that included statements such as ‘‘What I a proposed family storytelling activity, one of the need to heal will be given to me’’ or ‘‘I am stronger leaders collaborated with a personal friend to create than I think I am’’ and asked to choose the most ‘‘Adventures on Maple Street,’’ a collection of short relevant affirmation to read aloud in the closing stories with specific curriculum-related themes. circle. By the conclusion of the sessions, the adults These included the use of cognitive restructuring as were asked to create affirmations for both them- a coping technique, the responsibility to always do selves and other group members. one’s best despite the intrinsic unfairness of life, the Several sessions incorporated closing rituals importance of learning to trust oneself, the function that gathered all of the families together. The lea- of caring adults in the support systems of children, ders knew that most of the families had partici- and the power of holding memories of the deceased pated in large, impersonal ceremonies on local, in one’s heart (Underwood, Milani, & Spinazzola, state, national, and even international levels, so, in 2004). The stories, which were read aloud in an the absence of common cultural rituals, they wan- engaging fashion by guest speakers, served as the ted to create a more personal model of a memorial beginning activity at several of the group sessions in that the families could replicate at home. They were both the first and the second series to provide strongly committed to the importance of the use of continuity between the curricula of the two group ritual in healing and recovery (Rando, 1988). The series. Copies of these stories were given to all of the leaders knew that, because of the lack of personal families at the series’ conclusion to encourage re- remains, many of the families would be deprived of view of group learning, and many families reported the comfort sometimes provided by a burial site, so that they had read the stories again on more than the knowledge of how to create personal memorial one occasion. rituals in other places might facilitate their grieving. Having all of the families meet together for Each ritual always began with each family member certain activities such as the storytelling or cookie speaking the name of the special person who had decorating was included in the curriculum design died and then addressing a question that was re- so that the participants could see how they could lated to that session’s particular theme. For ex- use simple activities at home to address the con- ample, there might be questions related to a lesson tinuing challenges of grief or honor the memory of the deceased had taught the family about courage or the deceased. Again, even though serious topics something that remained special about the family were addressed in an activity such as how to iden- despite the death of this important person. Music, tify and hold on to memories of the deceased (ex- candles, light sticks, bubble blowing, and balloon emplified through the decoration of cigar boxes to launching were some of techniques that were used serve as containers for tokens of memories) or in a to symbolize the continuing light of the family’s discussion of the importance of acknowledging strength and the transcendent presence of the de- support system members who had provided help ceased. Despite the different religious and cultural Children and Terrorism 321 beliefs about death that some of the group members children, in fact, elaborated on the subject and presented, these rituals were all well received, provided a range of examples of unfairness like perhaps because they were cloaked in metaphor ‘‘when someone else plays with your presents first’’ and symbolism. or ‘‘two people give you the same present, and you Since all of the participants had experienced really don’t like it in the first place.’’ sudden, traumatic deaths of family members with- The activities that were chosen to help the out the opportunity for good-byes, the final session children understand these topics were described to in each group series was given careful considera- parents in letters that the leaders distributed at the tion. The theme of closure was reinforced in the end of each group. These letters provided sugges- activities for each small group, which included both tions for continuing that group’s lessons through acknowledgements of everyone’s contributions, as specific conversation between the parent and the well as symbolic parting wishes for one another. All child about the activities. For example, a letter might of the children were given small, wrapped boxes suggest that the parent ask the child about a parti- with fist-sized holes cut in the top to hold what the cular memory the youngster had shared at the leaders called ‘‘palancas.’’ The Spanish word for group meeting and then encourage the parent to ‘‘lever,’’ ‘‘palanca’’ was the name given to describe share a similar memory. The leaders felt it was es- the short notes that participants were asked to write sential to reinforce the importance of open channels to each other about something they admired about of family communication and thought that re- that other person. Just as a lever enables a person viewing the activities that had taken place in the to move something that is beyond one’s normal children’s’ groups would facilitate this. Letters were strength, the palancas, which were placed in the not given to the parents of the adolescents, how- boxes, could be removed and read whenever the ever, as the leaders believed the teens would ap- group member needed extra encouragement. preciate respect for their individuation. Members of the adult groups were given ‘‘suc- Despite the curriculum’s structure, a seminal cess kits,’’ small hand-decorated boxes that in- point upon which it rested was the recognition of cluded the following items: a stick of gum to help the ongoing nature of the trauma and the potential the family stick together, a roll of Life Savers candy need to modify session content based on temporal for the days when life seems overwhelming, confetti events. During the course of the group series, for as a reminder to celebrate personal success, a rub- example, a change in the excavation location at ber band to reinforce the importance of flexibility, Ground Zero resulted in the uncovering of a sig- and a chocolate kiss for love. A concluding cele- nificant amount of human remains. The leaders bration brought all of the family members together recognized that the groups needed to address the for a dinner during which a slide show of pictures ways in which the families had been impacted by taken during the sessions was shown. The project these discoveries. leaders acknowledged the contribution of each staff A staff meeting was scheduled before that member and volunteer, and the family members week’s session to process the staff’s reactions to the used this opportunity to express their gratitude and events and to prepare guidelines for discussion, presented the leaders with an album of letters of especially with the children. The next week, the special thanks written by each family. mother of a 9-year-old boy reported that, when she and her son returned home from that particular Special Curriculum Issues session, he had climbed into bed with her, and Because the objectives for all of the groups were the they lay in the darkened bedroom, sharing what same, the staff was faced with the creative challenge they had talked about in their groups. Their ability of designing a developmentally relevant curriculum to approach the difficult subject of the way in for the youngest children that addressed some of which the child’s father’s remains would be han- the more abstract curriculum concepts such as the dled, the mother felt, was a result of their con- importance of trust or coping with the unfairness versations that night in their respective groups. of life. Holding a pretend birthday party during Subsequent group series were modified to address which some of the children were given bigger pieces heightened terrorist threats in the New York area, of cake than others helped even the 4-year-olds to extensive media coverage of plans for the Ground understand the abstraction of the latter topic. The Zero memorial, and the declaration of war against 322 Assessment and Treatment

Iraq. Each time it seemed prudent to adjust a itiated a monthly group meeting for girls aged 5– session’s content to reflect current events or spe- 11 that began in the fall of 2003. cific trauma-related issues in participants’ lives, a The leaders considered the monthly 90-minute pregroup meeting was held so that the group lea- session as a pilot program to evaluate the effec- ders could process their own reactions before they tiveness of this less-concentrated form of interven- processed those of the group. tion. Ratings of satisfaction from the 14 participants were extremely positive, and each girl indicated she Phase 2 had learned at least one new coping strategy during the 9-month series. Several of the girls also reported At the conclusion of the series, the participants they felt they had been helpful to other members of clearly articulated the need for additional sessions, the group and that they especially liked meeting so two special ‘‘pulsed’’ interventions, designed for without boys. potentially challenging times of the year such as Another pilot intervention that began when the Father’s Day and the winter holidays, were devel- GOALs series ended in spring 2003 was a biweekly oped. An additional 6-week series that used the adult support group. With an unstructured, open same format as the first was also created in re- format, this group provided members with an op- sponse to participants’ requests and delivered the portunity to address contemporaneous concerns following fall. The age range for this second series that related to either themselves or their children. was lowered to 3 years, both in response to par- The parenting of young children and the challenge ental requests for a program for their younger of recognizing their grief developmentally were children and the availability of a social worker with common discussion topics. These concerns,how- a clinical specialty in infant and prekindergarten ever, were frequently interspersed with conversa- mental health. Tables 21.2–21.4 outline the ob- tions about the continuing retrieval of personal jectives for each series and for the pulsed inter- possessions from Ground Zero or the difficulties in ventions. Since these objectives were reviewed for dealing with the government’s financial settlement, staff and volunteers in the training sessions that which was designed to provide the families with took place before each series began, the rationale monetary compensation for their losses. Compen- for the selection of each objective was discussed in sation was to be based on a complicated formula order to reinforce the grounding of the project that included the deceased’s salary, lifetime earn- objectives in specific theory bases. ing potential, life insurance, supplemental benefits, When the second group series concluded after and family membership. In addition, the families the pulsed intervention in December 2002, many were asked to provide personal information about of the participants expressed a need for additional the deceased that reflected the degree of loss the meetings. Because their children had aged, they family experienced. The vagueness of the criteria wanted them to be exposed to the older children’s troubled the women, as did the emotional chal- curriculum. So, with support from Project Phoe- lenge of gathering data to support the impact of nix, the New Jersey FEMA project, and the New the death on the family. They clearly welcomed Jersey Division of Mental Health Services, a third the opportunity the group provided to discuss group series began in February 2003. The curri- these issues with each other because they under- culum for this series expanded upon themes that standably felt that no one else could really em- had been addressed in earlier sessions and in- pathize. cluded topics such as the differences in family In spring 2003, Project Phoenix funded the expressions of grief, personal and family resilience, dissemination of the project to other counties in self-care, and social support. At the conclusion of New Jersey that had been severely affected by 9/11. that series, the parents of the young girls aged 6–8 They also funded the publication of the curriculum stated that they believed that continued groups for greater distribution (Underwood, Milani, & would be beneficial for these children. The leaders Spinazzola, 2004). This expansion of the project had themselves observed the unusual cohesiveness required a clearer delineation of the less codified among the girls and were impressed that many of elements of the project, such as the leaders’ quali- them maintained contact with each other outside fications and training, membership screening, and the groups. Consequently, the project leaders in- guidelines for curriculum adaptation. ) (continued alive. Children, in particular, generated by loss. can be an important factor in ability to create a personal is imperative to help them identify children who must experience techniques for preserving occurs. These tasks are complicated about and reactions to the loss different, more positive perspectives must form a cohesive identity. In specific activities that are designed to Although every member of the family tasks to participants is helpful in strategies are reviewed in this session. may be lost if they are not highlighted confusing and even chaotic. before the loss. These resiliencies are even more important in stressful of loss. Because there is wide range of so it’s important to review a variety of step in the grieving process. memories are reviewed and practiced. repertoire of coping techniques. Additional age-appropriate can assist in the development of coping strategies. have memories of themand that recorded. are personal and unique and alternative techniques for dealing with the complicated feelings circumstances and are reinforced in each group session. ‘‘normal’’ feelings, it’s important tohas review and experienced validate the them. deathwill of be the individual same and person,uniting unique. their families. Understanding feelings these differences the skills and competenciesavailable that to characterized help their them lives through the present challenges. when the loss isthem sudden at and each traumatic new and developmental are passage. prolonged Explaining for these providing structure and order to a process that can seem closed, short-term groups, this processhelp can be members accelerated focus by on shared goals. 2. Holding on to memories of the deceased is a critical 3. Because they are such critical components in grief resolution, 4. One of the important elements in a resilient personality is the 3. Research shows that being able to look at life situations from 1. Identifying and sharing memories is one way of keeping the deceased 2. Problem-solving skills are often compromised by grief, 4. Personal coping techniques are critical life skills that are 1. The second task of grieving is to experience the feelings 3. At a time when the bereaved can feel that life is out of control, it 2. The tasks of grief are the foundation upon which all mourning 1. In order for the group process to be effective, the members Selection Rationale deceased. ories. nitive restructuring. the deceased. of feelings. coping strategy. grief. competencies. prompted by traumatic loss. 4. Learn a third coping strategy. 2. Identify family memories of the 3. Review ways to capture mem- 3. Introduce the technique of cog- 1. Identify personal memories of 2. Review strategies for expression 4. Teach the use of affirmations as a 1. Identify personal feelings of 3. Identify personal resilience and 1. Develop group cohesiveness. 2. Identify the tasks of grief Objectives Session objectives and selection rationale for series 1 Together Our Memories’’ Our Feelings’’ One Another’’ 3. ‘‘Patching 2. ‘‘Living With 1. ‘‘Getting to Know Table 21.2. Session Number

323 the time to identify the for the family to articulate what and use these systems. overlooked by the immediacy of important to identify these will choose to express that is traumatic reminders. The stage; community resources are type of consolation, the phrase which there was no closure, this techniques, the family members will and express their feelings about the Sharing these feelings can deceased. Because family life may be without the deceased. Since so many are highlighted. reminders, especially the anniversary of and also develop some family coping them. Also important is the recognition of are crucial elements for both mental and reviewed and practiced. will be different for each of them and that process takes on added importance at the conclusion. be given a chancestrategies. to share those personal approaches sentiment. ‘‘moving on’’ often generates angerthe in process the of bereaved. going It’s on important with life means to them and how they the children will continueavailable the if process the at family each needs developmental help or support in the future. changes and how eachthe family socioemotional member roles might the address deceaseddealing ﬁlled with since concrete these tasks. are often changes take place in a family when a special person dies, it is physical health. Even young children are encouraged to develop anticipatory stress model helpsthe prepare event. them for these changes in their lives,normalize especially and those validate that them. may be positive. chaotic after a traumaticspeciﬁc loss, changes family they members face. may not have taken 4. Because group members are coping with traumatic losses for 2. Often used in an attempt to provide the bereaved with some 3. While each member of the family will have individual coping 1. Remind each family member that the grief process 3. To enhance skill acquisition, coping techniques are 2. The next task of grieving is to adjust to the environment 1. Mental health literature is clear that support systems 4. Coping techniques to deal with changes and challenges 3. One of the challenges that families face after a distressing loss 2. It’s important to give permission to the bereaved to identify 1. The third task is to adjust to an environment without the Selection Rationale on.’’ validate its individuality. oping a strong support system. changes. may now be different. 4. Effectuate group closure. 3. Review coping strategies. 2. Explore the concept of ‘‘moving 1. Review the grief process and 3. Practice coping strategies. 2. Enhance family resilience. 1. Review the importance of devel- 4. Learn a fourth coping strategy. 3. Anticipate future changes. 2. Identify reactions to those 1. Review ways in which family life Objectives ) ’’ ... Continued ( Hold in Our Hearts’’ with a Little Help From We Were and the Way We Are’’ 6. ‘‘What We 5. ‘‘Getting by 4. ‘‘The Way Table 21.2. Session Number

324 ) (continued of grief if it is reinforces a sense It is important to cohesiveness. changes; provide a context at a future in which all members of the We always have maintaining effective coping is the perception that the way in which one session intuition and to make decisions traumatic loss shifts in the grieving the structure of the program will provide participants with the family’s focus from thefamily, event per even se the to the youngest positive children, ways have responded. process can make thesemore challenges control feel over more the manageable. problems we can identify. of control over the reactions to seasonal and life changes. for understanding these feelings if they occur. Intentional thinking an understanding of thebuilds relevance upon of another. its content and the time, increases a sense of resiliency and coping. world is no longerdirectly a confront safe this place perception andnot since that resolved. it people will cannot impede be the trusted. resolution about trusting others. in the face of life challenges, especially for children. 1. Identifying and confronting the challenges one faces 2. Structured introductions can facilitate the development of group 3. Recognize that changes in feelings often accompany seasonal 1. One of the consequences of a sudden or traumatic death 2. Problem solving, even if the solution will be implemented 3. Validating family strengths and growth in the face of 2. Resiliency skills are founded on the ability to trust one’s 3. Support systems are an essential element in nurturing and Selection Rationale seem the most challenging. former participants and introduce new members. reﬂections of beginnings and endings and focus attentionpersonal on intentions for theing com- season. trust presented by atraumatic sudden loss. or one of these challenges. family members have facednegotiated and successfully. liency skills. the environment. 1. Identify the aspects of grief that 3. Recognize seasonal changes as 2. Develop a plan to address at least 3. Identify the challenges other 2. Use metaphor to enhance resi- 3. Identify trustworthy people in 2. Catch up on current status of 1. Acknowledge the violation of Objectives 1. Review group rules and agenda. 1. Understanding Session objectives and selection rationale for series 2 Ourselves’’ Forward’’ Learning to Fly’’ 2. ‘‘Learning To Trust Table 21.3. Session Number 1. ‘‘Looking Back, Going 3. ‘‘Finding Our Wings and

325 and recovery. It is important death can Sharing these stories increases the dimension terrible and unfair things happen in to some enhances the families’ recognition of a to feelings of victimization and and maturation. unfairness, we always have control over and strengths. to say good-bye to each other and identify memories of the member that they lose their deﬁnition of the resiliency concepts reviewed in the groups what they will carry with them from the group experience. to facilitate their use by participants. helplessness. Recognizing their arbitrary natureto is understand essential that, to while healing wehow may be we powerless choose to to stop the respond when it happens. life. It is importantdegree. to Recognition realize of that this unfairness is is a ever critical present element of growth extended family. Concentrating on the larger family system larger base of support. deceased that are not necessarilymemory known bank by the of other everyone members. to in the the life family of and the may deceased. give added help the family focus on its previous accomplishments 3. It is important that participants have the opportunity 2. Self-soothing is a critical element in resilience. 1. It is important to give structure and organization to 2. Perceiving life’s unfairness as personally directed can lead 1. Another consequence of traumatic loss is the recognition that 3. Families can be so preoccupied with the deceased 2. In many families, each member will have personal 1. Recognizing that the family had a history before the traumatic Selection Rationale perience. suggest strategies for expanding upon them in the future. covered in the groups. is not personal. do one’s best despitethings the that unfair happen in life. intact despite the lossimportant of member. an sharing of family stories. signiﬁcant family times and events. 3. Bring closure to the group ex- 2. Reinforce self-care skills and 1. Review the resiliency concepts 2. Understand that life’s unfairness 1. Address the need to continue to 3. Remind families that they remain 2. Create an opportunity for the 1. Help families recall and name Objectives ) Continued ( Letting Go’’ Fair’’ Our Joys and Cel- ebrating Our Strengths’’ 6. ‘‘Holding On and 5. ‘‘When Life Isn’t Table 21.3. Session Number 4. ‘‘Remembering

326 Children and Terrorism 327

Table 21.4. Special sessions: ‘‘Pulsed’’ interventions

Spring Session: 1. Create a container for 1–3. Scheduled near Mother’s or Father’s Day, this special ‘‘We Are family memories of session reflects an awareness that the feelings of Family’’ the decreased. grief may resurface with intensity around the holidays that celebrate family. The memory of the deceased is acknowledged in the creation of ‘‘spirit boxes’’ and the continued, albeit changed, strengths of the current family unit. 2. Review family strengths. 3. Celebrate continuing family resilience. Fall Session: 1. Provide the family 1. The change of the seasons is often a time when the death ‘‘Seasons of with an opportunity to of a family member is felt more keenly. Families Strength’’ identify their unique can benefit from an opportunity to get special support strengths. from others and from the chance to focus on their continuing strengths. 2. Take time to 2. Acknowledging sources of support helps the family to acknowledge support recognize and name all of the kindnesses the family has systems. received in the aftermath of the death. It is also a way to help families restore a feeling of balance by giving back to others in addition to receiving from them. 3. Celebrate their 3. Acknowledging the bonding that has taken place continued connection between families during the course of the groups affirms with other members their connections and encourages continuing relation- of the GOALs group. ships.

To standardize the instruction of group lea- group facilitators meet the criteria for ‘certified ders, the project leaders used their expertise in the group psychotherapist’ as set forth by the American development and implementation of training to Group Psychotherapy Association. These criteria develop a written didactic and experiential training include an advanced clinical degree, extensive ex- protocol (ibid.). This 8-hour training reviewed the perience in running groups, a specified number of theoretical basis of the GOALs Project, with spe- hours of supervision, and certain academic courses cific emphasis on the process of grief, the impact of in group theory and dynamics. Although the groups traumatic loss on children and family systems, the are based on a psychoeducational support model, significance of resiliency skills as part of recovery, the leaders felt that a facilitator with group therapy and the ways in which a psychoeducational sup- expertise and clinical credentials would best be able port group can assist in the grief process. It also to deal with the complications of traumatic loss and focused on leadership tasks and skills and the its potential effects on group dynamics. The project importance of self-assessment in preventing com- leaders were especially sensitive to the mental passion fatigue. The training sessions always in- health complications of grief after trauma and felt cluded participation in several of the curriculum that staff with clinical training would be in the best activities to help potential leaders anticipate ways position to make assessments and referrals for ad- in which group members might respond to a ditional mental health services if needed. These particular task. The instruction was modeled rigorous standards were not, however, as necessary after the GOALs group paradigm, with a discrete for group assistants, although previous experience opening and ending activity to bookend the di- in working with children was considered essential dactic content. The participants received written for anyone involved in the project at any level. copies of all of the training materials for review and The project leaders suggested more detailed reference. Table 21.5 provides an outline of a ty- screening for future group members and felt that pical training session. the best candidates for this intervention would With regard to specific qualifications, the pro- be families who had acknowledged the reality of ject leaders recommended that all of the potential their loss even if their level of acceptance was 328 Assessment and Treatment

Table 21.5. Staff training outline

Activity Rationale

1. Opening Exercise: ‘‘Web of 1. Using this activity, which is part of the adolescent Connection’’ curriculum, models how it is conducted. It also visually reinforces the connections that already exist between leaders by asking participants to introduce themselves by providing their names as well as one personal characteristic they bring to their involvement in the GOALs project. 2. Review of the GOALs Project: 2. To capture the essence of the groups as well as describe Video Presentation the theoretical foundations upon which they are based, participants are shown a 30-minute videotape (Shepherd-Levine, Underwood, Spinazzola, & Milani, 2003). 3. Experiential Exercise: 3. Understanding one’s personal relationship to death and Personal Awareness of Death the process of grief is essential to assisting group members in accomplishing the tasks death presents to them. Participants are asked to complete a short personal loss inventory to help them assess their experience with death and traumatic events. Discussion of this questionnaire can also assist project staff in their assessment of participants in relation to their possible roles in the groups. 4. Didactic Presentation and 4. Since grief theory is one of the cornerstones of all group Discussion: The Tasks of Grief and content, it is reviewed in a lecturette. This group model How They Are Complicated by uses the ‘‘tasks of grief’’ outlined by Worden (1992). Trauma The work of Eth and Pynoos (1985) is used to describe some of the complications of traumatic loss. 5. Experiential Exercise: How 5. As a way to acknowledge and recognize the skills Children Grieve participants bring to the groups, a small-group exercise asks them to identify grief reactions at different ages. 6. Didactic Presentation: Looking at 6. Because this model focuses on the recovery of the Death in a Family Context and entire family, the impact of traumatic death on the Using Resilience to Heal. family system is discussed, with emphasis on a wellness model that emphasizes family strength and resilience. 7. Group Discussion: Leader’s Role 7. Even though most of the participants will have had prior experience running groups, it’s important to review the leader’s role in this psychoeducational support group model (Underwood, in press). 8. Curriculum Review 8. Goals and objectives for each session are reviewed. 9. Experiential Exercise: Team 9. An exercise from the curriculum is adapted for the Totem Poles training to help build cohesiveness among the participants, model a group activity that reinforces family resilience, and demonstrate ways in which leaders can facilitate group process and content. 10. Closing Activity: Personal 10. The training borrows from the groups in its use of a Afﬁrmations closing afﬁrmation ritual.

intermittent. They felt that families who were still before this time would probably not be beneficial. struggling to accept what had happened to them Families also needed to have enough internal orga- might be too challenged by the group’s objectives, nization to be able to commit to regular attendance. which included specific acknowledgement of the Since parents and caretakers with extreme mental reality of the death. Because families needed at least health needs, such as severe depression or post- 4–6 months after the death to assimilate the reality of traumatic stress disorder, would not necessarily the changed family structure, group membership have the reserves of emotional strength required for Children and Terrorism 329 group interaction, the group leaders needed to viously, the groups needed to spend more time possess the appropriate clinical skills to be able to on the development of cohesiveness because of make these eligibility determinations. the differences presented by the circumstances of The project leaders also decided to expand the members’ losses, although the project leaders felt pool of members from exclusively 9/11 families to that all of the participants would share the tasks of include families that had experienced deaths under grief recovery, regardless of when or how the death other circumstances. While the similarities shared had taken place. When members who had experi- by the 9/11 families had initially been more pro- enced other types of loss events were finally invited found than their differences, this had begun to fade into the third GOALs group series in the autumn of after the second anniversary of the event. Before 2003, the perspective that other losses could pro- that time, the similarities in the experiences of the vide was evident in the unanimous agreement 9/11 families were so intense and pervasive that among the 9/11 families that the new members including families that had experienced losses un- whose spouses had completed suicide faced even der other circumstances was contraindicated. For more challenges than they themselves had. example, all of the 9/11 families were invited to Clarification of the project’s community health almost weekly supportive and/or political events; orientation was as important to successful program they shared the same deadlines for the filing of legal replication as increased specificity in both program papers and other documents related to the disaster; content and delivery. Because the GOALs model is and many of them were consistently retraumatized grounded in belief in the resilience of an impacted by the continuing media coverage of the event. After community, replications of the project needed to the second anniversary, most of the families had validate and involve both formal and informal settled into a new routine with fewer disaster- community resources and be congruent with belief related interruptions. Their issues and challenges in that community’s inherent strengths. The pro- began to share commonalities with families that had ject leaders were aware that a degree of territori- experienced death under other circumstances, and ality often existed in community agencies that had the leaders felt that all of the families could benefit received funding for trauma-related services and from the perspective of varied losses. believed it was important to make this up-front The project leaders also believed that, by in- acknowledgement to other communities interested viting families into the groups that had recently in replication. Making sure that input from these experienced traumatic loss events, the 9/11 families divergent sources was included in project planning would be integrated into this larger, existing com- might mitigate some of the negative impact of munity of grieving families, which was seen as community competition. beneficial for several reasons. First, the stigma associated with the events of 9/11 could be dimin- Project Replication ished, and the family changes that accompany any With support from the Emergency Management death could be normalized. Second, the opportu- Office of the New Jersey Division of Mental Health nity for sharing various methods of dealing with the and Hospitals, leader training sessions were carried ubiquitous challenges of single parenting would be out in the spring of 2003 in the seven New Jersey increased. Finally, the 9/11 families would have the counties most affected by 9/11: Essex, Bergen, opportunity to serve as role models for other fa- Morris, Somerset, Monmouth, Union, and Passaic. milies who were not as far along in the grieving More than 65 mental health practitioners from process. Self-help literature makes it clear that this a variety of professional disciplines were trained type of opportunity can assist the more experienced in the GOALs model. Four of the participating group members in recognizing and sharing the counties subsequently went on to conduct their skills they have accumulated throughout the mour- own groups, with GOALs staff providing super- ning process (Reissman & Carroll, 1995). vision and technical assistance throughout each This inclusion of families with different loss series. These groups exhibited some cultural di- events required minor adjustments to the curricu- versity, but the affected population in the service lum. Specific references to 9/11 were replaced with areas remained mostly Caucasian. In the counties more generic language that recognized a variety of that tried unsuccessfully to launch programs, most loss circumstances over a wider span of time. Ob- of the reported challenges and difficulties were the 330 Assessment and Treatment result of political turf issues that had developed recovery, many of the families reported feelings of among agencies providing 9/11 relief. Thus, while abandonment and voiced concerns about having to expansion of service delivery was not universal, continue the process of recovery on their own. They having a cadre of trained professionals met a critical still faced decisions about the disposal of remains, component of New Jersey’s strategic commitment legal and financial questions, and the evolving im- to increasing the knowledge and skills of mental pact of single-family life. health practitioners as they relate to the impact of In particular, the members in the biweekly traumatic loss events on children and families. women’s group stated that the government’s fi- In addition, project staff provided training on nancial settlement was an aspect of their recovery the GOALs model to a variety of agencies and or- that has carried significant and unexpected negative ganizations within the New York metropolitan area, consequences. To a one, the group members re- including the counseling department of the Fire ported feeling ‘‘stigmatized’’ and ‘‘judged’’ by what Department of the City of New York, the trauma outsiders seemed to feel was their instant status team of St. Vincent’s Hospital, the New Jersey as millionaires. ‘‘The minute a stranger hears I’m a chapter of the National Association of Social 9/11 widow,’’ one woman reported, ‘‘the typical Workers, and the interfaith council of the Jersey City comment I hear is ‘you may not have your husband, mayor’s office. The instruction reviewed the theo- but at least you’re financially well off for life.’ ’’ retical basis of the project, outlined the objectives Public misinformation about the settlements, which and curriculum, and provided suggestions for the had been discussed for months in the media, had adaptation of the material to local needs. Train- also contributed to what several widows described ing also covered the ways in which the program as a ‘‘backlash against us.’’ ‘‘People think we all got could address issues of cultural diversity. Project six million dollars,’’ another woman complained, a leaders held the perspective that, despite cultural figure that was frequently cited in the press as the and ethnic differences in the expression of grief, the amount of the largest settlement. feelings generated in the grief process were as uni- Unfortunately, these settlements also created a versal as was its impact on the daily functioning of chasm that these widows felt separated them from the family. Because these universal issues were at the people who experienced losses under other cir- project’s core, minor adjustments in activities would cumstances. They described feeling guilty in other facilitate respect for differing ethnic approaches to support groups because they knew that people with death. other types of losses often found their standard of living changed by the death of the family’s bread- winner. They expressed strong sentiments about Phase 3 having continued access to the peer support of their group and began to explore ways to continue Continuing and Unmet Needs meeting when the GOALs program concluded. The final phase of the GOALs project acknowledges When a spouse began dating, other families the importance of ending direct services such as the found themselves coping with the impact on the groups in a way that integrates the traumatic ex- family. The developmental manifestations of grief in periences and the lessons learned from them into the growing children was another topic of increas- the life of the larger community (Van den Eynde & ing concern. In addition, a population that had not Veno, 1999). To this end, the project leaders re- been addressed in the existing GOALs model or in viewed what they considered to be unmet com- any other formally provided support services in- munity needs, as well as the development of specific cluded members of the extended family, who often interventions that would reflect the empowerment reported to their 9/11 FEMA advocates that they felt and resilience of the affected families and commu- excluded and unrecognized for their losses. Even nities. the group process within the GOALs series had re- The families themselves stated what they con- flected this same sense of disenfranchisement by the sidered to be their continuing needs for service. relatives, which often had a negative impact on the With several types of formal support having been nuclear family. Surviving spouses reported tensions withdrawn in what disaster mental health experts with in-laws, and children often mentioned the refer to as the ‘‘disillusionment stage’’ of trauma paternal grandparents and other relatives with Children and Terrorism 331 whom they were no longer in contact. An important of prevention programs who attempted to locate project direction, it seemed, would be the provision funding for program evaluation. Her contacts de- of a supportive and healing forum that brought all of clined due to concerns about the lack of control the family members together. The project leaders groups and the fact that the program had started considered arranging half-day programs called before the development of a research protocol. A ‘‘Days of Helping and Healing,’’ which would pre- local evaluator was subsequently retained who at- sent guest speakers to address the challenges to fa- tempted to employ psychometrically sound mea- mily reconciliation occasioned by traumatic loss. sures to assess the impact of the groups. Initially, the The final area of direct service need that had Behavior Assessment System for Children (BASC) been previously unmet was continuing support (Reynolds & Kamphaus, 1992) was administered services for boys between the ages of 5 and 11. during the fall of 2003 in response to the mothers’ Because the monthly pilot groups had been limited expressed concerns about their children’s current to girls, parents requested that this program be levels of adjustment. Results from the BASC did expanded to include the boys as well. not reveal any significant clinical symptomatology In the larger community, the project leaders felt among the respondents. This result is in line with that educators in the primary and secondary schools previously reviewed findings on the lack of pain the service area were ill equipped to recognize or thology in children and families’ reactions to manage the manifestations of long-term grief in trauma (Bonanno, 2004; Joshi & Lewin, 2004; children. It seemed critical to provide training to Padgett, 2002). help these teachers distinguish the symptoms of Subsequently, the State Hope Scales for Chil- grief from normal developmental changes in order dren (Snyder et al., in press) and Adults (Snyder to increase their capacity to become active partners et al., 1996) were selected as having sound psy- in longer-term recovery. There also seemed to be a chometric properties and measuring a proposed need to alert teachers to curriculum material that impact of the GOALs program: an increase in hope might create trauma or loss reminders and thereby expressed as a sense of ability to initiate and sus- compromise the learning of affected students. Table tain action toward a desired goal. These measures 21.6 shows an outline of the specific interventions were administered to a group of participants before the leaders designed to address these needs. and after the spring of 2004 in a six-session program for 20 children and 17 adults. There were significant increases in hope for both children Evaluation (t ¼ 3.04, p < .007) and adults (t ¼ 4.00, p < .001). Because of a lack of control groups, this provided While the planners sought to derive the interven- limited support for the proposed program logic. tion from their experience with conceptually and For the program staff, the ongoing observations empirically grounded approaches, a substantial ev- of and feedback from group members, while not aluation component was not associated with the empirical data, reinforced the importance of the intervention. In fact, attempts to evaluate the in- program. From the parent who reported that his 4- tervention may be considered a case study of issues year-old daughter would read from her box of pain the evaluation of a grass-roots response to an lancas before bedtime every night to the teenaged unprecedented event. The initial GOALs groups girl who wore her ‘‘web of connection’’ bracelet started in the spring of 2002, and the planners until it fell off her wrist, stories of how the lessons focused on the timely development of an appro- have been incorporated into the participants’ ev- priate response. Hence, as with many community- eryday lives continued to surface months after the based interventions, evaluation was not built in formal groups had ended. One anecdote in parti- from the start. Also, the initial intervention was cular seems to capture the intention that was central considered a pilot and thus not at an evaluable level to the project’s creation. A 9-year-old girl had been (Wholey, 1979). Moreover, aside from participant introduced to the monthly groups in November feedback, the imposition of evaluation was con- 2003. Quiet and shy and still recovering from her sidered culturally insensitive in that context. mother’s death, the group leaders were unsure of Before the fall of 2003, GOALs staff members what she took away from the sessions. Several days consulted with a national expert on the evaluation after the girl’s attendance at her third session, the the series Rationale Using an empowerment theory ofsupport community groups intervention, recognize these thecontinuing importance support of to providing those9/11. families Techniques who in suffered the lossesparticipants group on and recognize use the cognitive resiliencethe techniques of challenges to created address by some complicated of bereavement. This biweekly group series is the companion to a similar for young girls. Itchallenges prepares in children the for grief somesolving, process of reinforces through the the education continuing use andto of problem enhance cognitive coping, behavioral and techniques strengthens support systems. Strategically timed interventions allowlearned families during to group practice seriesfor skills and families provide to an share opportunity of an the activity deceased. that incorporates the memory that female group reinforce creative activities (e.g., writing, art) bibliotherapy and handouts; consultationgroup with leaders discussion and handouts review of cognitive behavioral techniques creative activities (e.g., writing,storytelling, art, music) exercise, cognitive techniques such asrestructuring cognitive Intervention meets in the eveningThe to groups accommodate will working use parents. following techniques: Continuation of biweeklychoeducation community-based groups that support beganThe and meeting first in psy- group January meets 2004. during the day, while the second coleaders who use the following techniques: Biweekly community-based support group, with male and family strengths, and recognizepart the of deceased family as life. a Activitiesexercises, continuing include meals, creative and art special projects, rituals writing to honor the deceased. Continuation of special programsbring held families at together selected to intervals engage in creative activities, ‘‘Family Days’’ Phase 3 activities widowers complicated grief process for adults of grief on children impact of 9/11 onsystem the family process mourning process times of the year with other group members Table 21.6. Identified Need Adults 1. Support for widows and 2. Information about the 3. Information about the impact 4. Recognition of the permanent 4. Enhancement of coping skills Boys aged 6–11 1. Support to normalize the grief 2. Information about grief 3. Strategies to facilitate the 4. Enhancement of coping skills Family units 1. Family support at challenging 2. Opportunity for reconnection

332 to Traumatic deaths can fracturechallenges family in systems, role creating functioningIn and particular, communication the patterns. inequitiesto of different formal types support of provided family family tension members and after dysfunction. 9/11all These added of workshops the will family bring that members can together assist to in explore family neutral recovery. topics Since children spend mostthe of school their setting, structured educators timeprovide are within appropriate on support the and frontproblems. identify line Educator potential to empowerment isthrough always the facilitated provision of information. to all ‘‘Days of Helping andFour Healing’’ workshops with guestto speakers grief address and issues transcendence, related of spirituality, respecting the differences importance infor grieving accessing styles, healing personal energy, strategies in and family adjusting structure to and thesmall functioning. changes groups Participants based also on form widow, their etc.) role to in receive theopportunity individualized family to support (sibling, discuss and parent, the an their impact perspective of in their the lossneeds family within assessments system. to Participants determine complete discussion. additional topics for future ‘‘Train the Teachers’’ Half-day workshops are offeredthese to educators identiﬁed to address needs.video material, Workshops and interactive uselearning exercises objectives. to didactic accomplish information, Teacher focus groups generatereminders. examples of A curriculum shortlocal pamphlet schools is that summarizes writtenaddresses the educator and groups’ remediation ﬁndings distributed strategies. and of connection between extended family and nuclear family members members to join in healing activities the grieving process inespecially children, as it relatesdevelopmental to differences work within their limitedresponsibility range of access additional school and community resources regular curriculum can createand/or trauma loss reminders andto strategies address these remindersclassroom in the Entire family 1. Opportunity to increase feelings 2. Opportunity for extended family Educators 1. Accurate information about 2. Practical strategies to facilitate grief 3. Knowledge about ways in which to 4. Recognition of the ways in which

333 334 Assessment and Treatment leader received a phone call from the child’s aunt, youths who are evidencing significant stress reac- who related the following story: ‘‘We were out tions, they share many elements with the Family running errands, when, out of the blue, my niece GOALs project. began talking about the kind of car she wanted to drive when she grew up. She even said she knew what she wanted to have on a personalized license References plate. When I asked her what she wanted, my niece responded, ‘GOALs. That means ‘‘going on after Appleton, V. (2000). Avenues of hope: Art therapy and loss,’’ and that’s what I’m doing: going on after loss.’’’ the resolution of trauma. Art Therapy: Journal of the American Art Therapy Association, 19(1), 6–13. Barker, P. (1985). Using metaphors in psychotherapy. Summary and Conclusions New York: Brunner-Mazel. Berkowitz, S. J. (2003). Children exposed to community violence: The rationale for early intervention. This chapter has described the development, im- Clinical Child and Family Psychology Review, 6, 293– plementation, modification, and dissemination of 302. community-based psychoeducational programs for Bloch, S., & Crouch, E. (1985). Therapeutic factors in families that lost their fathers in the 9/11 terrorist group psychotherapy. New York: Oxford University attacks on New York City. The urgent need to re- Press. spond to the community-wide impacts of this event Bonanno, G. A. (2004). Loss, trauma, and human precluded the application of an orderly, deductive, resilience: Have we underestimated the human laboratory-based methodology. As a result, the capacity to thrive after extremely aversive events? GOALs program, a grass-roots intervention, drew American Psychologist, 59, 20–28. Bryant, R. A, Harvey, A. G., Dang, S. T., Sackville, T., upon its creators’ extensive experience in the de- & Basten, C. (1998) Treatment of acute stress velopment and provision of community-based in- disorder: A comparison of cognitive-behavioral terventions that apply existing clinical principles therapy and supportive counseling. Journal of and related empirical findings. As such, this pro- Consulting and Clinical Psychology, 66, 862–866. gram incorporated nearly all of the essential Buchele, B. J., & Spitz, H. I. (Eds.). (2004). Group components of the current knowledge as identified interventions for treatment of psychological trauma. by reviews of family and group interventions New York: American Group Psychotherapy in response to terrorism and community violence Association. (Gurwitch et al., 2002; Saltzman et al., in press) and Burrough, C., & Mize, D. (2004). Ongoing, long-term trauma (Catherall, 2004; Klein & Schermer, 2000); grief support groups for traumatized families. In evidence-based prevention programs for youth N. B. Webb (Ed.), Mass trauma and violence: Helping families and children cope (pp. 142–166). New (Nation et al., 2003); family strengthening and re- York: Guilford. silience (Kumpfer & Alvarado, 2003); and research Butcher, J. A., & Maudal, G. R. (1976). Crisis on mediators of effective group approaches (Bu- intervention. In I. B. Weiner (Ed.), Clinical methods chele & Spitz, 2004) (exceptions were mainly the in psychology (pp.591–648). New York: John exclusion of some of the clinical, indicated inter- Wiley. ventions). For example, research on group pro- Catherall, D. R. (Ed.). (2004). Handbook of stress, cesses (Bloch & Crouch, 1985; Worchel, 1994), has trauma, and the family. New York: Brunner- concluded that factors such as universality, altru- Routledge. ism, and vicarious learning affect group outcomes. Cook, A. S., & Dworkin, D. S. (1992). Helping the Saltzman et al. (in press) have cited studies invol- bereaved. New York: Basic Books. ving traumatized adolescents in high-crime com- Curry, C. (2002). Keeping your kids afloat when it feels like you’re sinking. Ann Arbor: Servant. munities in Southern California (Saltzman et al., Dembert, M. L., & Simmer, E. D. (2000). When trauma 2001a, 2001b), in postwar Bosnia (Layne et al., affects a community: Group interventions and 2001), and in the domestic school-based applica- support after a disaster. In R. H. Klein & V. L. tion of the program (Saltzman et al., 2001a, 2001b), Schermer (Eds.), Group psychotherapy for psycholo- as providing evidence of the effectiveness of the gical trauma (pp. 239–264). New York: Guilford. UCLA Trauma/Grief Group Psychotherapy Pro- Dunst, C. J., Trivette, C. M., & Deal, A. G. (1988). gram. Although these programs are intended for Enabling and empowering families: Principles and Children and Terrorism 335

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Cultural Considerations Caring for Culturally Diverse Communities in the Aftermath of Terrorist Attacks David Chiriboga

Chaos, loss of control, and health fears are common after catastrophic events. Engel et al., 2003

This chapter reviews the literature bearing on A second general point, one that is similar to clinical interventions with diverse communities in messages in other chapters of this book, is that the chaotic aftermath of a terrorist attack. In this caring for culturally diverse communities in the regard it should be emphasized from the outset that aftermath of an attack will be most effective if no group is homogeneous with respect to beliefs, planning begins before any such attack. As the values, and psychological characteristics. While reader progresses through this chapter, it will be- health professionals and others speak in terms of come clear that the clinicians who provide inter- broad ethnic, cultural, and geographic categories ventions in the aftermath of a terrorist attack often (e.g., New Yorkers, Mexican Americans, South- face nearly insurmountable difficulties with lin- erners, African Americans), there obviously are guistic, cultural, and possibly legal barriers. Such significant intragroup differences. Indeed, in many obstacles can be overcome if the provider estab- cases the differences within specific populations of lishes an effective working relationship with cul- interest are as great as those across groups, and tural and religious organizations. The latter often possibly greater. Thus the existence of group dif- have very effective channels into the community ferences does not necessarily mean that basic down to the individual level. Since there is evi- techniques in clinical intervention must vary by dence that disadvantaged groups, who are likely to group or subgroup. The previous chapters have include disproportionate numbers of ethnic spelled out in detail the pervasive impact of ter- minorities, are generally the hardest hit by natural rorism and presented information about clinical as well as intentional disasters (for an extensive interventions that has general applicability. For review see Norris, 2001), developing intervention example, those most directly affected by an attack strategies that are sensitive and appropriate to are more likely to experience a greater psychological cultural differences are a matter of interest. impact, regardless of their cultural and ethnic group. On the other hand, to the extent that General Considerations members of specific groups may be more likely to have special vulnerabilities, these vulnerabilities As documented elsewhere in this book, there is a deserve attention. long history of general disaster and crisis research,

338 Cultural Considerations 339 going back to Tyhurst’s (1957) study of natural Another general question that frames any dis- disasters, as well as Lindemann’s (1944) seminal cussion of how members of ethnic and racial study of the Coconut Grove disaster. In addition, groups respond to terrorism concerns their prior Bradburn and Caplovitz (1965) conducted two na- experience. At what point, for example, does con- tional probability studies with wide age ranges both tinued and/or violent acts of discrimination and before and after the assassination of President John persecution become the functional equivalent of F. Kennedy and found a nationwide decline in psy- terrorism? The growing anti-Semitism that has been chological well-being. Similarly, Three Mile Island, reported in European countries might be con- Bosnia, Kosovo, the plight of Asian refugees, and of strued as incremental terrorism, and the steady course the 1995 Oklahoma City bombing and the pace of cemetery and synagogue desecration may 2001 Twin Towers attack in New York City have all create feelings that are similar to those of a victim expanded our knowledge of how diverse popula- of terrorism. The circumstance of persons living in tions respond to large-scale crises and terrorism. Palestine or Iraq, in contrast, may be equivalent There is, however, one conspicuous gap in our know- to chronic terrorism. Furthermore, antagonism ledge base: A review of the literature suggests that against people in the United States who are per- the majority of studies focus on the aftermath of an ceived as being associated with Islamic terrorism act of terrorism. That is, they have tended to dis- or any other terrorist group may create its own regard the stress that researchers (e.g., Lazarus, trauma. All of these experiences may predispose 1966; Chiriboga & Catron, 1991) have for years people to adverse reactions in the context of a dis- referred to as the anticipation period. crete act of terrorism. With these thoughts in mind, Study of the anticipation period includes we review the demographics of ethnic minorities an evaluation of perceived or anticipated threat, as in the United States and basic issues related to well as the value of preparing people for the pro- mental health. spect of future stress. There is some evidence that people vary in how much they worry about future threats at a society level (see, for example, Fiske & Ethnic Minority Status and Treatment Chiriboga, 1990) but very little information about how people from differing ethnic minority back- The U.S. Census Bureau (2004) has provided es- grounds respond to the general threat of terrorism. timates for various population groups based on its In a study by Boscarino, Figley, and Adams (2003) survey of households conducted in the year 2002. of more than 1,000 New Yorkers a year after the Because the bureau is now including questions that 9/11 attack, Hispanics and African Americans allow responders to endorse not only a fairly ex- were reported to be more fearful of a future as- tensive array of racial and ethnic categories but also sault. Anticipatory fear and anxiety may be heigh- more than one category, it is possible to begin to tened by fact that television and the Internet have appreciate in some detail the cultural diversity of made the news of worldwide terrorism much more the United States. Respondents can now say they present in people’s lives. are not ‘‘Spanish/Hispanic/Latino’’ or, if they are, Repeated changes to the threat level, as issued they can check off one of four categories. Similarly, by the Office of Homeland Security, may play into for the ‘‘race’’ question, respondents can check any the hands of terrorists by keeping a focus on the of 15 different categories—all in addition to the potential danger. The continuing threat of terror- ‘‘Spanish/Hispanic/Latino’’ categories. ism, which varies in intensity and perceived im- While providing a more definitive view of mediacy, may exacerbate the distress of those ethnic racial mix—multiculturalism—the greater minorities who have prior experience with trau- complexity can make information more difficult to matic events, even in the absence of an actual act of interpret. For example, results from the 2002 terrorism. Hence, one of the underlying themes of American Community Survey (U.S. Census Bureau, this chapter is that careful and selective attention 2004) indicate there were 33,768,036 individuals to community needs for information and organi- living in the United States whose racial identifica- zational activities before any attack may play an tion was solely African American, but this number important role in lessening the impact of an act of expands to 35,824,849 if one includes those who terrorism. see themselves not only as African American but 340 Assessment and Treatment also as a member of one or more other racial groups. that they are generally less likely to utilize mental Moreover, as shown in table 22.1, 33,175,449 health services and face more barriers to care than Americans endorsed being African American and do populations that represent the majority culture were not also classified in the ethnic category of (Smedley, Stith, & Nelson, 2003; U.S. Department ‘‘Spanish/Hispanic/Latino.’’ The point is that what of Health and Human Services, 2001). would seem to be a very simple question of who is These access barriers have multiple origins, African American can be ambiguous. This in turn and a great deal of attention has been paid not only serves to emphasize the idea that one cannot take a to these origins but also to their clinical implica- person’s race or ethnic category for granted. tions. While it is beyond the scope of this chapter Table 22.1 also provides estimates of His- to describe at any level of depth the approaches panics by three specific categories and several and skills necessary for clinical interventions with other groupings. Perhaps the most important in- culturally diverse patients and communities, there formation to be gleaned from the table is that are numerous excellent texts on the subject (see 89,302,016 people (total estimated population Bemak, Chung, & Pedersen, 2003; Council of minus the number who endorsed only the non- National Psychological Associations for the Ad- Hispanic white category) living in the United States vancement of Ethnic Minority Interests, 2003; in 2002 were not unambiguously ‘‘white.’’ To vary- Dana, 2000; Fukuyama & Sevig, 1999; Palmer, ing extents these 89þ million people, some 31.8% 2002; Paniagua, 2005; Sue, Casas & Manese, of the entire population, represent the culturally 1998; Sue & Sue, 2003; Wehrly, Kenney, & diverse community addressed in this chapter. To Kenney, 1999). These texts document specific re- varying extents the standard approach to inter- commendations and issues involved with cultu- ventions in the aftermath of a terrorist attack may rally diverse client populations. The most frequent not be effective with these people. recommendations include having knowledge of Before considering strategies for effective in- and displaying respect for the client’s cultural terventions in the context of terrorism, it is im- heritage, providing services in the language of portant to assess what is known about the general clients who are limited in English proficiency, and clinical and treatment needs of diverse commu- understanding how the client’s cultural back- nities. One of the more important themes evident ground might affect symptom manifestation, sig- in the clinical literature on minority populations is nificance, and treatment. The issues underlying

Table 22.1. Data from the 2002 American Community Survey (U.S. Census, 2004), showing numbers of Hispanics and non-Hispanics from various categories

Total U.S. Population (2002) 280,540,330

Hispanic or Latino (any race) 37,872,475 Mexican 23,999,836 Puerto Rican 3,608,309 Cuban 1,357,744 Other Hispanic or Latino 8,906,586

Not Hispanic or Latino 242,667,855 White alone 191,238,314 Black or African American alone 33,175,449 American Indian or Alaska Native alone 1,651,069 Asian alone 11,113,311 Native Hawaiian and Other Pacific Islander alone 331,228 Some other race alone 655,179 Two or more races 4,503,305 Cultural Considerations 341 these recommendations are complex and far reach- aliens number in the millions and are estimated to ing. As one example, the American Psychological account for approximately 25% of all immigrants Association’s (2003) Division 17 guidelines list six to the United States (Massey & Capoferro, 2004). principles and 12 guidelines, most of which in- Coming from a diverse array of nations and clude multiple subcategories that should be con- countries, they live in an invisible, parallel uni- sidered when conducting therapy with ethnic verse when it comes to ordinary health and human minority clients. services (Prentice, Pebley & Sastry, 2005; Sid- The general information provided in clinical dharthan & Alalasundaram, 1993). For such texts and guidelines focuses on provider sensitiv- people, participation in any activity they perceive ities as well as language competence. There are, as government sponsored, even something as however, a number of specific risk factors related to simple but important as an emergency evacuation the minority experience that may facilitate inter- may be viewed with alarm due to the increased ventions in times of crisis as well as under more chance of discovery. The same fears of participa- normal conditions of care. tion may be found in immediate family members, even if documented and legally present in the Family History in the United States country, since they may be torn between leaving an undocumented family member or of being the Generally, first-generation Americans are less ac- cause of that person’s discovery. culturated, less assimilated, and less educated and Personal history can lead to the rather mun- make less use of formal social services. They are dane anxiety and distress of having to deal with a also more likely to be uninsured. Hispanics of all little-understood bureaucracy once again—a feel- generations in fact are far more likely to be unin- ing that is easily exacerbated by limited English sured than non-Hispanic whites or African Amer- proficiency. Perhaps more critical is the situation icans. All of these probabilities occur in varying faced by immigrants who arrive as refugees. mixes for any particular client. For example, Cuban Usually of low income and from rural areas, they Americans are likely—depending on which wave of have often encountered traumatic events in the immigration brought them to the United States—to process that led to their becoming refugees. And, be better educated than Mexican Americans. On while a great deal of attention has been paid to the other hand, in one census-based study of older their clinical needs (see, for example, Bemak, Cuban Americans, more than 60% reported diffi- Chung, & Pedersen, 2003; Miller & Rasco, 2004), culties in speaking English, compared to 32% of many—if not the majority—have received only older Mexican Americans who have problems with minimal clinical attention. As one consequence, English. Cuban Americans were also the most likely refugees are more likely than other immigrants to of all Hispanic groups to live in linguistically iso- be suffering from PTSD. Immigrants from Cam- lated households (Mutchler & Brallier, 1999; see bodia, Bosnia, and Somalia are particularly likely also U.S. Census Bureau, 2002). The latter phe- to exhibit symptoms compatible with the DSM-IV nomenon, called linguistic isolation, is of particular classification (American Psychiatric Association, interest to health providers because in times of 1994; Bemak & Chung, 2004; Chung & Kagawa- crisis it may be difficult to reach those who live in Singer, 1993; Kinzie, Boehnlein, Riley & Sparr, linguistic enclaves. When considering how to most 2002). effectively work with a community before, during, Trauma, of course, is not restricted to these and after a terrorist attack, clinicians must consider groups. For example, Hispanic immigrants from El the prevalence of linguistically isolated people in Salvador and Guatemala frequently present with a each locality. history of war-related or other trauma (e.g., Mo- lesky, 1986). Furthermore, Pantin, Schwartz, Pra- Legal Status and Personal History do, Feaster, and Szapocznik (2003) found prior of Immigration experience with human-induced violence or natural disasters to heighten responses to 9/11 in a Legal status and history of immigration are related nonrandom sample of Hispanic immigrants living but distinct categories. So-called undocumented in the Miami area—none of whom was directly 342 Assessment and Treatment affected by the attack on the Twin Towers. Gen- that Hispanic caregivers exhibit more signs of erally, it would appear advisable, with clients who depression than non-Hispanic whites, African have immigrated to the United States or who are Americans, or Asian Americans (Aranda & Knight, members of groups that may have experienced 1997). Further, as a result of the immigration discrimination, for the clinician not only to pay experience, people may be left with a fragmented particular attention to obtaining a history of ex- family that is unable to provide traditional levels of posure to past trauma but also not to assume that, support. Due to work demands and generational simply because the trauma occurred several years differences in family values, older immigrants may ago, it has abated in potential influence. There is also find themselves expecting more from the family some evidence that a terrorist attack is likely to than younger members can—or are willing to— exacerbate these problems, and, because many of provide. these experiences involve aspects of terrorism, clients may be especially likely to experience re- Community Resources activation, intrusive thoughts, and other hallmarks as a result of the current event (e.g., Bemak, While ethnic minorities, especially those from Chung, & Pedersen, 2003). Hispanic and Asian subgroups, may not be linked into the usual health and human services system, English Fluency Versus Fluency they are often well networked into local community in Other Languages organizations and churches. For African Amer- icans, the church is a particularly effective resource Fluency in English is probably the most funda- and one that may prove to be invaluable for those mental aspect of acculturation (Chiriboga, 2004). involved with interventions in the pre- and post- Acculturation essentially refers to a person’s terrorism periods (e.g., Taylor, Chatters, & Levin, knowledge of various aspects of the host culture, 2004). including language, what to wear, and when to get to work. Those who are less acculturated are far Educational Attainment more likely to encounter barriers to the access of health and human services—obstacles that would Aside from persons from Japanese and Chinese almost certainly be greater during a crisis. The backgrounds, ethnic minorities are more likely to barriers may arise in part because so much of our manifest comparatively low levels of educational health systems, including interventions designed attainment. Immigrant populations, especially those around the prospect of a terrorist attack, are tar- who are older, are especially likely to have received geted to those who are proficient in English. For little by way of formal education (e.g., Chiriboga, this reason and also because of factors such as the Black, Aranda, & Markides, 2002). Hence, health stigma of mental health problems, those who are providers must ensure that services are provided in less acculturated tend to be underutilizers of health the appropriate language, and information and in- care services (Smedley, Stith, & Nelson, 2003). deed all communication should be tailored to the client’s abilities. Possibly the most effective strategy Social Supports Available would be to assume that clients have received no Through the Family more than a grade school education, although this creates the risk of ‘‘talking down’’ to some clients. The literature generally suggests that ethnic minority families are more likely than non-Hispanic Loss of Social Status whites to have larger and more closely-knit families and that these families provide a great deal While an improvement in status is probably not a of support during times of stress. On the other matter of concern, those whose status declined in hand, the health professional should not assume meaningful ways (e.g., physician to janitor) after that the family is always a robust provider of arriving in the United States may present with support. There is evidence that such is not always increased mental and physical health risks. This the case. For example, several studies have reported issue is more likely to be a factor for the recent Cultural Considerations 343 immigrant than for longer-term residents (Myers & reasons, some people may prefer the term ‘‘Latin Rodrı´guez, 2003). American’’ and would consider the label ‘‘Hispanic American’’ insulting. Stresses Experienced as a Result of the The critical factor here is not to assume that, Acculturation Experience just because someone appears to be of a particular group, that person self-identifies with that group The relocation to a new country may produce what or behaves in ways generally associated with that is sometimes referred to as ‘‘relocation shock.’’ This group (Paniagua, 2005). It is more culturally ap- disruptive experience seems to last for at most 10 propriate, instead, to ask clients how they self- years (Beiser, 1999). However, some evidence in- identify in terms of groups and whether they be- dicates that people who are relatively less long to any religious group. Of course, some acculturated—as exemplified by those who have people may self-identify outside of the presumed little or no ability in English—may experience reference group and have little contact with the more day-to-day stressors and have more symp- cultural and religious organizations one might toms of depression regardless of how long they expect. If so and if they do have problems as a have lived in the United States (e.g., Chiriboga, result of terrorism, they may be difficult to identify Black, Aranda, & Markides, 2002). and reach. In addition to these specific risk factors, there are additional factors that can strongly affect the treatment of ethnic minorities and that are also Place of Birth appropriate to interventions in the wake of a ter- More than 33 million residents of the United States rorist attack. What follows represents an amalga- were born in other countries, with the majority mation of points raised in various books and (more than 17 million) coming from Central and articles on the treatment of ethnic minority clients. South America and approximately 25% coming from Asia (U.S. Census, 2004). Little or no in- Cultural Identity formation is available on their age of entrance into The health provider should not assume that, sim- the United States or on their level of acculturation ply because clients appear to be from a particular and assimilation. Acculturation, which involves ethnic minority group, this is the group with learning the host country’s language and also the which they identify. Those whose racial ancestry kinds of behaviors suitable to the host culture, traces back to Africa but whose immediate past often takes years—even generations—to grow to a traces to the Dominican Republic, for example, level at which the individual is comfortable with a may self-identify as Hispanic Americans and in- new language and know how to get along in the deed be most fluent in Spanish. Differing genera- host society. Indeed, in one epidemiological study tions of ethnic minorities may also have different of 3,050 Mexican American elders from five states, values and behaviors and self-identify quite dif- nearly 47% of whom were born outside the United ferently in terms of ethnic minority group. Making States, more than 30% did not speak English and the ad hoc assumption that someone belongs to more than a third could not read English (Chir- a particular group may thus trigger inappropriate iboga, Black, Aranda, & Markides, 2002). lines of questioning or unsuitable proposals for For such immigrant populations, cultural va- action. For example, like many Hispanics, because lues and beliefs may interfere with mental health African Americans often hold deep religious be- interventions. At the least, mental health practi- liefs, religious institutions can not only play an tioners involved in pre- and postattack interven- important role in their lives but also provide a tions should be sensitive to the interpretations of vehicle for interventions (e.g., Fukuyama & Sevig, symptoms made by people of diverse backgrounds. 1999; Taylor, Chatters, & Levin, 2004). However, These interpretations are influenced by personal an African American atheist might be quite in- history and cultural background, both of which will sulted if the provider assumed that religion or re- also affect decisions on what actions to take (e.g., ligious groups should have anything to do with Engel et al., 2003). For example, mental illness may helping that person. Similarly, for geopolitical be viewed as a mark of shame, something that 344 Assessment and Treatment dishonors the family; such a perspective may create sicians with regard to mental health problems in a barrier to help seeking and may require strategies diverse cultural groupings. such as labeling an intervention as educational or as partnership training rather than therapeutic (e.g., Health Literacy Smedley, Stith, & Nelson, 2003). A recent Institute of Medicine (IOM) report esti- The Greater Importance of Gatekeepers mates that nearly 90 million Americans have problems understanding written (and probably oral, Gatekeepers are usually defined as people who although the research on this topic is less extensive) facilitate and negotiate access to various resources. communications concerning their health (IOM, As such, they hold an especially important position 2004). Health literacy problems may be found in in the lives of immigrants and those for whom people who utilize any language: A Spanish-only literacy, education in general, and language create speaker may have problems comprehending in- barriers (Myers & Rodrı´guez, 2003). Gatekeepers structions about their health in Spanish. Surpris- can be from organizations (cultural, religious, etc.) ingly, more than half of those with limited abilities or can be individuals (family members or friends). in comprehending health information are Cauca- Their presence may be most important when a sians; in general, those who are poor or elderly, client lives where there are relatively few people belong to ethnic and racial minorities, and/or have with whom that person shares cultural and lin- less than a high school education have a higher guistic characteristics. On the other hand, in areas probability of health illiteracy. where many people with similar backgrounds re- The consequences can be grave: These people side, the need for specific gatekeepers is usually have been found to be less likely to use health reduced. Examples include the Chinese residents services, self-report poorer health, and are less of San Francisco’s Chinatown or the Cuban Amer- knowledgeable about their existing health condi- icans living in Miami, where close to 70% of the tions (IOM, 2004). Such findings raise serious residents are of Hispanic origin. Emphasis, how- concerns about the efficacy of preattack, periattack, ever, should be placed on ‘‘the usual case’’: Under and postattack information and intervention efforts, emergency conditions such as those associated with regardless of the provider’s cultural competence. a terrorist attack, gatekeepers and other sources of The findings, indeed, highlight the problems of information may be unavailable. attending to the needs of ethnic and racial mino- Usual Sources of Care rities, who often present with risk factors for health illiteracy in addition to their minority status: They While people from cultural backgrounds from are more likely to be poor and less educated. outside the United States may be more likely than Moreover, immigrant populations may also be un- mainstream citizens to seek alternative medical familiar with the way health services are provided in providers, they still are highly likely to seek medical the United States and may therefore be less effec- care from physicians. For example, 80% of African tive—for this reason alone, let alone the level of American and 78% of Hispanic American bene- health illiteracy—in seeking help. ficiaries of Medicare said they sought help from a specific doctor when necessary (Centers for Medi- care and Medicaid Services [CMS], 2002). These Language percentages are lower than the 91% of white non- Approximately 47,663,000 residents in the United Hispanic citizens but still suggest that health pro- States speak a language other than English at viders who provide physical and mental health care home, and of these, nearly 21 million have pro- in the aftermath of a terrorist attack should develop blems speaking English (U.S. Census, 2004). As an working relationships and communication systems example, 13,639,423 Hispanics spoke English with primary care physicians. Of particular concern less than ‘‘very well,’’ and the same was true for for those charged with clinical interventions, ethnic 7,248,604 Asian and Pacific Islanders. Age differ- minorities are often reluctant to seek help for ences should be considered because elder mem- mental health problems (Chen, Chung, Chen, bers of culturally diverse communities may be Fang, & Chen, 2003; Leong & Lau, 2001). Hence it particularly needful of help during a crisis but would seem critical to educate primary care phy- also particularly unlikely to receive help due to Cultural Considerations 345 language-related problems. Among those aged 65 a. Guideline Standard 1. ‘‘Health care organiza- and over, for example, 2,340,868 individuals were tions should ensure that patients/consumers reported in the census to speak English ‘‘less receive from all staff members effective, un- than ‘very well.’ ’’ In addition, as mentioned earlier derstandable, and respectful care that is pro- over 1 million people aged 65 and over live in vided in a manner compatible with their households where no adult or adolescent is fluent cultural health beliefs and practices and pre- in English. ferred language.’’ This in a nutshell outlines Although few if any studies have considered what those who provide mental health services the question of whether gatekeeper-enabled fa- in the aftermath of a disaster should consider. milies have better access or receive better care for In many ways these things are what any client their members, there are numerous anecdotal re- should expect, but staffing patterns and fund- ports and at least hints in the literature. In one ing for training often make compliance diffi- large epidemiological study of Mexican American cult. The chaotic conditions that can follow a elders, Chiriboga, Black, Aranda, and Markides major terrorist incident make a difficult task (2002) found that, where English was more likely that much harder. There are, however, steps to be spoken at family gatherings, elders also had a that can be taken. lower probability of reporting depressive symp- b. Mandated Standard 4. ‘‘Health care organiza- toms. This suggests that, when some members of tions must offer and provide language assis- the extended family are conversant with the host tance services, including staff and interpreter culture, they may have more access to resources. In services, at no cost to each patient/consumer the case of terrorism, the family may be more ef- with limited English proficiency at all points of fective in providing resources and linking elders contact, in a timely manner during all hours of (as well as themselves) to more formal resources operation.’’ This standard is a difficult one to and may also facilitate any intervention efforts by meet even in normal times, and, obviously, in health providers. a time of crisis its achievement becomes even Considering the statistics on English fluency, more problematic. The likelihood of having as well as the great diversity of languages spoken trained bilingual (or multilingual) staff avail- by those who have problems with English and the able is low, and while the use of telephone relatively low numbers of health providers who are interpreter services is recommended, the 9/11 bilingual, the task of communicating even in the experience indicates that the nation’s tele- absence of a terrorist attack is challenging. This is phone system is likely to be overloaded during one reason the U.S. Department of Health and a crisis. One part of the solution is for local Human Services’ Office of Minority Health (OMH), and regional intervention services to form established in 1989, has developed 14 standards partnerships with community-based programs for what it calls ‘‘culturally and linguistically ap- that serve the needs of the various ethnic propriate services,’’ commonly referred to as CLAS minority populations. Such community part- (OMH, 2001). If implemented well before a dis- ners can assist in the identification of those aster of any sort, these standards should improve who might be at greater risk following an act of the effectiveness of emergency interventions for terrorism. Whatever the strategy developed for ethnic minorities. outreach, health providers should recognize The CLAS standards actually consist of four that Medicaid and the State Child Health In- mandates that are required of all recipients of surance Program (SCHIP) provide states with federal services, nine guidelines that consist of matching federal funds to help defray the costs activities recommended for adoption by programs, of translational services. and one recommendation that is suggested for c. Mandated Standard 5. ‘‘Health care organiza- consideration by health care programs. Here we tions must provide to patients/consumers in briefly review the four mandated standards (Stan- their preferred language both verbal offers and dards 4–7) and three of the guidelines (Standards written notices informing them of their rights 1, 11, 12) that seem particularly relevant for the to receive language assistance services.’’ The provision of care in the aftermath of terrorism verbal offer component of this mandate might (OMH, pp. 7, 10–13, 17, 18): be satisfied by either tape recordings or—at the 346 Assessment and Treatment

most sophisticated levels—by touch screen provides tables on a county and state level that multimedia computer programs; the latter detail multiple categories of race and ethnicity. require neither language nor computer literacy For example, under the category of Asian and and can provide spoken feedback to clients in Pacific Islander, four separate subcategories are the (preprogrammed) language of their choice provided (American Community Survey, (Sweeney & Chiriboga, 2003). Regardless, at 2004). the organizational level, such information is g. Guideline Standard 12. ‘‘Health care organiza- mandated. tions should develop participatory, collabora- d. Mandated Standard 6. ‘‘Health care organiza- tive partnerships and utilize a variety of formal tions must assure the competence of language and informal mechanisms to facilitate com- assistance provided to limited English profi- munity and patient/consumer involvement in cient patients/consumers by interpreters and designing and implementing CLAS-related ac- bilingual staff. Family and friends should not tivities.’’ In typical bureaucratic language this be used to provide interpretation services standard lays out perhaps the most critical (except on request by the patient/consumer.’’ element in effective postterrorism interven- Clearly meeting this standard—again one that tions: the development of community-provider is difficult for organizations to comply with in partnerships. Such partnerships, perhaps with the best of circumstances—becomes extremely local churches and minority-focused organi- problematic under emergency conditions, zations, can identify ethnic minority clients. especially when the provider may be attempt- Community partners could also be trained in ing interventions with people from outside the preattack actions such as community training usual catchment area. The OMH guidelines and information dissemination; attack phase specifically note that, in emergency situations, interventions such as quickly reaching out to the use of telephone interpretation may be the isolated members of the community (e.g., only available recourse. those with language barriers); and postattack e. Mandated Standard 7. ‘‘Health care organiza- interventions such as identifying people who tions must make available easily understood exhibit signs of posttraumatic stress, helping to patient-related materials and post signage in connect them with providers, and providing the languages of the commonly encountered translation services if necessary. groups and/or groups represented in the service area.’’ For those charged with mental health interventions in the aftermath of a terrorist attack, it might be helpful to develop Considerations Specific to Terrorism basic informational packets in all languages likely to be required. The rapidly evolving literature on terrorism has f. Guideline Standard 11. ‘‘Health care organiza- generally paid only minimal attention to how psy- tions should maintain a current demographic, chologists should specifically address the needs of cultural, and epidemiological profile of the ethnic and racial minorities. One exception is a fact community as well as a needs assessment to sheet (2004) produced by the American Psycho- accurately plan for and implement services that logical Association’s Task Force on Resilience in respond to the cultural and linguistic char- Response to Terrorism. The task force’s recom- acteristics of the service area.’’ In other words, mendations are primarily quite general in nature providers must be aware of the populations and overlap substantially with the general clinical within catchment areas that are likely to have literature discussed in the preceding section. Three special needs. This allows them to plan for the issues, however, are particularly deserving of at- provision of written and other information in tention with respect to terrorism. The first concerns clients’ primary languages. One resource for the fact that some members of ethnic minority planners is the information that is available at groups may be more likely to look like the people the website of the U.S. Census Bureau, where who have been identified as terrorists and therefore information on language fluency by county can may have a heightened risk of being viewed as be plotted in map format. One site of interest terrorists or being attacked. The second concerns a Cultural Considerations 347 phenomenon referred to by Comas-Dıáz and Ja- dealing with diverse and/or immigrant populations cobsen (2001) as ‘‘ethnocultural allodynia,’’ which as opposed to the general population, the issue of deals with the fact that members of ethnic minority reactivation becomes a matter of special concern groups are more likely than mainstream patients to since immigrants and racial or ethnic minorities are present with a history of multiple experiences with more likely to have a history of experiences with bias and discrimination. This history may lead to an discrimination, war-related trauma, internment, and unusual sensitivity to situations with even a hint of refugee trauma, as well as with the immigration discrimination. Even without a specific cause, they process (e.g., the experiences of the ‘‘boat people’’ may feel as though others are identifying them as from Vietnam), which means that more than the possible terrorists and therefore feel considerable expected proportions have either a history of PTSD distress even without a specific cause. And, as no- or currently active PTSD (Beiser, 1999). ted earlier, immigrants and refugees may have past experiences that can exacerbate responses to terrorism. The Invisible Minorities: Vulnerable The third issue pertains to the significance of and Unprotected the community for ethnic minorities. Citing the work of Clauss-Ehlers (2004), the fact sheet of the As mentioned earlier, people who lack fluency in American Psychological Association (2004) points English often experience serious barriers in terms of out that psychologists who are interested in fos- access to human services. The group that is po- tering greater resilience in ethnic minority com- tentially most vulnerable consists of older minorities munities may do well to consider the resilience of who have immigrated to the United States. Among the community. By implication, actions that en- those aged 65 and over, 2,340,868 were reported in hance such resilience, including inclusion of com- the census to speak English ‘‘less than ‘very well.’ ’’ munity partners in training activities and involve- In addition, there were 11,893,572 (4.7% of the ment of local agencies in identification of people at population) people aged 5 and over living in what potentially heightened risk of adverse reactions, the U.S. Census Bureau (2004) categorizes as ‘‘lin- become particularly important. However, it is also guistically isolated households,’’ which are house- worthy of note that this frequent source of strength holds in which no member aged 14 or over either may also be a particular vulnerability: Ethnic speaks only English or speaks English ‘‘very well’’ if minority members who may have recently moved, the primary language is not English. Of the latter, immigrated, or experienced some fragmentation 1,279,432 were aged 65 and over. One must con- of family and community ties due to circums- sider the barriers faced by those people that do not tances other than relocation may, during a crisis, have family members who can serve as gatekeepers find themselves without the sources of support to the English-speaking world. upon whom they might normally rely (Organista, Even more vulnerable are the illegal and un- Organista, & Kurasaki, 2003; Myers & Rodrı´guez, documented clients, whether younger or older. Al- 2003). though little information about them is readily More discussion of these and related points available, it seems reasonable to assume that such follows. A key point to keep in mind is that not people are less likely to speak English and to have only may members of ethnic minority commu- access to English speakers and, further, will feel nities have special needs but in many cases they more reluctant to seek help from formal providers may also be quite hard to identify and locate, even when there is a need. From a clinician’s point of if partnerships with organizations and leaders of view, it is important to note that, pursuant to the minority communities are established. Illegal Immigration Reform and Immigrant Re- sponsibility Act of 1996, undocumented aliens History of Exposure to Traumatic Events qualify only for emergency medical care (see also Siddharthan & Alalasundaram, 1993). Hence re- Several chapters in this volume point out that, for imbursement problems may accrue for any longer- those with a history of PTSD, exposure to additional term intervention. A critical point is whether ex- severely traumatic events can reactivate old pro- tension of care is required due to the continuation blems (see also North & Westerhaus, 2003). When of acute need. 348 Assessment and Treatment

A third group whose access to services may be at them by other members of the community. seriously compromised in the event of a terrorist Freyd (2002; see also Ibish, 2003) provides a attack are homeless people in general and minority number of examples of community anger directed homeless people in particular. As Conroy and Heer at Muslim-appearing adults and children in the (2003) report, Hispanic homeless people are vir- aftermath of 9/11. Moreover, Esses, Dovidio, and tually invisible—even to those who study home- Hodson (2002) note that America’s attitude toward less people, since this group often hangs out in immigration and immigrants may be becoming locations that are different from those of most more negative as a result of 9/11, a factor that may homeless people. be creating a condition of chronic distress among A fourth group, migrant workers, documented Muslims and Muslim-appearing people. These or not, may be invisible due to their frequent examples illustrate the need for preparations and movement across county and state lines. Because actual interventions now, as opposed to after some of this, migrant workers are likely not to be well future attack has taken place. integrated with other members of the local min- Therefore, in the aftermath of a terrorist attack, ority communities. Migrant and undocumented it would seem unreasonable to assume that health individuals may also be more likely to reside in professionals will have adequate resources to pro- hard-to-serve rural areas. While more than 90% of vide CLAS-compatible services to all of their po- Hispanics lived in metropolitan areas in 2000, tential clients. rural areas have witnessed a dramatic growth: From 1990 to 2000 their number grew from 120% to 416%, depending on the region of the country Technology and Intervention: (Kandel & Cromartie, 2004). A New Frontier A fifth group at particular risk consists of ethnic and racial minorities who work in relatively menial More than ever we now have the capability of dis- jobs that pay very low salaries. As de Bocanegra and seminating information to a geographically dis- Brickman (2004) report, a small and nonrepre- persed audience in multiple languages. Indeed, sentative sample of 77 low-income Chinese workers soon after the September 11 attacks, a Committee (primarily from New York’s garment district) were on Science and Technology for Countering Ter- still suffering economically and frequently in need rorism (2002) was established, and it subsequently not only of jobs but assistance with living expenses submitted a report detailing in part the potential some 8 months after 9/11. In part their continued role of technology. Not all of this role involves problems may have resulted from a historic un- the use of unusual and federal resources. Along derutilization of services. Anecdotal evidence also with newspapers and television, the Internet, CDs, suggests that their low incomes and precarious DVDs, and cell phones are potential resources for economic status made this group particularly vul- those charged with preparedness and pre- and nerable to trauma in the aftermath of the attack postinterventions. Interestingly, cell phones and since they had relatively fewer options. The vul- beepers are disproportionately owned by ethnic nerability arising from economic disadvantage is a and racial minorities in comparison to whites (Katz factor that is generalizable to all groups, but it is & Aspden, 1998; Wareham & Levy, 2002), al- more commonly encountered in ethnic minority though their Internet usage lags behind that of the populations. mainstream community. Internet usage by His- panics in the United States is increasing, in part Guilt by Association: Clinical Interventions because it is growing in Mexico and other Latin With Those Falsely Identified as Terrorists countries (Curry, Contreras, & Kenney, 2004). The use of multiple media technologies, what There is ample evidence that people from the is collectively referred to as the information tech- Middle East, those who follow the Muslim religion, nology (IT) infrastructure, should provide a rea- and even those who appear to be from the Arab sonably effective way to disseminate information world may bear a double burden after a terrorist from international to national to state and local attack. They experience not only the trauma of the and finally to the community-member level. Not- attack but also discrimination and anger directed withstanding the dependency of these tools on the Cultural Considerations 349 electrical grid, which may of course be disrupted needs, the procedures implemented in Linn by acts of terrorism, there are capabilities that County could readily become part of the larger can be utilized to rapidly inform members of the national programs being developed. The bottom diverse and geographically dispersed minority line is that providing the agencies at all levels of community as well as mainstream Americans. government with appropriate information on the A vital component of this effort is a more in- necessary and appropriate psychological interven- tegrated, national system of command, control, tions for its diverse citizenry and also incorporat- communication, and information (C3I). Responsi- ing local minority-oriented religious and secular bility for the latter falls under the National Com- organizations would be helpful in preevent and munications System (NCS) and the Government immediate-event interventions. This step should Emergency Telecommunications Service (GETS). be a priority for those who are concerned about At all levels the technology is currently available— psychological interventions with a culturally and but not necessarily implemented—to automatically ethnically diverse population. dial phones (land based as well as cell) with in- At the level of postattack, the need shifts from formation about appropriate actions to take in the informing the population of minorities at risk and case of an attack—in the language of the call relearning more about who and where they live to ceiver. This type of service therefore has the po- the issue of providing mental health intervention. tential of becoming an invaluable tool for first If location strategies and community partnerships responders, who must deal with the immediate have been developed, communication with com- impact of a catastrophic terrorist attack, since calls munity partners and potential patients becomes in the language of the receiver could be sent not paramount. Given the great number of potential only to individuals but also to agencies that serve languages, as well as the fact that the providers minority communities. Indeed, there is evidence may be called to areas outside their own catch- that such automated telephone emergency systems ment, interpretation becomes an issue. If commu- can also be used as an information-dissemination nity partners have undergone training in the ethics tool prior to the emergency (Rich & Conn, 1995). and health terminology, they may be an appro- Full implementation of a language translation priate resource. In addition, it would be advisable emergency system, while deemed critical by the to develop collaborations, before the fact, with the Committee on Science and Technology for Coun- telephone services that have historically been used tering Terrorism (2002) is still estimated to be to provide interpretative services in medical set- perhaps 3 years from deployment. One major tings. drawback is the host of agencies, from federal to There is evidence that such services are effec- local, that not only are involved but also often have tive, although they may substantially increase the competing or conflicting needs. amount of time required for a clinical session At the regional and local level, emergency re- (Oviatt & Cohen, 1992). Historically, the AT&T sponse agencies often maintain and use the basic Language Line (http://www.languageline.com) has technologies to warn citizens in a defined area of been the largest provider. While it has already pending disasters such as floods or hurricanes. For been mentioned that, during an attack, the avail- example, Linn County, Iowa, has adapted a geo- ability of telephone systems may be temporarily graphic information system (GIS), formerly used to compromised, psychological interventions requir- map mundane things such as trees and fire hy- ing interpretation (other than alerts and advisories) drants, as part of its metropolitan evacuation plan. would generally occur at a time when phone ser- With cooperation from the local Red Cross, all of the vice would generally be restored. It is in this county’s citizens were sent postage-paid cards, with context—the first week following an attack—that which the citizens supplied information about clinicians would presumably begin to face an ur- special needs in case of an emergency evacuation gent demand for interpretative services. There are (Linn County is home to a nuclear power plant, several models that might guide those charged whose proximity prompted concerns with evacua- with developing intervention services. One ex- tion procedures). ample is that developed by the Center for Im- By providing information on language pro- migrant Health at New York University School of blems and identifying other culturally related Medicine. This program is a comprehensive one 350 Assessment and Treatment that includes screening and training (with a 48- think through what is necessary before, during, and hour course on interpretation and a course in after any critical event. Given the greater vulner- medical translation) of potential interpreters, as ability of many ethnic minority groups, especially well as a train-the-trainer program. They have also immigrants and refugees, one value of this model is tested the efficacy of a ‘‘remote-simultaneous med- its readily adaptability with respect to working with ical interpreting system.’’ these groups. One key premise of both the matrix and the IOM report is the importance of preparation and of Planning for the Future people at all levels working together. In the context of cultural issues, a clear message is that state and One of the long-term needs is for well-designed local agencies should involve the various cultural research that can guide preattack, attack, and communities in the planning phases. These com- postattack planning that is linguistically and cul- munities can in turn form action groups that can turally appropriate to a diverse clientele. Clearly, facilitate preevent preparation (for example, by psychological response and intervention with di- hosting special sessions designed to inform people verse populations has not explicitly been a high about what to do in the event of a terrorist attack). priority in disaster planning (Butler, Panzer, & This is particularly important in the case of those Goldfrank, 2003). At the same time, there is no who speak little or no English and whose specific reason such interventions should not exist. For gatekeepers and/or community supports may be example, the stated purpose of the Federal Emer- unavailable during the chaotic days and weeks gency Management Agency (FEMA) is ‘‘teaching following a terrorist attack (see Table 22.2). people how to get through a disaster ...helping Another benefit of employing the Haddon ma- equip local and state emergency preparedness ... trix is that it encourages health professionals to coordinating the federal response to a disaster ... consider responses to terrorism as a process that making disaster assistance available to states, com- begins well before an actual terrorist attack and munities, businesses and individuals ...training integrates activities across a broad spectrum. On the emergency managers’’ (http://www.fema.gov/about/ downside, cultural competence is a broad and what.shtm). The FEMA webpage also speaks of ‘‘the challenging task, and, as the IOM report concludes, life cycle of disasters’’ and psychological interven- consideration of the cells of the matrix reveals that tions with vulnerable populations, among whom ‘‘the nation’s mental health, public health, medical, ethnic minority groupings figure prominently. and emergency response systems currently are not able to meet the psychological needs that result Federal and State Responses from terrorism’’ (Butler et al., 2003, p. 1). The Haddon matrix focuses on what should be There is general agreement at state and federal done before an event, in the immediate aftermath levels that effective interventions for community of the event, and during the extended postevent health should take place before a terrorist attack phase. These phases overlap completely with the occurs. Engel et al. (2003; see also Freedy, Shaw, classic stress model (e.g., Lazarus, 1966) and are Jarrell, & Masters, 1992) propose a stepped po- also similar to models proposed by Kubler-Ross pulation-based model of clinical intervention that (1969) and Horowitz (1997) as interventions for begins with preattack intervention strategies that people who are dealing with extremely distressing include screening for those at heightened risk, as events. While the focus of this chapter is more on well as general surveillance of how communities postevent treatment as it applies to those from are coping at all stages of an attack. At a broader diverse cultures, the first two phases also deserve level, a model called the ‘‘Haddon matrix’’ has attention. In particular, the IOM report emphasizes served as the organizing factor behind a report the critical importance of prospective activities, by the Institute of Medicine’s Committee on Re- including evidence-based research, that will lead sponding to the Psychological Consequences of to effective preevent activities at every factor level, Terrorism (Butler, Panzer, & Goldfrank, 2003). as well as ‘‘psychological first aid’’ (PFA) inter- The matrix has often been used in the development ventions that can be applied during the first mo- of public health interventions and helps planners ments and days following an act of terrorism. Cultural Considerations 351

Table 22.2. Haddon matrix for multicultural responses to terrorism

Signiﬁcant Factors

Health-related Professionals, Workplace, and Religious Gatekeepers, Families, and Phases Federal State Local Organizations Individuals

Preattack Develop Disseminate Implement Attend training Attend information and training programs programs to programs that programs that programs and rehearse steps to local agencies, are CLAS* include CLAS take religious organizations, programs, and individuals Attack Limit Limit Take steps to Ensure that Cooperate with family and local immediate immediate reduce harm immediate agencies and identify key effect of attack effect of attack needs of ethnic resources minority members are met Postattack Provide Disseminate Assist Outreach to Identify people in need resources information frontline community and provide health members resources professionals

*CLAS¼culturally and linguistically appropriate service (Ofﬁce of Minority Health, 2001)

Perhaps the two most relevant findings of the points is the necessity of taking action before any IOM report, in terms of cultural issues, are that event, rather than after the fact. the community should be fully represented in On the other hand, the IOM report also pays preevent planning and that it is important to de- relatively little attention to the needs of minorities. velop evidence-based training and education pro- Furthermore, while its emphasis on the need for an grams. The first is valuable because, if carried integrated and coordinated system that evolves from through, it emphasizes the need to include re- the federal level to that of the individual is praise- presentatives of ethnic minority groups at every worthy, it omits what from a cultural perspective level of planning. Unstated but potentially critical might indeed be the most critical—the international is that the representation should include not only level, which, after all, is where the diverse needs of a the major ethnic groups but also those that might multicultural world are most clearly seen. More- have special vulnerabilities, including people of over, there is considerable activity at this level. The the Muslim faith and perhaps refugee groups such World Health Organization (WHO), for example, as as the Cambodians and those from the Slavic areas, part of its growing concern with world conflicts, who have already been subjected to terrorism and sponsors training in culturally competent responses severe deprivation. The role of professional asso- to terrorism. One training program offers an inter- ciations such as the American Psychiatric Associa- national diploma in humanitarian assistance during tion and the American Psychological Association periods of conflict or natural disasters (Mitchell, are barely mentioned. 2003). Underlying concerns of the WHO are the The lack of attention to professional organi- preparation of people before an untoward event zations is troubling because, as the IOM report and occurs, the maintenance of their training, and the other chapters of this book make clear, there is a capability of ensuring some continuity of employ- paucity of direct information on psychological in- ment for those who are responsible for direct interventions appropriate to any group exposed to terventions. This concern is mirrored in the IOM a terrorist attack, let alone those of ethnic and report and can help to ensure that identified needs minority communities. Again, underlying both of minorities are kept at the forefront. 352 Assessment and Treatment

The Community Level involved to better understand their respective roles and responsibilities. In considering how to most effectively develop an infrastructure for interventions with victims of a Gatekeepers terrorist attack, proponents of the Haddon matrix Gatekeepers and community facilitators may be and others generally agree that community in- unavailable in the event of an attack. To a much volvement is essential. This is even more the case greater extent than native-born and highly as- when the target populations include ethnic mino- similated individuals, recent immigrants and those rities, for the reasons cited earlier. By developing who are less acculturated may rely heavily on gate- partnerships among its members, the community keepers, who are most often relatives or other itself is empowered: Instead of being guided by members of the informal network, and there is no well-meaning ‘‘experts’’ and authority figures from guarantee that these people will be accessible in the dominant culture, the minority groups them- the immediate aftermath of a terrorist attack. selves are enabled to take charge of actions that will result in an enhanced well-being of the com- At the Level of the Individual munity and its individual members. One unresolved issue is the question of whether Primary Care Physicians postattack individual (as well as community) in- Since members of ethnic minority communities— terventions should be tailored to the particular like nearly everyone else—are most likely to turn to needs of a diverse cultural community or whether primary care physicians for medical assistance, the the more critical issues involve outreach and in- latter represent an important partner in planning formation dissemination. Marin (1999) has de- and implementing mental health interventions. scribed steps to take in developing what he Emergency room staff members are also more likely calls ‘‘culturally appropriate interventions,’’ whose to function in a primary care capacity for ethnic driving assumptions are that (a) behavior is influ- minorities and hence should also be brought in enced by culture, (b) interventions designed for a as partners to participate in the planning and im- specific group will be more readily accepted, and plementation stages of programs that address the (c) simple adaptations and translations of existing pre-, peri-, and poststages of a terrorist attack. approaches are not sufficient. Significantly, Marin hopes that the targeted group would accept such Invigorating and Expanding the Role of tailored interventions, but he also acknowledges Community and Religious Organizations that it is not known whether interventions that are effective with mainstream Americans would be Among certain minority groups, religion and re- equally effective with minorities. Clearly there is a ligious organizations may play a vital role in aiding need for evidence-based practice in this area. With victims of terrorism. For example, because of their this in mind, what follows are several areas that historic importance to community life, ministers deserve attention from clinicians and researchers and church members may be a particularly valu- responsible for planning more culturally compe- able resource for African Americans (e.g., Taylor, tent interventions. Chatters, & Levin, 2004). Development of an Effective Screening Tool Development of Training Modules In order to identify ethnic minority group mem- Language-appropriate modules for first responders, bers who are at particular risk, we need to include clinicians, and community partners would assist in screening tools that effectively identify minority as the preattack preparations. Sensitivity to the needs well as majority Americans (National Institute of of the minority communities is a difficult goal to Mental Health, 2002; Jang, Kim, & Chiriboga, achieve not only because of logistic demands but 2005). A history of traumatic events and/or PTSD, also because of the task of providing multicultural for example, are risk indictors for everyone, but training (e.g., Strous, 2003). Training manuals and they are likely to be more prevalent among im- workshops associated with them will help all those migrants and refugees and therefore should at Cultural Considerations 353 least be considered in the development of such a well-executed studies of the effectiveness of efforts tool. to develop community partnerships and the determination of how in general to tailor interven- The Need to Develop Evidence-Based tions to address the needs of specific cultural Interventions for Ethnic Minorities groups. This of course is a rather obvious state- Only recently has evidence begun to surface that ment, given the daunting lack of evidence-based some widely accepted strategies for postdisaster research even for mainstream Americans. care, such as one-on-one recital of traumatic events, Conducting research and planning how to may not be appropriate (National Institute of better attend to the needs of a diverse population is Mental Health, 2002). There are a number of pro- obviously not the most compelling priority that mising avenues to explore in this regard, including faces any local, state, or federal organization. There approaches that are not heavily dependent on lan- are many challenging and costly tasks to meet as our guage fluency or health literacy. For example, nation—or any nation—attempts to develop stra- Shapiro (1999) has conducted a promising ap- tegies to assist those caught up in the aftermath of proach using eye movement desensitization in the terrorism. However, one of the unique aspects of treatment of traumatic memories; one session was the challenge presented by terrorism is that it affects found to desensitize memories. Similarly, on the everyone, from individuals up to the country’s basis of interventions with 110 trauma patients, leaders. Because of this universal need—for plan- Larsen reports that a system of memory recall ning, preparation, and actual implementation— coupled with eye movement tracking may be ef- and because our efforts in the United States are still fective. Moreover, Larsen found that, in the two in a relatively early stage, there is a window of op- instances in which interpreters were needed, the portunity to put into place strategies that can at least intervention remained efficacious (personal com- acquaint mental health practitioners with the basic munication, June, 2004). problems of dealing with people of diverse origins. Another intervention with particular promise In its most basic implementation, the Haddon for ethnic minorities may be the support group. model suggests that professionals who are operat- For example, Molesky (1986) has suggested that ing at each level of the matrix should involve re- the use of support groups with members of min- presentatives of ethnic minority populations in the ority groups may be particularly effective in crises decision-making process. These representatives, in because they may replicate the circumstances turn, should take actions that help not only to of communally oriented life in Central America. disseminate information but also to inform both However, well-crafted, randomized clinical trials health professionals and the populations in ques- and similar tests have yet to yield definitive state- tion about how to get in touch with one another in ments of best practices for nonminorities, let alone times of unexpected crises. Implementing such a ethnic minorities (National Institute of Mental procedure not only for terrorist events but also for Health, 2002). In all such efforts, a basic point to any unexpected disaster, natural or unnatural, will bear in mind is that one intervention does not help to ensure that the kinks will be straightened necessarily fit everyone’s needs. out by the time a real act of terrorism occurs. Finally, it is perhaps worth pointing out once Development of Evidence-Based again that being able to provide linguistically and Intervention Manuals culturally appropriate care to the victims of terror- Such manuals should include sections on how to ism does not necessarily require that one hire health effectively intervene, at all stages of an attack, with professionals from each and every culture. Certain ethnic minority segments of the population. strategies can be utilized, at least in the short run, to transcend language barriers. Community involvement presents another important strategy, Summing Up especially if representatives of diverse populations are included in planning or advisory committees. One of the more obvious and immediate needs The new technologies that facilitate translation, as underlying all future steps is the requirement for well as those that can provide both general and 354 Assessment and Treatment specific client information, constitute a particularly Bradburn, N.M., & Caplovitz, D. (1965). Reports on promising avenue for future development. These Happiness: A Pilot Study of Behavior Related to technologies have the advantage of placing in- Mental Health. Chicago: Aldine. formation at the immediate service of the client and Butler, A. S., Panzer, A. M., & Goldfrank, L. R. (Eds.). the therapist and assisting in triage and general case (2003). Preparing for the psychological consequences of terrorism: A public health strategy. Washington, management. 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The Psychological Consequences of Terrorist Alerts Rose McDermott Philip G. Zimbardo

Why, of course, the people don’t want war. ...That is understood. But, after all, it is the leaders of the country who determine the policy, and it is always a simple matter to drag the people along, whether it is a democracy, or a fascist dictatorship, or a parliament, or a communist dictatorship. Voice or no voice, the people can always be brought to the bidding of the leaders. That is easy. All you have to do is tell them they are being attacked and denounce the peacemakers for lack of patriotism and exposing the country to danger. It works the same in any country. Hermann Goering, during his Nuremberg war crimes trial

On April 18, 1775, patriot Paul Revere rode his worthy sources about specific dangers or threats that horse on his famous ‘‘midnight ride’’ from Boston may be dealt with by taking some recommended harbor toward Lexington, warning local colonial action. If the threat is likely to persist over an ex- leaders along the way that the British—the tended period of time, debriefing after each danger redcoats—were coming. He urged them to take up signal is essential to correct misinformation, mod- arms to oppose their tyrannical rulers. When the ify faulty recommendations, reinforce citizens for British arrived the next day, they were defeated at heeding the message, and reassure them of the value Concord by the colonial militia, and America’s of their collaborative efforts. Finally, if the threat Revolutionary War had its auspicious beginning. does not materialize, a reputable authority must Revere’s warning was effective for four reasons: explain why and then also lower or remove the alert. (1) He was known to be a highly credible com- Experimenters working with volunteers in institu- municator, both expert and trustworthy; (2) his tional and medical research are required to inform alarm was focused on a specific anticipated event; and debrief their subjects; a democratic government (3) it was designed to motivate citizens to act; and should follow similar procedures of ethical behavior (4) it called for a concrete set of actions. Moreover, toward its constituency. the people who heard Revere’s warning were We acknowledge that such debriefing can incur primed to accept it; they believed that the redcoats a substantial security cost. However, one of the real, represented an imminent threat. This Paul Revere if inadvertent, political advantages of the terror alert paradigm for the successful dissemination of public system is to direct increased funding to first re- alarms is supported by contemporary psychological sponders at a time when their resources are parti- research. To be optimally effective, such distress cularly constrained, given that many of these signals should arouse only a moderate level of officials are currently serving abroad as part of the motivation—too little fails to energize action and National Guard. Unlike alerts, which require a too much creates emotional overload and compet- single credible source, locally specific debriefing ing, distracting behaviors. can prove adequate to ameliorate the perception of Moreover, the warning notice must be based on threat and its concomitant negative psychological reliable evidence and presented clearly by trust- sequelae. To the extent that state and local officials

357 358 Assessment and Treatment feel their credibility depends on getting their mes- culture on which our current governmental system sage out before national leaders, such responders rests. may also serve a dual purpose in aiding with ap- We begin with a brief history of the use and propriate, timely, and geographically specific de- implementation of the color-coded scheme. Next, briefing. Using first responders to help with we present evidence summarizing the counter- debriefing can help defray costs that will accrue to productive impact of this system on the national these forces nonetheless and help alleviate the de- state of mental health. In short, we argue that the briefing burden that falls on federal officials. Fur- impact of this system does the terrorists’ work for thermore, adequate debriefing serves to make them by inducing a destructive degree of anxiety, citizens feel included in the process of their own depression, and paralysis in the population at defense in ways that reinforce the democratic pro- large. Then we combine two theoretical models, cess; in this way, the additional cost of debriefing, social identity theory and terror management the- however allocated and directed, can be justified on ory, both drawn from social psychology, to help normative grounds. explain how the current system encourages sup- One of the important ways in which the current port for standing, charismatic leadership. We then color-coded system diverges from the more effec- discuss the reason that government leaders may tive Revere paradigm is that, in reality, only two real have political and strategic incentives to continue colors exist. A five-stage scheme may have been to employ the current system despite the wide- chosen to produce an agile, specific system (Cohen spread mental health damage it incurs. Next we & Shapiro, 2005), but no one foresaw how this draw on these earlier arguments to explain how strategy would play out in practice. Red means that and why the current system poses threats to de- the United States is under attack, so red is not in mocratic values we should cherish. Finally, we effect an alert but rather an immediate warning of offer some suggestions for how to develop a more an ongoing event that should be obvious to all. And effective and less destructive terrorist alert system. because no politician appears willing to lower the alert below yellow for fear that an attack will be staged during a period of ostensible calm, only Implementation and Use yellow and orange remain actually viable colors. of the Current System Such a restrictive range hardly seems effective, efficient, or useful for informing people about the Terrorism is not about war in any traditional sense level of threat they face. of destroying the material resources of an enemy This chapter presents a theoretically informed nation and taking over that country. Rather, ter- critique of the current system of terrorist alarms. rorism is fundamentally about psychology. It is Terrorist alerts produce both political and psy- about taking strategic actions that incite terror and chological effects. Politically, terrorist warnings fright in civilian populations. One goal of some mobilize first responders as well as the public to terrorists is to make ordinary people feel vulner- increased vigilance, for example. However, while able, anxious, confused, uncertain, and helpless. ostensibly designed to improve the effectiveness of Ultimately, when terrorism works, citizens feel homeland defense, terrorist alerts also result in hopeless and lose trust in their leaders to guarantee various negative outcomes. In this chapter we the fundamentals of existence—safety and security. concentrate on three such specific problems. First, This is one of the reasons governments need to raising—as well as lowering—terrorist alarms work hard to preserve their basic values as they seek produces negative public mental health outcomes to make their populations more physically secure. and increases depression and posttraumatic stress Terrorism is about imagining the monster under disorder (PTSD) in the population at large. Sec- our beds or lurking in dark closets—the faceless, ond, this system encourages unthinking support omnipotent enemy who might be our friend, our for standing, charismatic leadership through a neighbor, or some horrible creature of our imagi- combination of heightened in-group bias and nation. It has no one place, time, space, or face. The mortality salience. Last, the current system of ter- power of terrorism lies precisely in its pervasive rorist alerts poses a threat to the diverse political ambiguity and in its invasion of our minds. The Psychological Consequences of Terrorist Alerts 359

Obviously, a difference exists between terror as ability, people want leaders to identify the ‘‘enemy’’ a category of actions and terror as a systematic po- for them, to give it a name, a face, and a location so litical strategy. The appropriate categorization de- that the public can channel their collective hatred pends on who undertakes a particular action for and unleash the strength of the military on a readily what purpose. As a result, the target of terror alerts winnable war against that evil, although weak, can vary between two distinct audiences: (1) the enemy. citizens of the United States who remain at risk; and The irony, of course, is that terrorists are also (2) the terrorists themselves and what they can often motivated to attack because they perceive learn about domestic intentions from watching re- themselves to be too weak to engage in a full frontal actions to their threat. In this chapter we examine military assault against their perceived enemies. Yet both effects. once they attack, they create their mirror image: a In particular, we argue that terror alerts can targeted population bent on the destruction of the increase the salience of the threat in ways that raise terrorists as well. The psychology of such a strategy negative public mental health outcomes without a at first seems ill formed, until analysts focus on the commensurate increase in public safety as a result. often hidden, secondary benefits of such a policy. Reactions to increased feelings of personal vulner- Terrorist leaders find recruits in the losses their ability vary considerably, from stimulating phobias, cause sustains, just as leaders in a targeted nation to triggering unresolved childhood conflicts, to can manipulate the very real psychology of fear and prolonging stress reactions, to blindly obeying anger perpetuated by the terrorists for their own powerful leaders, to arousing intense feelings of fear domestic political purposes, as the Goering quote and anger. Fear can make people more anxious and indicates. This transferential power lock deserves vigilant, motivating them to seek out more in- greater explanation and attention if efforts to break formation (Gray, 1982, 1987). it are to succeed. Anger is another form of displaced emotion that arises from feeling helpless or vulnerable. It can represent a turning out of intense and concealed Violations of Effective Alarm Principles feelings of weakness. Prejudice against out-groups is one consequence of such strong negative feelings, All of the basic principles embodied in the Revere which can prove particularly problematic when a paradigm were systematically violated in the design particular ethnic group is targeted and held ac- and delivery of the first six terrorist alarms issued countable for the acts of unrelated others. In addi- by U.S. government officials to warn the public of tion, negative emotions can lead to an increased imminent terrorist dangers after September 11, readiness to attack ‘‘safe’’ targets, such as margin- 2001. Different communicators, alleged to have realized peoples in our nation or even family mem- liable information from ‘‘credible’’ yet unnamed bers. Indeed, evidence suggests that angry people sources, warned of an imminent attack by terrorists support more punitive public policy choices. And, somewhere, sometime soon, in the United States or importantly, angry people also appear more opti- elsewhere in the world, against its offices or agen- mistic in their judgments about the risk of future cies. These warnings worked to create high levels of events (Lerner & Keltner, 2000). citizen fear, which over time morphed into gen- Human nature, or at least traditional male eralized anxiety for many. There were no concrete human nature, seems to abhor feelings of personal actions that citizens could take other than to remain weakness and uncertainty, seeking instead to ally on alert and keep their eyes open. This vague one’s identity with those manifesting strength and recommendation was termed ‘‘BOLO’’ for ‘‘Be on conviction. In times of crisis, people want to sup- the lookout.’’ This initial message, reiterated end- port leaders who are bold, single-minded, ag- lessly but emanating from a wide variety of different gressive, and even arrogant. Those who supported official and media sources, was then elaborated by Hitler and thus felt the shame and humiliation various ‘‘expert’’ commentators. The psychological foisted upon Germany following its defeat at the situation worsened when cognitive-emotional dis- end of World War I can be seen as succumbing to sonance was induced by the government’s collateral this temptation. In the face of ambiguous vulner- message to ‘‘go about your business as usual.’’ 360 Assessment and Treatment

It is psychologically impossible to remain both people what to be on the lookout for, it became hypervigilant and to go about your business as ‘‘normal’’ to be anxiously dreading the worst, given usual at the same time. How was it possible to go the lesson of the first horrific attacks on the World about our normal business after having declared Trade Center and the Pentagon, but being able to that the nation was under potential terrorist threat do nothing to prevent it. This situation produces and that our personal safety was about to be vio- the ironic and seemingly conflictual worst of all lated once again as it was on 9/11? The resulting conundrums: People remain too inured to report sense of confusion spills over into feelings of suspicious events and individuals but too anxious helplessness and results in suboptimal information to return to life as normal. processing, which in the event of a real attack would leave people less able to cope effectively. But then there was none! Not a single terrorist And Then There Were Seven attack on U.S. soil for the past 3 years. Where are the alleged thousands of terrorists inhabiting cells Something happened between the last of the ear- in our country? And where was the debriefing by liest unmarked six-pack of terrorist warnings and our authorities to explain why nothing happened? the later institution of the newly framed color- Had U.S. defenses proved invulnerable? Had at- coded alert that seemed at first to fit the psycho- tacks been thwarted? Were the terrorists merely logically effective Revere paradigm. It was clearly waiting until the vigilance passed and vulnerability presented by one communicator, Tom Ridge, the increased? Explanations were nowhere in sight or head of Homeland Security, and it amplified the sound. The high alert and its high anxiety induc- reliability of his informant by indicating that it was tion just silently evaporated until another month detected from multiple intelligence sources. It iden- or two went by, when the next call to alarm was tified the terrorist targets as ‘‘soft’’—U.S. homes and sounded again and again. We all know from the hotels—which, of course, targets everybody. In the classic story of the boy who cried wolf that, after next days, the target list expanded to include airlines only three false alarms, people cease to take ser- and other symbolic and strategic venues. The antici- iously the validity of previously credible messages. pated terrorist weapons escalated to the unthinkable: Indeed, they come to dismiss such warnings fairly ‘‘weapons of mass destruction’’—chemical, biologi- quickly over time because they prove to be in- cal, and radiological ‘‘dirty bombs.’’ With that much accurate; when warning comes without anything detail on the input side, the Homeland Security head happening afterward, people lose faith in the alert then added a shopping list of concrete actions that system itself. Americans should take on the output side to be Therefore, habituation effects set in, and peo- prepared for an all-out attack from any of the re- ple cease to take such notices of danger seriously, ported thousand terrorists operating on U.S. soil and as calls to action, after the first three or four times. preparing to use these weapons of mass destruction Indeed, providing immediate and accurate feed- against innocent civilians. back and debriefing after a failed warning serves Experts warned U.S. citizens over and over to prevent such habituation effects. Once people in all of the media outlets to gas up their cars in know why a false alert was issued, they can learn case of emergency evacuation, store emergency from the event. New information can help people supplies, and seal themselves in their homes using to better recognize real threats, while knowing plastic sheeting and duct tape. Specific warnings which potential ones they might safely ignore. were put up on the website of the Department of Such knowledge helps people assimilate threats in Homeland Security to aid in general emergency constructive ways that do not result in their feeling preparedness for the nation. For example, in the too overwhelmed to do anything at all, in which worst-case scenario of a neighborhood nuclear case they must either ignore the alert or remain blast, citizens were warned to take cover, assess the hypervigilant and anxious all of the time. situation, and limit their exposure to radiation. To Indeed, after six no-consequence alarms, many make sure the message appeared on the nation’s Americans became desensitized to the need to radar screen, after the mind-dulling previous six be on high alert—yet still to lead normal lives. false alarms, the Orange Alert was sounded, and Moreover, with no specific information that taught local, state, and federal forces swung into defensive The Psychological Consequences of Terrorist Alerts 361 action. At last, it seemed as though American ci- attacks as long as the target government acts to keep tizens had been given a concrete set of actions they the population continually fearful. This is what the could take to protect themselves, which seemed current system of color-coded terror alerts accom- better than just sitting idly by, waiting for in- plishes in effect if not in intent. Mismanaged and evitable death and destruction. misplaced warnings distress people well beyond a However, then it all began to unravel, as experts realistic nationwide risk level for any new terrorist asserted that we could suffocate ourselves by sealing attack, and they force the government to spend off the ventilation to our houses. We learned that billions of dollars in combating potential incipient some of the ‘‘reliable’’ sources of information were threats. These danger signals are creating a pre- hoaxes. And, again, there was no debriefing from traumatic stress syndrome among Americans that the government as to why the attacks did not occur gets reinforced and deepened with each new alert, or what had been done to prevent them. Instead, especially among those with more fragile psyches. the Orange Alert stayed in effect for weeks while the One possibility to consider is that terrorists, Department of Homeland Security continued a seeing the frenzy caused by the first alarms, learned nationwide campaign to promote emergency pre- to intentionally put out misinformation on channels paredness, fashioned after the programs of the that they know or assume are monitored by U.S. Federal Emergency Management Administration’s intelligence. That ‘‘chatter,’’ detected by U.S. in- natural disaster readiness programs. telligence services, stirs up the desired national Five more color-coded terror alerts followed turmoil and wastes a good deal of money in in the wake of the seventh. The one just before heightened security—without terrorists’ ever hav- the 2004 presidential election appeared the most ing to engage in actual attacks. In fact, terror alarms threatening because it predicted attacks on major reinforce a public willingness to spend huge sums financial centers and government buildings, which of money on military defense and homeland se- presented the potential prospect of interrupting the curity efforts, none of which have actually been electoral process itself. The credible source for this shown to have made the American public more alarm was a CD found in a terrorist’s computer, secure in any real way. Indeed, members of al- which subsequently proved to be more than 3 years Queda, many of whom were originally schooled in old; indeed, this information might well have been the Afghan war against the Soviets, may in fact recall research conducted before the attacks on the World that part of the U.S. strategy in the Cold War was to Trade Center occurred. But even when the age of force the Soviets to spend themselves into self- the source was discovered, the high alert stayed in destruction without ever having to fight the other place for several months, throughout the electoral superpower directly. This lesson may not have been campaign and the voting itself, under the reason- lost on those who saw one superpower decline able argument that it is not unusual for terrorists to precipitously, at least in part, because of excessive plan their attacks far in advance. military spending. A cell was in fact broken up in London a few Another conjecture concerns the unintended days after the last orange alert. The information that consequences of these many false alarms and per- led to the warning helped break it up. That is in fact haps some intended ones as well. Given the absence how the alert system should work. What remains of actual terrorist attacks in this country since 9/11, interesting in this case is the reason the danger signal as compared with Israel, for example, where many stayed in place for so long after the cell was dis- attacks have actually taken place, these warnings rupted if such action provided the original reason have worked to sustain a heightened sense of for the alert. anxiety and confusion. In Israel, where specific warnings, similar to weather reports, are given on the radio, more than 300 Israelis have been killed, Public Mental Health Outcomes and more than 4,000 more have been wounded in suicide bombings since the start of the intifada in Mismanaged alarm procedures do the terrorists’ 2000 (see Chapter 13 in this volume). Between work for them. If the goal of at least some terrorists is November of 2000 and May of 2004, 147 successful to instill fear and anxiety in the hearts and minds of and 376 foiled suicide attacks were carried out in civilians, they will not need to engage in any actual Israel. This constitutes less than 5% of the total 362 Assessment and Treatment number of attacks against Israeli targets in that time depressive symptoms had not been at the World but represents the majority of those inside the state Trade Center at the time of the attack, nor had they of Israel proper. To combat this threat, Israel spends themselves ever been in any personal danger from about 8.75% of its gross domestic product on de- the assault. In addition, those reporting symptoms fense, which was more than $8.97 billion in 2002 were not more likely to be related to one of the (Cordesman, 2005). victims of the violence. Moreover, these alerts also create a climate of Outside of New York City, the story remains hostility and danger that encourages political dissimilar. In a random-digit dial telephone survey of engagement. People are more willing to accept a representative sample of the United States, more both restrictions on their personal freedoms in the than 40% reported at least one of five ‘‘substantial form of legislation like the Patriot Act and violent stress symptoms,’’ and 90% reported low levels of actions against others, such as those that were stress symptoms (Schuster et al., 2001). Not sur- directed at the prisoners in Abu Ghraib. Our ar- prisingly, those closer to New York City reported gument is not that the prison guards at Abu Ghraib the highest rates overall, but many people who did their dirty deeds in response to fears of ter- lived at a great distance from the terrorist attack rorism. Rather, President Bush has said that his venue reported high levels of stress symptoms as goal is to keep the terrorists contained abroad so well. that they will not strike here at home. Further- In a very large sample of 2,729 U.S. residents more, once afraid, people become more willing to living entirely outside New York City, Silver, Hol- accept punitive action against others; this tendency man, McIntosh, Poulin, and Gil-Rivas (2002) found may become heightened if they believe such steps that 17% reported PTSD symptoms in the first 2 will also help prevent violence against them. months after 9/11, and about 6% still reported How exactly do these terror alarms do the symptoms more than 6 months later. The highest terrorists’ work for them? Two strands of evidence levels of stress were found among women, those suggest both the tremendous and continuing toll of were who maritally separated, those with preexist- the terrorist attacks and their aftermath on the ing medical or psychological health problems, and health of the American public. First, a number of those who had stopped active coping efforts early in studies indicate the enduring psychological impact the aftermath of the attacks. Spiegel et al. (2002) of terrorism in Americans’ psychological responses also reported that the highest levels of distress were to the attacks on September 11, 2001. Second, found among those with inadequate social support additional evidence suggests the powerful impact and maladaptive coping strategies. Such strategies of announcements of changes in the National Ter- included self-blame, substance abuse, and emo- ror Alert System of the Department of Homeland tional suppression. Schuster et al. (2001) studied Security on a large population of stable, largely children’s reactions by interviewing their parents married, well-trained first responders who work for and found that more than a third of parents re- Con Edison in New York City and have been sys- ported that their children demonstrated at least one tematically followed since the original attacks. of five stress reactions, and more than half reported Several studies indicate the high and enduring that their children worried about their own safety or level of psychological trauma following the 9/11 that of loved ones. attacks in New York and elsewhere. In a random Reporting similar findings in a sample of telephone survey, Galea et al. (2002) found that, 1,142, Johll & Brant (2002) also found that wo- among Manhattan residents, 8% reported symp- men reported more stress. Interestingly, in this toms that met the official diagnosis for posttrau- study, the authors found that those residing in matic stress disorder (PTSD), and 10% reported New York turned more to social support and active depressive symptoms in the months following the problem solving in the wake of the attacks than attacks on the World Trade Center. The closer a did other people who lived farther away from the person lived to New York, the higher the rates of tragedy. One potential explanation for this finding PTSD. In the area closest to the attacks, rates derives from Schuster et al. (2001), who have re- of PTSD ran as high as 20%. The vicarious nature ported a positive correlation between television of the impact of the terrorist attacks is revealed by exposure and stress reactions. Galea et al. (2002) the fact that most of those who reported PTSD or have also found that people who lived farther away The Psychological Consequences of Terrorist Alerts 363 from the attacks, not surprisingly, relied more on social categorization to explain how people become television, radio, and the Internet to learn about motivated to increase their sense of self-esteem what happened. They too found a positive corre- through their sense of belonging to a group of si- lation between the degree of media exposure and milar others. This in-group identification leads to a stress symptoms. bias toward those who are part of the in-group and However, these effects might easily have re- against those who are not part of the group, the so- sulted simply from the attacks themselves. What called out-group. One of the most important con- evidence do we have that the terror alert system sequences of social identity theory lies in the insight exacerbated or prolonged the psychological effects that people want to see themselves and their own triggered by the attacks? The most convincing group members as being superior to excluded evidence comes from a Cornell medical school others on whatever relevant, albeit potentially ar- study of 1,924 New York City Con Edison disaster bitrary, dimension upon which group inclusion is relief workers, a sample that represents a re- assessed. In particular, when allocating resources markably stable population. All of the subjects are across groups, individuals appear prone to give employed and trained to respond to crises in an more to members of their own group and less to effective and efficient manner. Most of them are outsiders. This pattern of distribution persists even married. Yet researchers at Cornell University’s when people do not personally benefit from this Weill Medical College found that changes in the system of allocation and even when doing so proves color-coded alert were linked with increased levels personally disadvantageous (Turner, Brown, & of psychological distress, even among those who Tajfel, 1979). People allocate resources in this way were already upset as a result of their direct contact not simply to provide an advantage for the in-group with the World Trade Center site after 9/11. These but also to create an explicit relative advantage for relief workers showed significant increases in rates the in-group over the out-group (Tajfel, Billing, of physiological arousal, general and phobic anxi- Bundy, & Flament, 1971). From this perspective, ety, depression, and other PTSD symptoms when terrorist attacks—or the threat of them—would the alert code shifted from yellow to orange, which simultaneously increase in-group identification occurred on the third and fourth color-coded among Americans, with consequent rally-round- alerts on March 17 and May 20. Curiously, these the-flag support for the country’s leadership, and symptoms were elevated again when these warning simultaneous out-group denigration or hatred of were lowered (Kramer, Brown, Spielman, Goisan, foreign groups perceived to be responsible for the & Rothrock, 2004). In all likelihood, this means violent acts. that calling attention to the danger signals proved The in-group bias posited by social identity sufficient to trigger strong negative emotional re- theory becomes enhanced through the mecha- actions, even among a sample of men who are nism of terror management theory (Pyszczynski, trained relief workers. Solomon, & Greenberg, 2003) and its validating research, which shows that human behavior is significantly affected by anything that makes peo- Social Identity and Terror Management ple aware of their own potential death or sensitizes them to their mortality. Death-related thoughts Why should terror alerts increase levels of psy- affect everyone at conscious and nonconscious chological distress? What other impact might such levels and channel people to express long-standing alarms have on the general public? Drawing on two values and ‘‘increased need for safety and psy- theoretical models from social psychology, we ar- chological security that this horrible reminder of gue that they serve to enhance social identity in- our vulnerability has awakened in us all’’ (Pyszc- group biases while simultaneously heightening the zynski et al., 2003, p. 112). salience of mortality for the targets of terrorist acts. Terror management theory has demonstrated These effects combine to simultaneously exacerbate that reminding people of their mortality affects symptoms of psychological distress and increase their evaluations of others. When mortality is support for the current leadership. made salient, people find others who conform to Social identity theory (Tajfel & Turner, 1986) their own worldview to be more attractive, while draws on the basic human tendency to engage in judging those who threaten their worldview to be 364 Assessment and Treatment less so (Greenberg et al., 1990). In particular, This evaluation extends to reward and pun- subjects evaluate those who praise their cultural ishment as well. When mortality was made salient worldview especially positively and assess those to subjects prior to decision making, they proved who criticize it especially negatively. In addition, much more likely to reward a hero who upheld mortality salience makes people seek out cognitive their cultural values, while recommending espe- consistency as well. When their death is made cially harsh sentences for those who violated those salient, people show an increased preference for values (Rosenblatt et al., 1989). The authors have seeking out information supporting their decisions demonstrated that these effects do not result sim- as opposed to information that conflicts with it ply from greater physiological arousal or heigh- (Jonas, Greenberg, & Frey, 2003). Indeed, mor- tened self-awareness. ality salience increases stereotypic thinking and Researchers have also tied terror management induces preferences for stereotype-confirming in- theory to social identity theory by demonstrating dividuals (Schimel et al., 1999). that making people aware of their death increases This bias has been explored in explicitly poli- intergroup bias in minimal groups (Harmon-Jones, tical contexts as well. Mortality salience increases Greenberg, Solomon, & Simon, 1996). Taken to- people’s preference for charismatic political candi- gether, this research suggests that reminders of dates and decreases inclination for relationship- death serve to increase both in-group bias and oriented political candidates (Cohen, Solomon, out-group derogation. In short, mortality salience Maxfield, Pyszczynski, & Greenberg, 2004). This increases support for and decreases criticism of so-called fatal attraction clearly demonstrates the standing, charismatic leadership. impact of mortality salience on the evaluation of political leaders as a function of their leadership style. In a test of this hypothesis specifically de- Strategic and Political Manipulations signed to examine people’s reactions to George of Alarms Bush and the mortality salience induced by the terrorist attacks of 9/11, Landau et al. (2004) found Why would a government create and maintain such that heightened concerns about mortality in- an ineffective and psychologically damaging alarm tensified Bush’s appeal. In particular, reminding system? Here, when we argue that the alarm system people of their mortality increased support for remains ineffective, we mean that it seems inade- Bush and his counterterrorism policy. Subliminal quate for motivating appropriate citizen action; the exposure to reminders of 9/11 not surprisingly system may nonetheless serve as an effective de- brought mortality-related thoughts closer to con- terrent or political tool. One explanation for this sciousness, and this too increased support for him. ostensible conundrum posits that, although politi- Mortality salience led subjects to become more fa- cians may be aware that the current system is nei- vorable toward Bush and more likely to vote for ther ideal nor as effective as they might like, it serves him, while making them less predisposed toward important and legitimate subsidiary political goals. John Kerry and less likely to vote for him. In particular, while not necessarily efficient, the Such a bias extends to other behaviors as well. current system is not useless in effecting first Subjects whose mortality is made salient show responder mobilization goals. Indeed, first re- increased aggression toward those who threaten sponders may support this system because it pro- their worldview. In a clever experiment, McGregor vides them with desperately needed additional et al. (1998) showed that subjects forced others funding to meet their newly increased responsi- who threatened their worldview to consume a bilities. In addition, the system offers a kind of much larger amount of hot sauce. However, such political cover electorally. No one wants to be aggression appeared confined to those who jeo- caught under attack without having issued a pardized the subjects’ worldview; they did not warning first. How long the system will remain in force others who had made them drink an un- place under this interpretation depends on how pleasant tasting juice to eat more hot sauce. In- long it serves this purpose. Should another major terestingly, when subjects were allowed to express act of violence occur and should the current system their hostility openly toward the critical target, fail to provide adequate warning, politicians will no greater aggression was eliminated. doubt be forced to revisit its effectiveness. The Psychological Consequences of Terrorist Alerts 365

An alternate hypothesis for the current system supportive of punitive public policy choices (Lerner that bears examination suggests that leaders strive & Keltner, 2000; Gault & Sabini, 2000). Third, to manipulate public opinion through the strategic anger leads to more optimistic judgments; a gov- use of fear and anger in order to gain political ernment that encourages a population to be angry power and advantage. As the Goering quote sug- increases the likelihood that the public will remain gests, if leaders want or need backing for a parti- supportive of and optimistic about the likelihood of cular campaign that is likely to be unpopular or success in punitive acts, such as war (Lerner & expensive in lives and material, such as a war, or Keltner, 2000). Believing they will prevail, in turn, restrictions on civil liberties, then the effective use may render a public more willing to bear the cost of of anger, threat, and fear can work to enhance the effort. In addition, the extent to which leaders public support. In this way, a terrorism alarm themselves share the emotional reaction of the system can simultaneously serve as both a political public, they too may be affected in their decision- and a strategic tool. making abilities. Not only may angry leaders be Evidence in support of this argument comes inclined to be overoptimistic in their estimates of from Willer (2004, p. 1), who tracked the 26 times the probability of their own success, but anger also that the government issued a terror alert between hinders creative decision making more broadly February 2001 and May 2004. He matched these (Keinan, 1987; Forgas, 1992). to 131 Gallup public opinion polls conducted In this way, the larger problem with the current during that same period. Using a time-series re- alert system lies not only in its negative public gression analysis, Willer examined the relationship mental health outcomes. Rather, an alarm system between the warnings and the president’s approval that encourages unthinking and uncritical support ratings. He found that, on average, each alert re- for standing, charismatic leadership poses a far sulted in a 2.75 point increase in Bush’s approval greater risk to the diversity of political culture. rating in the week following the alert. Significantly, When people stop questioning the public policies this approval extended to increased support for the of their government and react with knee-jerk sup- president’s handling of the economy, an issue lar- port, democracy itself becomes threatened. Amer- gely irrelevant to the war on terrorism. This finding icans want to feel safe, but they also want to support demonstrates a substantial halo effect surrounding the basic ideals of justice, equality, and equal re- Bush following terror warnings, most likely because presentation. Public policy agendas that manage to they increase mortality salience. circumvent critical consultation on important is- This process of enhanced support for the pre- sues of security pose a threat to the maintenance of a sident and his policies can happen through several diverse political culture, whereby distinct voices specific psychological mechanisms triggered by an and interest groups receive equal treatment before alert system that simultaneously serves to enhance the law. a person’s sense of identification with the nation- group, while making one’s mortality increasingly salient. First, fear motivates people to become more Action Conclusions vigilant and to seek out more information, and mortality salience induces a preferential search for There are at least two important limitations to confirmatory evidence; in other words, fear gets the current color-coded terror alert system. First, people’s attention. However, high levels of fear warnings should be issued by a single credible can also prove distracting, so while leaders garner source based on specific information. To the extent people’s attention, they do not necessarily gain their possible, people should be told where and when fully critically engaged attention. People are scared the threat is most likely to occur and how long the of dying, and, in the midst of that fear, they look to risk will last. After the time has passed, people their leaders to provide a solution that is consistent should be debriefed and told whether an attack was with their preexisting worldview, which maintains preempted or whether and how the information that the in-group is good and the out-group is bad that incorrectly predicted a threat was flawed and and threatening. what steps will be taken to prevent such mistakes in Second, attacks such as those on 9/11 can the future. Only through such a system can people generate anger, and anger makes people much more remain attentive in ways that might prove effective 366 Assessment and Treatment in thwarting potential attacks without falling into and their families from harm should the threat paralyzing depression or anxiety. materialize. Such actions can include lessons about Obviously, the most difficult aspects of in- what people should look for and what kinds of stituting such a system lie in conflicting political suspicious actions or people should be reported to incentives. While it may be best for citizen aware- which authorities. Clearly, trade-offs exist in edu- ness and anxiety to have a single credible source of cating people about the best way to notice terrorist terrorist threats, many state and local officials have threats. Some of the realistic things that govern- strong incentives to get the message out first; recall ments may want people to do, such as spy on their the political fracas that occurred when the governor neighbors, are not so nice and certainly run con- of California issued a specific alert about the threat trary to an established culture of individual rights to bridges in the Bay Area; federal officials felt that and freedom. making such an announcement was irresponsible, Further, having the government name parti- but the governor was unwilling to take the political cular groups as likely targets for suspicion, such as risk of not issuing an alert should a subsequent Muslims or people of Middle Eastern descent, can attack occur. Indeed, while the government has in produce adverse consequences, such as the lynch- fact hardened important sites such as bridges, not ing of innocents. Such warnings might indeed much of this preparation has been made public. create greater violence in reaction than any real The federal perception is that making known the threat may pose. As a result, government officials extent of our protective measures with regard to need to think carefully about how to educate the critical infrastructures provides an incentive for public about the specific ways in which they need to terrorists to hit softer targets. According to this lo- remain alert to threat. Indeed, one of the functions gic, it is better for terrorists to hit a protected critical of heightened airport scrutiny, intentional or infrastructure than to concentrate on unprotected otherwise, is merely to keep people aware that the civilian targets such as malls (Cohen & Shapiro, threat is real: Vigilance remains necessary; risk ex- 2005). Thus, the federal government opposes an- ists everywhere; and bad things can happen despite nouncing specific threats to hardened targets such the best of intentions and preparations. The un- as bridges, which remain easier to protect than conscious message is that the government is trying softer targets, which terrorist might choose if they its best and doing all it can do to protect its citizens, believed that everyone was watching their first tar- so if something goes wrong, it is the fault of the get, making success less likely. perpetrators, not the defenders. Yet local leaders feel their credibility depends Alerts should be targeted geographically as on being the ones to issue local warnings, and their much as possible, so that those who are outside the political incentives do not always align with a single greatest risk zone need not worry unnecessarily. In source model. New alert models must remain aware addition, some warnings, especially those that re- of the perceived political needs of local leaders. One main vague in intent, should be issued only to first possibility is to have a single national source for responders and other trained personnel. Often- information on terrorist threats, followed closely by times, alerting the general public serves no useful local reports on specific area threats. However, such purpose but increases psychological distress for no a strategy would require close and trusting re- practical reason. Raising alert levels may be useful lationships between federal and local leaders, which for particular security personnel and other first re- may prove challenging in reality, especially under sponders to take specific actions, including raising conditions of threat and time pressure. force levels, but it may only cause confusion and Second, for alerts to prove effective in actually anxiety on the part of the general public. Autho- reducing the risk of harm, they need to be speci- rities should utilize the opportunities provided by fically tied to actual behaviors. A heightened alert first responders to support both preparedness and must mean more than merely increased vigilance, response in natural environments such as hospitals, or it will result in nothing more than increased police stations, and fire departments. In addition, anxiety, depression, and hopelessness in the gen- for government communication to improve, au- eral population. Intensified alerts should come thorities should understand the critical role that the with specific, concrete, realistic actions for people nation’s health care system should play, including to take to reduce the threat or protect themselves primary care providers, psychologists, and social The Psychological Consequences of Terrorist Alerts 367 workers (Heldring, 2004). Doctors remain trusted, tions and essential features of the psychology and credible sources in the eyes of most people and rationality of terrorism, as well as from less poli- often provide the first contact for those who are tical involvement and manipulation. Further, the injured in attacks. general public should remain aware of the threats Even assuming no manipulative political intent, to diverse political culture and a genuinely re- conscious or coincidental, there needs to be a ser- presentative democratic government posed by ap- ious reexamination of how to best construct future peals to in-group superiority, out-group prejudice terrorist alarms, guide their optimal utilization, and denigration, and death threat reminders, and, when they do not materialize, explain the which all combine to generate uncritical support reason to the public. Of course, we are all relieved for the standing leadership and punitive public when the alarms prove false, but when repeated policy choices. over time they may serve only to induce a kind of psychic numbing, lulling us to sleep and leaving us unprepared to act constructively and effectively if Responses to the Terrorist Threat and when the wolf actually does come to the door. There are terrorists who are indeed dangerous Terrorists remain effective at getting attention on and who hate some of what the United States stands the international stage. This is indeed part of the for in their eyes. They will try to attack the country in reason they engage in campaigns of wanton fear various ways, including suicide bombings. Security and destruction, and they will continue to do so as and preparedness are essential components in long as they have unresolved grievances. To the countering terrorism. In particular, advice about extent that Western governments, including the how to prevent public overreaction and promote United States, want to wage a truly effective war on citizen cooperation when in dangerous situations, terrorism, they need to begin to understand and where mass hysteria can kill, as in bombings, are grapple with some of the psychological and stra- necessary. Further, honesty, transparency, and ac- tegic motivations of terrorists. Military action alone countability on the part of leaders is essential if ter- is unlikely to suffice as an adequate response to rorist alarms are to be taken seriously in the future. terrorist action and activity. In this, Buddhists are Currently, the government does not seem to be not alone in their belief that violence begets vio- using the best scientific advice available on how to lence. Recent studies appear to validate the intui- construct terror warnings or how to educate the tion that military action against terrorists only public in this new threat. Managing human-made increase aggressive responses and reprisals. In one disasters requires models that are different from time-series analysis, for example, Enders & Sandler those that have traditionally been used to handle (1993) found that, 20 years after a retaliatory raid natural disasters. In fighting terrorism, strategists against Libya in 1986, terrorist attacks against the need to think like terrorists in order to select and United States from this region were still increasing. protect likely targets. The United States ought to Silke (2004) notes similar patterns in his review reassess its full-coverage security of venues that are of the impact of military action on subsequent unlikely to ever be considered targets by terror- terrorist activities. ists. Security focus should be placed on higher Terrorists are neither crazy nor irrational, even probability targets, including limited municipal when their actions are evil. All of the recent ac- resources (e.g., water supplies), symbolic, senti- counts make it evident that terrorists do not fit any mental targets (e.g., Disneyland), places with po- mentally pathological profile. A 2003 survey by tential for major urban disruptions that can never Horgan has found no empirical support for the have comprehensive security checks (e.g., urban notion of a terrorist ‘‘personality.’’ The National subways), or school buses. Research Council has reported that ‘‘There is no High levels of sustained stress in many citizens single or typical mentality—much less a specific of all ages can have a greater long-term destructive pathology—of terrorists’’ (Smelser & Mitchell, impact on the nation than the consequences of any 2002, p. 3). Indeed, one woman who spent years single terrorist attack. Emergency preparedness for studying Palestinian terrorists argues that ‘‘What any form of terrorist assault would benefit from a is frightening is not the abnormality of those who wider appreciation of the mental health implica- carry out the suicide attacks, but their sheer 368 Assessment and Treatment normality’’ (as quoted in Silke, 2003). This finding Addendum is strikingly reminiscent of Hannah Arendt’s similar conclusion in her analysis of Nazi henchman In an investigative report dated October 12, 2005, Adolf Eichmann, who appeared terrifyingly nor- MSNBC commentator Keith Olberman analyzed the mal; the banality of his evil seemed the most recent threats against the New York City subway frightening aspect of his personality. system in light of previous terror alerts. He docu- Indeed, the only systematic attribute that be- mented 13 cases between May 2002 and October havioral researchers have found associated with 2005 in which a significant political downturn by terrorists is a propensity toward rage (Plous & the Bush administration was immediately followed Zimbardo, 2004). Moreover, this factor may simply by a terror warning within a matter of days. These be a function of the larger demographic reality that coincidences included John Kerry’s nomination as most terrorists are males between the ages of 15 and the Democratic candidate for president, followed 2 30, the group that is most likely to commit violent days later by a jump in the color-coded system to crimes in general, regardless of place or motivation orange, based on a threat against financial centers in (Daly & Wilson, 1988). Upon reflection, it should New York, New Jersey, and Washington that turned make sense that effective terrorists cannot be crazy out to be 4 years old. Similar threats against the New even if their intentions are malevolent. Successful York City subway were issued in the wake of some terrorist action requires patience, problem-solving of Bush’s lowest public opinion poll numbers ever, skills, and the ability to work efficiently in groups, following the administration’s debacle in response all traits that run counter to the existence of sys- to Hurricane Katrina’s flooding of New Orleans, tematic mental illness. renewed violence and political opposition in Iraq, We contend that more effective responses to and questioning by the grand jury of Karl Rove’s terrorist threats would encompass a two-track participation in outing CIA agent Valerie Plame to policy. First, to the extent that domestic govern- New York Times reporter Judith Miller. ments use terrorist threats for their own domestic Significantly, even former head of Homeland political purposes, they should realize that such Security Tom Ridge publicly questioned the timing strategies reduce the prospects for achieving an ef- of such alerts in view of the classified information fective dialogue with their population, as well as he received: ‘‘More often than not we were the least with their enemies, and accomplish the terrorists’ inclined to raise it. Sometimes we disagreed with work by effectively debilitating the target popula- the intelligence assessment. Sometimes we thought tion with fear and other forms of mental disorder even if the intelligence was good, you don’t ne- and distress (Zimbardo, 2001a, 2001b, 2003). After cessarily put the country on [alert]. ...There were all, the widespread public perception that alerts can times when some people were really aggressive be manipulated for political reasons undermines about raising it, and we said ‘for that?’ ’’ Although their very credibility. Indeed, this manipulation correlation between events does not necessarily is not lost on people. Time magazine reported in its signify or document causation, the pattern of August 6, 2004, poll that fully 38% of Americans events remains striking, especially in light of the think that the alerts might be manipulated for po- concerns raised in this chapter about the negative litical reasons (Tumulty, 2004). impact of such alerts on public health. In his re- Second, when realistic terrorist threats confront port, Keith Olberman concluded by asking, ‘‘if American citizens, warnings should be credible, merely a reasonable case can be made that any of specific, timely, and designed to motivate people to these juxtapositions of events are more than just take particular reasonable actions to protect them- coincidences, it underscores the need for questions selves and others. When such threats do not ma- to be asked in this country—questions about what terialize, effective debriefing should explain how is prudence, and what is fear-mongering; ques- and why the threat was either misplaced or averted. tions about which is the threat of death by terror, Open and honest dialogue about realistic threats and which is the terror of threat’’ (cited at http:// can help to preserve democratic values concerning www.msnbc.msn.com/id/6210240/). effective representation. With this plan of attack, greater safety and security could be achieved with Acknowledgments. We would like to thank Jacob more effectiveness, less cost, and less anxiety. Shapiro for his helpful comments and suggestions. We The Psychological Consequences of Terrorist Alerts 369 would also like to thank the participants of the Dart- Harmon-Jones, E., Greenberg, J., Solomon, S., & mouth seminar, especially Carol Bohmer, Stephen Simon, L. (1996). The effects of mortality salience Brooks, Richard Ned Lebow, Jennifer Lind, Roger Mas- on intergroup bias between minimal groups. ters, Anne Sa’adah, Allan Stam, Ben Valentino, Chris- European Journal of Social Psychology, 26(4), tianne Hardy Wohlforth, and William Wohlforth, for 677– 681. Heldring, M. (2004). Talking to the public about lively discussion and extremely helpful suggestions on terrorism: Promoting health and resilience. Fa- the previous version of this chapter. milies, Systems, and Health, 22(1), 67–71. Horgan, J. (2003). 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theory I: The effects of mortality salience on Distress and coping after the terrorist attacks: reactions to those who violate or uphold cultural Preliminary survey results. Paper presented at the values. Journal of Personality and Social Psychology, American Psychological Association annual meet- 57(4), 681–690. ing, Chicago. Schimel, J., Simon, L., Greenberg, J., Pyszczynski, T., Tajfel, H., Billing, M., Bundy, R., & Flament, C. Solomon, S., Waxonsky, J., et al. (1999). Stereo- (1971). Social categorization and intergroup be- types and terror management: Evidence that havior. European Journal of Social Psychology, 1(2), mortality salience enhances stereotypic thinking 149–178. and preferences. Journal of Personality and Social Tajfel, H., & Turner, J. (1986). The social identity Psychology, 77(5), 905–926. theory of intergroup behavior. In S. Worchel & Schuster, M., Stein, B., Jaycox, L., Collins, R., Marshall, W. Austin (Eds.), Psychology of Intergroup Relations G., Elliott, M., et al. (2001). A national survey of (pp. 7–24). Chicago: Nelson-Hall. stress reactions after the September 11, 2001, Tumulty, Karen. (August 16, 2004). Hijacking the terrorist attacks. New England Journal of Medicine, Campaign. Time Magazine. 345, 1507–1512. Turner, J., Brown, R., & Tajfel, H. (1979). Social Silke, A. (2003). Ultimate outrage. The Times of London. comparison and group interest in ingroup favor- ———. (2004). Terrorism, 9/11, and psychology. itism. European Journal of Social Psychology, 9(2), Psychologist, 17, 518–521. 187–204. Silver, R., Holman, A., McIntosh, D., Poulin, M., & Willer, R. (2004). The effects of government-issued Gil-Rivas, V. (2002). Nationwide longitudinal terror warnings on presidential approval ratings. study of psychological reactions to September 11. Current Research in Social Psychology, 10(1), 1. Journal of the American Medical Association, 288, Retrieved January 27, 2006, from http://www 1235–1244. .uiowa.edu/~grpproc/crisp/crisp.html Smelser, N. J., & Mitchell, F. (Eds.). (2002). Terrorism: Zimbardo, P. (2001a, November 4). Mind games: Perspectives from the behavioral and social sciences. Don’t play on terrorists’ turf. San Francisco Panel on Behavioral, Social, and Institutional Chronicle, C6. Issues, Committee on Science and Technology for ———. (2001b, December 30). Psychology of terror- Countering Terrorism, Center for Social and ism: Mind games, mind healing. San Francisco Economic Studies, National Research Council. Chronicle, D6. Washington, D.C.: National Academies Press. ———. (2003). Phantom menace: Is Washington Spiegel, D., Butler, L., Azarow, J., Koopman, C., terrorizing us more than Al-Queda? Psychology DiMiceli, S., & McCaslin, S. (2002, August). Today, 36, 34–36. V Prevention and Psychological Problems in Reaction to Acts of Terrorism This page intentionally left blank 24

Defusing the Terrorism of Terror A. J. W. Taylor

The study of terrorism—the ideology, recruitment, by the ‘‘seductive charm’’ of charismatic leaders, training, financial, and organizational base of any who, in return for absolute compliance in a well- faction seeking to change the balance of power—is designed conditioning program, provide ready an- fraught with difficulties of an intellectual, profes- swers to ‘‘life’s perplexing questions.’’1 sional, and political kind (Silke, 2003, pp. xv–xxi). However, in her study of gross violators of Intellectually, the topic has more than the usual human rights, which might also have a bearing on insecurity of applied research in which the occur- terrorists, Smeulers (2002) has drawn on the social rence of events and the extent of their consequences psychological laboratory studies of Milgram (1969) are not under the researchers’ control. Profession- and Zimbardo (Haney, Banks, & Zimbardo, 1973) ally there are few attested protocols for researchers and the fieldwork of Gibson and Haritos-Fatouros to adopt, and governments are more inclined to (1986) to make the chilling comment that most move swiftly to retaliate against terrorists than to perpetrators are ordinary people and that within promote studies of the complex causes of terrorism specific circumstances anyone might become a and to apply the remedies. perpetrator. She goes on to report the residual traces In taking such peremptory action, governments of humanity remaining in some killers on particular have the support of Stahelski (2004), a specialist in assignments that caused them such revulsion as to the operation of extremist cults who recommends make them quit. the ‘‘elimination’’ of terrorist leaders, ‘‘aggressively In their retaliatory moves against terrorists, disrupting’’ the training camps, and ‘‘aggressively governments are known to fudge the matter of pursuing and eliminating’’ the funding sources of human rights, avoid due process of law, and use the fundamentalist religious schools that provide dubious tactics to achieve the results they desire— malleable recruits for terrorist training schools. He sometimes at the expense of scapegoats. In fact, a has described the terrorists as dispossessed and detached observer would find it difficult sometimes social misfits who emanate primarily ‘‘from dys- to differentiate between the opposing parties on functional families where the father is absent, es- moral grounds because governments have spon- tranged, or economically or politically impotent,’’ sored the terrorist groups they now oppose, and and he has reported that recruits are captured their own agencies have operated in ways not unlike

373 374 Prevention and Psychological Problems in Reaction to Acts of Terrorism those of terrorists whom they revile (cf. Meldrum, attacks of September 11, 2001, in New York with 2002, p. 79).2 Sluka (2000, p. 6) has given specific those from the British bombing of Hamburg in July examples of this double standard of morality, citing 1943 and the United States’ atomic bombing of Rummell’s conservative estimate of some 170 mil- Hiroshima in August 1945 (to say nothing of Na- lion victims of such government action in the first gasaki 10 days later). He shows that these attacks 88 years of the twentieth century, with nearly the by the Allies in World War II caused far more death same number afterward from the ‘‘government- and destruction than al-Qaeda in September 2001, inspired genocides and starvations’’ in Bosnia, and that, in those cities the clearance, reconstruc- Rwanda, Somalia, Sudan, and elsewhere.3 Sluka tion, and recovery proceeded apace without much (2000, p. 15) then follows E. V. Walter in de- outside help. Then, after lamenting the ‘‘new class scribing the functions of such government- of experts of terrorism and security identified by promoted death squads as maintaining order and their mastery of Machiavelli,’’ Dynes goes on to counteracting ‘‘fissiparous tendencies’’ by inhibiting praise ‘‘the willingness [of those ready at the orga- resistance, preventing change, and maintaining the nizational level] to overturn or by-pass experience political status quo of the ruling elite. Somewhat since the situation to be faced has novel elements dryly, he follows Chomsky and Herman in de- requiring ingenuity’’ and to warn against the ap- scribing state-sponsored terrorism as ‘‘wholesale’’ parent centralization of problem solving and deci- and that of its assailants as ‘‘retail’’ (Sluka, 2002, sion making that seemed to be emerging in the p.1). newly created U.S. Department of Homeland Aside from such contentious moral issues, Security. there are questions about the kind of protective In synchrony with the United States after 9/11, measures societies should adopt against terrorism many countries throughout the world tightened and at what psychological and economic cost. In their security screens against potential terrorists. In the United States, the intelligence agencies that the antipodes Australia already had a strict policy were found incompetent for the way they handled against asylum seekers that led to riots, self- the warnings preceding the 9/11 al-Qaeda attacks mutilation, and suicides in detention camps. In a on the World Trade Center and the Pentagon dramatic move on August 29, 2001, it had also have quadrupled, intensified, and prolonged their blocked the arrival of 460 Afghan fugitives from an precautionary systems, regardless of the negative overloaded vessel, the Tampa, and transferred them economic and emotional effects of creating and to the remote Nauru Island some 4,000 kilometers maintaining a high state of vigilance (see McDer- northeast of Sydney. Following 9/11, the Australian mott & Zimbardo, Chapter 23, this volume). Then Government (2004, Ch. 7) made a number of bi- the gross disparity between the expenditure of lateral counter-terrorism arrangements with coun- resources to deal with the comparatively few vio- tries throughout South-East Asi, and it reinforced lent deaths from ‘‘external’’ agents as compared those measures after 83 Australians were among with fatalities from other causes must also come the 203 killed by the al-Qaeda bombing of two into consideration. Wallace and Pritchard (2004), nightclubs in Bali on October 12, 2002. for example, pointed out that, in 2000, grave as the In New Zealand, the government held a high- losses of nearly 3,000 ‘‘external’’ deaths through level conference (World Terrorism and Political Vio- terrorism were in the United States, those occurring lence: Implications for New Zealand, 2002) and took ‘‘internally’’ from road deaths, suicide, and homi- precautionary measures to hunt terrorists abroad— cide were about 30 times greater, but the allocation without going beyond the scope of the United Na- of resources was far from equitable. The Interna- tions (Smith, 2003). However, it caused widespread tional Federation of Red Cross and Red Crescent consternation by holding a refuge seeker (Ahmed Societies (IFRC&RCS, 2005, p.131) made a similar Zaoui) in solitary confinement for 10 months in point about the neglect of chronic disease and many Kafkaesque fashion without legal charges being long-standing conflicts.4 brought, until his mental condition so deteriorated Regarding the emotional effects of terrorist at- that the Department of Corrections was obliged to tacks, the pioneer disaster researcher Russell Dynes transfer him to less restrictive quarters. The man (2003) attempts to reduce the hyperarousal by was a reputable academic and cleric who in 1991 comparing the immediate effects of the terrorist had been elected to the first democratic government Defusing the Terrorism of Terror 375 of Algeria. The military there responded with an investigations without heeding the advice of stal- iron fist by torturing and killing thousands of civi- warts such as Raphael, Lundin, and Weisaeth lians. Zaoui escaped to seek sanctuary and elicit (1989). It is true that field-workers contemplating support in Europe, Africa, and Southeast Asia be- research after disasters will have to overcome par- fore making his way further South in December ticular obstacles concerning methodology, meth- 2002. The New Zealand Refugee Status Appeals ods, design, logistics, and funding—as well as the Authority conceded the merits of his case (cf. Zaoui, appropriate time to launch their studies.6 However, 2004), but at the time of this writing he remains in it seems that 9/11 gave the National Institute of an anomalous legal position—although thanks to Health, the U.S. Department of Veterans Affairs, and the New Zealand Supreme Court he is being held the National Center for Posttraumatic Stress Dis- under far less restrictive conditions than the Crown orders the necessary impetus to address some of would impose. these issues, because they combined in 2004 to Currently in the United States, as in the launch the first of a series of four annual conferences McCarthy era of the 1950s, the administration is on innovative trends in trauma research methods. known to suspect the loyalty and political allegiance However, it remains that any plausible findings of potential researchers and to challenge their mo- from empirical research on highly sensitive public tivation (cf. http//:www.counterpunch.org/dprice2 issues such as terrorism deserve consideration.7 .html). It has brought indirect and subtle pressure to Toward that end, the rest of this chapter focuses on bear on communities in which investigators live and the definition and origins of terrorism, its changing put their personal safety and that of their families at appraisal, and frontline responses. It construes risk. Such extraneous pressures could not but have terrorism as a kind of disaster, presents a classifi- compromised the intellectual and emotional de- cation of disasters, explains their various phases, tachment of all but a handful of hardy souls who discusses victims/casualties and their psychological pursue terrorism as a topic of behavioral research. needs, phasic community reactions, cross-cultural Obviously the continuing high level of public features, and the importance of belief and value concern about terrorists and terrorism needs to systems in effecting the recovery of casualties. abate before field-workers can safely bring the Terrorism is a complex phenomenon that needs subject more into the mainstream for proper to be put into a disciplinary framework before it can scrutiny.5 Conceivably researchers who collect data properly be understood, defused, and remedied. in the classroom or laboratory might find them- The understanding will generate less anxiety, the selves under less extraneous pressure than their defusing will lead to a more rational appraisal of colleagues in the field, but their findings might be causative factors, and the remedies will be other too simplistic for immediate application to the in- than those of counterattack, retribution, and definitely more complex problems people face in the terrence. real world. For example, Pyszczynski, Solomon, and Greenberg (2003) worked with student volunteers in contrived studies of conflict in the safety Definitions and Origins of a laboratory to generate a plausible Terror Man- agement Theory—derived from Becker’s (1971) According to the Oxford English Dictionary (1999), earlier focus on the existential meaning of death— the word ‘‘terrorism,’’ which is defined as the ‘‘un- and they offered it as a partial explanation for the lawful use of force by militant organizations for psychological after-effects of 9/11 on the general economic, ideological, political, and religious pur- population. However, as DeLisle (2003) has said, poses,’’ is of comparatively recent origin. It was at- the direct extrapolation of such a laboratory finding tributed first to the Jacobins and their agents in the from a sample of students to the consequences of French Revolution for the cruel manner in which terrorists operating in situations of international they kept people in ‘‘implicit subjection by a mer- political conflict is open to question. ciless severity.’’ Subsequently it was the method Regrettably, too many clinicians abandon their used by clandestine groups or expatriate organiza- responsibility for conducting research once they tions ‘‘aiming to coerce an established government have qualified, and too many of the remainder adopt by acts of violence against it or its subjects.’’ More ad hoc procedures and questionnaires for quick recently, the advance of technology and weaponry 376 Prevention and Psychological Problems in Reaction to Acts of Terrorism and the creation of international networks enabled thoughtfully, he also distinguishes between com- small coteries of committed and highly skilled op- munities with ‘‘layered resilience’’ that have many eratives to target economic and political systems coping practices and those with fewer that are in- with greater destructive effect than before. herently vulnerable. However, the capacity of militants to create terror can be traced back to earlier times, and it has even been thought the last of different devastating The Changing Appraisal events in the chain of human survival. For example, paleoarcheologist David Keys (1999) took a Regardless of the causes and consequences of ter- macroscopic, longitudinal, and interdisciplinary rorism, a combined North Atlantic Treaty Organi- approach with more than 50 academic specialists zation (NATO) and Russian military workshop has and authorities in more than 20 disciplines, and he acknowledged terrorism to be ‘‘a fundamental produced a compelling argument for a volcanic method of waging social and psychological warfare’’ eruption about 535 or 536 A.D. that caused the (Wessely & Krasnov, 2002). It recognized that ci- worldwide collapse of major civilizations. His thesis vilians were having to live with the prospect of is that a massive explosion in the Indonesian ar- encountering terrorism, and thought it some con- chipelago brought about a severe climatic change, solation that communities and their systems were followed by food shortages that caused a virulent usually the targets rather than individuals.9 The plague to spread in North African and Mediterra- workshop commented that civilians could be ex- nean countries, and finally led invaders from the pected to respond with resilience and cohesion ra- north and east of Asia to extend their boundaries ther than panic, especially if they had confidence in into the Balkans and Europe in a fight for political the information given by the authorities and the and religious survival.8 news media. Nevertheless, it warned that both mil- With the detachment that such historical itary personnel and civilians could have similar ap- scholarship affords, one could also state that social prehensions about the biological, chemical, and eruptions without geophysical inducement also explosive methods that terrorists now use, expres- have the potential for bringing about significant sing confidence that the majority would recover social change (cf. Sjoberg, 1962). Bankoff (2003, quickly, leaving the remainder liable to present psy- p. 20) says as much, commenting that disasters chological problems leading to personality change can be significant catalysts of change in their own and mental illness. right, ‘‘triggering needed adaptations in human Still focusing on the techniques adopted by behavior and modification to structures, and even terrorists, O’Brien and Nusbaum (2002) speak of contributing to the overthrow of civilizations at the ‘‘David and Goliath’’ disparity between the re- times.’’ In short, as the Chinese calligrapher makes sources of personnel, weaponry, economic re- clear, the pictograph brush strokes of the character sources, and political power of the terrorists and for ‘‘stress’’ combine the two words ‘‘crisis’’ and their quarry, and they refer to it as ‘‘asymmetrical ‘‘opportunity.’’ terrorism.’’ Homer-Dixon (2002, n.p.) draws much In fact, Bankoff (2003, p. 23), an anthro- the same distinction, but he coined the term ‘‘com- pologist, takes the holistic approach to disasters, plex terrorism’’ to emphasize the ‘‘growing techno- regarding them as ‘‘embedded in the daily human logical capacity of small groups and individuals to condition ...in terms of a seamless web of relations destroy things and people, and ...the increasing that link society to environment and culture.’’ In his vulnerability of our economic and technological seminal article, he advances the ecological concept systems to carefully aimed attacks.’’ Of the two of community life as the dynamic interaction be- terms, complex terrorism is preferred because, of tween people and their environments, and he goes the two conceptualizations, it can more easily be on to say that disasters ‘‘are only one more im- broadened to encompass the other. permanent and irregular component of a threat to Even though the inclusion of such systems as a general human physical and psychological security target of terrorism might be new, economic factors represented by health problems, malnutrition, un- have frequently been a source of massive discontent or underemployment, income deficit, illiteracy, in the development of many countries. In 1995 substance abuse and endemic violence.’’ Quite IFRC&RCS were concerned about the ‘‘disaster Defusing the Terrorism of Terror 377 inducement work’’ (italics added) of powerful, loss of life from the exploding aircraft on 9/11, the self-promoting economic and political groups machinations of incalculable magnitude perpe- (IFRC&RCS, 1995, p. 52). With clarity and forceful trated by white-collar fraudsters that have surfaced expression, Korten (1996) points to the vulnerability in many parts of the world might not be as de- of complex socioeconomic global systems with structive in their effects as the activity of terrorists monolithic and monopolistic conglomerates that attacking the macroeconomic system.12 The man- centralize decision making at the expense of smaller, agerial depredations affected the livelihood of mil- independent units of production, distribution, and lions of employees, in many instances wiping out exchange. In particular, his argument is that, for the their pension funds and jeopardizing the security of sake of maximizing their own profits, the most many investors. The reputable billionaire investors powerful and affluent strata of society had destroyed Warren Buffett and Charlie Munger, no less, are the concept of work for the sustainability of in- quoted as saying that they were disgusted by the dividuals and their local communities. Indeed, in way in which ‘‘in the last few years ...shareholders 1998 the IFRC&RCS described the increasing alie- have suffered billions in losses while the CEOs, nation, degradation, famine, and poverty of people promoters, and other higher-ups who fathered who were most vulnerable to major adversity. It went these disasters [italics added] have walked away on to define disasters as ‘‘exceptional events which with extraordinary wealth’’ (Reuters, March 3, suddenly kill or injure large numbers of people 2002). Indeed, there are so many malefactors that or cause major economic losses’’ (IFRC&RCS, the U.S. Department of Justice (2001) has provided 1998, p.12), and it identified areas of ‘‘socio- a resource handbook for their victims (with an economic dislocation’’ in its map of relief operations appendix that just might give other people the (IFRC&RCS, 1998, p. 188). wrong idea about crimes they might perpetrate). In his introduction to that same volume Now the seemingly invincible auditors who earned (IFRC&RCS, 1998, p. 8), the secretary-general of more from advising their avaricious clients about the IFRC&RCS went so far as to declare that, as their business methods than from auditing com- ‘‘economic globalization becomes a reality, and as pany books are attracting the attention of regulatory the debate surrounding the role of civil society agencies and professional bodies—and the extent of evolves, opportunities are presenting themselves to their malfeasance when fully revealed might also governments and to other forms of civil action, to come to be regarded as disastrous. reduce risk and plan for a safer future.’’10 Then, immediately after September 11, from within the Frontline Response camp of international economists, none other than James D. Wolfenson, president of the World Bank, Turning from the scope of terrorism to its enact- reiterated his concern that poverty and inequality ment, records show that in 2001 there were 355 were at the root of global ills that generate terrorism international terrorist attacks, with 198 in 2002 (Sullivan, 2002). In January 2001 the World Eco- and 208 in 2003 (Patterns of Global Terrorism, nomic Forum even made terrorism the theme of its 2004).13 In addition, there were 33 in 2003 that annual conference, and among its galaxy of speak- were recorded as ‘‘nonsignificant’’ because they did ers Kofi Annan, secretary-general of the United not result in loss of life, serious injury, or major Nations, appealed for the adoption of an outlook property damage (Chronology of nonsignificant of global citizenship with humanitarian as well as international terrorist incidents, 2003). The attacks economic concerns to overcome ‘‘the fragility of took place on every continent but Australia and globalization’’ (2002). His subsequent High-Level Antarctica, and, leaving aside any others that might Panel on Threats, Challenges, and Change (2004, p. have been instigated by governments for whatever 2) went so far as to say that ‘‘combating poverty will reason, there is no doubt that the major attacks not only save millions of lives but also strengthen were those perpetrated by al-Qaeda in the United states’ capacity to combat terrorism, organized States on September 11, 2001—they attracted the crime and proliferation.’’11 greatest attention of the authorities, behavioral Were the disastrous effects of microeconomic scientists, and the general population worldwide factors also to be taken into account, it would be a in the hope of learning from the United States’ moot point as to whether, except for the terrible experience. 378 Prevention and Psychological Problems in Reaction to Acts of Terrorism

For the record, the leading agencies in the massive influx of skilled and unskilled volunteers United States responded with emergency trauma day after day. teams (cf. American Red Cross, 2002; Figley, Fig- Early in 2003 such a conference was held in ley, & Norman, 2002). Clinical authorities updated Washington, DC (Leading during times of trouble: their websites with information for health profes- A roundtable discussion of recent terror events, sionals about the possible consequences of trau- 2003), to the evident satisfaction of all of the matic stress, and others gave advice to the general participants. They shared their insecurities, spoke population about the services available for those in of their under- and overreactions—including those need.14 Providers began to appraise their inter- to the 17,000 reports of anthrax deposits in the ventions, and a number of epidemiologists started a postal system—and the need to have the news flow of papers based on their sample-surveys of the media on one’s side (cf. Taylor, 2006a). The role of general population of the whole country as well as the news media certainly warranted attention, be- those that were at greater risk in New York. Yet to cause the New Yorkers directly exposed to the be undertaken are psychological studies of the es- 9/11 attacks on the World Trade Center who also timated 25,000 survivors who evacuated the twin viewed the televised images of that event more towers of the World Training Center in orderly than seven times, were found to be more likely to fashion despite the chaos in which they found suffer posttraumatic stress disorders (PTSD) and/ themselves.The National Institute of Standards and or depression than a control group (Ahern et al., Technology, (NIST) (2004) compiled an extensive 2002). Another study found that 10% of a wide- dossier of over 10,000 pages of findings from stra- spread group had developed PTSD by proxy from tified groups of hundreds of survivors about the witnessing the graphic and persistent portrayal of architectural and operational aspects of the eva- the tragedy on television (Schuster et al., 2001). cuation procedures, among which there should be The latter was consistent with the findings of an some clues about the psychological reactions of earlier study after the Oklahoma City bombing evacuees to encourage behavioural scientists to go (cited by Hamblen & Slone, 2002). further. The initial account of blind Michael Hing- On the same theme, when appearing live on ston making his way down safely from the 78th New Zealand television as a commentator 2 days floor with his guide dog would also make a good after the September 11 tragedy, I felt obliged to start (Guide Dog News, 2001). question a television reporter about the wisdom of Here the importance of agencies coming to- the nonstop exposure that her channel was giving gether with community leaders in order to reinforce to the event. She replied that it was important for working relationships, improve performance, and the news media to make an indelible impression convert anxieties into acceptable fears has to be on the minds of its viewers. However, neither she acknowledged. The first of these meetings to dis- nor her program producer had considered the cuss the September 11, 2001, terrorist attacks was negative effects on viewers witnessing the constant held just 3 months later on December 9–11 (Jack- repetition of the plane striking the second tower son et al., 2002, p. 89). Understandably, because of and of people plunging to their deaths to avoid the imminent threat of further terrorist activity, the being burned alive, nor of their responsibility for conference focused on the firsthand experiences of causing such vicarious traumatic reactions. In fact the emergency responders regarding the perfor- the experience left many children in a state of mance, availability, and adequacy of their personal anxiety, and was sufficiently disruptive to leave protective clothing and equipment as they re- adults in no condition to begin thinking rationally sponded to the incidents. However, with 450 of of the causes and the consequences of the events. their colleagues having perished on duty, the large A few months later, after the unprecedented scale of the operation, the communication and news coverage of the war in Iraq, Mark Reinecke of command strategies rendered ineffective, and the Northwestern University Medical School provided range and duration of unfamiliar and demanding a fact sheet of advice to help viewers who were tasks, it was inevitable that other topics did not ‘‘battling war-induced stress’’ (retrieved March 29, escape mention.15 Among these were the removal of 2003, from http://www.msnbc.com/news/892080 decayed bodies and parts, methods of protecting .asp?0q12¼c8p&cp1¼1). But unlike the group of the crime scene, and ways of coping with the psychoanalysts after the 1985 earthquake in Defusing the Terrorism of Terror 379

Mexico, no one seems to have been invited to stage in the recovery process, and psychologists appear before radio and television audiences on should play their part in the proceedings. government and commercially run stations to give advice and reassurance (Palacios et al., 1986). Phases of Disaster However, in an initial overview of the research findings on populations after 9/11, Hamblen and The appropriate kind of intervention suggested for Slone (2002, n.p.) reported that, in common with different stages of after-effects caused by disasters reactions to other kinds of disasters, the initial brings to mind Drabek’s monumental task (1986) rates of distress and posttraumatic symptoms were in scanning more than 1,000 published reports of high: all kinds of catastrophes in a search for their essential components. Eventually he identified and Ultimately reducing the risk of traumatic stress named four major phases of disasters—prepared- reactions is best accomplished by abolishing ness, response, recovery, and mitigation—each of trauma in the first place by preventing war, which he subdivided and related to the individual, terrorism, and other traumatic stressors. The group, organization, community, society, and na- next best approach is to foster resilience and tion (see Table 24.1).16 Then he suggested prio- bolster support so that individuals have better rities that others might take up (i.e., automated coping capacity prior to and during traumatic information retrieval systems, taxonomies of dis- stress. The third best option is early detection aster events and response systems, access to com- and treatment of traumatized individuals to parative international databases, linking theory prevent a prolonged stress response. of human behavior with practice, increased To follow that prescription, the immediate job of practitioner/researcher interaction, and the mental those who provide psychological first aid after health needs of the first responders to a disaster disasters is to give the necessary encouragement scene). and support to casualties to help them regain their This chapter does no more than applaud stability. In addition, it requires social scientists to Drabek’s diligence and perspicacity while (a) en- help communities restore the essentials and get dorsing the need for a classification of disasters back into operation rather than try immediately and of potential casualties and (b) extending his to address the endemic causes of, say, terrorism, concern for the postdisaster mental health needs of Islamophobia, or anti-Semitism which currently emergency workers to a wider range of people grip the world (cf. Annan, 2004). Nonetheless, adversely affected. should people be intrigued by the possibility of trying to effect an improvement, they might con- Classification of Disasters sider the New Rules Project (2004) proposed by the Institute for Local Self-reliance, which calls Classification is at the heart of every intellectual, upon communities and regions to be viewed not empirical, and pragmatic endeavor. Paradoxically it only as places of residence, recreation, and retail helps researchers to establish the boundaries of a but also as places that nurture active and informed given topic and separates a subject into manageable citizens with the skills and productive capacity to parts for closer scrutiny. In disaster work it is a generate real wealth and the authority to govern prerequisite for assessing the adequacy of resources their own lives. To be sure, cultural, ideological, to meet clinical and organizational emergencies. philosophical, political, and religious differences However, before we consider any classification need to be brought into consideration at some scheme, three warnings need to be given. The first is

Table 24.1. Phasic responses to disasters

Preparedness Response Recovery Mitigation

Planning Preimpact mobilization Restoration Hazard perceptions Warning Postimpact emergency action Reconstruction Consequent adjustment 380 Prevention and Psychological Problems in Reaction to Acts of Terrorism that some people are inclined doggedly to seek ei- crash in Antarctica in November 1979, in which all ther the general factors or the unique, like the con- 237 passengers and 20 crew were killed (Taylor & tentious medieval scholars who had insufficient Frazer, 1981, p. 72; 1982), simply because I flexibility of mind either to clump or to split the wanted to bring together the many reports scat- components according to the pattern of material tered throughout professional journals about var- presented (Schachner, 1962, pp. 19–24). The sec- ious groups of people that had been involved in ond is that some people are either prehistoric ico- different types of disaster. At the time the existing noclasts or scatterbrained individuals who deny the reports fell short of elaborating the category of value of classification altogether: At best both ex- human disasters as distinct from the natural or the tremes approach each situation de novo and at worst industrial. However, I soon found that the pre- do not learn from their own experience, much less vious studies could be sorted into the three rela- from others. The third is that the process of classi- tively distinct categories and then be cross- fication can be a seductive diversion for those who matched with earth, air, fire, liquid, or biological admire elegance at the expense of utility and use it as components—despite the occasional disaster with a protective shield to avoid practical involvement in multiple compounding features, such as that from the problems of the real world. a dam failure dislocating a poor community, fol- For my part, I developed a framework for lowed by the methyl mercury contaminating its disasters and victims after the Mount Erebus plane water supply, and finally the widespread theft of

Table 24.2. Matrix of disasters

Natural Industrial Technological Human Reactors Avalanches Dam failures Ecologicalirresponsibility Earth Earthquakes Ecological neglect Motor vehicle and train accidents Erosions Landslides Eruptions Outerspace debris Meteorite crashes Radioactive substances Mudflows Toxic waste disposal Toxic mineral deposits Air Blizzards Acid rain Aircraft accidents Tornadoes Chemical pollution Hijackings Dust storms Explosions, surface and Spacecraft accidents underground Hurricanes Radioactive clouds and soot Meteorite and planetary Urban smog shifts Thermal shifts Fire Lightning damage Boiling liquid Arson Spontaneous combustion Expanding vapor accidents Electrical fires Hazardous chemicals Liquid Droughts Effluent contamination Maritime accidents Floods Oil spills River tragedies Storms Waste disposal Tsunamis Biological Elements Endemic diseases Design flaws Complex terrorism Epidemics Equipment problems Corporate Famine Illicit manufacture and use Criminal extortion of explosives and poisons via viruses and poisons Overpopulation Guerilla warfare Plague Hostage taking Pestilence Sports crowd violance Warfare Defusing the Terrorism of Terror 381 its precious savings by devious landowners who pensability that make for difficulty in bringing operated the company store (Erikson, 1994). closure to professional relationships. Not that the Then, following Drabek, it became possible to ‘‘helpers’’ should be encouraged to go the other compare the studies according to both the parti- extreme and adopt a buccaneer gung-ho attitude to cular phase in which they were conducted and the obscure the potential pathological consequences of specific effects on any particular sample of the po- suffering, but they should be prepared to accept a pulation on which they were based (Table 24.2). time-limited role in the compassionate application of the appropriate skills for which they have been 17 Victims, Casualties, and Their trained. Psychological Needs For such reasons and except for those that have either died from the calamity or suffered irrevocably Turning from the classification of catastrophes to a in some other equally significant way, the term corresponding classification of victims and casual- ‘‘casualty’’ is to be preferred for those whose lives ties, according to the New Shorter Oxford Dictionary, have been affected adversely by exposure to cata- the word ‘‘victim’’ first appeared in print in the strophe. Explicitly the term implies the member- Rhemish translation of the Bible in 1592, and it ship of a provisional rather than a permanent came into general currency in the seventeenth category. It applies to people that have survived the century to describe living creatures that were sa- initial impact of a life-threatening event of some crificed to the deities. After that the noun was magnitude, but it encourages self-reliance and is generalized to describe ‘‘any person put to death, consistent with the thought that, no matter what subjected to torture or suffering, or property loss, has happened, it is better to live in hope than to die through cruel or oppressive treatment or a de- in despair. It is consistent with the adaptation of structive agency.’’ Nietzsche’s saying—‘‘that which does not kill me The classification of victims began to serve a [can make] me strong’’—thereby fostering hope for purpose other than the religious in the Napoleonic recovery through the positive power of the placebo wars, when frontline medical staff introduced a effect and at the same time negating the stultifying triage system for sorting surgical casualties into four power of its counterpart, the nocebo effect. groups according to the critical nature of their in- Both of such polar opposites deserve con- juries (http://en.wikipedia.org/wiki/Triage). More sideration because, at present, clinicians and re- recently, medical and social scientists have come to searchers, unlike managers and educators (cf. classify casualties by the magnitude of the external accel/TEAM, 2005), tend either to denigrate or social chaos, the spread of disruptive effects, the trivialize the placebo for being subjective and be- extent of personal injuries sustained, sickness, beyond the realm of science, and they ignore the reavement, property loss, physical and emotional nocebo completely. Rarely do they comment on vulnerability, and the reserves of resilience that the fact that their own optimism and pessimism individuals and their groups have for coping with toward other people operate as self-fulfilling pro- adversity. Then finally, perhaps in an attempt to phecies to bring about their expectations. They are assert its nonpolitical organizational stance in not likely to change their stance until they can (a) making help available to everyone, the IFRC&RCS accept that one of their functions is to reinforce the defined victims more simply as people with basic natural powers of recovery of those seeking their needs for survival (DHA News, 1994, pp. 60–61). help, rather than to be held entirely responsible for Again, any such classification schema needs to any more identifiable remedial intervention, and be used with care because labeling people instantly (b) not feel ashamed or embarrassed to promote as victims can create secondary problems for both research into the recuperative powers of the mind. the labeled and the labelers. In the labeled it can The definition of the placebo (‘‘I will please’’) induce feelings of hopelessness and discourage- harks back to the use of the word by Chaucer in ment that make them succumb more easily to 1386 when describing ‘‘a flatterer, sycophant, adversity and keep them in a state of perpetual parasite’’ (Oxford English Dictionary [OED] Online, dependence on the clinical and social services that 2005). In 1811 the word was recorded as ‘‘an their community might provide. In the labelers it epithet given to any medicine adapted more to can induce feelings of dominance and indis- please than benefit ...a substance or procedure 382 Prevention and Psychological Problems in Reaction to Acts of Terrorism which a patient accepts as a medicine or therapy and regain composure. Within the limits of com- but which has no specific therapeutic activity for his mon sense, the time for them to register features of condition or is prescribed in the belief that it has no psychopathology comes later, should casualties such activity.’’ Today, clinicians are thought not find intrusive thoughts, avoidance behavior, and inclined to foster the practice, despite the gradually state of high arousal beginning seriously to interfere accumulating evidence of its efficacy, because of the with their everyday lives (cf. Young, Ford, Ruzek, risk to their reputations as biomedical scientists Friedman, & Gusman, 1998; Raphael, 2000). Do- (Benson & Stark, 1996, Chapters 1–3; Carroll, ing so would not put the casualties unduly at risk 2005). However, far from feeling intellectually because, as the World Health Organization (WHO) embarrassed by having fostered any inherent re- (2003, p. 4) has stated: cuperative powers, healers invoking the placebo Most acute mental health problems during the should be pleased to think that they have developed acute emergency phase are best managed with- their skills sufficiently to promote its application. out medication following the principles of They might then promote studies of its efficacy. ‘‘psychological first-aid’’ (i.e., listen, convey The nocebo effect (‘‘I will harm’’) is not so well compassion, assess needs, ensure basic physical known as the placebo, and its definition appears needs are met, do not force talking, provide or only as ‘‘Draft entry December 2003’’ in the OED mobilize company from preferably family or Online as the ‘‘detrimental effect on health pro- significant others, encourage but do not force duced by psychological or psychosomatic factors social support, protect from further harm). such as negative expectations of treatment or prognosis, cultural beliefs about illness, personality These procedures can be supported with programs traits, etc.’’ Even fewer studies have been under- of stress reduction in which stimulants are avoided, taken of the nocebo that of its opposite (cf. Carroll, exercise is encouraged, social supports are utilized, 2002). However, there are many everyday examples and life styles are reexamined (Davis, Eshelman, of the harmful effects induced by noxious parents and McKay, 1995; WHO, 1997). and work supervisors, to say nothing of certain However, no matter how prestigious the au- anachronistic cultural prohibitions to affirm the thority recommending treatments, health profes- significance of the concept. They are something that sionals themselves will still be held accountable for potential helpers should try to obviate. the potency and impotency of their interventions, The maximizing of the placebo and the mini- and for that reason they and their organizations will mizing of the nocebo have elements in common with have to address the difficult question of designing the processes of the therapist showing ‘‘absolute appropriate procedures for evaluating the quality of positive regard’’ emphasized by the Rogerian thera- their work.18 Novices can derive benefit from the pists, of ‘‘establishing rapport’’ on first acquaintance reassurance of Norris et al. (2001) and Norris, (usually mentioned without elaboration in profes- Friedman, and Watson (2002), who maintain that sional training courses), of monitoring the two-way disasters rarely engender severe, lasting, and per- transference effects in psychoanalytic treatments (cf. vasive effects unless the damage to property is ex- Wilson & Lindy, 1994), and of portraying the car- treme and widespread, financial problems for the dinal virtues of conveying ‘‘emotional warmth, em- community are serious and ongoing, or the disaster pathy, and congruence’’ to clients (cf. Patterson, is caused by human carelessness or intent, with a 1989/2000). But the intent is to encourage those in high prevalence of trauma in the form of injuries, need to draw initially on their own resources and threats to life, and actual loss of life. Yet those au- then for the helper to join in, rather than for the thors make no mention of casualties gaining benefit helper to play a more active part right away. psychologically from surviving catastrophic ex- Fostering self-help, once any threats to life and perience (cf. Tedeschi, Park, and Calhoun, 1998). limb are reduced, also requires health professionals In fact, and without going quite so far as to say with not to give undue attention immediately to any Samuel Johnson that ‘‘when a man knows he is to be particular psychological symptoms that casualties hanged in a fortnight, it concentrates his mind might report or to signs they might themselves wonderfully,’’ there is truth in the saying that the observe, but to allow casualties a few days grace in awareness of death causes a reexamination of value which they might begin to use their inner strength systems (Ursano, Tzu-Cheg, & Fullerton, 1992). Defusing the Terrorism of Terror 383

Despite the embarrassment that the bare test construction, has used prayer as one of four mention of human values might cause some be- topics to illustrate the application of psychometric havioral scientists, value systems give a sense of techniques, and the Journal of Community Psychol- meaning and purpose to life that becomes only too ogy has devoted two special volumes to the subject apparent after they have been fractured by emer- (Kloos & Moore, 2000, 2001). Then, after 9/11, the gencies and disasters. People who are hesitant to APA went so far as to advise its clinical members to acknowledge such subjective factors might be respond to disasters by recognizing professional persuaded (a) by the idea that human beings could challenges, attending to self-care strategies that be construed somewhat like computers, in that included their own spiritual needs, adopting pro- they too need a comparable basic DOS, Windows fessional support, and enhancing their commit- 95, 98, 2000xp, or Linux operating system; and ment to those in need (cf. http://www.apa.org/ (b) by the realization that the WHO’s definition of practice/practitionerhelp.html [retrieved January health does not reflect merely the absence of dis- 31, 2006]). Subsequently, the APA commissioned a ease or infirmity but also the state of complete book by Pyszczynski, Solomon, and Greenberg mental, physical, and social well-being (WHO, (2003), in which the authors elaborate on Ernest 1997). They might also go further to reflect on the Becker’s Denial of Death (1973) when applying additional spiritual dimension of te kaha wairua, their ‘‘Terror Management Theory’’ (TMT) to post- which, together with te kaha hinengaro, te kaha ti- 9/11 reactions. TMT proposes that innate anxiety nana, and te kaha whanau, constitutes the tradi- about annihilation combined with the inevitability tional Maori fourfold concept of spiritual, mental, of death creates a basis for terror for the adversaries physical, and sociocultural health (Durie, 1985).19 on both sides and that it can be reduced only by Finally, they might appraise the physiological un- addressing the causes of fundamentalism. derpinnings of religious belief (cf. Benson and However, at the more immediate interactive Stark, 1996, Chapter 8) and consider W. R. Mill- level with casualties after a disaster, I have found it er’s (1999) integration of spiritual and psycholo- helpful to create six somewhat distinct categories gical treatments in a book published by the according to their kind of involvement they had in American Psychological Association (APA), no less. the event (Table 24.3)—while accepting that the Spirituality is a term that covers religious at- blurring of categories might occur when some titudes, experiential dimensions, existential well- people fall into more than one grouping. Not all of being, paranormal beliefs, and religious practices those in any particular category will necessarily (McDonald, 2000). It offers a sense of meaning require the same kind of intervention because their and purpose in life and sets a framework for per- needs will depend on their personal perceptions of sonal conduct and group relationships that can particular traumatic events, their unfinished busi- at least withstand scrutiny. It is of particular re- ness from previous events, their current state of levance in the recovery period after disasters, when mental and physical health, their mental resilience, casualties search for explanations of events, as I and the adequacy of their support systems. A few elaborate later with an example from the Cook casualties might also find that the disaster experi- Islands after a devastating cyclone (Taylor, 2001). ence has exacerbated dormant emotional problems Nevertheless, its incorporation into recovery plans that now demand more intense attention than presents a challenge for health professionals—not psychological first aid provides, but at least the all of whom will be emotionally or intellectually categories provide a starting point for health pro- willing to consider the metaphysician-scientist- fessionals who are concerned about appraising the practitioner model that O’Donohue (1989) ad- diversity of perceptions and psychological pro- vanced. Beit-Hallami and Argyle (1997) attempted blems of people affected by all kinds of disasters valiantly to bridge the academic divide, but with (cf. Office for Victims of Crime, 2000; 2001). a touch of resignation Argyle (2002) was forced to With these provisos, the primary casualties are conclude that perhaps the best psychology can those who suffer directly from a catastrophe. Many hope for is to study the causes, correlates, and do not survive, but those who do might develop effects of religion but not to explain it.20 symptoms ranging from the mild to the severe that Despite the intellectual difficulties, Loewenthal can be instant, delayed, transient, or chronic. They (2001, pp. 82–83), a leading British authority on have to reassemble their shattered lives sufficiently 384 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Table 24.3. Classification of victims and casualties seem not to have been heeded in Banda Aceh after the devastating tsunami came ashore on 26th De- 1. Those who are adversely affected at the epicenter of a disaster cember 2004 (IFRC&RCS, 2005, p.87). 2. Their families and close friends The tertiary casualties are the workers in all 3. The emergency workers and those whose jobs oblige types of agencies who succumb during the course them to become directly involved in the rescue and of their postimpact assignments. If once they were recovery operations described as the ‘‘hidden victims’’ of disaster, today 4. The grieving community that identifies with those who they are recognized more openly as being vulner- are suffering able to occupational fatigue and stress reaction. 5. The psychologically troubled whose reactions are Fatigue arises from the impulse of workers after a exacerbated; troublemakers who are inclined to disaster not to impose a daily routine of a rea- exploit the situation and use it to their own advantage sonable length that allows them sufficient time 6. Various other people who are adversely affected between shifts for rest and recovery. Stress arises from the substantial imbalance between demands that are made and the ability of individuals to re- to satisfy their basic needs for shelter, food and spond with the organizational support available. drink, belonging and security, while leaving aside To their own detriment, emergency workers their needs for self-esteem and self-actualization sometimes identify too closely with the primary until the semblance of normality returns (cf. Ma- victims and lose their objectivity (Asken, 1993), slow, 1987). Like everyone who suffers acutely, particularly if they are engaged in gruesome and they will be faced with rebuilding their perception prolonged body-recovery work and if their collea- of the world in a way that restores meaning and gues are among the dead.22 In such circumstances purpose to their lives (Bracken, 2002). Eventually many of the firefighters in the immediate aftermath some will find that they have been strengthened by of 9/11 were said to have broken ranks, disobeyed their experience of adversity. orders, and acted impulsively (McKinsey Report, The secondary casualties are the family mem- 2002), rushing up the towers in a way that has been bers and close friends of the primary group who likened to ‘‘Pickett’s charge’’ of futility, which oc- develop symptoms vicariously, sometimes with a curred in the U.S. Civil War (Massey, 2002). In greater intensity than those more directly involved. states of sustained high arousal many resisted the Depending on the intensity of their personal at- attempts of management to get them to moderate tachments and extent of loss, they will need time, their hours of duty and change their strategic opportunity, and encouragement to grieve and ex- priorities (Eisner, 2002). press a mixture of feelings that include anger, dis- Consequently, emergency workers should be tress, guilt, and despair at their loss before they can encouraged to develop emotional shields for the pick up the threads of life again (cf. Young, 2001, duration of their assignments and to undergo oc- Chapter 5). Their reactions are likely to be pro- cupational debriefing afterward to help them regain longed if delays occur in the identification of their their composure and their resilience for living— loved ones, which makes it difficult to bring closure otherwise they might become case hardened and to a fatal episode to fulfill their cultural and re- burned out.23 I raise this point because many of the ligious obligations.21 However, the careful identi- emergency personnel who collected parts of 257 fication of the dead makes delays inevitable, and the victims in 347 bags after the crash of an airliner Pan American Health Organization and the World were found to have made spontaneous conceptual Health Organization (2004) warn against the transformations to help them deal with the im- greater psychological harm caused to relatives and mediate horror of the job, but afterward they ex- their communities by speedy and anonymous mass pressed the need to restore the reality of the burials or cremations: they are also at pains to ex- assignment.24 Initially when working, they found plode the myth that hasty mass burials are necessary themselves regarding the body parts as broken to prevent disease from spreading—except in re- dolls, tailor’s dummies, waxworks, meat from a gions where disease is endemic or where the fresh slaughterhouse, medical specimens, jigsaw puzzles, water supply is endangered. However, the warnings and scientific problems to be solved, but when off Defusing the Terrorism of Terror 385 duty they reflected on the human side of the work. psychological signs, provide simple, informative Consistent with van Der Kolk’s conceptualization handouts for follow-up purposes should help be some years later (1996), the creation and adoption required later, and impose reasonable limits on of such personal cognitive defenses helped to pre- their own daily schedules of work. vent traumatically disturbing images from being The quaternary group of casualties might be fixed in the nondeclarative part of memory and symptom free except for their behavioral excess. It gradually made them available for processing, ab- consists of the well-intentioned but emotionally sorption, and availability in the declarative part. labile people in the community at large who identify Following the same plane crash, an interest was with the primary victims and act inappropriately taken in the design and operation of mortuaries and themselves. It includes those who display what has embalming facilities, and changes were recom- been called the ‘‘cornucopia syndrome’’ from mended that might be beneficial to the operatives, opening their pantries and their hearts with good- as well as the families of the deceased who identify will but little imagination to impose burdens of their loved ones (Taylor, 1984, 1987). Research was perishable food, unsuitable clothing, and offers of also undertaken with students of health science hospitality on unwilling recipients.27 These are the and medicine to assess their reactions to the cadaver people for whom the term ‘‘compassion fatigue’’ work they did in their training and to minimize was originally coined because they could not sus- any emotional impact (Hancock, Williams, & tain for long the additional burden their emotions Taylor, 1998; Hancock, Williams, Taylor, & Daw- obliged them to carry—plus the fact that any con- son, 2004).25 stantly accumulating and evolving trauma scene Yet to come into consideration are the trainee makes more demands than anyone can possibly mental health service providers who might need to meet.28 The category includes those that converge witness brain prosections and postmortems in on disaster sites, like the estimated 10,000–15,000 their training to help them to prepare for on-the- volunteers who turned up daily at the World Trade scene disaster fatalities they might encounter later Center to help in the recovery of victims, most of on.26 Reports of the reactions of the health care whom complicated the operations (Rick Shivar, workers who conducted body recovery operations External Affairs Directorate, U.S. Federal Emer- at the World Trade Center have yet to come to gency Management Agency, live video conference, light, but the early indications of the 10 uniformed March 14, 2002). So many firefighters were said to staff that worked at the Pentagon are that medical have arrived uninvited from neighboring counties training and clinical exposure were perceived as and even from other countries that a special ‘‘ma- ‘‘somewhat protective by some but did not seem to verick holding pen’’ was proposed for the co- prevent vulnerability to the emotional impact of ordination, management, and deployment of all their experiences’’ (Keller & Bobo, 2002, p. 8). kinds of volunteers until they were needed (Lud- Apart from preparation for working near dis- wig, 2002). aster sites, the normal professional training and The same quaternary, or fourth, group includes experience of health professionals does not pre- the citizens who in 1981 hammered on the door of a pare them for the transient trauma recovery work mortuary in Rome, demanding to see the corpse of a of the kind to which Knop (2001) and Gold and 7-year-old boy that had died tragically after slipping Faust (2002) have drawn attention. For example, down a pothole (Paese Sera, July 18, 1981). Thanks the conventional courtesies of professional referral to the power of nonstop overnight television cov- for specific appointments to the security of con- erage of the scene, the viewers had identified sulting rooms do not apply in emergency situa- emotionally with the boy’s family as the emergency tions. To the contrary, providers of psychological services made futile attempts to recover the boy first aid have to be prepared to adapt their sche- alive. But the news reporters, who had created and dules, procedures, and interventions to the pre- sustained the high level of excitement, stopped vailing circumstances. They might have to work in short of releasing the pressure and helping viewers makeshift quarters, reach out to find clients, make to regain their composure. Instead, they left them to arrangements as appropriate for the management make intrusive claims at the mortuary on the basis and care of anyone showing a warning cluster of of their newly acquired quasi-family connections. 386 Prevention and Psychological Problems in Reaction to Acts of Terrorism

The quinternary, or fifth, group of disaster ca- In this connection the point could be made sualties consists of the troubled and the trouble- again that good clinicians exude acceptance, em- some with pathological proclivities that, in times of pathy, and absolute positive regard toward their phantasmagoria, lose their self-control. The trou- clients and patients. Rarely do they operate other- bled give free rein to their fantasies by indulging in wise, unless they are burned out. And rarely do they voyeuristic activities, collecting pictures of body consider malingering as a differential diagnosis ‘‘in parts, and even expressing necrophilic desires. those situations in which financial remuneration, Some of them pretend to have been involved in any benefit eligibility, or forensic determination play a well-publicized disaster, either to play on the role’’ (American Psychiatric Association, 2000, pp. sympathy of donors or to seek notoriety. It is a moot 467, 471). However, in trauma work, especially point whether this category might include the when substantial economic and psychological ‘‘disasterotropic,’’ who chase tornadoes, tsunamis, benefits are to be gained, such a differential diag- and volcanic activity to satisfy desires other than the nosis should not be entirely overlooked (Taylor, scientific, or the surge of tourists with ghoulish 2003a). tastes that visit the sites of devastation—such as The final category is for the miscellaneous those for whom the government of Honduras made group of casualties that has a diverse array of as- provision after Hurricane Mitch in 1998 or those for sociations with disasters that present problems with whom a Ukraine tourist agency is now promoting which they have difficulty in coping. It includes visits to the site of the leaking radioactive power those that, but for chance, would themselves have station at Chernobyl. been primary victims and who constantly torment The troublesome are those who in times of themselves with questions as to why they were social chaos go on the rampage to loot, plunder, saved from fatality. It also includes those who in all and riot. Their more calculating and sophisticated innocence had persuaded their friends and ac- counterparts with greater impulse control perpe- quaintances to go into a situation that subsequently trate insurance fraud, and hoaxers have to be taken became disastrous, as well as those who believe that seriously.29 Sundry reports in the news media in some way—by their activity or inactivity—they showed that after 9/11 thieves tried to steal gold have brought about a given disaster. It includes from the vaults in the rubble, a photographer trauma workers and researchers, who in their distributed a picture he claimed to be of one of the postdisaster work are sometimes unaware of the planes a few moments before the impact, a few insidious effects of the strain and fatigue upon people in different parts of the United States made themselves. Moreover, unlike the compassion fati- dramatic—but fraudulent—appeals for relief, with gue prevention service that the Green Cross now some posting names of missing people fraudu- provides for trauma teams (http://www.green- lently on the official website. Another matter in cross.org), they had neither personal nor profes- Canada dreamed up the story of five terrorists sional networks available to support them (Gentry, crossing the border to divert attention from his 2002). A glaring example is that of a first-line own criminal activities.30 At the higher end of the responder of an international aid agency I en- scale of criminality, one of the firms with offices in countered on a disaster scene who was quite dys- the World Trade Center came under suspicion functional after spending years of travail in battle- with regard to about $105 million of investment torn Angola, Burundi, Cambodia, Cyprus, Kosovo, funds that went missing with a financier soon after Laos, Liberia, Serbia, Somalia, and Vietnam. All he the catastrophe, and some 2 years after the event could do to gain respite was to express cynicism, the Empire State Development Corporation re- indulge his interest in the history of conflict in the ported that it had been obliged to recover $1.2 region wherever he found himself, and smoke like a million in payments from 66 companies that had chimney. I was not at all surprised to learn that he claimed emergency grants. Hoaxers in the United resigned soon after we met. States and elsewhere caused bomb scares at many The classification systems for disasters and airports, and in many countries they caused casualties can be combined conveniently and ap- widespread fear and disruption by distributing plied to the study of any given catastrophe and its white powder resembling anthrax.31 human effects (Figure 24.1). First, the elements, Defusing the Terrorism of Terror 387 factors, and phases of a disaster can be located in nity, a case can be made for restoring the earlier three-dimensional space, and then the correspond- stages of warning, threat, and impact that Powell, ing features of the casualties can be compacted into Rayner, and Finesinger published originally in the form of a smaller cube and placed in the pre- 1953 (cited by Cisin & Clark, 1962). Potentially cise disaster location. Then, with several disaster each of such stages has anxiety-producing features studies so placed, it is possible to have a com- that are worthy of detailed consideration, and with prehensive grasp of different types of disasters and the present and prolonged imposition of wide- of different types of casualties. spread national and international security measures, there would be no shortage of subjects with Phasic Community Reactions whom they could be explored. After the heroic period follows the honeymoon of Before considering some applications of the model, supreme optimism, in which the community enjoys it is necessary to mention the sequence of com- being the center of worldwide attention, with pro- munity reactions that typically occur after any mises of support coming from all quarters to help to catastrophe. These tend to overlay any clinical restore the status quo. After about 3 weeks dis- symptoms that individuals might describe and illusionment sets in, when these promises have not color the responses a community might make to all been fulfilled, some are found to be conditional, any plans for rescue and recovery work. The se- the donations received are neither readily nor quence begins with the heroic period, which occurs evenly dispensed, internal dissensions arise, and immediately after the impact of any disaster, in the future looks bleak. Finally, after many months which the community excels in attending to the the restabilization phase occurs, in which recovery needs of its members long before outside aid can plans begin to bear fruit, signs of reconstruction are be brought in (Young et al., 1998, pp. 17–19). seen, the community restructures itself, some However, in view of the mounting apprehension evacuees return home to the disaster zone, com- and anxiety about pending terrorist threats and the memoration days are established, memorials are fear generated by the hypersensitive precautions erected, and the catastrophe is incorporated into taken by the authorities to safeguard the commu- the cultural life of the community.

Recovery Response Mitigation Preparedness

quake Earth cyclone hurricane oil rig explosion aircraft evacuation study Air aircrash Fire dormitory fire

shipping collision/capsize Liquid tanker oil spill

Biological Casualties/Victims

Natural 1 terrorism 2 Industrial 3 4 Human 5 6 1 4 3 2 2 Types of 3 1 Kind program of help

Figure 24.1. A conceptual model to integrate disaster studies. 388 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Cross-Cultural Considerations able to persuade more of the bewildered community to tag along with them, praising the heroic Mention of the cultural life of a devastated com- deeds of their stalwart rescuers, and being critical of munity brings to mind the need for clinicians and those who were unprepared and had chosen to ig- researchers to attend to cross-cultural factors whe- nore the weather reports or who had behaved badly ther they are working either in a multicultural by taking to alcohol or looting unoccupied pre- community at home (see Mollica, Wyshak, & La- mises. velle, 1987) or in a community abroad where the However, the clergy of all four of the recognized attitudes, beliefs, customs, and language differ Christian denominations (i.e., the Cook Island markedly from theirs (DeVries, 1996, Chapter 17; Christian Church, the Latter Day Saints, Roman Lindner, 2001). In particular they have to be sa- Catholics, and the Seventh Day Adventists) ham- tisfied that their specific clinical concepts, methods mered home Old Testament admonitions in their of assessment, and treatments are appropriate for daily community services and obliged the survivors the ethnic groups and the settings in which they to search their souls and seek redemption for their are to be applied (Marsella, Friedman, Gerrity, moral transgressions, which had brought the cy- & Scurfield, 1996; Culbertson, 1997; Waxler- clone on them as a punishment. At a time when Morrison, Richardson, Anderson, & Chambers, their congregation was grieving and struggling to 2001). Finally, following the development of cultural regain enough courage to continue with life, they anthropology and cross-cultural psychiatry since the made no reference to the teachings of the loving 1930s, trauma clinicians concerned with the dis- God of the Gospels. Only a few of the villagers were sonance of systems, as well as the psychopathology heard to question the validity of the religious in- of individuals and groups, will need to regard cul- tervention, despite the fact that their island lay in tures as dynamic entities and anticipate the possible the seasonal path of hurricanes and that the devout consequences of any intervention they propose or and innocent were among the affected. changes they might feel obliged to recommend. In response to their direct inquiries about my On such matters three fairly recent assignments personal position on the matter, I could only say in different countries in the South Pacific yielded that, in all honesty, for me there were other more a few clinical features worthy of special mention compelling explanations—such as El Nin˜ o and (Taylor, 2003b). The first occurred in Manihiki, a global warming—than the religious to account for remote island in the Cook group, near the equator, the cyclone. But later, with distance, detachment, where a 30-meter cyclonic wave swept over the 5- and access to theologians and libraries, I took the meter-high island and caused the loss of 20 people opportunity to reflect on the origins of different from the total population of 680 (Taylor, 1998). religious explanations for adversity before trying to There the discourse included the open presentation resolve the issue—at least to my own satisfaction of dreams and prophecies, and it was often em- (Taylor, 1999). The problem seemed to be that the bellished with tales and legends from the past (cf. Cook Island pastors were faithfully repeating the Luomala, 1984, pp. 876–879). In a couple of in- fundamentalist doctrines of the early nineteenth- stances the conventional ‘‘memory-evocation’’ tech- century missionaries to account for adversity, nique for trauma reduction was enriched when without regard for later theological interpretations villagers led the way through the rubble of their as well as developments in science. To them, as settlement to retrace the frantic journeys they had Keys (1999, p. 67) wrote in another connection, it taken to reach ‘‘higher’’ ground. There, in im- was as if ‘‘the broad outline of human history was mediate virtual reality in situ instead of long after- seen as a divinely preordained chronological struc- ward through recall of detail during an interview in ture which one day would end with the resurrection a conventional consulting room, they reentered the of the dead, the Day of Judgment, the dissolution of derelict homes that had given them sanctuary and the mortal world, and its replacement with an now evoked tearful memories of previous occu- everlasting Kingdom of God in which the righteous pants, organizations, possessions, and long-past would live forever.’’ events. As they spoke, they reexamined the actions Fortunately, the Christian clergy in Tuvalu, the they had taken for self-preservation during the place of the second South Pacific assignment, took maelstrom, expressing regret for not having been a more liberal stand after a dormitory fire in which Defusing the Terrorism of Terror 389 the house mother and 19 schoolgirls lost their a memorial for the site. A year after the event there lives. They asserted that fire was not an act of God, was far less talk of ghosts and spirits to be heard a Kole fakasola, but a pure accident, a fakalavalava than there had been around the time of the tragedy. (Taylor, 2000). They further asserted that any A gala recreation day was held to commemorate the behavioral reactions of the bereaved were within first anniversary of the tragedy to which relatives of the normal range to be expected, rather than a sign the deceased from far-flung islands were welcomed. of madness, a fakavalevale. In offering such ex- Moreover, by then the number of students at the planations they used the supportive strength of the school had increased rather than decreased, as scriptures and of their culture to help the bereaved initially had been feared. come to terms with the tragedy. As to be expected, the schoolgirls who escaped The clergy also conducted a moving matafaga the blazing dormitory had symptoms of avoidance, dawn service at which the congregation gathered in intrusive imagery, episodes of reliving the experi- the darkness and took turns spontaneously sharing ence, and sleep disturbance. They had very mixed their grief until the rising sun streamed through the feelings about having survived while their friends building as if to give them enough hope to face the in the same dormitory had been burned alive. The new day. It was a remarkable ceremony that could others, like many adolescents, were reflective but only have been therapeutic to the overburdened. At less expressive. At the time of the fire they had the other end of the scale of sensitivity but no less rushed to the scene, having been aroused by the helpful in stress reduction were the fervor and ex- alarm given by the staff and the noise of the citement of the regular drumming and dancing burning timbers, and they formed a bucket brigade competitions that took place between the villages— with their teachers to bring water from the ocean the people needed no encouragement to use phy- nearby until the fire raced beyond control. There- sical exercise to reduce their stress. after they remained as silent sentinels, watching at a However, because Tuvaluans of all ages spoke safe distance from the site until the fire died away about the existence of ghosts and evil spirits asso- and the staff could protect the burned bodies from ciated with the dead, it seemed appropriate to ask marauding dogs. They crept back to bed for a the clergy what they could do to exorcise the mal- troublesome few hours and returned the next evolence. There was talk of abandoning the school at morning to witness the recovery of the unidentifi- which the victims were buried—and, had that able charred remains of their friends. Some of the happened, there would have been serious reper- senior pupils took part in wrapping the dead in cussions because there was only the one post- woven-flax sleeping mats before the coffins were primary school in the remote island chain. The made, and a few acted as pallbearers later at the brighter students would have lost the opportunity to funeral service in the evening. compete for higher education abroad, their job The active participation seemed to help many prospects would have been adversely affected, and of the school pupils come to terms with the trauma they would have had more of a struggle to provide of the event—much as Milne (1979) had found security for their parents in old age as their culture with the survivors of Cyclone Tracy and as Hoiberg required.32 and McCaughey (1982, p. 25) found with injured To their credit, the clergy in Tuvalu responded sailors after a collision between ships at sea. They positively in their sermons and pastoral work by remained on the spot with their group, and they putting the malevolent spirits into theological stayed together either in their own homes or with context. One minister, at the behest of school- their extended families on the capital island, Fu- children that swore they heard the voices of ghosts nafuti, for about 4 weeks while their school was over the grave, even appealed directly to the spirits closed. The continuing association gave them an of the deceased to rest in peace and not to trouble opportunity to restore their emotional security their friends who were grieving. About the same with the group with which they had undergone time, several students were seen sitting by the the traumatic experience, while remaining in the common grave and talking to their companions supportive fold of their immediate and extended that had died. Their evident need to feel able to families. approach the grave rather than to shrink away To a European, it was interesting that the from it was borne in mind later by the designers of whole community rather than specific nuclear 390 Prevention and Psychological Problems in Reaction to Acts of Terrorism families were grieving. This was because, under Although their partners had been taken prisoner, the Polynesian kinship system, relatives of the same for self-protection some of the families had made generation as the parents were regarded culturally themselves prisoners in their own homes. During as parents, no matter how biologically distant their interviews with the families, the reactions of the personal position in the extended lineage (Da- first few were so extreme that the clinical program nielsson, 1956, p. 89). Similarly, relatives of the was extended to include them. same generation as the grandparents were all In the event, 10 former hostages and 31 key grandparents, and cousins were as brothers and family members were interviewed in depth (to- sisters. The interweaving of family relationships gether with two of the families of the coup lea- made for a more extensive sharing of grief in the ders), their clinical needs were assessed, and they postimpact phase than would be the case in Wes- completed clinical questionnaires. They were given tern societies, but it also made for closer support in advice to help them put their suffering into better the recovery period. context, with prescriptions for minimal dosages of In Fiji, the third assignment was to assess the medication where necessary to reduce anxiety and reactions of parliamentarians taken hostage by induce routines of sleep. terrorists once they had been released (Taylor, But it was most noticeable that all of the re- Nailatikau, and Walkey, 2002). Following McDuff spondents, whether Christian, Hindu, or Muslim, (1992, Abstr.), the plan was to ‘‘create a healing used sacred texts and phrases to cope with the social environment immediately after release ... continuing saga of intimidation, threats, and the that encourage[s] strong cohesiveness ...isolates extreme uncertainty of their situations. The per- the victims from external groups, promotes sonal benefit the believers derived from their faith, abreaction, and provides an opportunity for rest and their readiness to expound the tenet, con- and replenishment ...restore[s] a sense of power to trasted sharply with the experience derived from the victims and ...reduce[s] their feelings of iso- trauma groups encountered in European coun- lation and helplessness and of being dominated by tries, in which belief systems are rarely dis- the terrorists.’’ The task was also to monitor the cussed.34 The difference led to reflections about hostages’ emotional reactions to the critical event the importance of belief and value systems in (Frederick, 1987), to look for signs of the adverse helping casualties to retain their hold on life emotional attachments that sometimes develop (Taylor, 2001). between captors and captives (Strentz, 1979; Turner, 1985), and to offer whatever assistance Belief and Value Systems seemed appropriate.33 However, because the coup was unresolved Yet the propensity of some believers to perpetrate and continuing, it was difficult to gain access to the violence in the name of religion calls for serious hostages still in custody. Those that had been reconsideration, as also does the evangelical zeal of leased early were difficult to locate because they those claiming religious authority for predicting had scattered to the four winds—some had gone the inevitability of Armageddon unless mankind into hiding, and others had gone abroad. Conse- becomes converted to Christianity (cf. http://en quently, approaches were made to the families of .wikipedia.org/wiki/Armageddon). From such evi- the hostages still in custody to let them know what dence, those hoping to seek peaceful coexistence provisions had been made for the reception of through formalized religion would be doomed to their loved ones and to ask whether they would disappointment unless they had the strength to pass on information in their letters to help them make more of a humanistic than a political inter- sustain their resistance to captivity. pretation of religious teachings. In a condemnation Like some of the released hostages, the families of this proposition, Sells (1996) has detailed the were difficult to locate. For reasons of personal attempts that were made in Bosnia to cloak a basic security a few had made a point of constantly ethnic war with religious overtones to justify the shifting their whereabouts. Those that stayed put atrocities perpetrated there. Ignatieff (1998) has had reinforced the fences around their homes and done the same for Afghanistan, and Read (2001) taken extra precautions to have relatives and has gone further back to make a critical reappraisal friends keep a watchful eye on unknown visitors. of the complex motivations of the Crusaders. Defusing the Terrorism of Terror 391

It follows that religious explanations for dis- that lie behind many kinds of human disasters. The asters merit further debate. However, they are proposition is that some of the tensions might also much neglected by psychologists, with authorities be found behind terrorism, and for that reason such as Beit-Hallahmi and Argyle (1997) making behavioral scientists should develop a healthy re- no mention of them in their most comprehensive spect for a general systems theory is receptive to appraisal of religious behavior, beliefs, and ex- contributions from different fields. It would require perience. Perhaps the different explanations for researchers to resist the competitive trend for su- disaster simply reflect the prevailing educational, premacy between the different disciplines on which experiential, and intellectual climate of the times they have been brought up and, like Bertalanaffy in which they were originally made. They could (1951) and J. G. Miller (1990), be open to the be construed as having the function of myths— thought that the disparate findings from studies of defined by McLeish (1996, p. v) as providing ‘‘the cells, microorganisms, organs, organisms, groups, continuum of identity which allows the commu- organizations, communities, and beyond might nity to make sense of everything it experiences or ultimately be integrated as equally vital compo- thinks’’—except that they are based on either su- nents of a vibrant whole. pernatural belief or direct evidence, and sometimes The fresh epistemological approach would re- a mixture of both. The first is drawn either from vive the Baconian commitment to the integration of superstition or scripture, the second from ob- knowledge rather than its fragmentation (Colver- servation and verification, and the third from an son, 1989). It could begin with a reconsideration of amalgam when either kind of explanation alone is the reformulation of Kuhn’s (1970) fundamentals insufficient to account for the facts as observed. to highlight the conceptual changes that have oc- In due course it might be possible to complete curred in the history of science. Then it could lead the Fiji hostage study, with the former hostages to an indulgence in Hellemans and Bunch’s (1988) providing responses perhaps of a less reactive but assembly of historical facts from diverse fields of of a more reflective kind—and from the evidence scientific endeavor that strings the major con- of Engdahl, Harkness, Eberly, Page, and Bielinski tributions of science together with regard more to (1993), who interviewed former hostages after a their significance than to their disciplinary source. minimum period of 20 years had elapsed since The challenge is for behavioral scientists to their release, any delay might not be too proble- entertain such a theory, be open to contributions matic. However, as a first step toward addressing from different academic disciplines about the cau- the wrongs in all such situations, it seemed that ses and the consequences of terrorism, and consider justice should be construed formally as a basic whether the outcome might help them to unravel human need to merit a place in the familiar hier- more of the complexities of the problems they face. archy of the kind that Maslow espoused (Taylor, To do otherwise, ignore the available leads, and 2003c, 2006b). Maslow (1987, p. xxv) himself continue simply to endorse ruthless policies of de- warned of the consequences of injustice, and he terrence and retribution, would be foolhardy in the described justice as ‘‘almost a basic need,’’ placing it extreme. with fairness, honesty, and orderliness in a cluster as being a precondition for their fulfillment (Ma- slow, 1987, p. 22). The suggestion is that, in light Notes of the many recent violations of human rights, if Maslow were alive today, he might bring justice 1. The five-stage process that Stahelski describes more firmly into his model of human motivation. (i.e., stripping away all other group memberships, as well as each recruit’s personal identity and that of enemies, identifying enemies as subhuman and evil) closely resembles those adopted by military boot Overview camps in converting raw recruits into fighters. 2. The immorality of the end justifying the means is Collectively, the studies concluding this chapter compounded when, in a process termed ‘‘rendition,’’ will point to the amalgamation of constitutional, for the purpose of interrogation, governments place sus- cultural, economic, historical, political, psycholo- pected terrorists outside the boundaries covered by gical, religious, social, and sociological tensions the Geneva Convention relative to the protection of 392 Prevention and Psychological Problems in Reaction to Acts of Terrorism civilians (1949), the Geneva Convention relative to the he would go beyond the Oxford English Dictionary’s treatment of prisoners of war (1949), the UN minimum online definition of terrorism as ‘‘a policy intended to standard rules for the treatment of prisoners (1977), strike with terror those against whom it is adopted’’ and the Convention against torture and other cruel and to seek extra protection for civilians and non- degrading treatment or punishment (1984). combatants. 3. Currently, government-sponsored attacks on 12. Consider, for example, the debacles of the Bank sectors of their civilian population and the lack of of Credit and Commerce International, the Barings progress in providing basic essentials for human de- Bank, and the insider trading at Lloyds in the UK, of Elf velopment are matters of great concern to the secretary- Acquitaine in France, LG Card in Korea, Akold in the general of the United Nations (Annan, 2005). He Netherlands, the Parmalat Corporation in Italy, the affirms that, while ‘‘poverty and denial of human rights Allied Irish Bank, Andersons, Enron Energy, Xerox, may not be said to ‘cause’ civil war, terrorism or or- Worldcom, Merrill Lynch, and a number of big in- ganized crime, they all greatly increase the risk of investment banks in the United States, and of Ariadne, stability and violence’’ (Annan, 2005, sec. 1, para. 16). Reid Murray, and the HIH Insurance Company in 4. See the series of articles on chronic disease pre- Australia—to say nothing of the celebrated cases of JBL, vention in ‘‘resource-poor’’ nations that Richard Horton Equity Corporation, and Ansett NZ, plus many other (2005) introduced in his editorial in The Lancet. large companies that sailed close to the wind in the 5. The level of interest of the population at large is heady days of global free-market deregulation. Cer- such that a Google search on ‘‘terrorism’’ made on tainly the revelations of the indefatigable campaigner December 23, 2003, brought a response of ‘‘about Lincoln Steffens (1931) against local government cor- 7,830,000’’ items, and a similar search specifically on ruption in the United States at the turn of the last cen- 9/11 brought more than 12,000,000. tury have almost passed into oblivion. 6. This point occurred to me in Beijing during the 13. Although the 2003 figure was subsequently student protests in 1989, when demonstrations in found to be inaccurate (New York Times, June 11, 2004) Tienanmen Square and on the main streets ranged from and the official record does not include the domestic the passive to the militant and involved hundreds of activities of animal rights supporters (cf. Notebook, thousands of people (Taylor, 1992). 2004), the presentation here simply reflects the overall 7. A summary shows no less than 240 of such stu- magnitude of terrorist incidents. dies of Americans’ responses to 9/11 have been re- 14. The fact sheets prepared by the American Red ported. Retrieved January 30, 2006, from http://ps Cross stand out for the sensible advice they present, .psychiatryonline.org/cgi/search?andorexactfulltext together with those on the websites of major profes- ¼and&resourcetype¼1&disp_type¼&sortspec¼ sional organizations and clinical service providers. relevance&author1¼&fulltext¼septemberþ11& Benevolent websites such as those of David Baldwin pubdate_year¼&volume¼&firstpage. (http://www.trauma-pages.com/pg5.htm) and Hope 8. However, the thesis has been criticized for its Morrow have increased their materials on terrorism ‘‘suppositional flow charts’’ (Browne, 1999) and for substantially (http://home.earthlink.net/~hopefull/ vaulting ‘‘blithely ...where the academics stumble on home/home_contents.htm), and sages such as George interpretative doubts and methodological provisions’’ Doherty (http://www.rmrinstitute.org/mhm131d7.html) ( James, 1999, p. 698). and Ken Pope (http://kspope.com/index.php) offer regu- 9. The assurance brings cold comfort to those that larcommentaries on the topic. might already agree with Thomas Hobbes’s (1588– 15. With discoveries of duplication, mistaken death 1679) melancholy appraisal that continual fear and the reports, and fraudulent claims, the official notification dangers of violent death make life ‘‘solitary, poor, nasty, of the number killed dropped from 6,700 in the first brutish, and short.’’ harrowing weeks to 2,801 by the first anniversary and 10. It is a sobering thought that a few reviled ter- to 2,752 just after the second. A far greater number of rorists became revered as ‘‘statespersons’’ because of the people were seriously injured. reforms they brought about once they gained political 16. The phases of which, for convenience of recall, power, although others simply redressed the balance some users have changed to the four Rs—Readiness, Re- of oppression against their enemies in a continuing sponse, Recovery, and Reduction. seesaw of action and reaction that ceased only when 17. As Fritz and Mathewson (1957, Chapter 3) bankruptcy, exhaustion, or common sense prevailed pointed out long ago, those offering to help should also (cf. Abramowitz, 1946: Mandela, 1995). question their motives to ensure that they have their 11. However, the secretary general’s call for the need for ‘‘convergence’’ under control when moving to United Nations to agree on a definition of terrorism is disasters sites. According to skeptics Gist and Devilly interesting (Annan, 2004, paragraphs 84, 91) because (2002, p. 741), reports from New York City after the Defusing the Terrorism of Terror 393

Word Trade Center attacks indicated that ‘‘more than 23. Although the actual therapeutic benefits of such 9000 purveyors of debriefing and other popularised debriefings are still debated (cf. Gist & Woodall, 1998, interventions ...swarmed there, advocating interven- versus Everly & Mitchell, 2000), a consensus is tion for any person even remotely connected with the emerging that some form of psychological first aid is of tragedy.’’ value in helping people to cope with the trauma 18. Clinicians grappling with the problem will (Australasian Critical Incident Stress Association, 1999; benefit from the 2004 reprint of Helen Sergent’s per- Litz & Gray, 2002). ceptive 1961 article on the epistemological and meth- 24. The emergency personnel were New Zealand odological issues involved. However, there might also rescue climbers, Antarctic field staff, police victim be difficult ethical questions to be faced—as in the case identification personnel, U.S. Navy chaplains, medical of Ahmed Zaoui, the man held without charge on staff, photographers, and helicopter crews that col- suspicion of being a terrorist, when his mental state lected dismembered bodies, as well as the regular was found to be so fragile that, in order to encourage medical staff of the mortuary at the Auckland Medical the placebo response, it was decided not to share the School as augmented with forensic dentists, funeral professional opinion with him directly as had been directors, embalmers, and additional police. promised when establishing rapport but to disclose it 25. However, the basic explanations behind the in full to his lawyers. transient reactions have yet to be elicited, and it could 19. Here I might add that the WHO considered be that confrontation with the notion of personal death including a fourth dimension of spiritual values, but it as reported in the Terror Management Theory may be was unable to persuade its vast assemblage of member worth considering. countries that the purpose was not to endorse pagan 26. The deficit can be rectified through well- worship: Other objectors might not have wished to be planned seminars arranged by departments of pathol- thought of sponsoring either the ‘‘Armageddon cult’’ ogy at medical schools and funeral directors—taking (cf. Geering, 1986) or ‘‘the hidden dangers of funda- care that no participators have necrophilic needs. mentalism’’ (Woodall, 2006). Nonetheless, the Public 27. The most lurid of these was the donation of Health Advisory Committee to the New Zealand Min- ‘‘adult sex toys’’ to a Red Cross chapter in New Zealand ister of Health (2004, p. 8) made a stand by defining after a flood had caused such devastation that enhan- ‘‘health’’ broadly as including ‘‘physical, mental, emo- cing sexual performance was not in the forefront of the tional, family/whanau, community and spiritual well- minds of the casualties. being.’’ 28. In the Christmas season of 2003, for example, 20. Strong tendrils also came from the theological simultaneous public appeals were made for victims and side to integrate religion, mental health, and psychol- casualties on all sides in Afghanistan, Iraq, Israel, and ogy. Long ago the clergy reached across a field that Palestine; for victims of HIV and AIDS in Africa; for came to be known as pastoral psychology and now has victims of a natural gas explosion in China, mud slides several journals (e.g., Mental Health, Religion and Cul- in California, an enormous earthquake in Iran; and for ture, Psychology and Christianity, Psychology and Judaism, the abandoned boat refugees in confinement on the Psychology and Theology, Religion and Health). Whether Pacific Island of Nauru, plus those affected locally by or not in response, the American Psychological Asso- an avalanche, bush fires, mountain-climbing accidents, ciation created Division 36, Psychology of Religion, to a plane crash, and road traffic accidents. Attention was explore the common ground between the two academic also drawn to an outbreak of bovine spongiform en- and professional disciplines. cephalopathy (BSE)—‘‘mad cow disease’’—in the Uni- 21. Even in the very best of forensic and mortuary ted States that might have similar consequences to facilities in New York, a year after September 11, only those that occurred in Britain 2 years before. People 1,439 (51%) of the victims had been identified from who are bombarded with such a variety of concerns the 292 bodies and 19,932 body parts that had been might do well to adopt the prayer of Alcoholics recovered at the World Trade Center site (Chen, 2002). Anonymous for the serenity to accept the things they When the operation was brought to a close 3 and a half cannot change, the courage to change the things they years after the attack, 1,592 (58%) had been identified, can, and the wisdom to know the difference. and the authorities conceded that they had ‘‘hit the 29. However, when the statistics become available, limits of science’’ (Lipton, 2005). the actual number of crimes committed in New York 22. In the same way, psychotherapists are prone to immediately after 9/11 might possibly be lower than succumb to ‘‘countertransference’’ effects with their normal, because criminals might have either been clients unless they take standard precautions with distracted by the enormity of the events, deterred by clinical supervisors or co-counselors that help them to the heightened police presence, or undetected because retain their objectivity. the police had to give higher priority to other matters. 394 Prevention and Psychological Problems in Reaction to Acts of Terrorism

30. In the USA United States some 17,000 ‘‘anthrax American Psychiatric Association. (2000). Diagnostic incidents’’ were reported in the first 12 months of the and statistical manual of mental disorders (DSM-IV- scare that closed the postal service for at least 4 hours TR) (4th ed.). Washington, DC: Author. (Leading During Times of Trouble, Biosecurity & Bio- American Red Cross. (2002). Terrorism: Preparing terrorism, 2003), and some 2,500 anthrax scares were for the unexpected. Retrieved January 29, 2006, reported in Australia (McKinnon, 2002). The odd fri- from http://www.redcross.org/services/disaster/ volous remark by aircraft passengers in New Zealand 0,1082,0_589_,00.html. and elsewhere about carrying weapons is known to Annan, K. (2002). In address to World Economic have had immediate and serious repercussions. Forum, Secretary-General says globalization must 31. The epidemiologist Leonard Horowitz (2004) work for all. Retrieved January 29, 2006, from went so far as to posit a relationship between the www.un.org/News/dh/latest/address_2001.htm ‘‘petro-chemical pharmaceutical cartel’’ and the poli- ———. (2004). The brotherhood of man. Inaugural tical bureaucracy in engineering the anthrax scare. Robert Burns Memorial Lecture. Retrieved January 32. The problem could not have been anticipated, 29, 2006, from http://www.un.org/News/Press/ otherwise the local authorities would have acted swiftly docs/2004/sgsm9112.doc.htm to bury the bodies as planned in the nearby cemetery ———. (2005). In larger freedom: Toward develop- without waiting for the official party of politicians to ment, security, and human rights for all. Report arrive from the island capital. However, putrefaction of the secretary-general. Retrieved January 29, from the tropical heat made it imperative for the burials 2006, from http://www.un.org/largerfreedom/ to be on the school-site. contents.htm 33. There is now evidence of a complementary Argyle, M. (2002). State of the art: Religion. Psychol- relationship—tentatively named the Jolo syndrome ogist, 15(1), 22–26. after the remote jungle islands in the Philippines—in Asken, M. J. (1993, June). Fire psychology: Post-call which the positive attachment of the rebels to the visits to victims. Firehouse, 100. captives was so strong that two of their French hostages Australasian Critical Incident Stress Association. feared they might never be released (Reuters, Septem- (1999). Guidelines for good practice for emer- ber 22, 2000). Positive reciprocal relationships are gency responder groups in relation to early known to sometimes develop between guards and pri- intervention after trauma and critical incidents. soners and between prisoners and their visitors, but Glenelg Declaration. Retrieved January 29, 2006, they are not so incomprehensible as to warrant a spe- from http://www.ctsn-rcst.ca/glenelg.html. cial name. Australian Government. (2004). Transnational terror- 34. An exception was made by the U.S. Department ism: The threat to Australia. Canberra: Australian of Justice (2000, recommendation 4) after the Okla- Department of Foreign Affairs and Trade. homa bombing because of the need to address ‘‘diverse Bankoff, G. (2003). Vulnerability as a measure of needs, beliefs, and lifestyles of all affected victims.’’ change in society. International Journal of Mass However, the manual for clergy and congregations it Emergencies and Disasters, 21(2), 5–30. subsequently sponsored (Delaplane & Delaplane, 2002) Becker, E. (1971). The birth and death of meaning: An made no mention of meeting the needs of religions interdisciplinary perspective on the problem of man. other than those of Christians and Jews. New York: Free Press. ———. (1973). The denial of death. New York: Free Press. References Beit-Hallahmi, B., & Argyle, M. (1997). Religious behaviour, belief, and experience. London: Abramowitz, I. (Ed.). (1946). The great prisoners: The Routledge. first anthology of literature written in prison. New Benson, H., & Stark, M. (1996). Timeless healing: The York: Dutton. power and biology of religious belief. London: Simon accel/TEAM. (2005). Employee motivation, the orga- & Schuster. nizational environment, and productivity. Re- Bertalanaffy, von L. (1951). Problems of general system trieved January 29, 2006, from http://www theory. Human Biology, 23, 302–311. .accel-team.com/. Bracken, P. (2002). Trauma: Culture, meaning, and Ahern, J., Galea, S., Resnick, H., Kilpatrick, D., philosophy. London: Whurr. Bucuvalas, M., Gold, J., et al. (2002). Television Browne, M. W. (1999, February 27). A review of images and psychological symptoms after the the book Catastrophe: A quest for the origins September 11 terrorist attack. Psychiatry, 65(4), of the modern world. New York Times Book 289–300. Review, 30. Defusing the Terrorism of Terror 395

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Psychological Resilience in the Face of Terrorism Lisa D. Butler Leslie A. Morland Gregory A. Leskin

Psychological resilience in the context of terrorism and military preeminence. This convergence of ef- was little studied by U.S. researchers before Sep- fects, both tangible and symbolic, tore through any tember 11, 2001. Prior to that, the United States possible cultural membrane of denial, forcing citi- had suffered a number of terrorist attacks at home zens to contemplate existential vulnerability and and abroad, including the 1993 bombing of the threat (Becker, 1973; Pyszcznski, Solomon, & World Trade Center in New York, the 1995 bom- Greenberg, 2003) and to consider what might en- bing of the Murrah Federal Building in Oklahoma hance resilience in the face of possible terrorist at- City, the 1996 truck bombing of a U.S. Air Force tacks in the future. barracks in Dhahran, Saudi Arabia, and the 1998 Experts in terrorism (Kaplan, 1981) have ob- bombings of U.S. embassies in Kenya and Tanza- served that such acts are intended to create a fearful nia, among others, each of which would certainly state of mind in an audience far wider than the im- qualify as ‘‘terrorist spectaculars’’ (dramatic, attention- mediate victims. In fact, terrorism is ‘‘aimed at riveting, deadly acts that seize the interest of the noncombatants’’ with the objective of the ‘‘deliber- media and public; Hoffman, 1999). ate creation of dread’’ (Stern, 2003, p. xx). Clearly, However, the impact of the terrorist attacks terrorism is political warfare on a psychological on New York and Washington, DC, in September, ﬁeld of battle. And in this modern electronic era of 2001, seemed to be of another order. These events virtually simultaneous mass communication, ter- were incomparably and indelibly etched into the rorism’s reach (and thus its impact) has extended— national consciousness, and they ushered in a new everyone with a television or an Internet connection psychological zeitgeist in U.S. political and perso- can be witness to a ‘‘virtual ground zero’’ (Butler, nal life. The unique psychological potency of these Garlan, & Spiegel, 2005). Indeed, in one nationally attacks may be attributable to the searing real-time representative sample, assessed 3–5 days after the and repetitive media coverage, the extent of their attacks (Schuster et al., 2001), each of the 560 lethality and breadth of their physical and eco- people interviewed already knew of the attacks nomic destruction, and the deeply disturbing ma- when contacted for the survey (B. Stein, personal lignancy of the attacks, which included deliberate communication, January 17, 2005). This develop- assaults on cherished symbols of U.S. economic ment underscores the need to elucidate the effects

400 Psychological Resilience in the Face of Terrorism 401 of exposure—whether direct or indirect—to ter- 1993) began to enumerate the benefits and posi- rorism and to identify factors that may allow in- tive changes that some people report following dividuals to be more resilient to such experiences. adversity. The specter of terrorism has another critical aspect. Present distress can stem not only from Origins of Resilience Research events that have occurred but also from anticipation of events that may yet occur. As Miller (2002) has The empirical study of resilience originated in de- observed, ‘‘Essentially, terrorism is the ‘perfect’ velopmental research (e.g., Garmezy & Rutter, 1983; traumatic stressor, because it combines the ele- Garmezy, Masten, & Tellegen, 1984; Werner & ments of malevolent intent, actual or threatened Smith, 1982) and was initially described as ‘‘stress extreme harm, and unending fear of the future’’ (p. resistance’’ among children at risk for poor outcomes 296). Acute concern about the possibility of a new due to genetic or environmental circumstances. ‘‘The attack can be heightened by feelings of unpredict- observation of unexpectedly good development ability and baleful inevitability and fueled by past among high-risk children gave rise to the study of and current experiences of stress or trauma and resilience, an effort to identify the processes under- the anticipated impact of a future event, all tele- lying successful adaptation under adverse condi- scoped into present fearful preoccupations (Butler, tions’’ (Masten & Wright, 1998, p. 13). Field, et al., 2005). In the months following Sep- Investigations in two other research streams tember 11, more than half of a large national prob- paralleled these developments. Researchers in life- ability sample reported fears of future terrorism and span development (e.g., Rowe & Kahn, 1987) sought harm to their families, and a substantial minority to identify factors that fostered successful (i.e., quick continued to report these fears 6 months after the and thorough) recovery from the challenges of aging. attacks (Silver, Holman, McIntosh, Poulin, & Gil- In research on intrapsychic aspects of adaptation, Rivas, 2002). In fact, Zimbardo and Kluger (2003) personality psychologists began to identify resilience have argued that efforts ostensibly directed at the potentials in the ego resources available to or mobi- nation’s protection, such as the national color-coded lized by some people under a variety of challenging warning system, have compounded rather than circumstances (e.g., ego strength, reviewed in Meyer dispelled distress about future possible attacks, & Handler, 1997; ego resiliency, Block & Block, leaving Americans feeling frightened and helpless, a 1980) and in personalities characterized by traits of condition they describe as a ‘‘pre-traumatic stress hardiness (Kobasa, 1979) and a sense of coherence syndrome.’’ Thus the effort to understand and pro- (Antonovsky, 1987). Both hardiness and coherence mote resilience must confront both adjustment to an involve individual approaches to action and meaning attack that has happened and the ongoing manage- that are associated with physical and psychological ment of anxiety in the face of an uncertain future. health under conditions of stress. The impetus for this research was observations of successful or superior adaptation demonstrated by some indivi- Resilience duals who were facing difficult or stressful circumstances. The goal was to discern the intrapersonal The 1990s were witness to an important expansion and environmental factors associated with such in emphasis on the variety of possible outcomes adaptation. following traumatic experience. Perhaps not sur- The study of resilience related specifically to prisingly, most previous research has focused on traumatic events (rather than generally stressful or the clinically significant end of the distribution— challenging experiences) began in earnest as the those most affected by the event and the factors that study of traumatic stress got its theoretical and put them at risk for such outcomes. However, in empirical footing, prompted in part by prospective their seminal contributions, O’Leary and Ickovics developmental research involving child maltreat- (1995; see also Carver, 1998) urged researchers to ment (reviewed in Masten & Wright, 1998), but move beyond a vulnerability and deficit model to has since been applied to the range of traumatic one that encompasses successful adaptation (resi- experience. In this sense, the study of resilience lience) and thriving, and Tedeschi and Calhoun and thriving is the complement to research on the (1995) and others (e.g., Joseph, Williams, & Yule, negative effects of trauma that has flourished in the 402 Prevention and Psychological Problems in Reaction to Acts of Terrorism past several decades. To understand responses to through deliberate suicidal action, physical injury trauma, the full spectrum of possible outcomes secondary to maladaptive behaviors (such as sub- must be considered, along with the factors that stance use or recklessness), or possibly direct may affect those outcomes, including those that physical decline. increase vulnerability or risk and those that confer The second negative outcome—survival with protection or enhance resilience. impairment—characterizes a postevent diminution in functioning coupled with a failure to return Functional Outcomes Following to previous levels over the long term. This is the Psychological Trauma condition to which much of the traumatic stress literature applies, such as when someone experi- In calling for this ‘‘paradigm shift’’ to include po- ences chronic and disabling posttraumatic stress or sitive adaptation among the foci of research, depression symptoms. In the National Comorbid- O’Leary and Ickovics (1995; see also Carver, 1998) ity Survey (Kessler, Sonnega, Bromet, Hughes, & noted a range of possible functional endpoints Nelson, 1995), for example, more than one-third following exposure to a traumatic or other adverse of those who reported an index episode of post- life experience (see Figure 25.1, adapted from traumatic stress disorder (PTSD) failed to fully O’Leary & Ickovics, 1995). Of note, only two of recover over the next decade, even among those these outcomes are negative; the other two involve who had sought treatment for their symptoms. maintenance, recovery, and/or enhancement of psy- The third outcome, and the one most com- chological functioning following a significant life monly understood as resilience, refers to ‘‘good challenge. adaptation under extenuating circumstances’’ In the most dire instance, the individual suc- (Masten & Reed, 2002, p. 76) and may be seen in a cumbs to the effects of the experience. Based in a recovery trajectory that involves a return to baseline health outcome perspective, O’Leary and Ickovics functioning following challenge. Resilient people (1995) employ the term succumb to describe re- are less vulnerable; they bend rather than break in duced functioning that ultimately ceases, some- the face of adversity. Findings from the traumatic times following additional postevent decline stress literature suggest that, despite the fact that (Carver, 1998). In the case of a serious psycholo- most people will face a serious life-threatening or gical challenge, succumbing could also refer, for loss event during their lives, the majority will bear example, to an event-related deteriorating depres- few long-term impairments (Kessler et al., 1995; sion that results in the death of the individual Norris et al., 2002). Indeed, resilient outcomes are

Adverse Thriving Event

Recovery (resilience)

Survival with impairment Level of Functioning Level

Succumbing

Time Figure 25.1. Potential outcomes following adversity. Psychological Resilience in the Face of Terrorism 403 so common that Masten (2001) has referred to the Resilience as Process phenomenon in the developmental literature as ‘‘ordinary magic.’’ Resilience phenomena may also be identified in The final outcome, termed thriving (O’Leary & trajectories of recovery. In this way, resilience can Ickovics, 1995; also known as posttraumatic connote features of an initial reaction to a trau- growth [Tedeschi & Calhoun, 1995]; stress-related matic event and characteristics of the recovery path growth [Park, Cohen, & Murch, 1996]; or adver- associated with achieving a return to baseline sarial growth [Linley & Joseph, 2004]), refers to functioning. This is a relatively uncommon re- postevent adaptation that exceeds preevent levels. search focus, however, as those who report few The readjustment experience, in other words, is negative sequelae, uncomplicated recovery, or even transformative and represents a ‘‘value-added’’ end enhanced health are generally ignored in the clin- state (O’Leary & Ickovics 1995; see also Carver, ical literature because of the (understandable) clin- 1998). Carver has suggested that the term resilience ical focus on those suffering the negative effects should be applied to cases of ‘‘homeostatic return of a psychological challenge. As Rowe and Kahn to prior condition,’’ while thriving should be re- (1987) have noted with respect to aging, few dis- served for cases in which an individual is judged to tinctions are made within the category of healthy be ‘‘better-off-afterward’’ (Carver, 1988, p. 247). individuals, despite substantial heterogeneity (see In the present chapter, we examine the domain also O’Leary & Ickovics, 1995). In addition to the of resilience and factors that may augment or un- distinction between those who recover and those dermine adaptive functioning. While there is no who thrive, we believe it is important to investi- singular way to describe or measure resilience, it gate the varied ways in which people respond and can be defined by a set of outcomes that involve recover. recovery following challenge. There are also im- As Figure 25.2 (adapted from Carver, 1998) portant aspects to the process of that recovery that illustrates, resilient individuals demonstrate im- signal or instantiate elements of resilience. In other provement and ultimately recovery following words, resilience, broadly defined, refers to the fact challenge (Lines A–C). Among those who recover, that an individual recovers and also the ways in there are presumably differing degrees of resilient which that person responds to the event over time. adaptation. Those who are most resilient may, for We believe that this process emphasis allows for a example, react initially with less disruption (Line more complete investigation of the means and A) or recover more quickly despite a significant mechanisms of recovery. initial setback (Line B compared to Line C). Ad- ditionally, some may show an enhanced adapt- Resilience as Outcome ability in the face of future events (for example, if Line C were the recovery trajectory for the first In the traditional view of resilience as endpoint, event and then Lines A or B were observed for the Masten (2001, p. 228) has defined resilience as ‘‘a second event)—a result that Carver (1998) con- class of phenomena characterized by good out- ceptualizes as evidence of posttraumatic thriving. comes in spite of serious threats to adaptation or Bonanno (2004) has recently argued that ‘‘re- survival.’’ This view represents a snapshot of out- silience represents a distinct trajectory from the come interpreted in the context of antecedent cir- process of recovery’’ (p. 20), one in which the cumstances. Consequently, resilience has been person maintains a relatively stable equilibrium, variably defined as, for example, achievement in and consequently little or no recovery is required, educational and social settings, age-appropriate something akin to the ‘‘stress resistant’’ category accomplishments or behaviors, and the presence of described in the early developmental literature desirable outcomes (e.g., well-being, happiness) or (Garmezy, 1985). Bonanno’s assertion clearly hin- the absence of undesirable ones (e.g., mental ill- ges on what ‘‘relatively stable’’ means (which he ness, distress, risky or criminal behaviors; Masten does not fully specify), and it raises questions about & Reed, 2002). With this emphasis on out- the requirements of the situational challenge that come, research has focused on identifying risk and would make it a candidate for a potentially resilient protective factors that moderate or predict ad- outcome, including the nature of the event experi- justment. enced, the degree of exposure endured, and the 404 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Adverse Event

Recovery

Level of Functioning Level C

Time

Figure 25.2. Trajectories of recovery. extent to which the event actually challenged the drawn upon in times of need (i.e., when other re- individual’s resources. However, stress resistance is sources are lost or at risk). only one among a range of possible resilient adap- Although little empirical work has been done to tations following highly stressful or traumatic ex- examine correlates and predictors of resilience in periences, and we believe that it is best understood the context of terrorism, much of the trauma lit- in the context of this range. erature generally (and the terrorism and disaster literatures specifically) provide applicable information. In the simplest sense, every finding re- Resilience and Risk in Trauma garding a poor outcome provides information about who was spared. To paraphrase Masten and Wright In the context of exposure to terrorism or disaster, (1998), risk (or vulnerability) and compensatory the risk of distress may be understood as a function (or protective) factors are often different names for of the interplay of a number of factors, among them the same continuous variables (e.g., the quality of the individual’s personality, demographic, and his- social support). However, some assets and re- torical characteristics, the degree of exposure to the sources may operate only at the positive end (by event and its aftermath, the level of actual or threa- their presence; e.g., benefit finding); similarly, there tened loss due to the event, initial reactions to the are factors that may harm you if they occur (e.g., a event, and the resources (psychological, social, and panic attack during a trauma) but do not help you if material) available to the person both during and they do not occur. In this section we briefly review following the event. Indeed, an emphasis on the characteristics of the individual known to confer construct of resources in conceptualizing the impact protection or increase psychological risk in the face of trauma, as delineated by Hobfoll (1991), may be a of trauma. useful way of understanding risk and resilience with respect to terrorism. Many of the factors that put Characteristics of the Individual people at risk for negative outcomes (e.g., poor premorbid functioning) or that challenge resilience (e.g., Much research has sought to characterize people significant losses) can be viewed in the context of who are resilient under conditions of stress (and, resource insufficiency or loss, while factors asso- in some cases, traumatic stress). In general it may ciated with higher resilience (e.g., active engagement, be said that resilience appears to be an interactive social support) represent resources themselves— process involving beliefs, attitudes, approaches, both personal and environmental. Many of these re- and behaviors that determine the way the person sources can be cultivated at any time, so they may be views and engages the world. Psychological Resilience in the Face of Terrorism 405

addition, the construction of meaning may be an Features of Resilient People active ingredient in the beneficial effects of dis- Pioneering developmental research initiated by closing trauma through writing (Park & Blumberg, Emmy Werner and colleagues in the 1950s laid the 2002). Although little research has examined per- conceptual groundwork for much of the adult re- sonality correlates of these approaches, there is search that was to follow. In her longitudinal study some evidence for an association with optimism of high-risk Hawaiian children (Werner & Smith, (Davis et al., 1998). 1982), Werner identified four characteristics of Elements similar to those identified by Anto- resilient children: (1) They utilized an active pro- novsky (1987) are also present in Kobasa’s (1979) blem-solving approach; (2) they employed a con- description of hardiness, which involves disposi- structive approach to perceiving challenging or tions to commitment, control, and challenge that even painful experiences; (3) they relied on per- are associated with better physical and psycholo- sonal faith that maintained meaningfulness in life; gical outcomes (see also, Manning, Williams, & and (4) they had the ability to gain positive at- Wolfe, 1988). Hardy people are committed to their tention from others. lives and engage actively in responding to the tasks Echoing the first three of these themes, Anto- that confront them; they believe that they can in- novsky (1987) proposed that resilient people have a fluence events, and they accept change as a chal- sense of coherence characterized by the belief that the lenge (rather than a threat) that can result in events in one’s life will be comprehensible, man- benefits. Hardiness has been found to enhance re- ageable, and meaningful. Comprehensibility as- silience under conditions of traumatic stress (e.g., sumes an order and explicability to what happens in King, King, Fairbank, Keane, & Adams, 1998). life. The belief in manageability presupposes that Additionally, the related constructs of self- one will have the resources—both personal and efficacy (Bandura, 1982), a sense of mastery (Mei- interpersonal—to meet the demands of the event. chenbaum, 1985) with respect to challenges, and The notion of meaningfulness applies both to optimism about the future (Scheier, Weintraub, & finding significance in the adversity and to believing Carver, 1986) can contribute to resilience. Each that the challenge is deserving of engagement, even involves beliefs that one’s skills and actions will when difficult. have positive effects on circumstances, which may Tedeschi and Calhoun (1995) have noted that lead to sustained problem-focused efforts and, these elements may be the keys to successful consequently, improve the odds of success. adaptation to trauma because they are precisely the More recently, research has begun to examine domains that traumatic experiences challenge. For the role of positive emotions in coping and resi- example, among variables found to contribute to lience. Fredrickson (2001) has delineated a maladaptation following a large-scale traumatic broaden-and-build theory, proposing that positive event are violations of existential assumptions about emotions may quiet or even undo negative emo- the worthiness of the self and the benevolence and tions that narrow response options, while the cog- meaningfulness of the world (Janoff-Bulman, nitive broadening that accompanies states of 1992). Following the terrorist attacks on September positive emotion may expand the range of thought- 11, negative changes in existential outlook were action repertoires. In a prospective study examining strongly associated with higher distress and lower resilience and positive emotions following the levels a of well-being (Butler et al., under review), terrorist attacks of September 11, Fredrickson, while positive changes were associated with self- Tugade, Waugh, and Larkin (2003) found that reported posttraumatic growth (Butler, Blasey, positive emotions mediated the relationships be- et al., 2005). tween ego resiliency (measured prior to the event) Indeed, finding benefits and meaning in the and two outcomes: lower depression and greater experience appear to be significant in successful growth in psychological resources. adaptation to adversity (Janoff-Bulman, 1992; The development of resilient personality fea- Taylor, 1983; Tennen & Affleck, 2002), including tures may also rely in part on the experience of cancer (e.g., Carver & Antoni, 2004), bereavement stressful (but not overwhelming) life events. Rutter (e.g., Davis, Nolen-Hoeksema, & Larson, 1998), (1987) has asserted that successful adaptation in and trauma (e.g. Fontana & Rosenheck, 1998). In the past may have a ‘‘steeling’’ effect and therefore 406 Prevention and Psychological Problems in Reaction to Acts of Terrorism increase the likelihood of mastery in meeting fu- be stronger for men (Norris et al., 2002) and may ture challenges. In other words, ‘‘protection de- also, in part, reflect the availability of emotional velops not through the evasion of risk, but in the support. successful engagement with it’’ (O’Leary & Icko- In addition to personality and demographic vics, 1995, p. 127). This is an eminently plausible characteristics, historical features may also con- prediction, stemming from the developmental lit- tribute to a person’s response to trauma. Their erature and related to the notion of stress in- presence may indicate compromised resources or oculation (Meichenbaum, 1985), that could have poor learning histories with respect to dealing with important implications for differentiating trajec- trauma, resulting in less resilience when con- tories of adaptation to trauma. As yet, the steeling fronted with threat or possible future terrorism. effect has been little studied in the traumatic stress Efforts to bolster resilience in such cases would be or posttraumatic growth literatures. especially important. It is worth noting that the previously mentioned personality features and approaches can History of Traumatic Experience be, at least in theory, learned, cultivated, and Prior trauma, including both childhood and adult practiced. However, research indicates that there experiences, may reduce one’s resilience to later are some fixed personal characteristics that also traumatic events. Several studies, for example, have predict outcomes following traumatic experience. shown that combat-exposed veterans diagnosed with PTSD have higher rates of childhood trauma, Demographic Factors Associated such as physical abuse, than combat-exposed ve- With Risk and Resilience terans without PTSD (e.g., Bremner, Southwick, Some static individual characteristics, identified in Johnson, Yehuda & Charney, 1993). Additionally, the wider trauma and disaster literatures as risk King and colleagues (King, King, Foy, & Guda- factors for distress (Brewin, Andrews, & Valentine, nowski, 1996) found that other previous life trau- 2000; Norris et al., 2002), have also been confirmed mas (e.g., motor vehicle accidents, physical assault, in terrorism samples. For example, females and to a natural disasters) also predicted PTSD in veterans. lesser extent those of lower socioeconomic status or Prior trauma (such as physical or sexual assault) with less education and those who are middle aged may also extend risk to women exposed to later are at higher risk for a variety of negative outcomes trauma (Resnick, Kilpatrick, Dansky, Saunders, & following terrorism than are males, those who are Best, 1993). Similarly, studies following September affluent and well educated, or those who are older 11 reported elevations in trauma symptoms, de- (DeLisi et al., 2003; Galea et al., 2002; Njenga, pression symptoms, and general distress among Nicholls, Nyamai, Kigamwa, & Davidson, 2004; those with histories of trauma (Silver et al., 2002) North et al., 1999; Schlenger et al., 2002; Verger and stressful life events (Galea et al., 2002). As et al., 2004). The positive relationship between age previously mentioned, research is needed to de- and adjustment may be due to the tendency for older termine whether there is a subset of people who are individuals to have more experience with stress actually steeled by these experiences and thus are and coping and fewer drains on coping resources, more resilient (than they would have been other- compared to middle-aged people (Norris et al., wise) when faced with later adversity. 2002). There are mixed findings in the disaster and Psychological Functioning trauma literature with respect to ethnicity and Adjustment problems prior to a traumatic event marital status. Norris and colleagues (2002) report may also predispose one to greater difficulties in that in most disaster studies those in the ethnic coping or further psychopathology, including an- majority group fared best, a finding borne out in xiety, depression, PTSD, neuroticism, and other some recent terrorism studies (e.g., Schuster et al., symptom or personality states. For example, North 2001; Galea et al., 2002). The findings with respect et al. (1994) found that survivors of a shooting to marital status sometimes indicate that being spree with preexisting major depression were at a married (versus unmarried, divorced, separated, or significantly higher risk for PTSD 1–6 months after living alone) decreases risk (Njenga et al., 2004; the event (see also Schnurr, Lunney, & Sengupta, Verger et al., 2004); however this association may 2004). Similarly, a number of retrospective studies Psychological Resilience in the Face of Terrorism 407 of the effects of September 11 found that reports of in the experience of a terrorist attack or its aftermath prior maladjustment were associated with trauma (i.e., a military response): threat to life and limb; and depression symptoms (e.g., Blanchard et al., severe physical harm or injury; receipt of inten- 2004; DeLisi et al., 2003; Schuster et al., 2001). tional injury or harm; exposure to the grotesque; Prospective studies (which eliminate the possibility violent or sudden loss of a loved one; witnessing or of a retrospective bias in reporting) have found that learning of violence to a loved one; learning of ex- neuroticism and elevated MMPI clinical scale scores posure to a noxious agent, and/or causing death or predicted PTSD in veterans (Lee, Vaillant, Torrey, & severe harm to another. Because event character- Elder, 1995; Schnurr, Friedman, & Rosenberg, istics are significant contributors to outcomes, 1993), and preexisting mental disorders predicted identifying their harmful features can improve our increased trauma symptoms and general distress understanding of the challenge they pose to resi- after September 11 (Silver et al., 2002). lience and indicate where preventative interventions may be aimed. Family Characteristics Family psychopathology and/or instability have also Direct Event Exposure been found to contribute to psychosocial outcomes Indisputably, those who are directly exposed to following traumatic stress (Ozer, Best, Lipsey, & terrorist acts through threat or injury to themselves, Weiss, 2003). For example, firefighters with a fa- the death or injury of loved ones, or witnessing the mily history of psychopathology were found to be death or injury of others, along with those who tend at greater risk for PTSD 4 months following expo- to the injured or recover the dead, face the greatest sure to massive fires and death (McFarlane, 1988), challenges to their emotional well-being. Findings and premilitary family instability (mental disorder, from around the world, including Ireland, Israel, contact with mental health professionals, substance France (reviewed in Gidron, 2002; Verger et al., use) was associated with higher risk of developing 2004), Nairobi, Kenya (Njenga et al., 2004), and PTSD among Vietnam veterans (Schnurr et al., the United States (North et al., 1999; Galea et al., 2004). 2002) indicate that a sizable subgroup, ranging Overall, meta-analytic studies have found that from 18% to 50% of directly exposed citizen sur- prior trauma history, psychiatric history, and family vivors of terrorist attacks, develop posttraumatic psychopathology make a small but significant con- stress symptoms indicative of a PTSD diagnosis tribution to the development of trauma symptoms (with rates typically highest among those most in both military and civilian samples following sub- seriously injured). Additionally, disaster research sequent adversity (Brewin et al., 2000; Ozer et al., suggests that symptom levels in the early phases of 2003). These analyses indicate that factors operat- recovery are likely to determine subsequent symp- ing during or after the trauma (such as trauma tom levels (Norris et al., 2002), highlighting the severity, peritraumatic responses, coping, social importance of early intervention. Training and ex- support, or additional life stressors) tend to have perience in facing such events appear to promote stronger effects on outcomes than do pretrauma resilience (and may also reflect the previously factors (Brewin et al., 2000; Ozer et al., 2003). As mentioned steeling effect): Several studies have Rutter (1987) has observed, ‘‘resilience cannot be found much lower rates of PTSD among police of- seen as a fixed attribute of the individual. ...If ficers (Wilson et al., 1997, cited in Gidron, 2002) circumstances change, resilience alters’’ (p. 317). and firefighters involved in rescue operations (North et al., 2002) following terrorist attacks, al- Characteristics of the Event though career self-selection is also likely a contributing factor. Although unique in many ways, acts of terrorism The intensity of stressor exposure (often oper- have much in common with other traumatic events, ationalized as proximity) is typically related to including features of criminal assaults, disasters, outcomes; thus, higher levels of exposure pre- and acts of war (Miller, 2002). Examining the dict greater subsequent distress. Schlenger and col- broader traumatic stress literature, the dimensions leagues (2002) found that levels of PTSD symptoms of traumatic events found to be associated with the were significantly higher in the New York City poorest outcomes (Green, 1993) may all be present metropolitan area than in other major cities or the 408 Prevention and Psychological Problems in Reaction to Acts of Terrorism rest of the country. This association was noted even adverse consequences, exposure alone does not among those who resided in Manhattan during the account for all who will have difficulties. Indi- attacks: Those living south of Canal Street (the vidual variations in psychological response, ap- area closest to the attacks) reported significantly proaches to coping, and available social support higher PTSD symptoms than those living north of may also play a role in determining a given per- this area (Galea et al., 2002; see also DeLisi et al., son’s outcome. 2003). The degree of perceived threat, injury, and material losses are each also consistent pre- Psychological Responses During dictors of traumatic stress symptoms across traumas and After the Trauma generally (Brewin et al., 2000; Ozer et al., 2003) and with respect to terrorism (Galea et al., 2002; Individuals respond in very different ways dur- Njenga et al., 2004; North et al., 1999; Verger ing and immediately following a traumatic event et al., 2004). (termed ‘‘peritraumatic’’ responses; Marmar, Weiss, & Metzler, 1997), and these differences can have Indirect Event Exposure significant implications for subsequent adjustment Terrorism is not directed only at those who will (Ozer et al., 2003). The importance of the sub- experience the attacks firsthand or suffer personal jective responses of fear, helplessness, and horror losses due to them, however. Terrorism’s magni- during a distressing event has been demonstrated tude is also gauged by the extent to which the acts across a number of traumatic experiences (re- terrorize those who are more distant from the viewed in Ozer et al., 2003), including terrorism events. Indirect exposure, particularly through mass (Njenga et al., 2004), and their centrality is cap- media, is the type of exposure that the greatest tured in the DSM-IV (American Psychiatric Asso- number of people are likely to experience in the ciation [APA], 1994) diagnostic criteria for acute event of future terrorist attacks, as it was in the case stress disorder (ASD) or PTSD. However, other of September 11. psychological reactions during and immediately Not surprisingly given the ubiquitous media after a traumatic event may be reported. In one coverage during and after September 11, most study following the Oklahoma City bombing studies included media exposure as a variable in (Tucker, Dickson, Pfefferbaum, McDonald, & Al- their assessments. As predicted, the amount of tel- len, 1997), peritraumatic hyperarousal symptoms, evision viewed during and shortly after the attacks dissociative reactions, fear for self and family, and was associated with levels of trauma symptoms, feelings of upset about one’s own actions or those depression, panic, and/or distress in the perievent of others (retrospectively reported) were each sig- period and in the following months (e.g., Ahern, nificantly correlated with posttraumatic stress Galea, Resnick, & Vlahov, 2004; Schlenger et al., symptoms 6 months later. 2002; Schuster et al., 2001), even among those without firsthand exposure or losses. However, the Peritraumatic Dissociation relationship between distress and media exposure One peritraumatic phenomenon is the response of has yet to be fully delineated. Some have proposed dissociation, which includes altered experiences of that TV viewing may represent an effort to cope self (depersonalization, numbing, feeling dazed) with distress about the event, rather than a cause of and the world (derealization, particularly time it (Schlenger et al., 2002), while others have sug- distortion) and episodic memory difficulties (am- gested that ‘‘vulnerable victims may have attempted nesia; Koopman, Classen, & Spiegel, 1994; Marmar to use information gathered via television as a cop- et al., 1994; APA, 1994). Although acute dissocia- ing mechanism but instead ended up retraumatizing tion is common in the context of extreme distress themselves’’ (Kalb, 2002, cited in Miller, 2002). If (APA, 1994), considerable research indicates that it the latter is the case, then limiting media viewing of may herald postevent pathology, including PTSD such events may be a way of conserving resources (reviewed in Ozer et al., 2003). Following the Ok- and remaining more resilient during and following lahoma City bombing, dissociative and avoidance the event. symptoms were also strongly associated with psy- Because not everyone who is directly exposed— chiatric comorbidity, impairment, and need for and some who are only indirectly exposed—suffer treatment (North et al., 1999). Psychological Resilience in the Face of Terrorism 409

Peritraumatic Panic repression-avoidant-blunting styles (Aldwin, 1999; Panic is another potential peritraumatic response. Roth & Cohen, 1986). Dichotomizing coping styles Panic attacks occur in 53%–90% of survivors into two broad modalities has both conceptual and (Nixon & Bryant, 2003; Falsetti & Resnick, 1997) psychometric appeal; however, it does not capture and may persist among those who develop PTSD the fluctuating and at times alternating nature of and even predict that development (Falsetti & Re- coping. For example, Folkman and Lazarus (1980) snick, 1997). Some researchers have proposed that have found that, in highly stressful situations, there acute panic reactions during a trauma may condi- is often vacillation between approach and avoid- tion cues that later trigger panic attacks (Falsetti, ance in attempts to manage the crisis. Resnick, Dansky, Lydiard, & Kilpatrick, 1995), Considerable research has focused on examin- which may explain findings that peritraumatic ing the ways in which different coping approaches panic can persist into the postevent period (Nixon can help a person minimize or avoid adverse out- & Bryant, 2003). Research following September 11 comes following a major stressor. Although there found that peritraumatic panic was associated with may be no one right way to cope with traumatic both depression and PTSD (Galea et al., 2002) and events initially (Norris et al., 2002), research sug- with higher levels of television viewing (Ahern et al., gests that some coping strategies are more or less 2004), although the direction of the relationships adaptive over time. Substance use, for example, is could not be determined. one way of coping aimed at avoiding or blunting Peritraumatic reactions may challenge resilient experience or managing aversive feelings associated functioning because some (e.g., hyperarousal, with trauma, but it has been associated with in- panic) may exacerbate the feeling of life threat, dicators of poor functioning in this context (North while others (e.g., dissociation) may bar access to et al., 2002). In contrast, spiritual faith is central to adaptive behavioral options and coping strategies psychological recovery for many following trauma and impede cognitive processing of the event. Al- (Tedeschi & Calhoun, 1995), and religious coping though such reactions are immediate and unbidden was found to be associated with lower levels of during the event, they are important risk factors distress and greater self-reported growth among that may be open to intervention once the acute survivors of the Oklahoma City bombing (Parga- crisis is over. It is not known what distinguishes ment, Smith, Koenig, & Pe´rez, 1998). those who experience peritraumatic panic or dis- Problem-Focused Versus Emotion-Focused sociation yet remain resilient. The utilization of Coping personal and interpersonal resources in the early posttraumatic period is likely critical. Research has also examined problem-focused versus emotion-focused coping (e.g., Folkman & La- Coping During and After the Event zarus, 1980) and found that these coping styles are more stable than other ways of conceptualizing Although many factors can influence the way one coping (Endler & Parker, 1990). Problem-focused responds to a major stressor, a central component coping includes strategies for gathering information in determining variability in psychological out- and other resources (skills, tools) to help deal with comes is the manner in which the individual at- the underlying problem, identifying objectives, tempts to cope. Coping has been defined as ‘‘efforts, planning future actions, making decisions, and re- both action oriented and intrapsychic, to manage solving conflict. In contrast, emotion-focused cop- (that is, master, tolerate, minimize) environmental ing typically involves managing feelings, some- and internal demands, and conflicts among them, times through avoidance, distraction, withdrawal, which tax or exceed a person’s resources’’ (Cohen & and disengagement from coping efforts. Emotion- Lazarus, 1979, p. 219). Coping is frequently con- focused coping strategies may be relatively conceptualized in terms of broad coping styles, often sistent across time, suggesting that some people dichotomous, such as approach versus avoidance may have a characteristic way of dealing with their (Roth & Cohen, 1986), and research has con- emotions (Aldwin, 1999). sistently found approach-monitoring-vigilant cop- Although people often focus on trying to ing styles to be associated with better outcomes control their emotions in the grip of a crisis, in a variety of situations, when compared to longer-term adjustment usually requires a more 410 Prevention and Psychological Problems in Reaction to Acts of Terrorism problem-focused approach, during which the dif- which the personality feature of hardiness may ficulties posed by the stressor can be actively ad- enhance resilience is through its influence on dressed. Problem-focused coping has the potential stress appraisal; hardiness has been associated with of resolving or successfully managing the chal- the minimization of threat, less negative affect, and lenge, and active engagement in the situation may increased active coping (Wiebe, 1991, cited in minimize the feelings of helplessness often asso- Tedeschi & Calhoun, 1995). ciated with trauma and replace them with an increased sense of control and personal mastery— Coping Following September 11 factors associated with resilience. This may be the Research following the terrorist attacks of Septem- reason active or problem-focused coping is ty- ber 11 has shed further light on the relationship pically associated with better psychological out- between coping strategies and psychosocial outcomes than avoidant coping (Holahan & Moos, comes such as general distress, PTSD, anxiety, and 1985; reviewed in Norris et al., 2002). For ex- well-being. In a nationwide longitudinal study example, in one study following the Oklahoma City amining psychological responses to September 11 bombing in 1993 (Sprang, 2000), those who re- (Silver et al., 2002), the use of specific coping ported task-oriented coping indicated significantly strategies in the immediate aftermath consistently lower levels of perceived future risk and feelings of predicted psychological outcomes over time. After victimization than those who engaged in avoidance controlling for demographics, time, and severity of or emotion-oriented coping. loss experienced in the attack, people who used However, some coping requirements may be denial, self-distraction, or self-blame; sought social situation specific, particularly when the stressor support; or disengaged from coping efforts had is uncontrollable and unpredictable (Lazarus & significantly higher levels of distress and/or trauma Folkman, 1984), as in the case of dread regarding symptoms, whereas those who engaged in active a possible terrorist attack. A study of coping and coping or acceptance reported significantly lower terrorism-related anxiety among Israeli bus com- levels of distress and symptoms. In fact, coping muters (Gidron, Gal, & Zahavi, 1999) found that strategies shortly after the attacks were the strongest problem-focused coping while commuting (i.e., predictor of PTSD and the second strongest pre- checking behaviors such as observing other pas- dictor of global distress (after prior mental health), sengers and looking under seats for suspicious with immediate disengagement from coping efforts packages) was positively associated with anxiety, markedly increasing the likelihood of ongoing whereas emotion-focused behaviors (i.e., trying to distress and posttraumatic symptoms. In this study, calm or distract oneself or minimizing the threat) active coping was the only strategy that appeared to were not. Moreover, analyses indicated that the be protective against ongoing distress (when prior ratio of use of these different coping strategies was mental health was controlled for). In fact, Silver and key: Higher levels of problem-focused relative to colleagues note that the absence of greater numbers emotion-focused coping were associated with ter- of protective coping strategies was surprising. rorism distress. Gidron and colleagues suggest that Interestingly, while the receipt of social support combining minimal problem-focused preventative is almost always associated with better mental and acts with distraction and reduced perceived vul- physical health outcomes (Cohen & Wills, 1985; nerability may be the most beneficial strategy un- Ozer et al., 2003), the seeking of social support as a der these circumstances. coping strategy is almost always associated with poorer outcomes (Monroe & Steiner, 1986), as it Appraisal and Coping was in the study by Silver et al. (2002) mentioned Coping may also be conceptualized as a process earlier. In many cases, this association may simply that depends on the way a person cognitively reflect the possibility that those who are more appraises a situation. According to Lazarus and distressed (and therefore more likely to have poor Folkman (1984), cognitive appraisals associated outcomes) are more likely to seek support. In the with stress may be categorized as harm/loss, threat, first few days after September 11, those who re- and challenge, and these appraisals are influenced ported the highest stress levels were significantly by environmental demands and individual beliefs, more likely to have talked to someone about their values, and commitments. Of note, one way in feelings at least ‘‘a medium amount,’’ as well as Psychological Resilience in the Face of Terrorism 411 turned to prayer and religion, made donations, and PTSD (Galea et al., 2002), suggesting that and checked on the safety of their loved ones having a supportive environment in place en- (Schuster et al., 2001) as ways of coping. Seeking hances resilience directly or by providing assis- out others to talk at least ‘‘a little bit’’ following the tance to draw on when needed. trauma was a virtually universal reaction (98%). One benefit of social contact is that it allows Consistent with these overall findings, in an- survivors to communicate their experience to other study examining responses after September others, which may normalize and modulate their 11, denial, behavioral disengagement, mental dis- emotional reactions through experiencing them in engagement, and focus on and venting of emotions combination with social support (Spiegel, 1999). was predictive of anxiety 2 months after the attacks Conversely, lack of social support (reviewed in among indirectly exposed college students, with Brewin et al., 2000) and the presence of social en- venting of emotions uniquely predictive of long- vironments that inhibit direct discussion of the term anxiety (Liverant, Hofmann, & Litz, 2004). event are clear risk factors for distress, including Similarly, a study examining resilience in an in- terrorism-related distress (Butler et al., under re- directly exposed Internet sample following Sep- view; Wayment, 2004). Communication also re- tember 11 (Butler et al., under review) found that quires that the experience be put into words, which higher levels of psychological well-being and/or may elicit emotional and instrumental social sup- lower distress in the first few months were asso- port from the listener, as well as promote cognitive ciated with less emotional suppression, denial, self- processing through structuring, elaborating, and blame, emotional venting, substance use, and differentiating the cognitive representation of the seeking of social support; and more active coping experience (Harber & Pennebaker, 1992). Emo- and planning. Less self-blame remained a predictor tional support is typically provided by friends and of positive outcomes at 6 months, highlighting the family, as well as by support and therapy groups, importance of cognitive appraisal and attribution to while instrumental support refers to the receipt of resilience. practical help from others in accomplishing needed In sum, research suggests that active, problem- tasks. Ozer and colleagues’ (2003) meta-analysis focused coping strategies are most likely to promote concludes that the beneficial effects of perceived outcomes of resilience, whereas avoidant, emotion- social support (primarily emotional support) may focused coping strategies contribute to outcomes of be cumulative or function as secondary prevention distress. In addition, cognitive factors such as ap- following trauma, as these effects are seen more praisal and attribution of blame seem to be im- distinctly as time since the event increases. portant in determining how coping may operate as a protective factor against ongoing distress. In the Personality and Support next section we turn from the domain of intra- Personality factors may influence one’s ability to personal resources to those that may be found in the maintain interpersonal relationships following a environment, specifically social support. traumatic event or develop and accept new social supports in the days and months after the incident. Social Support During and After the Event Regehr and colleagues (2001) found that firefighters who indicated more relational capacity One of the most consistent contributors to re- (basic trust in others, less sensitivity to rejection, covery and psychological well-being during and and ease in making friends) had less severe PTSD following stress or trauma is social support (Bre- and depression. Coupled with cognitive appraisal win et al., 2000; Cohen & Wills, 1985; Holahan & of social support, these factors accounted for 88% Moos, 1985; Norris et al., 2002; Ozer et al., 2003). of variance in distress. Similarly, in a study of risk Social support’s stress-buffering effects (Cohen & and resilience factors among male and female Wills, 1985) may reduce the experience or impact Vietnam veterans (King et al., 1998), functional of stress and thereby increase the individual’s social support (the quality of the support, including ability to function adaptively in difficult times. In perceived emotional sustenance and instrumental one study following September 11, higher levels of assistance) and hardiness were directly related to social support in the 6 months before the attacks the development of PTSD, while structural social was associated with less attack-related depression support (the size of the support system) predicted 412 Prevention and Psychological Problems in Reaction to Acts of Terrorism functional social support. Hardiness also con- which adaptation is judged to be successful, and tributed to PTSD outcomes through its relationship the features of the individual or the environment to both types of support. That is, hardiness ap- that may help to explain resilient outcomes’’ (p. peared to enhance individuals’ abilities to build and 144). We have discussed the danger to well-being utilize social support, and those with more intact, that terrorism (in threat and deed) poses, and we well-functioning support networks exhibited fewer have described possible trajectories of functioning PTSD symptoms. after trauma, with successful recovery representing resilience. We have also identified factors in the Community Involvement and Prosocial Actions empirical literature found to be important con- Community involvement and altruism are aspects of tributors to positive and negative outcomes fol- social contact that may help both the actor and the lowing stress and traumatic stress. Some appear to recipient. Large social networks can provide in- be risk or vulnerability factors for poor adaptation formation and tangible help in managing event- (e.g., poor premorbid functioning, direct exposure, related stressors (Cohen & Wills, 1985), and re- certain peritraumatic reactions, avoidant coping), affirming ties to social and religious institutions may whereas others seem to confer protection or en- provide emotional and spiritual comfort in addition hance one’s ability to successfully negotiate the to beneficial community engagement. Indeed, pro- experience without long-term psychosocial dis- viding emotional and instrumental support to others ability (e.g., positive attitude and active engage- during times of crisis can be as helpful as receiving it ment, previous successes in adaptation, finding (Taylor, Falke, Mazel, & Hilsberg, 1988) and may meaning and benefits in adversity, problem- account in part for the outpouring of prosocial ac- focused coping), and still others can either support tions (such as donating blood, money, and time) or undermine resilience depending on their quality following September 11 (Schuster et al., 2001). Of (e.g., appraisals, functional social support) or, in note is the finding, in a sample without direct con- some cases, quantity (e.g., structural social sup- nection to September 11, that attack-specific distress port). Not surprisingly, many of these factors are (grief, survivor guilt, and intrusive thoughts) was interactive and that must be taken into account found to be positively associated with collective (and modeled in analyses) for a full appreciation of helping behaviors (e.g., giving blood, goods, or the dynamics of resilience to emerge. money; volunteering) in the first few weeks follow- Resilience may be seen as an issue of resources: ing the attacks, and engagement in those activities the quality and quantity of psychological and in- was associated with greater decreases in grief and terpersonal assets that can be drawn upon and survivor guilt over time (Wayment, 2004). brought to bear in traversing life’s most difficult Thus, drawing on social resources during times experiences. Such resources may be circumstantial of crisis is one of the ways people can shore up or dispositional, learned through successes or life’s emotional support and other sources of aid to meet knocks, or provided by supports we have in place the challenge and cope on an ongoing basis. How- or that come to our aid in times of need. However, ever, resilience resources may be strained during resources may be limited by experience or situation, and following trauma, and the addition of other life and they may be drained, inaccessible, or over- stressors in the aftermath of the event can exacer- whelmed by traumatic events. Moreover, identify- bate difficulties (Brewin et al., 2000; King et al., ing these resource domains is only a first step in 1998) and undermine hardiness and the availability elucidating the underpinnings of resilience. of functional support (King et al., 1998), suggesting Clearly, additional research is needed to fully that a large support network should be developed delineate the protective processes and mechanisms before the event. that enable resilient functioning and to examine their interrelationships and their effects under conditions of traumatic stress. Rutter (1987) has Conclusions noted that protective elements include factors that reduce the risk itself or exposure to it; decrease Masten and colleagues (Masten et al., 1999) have the likelihood of negative chain reactions during noted that, ‘‘to study resilience, investigators must and after the event; promote self-esteem and self- specify the threat to [adjustment], the criteria by efficacy through successful task accomplishment or Psychological Resilience in the Face of Terrorism 413 social supports; and open up positive opportunities stress disorder after September 11: The role of that may change the initial risk trajectory. background characteristics, event exposures, and However, to date, the majority of research on perievent panic. Journal of Nervous and Mental resilience and risk has been descriptive. Certain Disease, 192, 217–226. personality features, cognitive approaches, coping Aldwin, C. M. (1999). Stress, coping, and development: An integrative approach. New York: Guilford. styles, and social supports appear to contribute to American Psychiatric Association. (1994). Diagnostic resilience, but little has been done experimentally and statistical manual of mental disorders (4th ed.). (with adults) to examine the effects of developing or Washington, DC: Author. augmenting these qualities on subsequent long- Antonovsky, A. (1987). Unraveling the mystery of health: term adjustment, particularly under conditions of How people manage stress and stay well. San traumatic stress. Rutter has also pointed to the need Francisco: Jossey-Bass. to identify and specify the parameters of difficult life Bandura, A. (1982). Self-efficacy mechanism in human experiences that ultimately bolster resilient func- agency. American Psychologist, 37, 747–755. tioning. This could take research into the realm of Becker, E. (1973). The denial of death. New York: Free longitudinal studies examining trajectories of adap- Press. tation—succumbing, surviving with impairment, Blanchard, E. B., Kuhn, E., Rowell, D. L., Hickling, E. J., Wittrock, D., Rogers, R. L., et al. (2004). recovering, and thriving—and their predictors and Studies of the vicarious traumatization of college mechanisms, rather than simply focusing on func- students by the September 11th attacks: Effects of tional endpoints. proximity, exposure, and connectedness. Behaviour In their comprehensive review of disaster trau- Research and Therapy, 42, 191–205. ma, Norris, Friedman, and Watson (2002) conclude Block, J. H., & Block, J. (1980). The role of ego-control that distress is most likely when two or more of the and ego-resiliency in the origination of behavior. following features are present: human perpetrators; In W. A. Collins (Ed.), The Minnesota Symposia on intentional violence; high prevalence of injuries; Child Psychology, Vol. 13 (pp. 39–101). Hillsdale, threat to life; loss of life; severe, extensive property NJ: Erlbaum. damage; and significant, ongoing financial difficul- Bonanno, G. A. (2004). Loss, trauma, and human ties for the community. All of these conditions are resilience: Have we underestimated the human capacity to thrive after extremely aversive events? likely to be present in any future large-scale terrorist American Psychologist, 59, 20–28. assault, as they were in the attacks of September 11. Bremner, J. D., Southwick, S. M., Johnson, D. R., Nonetheless, most traumatic events leave in their Yehuda, R., & Charney, D. S. (1993). Childhood wake a range of levels of functioning due to differ- physical abuse and combat-related posttraumatic ences in exposure to the event and the personal stress disorder in Vietnam veterans. American resources that were available and brought to bear on Journal of Psychiatry, 150, 235–239. adaptation. We concur, therefore, with Rowe and Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Kahn’s (1987; see also O’Leary & Ickovics, 1995) Meta-analysis of risk factors for posttraumatic urging that research examine this range of psycho- stress disorder in trauma-exposed adults. Journal of social outcomes and undertake the task of explain- Consulting and Clinical Psychology, 68, 748–766. ing their heterogeneity. In doing so, much will be Butler, L. D., Blasey, C. M., Garlan, R. W., McCaslin, S. E., Azarow, J., Chen, X. H., et al. (2005). added to our understanding of resilience and to the Posttraumatic growth following the terrorist at- potential for fostering it in the face of threat and tacks of September 11, 2001: Cognitive, coping, possible future acts of terrorism. and trauma symptom predictors in an Internet convenience sample. Traumatology, 11, 247–267. Acknowledgment. The authors wish to thank Robert Butler, L. D., Field, N. P., Busch, A. L., Seplaki, J. E., W. Garlan for his tremendous help with and thoughtful Hastings, T. A., & Spiegel, D. (2005). 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Promoting Resilience and Recovery in First Responders Richard Gist

It has become almost axiomatic in the field of trauma Inherent in these seeming contradictions is an response to assert that first responders—law en- array of issues that must be teased out and care- forcement officers and agents, firefighters, rescue fully considered if we are to understand the in- specialists, emergency medical technicians, and teraction between the nature of these occupations, paramedics—are at severely heightened risk for the people who perform within them, the structure posttraumatic stress disorder (PTSD) and related of their work and encounters, and the impact of psychiatric maladies because of the nature and those encounters on their career growth and per- emotional impact of their work. While a number of sonal functioning. Some of those issues include reports have appeared indicating higher rates of en- matters related to the construction of the PTSD di- dorsed reactivity and probable caseness (see, for ex- agnosis and its application to a population wherein ample, Clohessy & Ehlers, 1999), several reports exposure to situations often deemed traumatic is have also concluded that first responders are, in fact, expected and sometimes daily fare. When does such uncommonly resilient (cf. Gist & Woodall, 2000). exposure fall outside the range of ordinary experi- Moreover, while programs such as critical incident ence for those who are so situated? stress debriefing, which are designed to mitigate Other issues involve identifying, operationaliz- traumatic impacts and prevent PTSD, have per- ing, and effectively impacting the most salient meated these fields and even extended into an ever- sources of occupational stress and especially plumb- broadening range of other workplaces (see Mitchell ing the interaction of persistent strain with episodic [2004] with regard to claims of penetration and range stress. Still others involve the nature of stress miti- for the intervention set in question), the key inter- gators in these particular occupations. Secondary vention has become increasingly controversial as interventions imposed after the fact are generally less empirical reports have accumulated, showing it to be likely to provide meaningful preventive impact than inert at best and possibly even detrimental to some are primary interventions deployed to mitigate the (cf. Rose, Bisson, Churchill, & Wessely, 2004 or Van impact of the nearly inevitable exposure inherent in Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, the social roles and primary functions these occu- 2002; see also McNally, Bryant, & Ehlers, 2003, for a pations represent. It is also necessary to consider a comprehensive overview). range of contextual issues because the impacts of

418 Promoting Resilience and Recovery in First Responders 419 these events on individual providers reflect the in- nizations are their communities’ first resource for teractions of workplace experience with personal, most issues related to hazards and safety, but now interpersonal, social, and community features of they must also provide expertise for hazardous each provider’s life and circumstances, as well as the material identification and mitigation, mass ca- roles such experiences play in personal and profes- sualty triage, decontamination, and technical rescue sional development across the life cycle of individual in the event of structural collapse or environmental and career growth. It is by no means a simple portrait contamination. Because the occupations have ex- to paint. tended on both ends of their spectra, the pra- The prospect of terrorist events, especially ctitioner’s contact with the ordinary citizen has those that might involve weapons of mass destruc- become more frequent and more personal at the tion or actions intended to instigate fear and dis- same time that issues and impacts of a more global equilibrium, complicates the matter further. These and technical nature have become increasingly events, by nature and design, are likely to fall out- critical elements of social role and expectations. side the ordinary experience of even veteran first What draws people to these jobs and shapes responders. However, it is the practiced capacity to their careers within them continues to hold features deal with the ordinary and usual challenges of the of idealism and service—these are constantly chal- occupations that must provide the skill base that lenged, however, by confrontation with the very enables these professionals to respond effectively elements of life from which their social roles daily and provides the capability for their resilience in the insulate their fellow citizens. Law enforcement of- aftermath. ficers are consistently confronted with those who prey upon the social order. Firefighters and medics quickly learn that death is an omnipresent and ul- The Nature of the Work timately inescapable part of daily life. Nested within that constant strain are periodic episodes that stand Law enforcement and firefighting are more than out as particularly challenging. occupations or professions. These enterprises re- Such circumstances result almost unavoidably present essential social functions that must be in cognitive disequilibrium. The manifestations of exercised for any community to prosper. Law en- such disequilibrium are not generally inconsonant forcement represents the formalized embodiment of with those of other forms of distress, making it a community’s need for social regulation to ensure facile to describe them as symptoms of any number that balance is maintained between the prerogatives of conditions in which generalized distress plays a of the individual and the priorities of the com- presumed etiologic and diagnostic role. Since this monwealth; firefighting evolves as the extension of disequilibrium tends to manifest itself most visibly the needs of the collective to come together with following exposure to emotionally laden occupa- precision and effectiveness to facilitate the protec- tional events, it is equally simplistic to attribute the tion of its members from threats too large for any distress to the essential nature of the seemingly one to master by oneself. Each finds its roots in the precipitating event. It may, however, prove coun- voluntarism that de Tocqueville ([1835–1840] terproductive to couch such disequilibrium as a 2001) celebrated in his early commentaries on symptom of psychic injury resultant of some American life, but each has evolved into formal particular exposure. Superior utility and under- governmental structures and entities that hold in- standing may appertain from couching it instead as creasingly proscribed roles in a complex, techno- a sign of processes that hold at least an equal logically based society. propensity to stimulate personal and professional The complexity of their modern roles is adaptation and growth (Gist & Woodall, 1999). reflected in the size and responsibilities of con- Such growth does not necessarily come gently, temporary law enforcement and fire service orga- nor can it always be expected to come without nizations, as well as in the wide range of events in distress. How that distress is characterized, how- which their response is expected. Law enforcement ever, is a central attributional feature that likely includes duties that range from daily patrol and holds a strong capacity to influence its perceived traffic management to counterterrorism, forensic nature and its ultimate impact. While the distress science, and tactical operations. Fire service orga- of such disequilibration is typically cast as 420 Prevention and Psychological Problems in Reaction to Acts of Terrorism pathognomonic in the literature of traumatic Graesser & Olde, 2003). While successful for most stress, cognitive disequilibrium is well recognized people over time, such resolution may indeed prove in educational development as a salutatory if some- to be difficult for everyone at various points and too times discomfiting factor that motivates people to challenging for some at particular junctures. How to reexamine their understanding of a situation or cir- anticipate, mitigate, mediate, and accommodate cumstance, embrace broader and alternative views, those challenges becomes pivotal to effective man- and emerge with a fuller understanding and appre- agement of human capital in these enterprises. ciation of the matter at issue (cf. Mills & Keil, 2004). When viewed in this light, it can emerge as the es- Dealing With Occupational Stress sence of the enterprise’s rewards even more than the reservoir of its liabilities. Recognition of stress as a significant factor affecting Woodall (1997), as a career firefighter com- the health and safety of public safety providers no pleting a doctorate in human and organizational longer meets macho resistance within the industry; development, garnered the Student Paper of the no longer do stress management or behavioral Year award from the Sociological Practice Asso- wellness programs encounter denial so intense as to ciation for his ethnographic treatment of the role of demand or justify missionary zeal to secure their these ‘‘critical incidents’’ in the career development endorsement or adoption. Behavioral wellness, in- of successful professional firefighters. He collated cluding personal and occupational stress manage- data from interviews with a wide range of students ment, was accorded direct recognition and standing and alumnae of the National Fire Academy’s Ex- in the Joint Wellness Initiative of the International ecutive Fire Officer program to investigate how Association of Fire Fighters, AFL-CIO, and the In- such incidents were remembered, accommodated, ternational Association of Fire Chiefs (IAFF/IAFC, and incorporated into the occupational under- 1997, Chapter 5); these are also recognized com- standing of those who had objectively advanced in ponents within the National Fire Protection Asso- their organizations and profession. He summarized ciation standards regarding occupational health the conundrum in the following fashion: and safety for firefighters (NFPA, 1997, Standard 1500). It is the very nature of a firefighter’s journey, the Most of the attention initially afforded these seemingly endless exposure to human pain and topics centered around a relatively singular and suffering, that has afforded them the opportu- narrow construction of occupational stress and nity to appreciate the joys of life by knowing occupational stressors (dubbed ‘‘critical incident and understanding human tragedy. By experi- stress’’) and a specific popularized model of peer encing, although most times vicariously, the intervention (critical incident stress debriefing emotional and physical pain of the sick, injured, [CISD]). Much like the suicide prevention and and dying, they become capable of experiencing crisis intervention movement of a quarter century the true meaning of life. These resilient emo- ago (cf. Echterling & Wylie, 1981), the CISD phe- tional skills serve them both at home and on the nomenon arose primarily as a grassroots amalgam job. Their experiences afford them the emo- spurred by a few charismatic leaders without tional skills required to function in dangerous standing or recognition in mainstream medicine or and tragic environments. By the same token, psychology. these skills also afford them the opportunity to The core contentions on which the enterprise take that little extra moment to appreciate the was erected derived from an essential assumption joys of life, understanding all the while just how that occupational events function on an individual fleeting those joys can be. (p. 155) level as psychic traumata, ‘‘wounding’’ the psyche Such resolution might be better conceptualized as a of people confronting them in such a way as to dynamic equilibrium between the cognitive and disrupt their capacity to function normally in the emotional challenges inherent in the occupations aftermath (cf. Mitchell, 1983, 1988; Mitchell & and the cognitive resolution one can achieve by Bray, 1990; Mitchell & Everly, 1995). The premise asking progressively better questions about the that these exposures, if not contravened through nature of things each time one’s understanding direct and focused rapid interventions, would lead encounters significant conceptual challenge (cf. to posttraumatic stress disorder and related Promoting Resilience and Recovery in First Responders 421 psychiatric maladies (cf. Mitchell, 1992) quickly objective academic research. Proclamations made became an unquestioned axiom. in that regard, when investigated to any depth, proved not to have been derived from the sorts of Critical Incident Stress Debriefing systematic testing and study normally associated with evidence-based practice (Gist et al., 1997; When distilled to its essence, CISD is a simple ap- Gist & Woodall, 1995, 1999; Gist, Woodall, & plication of an objectively rather loose amalgam Magenheimer, 1999). of rudimentary notions regarding structured re- The intensive marketing of the rubric and the exposure, proximal early catharsis, anticipatory broadening range of its application, especially as guidance, and peer modeling folded into an other- contrasted with observations from serious practi- wise unremarkable group-process approach (cf. tioners regarding limitations or misadventures in Mitchell & Everly, 1995). This blending of widely actual application, eventually led these claims to be venerated but generally untested axioms regarding subjected to direct scientific scrutiny. Initial studies crisis intervention (e.g., temporal and physical in several parts of the globe clearly suggested that the proximity of intervention to stressor exposure; claims of preventive impact had been seriously cathartic utility of early narrative reconstruction and overstated—indeed, systematic studies repeatedly emotional expression) with popularized self-help found no evidence of preventive impact compared standbys such as peer-mediated disclosure and to nonintervention controls (see, for example, psychoeducational information lent the procedure Deahl, Gillham, Thomas, Dearle, & Srinivasan, both an attractive familiarity and a strong dose 1994; Lee, Slade, & Lygo, 1996; McFarlane, 1988) of presumptive face validity. Since its first formal or compared against informal vehicles of social articulation in a proprietary trade magazine of support (cf. Hytten & Hasle, 1989). Even more the emergency medical services (Mitchell, 1983), disturbing, though, were findings—ultimately re- the technique has been aggressively marketed on peated across a range of studies—that specific ap- the following express premises: plications of debriefing interventions resulted in paradoxically inhibited courses of recovery for sig- Even singular exposure to certain critical in- nificant numbers of recipients (Griffith & Watts, cidents could reliably give direct rise to post- 1992; Kenardy et al., 1996; Mayou, Ehlers, & traumatic stress disorder and other psychiatric Hobbs, 2000). morbidity. These reports have increasingly appeared in Nearly immediate (within 24–72 hours) ap- mainstream journals of the psychological and plication of this specific intervention proce- psychiatric disciplines and have now coalesced dure would reliably prevent such transition. into a strengthening body of scientific information. Failure to provide such specific intervention The overall direction of the empirical data has now (or even the provision of other intervention become decidedly clear: approaches) would potentiate or exacerbate traumatic reactions and their sequelae (cf. The Cochrane Reviews—Oxford-based systema- Mitchell, 1992). tic, critical reviews of research reports covering These assertions were repeatedly published a range of medical treatments—again updated and proclaimed in the trade venues of fire service their report regarding debriefing after traumatic and public safety occupations, and a wide fol- exposure in May 2001; that iteration evaluated lowing grew around debriefing as an almost 11 randomized, controlled trials (RCTs) of the evangelical self-help program. Debriefing seemed, intervention genre (Rose, Bisson, Churchill, & on its face, to be benign at its very worst and to Wessely, 2006). Conclusions have been very represent a reasonably caring organizational re- strong that debriefing has proven ineffective at sponse to the impact of difficult duty. Despite the best with respect to preventing PTSD and may claims of its principals and their disciples that it actually inhibit the normal course of recovery. enjoyed a detailed and specific grounding in The closing recommendation from that update empirical research, these contentions—especially specifically states, ‘‘There is no evidence that those regarding its purported preventive efficacy— psychological debriefing is a useful treatment had not been established in the usual venues of for the prevention of post-traumatic stress 422 Prevention and Psychological Problems in Reaction to Acts of Terrorism

disorder after traumatic incidents. Compulsory modeling techniques to measure the impact of debriefing of victims of trauma should cease.’’ interventions on trajectory of change over time. Several well-partitioned field studies (quasi ex- CISD yielded no preventive impact in any of the periments, rather than RCTs) of debriefing fol- dimensions measured. lowing occupational incidents in law enforcement, fire and rescue services, and emergency medical workers have also been re- The Empirical Imperative ported in refereed research venues. These studies, too, found debriefing inert at best with These data have compelled an increasing range of respect to preventing PTSD (Carlier, Lamberts, scientific bodies and professional organizations— van Uchlen, & Gersons, 1998; Macnab, Russell, including many originally quite supportive of Lowe, & Gagnon, 1998), and at least two stu- the notion—to reexamine the assumptions and dies echoed findings of the RCTs regarding recommendations related to the application of in- paradoxical outcomes for some debriefed par- terventions styled on the principles of debriefing ticipants (Carlier, Voerman, & Gersons, 2000; and have led, in their turn, to a number of pub- Gist, Lubin, & Redburn, 1998). lished statements prescribing limitation or contra- A more recent and thorough meta-analysis, in- indication (e.g., Bisson, McFarlane, & Rose, 1998); cluding both RCTs and partitioned-field studies Parry, 1999; Raphael, 1999; Wessely & Krasnov, (Van Emmerick et al., 2002) has established 2002). Current guidance from the United King- that effect sizes for debriefing showed no sig- dom’s National Institute for Clinical Excellence nificant preventive efficacy, held the possibility (2005) specifically contraindicates offering de- of paradoxical impacts, were generally smaller briefing to trauma victims, and an advisory bulletin than those found for nonintervention controls, from the World Health Organization (2005) echoes and were notably smaller than those of other that contraindication. The findings of the largest interventions against which it had been con- consensus panel convened to date (Ritchie, 2002) trasted. Though these confidence intervals specifies that the term ‘‘debriefing’’ should be re- overlapped and hence could not be conclusively stricted to operational review of responder activities stated as statistically significant differences, the for purposes of incident management (specifically authors noted that the mean effect size for nonpsychological in nature) and does not re- natural resilience with respect to PTSD was at commend any use of approaches based on narrative least moderate, while that of the contrasted in- reconstruction or cathartic ventilation in the im- terventions was moderate to strong; only the mediate aftermath period (Watson, 2004). confidence interval for debriefing effect sizes Emerging studies reported in a variety of first- included zero and negative values (indicating an tier journals and symposia have indicated additional inert or even a paradoxical intervention). concerns that prove particularly troublesome. Those The rejoinder that these conclusions relied experiencing increases in hyperarousal symptoms, principally on data from individual applications for example—those who are generally those most rather than intact occupational groups has been likely to perceive themselves and be perceived by severely weakened with preliminary reporting others as distressed and needing intervention— of the largest and most tightly controlled study have been particularly prone to paradoxical impacts to date, involving military personnel studied in from these interventions, no matter how con- intact units before and after deployment (Litz, structed (Sijbrandij, Olff, Gersons, & Carlier, 2002). Adler, Castro, Suvek, & Williams, 2004). More Those who favor repressive coping styles—again, than a thousand personnel attached to multiple among those most often prodded to participate— military units received either group CISD from may do quite well absent intervention but deterio- fully trained debriefers using precisely managed rate with supportive and educational approaches protocols, a traditional ‘‘stress education’’ that most others would find helpful and reassuring, handout and talk, or an ‘‘assessment only’’ a repeated finding with cardiac patients across sev- control condition. Postdeployment measures eral studies and locations (Frasure-Smith et al., were compared against predeployment base- 2002; Ginzburg et al., 2002; Shaw, Cohen, Doyle, & lines utilizing contemporary growth curve Palesky, 1985). Still other studies have suggested Promoting Resilience and Recovery in First Responders 423 that those who most endorse these encounters the traumatic episode. The goal of this exercise is may also be among those most likely to experi- generally described in terms of creating a calibrated ence paradoxical inhibition of resolution relative perspective of the event. Such reconstruction may to similarly situated persons to whom no inter- serve to intensify already disturbing reactions by vention was provided (Mayou, Ehlers, & Hobbs, reconnecting the individual with sources of pro- 2000). found discomfort and disequilibrium well before sufficient distancing has had an opportunity to Deconstructing Debriefing develop. This revivification is unlikely to serve its intended purpose and may, especially for parties Why should something with such seeming face disposed toward repressive coping styles, be more validity and close congruence to dominant notions likely to arrest than to accelerate the processes in- of traumatic reactivity and intervention prove al- herent in normal resolution. most universally to have been nonefficacious? Why Group applications of debriefing, rather than would such a procedure be counterproductive for creating a shared picture of circumstances and some, potentially yielding paradoxical inhibition of events, may further compound these issues by ex- resolution trajectories for those most particularly posing those who are struggling to keep their own disturbed by their experiences? To understand this arousal in check to additional, potentially even calamity, we must first deconstruct the process. more vivid and arousing constructions of the event The dominant model (Mitchell and Everly, 1999) and its images. Especially when the process is in- prescribes seven phases: voked within the frequently recommended postimpact envelope of 24–72 hours, the potential Introduction Phase for these paradoxical impacts may be heightened as The standard CISD protocol begins by having the one progresses from this element through the practitioner outline the process and prescribe ‘‘thoughts’’ and ‘‘reactions’’ phases to follow. Given certain ground rules for the session. Included in that Charlton and Thompson (1996) found only these instructions are statements of purpose and positive reappraisal and distancing to be coping presumption intended to encourage participants to strategies predictive of successful adaptation, this engage themselves in the process and participate in early insistence on reconstruction may well run the phases to follow. Rather than the statements of counter to the very processes most likely to promote limitation and potential risk that fully informed eventual resolution, problems that may be system- consent would ordinarily demand before pro- atically compounded in the following two phases of ceeding with an intervention widely reported to be the classic CISD rubric. inert at best and paradoxical for some, these instructions have tended instead to promote claims ‘‘Thoughts’’ Phase of exaggerated preventive efficacy. Rather than the This phase asks participants to articulate their in- proviso that one should carefully consider one’s itial thoughts as the impact and magnitude of the decision to participate in light of these concerns, traumatic event first came to their awareness. This participants in group encounters are instead told is apparently intended to establish a sort of cog- that their participation may be helpful not only to nitive baseline from which subsequent reappraisals them but also to others. Participants are typically might emerge. It may instead present, at least for promised confidentiality, despite being told that some, the potential to paradoxically solidify nega- the intervention is not a therapeutic one (hence tive elements of events resurrected through the negating the precise relationship required to in- narrative reconstruction of the ‘‘facts’’ phase. This voke any such protection). They are also generally can again be compounded in group applications, told that no records will be kept, contravening where some participants may not have been fully strict ethical and legal prescriptions regarding cognizant of the level of danger to which they were documentation of services. exposed or may not have construed their experience in as threatening or unnerving a fashion as ‘‘Facts’’ Phase that which may be heard from others. The impact The CISD protocol calls next for the specific re- of this paradox may be further exacerbated porting of what participants saw and heard during by immediate implementation of the intervention 424 Prevention and Psychological Problems in Reaction to Acts of Terrorism attempt, leading readily to situations in which the shot, ostensibly prophylactic group encounter and encounter serves to encourage dissemination of cannot reasonably be attempted until initial reac- idiosyncratic, unsubstantiated, and/or disconcert- tions have had sufficient time to stabilize and abate. ing information among those immersed in dis- Indeed, such short-term and short-lived exposure to tressing and disequilibrating circumstances. memories of threat in people who may not currently Such postevent processes can lead to reappraisal have a pathological condition but who present with of one’s memory of the event in ways that may in- pronounced subjective distress conceivably increase one’s subjective estimation of the threat. Such troduces a risk of generalizing these memories and reappraisals have been posited as central in the de- priming certain stimuli that are, or could become, rivation of fear responses (Davey, 1993), and others triggers for consolidating the fear response (McNally have shown that such increased subjective appraisal et al., 1987). Regardless of any intention to subse- of danger correlates with pathologic outcomes (So- quently normalize this subjective arousal, those al- lomon, Mikulincer, & Benbenishty, 1989; Stallard, ready struggling to regulate arousal, intrusion, and Velleman, & Baldwin, 2000). This may be ex- reexperiencing may find that these elements of the acerbated in vulnerable individuals, as these cog- debriefing rubric reinforce, entrench, and exacer- nitions are again paired with arousal sensations bate their subjective discomfort rather than mitigate when the process moves into the ‘‘reactions’’ or or diminish it. ‘‘feelings’’ phase. ‘‘Symptoms’’ Phase ‘‘Reactions’’ (or ‘‘Feelings’’) Phase Narrative reconstruction of the traumatic episode This phase invites participants to articulate their and the various reactions it may have engendered is emotional responses to the event, often through followed by a descriptive exercise in which parti- queries such as ‘‘What was the worst part of the cipants are queried regarding ‘‘symptoms’’ they experience for you?’’ This serial progression from may be experiencing. While the rhetorical justifi- narrative reconstruction of events (‘‘facts’’ phase) cation for this phase is to normalize whatever re- through cognitive retrieval of proximal perceptions actions may be felt, there is a subtle but possibly (‘‘thoughts’’ phase) to reconnection of these with profound difference to be drawn between dis- the immediate emotional impact of the experience cussing common manifestations of postimpact in the ‘‘reactions’’ phase completes a process of distress and priming people to consider these dis- revivification. Those who fully submit themselves comfitures as if they were pathologic indicators to the procedure, especially the most vulnerable, associated with psychological dysfunction. More- can find themselves intolerably close to those over, repeatedly labeling the event ‘‘traumatic’’ su- states of terror, helplessness, and confusion from perimposes a set of attributions and expectations which distancing is most vital. When instituted that might not otherwise apply. Such attributions before reliable pictures of fact have been estab- may dispose vulnerable people to interpret the in- lished and early arousal has had an opportunity escapable disequilibrium of disruptive life events as to abate, this process of revivification—especially pathological anxiety—becoming, in effect, a self- when delivered to people who might normally fulfilling prophecy of despair. Once again, this is have gone on to process the information success- particularly pertinent when the topic is introduced fully if left unassisted—runs the risk of sensitizing before the normal processes of identification and such persons to intrusive internal stimuli at a time attribution of subjective discomfort have begun, when desensitization is vital to immediate stabili- much less stabilized. The greatest risk may reside zation. with those who are already experiencing heigh- The processes of desensitization necessary to tened distress. address pathological elements inherent in diag- The very labeling of subjective experiences that nosable PTSD require systematically graded are, in most cases, signs of inescapable dis- exposure to defined stimuli and progressive habi- equilibrium as if they are symptoms of pathology may tuation to them. This serves to extinguish the fear contribute to a ‘‘medicalization’’ of the experience— response and provide corrective information to to wit, ‘‘I didn’t think of myself as sick until you sent challenge aberrantly held beliefs (Foa & Kozac, for a remedy’’ (Gist, 2002). Here again, the com- 1986). This is unlikely to be accomplished in a one- bined impact of one phase (in this case, the ‘‘symp- Promoting Resilience and Recovery in First Responders 425 toms’’ phase) with that of its succeeding phase (the ‘‘Reentry’’ Phase ‘‘teaching’’ phase) holds even further potential to This is intended as a time to reinforce consolidation compound complications for vulnerable partici- of material learned from the group experience, a pants, especially when implemented at a juncture typical element of any group-process model. Where where the strongest susceptibility to suggestion is the information communicated in a group setting likely to be present. is valid and useful, such consolidation is likely to be productive. Consolidation of counterproductive ‘‘Teaching’’ Phase ideas and information, however, is no less likely an Debriefing protocols provide for a psychoeduca- outcome than consolidation of productive learning. tion element intended to provide modeling of and Where there is likely at best to have been a liberal information about adaptive approaches to addres- mixture of both, the resulting outcome would seem sing the trauma and its sequelae. This discussion destined to be nonproductive at best. generally centers around colloquialized discussions of PTSD and its symptomatology. Debriefers Reconsidering Occupational Stress have frequently been known to distribute lists of problems that participants are told they may ex- Particularly with respect to occupational and orga- pect to experience (e.g., increased irritability, nizational events, context and circumstance may avoidance of reminders of the trauma, disturbed prove much more determinant of impact than the sleep, intrusive memories of the event) and then to nature or magnitude of a given incident (Alexander provide suggestions, often simplistic at best, re- & Wells, 1991; Gist et al., 1998), while individual garding coping strategies and approaches. Such a circumstances and proclivities preextant to the narrow focus on the core constructs of PTSD may event have proven decidedly more predictive of lead one somewhat astray from dealing with dis- lasting sequelae than have features such as proxi- aster as a social experience (see Staab, Fullerton, & mity and exposure alone (Cook & Bickman, 1990; Ursano, 1999, for an alternative construction). So- McFarlane, 1988, 1989). More than two decades cial comparison under threat, however, may prove a ago Taylor (1983) posited that cognitive adapta- more salient construction for understanding both tion to stressful events might be more effectively successful adaptation and the paradoxical impacts characterized from a salutogenic, developmental sometimes associated with debriefing. perspective rather than being presumed pathogno- Perceived threat lends a unique urgency to the monic of psychopathologic risk. search for affiliation and social comparison (Kulik, A rigorous and very productive line of empirical Mahler, & Moore, 1996). These contacts tend to research emerging since that time (see, for example, follow particular patterns that underscore the need Taylor & Brown, 1988; Taylor & Lobel, 1989) for specifically appropriate models (see also Tay- provided affirmation and considerable refinement lor, 1983). Given that Gump and Kulik (1997) to these propositions and melded them into an al- found that settings composed of those who share ternative, more discernable and testable construc- traumatic exposure contain demonstrable elements tion for the operation of such stressors in both of social contagion, blanket application of an in- individual and collective adjustment to negative discriminate group process may stand particularly events (Taylor, 1991). Those constructions re- prone to stimulation of negative outcomes, espe- cognize the unique salience and impact of extra- cially when invoked before constructive coping ordinary threat as a stressor while still embracing strategies have had time to fully evolve in the af- the long-standing conventional wisdom that ad- fected individual or population. Add to this the versity can, and in fact most commonly will, pro- hypothesis that overestimation of threat and fear vide challenges from which character and resilience expectation play a causal role in the origins and are built. maintenance of anxiety (Wiedemann, Pauli, & Exposure to critical incidents is not only un- Dengler, 2001) and that for people with panic avoidable in fire and rescue work; it is in fact the disorder, the expectation of panic is associated essence of the enterprise. For most providers in with actual panic occurrence (Kenardy & Taylor, most situations, these encounters are not sources 1999), and the potential for selective misadventure of threat or loss but are rather episodes of challenge, again increases. in which skills and effort central to one’s personal 426 Prevention and Psychological Problems in Reaction to Acts of Terrorism and professional role identity are focused on the A Systems View of Occupational Stress legitimate demands of the occupation (see McCrae, 1984, for an overview of situational determinants of It is not some specific and conceptually isolated set coping strategy). The organization may be argued to of critical incidents that can be posited to de- hold a range of responsibilities to ensure that per- termine the most salient links in the processes of sonnel are adequately prepared, equipped, de- reaction and resolution. It is, in fact, the backdrop ployed, and configured for effective response and of daily hassles in the form of personal and orga- for ensuring that the impact of equivocal events is nizational strain that can ultimately be said to de- effectively addressed in organizational and opera- fine the relative impact of a given stressor. This tional review (Gist & Taylor, 1996), but individual was highlighted in a thorough study of more than decisions, actions, coping patterns, and responses 200 firefighter/paramedics and firefighter EMTs in are also highly determinant of adjustment. These the State of Washington (Beaton & Murphy, interact with organizational determinants in com- 1993), in which past critical incidents ranked well plex and sometimes unpredictable ways that render below obvious concerns such as sleep disruption, uniform approaches to remediation suspect, if not wages and benefits, labor/management issues, overtly dangerous (Moran, 1998). Accordingly, personal safety, equipment, job skill concerns, and appropriate strategies for intervention and assis- family/financial strains as elements of perceived tance must separately and distinctly address orga- job stress. Past critical incidents failed to sig- nizational, situational, and individual factors and nificantly enter regression equations that predict determinants and must be capable of effectively job satisfaction and morale for paramedic fire- addressing both the unique contributions of each fighters and barely achieved significance for fire- and the interactions among them. fighter/EMTs. Moreover, Wright (1993) reported Distinction must also be drawn between ap- in a preliminary study of successful career para- proaches focused on issues and assumptions related medics that the principal factors influencing per- to presumed vulnerability factors versus those fo- ceptions of stress in a series of hypothetical calls cused on building and enhancing resilience. De- hinged not on the manifest content of the en- spite the presumptions of the debriefing movement counter or even on patient outcome but rather and its conceptual cousins in disaster response re- were driven by perceptions of personal and orga- garding exposure, risk, and causation, an increasing nizational success in the address of component body of empirical research has focused on con- evolutions. sistent finding of remarkable resilience in a sizable, The most promising strategy for primary pre- often strongly dominant, portion of those exposed vention of problems related to occupational stress to ostensibly traumatizing events. The distinctions interventions in these professions must deal with between these competing views reach much further enhancing those features of organizational perfor- than simple twists of title or subtle shifts of atten- mance, personal conditioning and development, tion and became a principal focus of the National and social support that provide effective response Institute of Mental Health’s proposed plan for basic and promote personal and organizational resi- behavioral science research (Basic Behavioral Sci- lience. Similarly, strategies for incident-specific ence Task Force, 1996). interventions must look to support the operation Effective strategies for intervention and assis- and, if necessary, the regeneration of these same tance, then, must begin with strategies to enhance factors through the least intrusive vehicles con- resilience and integrate these strategies with ap- sistent with the given circumstance. Moreover, they proaches that supplement and reinforce resilient must at the same time carefully consider and responses of individuals and organizations. When evaluate the interactions between individual cir- specific interventions are undertaken, they must cumstances of the affected people and broader or- occur without supplanting natural contacts and ganizational impacts and needs. Inherent conflicts supports that promote autonomy and resilience between personal and organizational interests with artificial structures that may instead reinforce cannot be avoided, and separate routes of inter- vulnerability or encourage reliance on inappro- vention with clearly specified client relationships priate, ineffective, or ill-timed strategies of coping will generally be required for the system to operate and resolution. ethically and effectively. Promoting Resilience and Recovery in First Responders 427

Institute of Mental Health, the U.S. Department of Organizational Factors Defense, and a number of other agencies charged to Gist and Taylor (1996) outlined a series of organi- examine early interventions following mass vio- zationally based strategies that, they argued, should lence and terrorist events (Ritchie, 2002). While be considered before, during, and after particularly psychological debriefing was not recommended for stressful operations to promote maximum resi- first responders, operational debriefing was re- lience within both the formal and the informal or- cognized both for its critical role in the management ganizations of the workplace, which, in turn, would of events and for the widely recognized palliative help to support maximum resilience in those effects that accrue to participants in the process. exposed to stressful occupational events. These fo- Ørner (2003) has described an evidence base cused on the incorporation of enhanced informa- for early intervention in emergency services popu- tion and more effective practices into existing lations constructed on determining and supporting organizational relationships affecting management, natural adjustment and coping patterns of these command, supervision, and human resource sup- personnel. Macnab, Sun, and Lowe (2003) note port and on the addition of skills and resources to that, while debriefing and related interventions had supplement existing patterns where deficits might shown little preventive impact on personnel fol- exist or develop. The recommended approaches lowing a fatal air ambulance crash, preexisting advocated empowerment in daily activities and re- stress management and coping strategies showed a sponses over remedial interventions, which they noteworthy mediating effect. Systems of interven- described metaphorically as opting to promote tion and assistance that reflect help-seeking and flood control engineering rather than sandbagging attribution patterns of affected persons are more as a better strategy for advancing risk management. likely to be utilized by those in need and to support Adoption and consistent utilization of prac- resilient responses (Yates, Axsom, & Tiedeman, ticed incident management systems represent 1999). Avery and King (2003) describe an effort in a major factors favoring organizational resilience program initially modeled around debriefing and (Alexander & Wells, 1991; Gist, Lubin, & Red- related interventions to reshape its initiatives along burn, 1998). These systems have achieved in- these lines. creasing sophistication over the past two decades, This program focused on the inherent resi- culminating in a synthesized approach that has lience of emergency responders. Hands-on, prac- emerged as a national standard (Federal Emergency tical ways of preparing responders to adjust to the Management Agency, 2004). The protective benefit stressors encountered in their work were coupled lies in providing a well-rehearsed, systematic ve- to the realization that frequent exposure to intense hicle by which the command systems used each day and varied stressors can create service needs that in routine operations expand to anticipate and ad- are often more determined by the nature of the dress the needs of complex and escalating situa- individual’s world at the time of a critical exposure tions. When coupled to a consistent program of than by the nature of the exposure itself. Service operational review such as the military’s After Ac- possibilities with potential to address those situation Review protocols (see Gist & Woodall, in tions and needs are also a strong part of the in- press, for discussion of its application to fire and itiative. rescue service), this provides a strong foundation both to mitigate and contain the stress of the op- Psychological First Aid eration and to reframe its personal impacts in the Ruzek (2002) proposes a strategy for postevent context of coordinated occupational activity (pro- intervention with response personnel based on viding, in essence, distancing and reframing; see pragmatic elements of education and practical Charlton & Thompson, 1996). support. These approaches are consistent with the However, events occur that require coordinated general tone of psychological first aid (PFA) notions strategies of response. The range of possibilities for currently gaining favor as supportive responses in reasoned intervention is broad indeed, and a the immediate aftermath of stressful events. There number of suggestions have emerged. The most has been little clarity of specific objectives or sys- detailed recommendation set to date has emerged tematic definition of technique regarding PFA, from the consensus panel convened by the National hence little can be adduced in the way of empirical 428 Prevention and Psychological Problems in Reaction to Acts of Terrorism data regarding efficacy. But the intent of PFA the organization acknowledges the difficulty of the centers on practical and palliative impacts rather encounter, that adequate information is provided to than the prevention of later PTSD, and apprecia- evaluate its context and learn from its implications, tion for these less specific impacts has been and that avenues for future assistance, should they suggested as the principal source of positive en- be needed, are noted and made available. This can dorsements given most visible early interventions, be accomplished in many ways, tailored to the or- including debriefing (Gist, 2002). ganization, the personnel, and the circumstances. Such impacts should not be slighted. Data now More importantly, it can be crafted from routine suggest that fewer persons may be likely to develop interactions in understated fashions, helping to diagnosable PTSD than has often been suggested ensure the most unintrusive form of support con- and that many who do may resolve to subclinical gruent with the situation at hand. levels without overt intervention (cf. Galea et al., 2002; Galea et al., 2003). The dominant resolution Early Assessment trajectory of early resilience was posited by Bonanno Identification of those for whom resilience proves (2004) as parallel to the trajectory of recovery, dif- insufficient demands a simple but effective early fering principally in the extent of early arousal and screening device. Brewin et al. (2002) reported a distress and in the length of the refractory period. It simple 10-item screen to be given 3–4 weeks post- is reasonable to suggest, then, that early efforts to impact. Centered on intrusion and arousal symp- mitigate initial distress may hold potential to at least toms consistent with active PTSD, the screen simply moderate the subjective experience of impact. asks whether the respondent has experienced any of Traditional approaches to first aid in the the noted reactions at least twice within the past physical domain concentrated on similarly basic week. Six or more positive endorsements is de- ideas. The intent was not to prevent some single, termined to represent a positive screen. specific consequence through some single, specific Despite its simplicity, the instrument has technique. First aid represented instead the capa- achieved very promising utility in early trials. Sen- city to apply any or several in a range of techniques sitivity and specificity have been above 0.9, with to provide basic practical and palliative care where screening efficiency at 0.92. The most direct ad- injury was not sufficient to warrant definitive care, vantage, however, is that the instrument can be and the capability to provide critical life support administered quickly and easily in a variety of set- where needed until definitive care could be ren- tings (e.g., general practice), and scoring requires dered. The former case entailed a kit filled with only simple counting of affirmative responses. Since band aids, light antiseptics, gauze pads, and other the outcome is referral for more intensive screening, simple remedies; the latter centered on the most it could feasibly be used as self-screening tool and basic interventions to preserve life organized along might even be delivered through online and similar a simple mnemonic of ‘‘ABC’’: mass distribution venues.

airway Efficacious Early Intervention Following breathing a Positive Screen circulation The most widely endorsed treatment for those With respect to PFA, Gist, Jackson, and Song developing diagnosable PTSD is trauma-focused (2004) have suggested a loose set of concepts cognitive behavioral therapy (CBT) (see, for ex- clearly modeled on a metaphor, and a similar con- ample, National Institute for Clinical Excellence, struction may be apt: 2005; Litz, Gray, Bryant, & Adler, 2002; Ritchie, 2001; Watson, 2004; World Health Organization, attenuation of initial distress 2005). Current protocols recommend a short cycle basic needs (approximately five sessions) commencing some- compassion where near the 4-week diagnostic point regarding This does not necessarily require orchestrated at- symptom duration. tempts at visible psychological intervention, espe- Despite widespread recognition of superior cially in occupational settings. The objective in efficacy, providers who are suitably trained and occupational encounters is generally to ensure that prepared to administer trauma-focused CBT are Promoting Resilience and Recovery in First Responders 429 not easily found among the resources most often that ‘‘watchful waiting’’ with instrumental and pal- available to rescue personnel. Available providers liative support frequently proves to be the best are most likely to be employee assistance counse- practice. lors, agency-based counselors, or similar providers who are more likely to be trained in supportive techniques requiring much less intensive training Summary Observations and supervision to acquire or apply. These techniques, however, have been shown repeatedly to There is no question that emergency response work be inert relative to trauma-focused CBT (Bisson, is demanding. There is also no question, however, 2001). Programs to provide ‘‘just in time’’ training that those challenges bring their own rewards. and preparation in these approaches are being Undoubtedly emergency workers are strongly im- explored in several settings. pacted by the situations they encounter, and certainly those impacts yield meaning and strength Stepped Care more often than they engender pathology and dis- An effective program of services requires that ob- turbance. Helping prepare emergency responders jectives be mapped for development of resilience, and their organizations to build resilience, enhance enhancement of adjustment skills before exposure, systems, create responsiveness, anticipate resource management of exposure factors, metered support needs, and design accessible mechanisms to facil- congruent with coping styles and preferences fol- itate the balanced operation of these options re- lowing exposure, early assessment to identify those quires a much more proactive, consultative, and for whom additional services may be required, and organizationally driven approach than traditional accessible services with strongly demonstrated ef- intervention-driven, reactive approaches have pro- ficacy for those who require such intervention. vided. Such a system needs to be based in a thorough Even more important than the differences in understanding of the organizational systems in- orientation and technique may be the underlying volved, the culture and traditions within which the difference in humility. The roles prescribed for the systems operate, the groups and individuals who interventionists in traditional models are central, compose the organization, and the tasks and en- visible, self-affirming, and even aggrandizing. The counters they engage. roles prescribed for the consultant in the emerging A more subtle but in many ways more critical approaches are much more circumspect and re- limitation of traditional programs of support for quire that one seek and maintain a much less emergency workers has been a tacit assumption of central and visible presence. The intent is not to homogeneity within emergency responders. This rescue but to facilitate strength among those for may be driven by an implicit focus on a perceived whom rescue is their daily fare. strong commonality in the situations and stressors Resilience is not simply recovery in shorter time they seemingly face as seen from the perspective of those (Bonanno, 2004; Rutter, 1987). Resilience is a outside the experience. While law enforcement offi- complex set of interactions that allows people not to cers, fire suppression personnel, emergency medical avoid the discomforts of adversity and challenge but responders, and other providers of emergency re- to manage their ways through them, often to dis- sponse may indeed confront similar situations and cover enhanced strength as a consequence. The often do so together, the impacts of those exposures efforts to build pathways to resilience, design sys- may well be determined at least as much by the or- tems to support them, and provide graded support ganizational contexts surrounding that exposure to promote their operation must complement cau- than by any individual factors of the experience. tious, evidence-based approaches to assessment of Where specific factors rise to strong salience, these perturbation in exposed people and the provision may often be better understood, defined, and ame- of timely, efficacious intervention when and to liorated when viewed in the broader contexts of in- whom indicated. The challenge to first responder terpersonal and organizational systems. 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Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy Dori B. Reissman Stephan G. Reissman Brian W. Flynn

Because terrorism is a federal crime and grabs na- private service sectors involved in disaster re- tional attention, management of a terrorist attack is sponse (including terrorism). complicated. In a terrorist event, the Federal Bureau A national strategy for disaster and terrorism of Investigation (FBI) is in charge of managing the preparedness planning will address the core criminal investigation (U.S. Department of Home- health, safety, and infrastructure needs of land Security, 2004b). The jurisdictional Emer- those affected gency Management Agency coordinates various groups (i.e., response and recovery operations) to manage the consequences of such events. State and Local Emergency Management federal resources can be called upon to support local response efforts if the scope or severity of the The local emergency management agency (EMA) impact overextends the capabilities of local agen- supports the on-scene efforts of the first-response cies. In 2003, Homeland Security Presidential Di- agencies by obtaining and coordinating the re- rective number 5 (Office of the President of the sources and personnel needed to do their jobs. United States, 2003a) called for a single, compre- They coordinate the available resources (e.g., public hensive national approach for use by all levels of works) to deal with emergencies effectively, ‘‘there- government by integrating emergency management by saving lives, avoiding injury, and minimizing principles in response to a terrorist attack or other economic loss’’ (Haddow & Bullock, 2003, p. 55). disaster: The first responder’s role in an event is coordinated in proximity to the event. For example, if an attack The Secretary of the U.S. Department Home- is a localized explosion, the first responders’ activ- land Security (DHS), or designee, is the prin- ities are handled at the ‘‘incident command post,’’ cipal federal official for domestic incident which is set up near the affected area. If there management. are multiple sites, responders will be coordinated A standardized incident management system through an ‘‘area command’’ (Emergency Manage- will be used for all levels of government and ment Institute, 2005). The local EMA hosts and

434 Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 435 collocates key decision makers from multiple re- Incident Management sponse agencies (e.g., police, fire, EMS, environmental protection, Red Cross, hospital associations, An incident command system (ICS) or incident public health and medical agencies, public works) management system (IMS) is used by the EMA, at an emergency operations center (EOC) to jointly public safety officers, and emergency response manage the overall response. partners to integrate strategic analysis and plan- An important part of the EMA’s efforts revolves ning, daily tactical operations, logistical support, around preparedness planning for all types of and financial accountability into the response and emergencies (see Table 27.1). Rather than devel- recovery efforts (FEMA, 1996; Emergency Man- oping separate plans for terrorist attacks and other agement Institute, 2005). Disasters and other large- disasters (e.g., hurricanes, hazardous industrial scale events may require shared leadership or explosions, major transportation crashes), emer- unified command among multiple agencies. Uni- gency managers use an ‘‘all-hazards’’ response- fied command brings together entities with differ- planning strategy for disaster preparedness. The ent jurisdictional and/or functional responsibilities all-hazards approach addresses the commonly ‘‘to work together to develop a common set of in- anticipated essential needs of an impacted com- cident objectives and strategies, share information, munity and standardizes operations. Issues that maximize the utilization of available resources, and are unique to a particular hazard (e.g., chemical, enhance the efficiency of the individual response radiological, biological, nuclear, explosive) are organizations’’ (National Response Team, 2004). addressed as part of an ‘‘annex’’ (or appendix) All of the various groups involved in the response to the jurisdiction’s response plan. These plans are obligated to support the leading agencies, and should be written in collaboration with the com- different ones may be in charge or share leadership munity’s response partners and need to be ex- (or support) of the incident at different times ercised, reviewed, and updated regularly (Federal during the same event or for different types of Emergency Management Agency [FEMA], 1996a). events.

Table 27.1. Example of a local EMA’s responsibilities, as delineated by statutory authority (City of Des Moines [Iowa] Emergency Management Agency, 2004)

1. Hazard identification and planning: Conduct hazard identification and vulnerability analyses that identify the hazards presenting the greatest danger to the jurisdiction and the consequences and impact of the occurrences. 2. Maintenance of the emergency partnership: Develop and maintain effective relationships with emergency response agencies, as well as government, private, and voluntary sectors of the community. The objectives of the relationships are to facilitate mutual consultation, exchange information, and provide agreements for cooperative action. 3. Emergency response systems: Develop and maintain such systems as communications, warning, emergency public information, damage assessment, shelter, resource management, radiological defense, and the emergency operations center. 4. Coordination: Coordinate the response and recovery activities of the departments and organizations involved in emergencies. One role for the emergency management coordinator is to serve as chief of staff to the responsible executive, be it a city manager, mayor, or county executive, during a disaster or emergency situation. 5. Hazard mitigation: Provide oversight and motivation to departments and agencies to carry out their duties in ways that avoid or minimize potential emergency conditions. Regulatory: Participate in and contribute to the legislative and regulatory process as it relates to emergency management. 6. Information: Develop and implement public information and public relations activities. 7. Administration: Oversee budget and finance, personnel, programs, supplies, and reporting systems. 8. Training: Identify training needs and develop, participate in, and provide training programs. 9. Planning: Review and revise operations, recovery, mitigation, and other supporting plans on a regular basis. 10. Drills: Coordinate drills that test the written plans and procedures of emergency management and supporting agencies that are involved in emergency response and recovery. 436 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Note: An FRC is present Principal Federal Official JFO Coordination if ESFs are activated, Group and will represent the DHS Secretary if a PFO Federal Resource State/Tribal/Local Senior Federal is not assigned. Coordinator Official(s) Officials

JFO Coordination Chief of Staff External Affairs Staff

Safety Coordinator Office of Inspector General Liaison Officer(s) Infrastructure Liaison Defense Coordinating Others as needed Officer JFO Sections

Finance/Admin Section Operations Section Planning Section Logistics Section (Comptroller)

(Branches and sub-units established as needed)

Figure 27.1. Joint Field Ofﬁce (JFO) for federal-to-federal support (U.S. Department of Homeland Security, 2004b, p. 39, ﬁgure 9).

Traditionally, the ICS is composed of five or- confusion and delays in providing services during ganizational management sections: the incident large-scale events (e.g., acts of terrorism, natural manager (called the ‘‘principle federal official’’ for disasters). This deficiency may compromise public federal-to-federal coordination), and the opera- health, safety, and security. Therefore, all first re- tions, planning, logistics, and finance/administra- sponder agencies and federal agencies were offi- tion sections (Figure 27.1; Emergency Management cially advised to use a nationally standardized Institute, 2005). The incident manager sets the model for incident management based on the objectives and priorities of the event and has the principles of ICS (Office of the President of the overall responsibility for coordination. The opera- United States, 2003a; U.S. Department of Home- tions section carries out the day-to-day tactical land Security, 2003a). operations of the response. The planning section develops daily action plans during the event, is kept informed of investigative and operational details, The National Incident and anticipates needs as the event evolves. The Management System logistics section provides the resources and other services needed to support the incident response. In 2004, the U.S. Department of Homeland Security The finance/administration section monitors and introduced the official version of the National In- documents all of the costs related to the incident. cident Management System (U.S. Department of Such a command or management structure Homeland Security, 2004a). Future federal funding needs to be scalable and flexible to account for the for state and local response agencies may rest on unique characteristics of an unfolding situation. their adoption and implementation of NIMS. NIMS Although a variety of incident management or provides standard terminology, protocols, and command systems are used all over the country, procedures for all responders at the scene of an there has not been a standard approach for mana- event. The system is designed to address all types of ging emergencies or disasters. The absence of hazards, including those involved in terrorism (see standardized terminology, concepts, and strategic Figure 27.2). The scope of NIMS includes re- approaches to managing incidents can lead to sponder training and certification, compatible Group Center Incident Security Homeland Operations National Level Interagency Management The role of regional coordinating structures depending on the varies incidents Many situation. be coordinated by may regional structures using Larger, regional assets. incidents may more complex require direct coordination the JFO and between with regional national level, to components continuing a supportingplay role. Center Regional Response Coordination Field Level Regional Level Office Group Joint Field JFO Coordination of Homeland Security, 2004b, p. 19, figure 3). Ops Center The focal point for coordination of Federal point for The focal As appro- support is the joint Field Office. priate, the JFO maintains connectivity with elements in the ICP in supportFederal of local, and tribalState, efforts. when An Area Command is established of the incident and the complexity incident managment span-of-control so dictate. considerations State Emergency . uct: Incident Ops center Command Post Local Emergency Area Incident Command Command Post Incident Structure for NRP coordination: terrorist incident (U.S. Department

Strategic coordination Strategic Prioritization incidents and between associated resource allocation issue resolution point for Focal Support and coordination Identifying resource shortages and issues Gathering information and providing Implementing multiagency coordination entity decisions Directing on-scene emergency management

Command Post Multiagency Coordination Entity EOCs/Multiagency Coordination Centers Incident Command

Coordination Structures Coordination Structures Command NIMS Framework NRP coordination is based on the NIMS constr The structure for ICS/Unified Command on-scene supported an Area Command (if needed), by coordination entities and multiagency coordination centers, multiagency Figure 27.2.

437 438 Prevention and Psychological Problems in Reaction to Acts of Terrorism communication systems for use by response agen- Relief and Emergency Assistance Act (‘‘Stafford cies (i.e., interoperability), and ongoing evaluation Act’’; 2000) specifies procedures for requesting and quality improvement of the NIMS products. federal assistance (see Figure 27.3). Some of the key features of the system include the Each state has an emergency management following (U.S. Department of Homeland Security, agency that represents the governor in coordinat- 2004a): ing state-level disaster response. In addition to providing training and developing statewide re- Command and management: to delineate the sponse plans, the state EMA can request personnel chain and sharing of command and leadership and equipment through the National Guard, mu- in managing the event to coordinate multiple tual aid resources from both inside and outside the agencies (and jurisdictions), according to a state, and petition for federal assets to be deployed standard platform of ICS to the state. The Federal Emergency Management Preparedness: to demand that specific mea- Agency (FEMA), now part of DHS, assesses the sures, actions, and processes be included in extent of the damage and the appropriate types of emergency management plans by designated federal assistance needed by a petitioning state. agencies Then FEMA forwards the state’s request and FE- Resource management: to identify, track, and MA’s assessment to both the President of the deploy resources (using standardized termi- United States and the Secretary of DHS. In some nology and terms of reference) cases, the Stafford Act can authorize deployment of Communications and information manage- federal assets to a state without a governor’s re- ment: to ensure and expedite information quest. Once the assistance is deployed, a demo- sharing among the various agencies involved in bilization strategy is formulated to guide the a response. This aids in establishing a common release and return of federal response personnel view of the incident by all of the involved and other deployed federal assets. agencies and also encourages the crafting of accurate, consistent, and unified messages for public dissemination. Federal Response to Supporting technologies: to ensure that a Terrorism Incident equipment and technology selected by the various response agencies function in a com- The U.S. government has the primary authority to patible (interoperable) fashion prevent and respond to acts or potential acts of ter- Ongoing management and maintenance: to rorism against the people or possessions of the Uni- support the refinement of NIMS through best ted States. This responsibility is assigned to the U.S. practices research and lessons learned from Attorney General and carried out through the Fed- exercises and actual responses. This compo- eral Bureau of Investigation. ‘‘Crisis management’’ nent also includes setting national standards refers to law enforcement ‘‘measures to identify, ac- for responder training and credentialing. quire, and plan the use of resources needed to anticipate, prevent, and/or resolve a threat or act of terrorism’’ (U.S. Department of Homeland Security, Requests for Federal Assistance 2004b, p. 82). This can include intelligence, criminal surveillance, forensic investigations, and tactical Every state now has an Office of Homeland Security operations. ‘‘Consequence management’’ refers to (or a similarly titled entity) to link with the fed- ‘‘measures to protect public health and safety, restore eral counterpart, DHS, and to address issues sur- essential government services, and provide emer- rounding terrorism. These offices are often con- gency relief to governments, businesses, and in- nected to the state’s EMA and/or to a state law en- dividuals affected by the consequences of terrorism’’ forcement agency. The DHS is charged with leading (U.S. Department of Homeland Security, 2004b, federal preparedness for, response to, and recovery p. 82). Crisis management and consequence man- from terrorist attacks, major disasters, and other agement often take place concurrently. emergencies (U.S. Department of Homeland Se- In an actual or potential terrorist incident, lo- curity, 2004b). The Robert T. Stafford Disaster cal jurisdictions, followed by state authorities, have Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 439

Homeland Incident Security Ops Center Occurs Monitors threats & potential incidents Local First Responders Alerts Federal Arrive first at scene Mayor/County Assistance NRP Resources Executive May deploy in advance Activates local EOC of imminent Requests Delivers danger aid from

Governor Joint Field Office Activates State EOC Provides coordination of Federal resources Preliminary Damage Assessment & requests Presidential President Activates Emergency declaration Response Team Declares major disaster or other elements or emergency Deployed as Homeland necessary Security Ops Center Evaluates situation RRecommendsecommends

Activates DHS and others Reports Secretary, DHS Implement National to Response Plan Reviews situation, May convene assesses need for disaster declaration & activation Activates of NRP elements Interagency Incident Management Group Frames operational courses of action

Figure 27.3. Overview of initial federal involvement under the Stafford Act (U.S. Department of Homeland Security, 2004b, p. 93, ﬁgure 11). the primary authority to respond to the con- governments when a major disaster or sequences. In the past, the federal response to emergency overwhelms their capacity to terrorism and other disasters was governed by four respond. The FRP describes the activities principal federal response plans and other sup- and responsibilities of the federal govern- porting strategies: ment and the American Red Cross following a presidential declaration of a major disaster The Federal Response Plan (FRP) was used to or emergency under the Stafford Act. In- provide federal assistance for major disasters itially issued in 1992, the FRP was updated or emergencies (FEMA, 1999). in 1999, then again in 2002 to reﬂect The FRP outlines the ways in which the changes due to the passage of the Homeland federal government assists state and local Security Act of that year. 440 Prevention and Psychological Problems in Reaction to Acts of Terrorism

The National Oil and Hazardous Substances to save lives and protect the health and safety Pollution Contingency Plan (NCP) addresses of the public, responders, and recovery the federal response to oil spills and hazardous workers substance releases (U.S. Environmental Pro- to protect and restore critical infrastructure tection Agency, 1994). to conduct law enforcement investigation to The first NCP was introduced in 1968 in resolve the incident, apprehend the subjects, order for the United States to have a co- and collect and preserve evidence for prose- ordinated approach to oil spills in U.S. cution waters. The scope of the plan was later to protect property and mitigate damages and expanded to include spills and releases of impacts to individuals, communities, and the hazardous substances or wastes. environment The Federal Radiological Emergency Response to facilitate the recovery of individuals, fa- Plan (FRERP) addresses the federal response to milies, businesses, and governments peacetime radiological emergencies (FEMA, 1996b). The NRP begins with an initial description of the The U.S. Government Interagency Domestic role of the federal government and the DHS in an Terrorism Concept of Operations Plan (CON- incident response. It addresses the issues of orga- PLAN) coordinates crisis management (law nization, leadership, and coordination of incident enforcement investigation) and consequence resources. This includes the designation of the se- management (life safety response) during a cretary of the DHS as the ‘‘principal federal official’’ federal response to terrorism (FEMA, 2001). (PFO) charged with coordinating the overall federal response to a terrorist attack. A critical section of Enacted by separate legislation, each of these plans the NRP identifies 15 functional response compo- has over time resulted in overlapping authorities nents called ‘‘emergency support function’’ annexes and confusion of role by the assigned federal (ESFs), which address specific categories of assis- agencies. Therefore, a single comprehensive strat- tance that are common to all disasters (see Table egy was developed to unify domestic national re- 27.2). Each ESF is headed by a lead federal agency sponse, thus becoming the National Response Plan that is responsible for coordinating the delivery of (NRP) utilizing NIMS (Office of the President of the goods, personnel, and services to the affected area United States, 2003a; U.S. Department of Home- and is supported by numerous other federal agen- land Security, 2004a, 2004b). Enacted by the U.S. cies. Public health, mental health, and medical is- Congress, the NRP supercedes the previous federal sues are coordinated by the U.S. Department of response plans. Health and Human Services (DHHS). Depending upon the size and scope of the event, some or all of National Response Plan the ESFs may be activated during a response (U.S. Department of Homeland Security, 2004b; see In 2003, DHS introduced the Initial National Re- Table 27.2). sponse Plan (INRP) as a general and conceptual Special incident annexes are adjunct manage- document to address broad issues of consolidation ment protocols to the NRP that account for unique and structure (U.S. Department of Homeland Se- aspects of specific hazards or their exposure curity, 2003a, 2003b), followed by a draft NRP in pathways and include the following (DHS/NRP May 2004. The NRP is designed to establish a annexes, 2004): ‘‘single, comprehensive approach required to enhance the ability of the United States to manage biological incident annex domestic incidents’’ (ibid., 2004b). The NRP de- catastrophic incident annex scribes the manner of coordination and the avail- cyber incident annex able federal resources that can be used to assist state food security and agriculture incident annex and local government responses during terrorist oil and hazardous materials incident annex attacks or other disasters. The primary goals of the nuclear and radiological incident annex NRP are as follows: terrorism incident annex Table 27.2. Essential support functions of the National Response Plan (U.S. Department of Homeland Security, 2004b)

ESF Responsible Federal Department Scope

ESF 1. Transportation Federal and civil transportation support Department of Transportation Transportation safety Restoration/recovery of transportation infrastructure Movement restrictions ESF 2. Telecommunications and Information Coordination with telecommunication industry Technology Restoration/repair of telecommunications network Department of Homeland Security Cyber and information technology ESF 3. Public Works and Engineering Infrastructure protection and emergency repair Department of Defense: U.S. Army Corps of Infrastructure restoration Engineers Engineering services, construction management Critical infrastructure liaison Natural resources restoration ESF 4. Fire Fighting Fire-fighting activities on federal lands U.S. Department of Agriculture: Forest Service Resource support for rural and urban fire-fighting operations ESF 5. Emergency Management Information collection, analysis, and dissemination Department of Homeland Security: FEMA Reports, bulletins, advisories, and assessments Action planning and tracking Resource tracking Science and technology support (modeling, information provision, and interpretation) ESF 6. Mass Care, Housing, and Human Shelter Services Feeding Department of HomelandSecurity: FEMA Emergency first aid Disaster welfare information Bulk distribution of emergency relief items ESF 7. Resource Support and Logistics Resource support Management Logistics General Services Administration ESF 8. Public Health and Medical Services Public health Department of Health and Human Services Medical Behavioral health care services Assays, disease models ESF 9. Urban Search and Rescue Lifesaving assistance Department of Homeland Security: FEMA Urban search and rescue ESF 10. Oil and Hazardous Materials Re- Hazardous materials (hazardous substances, oil, etc.) response sponse Environmental safety; short- and long-term cleanup Environmental Protection Agency ESF 11. Agriculture Nutritional services U.S. Department of Agriculture Agricultural production Animal health ESF 12. Energy Energy system assessment Department of Energy Repair/restoration Energy industry utilities coordination Energy forecast ESF 13. Public Safety and Security Operational and personnel security Liaison between criminal investigation and response/recovery ops Inspector general activities ESF 14. Economic Stabilization, Community Assess economic impacts and/or assist states and local Recovery, and Mitigation governments and the private sector in addressing impacts Department of Homeland Security: FEMA Long-term community recovery Mitigation response and program implementation ESF 15. Emergency Public Information and Emergency public information and protective action guidance External Communications Annex Media and community relations Department of Homeland Security Congressional affairs International affairs Tribal and insular affairs

441 442 Prevention and Psychological Problems in Reaction to Acts of Terrorism

From established Reports and Notification reporting mechanisms, e.g.: FBI SIOC National Response Center RRCC HSOC NCTC Other Federal EOCs State EOCs Federal agency command posts Further ISAOs assessment Non-national HSOC coordinates with needed incident Incident mitigated by depts. and agencies to Assessment Federal, State, local, investigate and assess and tribal agencies

Use of other supporting national Actual/Potential Incident interagency and of National Significance agency-specific plans

DHS actions may include: Issuance of coordinated alerts and warnings Sharing of incident information Activation of NRP organizational elements (NRCC, IIMG, JFO, etc.) and deployment of resources

Activation or deployed resources conduct prevention, preparedness, response, and recovery actions

Figure 27.4. Flow of initial national-level incident management actions (U.S. Department of Homeland Security, 2004b, p.47, ﬁgure 10).

National Level Coordination intelligence and operational information with federal, state, local, and tribal intelligence and law en- The secretary of the DHS is charged with co- forcement agencies as appropriate. It also monitors ordinating and integrating federal assets with state, nonterrorist hazards and receives reports regarding local, tribal, and nongovernmental efforts during natural hazards (e.g., severe storms, floods), oil a response (see Figure 27.4; DHS/NRP, 2004). The spills, and other hazardous materials releases. interagency incident management group (IIMG) When notified of an incident with possible national- coordinates and manages federal operational re- level implications, the HSOC assesses the situation sources during incidents of national significance. and briefs the secretary of the DHS, who determines The IIMG is composed of senior representatives the need for NRP activation (see Figure 27.4). The from the DHS, other federal departments and HSOC also houses the National Resource Co- agencies, and nongovernmental organizations and ordination Center (NRCC), which coordinates and national experts as required, including appropriate tracks federal resources. subject matter expertise. The group serves as the The Stafford Act also authorizes the president focal point for federal strategic and operational to use the military to assist civilian authorities in coordination and decision making. responding to disasters (see Figure 27.3). The The Homeland Security Operations Center Department of Defense (DOD) supplies what the (HSOC) is the ‘‘primary national-level hub for NRP refers to as defense support to civil authorities operational communications, information, and re- (DSCA), which offers support during domestic source coordination pertaining to domestic inci- incidents, including terrorist attacks. DOD support dent management’’ (DHS/NRP, 2004). The HSOC is dependent upon the request not interfering with maintains daily situational awareness and shares the department’s military readiness or operations Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 443

(ibid.). The military, through its various assets, at the HSOC will be elevated. National and re- routinely provides support to civilian disaster op- gional coordination centers will activate the ne- erations, including Hurricane Katrina in 2005; air cessary ESFs to mobilize and deploy personnel and patrols after 9/11, and supporting security activ- resources to support the incident manager (see ities for the 2002 Olympics and at Super Bowl Table 27.2). These centers also assess the need games. for and facilitate the deployment of medical and specialty teams composing the National Disaster The Joint Field Office Medical System. They also support teams that assist with incident management or the setting up of The Joint Field Office (JFO) collocates all of the emergency facilities. Other response actions in- federal agencies that are essential to enhance co- clude the establishment of the JFO and other field ordination and communication in a temporary facilities. facility close to state and local emergency opera- At the regional level, the required resources will tions centers (see Figure 27.2; DHS/NRP, 2004). depend upon the size and scope of the event. The The organization of the JFO is scaled to match the regional resources coordination center (RRCC) will magnitude of the incident and incorporates NIMS begin the local federal response coordination, while principles regarding the span of control and the the JFO is established in the affected area. During a functions of ICS (see Figure 27.1). The JFO co- terrorist response, law enforcement activities occur ordination group is led by the principal federal concurrently with life safety operations and must be official and consists of the federal coordinating coordinated to ensure the primacy of these activ- officer; the senior federal law enforcement official; ities. Once the immediate response missions and state, local, and tribal officials; and senior federal lifesaving activities conclude, the emphasis shifts officials. This group ‘‘provides strategic guidance from response to recovery operations and hazard and resolution of any conflicts in priorities for al- mitigation. The JFO planning section develops a location of critical Federal resources’’ (U.S. De- demobilization plan for the release of appropriate partment of Homeland Security, 2004b, p. 33). components. Additionally, the JFO initiates a dis- The federal coordinating officer manages fed- aster recovery center to provide information about eral resource support activities related to disasters assistance and recovery programs to the victims. and emergencies as authorized by the Stafford Act, These efforts are coordinated with local jurisdic- assists the unified command and/or the area com- tional authorities through state and local govern- mand, and coordinates with state operations. The ment emergency operations centers. senior federal law enforcement official is a member of the agency with primary jurisdictional respon- Federal Health and Medical Assets sibility and is typically the ‘‘FBI special agent in charge’’ during a terrorist event. A public informa- There are numerous federal public health, mental tion function is coordinated through a joint in- health, and medical assets that can be deployed to formation center (JIC), which acts as a central point the scene of a terrorist attack through the emer- for coordination and the issuing of public in- gency support functions of the National Response formation. In a terrorist incident, there may be two Plan. Of these, ESF 8, 10, and 6 are the most closely operations sections: one focusing on law enforce- associated with public health, mental health, and ment and criminal investigation and the other medical response (see Table 27.2). focusing on response and recovery operations. ESF 8: Health and Medical Services Response Actions ESF 8, the most comprehensive of the ESFs, provides coordinated federal assistance to supplement Initial response activities are focused on rescue and state and local resources in response to public the preservation of life, property, the environment, health and medical care needs following a terrorist and the critical community infrastructure. Federal, attack or other disaster or emergency. These assets state, and local governments will implement their can also be activated and predeployed in antici- agencies’ response plan based on NIMS principles pation of an emergency event. The U.S. Depart- (see Figures 27.2, 27.3, and 27.4). Activity levels ment of Health and Human Services coordinates 444 Prevention and Psychological Problems in Reaction to Acts of Terrorism this ESF, which provides support from numer- 11. All-hazard public health and medical con- ous federal agencies including the Veterans Ad- sultation, technical assistance, and support ministration (VA), the Department of Defense, the refer to assistance in assessing public health Department of Transportation (DOT), and the and medical effects of all hazards on both the Department of Homeland Security. Included in general population and high-risk groups. This ESF 8 are the overall public health response; triage, can include field investigations, collection and treatment, and transportation of victims; and eva- analysis of samples, and advice on medical cuation of patients out of the disaster area. The ESF treatments and protective actions with regard 8 functions in the NRP include the following: to health, medical, and sanitation issues. 12. Behavioral health care involves assessments of 1. Public health and medical needs are assessed, mental health and substance abuse treatment and any impact to the public health care sys- needs; the provision of disaster mental health tem and health care facility infrastructure is training materials for disaster workers; and determined. liaison with assessment, training, and program 2. The general population and special high-risk development activities undertaken by federal, groups are monitored for injury and disease state, and local mental health officials. patterns, as well as potential disease outbreaks. 13. Public health and medical information refers to 3. Medical care personnel, including federal assistance provided to state and local com- personnel and volunteers from unaffected munities for developing and issuing public areas, provide care for ill or injured victims health, disease, and injury prevention in- on site. formation that can be transmitted to members 4. Health and medical equipment and supplies of the general public who are located in or near may be requested from DHS and includes the affected area. materiel from the Strategic National Stockpile, 14. Vector control assistance is provided for threat as well as other medical supplies. assessment, as well as for the collection and 5. Patient evacuation and movement of seriously analysis of samples and recommendations for ill and injured patients to other areas are ar- protective actions and medical treatment. ranged through ESF 1. 15. Potable water and wastewater, solid waste 6. For situations requiring ongoing patient care, disposal, and other environmental health additional medical personnel can be brought issues include field investigations, sample in to support the existing medical infra- collection, and analysis. This includes the structure and provide definitive medical care provision of supplies and technical to victims in the affected community. assistance. 7. The safety and security of human drugs, 16. Victim identification and mortuary services biologics (including blood and vaccines), come from DHS and DOD and include disaster medical devices (including radiation-emitting mortuary teams (DMORTs) from the National and screening devices), veterinary drugs, and Disaster Medical System (NDMS); temporary other federally regulated products following a morgue facilities; victim identification by fin- major disaster or emergency are addressed. gerprint, forensic dental, and/or forensic pa- 8. Food safety and security personnel assess thology methods; and the processing, the safety and security of federally regulated preparation, and disposition of remains. foods following a major disaster or emergency. 17. Protection of animal health by delivering 9. Agricultural safety and security refers to en- health care to injured or abandoned animals suring the safety and security of animal feed and performing preventive veterinary medicine and therapeutics following a major disaster or following a major disaster or emergency. This emergency. includes the examination and care of animals 10. Worker health and safety refer to assistance in used for search-and-rescue efforts. monitoring the health and well-being of 18. The blood and blood products function in- emergency workers; they also entail addressing cludes assessing the availability of blood pro- precautions to ensure the health and safety of ducts and the taking of emergency measures to other workers. augment or replenish existing supplies. Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 445

ESF 10: Hazardous Materials (National Disaster Medical System website, http:// This function is designed to provide federal sup- www.ndms.fema.gov/). Federal partners in the port to state and local governments in response to NDMS include the DHS, DHHS, DOD, and the VA; an actual or potential discharge and/or release of nonfederal sources include major pharmaceutical hazardous materials following a major disaster or suppliers, hospital supply vendors, the National emergency. ESF 10 is closely connected to the Foundation for Mortuary Care, international dis- National Contingency Plan. The health and medi- aster response organizations, and international cal issues in ESF 10 are statutorily addressed by health organizations. the DHHS through its Agency for Toxic Substances The NDMS was developed to assist state and and Disease Registry (ATSDR) and through the local agencies, address medical and public health U.S. Environmental Protection Agency (EPA) with effects of major disasters, and provide support to a specific focus on the following: the military medical system in caring for casualties resulting from overseas armed conflicts. The NDMS providing assistance in the assessment of consists of specialty medical teams that deploy health hazards personnel, supplies, and equipment anywhere in determining whether illnesses, diseases, or the country. These teams typically arrive with en- complaints may be attributable to exposure to ough personnel, supplies, equipment, and shelters a hazardous substance to be self-supporting for up to 72 hours. The per- establishing disease and exposure registries sonnel are a mix of clinicians and support staff. and conducting appropriate tests These responders are employed in other jobs, both developing, maintaining, and providing in- in the government and in other areas of health care. formation on the health effects of toxic sub- They have volunteered to be part of their teams and stances are paid by the federal government for their time when they are activated. ESF 6: Mass Care Of the more than 70 teams that have been This function is coordinated by the DHS, and formed, more than half are disaster medical assis- the primary functional leadership is through the tance teams (DMATs) that provide primary care in American Red Cross, a nongovernmental entity. the affected area. Additionally, the NDMS has ESF 6 is designed to coordinate federal assistance in specialty teams that can be deployed to handle the support of state and local efforts to meet the mass following: care needs of disaster victims such as shelter, food, and emergency first aid. It also provides for the burns establishment of systems to distribute bulk emer- pediatrics gency relief supplies. Moreover, it provides for the trauma care collection of information to operate a disaster wel- mental health fare information (DWI) system for the purpose of veterinary medical assistance reporting victims’ status and assisting in family re- disaster mortuary operations unification. Recovery issues may be handled by the pharmaceutical distribution American Red Cross but under different congres- search-and-rescue operations sional authorities. As recovery operations are introduced, close coordination is required between In addition to sending personnel to the affected those federal agencies responsible for recovery op- area, another component of the NDMS is a system erations and the voluntary organizations, including to evacuate patients from a disaster site to a vo- the American Red Cross, that are providing re- luntary network of government, public, and pri- covery assistance. vate hospitals. The NDMS is designed to be FEMA’s National Disaster Medical System activated when states have been overwhelmed by a (NDMS) is a nationwide medical mutual aid net- disaster and a request has been made for federal work of both federal and nonfederal health care assistance, although its members can be pre- personnel who can be deployed from anywhere in deployed in anticipation of an impending disaster the country to provide on-site medical care in an or to support medical needs at a large event (e.g., area affected by a terrorist attack or other disaster the Olympics). 446 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Mental Health Functions modifications have been recommended and are likely to be implemented in future disaster re- The need to consider the mental health sequelae of sponse (Norris, Donohue, & Felton, et. al., in major disasters was first institutionalized by FEMA press). A wide variety of training and educational many years ago. As that agency began to encounter materials and tools have been developed by disaster victims and to provide basic disaster re- SAMHSA (http://www.samhsa.gov/Matrix/matrix_ covery services, it became clear that many of these disaster.aspx), the SAMHSA Disaster Mental Health victims were under extreme stress. Their psycho- Technical Assistance Center (http://www.mental logical reactions were so severe that they were health.samhsa.gov/dtac), the SAMHSA-funded Na- unable even to properly complete the paperwork tional Child Traumatic Stress Network (http:// necessary to obtain relief. Their behavior was dis- www.nctsn.org), the National Institute of Mental organized, and they were generally having diffi- Health (NIMH; http://www.nimh.nih.gov/health culty with their own recovery and that of their information/index.cfm), the VA’s National Cen- family and other community members. ter for PTSD (http://www.ncptsd.va.gov), and the Although the vast majority of people who Centers for Disease Control and Prevention (CDC; survive these extraordinary events sometimes ex- http://www.bt.cdc.gov/mentalhealth). In the future, perience very significant fear and distress, they do more attention is needed to ensure the appropriate not necessarily develop a mental disorder that reintegration of psychosocial issues into the assess- quires ongoing formal treatment by a licensed ment of public health and medical needs as part mental health professional. While there is some of the overall response efforts among affected po- disagreement in this arena, there is little evidence pulations (Reissman, Spencer, Tanielian, & Stein, that professional services significantly change the 2005). trajectory of their recovery. In most cases, trained and well-supervised nonprofessionals and para- Crisis Counseling and Support professionals, as well as professionals from other disciplines (e.g., clergy, guidance counselors), can The United States was certainly the first (and is play significant roles. perhaps the only) country to establish a federally As the field of disaster mental health and the authorized and funded program to meet the mental sophistication of the federal disaster response have health needs of disaster victims (Gerrity & Flynn, developed over the years, new roles, relationships, 1997). First implemented in the mid-1970s, the and programs have emerged. The primary locus of Crisis Counseling Assistance and Training Program responsibility for responding to the mental health (CCP), which FEMA administers, is included in its needs of disaster victims rests within ESF 8 of the enabling legislation (Stafford Act, 2000). A pre- FRP and NRP. The Substance Abuse and Mental sidential disaster declaration is required for states to Health Services Administration (SAMHSA) within be eligible for activation of the crisis counseling the DHHS is the lead federal agency for the federal provisions. The CCP provides short-term, informal mental health response. Under ESF 8 the pri- crisis counseling services, general and targeted in- mary mental health missions are to ‘‘assist in as- formation and education outreach to individuals sessing mental health needs; provide disaster men- and communities, and referral for those who may tal health training materials for disaster workers; need formal treatment for a mental disorder. A more and provide liaison with assessment, training, and complete description of this program can be found program development activities undertaken by at http://www.mentalhealth.samhsa.gov/cmhs/Emer Federal, State, and local mental health officials’’ gencyServices/progguide.asp. (FEMA, 1999; Gerrity & Flynn, 1997). Funding is provided through the states to local service providers. The program is based upon the Needs Assessment belief that fear and distress are widespread after disasters, that relatively few people will develop SAMHSA has designed a methodology that is used a full-blown mental disorder from their exposure to assess needs in impacted areas to inform the to disaster, and that those who do can be treated design of crisis counseling programs. Upon critical within the capacity of existing mental health re- review of the needs assessment methodology, sources. As a result, the program makes extensive Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 447 use of trained nonprofessionals (who are su- Center for Child Traumatic Stress and National pervised by mental health specialists) for many Center for PTSD, 2005). Additional informa- services and provides informal counseling for a tion can be obtained at http://www.ncptsd relatively short time. The program also relies .va.gov/pfa/PFA.html and http://www.nctsn. heavily on assertive outreach to the general public org. and special needs populations using psychoedu- The Office for Victims of Crime (OVC) in the cational approaches. Justice Department supports services (includ- However, the program does not include for- ing mental health services) for victims of mal, ongoing professional psychological or psy- crimes. While these programs are not activated chiatric (i.e., clinical) treatment. Those who need in natural disasters, they have been a critical formal care for diagnosed disorders are referred part of the service array following acts of ter- to existing mental health services. However, the rorism. scope and scale of the terrorist attacks in Sep- Project School Emergency Response to Vio- tember 2001 led to the provision of enhanced lence (SERV) within the Safe and Drug-free services through the crisis counseling mechanism. Schools Program in the Department of Edu- These were provided contingent upon assessments cation provides support for services (including that were conducted using a 12-item ‘‘SPRINT-E’’ mental health) to local education agencies tool (Norris Donohue, & Felton et. al., in press). A following acts of violence in schools. Project manual has now been prepared to standardize the SERV provides assistance to help children re- implementation of SPRINT-E to identify persons in cover from a violent or traumatic event in need of further evaluation and treatment by as- which the learning environment has been sessing demographics, risk categories, and psy- disrupted. Immediate assistance lasts for up to chological reactions surrounding a disaster or 60 days from the date of the incident. Ex- terrorist action (VA/National Center for PTSD, tended services last for up to a year from the White River Junction, VT). incident. Additional information is available at http://www.ed.gov/programs/dvppserv/index Other Federal Disaster Mental .html. Health Programs Disaster research, education, mentoring, and training grants in disaster mental health are While no program is as large and frequently acti- sponsored by the National Institute of Mental vated to meet the needs of disaster victims and Health (NIMH). Additional information is survivors as the Crisis Counseling Program, in available at http://www.redmh.org. recent years a few other federal programs have become available to help address mental health needs. The most significant ones are listed here: Promoting Behavioral SAMHSA established a limited grant program Health Preparedness to meet both mental health and substance abuse needs following events that do not ac- The federal role in the delivery of mental health tivate eligibility for the Crisis Counseling Pro- services in large-scale emergency situations is gram (e.g., an event that results in significant complex. As this chapter documents, the federal psychosocial distress yet does not receive a response environment is increasingly formal and presidential disaster declaration). As an ex- ever changing. Integration of effort and resources is ample, this program was used to fund services essential but complicated given the size, compart- for survivors, families of deceased victims, and mentalization, territoriality, and diverse funding other impacted community members following streams inherent in the federal structure. In addi- the nightclub fire in Warwick, Rhode Island, tion, significant planning and preparation are in February 2003. Additional information is needed to effectively coordinate the multiple dis- available at http://www.samhsa.gov/Matrix/ ciplines that may be involved in offering disaster matrix_disaster.aspx. mental health services at the local and state level Manualized ‘‘psychological first aid’’ for chil- (Compton, Gard, Kaslow, Kotwicki, & Reissman, dren and adults, funded by SAMHSA (National et al., 2005). 448 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Among the most important roles in integrating health care and public health systems and out- medical, public health, and mental health in dis- lining a public health model for disaster mental aster and emergency response are the following: health. The consensus workshop suggested that Direct service delivery (e.g., through general technical assistance can be provided to help im- and specialized NDMS teams) that facilitates prove the capacity of organizations and caregivers the integration of effort to offer what is needed to reestablish community Consultation to leadership in the preparedness structures, foster family recovery and resilience, and response phases to ensure that mental and safeguard the community (NIMH, 2002). It health issues are appropriately recognized and also proposed giving assistance, consultation, and integrated training to relevant organizations, caregivers, re- Training that cuts across specialty and dis- sponders, and leaders. The training content might ciplinary lines include the following topics: An integrated federal approach that facilitates the development of a comprehensive strategy identification of normal psychological re- and integrates state and local preparedness and sponses response efforts suggestions on when to refer someone to a One of the most overlooked, yet critical, op- mental health professional portunities for mental health providers is the stress identification and management provision of technical assistance, consultation, communication in a crisis and training (Reissman, 2004; Reissman, Spencer, needs of special populations Tanielian & Stein, 2005; Ursano, Norwood, & changes in psychological issues over time Fullerton, 2004). When one thinks of the roles integration of systems of care mental health professionals can play, too often the management of survivors in the workplace direct service intervention role is what comes to Basic to the establishment of psychological mind. However, major contributions can be made health is the perception that one is safe and secure. in other areas as well. In addition to the resources By definition, when one experiences extraordinary already identified in this section, several publica- events such as natural disasters or acts of terror- tions may be especially helpful to those wishing to ism, these feelings of safety and security are com- focus more on the theory, challenges, opportu- promised (Ursano, Norwood, & Fullerton, 2004). nities, and status of the field of disaster mental In the case of terrorism, this erosion of the per- health. ception of safety and security is the very intent, The first publication is Mental Health and Mass and they create a loss of confidence in the collec- Violence (National Institute of Mental Health, 2002), tive well-being. It is important and legitimate work which is the result of a consensus workshop held in for mental health providers to ensure the provision the fall of 2001 that brought together 58 disaster of and monitor the perception of these needs. In mental health experts from six countries to attempt doing so, the NIMH (2002) publication suggests to reach consensus on what works and what does the following priorities: not and to identify the knowledge gaps. Aside from reflecting a very intensive and credible process, one Ensure food and shelter. While this may seem of the primary contributions of the document is its obvious, survivors must have housing and articulation of the important roles mental health nutritional support as soon as possible. Proper can play in addition to those roles most commonly rest and sustenance are essential to maintain- known. ing health psychological function. The second is Preparing for the Psychological Provide orientation. In large-scale and/or on- Consequences of Terrorism: A Public Health Strategy going events, obtaining a comprehensive pic- (Butler, Panzer, & Goldfrank, 2003), which was ture of what is occurring and how people are developed by the Institute of Medicine (IOM) with impacted is difficult. Mental health providers the involvement of experts. This publication is should help fill in the gaps for victims and especially helpful in both describing the reasons survivors so that their understanding of the mental health should be fully integrated into event is based, as much as possible, on Integrating Medical, Public Health, and Mental Health Assets into a National Response Strategy 449

credible information rather than impression outbreaks of disease, hazardous exposures) are and rumor. addressed by the following questions: Facilitate communication with family mem- Do we want people to seek immediate medical bers, friends, and the community. Reliable care or wait to be evaluated? communication with and about family and Do we want people who are at high risk of friends is an important part of stress reduction exposure to biological pathogens to obtain in extraordinary events. It is also typically medications or vaccinations to prevent illness difficult to obtain, especially in the early hours through an emergency mass distribution and and days. One of the first and most stressful delivery system? questions for disaster survivors is, ‘‘are my Do we want people to take shelter in the af- loved ones dead, alive, injured, or safe?’’ fected area or to evacuate? Helping to answer those questions and Are their particular instructions appropriate to ensuring ongoing communication is an subgroups in the population such as children, important role in enhancing psychological those whose systems are immunosuppressed, health. and elderly people? Assess the environment for ongoing threats or toxins. Often when events appear to be over, Our sense of safety and security involves pro- they are not. If mental health providers are cessing information by means of a complex set of able to have regular and accurate information beliefs and perceptions. Is the event over? Am I out about ongoing situations, they can help ensure of harm’s way? Am I confident in the ability of the that this information is communicated and government and other leaders to eliminate or re- received by survivors in a way that helps reduce the threat and keep me safe? Everly and Flynn duce stress and leads to compliance with de- (2005) have offered a solid framework for the sired behavior. principles and practice of psychological first aid as one aspect of a psychological continuum of care. Disaster mental health issues extend beyond the Further exploration of individual and community treatment needs of those with preexisting or newly psychological resilience in the face of disasters and emerging (because of current exposures) psychiatric terrorist acts may be extremely useful for the design illness and management of those concerned about and evaluation of effective public health program- their health. Contrary to stereotype, it is not dealing ming and services (Reissman, Klomp, Kent, & with ‘‘how people feel’’ about what they have ex- Pfefferbaum, 2004). Mental health providers can perienced. In the early stages, although feelings are play important roles in assessing the environment, important to the extent that they influence behavior, communicating that status, and helping individuals they are not the primary focus of mental health’s and groups to understand, believe, and be re- role and efforts. Our primary concern is influencing assured by what they see and hear. individual and collective behavior in ways that enhance compliance with direction from credible health and safety authorities (Reissman, Spencer, References Tanielian, & Stein, 2005). In addition, we want to decrease the potential Butler, A. S., Panzer, A. M., & Goldfrank, L. R. (Eds.). for people to act in ways that are detrimental to (2003) Preparing for the psychological consequences their own health and safety and/or that adversely of terrorism: A public health strategy. Washington, affect the function of public safety, medical, and DC: Institute of Medicine, National Academies public health authorities. Serious health con- Press. Retrieved March 13, 2006, from http:// www.iom.edu/CMS/3775/3895/11573.aspx. sequences can result from actions taken by in- City of Des Moines Emergency Management Agency. dividuals and groups in reaction to disasters and (2004). Duties and responsibilities. City of Des terrorism, many of which completely disregard the Moines, Iowa. Retrieved February 2, 2006, from advice and instruction of health and safety au- http://www.co.des-moines.ia.us/EMA/EMAHome thorities. Some of the issues that have a dramatic .asp#Duties. impact on community-based strategies to contain Compton, M. T., Gard, B., Kaslow, N. J., Kotwicki, R. J., and control health and medical emergencies (e.g., Reissman, D. B., Schor, L., & Wetterhall, S. (2005, 450 Prevention and Psychological Problems in Reaction to Acts of Terrorism

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Reﬂections on the Psychology of Terrorism Laura Pratchett Lisa M. Brown Bruce Bongar

One ought never to turn one’s back on a threatened danger and try to run away from it. If you do that, you will double the danger. But if you meet it promptly and without ﬂinching, you will reduce the danger by half. Never run away from anything. Never! Ralph Waldo Emerson, 1803–1882

Terrorism is about one thing: Psychology. It is the psychology of fear. Philip G. Zimbardo, 2004 The chapters in this book attest to the emergence models of human behavior that promote our of the psychology of terrorism as a comprehensive knowledge of generalizable principles of human discipline with an interdisciplinary perspective. behavior across a wide array of settings and situa- Although this is a relatively new discipline, it is a tions. For example, to derive the psychological quickly evolving field that strives to apply psycho- underpinnings of terrorist acts, an understanding of logical theory and concepts to foster scientific ad- how political and belief systems have evolved over vancement. Ideally, scientific research progresses at time, and the consequences of these changes, is a steady pace, building on new methodologies, imperative. This insight provides clues that can be technologies, and theoretical insights and benefit- used to prevent the recurrence of some types of ing from multiple perspectives and converging terrorism and offers cautionary signs about the evidence. However, since the events of September potential for new forms of terrorist activity. A his- 11, 2001, U.S. government agencies, policy makers, torical and psychological analysis of change helps and academic research centers have been seeking us begin to comprehend the problems we en- empirical evidence to identify service priorities, counter today. An integrated, multidisciplinary guide decisions regarding resource allocation, and approach benefits stakeholders because it provides develop, administer, and evaluate antiterrorism a faster understanding of emerging trends and programs with new urgency. To encompass the provides an interface between academic research entire realm of psychological factors associated with and applied settings. The goal of this book is to terrorist acts, the field of terrorism psychology now provide a comprehensive overview of systems, re- contends with problems of a historic nature and sponders, and personal reactions to terrorism and others that come from growing pains. to demonstrate the collaborative role that psychol- Although other professions can provide re- ogy plays across various settings and situations. search expertise, psychologists offer the best ex- Bongar (Chapter 1) discusses some of the tasks planations of and theoretical insights into behaviors that psychologists face with respect to contemporary that can be translated into testable propositions and terrorism. These roles include defining and studying useful predictions. Psychological theories should be anticipated psychological reactions to mass trauma used to guide the development and refinement of that might occur in the population following a

452 Reflections on the Psychology of Terrorism 453 terrorist attack; preparing society for acts of terror by civilian to terrorist as a developmental process in sharing an understanding of collective responses which the person proceeds through a number of such as panic and mass psychogenic illness; studying stages that offer progressively fewer solutions. In and disseminating information about the motiva- the first stage, the individual perceives a lack of tions, dynamics, and strategies of terrorists; and as- fairness or relative deprivation of society toward sessing and treating those who are exposed to the group with which the person identifies. For terrorist attacks. those who have a tendency to displace their frus- Taylor (Chapter 24) describes the way in tration as anger directed at others, a lack of pro- which political and moral questions interfere with cedural means or personal ability to address an conducting research in this area, particularly field injustice can create a sense of moral justification research. He argues that terrorism can be cate- in the means used to advance their cause. Mo- gorized as a type of disaster, allowing for a con- ghaddam highlights the social influence of the ceptualization of casualties, reaction phases, and group members who are becoming increasingly cross-cultural issues. He states that individuals, disaffiliated with and disengaged from mainstream groups, and nations have different needs and society through isolation, their new attachment, priorities at any of four phases—preparedness, and fear. They then develop a dichotomous moral response, recovery, and mitigation. He cogently position that is unintentionally reinforced by au- argues that further attention needs to be paid to thorities who espouse the same rhetoric but from the subject of terrorism to adequately address the an opposing perspective. The final, intensive step needs of various affected populations. in the developmental process is the removal of personal reservations to undertaking acts of terror. The Psychology of the Terrorist In Chapter 8, Merari emphasizes the importance of social dynamics and group processes Terrorism as a decision and an action are also in promoting suicide terrorism. He discusses and evaluated and discussed in a number of chapters. rejects theories that propose religion as a pre- McCauley (Chapter 2) discusses three theories requisite for suicide terrorism and for poverty, commonly postulated to account for an individual’s revenge, or suicide-related pathologies as etiologies motivation to conduct acts of terrorism. He dis- for suicide terrorism. Merari describes the demo- misses the notion of individual psychopathology of graphic variables associated with suicide terrorism, terrorists based on the lack of supporting literature such as age, gender, and marital status, but cau- and points out that the idea of terrorists as psy- tions that these factors may be a function of the chopaths is contradicted by the lack of impulsivity terrorist groups’ policies rather than a trait profile and the existence of cooperation with others and a of an individual who is most likely to commit an willingness to die for a cause. He argues that the act of suicide terrorism. Echoing the messages of letters found in the luggage of the September 11, earlier chapters, Merari emphasizes the role of 2001, attackers provides evidence that undermines social influence both in motivating people to join the theory that terrorism is an emotional response terrorist organizations and in the indoctrination of anger to perceived group or individual frustra- process leading to a commitment to perpetrate an tions. Rather, he contends that the motivations of act of suicide terrorism. terrorists in undertaking their actions are often reflective of those normal responses exhibited by combat veterans—attachment to each other and to The Strategy of Terrorism a ‘‘greater cause’’—and draws parallels between the training of armed forces and the path an individual The importance of fear as a weapon utilized in the may take on the route to employing terrorist vio- tactics of terrorism is discussed in a number of lence. McCauley asserts that the dual strategies of chapters. Breckenridge and Zimbardo (Chapter 9) terrorism are to recruit sympathy from the con- illustrate the way that fear is used when a group has stituent population and to undermine civilian insufficient material power to wage a conventional confidence in the enemy authority. war. This tactical disadvantage is overcome by their A second theory is offered by Moghaddam ability to evoke a disproportionate level of fear in (Chapter 5). He conceptualizes the trajectory of the enemy community. This in turn serves to 454 Prevention and Psychological Problems in Reaction to Acts of Terrorism weaken the authority of the enemy leaders by un- need to be honest and provide timely information dermining the public’s confidence in their ability that in turn is disseminated by the media in an ac- to ensure people’s safety. The mechanisms by curate and nonsensational fashion. which this fear operates—availability heuristics, affect heuristics, bias for negatively valenced information and social amplification—are discussed Institutional Responses to Terrorism in detail. Embry (Chapter 12) explains how the princi- In Chapter 4 McCauley compares the implications ples of classical conditioning were used to great of two opposing frames of reference used by au- effect on September 11, 2001, to create an asso- thorities in response to acts of terrorism: that of a ciation between fear and anxiety and the symbols criminal justice response, such as the response that of everyday life in the United States. The chapter occurred after the World Trade Center bombing of maintains that targeting strong iconic symbols, 1993, versus that of a war against terrorism. He such as the Twin Towers, whose name echoes their contends that framing makes a difference in de- visual appearance, and the use of airlines that are termining whether people are more likely to en- verbally associated with the country’s name in- dorse a risk-averse response (such as one involving creased the impact of the connection. The asso- the criminal justice system) or a more risk-taking ciation of fear was magnified by the timing of the response (such as war). He compares the strengths events and the subsequent media coverage, which and weakness of these two approaches and con- was inevitable. The impact of this fear is designed cludes that, despite the positive aspects of resorting to undermine government authorities, reduce to a war on terrorism, (i.e., increased patriotism, productive capacity, increase healthcare costs, and resource allocation, public perception of action), diminish society’s capacity to accurately detect war is not the best solution for fighting a chronic future threats. problem involving an enemy that is difficult to find Terrorism is interpreted within the paradigm and identify. of a social influence campaign in Chapter 7. Ger- Banks and James (Chapter 16) describe the role wehr and Hubbard argue that even the most hei- that psychology plays in warfare and terrorism. nous of terrorist acts have little military value and They discuss and define the issues of military are actually messages communicated through acts threat, psychological threat, terrorism, and psy- of violence to multiple target audiences. These chological resilience and highlight the relation- message are intended to manipulate the emotions, ships among these concepts. Using examples from motives, reasoning, perceptions, and ultimately the history, they argue that war is usually an action behavior of the audience. They posit that the designed to impose the will of one group on an- success or failure of a terrorist campaign depends other as opposed to the direct annihilation of the on the ability to achieve each of the six stages group. In this context, the group that attains psy- outlined in the Yale model of social influence: chological control over its opponent is the victor. exposure, attention, comprehension, acceptance, Terrorism can be viewed within the same frame- retention, and translation. work. Because most terrorists do not have the The main vehicle for disseminating the message resources to conduct a full-scale war, the psycho- of contemporary terrorism is the media, and in logical threat they pose to society must be large Chapter 6, Shurkin deals with the conflicting roles in order to compensate for the small likelihood the media faces—both as an instrument for the de- of direct military action. livery of the terrorists’ message and as a channel to McDermott and Zimbardo (Chapter 23) cri- be utilized in combating terrorism. Shurkin dis- tique and voice concern about the terror alarm cusses the challenge that the media face in balancing system used by the authorities to communicate the these roles and its influence on public response. level of threat to the public. They argue that a Using the example of the nuclear incident at Three successful alarm system should be moderately Mile Island in 1979, he illustrates the difficulties arousing, incorporate reliable evidence, and be inherent in reporting evolving, novel incidents that communicated by a single credible source that threaten public safety and notes that the authorities provides specific information about the level of Reflections on the Psychology of Terrorism 455 threat and recommendations for action. In situa- difficulty of determining immediately whether an tions of an ongoing threat, misinformation should exposure has occurred due to the lack of in- be corrected, recommendations modified, citizens’ stantaneous physical trauma or symptoms. In responses to alarms reinforced, and efforts for con- addition to the expected psychopathologies in re- tinuing collaborative to ensure security reiterated. sponse to all terrorist attacks, widespread mass psychogenic illness is likely. The authors discuss the risk factors and impacts of occurrence. They Individual Responses to Terrorism also provide examples from recent history and guidelines for preventing and managing such re- As terrorism psychology moves beyond its initial sponses. dependence on research conducted with victims of Brandon and Silke (Chapter 13) discuss the natural disasters, it has become increasingly clear three possible positive outcomes of a terrorist at- that it is important to determine how individuals tack: survival, recovery, and resilience. They de- will respond psychologically to acts of terrorism. fine the processes of dissipation, adaptation, ha- Beutler and colleagues (Chapter 3) maintain that bituation, and sensitization within the context of natural disasters differ from terrorism in key ways people’s responses to the threat of and exposure to that can impact psychological sequelae because of terrorism. They argue that resilience due to adap- causal attributions, heuristics, and risk assessments tation and habituation is the most likely outcome used by individuals. While the majority of peo- for the majority of individuals and suggest that the ple are unlikely to develop symptoms that reach likelihood of this outcome will be increased by pathological levels, some may go on to develop preparing society to expect future terrorist attacks trauma-spectrum disorders such as acute stress and focusing on society’s strengths and capacity for disorder, posttraumatic stress disorder (PTSD), recovery. major depressive disorder, or substance abuse dis- Chapter 25 defines and describes four possible orders. The authors propose a model for under- responses to an act of terrorism: the individual standing the development of psychopathologies in succumbs, survives with impairment, exhibits re- terms of three stages of individual risk assessment. silience, or thrives. Butler, Morland, and Leskin They also discuss intervention approaches such as discuss a recent shift in the literature to examine psychological first aid and critical incident stress the concept of resilience—by far the most common debriefing (CISD). In the absence of more empiri- outcome associated with mass trauma. The chapter cally supported treatments, guidelines are given for discusses the factors that contribute to resilience, recommended interventions and those that are to including individual characteristics, event char- be avoided immediately following a mass-trauma acteristics, peritraumatic responses, and the coping incident. and social support resources that people make use In Chapter 19, Yehuda and colleagues describe of during and after an event. the existing knowledge and some of the unique An important mediating factor in the devel- problems associated with differentiating normal, opment of psychopathology or resilience following adaptive responses to terrorist attacks from serious an act of terror may be the role that spirituality psychopathology. They discuss the literature on the plays in the life of the exposed person. Kelly neurobiological, affective, and behavioral symp- (Chapter 10) addresses the role of faith and in- toms suggestive of PTSD and describe pre- and volvement in a faith-based community in the peritraumatic risk factors identified in the literature. aftermath of terrorism. Despite the irony that re- Sullivan and Bongar (Chapter 11) describe ligion is often used as a justification for acts of how the general public is likely to experience the violence, including terrorism, Kelly identifies three psychological impact of an actual or threatened positive aspects to using religion in the process of use of chemical, biological, radiological, nuclear, coping—an openness to religious flexibility and or high-yield explosion weapons by terrorists. The growth rather than rigid, punitive religious beliefs; psychological consequences of such an attack active engagement in spiritual reflection to find are likely to be magnified not only because of the meaning in the event; and involvement with a novelty of these weapons but also because of the faith-based community to receive social support. 456 Prevention and Psychological Problems in Reaction to Acts of Terrorism

Assessment and Treatment Issues with fun activities that allowed the families to join together to commemorate their loss. The program’s Given that some percentage of the population will outcome measures indicated significant increases in develop psychopathology from exposure to an act hope in both children and adults. of terrorism, several chapters in the book address Chapter 22 deals with issues to be considered issues that pertain to assessment and treatment. in planning and implementing interventions with Ruzek, Maguen, and Litz (Chapter 18) emphasize culturally diverse populations after a terrorist at- the importance of identifying those who are at high tack. Chiriboga discusses barriers to treatment, risk for adverse psychological consequences so that such as people’s perception of ongoing dis- intervention can occur before symptoms become crimination with respect to mental health inter- chronic. A multistep protocol is recommended that ventions provided to minority populations after a includes treating with psychological first aid, fol- terrorist attack. The victims’ culture, background, lowing up with high-risk individuals, providing immigration status, and trauma history influence survivor education and training in coping skills, their recovery from a terrorist attack. The chapter and using evidence-based treatment in an in- describes guidelines produced by the U.S. De- tegrated plan involving group and individual ther- partment of Health and Human Services’ Office of apy. Evidence-based treatments such as cognitive Minority Health for providing culturally and lin- behavioral therapy are described, the challenges of guistically appropriate services (CLAS). The author providing such treatments in the aftermath of a maintains that the guidelines may be relevant for terrorist attack are noted, and suggestions for im- clinicians to consider when planning for and re- provement of existing interventions are made. sponding to acts of terror. Brown et al. (Chapter 20) focus on the unique challenges faced by community-dwelling and institutionalized older adults after a terrorist attack. First Responders to Acts of Terrorism Using existing theoretical frameworks and models, they provide an overview of the risks and pro- In Chapter 14, Clizbe and Hamilton illustrate the tective factors associated with age. While the lit- needs, responses, and challenges faced by govern- erature suggests that older adults develop fewer ment agencies and relief organizations in their ef- psychological problems than younger adults, vul- forts to collaborate in response to the attacks of nerabilities that place older people at increased September 11, 2001. The chapter highlights the risk for adverse psychological consequences in the preexisting relationships among some agencies and aftermath of a disaster are described. The chapter the ways in which these relationships mediated the recommends steps that formal and informal care- efforts of both local and national-level organizations givers can take to assist homebound, disabled, and to work together in a cohesive fashion, despite the institutionalized older people in preparing for, unique challenges the situation posed as a result of responding to, and recovering from disaster. its novelty. The difficulties they faced in identifying Chapter 21 describes a psychoeducational in- and balancing the victims’ needs with the organi- tervention that was designed to address issues faced zations’ resources is addressed, and the authors by children and families who lost a father or hus- describe the utility of the Family Assistance Centers. band in the attacks of September 11, 2001. Un- Pfeiffer (Chapter 15) describes the way in derwood, Kalafat, and Spinazolla describe the which organizational bias influenced communica- planning and implementation of the program, tion between the police and fire departments re- which focused on crisis intervention, community- sponding to the events of September 11, 2001. based education, and personal empowerment to Using theories of social group behaviors, he con- build resilience. A group modality was selected to tends that positive in-group and negative out-group make use of the supportive, sharing experience of biases exist between the separate organizations and the community and to emphasize the treatment of that these leanings contributed to the resulting participants within their environment. The sessions diffusion of individual responsibility during this were designed for different developmental levels crisis situation. To help ensure that this scenario is and focused on resilience rather than pathology. not repeated, he makes recommendations for a Cognitive behavioral techniques were combined unified operating procedure. Reflections on the Psychology of Terrorism 457

In the process of simply performing their du- emergency management agencies in planning and ties, first responders cannot avoid exposure to supporting first responders and the changes im- terrorist attacks when they occur. In Chapter 17, plemented by the Department of Homeland Paton and Violanti discuss a risk management Security in standardizing a National Incident Man- paradigm for first responders that encompasses agement System to ensure better interagency in- both positive and negative outcomes. Since the teraction in dealing with future terrorist situations. specific characteristics of a situation are difficult to Finally, the authors explain the system of em- determine in advance, the authors describe a risk ploying all federal public health, mental health, management system that focuses on both personal and medical services through Emergency Support and organizational elements that mediate the effects Functions 6, 8, and 10. of exposure to acts of terrorism and emphasize the In each chapter of this book, the complex in- importance of primary prevention. teraction between terrorism and psychology has Chapter 26 discusses the risk and protective been revealed to further the state of knowledge in factors that operate among those who are first re- this new and evolving discipline. Yet we must close sponders to acts of terrorism. Gist explains how on a cautionary note about the enormous need for factors such as individual personalities, organiza- sound scientific psychological data to drive our tional structures, event characteristics, and the ef- clinical and other applied endeavors in this speci- fect of the event on career and personal growth alty realm for psychology. It has certainly not es- interact to determine the way a person will re- caped the reader’s attention that the most crucial spond. He maintains that chronic exposure to dilemma for intervention facing psychology, psy- stress can create a cognitive disequilibrium, which chiatry, social work, public health, nursing, family results in either psychological problems or growth. therapy, and other core mental health disciplines Until recently, CISD was routinely used following is the critical lack of solid, replicable scientific evi- traumatic events. The chapter describes CISD and dence to guide our primary, secondary, and tertiary explains that this intervention has become con- care along with scientifically grounded preventive troversial because some research has found that it activities. Common sense would dictate that good may actually hinder the normal recovery process. science be central in the development of this dis- Reissman, Reissman, and Flynn (Chapter 27) cipline. Thus, as the psychology of terror emerges also focus on recent changes in the area of first as a crucial and vital field of study and application responders—organizational changes that occurred for psychological science and clinical care, scien- in response to the events of September 11, 2001. tists and clinicians must constantly be on guard to The chapter reviews the response situation invol- ensure that we recall Hippocrates’ dictum, ‘‘Primum ving the federal health infrastructure following non nocere’’ (first do no harm), as well as Benjamin natural disasters and terrorist acts. The authors Franklin’s observation that an ‘‘investment in explain the role of organizations such as the local knowledge always pays the best interest.’’ This page intentionally left blank Appendix Resources in Psychology of Terrorism Matteo Bertoni Brynne Johannsen

American Biological Safety Association specifically dedicated to combating terrorism. It pro- (ABSA) vides news, reports advocacy activities on counter- 1202 Allanson Road terrorism, and gives visitors an opportunity to sign Mundelein, IL 60060 letters directed to important political figures who deal Telephone: 847–949–1517 with terrorism-related issues. Fax: 847–566–4580 Website: http://www.absa.org/index.shtml American Radio Relay League (ARRL) Email: [email protected] 225 Main Street ABSA promotes continuing advancements in the field Newington, CT 06111–1494 of biosafety and disseminates pertinent information to Telephone: 860–594–0200 biosafety professionals in a timely manner. Biosafety Fax: 860–594–0529 courses are offered at the beginner and advanced levels, Website: http://www.arrl.org/ and an annual conference is held to apprise biosafety Email: [email protected] professionals of the most current information. A pri- The ARRL is an organization composed of amateur mary goal of the association is to reduce the potential radio operators who provide critical communications effects of biologically derived materials and infectious in the event of a disaster or other emergency. Amateur agents. radio personnel are trained to be proficient in emergency communication skills. American Psychological Association (APA), Public Policy Office American Red Cross (ARC) 750 First Street NE National Headquarters Washington, DC 20002–4242 2025 E Street NW Telephone: 202–336–6062 Washington, DC 20006 Fax: 202–336–6063 Telephone: 202–303–4498 Website: http://www.apa.org/ppo/issues/terrorhome Disaster assistance information: 866–438–4636 .html Website: http://www.redcross.org/services/disaster/ Email: [email protected] ARC is the major organization in charge of providing The Public Policy Office of the APA, the largest U.S. disaster relief by focusing on meeting people’s im- association of psychologists, has at its website a section mediate needs. Its website has a Homeland Security

459 460 Appendix

Advisory System that provides information about the cils and 1,599 county/local/tribal Citizen Corps current status of the U.S. government’s terrorist alert Councils that serve 188,767,873 people, or 66% of the level and the implications these have for individuals, total U.S. population. families, neighborhoods, schools, and businesses. The ARC Homeland Security Advisory System also provides Civil Air Patrol publications on topics such as emergency preparedness National Headquarters and disaster planning. 105 South Hansell Street, Building 714 Maxwell AFB, AL 36112–6332 American Safety and Health Institute (ASHI) Website: http://www.cap.gov/ 4148 Louis Avenue The Civil Air Patrol is a congressionally chartered Holiday, FL 34691 nonprofit organization composed of civilian air patrol Telephone: 800–682–5067 personnel and formed as an auxiliary to the U.S. Air Website: http://www.ashinstitute.org/ Force. Services performed by the Civil Air Patrol are Email: [email protected] available to any branch in any agency of the federal ASHI is a nonprofit organization of professional edu- government. Aerospace education, cadet training, and cators who provide safety and health training, such as emergency response services are provided in order to first responder and disaster preparedness training. In- prepare civilian volunteers to lend assistance in case of struction centers include hospitals, fire departments, local or national emergencies. Volunteers may assist colleges, and schools. Current personnel who are with coastal patrol, air/ground observation, search trained through ASHI include the U.S. Border Patrol, and rescue, radio communications and relay, aerial U.S. Coast Guard, U.S. Customs Service, and federal air reconnaissance for homeland security, air-to-ground marshals. photography, radiological monitoring, disaster relief, and damage assessment. Association of Traumatic Stress Specialists (ATSS) Community Emergency Response Team (CERT) Jo Halligan U.S. Fire Administration Telephone: 512–868–3677 16825 S. Seton Ave. Fax: 512–868–3678 Emmetsburg, MD 21727 Website: www.atss-hq.com Telephone: 301–447–1000 Email: [email protected] Website: http://training.fema.gov/emiweb/CERT/ ATSS is a nonprofit organization that offers profes- index.asp sional certification and training to those who provide CERT is a component of the U.S. Department of treatment to people suffering from traumatic stress. Homeland Security (DHS) and the Federal Emergency Training is tailored to victims of crime, natural dis- Management Agency (FEMA). CERT is composed of asters, terrorist attacks, injuries and deaths sustained in people who have completed its train-the-trainer course the line of duty, school and workplace violence, and through its state training office for emergency man- political persecution; veterans; refugees; holocaust agement or FEMA’s Emergency Management Institute survivors; and others who have experienced traumatic (EMI). Team members provide support to first re- stress injuries. sponders and immediate assistance to victims, organize volunteers at disaster sites, and participate in the im- Citizen Corps provement of community safety. Training includes Website: http://www.citizencorps.gov/ disaster preparedness, disaster fire suppression, basic Email: [email protected] disaster medical operations, and light search-and- Citizen Corps is a government organization associated rescue operations. with the USA Freedom Corps, founded by President Bush after the events of September 11 and coordinated Conflict 21 and Center for Terrorism Studies through the Department of Homeland Security. Local, ANG Conflict 21 state, and tribal citizen councils make up the organi- Building 1451 zation. Citizen Corps helps coordinate citizen volun- Maxwell AFB, AL 36112 teer activities to assist in homeland security issues. Website: http://c21.maxwell.af.mil/cts-home.htm Citizens may volunteer to assist in activities related to Part of the National Guard, the center identifies and crime, disaster, and terrorism prevention. Publications develops innovative ideas for research and matches provide information on citizen preparedness. The main them up with issues and problems of the ANG, USAF, website allows one to search for local councils. Cur- and the Department of Defense. Teaching, collabora- rently there are 55 state/territory Citizen Corps Coun- tion, and coordination through the maximum use Appendix 461 of technology are particularly emphasized. The E9-1-1 Institute website has a section dedicated to the psychology Gregory Rohde, Executive Director of terrorism, as well as links to reports and related Email: [email protected] articles. Telephone: 202–292–4603 Jamie Radice, Administrative Assistant Corporation for National and Community Email: [email protected] Service (CNCS) Telephone: 202–292–4603 1201 New York Avenue NW The E9-1-1 Institute was formed to support the con- Washington, DC 20525 gressional E9-1-1 caucus, as well as to promote public Telephone: 202–606–5000 education on emergency communication issues. The TTY: 202–565–2799 congressional E9-1-1 caucus was created to increase Website: http://www.nationalservice.org / awareness among lawmakers, constituents, and com- Email: [email protected] munity members with regard to citizen-activated CNCS is part of the U.S. Freedom Corps, a presidential emergency response systems. The goals of the caucus initiative designed to foster a sense of responsibility in include the following: (1) providing 911 emergency re- its members and a commitment to service to U.S. ci- sponders with a callback number and the location of the tizens. CNCS coordinates programs such as Senior caller; (2) promoting the 911 system as the preferred Corps, AmeriCorps, and Learn and Serve America. public emergency resource; (3) promoting citizen- Volunteer members participate in programs on edu- activated emergency response systems; (4) securing cation, the environment, public safety, and homeland funding for 911 systems, operators, and networks; and security. (5) increasing awareness of emergency response issues among all levels of government. The E9-1-1 Institute Dart Center for Journalism and Trauma provides a forum for discussion of policies related to Department of Communication emergency communications. 102 Communications Building Box 353740 Emergency Medical Services (EMS) Magazine University of Washington Summer Communications, Inc. Seattle, WA 98195–3740 7626 Densmore Ave. Telephone: 800–332–0565 Van Nuys, CA 91406–2042 Email: [email protected] Telephone: 800–224–4367; 818–786–4367 Website: http://www.dartcenter.org/ Fax: 818–786–9246 The Dart Center is a global network of journalists, Website: http://www.emsresponder.com/publication/ educators, and health professionals dedicated to im- pub.jsp?pubId¼1 proving media coverage of trauma, conflict, and tra- Email: [email protected]; [email protected] gedy. The center also addresses the psychological EMS magazine has compiled an online collection of its impact and consequences of such coverage for those articles related to bioterrorism preparedness. Articles working in journalism. provide information on improving the delivery of prehospital emergency medical care and are Department of Homeland Security (DHS) directed toward paramedics, EMTs, administrators, Washington, DC 20528 and instructors working in private and public Operator number: 202–282–8000 services. Comment line: 202–282–8495 Website: http://www.dhs.gov/ Federal Emergency Management DHS is ultimately responsible for ensuring that emer- Agency (FEMA) gency response professionals are prepared for any 500 C Street SW situation. It deals with citizen preparedness, recovery, Washington, DC 20472 and assistance with regard to a terrorist event. The DHS Telephone: 202–566–1600 established the National Response Plan (available at Website: www.fema.gov the website), a comprehensive all-hazard approach to Email: [email protected] enhance the ability of the United States to manage FEMA is a formerly independent agency that was in- domestic incidents. The department offers grants for corporated into the U.S. Department of Homeland studies on terrorism and releases important infor- Security in 2003. It is responsible for preventing, mation on weapon of mass destruction. Its website planning for, responding to, and mitigating the con- contains interesting links to articles and other sequences of disasters. FEMA teaches people how to government-related agencies. respond to disasters, helps equip and prepare state and 462 Appendix local emergency agencies, trains emergency personnel, and local levels on the importance of emergency and coordinates federal response to emergencies. management services. Membership provides access to the top emergency management experts, as Fire Corps well as to a certification program in emergency 1050 17th Street NW, Suite 490 management. Washington, DC 20036 Telephone: 202–887–4809 International Center on Responses to Fax: 202–887–5291 Catastrophes (ICORC) Website: http://www.firecorps.org / 1601 West Taylor Street, 5th floor The Fire Corps is managed through the National Vo- Chicago, IL 60612 lunteer Fire Council, the International Association of Telephone: 312–355–5407 Fire Fighters, and the International Association of Fire Fax: 312–996–7958 Chiefs. It is funded through the U.S. Department of Website: www.ichrsc.org Homeland Security. Its functions include fire safety Email: [email protected] outreach, youth programs, administrative support, the Established in 2002 at the University of Illinois– provision of support to fire and rescue departments, Chicago, ICORC promotes research and scholar- and the promotion of citizen participation. The Fire ships to study and improve services to people who Corps was created to assist fire and rescue departments have been affected by social catastrophes. Its primary that are constrained by limited resources. activities focus on documentaries, ethnographic studies, and intervention. Harvard Program in Refugee Trauma (HPRT) Department of Psychiatry Policy Institute for International Massachusetts General Hospital Counter-Terrorism (ICT) 22 Putnam Avenue 3811 N. Fairfax Drive, Suite 720 Cambridge, MA 02139 Arlington, VA 22203 Telephone: 617–876–7879 Telephone: 703–797–4592 Fax: 617–876–2360 Fax: 703–797–4591 Website: http://www.hprt-cambridge.org /Layer3 Website: http://www.ict.org.il/ .asp?page_id¼36 Email: [email protected] Email: [email protected] The ICT is an Israeli research institute established in The HPRT has focused on empirical research to im- 1996 at the academic Interdisciplinary Center in Her- prove the treatment of psychopathology in refugee zliya (IDC), which is committed to developing in- populations and victims/survivors of disasters and novative public policy solutions to international terrorism. The site describes projects and research terrorism. It also has an office in Washington, DC. The conducted by the HRPT and provides clinical guide- ICT takes an unconventional approach to policy re- lines, useful screening instruments, educational and search by combining academic knowledge and theory training curricula for different constituency groups, with practical field experience. News and articles, some policy descriptions, and humanistic survivor narrative of them related to the psychology of terrorism, are material. available at its website.

International Association of Emergency International Society for Traumatic Managers (IAEM) Stress Studies (ISTSS) Beth Armstrong, Executive Director 60 Revere Drive, Suite 500 201 Park Washington Court Northbrook, IL 60062 Falls Church, VA 22046–4527 Telephone: 847–480–9028 Telephone: 703–538–1795 Fax: 847–480–9282 Fax: 703–241–5603 Website: http://www.istss.org/ Website: http://www.iaem.com/index.htm Email: [email protected] Email: [email protected] The ISTSS, founded in 1985, is an organization that The IAEM is a nonprofit educational organization enables professionals to share information about the that seeks to save lives and protect property dur- effects of trauma. It is involved in various activities, ing emergencies and disasters. The association ad- including publishing scientific research, consumer- dresses issues such as terrorism preparedness, emer- oriented pamphlets, and treatment guidelines; devel- gency preparation, and disaster assistance delivery oping worldwide networking and support systems; and educates decision makers at the federal, state, and promoting excellence in the field through training Appendix 463 and annual awards. The terrorism and trauma sec- Mercy Medical Airlift (MMA) tion of the website contains interesting and useful in- Box 1940 formation and links. Manassas, VA 20108–0804 Telephone: 800–296–1191, ext. 2 International Trauma Studies Program 703–296–1191, ext. 23 (ITSP) Fax: 703–257–1642 155 Avenue of the Americas, 4th Floor Patient Assistance Center: New York, NY 10013 4620 Haygood Road, Suite 1 Telephone: 212–691–6499 Virginia Beach, VA 23455 Fax: 212–807–1809 Telephone: 888–675–1405 Website: http://itspnyc.org 757–318–9175 Email: [email protected] Fax: 757–318–9107 The ITSP uses a multidisciplinary approach to the Website:http://www.mercymedical.org/ study, treatment, and prevention of trauma-related Email: [email protected] suffering. It was founded in 1998 as a collaboration of The MMA is a nonprofit organization composed of various departments of New York University (NYU), volunteer pilots and office assistants who provide including the Department of Psychiatry, the Depart- air transportation to those in need. Volunteer pilots ment of Applied Psychology, and the Center for War, work together with the Homeland Security Air Trans- Peace, and the News Media. portation System (HSATS) in times of emergency to transport priority cargo and emergency management Johns Hopkins Center for Public Health personnel. Preparedness (CPHP) 615 N. Wolfe Street, Room WB030 National Center for Injury Prevention Baltimore, MD 21205 and Control/Bioterrorism Preparedness Telephone: 443–287–6735 and Response Planning Fax: 443–287–6736 Mailstop K65 http://www.jhsph.edu/CPHP/index.html 4770 Buford Highway NE Email: [email protected] Atlanta, GA 30341–3724 As part of the School of Public Health of Johns Hopkins Telephone: 770–488–1506 University, the CPHP is charged with training public Clinician information line: 877–554–4625 health providers and improving their ability to re- Fax: 770–488–1667 spond to terrorist-related incidents. It currently pro- Website: http://www.bt.cdc.gov/ vides instruction and resources to public health Email: [email protected] professionals in Maryland, the District of Columbia, Mass trauma and bioterrorism preparedness and re- and Delaware. sponse are two of the emergency areas covered by the Medical Reserve Corps (MRC) National Center for Disease Control and Prevention. It Office of the Surgeon General provides clinicians with real-time information and U.S. Department of Health and Human Services training opportunities to help prepare for and respond 5600 Fishers Lane, Room 18C-14 to terrorism and other emergency events. Rockville, MD 20857 Telephone: 301–443–4951 National Center for Post-Traumatic Fax: 301–480–1163 Stress Disorder (PTSD) Website: http://www.medicalreservecorps.gov/ Executive Division Email: [email protected] VA Medical Center 116D The MRC is composed of medical, public health, 215 North Main St. and other volunteers who work in coordination with White River Junction, VT 05009 existing local emergency response programs and com- Telephone: 802–296–6300 munity public health initiatives. Volunteers address Fax: 802–296–5135 public health needs and help their community during Website: http://www.ncptsd.va.gov large-scale emergencies. Activities include outreach Email: [email protected] and prevention, provision of public health services Created in 1989 within the Department of Veterans during a crisis, assistance to emergency response teams, Affairs, the center addresses the needs of veterans with provision of health care to those with less serious military-related posttraumatic stress disorder. Each of injuries, immunization programs, blood drives, case its six divisions (behavioral science, women’s health management, and care planning. science, clinical neuroscience, program evaluation, 464 Appendix clinic laboratory and evaluation, and Pacific Islander) anxiety caused by disasters and terrorism. Of particular deals with a different aspect of PTSD. The branches are interest is the Disaster Technical Assistance Center located in different cities, but all are part of the VA (DTAC), which assists the states and territories with Health Care System. The webpage (http://www.ncptsd disaster response planning and supports collaboration .va.gov/about/divisions/index.html) provides a com- between mental health and substance abuse autho- plete description of each division’s specialty and re- rities, federal agencies, and nongovernmental organi- levant contact information. The website also offers zations. The website has a section in Spanish. information on how to deal with the aftereffects of terrorism. National Voluntary Organizations Active in Disaster (NVOAD) National Center on the Psychology Ande Miller, Executive Director of Terrorism (NCPT) Box 151973 795 Willow Road, Building 348 Alexandria, VA 22315 VA Palo Alto Health Care System Telephone: 703–339–5596 Menlo Park, CA 94025 Fax: 703–339–3316 Telephone/Fax: 650–618–0448 Website: http://www.nvoad.org/ Website: http://www.terrorismpsychology.org/ Email: [email protected] Email: [email protected] The NVOAD is a league of the major national voluntary The NCPT is dedicated to research, education and organizations that concentrate on disaster-related ac- training, public policy, and community service to im- tivities. It provides year-round communication and prove the ability to respond effectively to terrorism. A coordination among these various agencies so that cornerstone initiative has been the establishment of a disaster response is provided efficiently and performed volunteer rapid-response medical reserve corps in Palo without duplication. Matters addressed by the various Alto, which has become a model for other communities organizations include disaster prevention, response, in the United States. recovery and mitigation, facilitation of volunteer response, and enhancement of response capabilities. National Memorial Institute for the Prevention Through these functions, numerous large agencies of Terrorism (MIPT) are able to work together in a collaborative and Box 889 coordinated manner to ensure smooth disaster 621 North Robinson, 4th Floor response. Oklahoma City, OK 73101 Telephone: 405–232–5121 Neighborhood Watch Program (NWP) Fax: 405–232–5132 National Sheriff’s Association Website: http://www.mipt.org/ 1450 Duke Street The MIPT was established to help survivors and family Alexandria, VA 22314–3490 members of the victims of the 1995 Murrah Federal Telephone: 703–836–7827 Building bombing. The institute has several ongoing Fax: 703–683–6541 research projects that deal mainly with first responders. Website: http://www.usaonwatch.org/ Even if psychological matters are addressed only tan- Email: [email protected] gentially, the website remains a good resource of in- The NWP is administrated by the National Sheriffs’ formation. Association and is funded by the U.S. Department of Justice. In addition to crime prevention, disaster and National Mental Health Information Center emergency preparedness, and emergency response and Center for Mental Health Services training, the NWP provides terrorism alertness training Box 42557 to citizen volunteers. Local officials, law enforcement, Washington, DC 20015 and citizens work together to ensure the safety and Telephone: 800–789–2647 protection of their communities. Fax: 240–747–5470 Website: http://www.mentalhealth.samhsa.gov/ Operation HOPE, Inc. (OHI) Through its various programs, this center, which is part 707 Wilshire Blvd., Suite 3030 of the Substance Abuse and Mental Health Adminis- Los Angeles, CA 90017 tration of the U.S. Department of Health and Human Telephone: 213–891–2900 Services, provides guidelines and tips to help adults, Fax: 213–489–7511 adolescents, children, families, teachers, and profes- Website: http://www.operationhope.org/ sionals to cope with traumatic events and manage the Email: [email protected] Appendix 465

OHI is a nonprofit organization that was formed in the alert levels, as well as links to other disaster resources aftermath of September 11, 2001. It provides economic in Canada. education to inner-city communities. HOPE Coalition America (HCA) is an initiative put forth by OHI to ReadyAmerica provide economic counseling to assist businesses, in- Department of Homeland Security dividuals, and families to prepare for and recover from http://www.ready.gov/index.html disasters and emergencies. The ReadyAmerica website provides step-by-step instructions, as well as definitions and descriptions of the Provincial Emergency Program (PEP) different types of homeland security threats. Citizens are of British Columbia instructed on how to prepare for biological, chemical, Terrorism Consequence Management and Prepared- nuclear, radiological, explosive, and natural disasters. ness Headquarters Save a Life Foundation (SALF) 455 Boleskine Road O’Hare Aerospace Center Victoria, BC V8Z 1E7 9950 W. Lawrence Ave., Suite 300 Canada Schiller Park, IL 60176–1216 Telephone: 250–952–4913 Telephone: 847–928–9683 Mailing Address: Fax: 847–928–9684 Box 9201 Stn. Prov. Govt. Website: http://www.salf.org/index.html Victoria, BC V8W 9J1 Email: [email protected] Canada Save a Life Foundation is a nonprofit organization that Website: http://www.pep.bc.ca/hazard_preparedness/ trains volunteers in the use of life-saving techniques terrorism_consequences.html such as cardiopulmonary resuscitation (CPR), the The PEP of British Columbia is a branch of the Heimlich maneuver, and automated external defi- Ministry of Public Safety and Solicitor General of brillators (AEDs) in disaster and emergency situations. the Government of British Columbia. Its website provides information on the nature of terrorism, Website for Weapons of Mass Destruction publications that describe different types of terrorism First Responders (WMDFR) and disaster situations, emergency preparedness tips, Website: www.WMDFR.com instructions on creating a personal emergency plan, Email: [email protected] directions on steps to take in an emergency situation, WMDFR.com provides information, exercises, net- and information on what to do following an emergency working capabilities, planning information, and re- situation, including acts of terrorism. The agency pro- search aimed at assisting WMDFR in planning for and vides brochures containing specific information about implementing an efficient response in the case of a the different types of potential terrorist activities, in- biological, nuclear, chemical, radiological, or explosive cluding radiological, chemical, or biological attacks. terrorist attack, as well as decontamination procedures The website also gives the current status of terrorism should an attack occur. This page intentionally left blank Glossary

Acculturate: to adopt the social and behavioral tims; the League of the Red Cross and Red patterns of the surrounding culture Crescent Societies (LRCS), an international fed- Acute stress disorder: a variation of posttrau- eration of the national societies that is active in matic stress disorder that includes symptoms of nonconflict disasters and natural calamities; and anxiety and significant impairment in at least one the National Red Cross or Red Crescent Society, a essential area of functioning worldwide relief organization. Adaptation: a general term for any process Amygdala: an almond-shaped neural structure whereby behavior or subjective experience alters involved in producing and responding to nonverbal to fit in with a changed environment or circum- signs of anger, avoidance, defensiveness, and fear stances or in response to social pressure Analgesic: any drug or substance that induces Agency: a business or service authorized to act the absence of a pain sensation for others Anterior cingulate: the anterior cingulated cor- Alcohol abuse: excessive use of alcohol and al- tex plays a role in a wide variety of autonomic coholic drinks functions, such as regulating heart rate and blood American Red Cross: (also known as Red Cross pressure. It is vital to cognitive functions such as or the International Red Cross) a comprehensive reward anticipation, decision making, empathy, designation used for all or one of the components and emotion. of the International Red Cross and Red Crescent Anthrax: a serious disease caused by Bacillus Movement, a worldwide organization active in anthracis, a bacterium that forms spores. There humanitarian work. This organization has three are three types of anthrax (skin, lungs, digestive) components: the International Committee of the that can be used as a weapon. This happened Red Cross (ICRC), which acts primarily as a in the United States in 2001, when anthrax was neutral intermediary during armed conflict and deliberately spread through the postal system includes the Guardian of the Geneva Conven- by sending letters with powder containing tions, an advocate for the protection of war vic- anthrax.

467 468 Glossary

Apollonian: in Nietzschean philosophy, of or Cause: a basis for an action or response embodying the power of critical reason as op- CBR device: a chemical, biological, or radi- posed to the creative-intuitive ological instrument or apparatus used for a spe- Appraisal: a classification of someone or some- cific act of violence or terrorism thing with respect to the worth of the person or thing CBRN attack: a chemical, biological, radiological, or nuclear overt, aggressive action Assimilate: to absorb (immigrants or a culturally distinct group) into the prevailing culture Cognitive behavioral theory: an approach to psychotherapy that involves the extension of the Asymmetric war: a state of open, armed, often modification and relearning procedures to cog- prolonged conflict carried on between nations, nitive processes such as imagery, fantasy, states, or parties utilizing asymmetric approaches thought, and self-image that generally seek a major psychological impact, such as shock or confusion, which affects an Cognitive restructuring: a therapy whose em- opponent’s initiative, freedom of action, or will phasis is on learning to recognize and then change or restructure thought processes, re- Atherosclerosis: a disease affecting arterial blood framing thoughts in less stressful terms vessels and veins that have been surgically moved to function as arteries Cohesion: a tendency to stick together or be Atropine reactions: allergic reactions (e.g., dry united either physically or logically. The term mouth, tachycardia, blurred vision, palpitations, may be used in reference to social groups, difficulty swallowing, and death due to re- educational concepts, items in learning tasks, spiratory failure) following the injection of atro- and so on. pine, a premedication for anesthesia that Compassion fatigue: a state of tension and pre- decreases bronchial and salivary secretions occupation with individual or cumulative trauma Autonomic reactivity: any behavior executed as manifested in one or more ways including without one’s conscious awareness or control reexperiencing a traumatic event, avoidance or numbing of reminders of the event, and persis- Aversive conditioning: a learning process de- tent arousal. This often occurs among doctors, signed to modify undesirable or antisocial habits nurses, EMS personnel, police, firefighters, victim or addictions by creating a strong association advocates, and many others. with a disagreeable or painful stimulus Comrade: one who shares another person’s in- Barriers to care/treatment: obstacles that a per- terests or activities; a friend or companion son may encounter when seeking care (e.g., cultural differences, language difficulties, rural Constituency: the body of citizens who elect a areas without specialists, lack of insurance) representative for their area Biological pathogen: an infectious agent that can Coordination: a systematic exchange of in- create disease in its host formation among principal participants in order Botulinum bacillus: bacteria that cause three to carry out a unified response in the event of an types of botulism or a severe, sometimes fatal, emergency food poisoning brought on by ingestion of food Coping skills training: conscious, rational stra- containing botulin and characterized by nausea, tegies designed to deal with the anxieties of life vomiting, disturbed vision, muscular weakness, and fatigue Critical incident stress debriefing (CISD): a term that refers to the ‘‘Mitchell model,’’ a seven- Casus belli: an event used to justify starting phase, structured group discussion, usually held a war 1 to 10 days after a crisis. It is designed to miti- Catecholamine: a chemical compound derived gate acute symptoms, assess the need for follow- from the amino acid tyrosine; acts as a hormone up, and, if possible, provide a sense of postcrisis or neurotransmitter psychological closure. Glossary 469

Critical incident stress management (CISM): a Extinction: reduction of or loss in the strength comprehensive, integrative, multicomponent cri- or rate of a conditioned response when an un- sis intervention system conditioned stimulus or reinforcement is with- Cross-cultural issues: matters that may arise as a held result of evaluating cultures according to different Fatwa: in Islam, a legal pronouncement on a cultural dimensions; comparison of various specific matter issued by a religious law specialist practices in different cultural settings GABA: short for gamma-aminobutyric acid, the Cult: a religion or religious sect generally con- most important and abundant inhibitory neuro- sidered to be extremist or false. Its followers often transmitter in the brain. GABA helps induce relive in an unconventional manner under the laxation and sleep and balances excitation in the guidance of an authoritarian, charismatic leader. brain with inhibition. Depersonalization: a sense of disconnection General systems theory: an interdisciplinary from one’s body and feelings (e.g., observing field that studies relationships of systems as a oneself act but feeling as if one is not actually whole taking part) (see derealization) Glucocorticoids/cortisol: a class of steroid hor- Derealization: the feeling that things in one’s mones characterized by an ability to bind with surroundings are strange, unreal, or somehow the corticol receptor and supportive of a variety altered of important cardiovascular, metabolic, im- Dionysian: in Nietzschean philosophy, of or munologic, and homeostatic functions displaying creative-intuitive power as opposed to Glutamatergic functioning: the support of a critical-rational power variety of important cardiovascular, metabolic, Disaster categories: accidents such as plane immunologic, and homeostatic functions crashes, criminal acts such as terrorist bombings, Grief: deep mental anguish, such as that arising and natural catastrophes such as earthquakes from bereavement Dissipation: breaking up and scattering; disper- Group dynamics: the driving forces that result sion from the interaction of individual behaviors. Distributive justice: perceptions of the fairness These may differ depending on individuals’ cur- of a particular outcome rent or prospective connections to a sociological Education: knowledge or skill obtained or de- group. Urges to belong to or identify with a veloped by a learning process particular group may make for distinctly different attitudes (recognized or unrecognized), and a Epidemiology: the study of the distribution and group’s influence may quickly increase, influen- determinants of disease in human populations cing or overwhelming individual proclivities and and the application of this study to the control of actions. health problems Eschatological: regarding the ultimate destiny of Group intervention: an orchestrated attempt by humankind and the world family and friends to persuade a family member to seek help for an addiction or other similar Ethnicity: a quality or affiliation resulting from problem racial or cultural ties Habituation: the process of becoming ac- Etiology: the branch of medicine that deals with customed to something the causes or origins of disease Hegemony: the predominant influence (as of a Evidence-based treatment: specific clinical state, region, or group) over others practices that help bridge the gaps between what researchers find to be effective treatment and Help seeking: acquiring support or assistance what is implemented at the practice level Heuristics: a trial-and-error procedure or rule of Exposure: condition of being subjected to an thumb for making a decision, forming a judg- action or an influence ment, or solving a problem 470 Glossary

Hippocampus: a part of the brain’s limbic sys- Learned helplessness: a human condition in tem; plays a part in memory and navigation which apathy and submission prevail, causing an HPA (hypothalamic-pituitary-adrenal) axis: the individual to rely fully on others for help. People classical neuroendocrine system that responds to in a state of learned helplessness view problems stress and whose final product, corticosteroids, as personal (they view themselves as the pro- targets components of the limbic system, parti- blem), pervasive (they see the problem as affect- cularly the hippocampus ing all aspects of life), or permanent (they see the problem as unchangeable). Hypervigilance: watchfulness that is over and above what is normal or reasonable Lessons learned: knowledge derived from the implementation and evaluation of a program that Iatrogenic: of or pertaining to a disorder or can be used to identify strengths and weaknesses symptom inadvertently caused by a physician’s of program design and implementation treatment or management of a patient Lexicon: an alphabetic listing of the words of a Identity: one’s sense of self language; vocabulary Immunosuppression: the medical suppression Mass psychogenic illness (MPI): a feeling of of the immune system. This is usually done to sickness within a group of people (such as a class prevent the body from rejecting a transplanted in a school or workers in an office) who start organ. feeling unwell at the same time even though no In vivo exposure: subjection to a harmful action physical or environmental reason exists for ill or condition as a result of biological processes or health experiments that occur in living organisms Mass violence: an intentional violent criminal Individual intervention: a conscious attempt by act that results in physical, emotional, or psy- a person to get help for an addiction or similar chological injury to a large number of people problem Myocardial infarction: sudden interruption of or Indoctrination: instruction that seeks to per- insufficiency in the supply of blood to the heart, suade someone to accept a body of principles typically resulting from obstruction of a coronary presented for unconditional acceptance or un- artery and often characterized by severe chest critical belief pain (also known as a heart attack) Inhibitory mechanisms: characteristics of habi- National Voluntary Organizations Active in tual adaptive responses of neurons that restrain Disaster: an organization that coordinates the other responses from firing relief efforts of many voluntary organizations Insurgency: an instance of rebellion engaged in disaster response Interactional justice: the nondiscriminatory im- Nietzschean: a philosophy developed by Ger- plementation, by organizational agents, of pro- man philosopher Friedrich Wilhelm Nietzsche cedures for treating people respectfully and that argues that the ideal human would be able to explaining decisions adequately channel passions creatively instead of suppres- sing them Interobjectivity: mutual judgment based on ob- servable phenomena and uninfluenced by emo- Not-for-profit: an incorporated organization that tions or personal prejudices exists for educational or charitable reasons and whose shareholders and trustees do not benefit Intifada: an Arabic term for ‘‘uprising’’ that came financially into common usage in English as the popularized name for two Palestinian campaigns, the First Ongoing threat: a constant danger Intifada (1987) and the Al-Aqsa Intifada (2000) Opiate receptors: a specialized neural cell that is Isomorphic: having similar appearance but ge- responsive to or activated by a group of chemical netically different substances that contain opium and tends to have Justice as a basic need: a powerful human mo- a narcotic effect tive that may be a necessity for human survival Pathogenic: capable of causing disease Glossary 471

Peritraumatic: characteristic of serious injury or disorder or an adverse outcome. Examples are shock to the body around the time of an act of constitutional factors such as attractiveness or an violence or an accident engaging personality and bonding to family, Peritraumatic dissociation: immediate dissocia- school, and some other social institution. tion at the time of a traumatic event; occasionally Psychoeducation: education in a subject area develops into posttraumatic stress disorder that fosters treatment and rehabilitation. It in- Pneumonic plague: a frequently fatal form of volves teaching people about their problem, how bubonic plague in which the lungs are infected to treat it, and how to recognize signs of relapse and the disease is transmissible by coughing so that they can get necessary treatment before the difficulty worsens or reoccurs. Polemics: the branch of Christian theology devoted to the refutation of errors Psychogenic: originating in the mind or in mental or emotional processes; having a psy- Post hoc: after the fact chological rather than a physiological origin Posttraumatic: following or resulting from injury or trauma Psychological adaptive capacity: the emotional and mental ability to function, adjust, and cope Posttraumatic growth: improvement and devel- with issues that may be distressing opment of people after experiencing traumatic circumstances (e.g., more intimate, emotionally Psychological attenuation: the mental and open relationships with others; the recognition of emotional ability to reduce the force, effect, or new possibilities for one’s life path; a more pro- value of something found appreciation for what life has to offer; an Psychological debriefing: a single-session, enhanced sense of personal strength; religious or semistructured crisis intervention designed to spiritual development) reduce and prevent unwanted psychological Posttraumatic stress disorder (PTSD): a psy- aftereffects of traumatic events by promoting chiatric disorder that can occur following the emotional processing through the ventilation and direct experiencing or witnessing of life-threa- normalization of reactions and preparation for tening events such as military combat, natural possible future experiences disasters, terrorist incidents, serious accidents, or Psychological first aid: pragmatically oriented violent personal assaults such as rape. People interventions with survivors or emergency re- who suffer from PTSD often relive the experience sponders targeting acute stress reactions and im- through nightmares and flashbacks, have diffi- mediate needs. The goals of psychological first aid culty sleeping, and feel detached or estranged. include the establishment of safety (objective and These symptoms can be severe enough and last subjective), stress-related symptom reduction, long enough to significantly impair the person’s restoration of rest and sleep, linkage to critical daily life. resources, and connection to social support Premorbid: the state of mind prior to the onset Psychological hardiness: resistance to stress, of physical disease or emotional illness anxiety, and depression Prevalence rates: the number of cases of a dis- Psychological trauma: a traumatic event that ease or disorder within a specified population at a overwhelms an individual’s perceived ability to point in time cope and leaves that person fearing death, anni- Procedural justice: a process by which fair and hilation, mutilation, or psychosis. The individual equitable decisions are made feels emotionally, cognitively, and physically Prophylaxis: prevention of or protective treat- overcome. The triggering event commonly in- ment for disease cludes abuse of power, betrayal of trust, entrap- ment, helplessness, pain, confusion, and/or loss. Protective factors: characteristics, variables, and/ or conditions present in individuals or groups Psychometrics or psychometry: the branch of that enhance resilience, increase resistance to psychology that deals with the design, adminis- risk, and fortify against the development of a tration, and interpretation of quantitative tests for 472 Glossary the measurement of psychological variables such Relational Frame Theory: an approach as intelligence, aptitude, and personality traits designed to provide a pragmatic analysis of complex human language and cognitions that Psychopathology: (a) the study of mental illness or mental distress; (b) the manifestation of be- can be traced back to a single psychological haviors and experiences that may be indicative of process mental illness or psychological impairment; (c) Relief organization: an association that exists the name of an academic journal that specializes solely to give aid to a cause (e.g., disaster areas, in the understanding and classification of mental homelessness, hunger) illness in clinical psychiatry Resilience: the ability to cope with stress and Psychosomatic: relating to certain organic dis- catastrophe orders such as hypertension that are believed to Retributive violence: physical force exerted for be caused by psychological factors such as stress the purpose of violating, damaging, or abusing Qualitative: relating to or involving comparisons and given as repayment; an act of retaliation based on qualities Risk factor: a variable associated with an in- Quantitative: relating to or involving the mea- creased risk of disease, infection, or other illness surement of quantity or amount Role stereotypy: characteristic and expected so- Race: a population of humans distinguished cial behavior illustrated by a high degree of ste- from other populations. The most widely used reotyped behavior and movement racial categories are based on visible traits Schema: a mental set or representation (especially skin color and facial features) Screening: examination of a great number of Randomized control trials (RCTs): a research something (e.g., people) for the purpose of protocol for testing the effectiveness of a drug or identifying those with a particular problem or other type of treatment, in which research parti- feature cipants are assigned randomly to either treatment Secondary prevention: action aimed at mitigat- and control or placebo ing the health consequences of disasters (e.g., Reaction phases: stages in a particular pattern or the use of carbon monoxide detectors when course of response following an initiating event operating gasoline-powered generators after the Region-beta paradox: a general phenomenon in loss of electric power, employing appropriate which intense hedonic states trigger psychologi- occupant behavior in multistory structures cal processes that are designed to attenuate them; during earthquakes, and building ‘‘safe rooms’’ thus, intense states may abate more quickly than in dwellings located in tornado-prone areas); mild states. Because people are unaware of these may be instituted when disasters are psychological processes, they may mistakenly imminent expect intense states to last longer than mild Sensitization: the process of becoming highly ones. In Study 1, participants predicted that the sensitive, usually with the implication that one is more they initially disliked a transgressor, the not uniformly sensitive to all stimuli but only to longer their dislike would last. In Study 2, par- specific events or situations ticipants predicted that their dislike for a trans- Sequela (plural sequelae): a secondary con- gressor who hurt them a lot would last longer sequence or result; aftereffect than their dislike for a transgressor who hurt them a little, but precisely the opposite was the Serotonergic receptor: a specialized neural cell case. In Study 3, participants predicted that their that is responsive to or activated by serotonin and dislike for a transgressor who hurt them a that reliably undergoes a particular pattern of lot would last longer than their dislike for a change transgressor who hurt someone else a lot, but Sicarii: dagger bearers; members of a band of precisely the opposite was the case. These errors violent nationalists prepared to carry out assas- of prediction are instances of the region-beta sination and murder in a campaign to set Pales- paradox. tine free Glossary 473

Skin conductance test: an assessment that mea- principles of the systematic identification and sures changes in the skin’s conductivity of a weak solution of problems electrical current Terrorism: the unlawful use of force and vio- Slippery slope: an argument for the likelihood of lence against people or property to intimidate or one event, given another. Invoking the ‘‘slippery coerce some entity (e.g., a government or popu- slope’’ means arguing that one action will initiate lation) in the furtherance of political or social a chain of events that will lead to a (generally objectives undesirable) event later. Theodicy: the branch of theology that defends Social support: a network of family, friends, God’s goodness and justice in the face of the colleagues, and other acquaintances that one can existence of evil turn to, whether in times of crisis or simply for Thriving: making steady progress; prospering; fun and entertainment flourishing Somatic cues: bodily sensations a person experiences in response to a stimulus Thyombolytic therapy: use of a drug that breaks up or dissolves blood clots, which are the main Steeling effect: the dialectic between over- and cause of both heart attacks and stroke underprotection in development Toxic exposure: subjection to chemicals or Stepped care: a process in which people are as- substances that are capable of causing injury or signed to different levels of treatment based on death personal characteristics Trajectory of recovery: the course of returning Stress inoculation: a term for the development to a normal state of anxiety-reducing techniques that can be accessed whenever needed. The goal of stress in- Trauma: an emotional or psychological injury, oculation is to develop a procedure that will usually resulting from an extremely stressful and allow one to remain calm. life-threatening situation Subsyndromal: characterized by or exhibiting Traumatic grief: distress and intense sorrow in symptoms that are not severe enough for diag- response to the loss (caused by some direct ex- nosis as a clinically recognized syndrome ternal force) of someone or something to which Syllogism: deductive reasoning in which a con- one is strongly attached clusion is derived from two premises Triage: a system used by medical or emergency Symmetric war: a state of open, armed, often personnel to ration limited medical resources prolonged conflict carried on between nations, when the number of injured needing care states, or parties utilizing similar tactics that then exceeds the resources available; permits the imply predictability treatment of the greatest possible number of patients Symptom threshold: the lowest intensity at which a stimulus evokes a response; an initial Vector control: any method to limit or eradicate subjective indication of a disorder reported by an the mechanisms that transmit genes or diseases to afflicted person one’s offspring Tachycardia: abnormally rapid beating of the Vicarious traumatization: see compassion heart, defined as a resting heart rate of more than fatigue 100 beats per minute Worried well: a term applied to people who Technology: aspects of a culture involving the exhibit psychogenic symptoms of a disease when application of the findings, procedures, and they are at low or no risk This page intentionally left blank Index

Boldface numbers indicate tables and ﬁgures.

Abouhalima, Mahmud, 58 disasters and the Red Cross, 200 Abu Ghraib, 62, 362 fear and security, 118, 130n2 acculturation, 343 fear of ﬂying after 9/11, 23–25, 228 acute stress disorder (ASD). See ASD and hijackings, 181 adaptation, 176, 179–182, 455 risk assessment of, 120 ‘‘Adventures on Maple Street,’’ 320 security costs, 22 AEI-Brookings Joint Center, 120 Ajaj, Ahmad, 58 Afghanistan Al Jazeera television, 5 al Qaeda training camps, 60 al Qaeda cruise missile attacks, 23, 58 age of attackers, 105 insurgency, 61–62 Al Jazeera television interview, 5 refugees on the Tampa, 374 attacks on and public relations, 23 Russian invasion of, 220, 361 background of adherents, 70 war and religion, 390 CBRNE attacks, 153 African Americans collateral damage as recruitment tool, 62 census statistics, 339–340 declaration of war against U.S., 58 identity shift after 9/11, 27–28 described, 18 medical insurance, 341 long-term strategies, 4–5 and PTSD, 179, 251 numbers of adherents, 60, 64 religion as community resource, 342, 352 psychological strategy of 9/11, 167 satisfaction studies, 71 and religious terrorism, 96 Agency for Toxic Substances and Disease Registry and U.S. terror alerts, 361 (ATSDR), 445 Alar-poisoning panic, 37, 158 aggression, 22, 73, 108 alcohol/substance abuse Aguinaldo, Emilio, 97 after 9/11, 140, 362 air travel as coping mechanism, 409 airlines and future attacks, 172 evidence-based treatment for, 252–253

475 476 Index alcohol/substance abuse (continued) dissociative reactions and, 277 help for after 9/11, 201 and hyperarousal, 36 intoxication and PTSD, 280 interventions for, 247 and National Response Plan, 444 and psychological first aid, 48 rates of and terrorism, 169–170 and theta EEG, 280 Substance Abuse Mental Health Services Adminis- treatment for, 259 tration (SAMHSA), 366, 446 Asian Americans, 344 and trauma, 43–44 Asian disease problem, 57 Alexander II, 94 Assassins, 101 Algeria, 95, 139 assisted-living facilities, 300, 301 altruistic suicide, 107–108 asymmetric war. See warfare Alzheimer’s disease, 298, 300, 301, 305 AT&T Language Line, 349 ambient noise, 98n6 Atran, Scott, 4 American Community Survey, 339–340 atropine, 36, 160, 262 American Group Psychotherapy Association, 327 Atta, Mohammed, 16–19 American Media tabloid, 84 Aum Shinriky[o] American Psychological Association death toll intent, 5 and disasters, 200, 383 failure of, 155–156 Division 17 guidelines, 341 and mass psychogenic illness, 10, 160, 255 Division 36, Psychology of Religion, 393n20 and religious terrorism, 96 Homeland Security Department conference report, 7 Australia, 5, 374 Institute of Medicine´s Committee on Responding to Axelrod, Robert, 4 the Psychological Consequences of Terrorism, 351 Ayyad, Nidal, 58 minority population and resilience, 347 older adults and intervention, 304 Baader-Meinhof Gang, 14–15, 17, 19, 102 recovery materials after 9/11, 203 Bakunin, Mikhail, 94 resources for first responders, 225 Baldwin, David, 392n14 Task Force on Resilience in Response to Bali nightclub bombing, 235, 374 Terrorism, 346–347 Bana Aceh tsunami, 384 American Red Cross. See Red Cross Bazell, Robert, 84 amygdala, 280 BBC (British Broadcasting Company), 85n1 anger, 15–16, 18, 118–119, 359, 365 Becker, Ernest, 383 Annan, Kofi, 377 Begin, Menachem, 14, 82, 95 Antarctic plane crash, 380, 385–386, 393n24 Behavior Assessment System for Children (BASC), 331 anthrax attacks Behavioral Risk Factor Surveillance System, 182 education before, 262 Beirut Iraqi embassy bombing, 102 and hypervigilance, 274 Beirut Marine base bombing, 14 media coverage of, 84–85 bin Laden, Osama. See also al Qaeda psychological consequences, 157, 221 background of, 70 reports of, 386, 394n30 blame for 9/11, 181 Washington conference discussion, 378 declaration of war against U.S., 91 anticipatory reconstrual, 186 as political activist, 18 anti-Semitism, 339 psychology of attacks, 220 anti-war protestors, 17 on PTSD, 175 anxiety, 43, 183, 258–259, 276, 282. See also fear and WMDs, 155 apocalypse, 5, 20–21, 95–96, 155 Birds of Freedom, 105 Arab Americans, 260, 346, 348 Blair, Tony, 5 Archer, Michelle, 202 body recovery. See also first responders Arendt, Hannah, 368 Arctic plane crash, 385–386, 393n24 Aristotle, 16 conference topic, 378 Armstrong, Lance, 140 emergency workers and after 9/11, 385 Asahara, Shoko. See Aum Shinriky[o] National Foundation for Mortuary Care, 445 ASD (acute distress disorder). See also PTSD (post- and National Response Plan, 444 traumatic stress disorder) numbers identified after 9/11, 393n21 diagnostic criteria, 42–43 stress and, 233, 256 Index 477

BOLO (be on the look out), 359 chemical, biological, radiological attacks. See Bombing to Win,62 CBR attacks Booth, John Wilkes, 108 chemical, biological, radiological, nuclear, high-yield Bosnian war, 183, 293, 334, 341, 390. See also warfare explosives. See CBRNE attacks Brazilian radiation accident, 33, 37, 158–159 chemical warfare. See CBR attacks British National Health Service, 46 Chernobyl reactor accident, 37, 158, 386 Brokaw, Tom, 84 children. See also family members Brom, Danny, 9 adolescents and group therapy, 334 Brousse, Paule, 94 as collateral damage, 62 Buddhism, 367. See also religion communication after trauma, 314 Buffet, Warren, 377 death of and stress on older adults, 301 burden theory, 294 fear management plans, 129 Burke, Edmund, 90 GOALs Project, 319, 321, 456 burnout, 43, 384, 386 habituation and resiliency, 183–184 Bush, George W. Hawaiian high-risk study, 405 and the axis of evil, 21 Holocaust survivors and PTSD rates, 278 contradictions about flying after 9/11, 24 loss of and traumatic grief, 250–251 declares war on terrorism, 58 and mass psychogenic illness, 157 on hatred and 9/11 attacks, 15 National Child Traumatic Stress Network, 446 popularity and mortality salience, 364–365 Oklahoma City bombing, 235, 311 and terror alerts, 362 Project School Emergency Response to Violence (SERV), 447 Cambodia, 139, 341, 351 and PTSD, 42, 178–179 Caplan, Gerald, 305 schizophrenia and resiliency, 184 Caribbean, 169–170 sexual abuse and PTSD, 248 carjacking, 126 stress after 9/11, 362 casualties stress resistance research, 401–402 categories of after disaster, 383–387 and survivor education, 257 defined, 381 and vulnerability, 119, 293, 313, 378 ratio of physical to, 5–6, 288–289 China syndrome, 85n3 treatment of psychiatric, 157 Chinese Americans, 344, 348 wars, 216–217, 218 Church World Services (CWS), 202–203 WMD casualties, 5 cigarette manufacturers, 97 catecholamine, 276, 280–281 CISD (critical incident stress debriefing). See also Catholic Charities, 203 PTSD (posttraumatic stress disorder) Catholic nuns, 178 critical review of, 6–7, 45–46, 418, 457 CBR attacks as grass-roots movement, 420 al Qaeda, 5 misuse of after 9/11, 25 causal attributions of, 34 phases of, 423–425 education before, 262 and psychological first aid, 48 and EMA plans, 435 research issues, 421–422 interventions after, 260 treatment model, 44–45, 455 and the National Contingency Plan, 445 CISM (critical incident stress management). See also NATO workshop conclusions, 376 CISD (critical incident stress debriefing) psychological threats of, 221 critical review of, 46, 142, 282 and stress risk, 231 and PTSD, 229–230, 249 and survivor education, 257 treatment model, 44–45, 141–142, 145–146 telephone/Internet delivery of services, 265 citrus fruit contamination, 171 and terror alerts, 360 civil liberties, 117–118, 130n1, 130n4, 362, 365 training recommendations, 8 Clara Barton Center for Domestic Preparedness CBRNE attacks, 44, 153–157, 302–303, 455 Training, 195 CDC (Centers for Disease Control), 84, 182, 304, 446 CLAS (culturally and linguistically appropriate Center for Immigrant Health, 349–350 services), 345–346, 351, 354 Chaucer, 381–382 classical conditioning, 165–169, 171–172 Chechen rebels, 102 climate change, 376 478 Index

Coast Guard, 22 crime statistics Cochrane Reviews, 45–46, 421–422 after 9/11, 26, 29, 130n3, 386, 393n29 Coconut Grove nightclub fire, 156, 339 United States, 182 cognitive behavioral therapy (CBT) criminal justice, 58–61, 454 after Omagh bombing, 264 Crisis Counseling Assistance and Training Program and ASD, 259 (CCP), 446–447 GOALs Project, 318–319, 456 critical incident stress debriefing. See CISD Gulf War treatment, 263 Crystal City Sheraton, VA, 201 Israeli missile attacks therapy, 258–259 Cuban Americans, 341, 344 modifications in and PTSD, 263–264 Cuban missle crisis, 180 and potential terror threats, 261–262 cultural diversity. See minority populations and PTSD, 51, 144, 146, 248–249, 428–429 culturally and linguistically appropriate services. telephone delivery of, 265 See CLAS (culturally and linguistically appropriate and terrorism, 252, 266, 456 services) cognitive disequilibrium, 419–420, 457 Cyclone Tracy, 389 cognitive load, 98n6 cognitive restructuring, 248 de Tocqueville, Alexis, 419 cognitive therapy (CT), 50, 144 death squads, 374 cognitive-emotional dissonance, 359 debriefing, 422, 426, 427. See also CISD (critical Cold War, 94–95, 155, 221, 361 incident stress debriefing) collateral damage, 62–63 decision tree, 70 color-coded terror alert system. See also terror alerts Denial of Death, 383 effectiveness of, 360–361 Denton, Harold, 83 and fear, 121 Department of Veterans Affairs, 200, 201 flaws with, 11, 455 depression. See also PTSD (posttraumatic stress and the Revere paradigm, 358 disorder) threat levels and fears, 339, 401 as consequences of trauma, 402 Time magazine survey, 368 diagnostic criteria, 43 Committee on Science and Technology for Countering emotions and resiliency, 405 Terrorism, 348, 349 English language and, 345 communication, 8 and Hispanics, 342 compassion fatigue, 318, 327, 385, 386 major depressive disorder (MDD), 42 complex terrorism, 376 maturation hypothesis, 294 complicated bereavement, 251, 292 and older adults, 288, 292 comradeship, 19–20 and peritraumatic panic, 409 Con Edison, 362–363 posttraumatic, described, 140 confidentiality concerns, 198–199, 204 and PTSD, 40 conservation of resources (COR), 295 rates of in U.S., 167–168 contextualized democracy, 73 and resiliency, 260 Cook Islands cyclone, 383, 388 desegregation protests, 17 cookie decorating, 320 desensitization, 49–50, 353, 424 coping skills dirty bomb, 158 active, 260, 293, 362, 410 disaster medical assistance teams (DMATs), 445 and CISD, 422–423 Disaster Mental Health Technical Assistance defined, 409 Center, 446 and emotions, 261, 405, 409–411, 455 disaster mortuary teams (DMORTs), 444 repressive after attack, 184 disasters (natural). See also Red Cross training and mental health professionals, 258–259 classification of, 379–381 Cornell University, 363 community reactions, 387 cornucopia syndrome, 385 conceptual model for, 387 cortisol levels, 279–280 Crisis Counseling Assistance and Training Program Council for Excellence, 4 (CCP), 446–447 counterterrorism efforts, 97–98, 117–118, 127–130 differences with human-made, 290–291 countertransference, 393n22 disaster welfare information, 445 Crazy Horse, 218 and the disasterotropic, 386, 392n6 Index 479

effects of, 34, 382 emergency support function (ESF), 437, 440–441, in history, 376 443, 457 matrix, 380 Emerson, Ralph Waldo, 452 and minority communities, 338 empathy, 15 National Disaster Medical System (NDMS), 444 Empire State Building, 172 phases of, 379, 387 Empire State Development Corporation, 386 religious explanations for, 391 EMTs (Emergency Medical Technicians), 40. See also responses to as compared to terrorism, 33, 39, first responders 119–120, 199–200, 228, 455 English language, 344. See also linguistic isolation social support and coping behavior, 179–180 EPA (Environmental Protection Agency), 445 and socioeconomic dislocation, 377 Estonian ferry loss, 229 Stafford Act assistance, 438 ethnocultural allodynia, 347 volunteers and convergence, 392–393n17 evacuations discrimination, 339, 347 geographical information system (GIS), 349 disillusionment stage (trauma), 330 National Disaster Medical System (NDMS), 445 dissipation, 175–176, 178–179, 185, 455 and National Response Plan, 444 Doherty, George, 392n14 North Tower evacuation, 208–210, 378 Dominican Republic, 343 senior living facilities, 301 dopamine, 180 Everly, George, 142 dormitory fire, 388–389 experiential risk assessment, 35–36 dread risk, 35–36 extinction learning, 276 drought, 220 Exxon Valdez oil spill, 179 drug trade, 169–170 eye movement, desensitization and reprocessing Dubai Ports controversy, 172 (EMDR), 49–50, 353 Dura, Muhammed, 125 eyeblink startle response, 278 economic issues faith-based community, 139, 144–149, 338, 342. air travel after 9/11, 120 See also religion as cause of terrorism, 376–377 Families Going On After Loss (GOALS). See GOALs of CBRNE attacks, 154 Project and classical conditioning, 167, 172 family assistance centers (FAC), 200–201, 266 cost of mental health treatment, 265 family members. See also GOALs Project criminality after 9/11, 386 as casualties of disaster, 384 of dirty bomb attack, 158 and communication, 449 on families of 9/11 victims, 202–203 Fiji hostage taking, 390 hospitality industry after 9/11, 123 and first responders, 229–230, 234, 407 mad cow disease, 123 history of psychopathology and PTSD rates, 9/11 financial settlements, 322, 330 278–279, 281 and pessimistic ruminations, 168–169 impact on children after trauma, 313 plague in India, 159 and older adults, 292, 296 security, 22 and postevent stress, 240 undocumented aliens and reimbursement, 347 traumatic loss impact, 314 egoistical deprivation, 71 Fatah, 105–106 Eichman, Adolf, 368 FBI (Federal Bureau of Investigation), 200, 434, El Centro, 203 438, 443 el Motassadeq, Mounir, 64 FBI Crime Victims Assistance, 201 El Salvador, 341 FDNY (Fire Department of the City of New York). Elaboration Likelihood Model, 88, 91 See firefighters Emergency Management Agency, 434–435 fear. See also PTSD (posttraumatic stress disorder) Emergency Management Office of the New Jersey as act of worship for God, 19 Division of Mental Health and Hospitals, 329 after 9/11, 23–25 emergency mental health professional (EMH), aim of terrorists, 3–4, 8, 91, 453 141–142, 145–146, 149 and CBRNE attacks, 153–154 emergency reference cards, 298 and CISD, 424 Emergency Service Unit (ESU), 208 and classical conditioning, 165–169, 454 480 Index fear. See also PTSD (continued) absence of mass panic during 9/11, 156 color-coded terror alert system, 11 as casualties of disaster, 384 conditioning models, 277 and CBRNE attacks, 161 Council for Excellence survey, 4 cognitive disequilibrium, 419–420, 457 and desensitization, 424 coping skills and resiliency, 427 institutionalization and older adults, 302 and Emergency Management Agency, 434–435 management programs recommendations, 128–130 evacuation of World Trade Towers, 207 normative response to, 279 incident management strategy for, 436 peritraumatic panic, 276 language-appropriate training, 352 and postevent stress, 241 meetings after 9/11, 378 as preparedness strategy, 186–187 and minority populations, 349 and PTSD rates in children, 183 and NIMS, 436–438 as reaction to threat, 16 preparations for disasters, 51–53 and risk assessment, 35–36, 118–119 reluctance to use mental health services, 264–265 and social amplification, 122–123 respite centers after 9/11, 202 terror alerts, 359, 365 risk factors for PTSD, 40–41, 178, 418 and terrorism, 38, 116–118, 221, 228, 273 screening and assessment recommendations, 8, and vigilance, 170 428–429 Federal Aviation Administration (FAA), 228 and situational awareness, 210 Federal Emergency Management Administration, 361 stress and body recovery, 233, 256 Federal Emergency Response Plan, 195 stress management, 234–236 Federal Radiological Emergency Response Plan and suicide attacks, 112 (FRERP), 440 and terror alerts, 357–358, 362–364, 366 Federal Response Plan (FRP), 200, 439 and trauma, 38–39 FEMA (Federal Emergency Management Agency) flashbacks, 280 crisis counseling, 256, 446–447 Flight 93, 21, 237, 238. See also 9/11 disaster prebriefings, 52 Florida Health Care Association, 301 and Emergency Management Agency, 438 Florida hurricanes (2004), 292, 296–301 family assistance centers, 201 food banks, 202 National Disaster Medical System (NDMS), 445 framing effects, 57–58 occupational stress factors, 427 Frank, Robert, 16 older adults and 9/11, 297 Franklin, Benjamin, 457 planning meetings, 195 fraternal deprivation, 71 purpose of, 350 freedom fighters, 13–14, 69, 82 Fiji, 390–391 French bombings, 294 firefighters. See also first responders French Revolution, 3, 13, 60, 71, 375 actions after 9/11, 384–385 Freud, Sigmund, 73 acute stress reactions study, 278 Friedman, Thomas, 17 and CISD, 421 frustration, 16–17 culture of, 38, 53 Fulton, Fraserand, 92 and the GOALs Project, 330 fundamental attribution error, 126–127 International Association of Fire Chiefs (IAFC), 420 fundamentalism, 21, 71, 74–77, 101, 373. Joint Wellness Initiative of the International Asso- See also religion ciation of Fire Fighters, AFL-CIO, 420 National Fire Protection Association, 420 GABA plasma levels, 280 North Tower evacuation, 209–211 Gallup poll, 365 and occupational stress, 427 garbage pails, 319 Oklahoma City bombing, 225, 235 gas mania, 161 relational capacity and PTSD, 411 gas masks, 160, 260, 262 risks for PTSD, 407 gatekeepers, 344–345, 347, 352 roles of, 419 Gaza/West Bank, 70, 106, 111, 117, 139 Student Paper of the Year Award, 420 gender issues first responders. See also firefighters; organizational GOALs Project, 322, 331 bias; police officers; protective services and mass psychogenic illness, 157 professionals men and weakness, 359 Index 481

recovery after loss of child, 250 GOALs Project, 315, 327, 334, 456 and resiliency, 406 and minority communities, 353 suicide attacks, 105–106, 250 older adults and, 292 women and group therapy, 252 in postterrorism care, 254 women and stress after 9/11, 362 and traumatic grief, 250 generalized anxiety disorder (GAD), 43 Guantanamo Bay, 62 Geneva Declaration on Terrorism, 117, 123 Guatemala, 341 Genovese, Kitty, 212 Gulf War. See also warfare geographical information system (GIS), 349 and children’s PTSD rates, 183 Giles, Robert, 85 disymmetric war, 165 Giuliani, Rudy, 29, 156 illness treatments, 263 Glassner, Barry, 121 missile attacks on Israel, 36, 156, 159–160 GOALs Project psychological defeat, 219 community-based intervention goals, 313–314 Guzma´n, Abimael, 97 conceptual framework, 312–313 evaluation, 331, 334 habituation, 176–177, 181–183, 185–186, 360, 455 group sessions design, 318–321, 323–324 Haddon matrix, 350–352, 353 participants, 315–316, 456 Hadith, 18 Phase 1 considerations, 314–315 Hamas, 96, 105–106, 108, 110. See also Palestine Phase 2 group sessions design, 325–326 Hamburg bombings, 374 Phase 2 pulsed interventions, 322, 327 Handbook of Social Psychology,17 Phase 3, 330–331, 332–333 hara-kiri, 107 program design, 318 hardiness, 405, 410, 412 project replication, 329–330 Harvard Law School survey, 130n1 screening assessment, 327–329 hashashin (Order of Assassins), 102 staff, 316–317 hate crimes, 26 training, 322, 327–329 hatred, 15–16, 19 Goering, Hermann, 357, 359, 365 heuristics, 39, 41, 91, 125–126 good copy problem, 71–72 High-Level Panel on Threats, Challenges, and Gotbaum, Joshua, 199, 206 Change, 377 government. See also FEMA (Federal Emergency Man- Hill and Knowlton, 83 agement Agency); Homeland Security Depart- Hindus, 106 ment; individual agencies Hingston, Michael, 378 disaster/terrorism preparedness, 195 hippocampus, 280 and organizational bias, 211 Hippocrates, 457 terror alert system, 367 Hiroshima/Nagasaki, 218–219, 374 and terrorism, 22–23, 164–165, 373–374 Hispanics, 179, 339–341, 344 Government Emergency Telecommunications Service Hitler, Adolph, 13, 162n3, 359 (GETS), 349 Hizballah, 75, 102, 105–106 Green Cross, 386 Hobbes, Thomas, 392n8 Gresham’s Law of Journalism, 85 Hoffman, Bruce, 157 Ground Zero. See also 9/11 Holocaust, 37, 160, 183, 278, 294–295 and fear management, 128 Homeland Security Act, 439 memorial, 321 Homeland Security Advisory System. See color-coded mental health services at, 318 terror alert system neglect of older adults near, 297 Homeland Security Department. See also National personal possession retrieval, 322 Response Plan (NRP) respite centers after 9/11, 201–202 centralization of decision-making, 374 group dynamics, 17, 20–22, 28–29 color-coded terror alert system, 339, 360–361 group identity, 26–28 crisis preparation recommendations, 146 group therapy. See also PTSD (posttraumatic stress curriculum conference, 7 disorder) and Emergency Management Agency, 438 and CISD, 421, 423–424 Homeland Security Operations Center (HSOC), efﬁcacy studies, 248–249 442–443 families of 9/11 survivors, 312–313 and National Response Plan, 444 482 Index

Homeland Security Department. (continued) International Longevity Center, 288 and NIMS, 436–438 International Policy Institute for Counter-Terrorism, 4 Presidential Directive number 5, 434 Internet. See also media unified command model, 207, 213 and anticipatory fear, 339 homeless people, 348 delivery of mental health services, 265–267 Horowitz, David, 16 fear management, 129 hostage taking on Fiji, 390 information dissemination, 348–349 Hotel and Restaurant Association, 202 magnification of terror attack effects, 6 hotlines, 201, 258, 266–267 and terrorists, 123 Hovland, Carl, 88 interobjectivity, 77 Human Behavior and Weapons of Mass Destruction intifada, 111, 112, 183–184 (HBWMD) Crisis/Risk Communication Work- IRA (Irish Republican Army), 62, 70, 92, 102, 108–110 shop, 231 Iranian Revolution, 71, 94 human rights, 62, 373–374. See also civil liberties Iraq Hurricane Andrew, 179 embargo victims, 62 Hurricane Charley, 299 fear and public policy, 117 Hurricane Katrina, 368, 443 GOALs Project, 321–322 Hurricane Mitch, 38, 386 incremental terrorism, 339 Hussein, Saddam, 159, 162n3 insurgency, 61 hyperarousal and New York City subway alerts, 368 after Oklahoma City bombing, 408 news coverage and stress, 378 and CISD, 422 war and public relations, 23 described, 36, 177 War of the Cities, 159 and mass psychogenic illness, 157 Ireland, 261. See also IRA (Irish Republican Army) and 9/11, 374 Irish National Liberation Army (INLA), 109 reduction of, 282–283 Islam. See also religion and stress, 279, 280 and contextualized democracy, 73 hypervigilance, 185–186, 274, 360 as foundation for bin Laden, 220 and martyrdom, 74 ICS (incident command system), 435–436 militancy as basis for terrorism, 138 Illegal Immigration Reform and Immigrant Responsi- and Mohammed Atta, 19 bility Act of 1996, 347 mosques, 71–72 immigrants, 341–342, 348, 374. See also linguistic religious freedom and, 150 isolation; minority populations Wahhabism, 75 Immigration and Naturalization Service, 22 Islamic Jihad, 106 in vivo exposure, 249, 263–264 Islamic Salvation Front, 18 incident annexes, 440 Ismailis, 3 Incident Command Post (ICP), 210–212 Israel Indian plague, 159, 266 anxiety management, 258–259 Indonesia, 376 citrus fruit contamination, 171 inhibitory mechanisms, 75–76 coping skills in, 261 Initial National Response Plan (INRP), 440 gas masks education, 262 injustice, 71 group therapy study, 249 inoculation theory, 294 media and fear, 124 Institute for Local Self-reliance, 379 PTSD rates in, 47, 111–112, 183–184, 265 Institute of Medicine (IOM), 7–8, 203, 288, 344, social support and coping behavior, 179 350, 448 suicide attacks and public morale, 187 insurance, 341 suicide bomber detection, 9 insurgency, 61 and terror alerts, 361–362 interagency incident management group (IIMG), 442 and TWA 847, 88 International Association of Fire Chiefs (IAFC), 420 Israel Center for the Treatment of Psychotrauma, 9 International Critical Incident Stress Foundation, 142 International Federation of Red Cross and Red Jakobovits, Immanuel, 139 Crescent Societies (IFRC&RCS), 374, 376–377 Japan firebombing, 218 International Herald Tribune–Pew poll, 18 Jenkins, Brian, 154–155 Index 483

Jersey City interfaith council, 330 Madrid train bombings, 89, 117 Jewish preschool killings, 92 major depressive disorder (MDD), 42 JFO (Joint Field Office), 436 Mao, 13 Johnson, Samuel, 382 marijuana. See alcohol/substance abuse Joint Field Office (JFO), 437, 443 Marxism, 106 Joint Wellness Initiative of the International Associa- Maslow, Abraham, 196, 391 tion of Fire Fighters, AFL-CIO, 420 mass hysteria. See OMUS Jolo syndrome, 394n33 mass panic, 155–156 Jonestown massacre, 102 mass psychogenic illness, 156–157, 160–161. Journal of Community Psychology, 383 See also OMUS jujitsu politics, 62–63 Massachusetts Corps of Fire Chaplins, 200 justice, 72–73, 76–77, 391 Massachusetts Department of Health, 200 Massachusetts State Police, 200 Kaczynski, Theodore, 15 Massada, 102 Kahn, Inamullah, 139 maturation hypothesis, 294 kamikaze pilots, 110 McCarthy era, 375 Karson, Samuel, 228 m-chlorophenylpiperazine, 280 Kay, David, 155 Meals on Wheels, 296 Kennedy assassination, 179, 339 media Kentucky flood, 294 anthrax attacks, 84–85 Kenya bombings, 87 attacks on journalists, 124 Kerry, John, 364, 368 and CBRNE attacks, 154, 156 Keys, David, 376 and Israeli missle attacks, 36 Khaddafi, Muammar, 23 limits on during counseling, 264 Khan, A.Q., 155 magnification of terror attack effects, 6, 305, 378, Khartoum, 23 400–401 Koran, 19. See also Islam and Narodnaya Volya, 94 Korean War, 59, 63 and 9/11, 24, 166–167, 313, 329 Kurdish Labor Party (PKK), 102, 105–106, 117 as oxygen of terrorism, 123–126 Kurdistan Workers Party, 97 and piggyback events, 171 and postevent stress, 240, 408 Lebanon, 101, 185. See also Hizballah pothole rescue in Rome and, 385 Lexington Avenue Armory, 201 public opinion influence, 118, 121 Liberation Tigers of Tamil Elaam. See Tamil Tigers risk assessment after attacks, 35, 116 (LTTE) security personnel stress, 170–171, 235, 241 Liberty State Park, NJ, 201 as terrorism handmaid, 82, 92, 95, 130, 221, 273 Libya raid, 367 Three Mile Island reporting, 82–85, 454 linguistic isolation, 341–343, 347–351. See also CLAS Yale model of social influence, 90 (culturally and linguistically appropriate services) Medicaid, 167–168, 345 Linn County, Iowa, 349 medical insurance, 345 Little Bighorn, 218 medical professionals Lockerbie plane crash, 260, 264–265 care after Hurricane Charley, 299 Logan Hilton, 200 and CBR attacks, 262–263 Logan International Airport, 200 disaster medical assistance teams (DMATS), 445 Logan Massport Authority, 200 immigrants and service provision, 342, 344, Loma Prieta earthquake, 37 347, 352 London bombings, 110, 187, 218. See also World and mental health care, 265 War II National Disaster Medical System, 443 Long Island Council of Churches Disaster older adults and stress, 292, 304 Taskforce, 203 placebo effect, 382 long-term care providers, 299–300 and survivor education, 257 Lutheran Disaster Relief, 203 and terror alerts, 366–367 treatment after CBR attacks, 260 MacArthur, Douglas, 61 medically unexplained physical symptoms (MUPS), mad cow disease, 123, 393n28 156–157 484 Index

Medicare, 344 Mitchell, Jeffrey, 44 Mental Health and Mass Violence, 448 Mneimneh, Hassan, 18 mental health professionals. See also emergency mental Mohammed, Khalid Shaikh, 56 health professional (EMH) Moores, Leon E., 5 CBR attacks, 262–263 morbid grief. See traumatic grief CBRNE attacks, 161–162 Morgan Stanley’s Individual Investor Group, 156 CLAS (culturally and linguistically appropriate Morocco attacks, 110 services) guidelines, 345 Morrow, Hope, 392n14 coping skills training, 258–259 mortality salience, 364–365 cultural diversity challenges, 338 mosques, 71–72 and disaster preparedness, 447–449 Mother Teresa, 139 effects on during a terror attacks, 265–266 Mount Erebus plane crash, 380 and FEMA, 446 Moussaoui, Zacarias, 64 GOALs Project training, 329–330 Munger, Charles, 377 immigrants and barriers to service, 343–344 Murrah Building. See Oklahoma City bombing intervention and treatment recommendations, Muslim African Americans, 27 47–51 Muslim Americans, 26–28 and minority communities, 340–341, 349–350 and 9/11, 225, 311–312 Napoleon, 88, 219 obstacles to care for survivors, 264–265 Narodnaya Volya, 13, 94 and older adults, 298–299, 305 National Association of Social Workers, 330 postterrorism interventions, 247, 255–256 National Center for Child Traumatic Stress, 319, 447 research priorities for PTSD, 282–283 National Center for PTSD, 267, 375 and resiliency after terror attack, 10 National Center for Victims of Crime, 203 self-help activities for survivor groups, 254 National Center on Post Traumatic Stress survivor education, 257 Disorder, 203 and terror alerts, 366–367 National Child Traumatic Stress Network, 446 Merari, Ariel, 5, 17 National Communications System (NCS), 349 Message From the Far East,61 National Comorbidity Survey, 402 metastereotypes, 28 National Contingency Plan, 445 Metropolitan Edison, 82–83 National Disaster Medical System (NDMS), 443–445 Mexican Americans, 341, 343, 345 National Emergency Management Agency, 194 middle-aged adults, 294, 406 National Fire Protection Association, 420 migrant workers, 348 National Foundation for Mortuary Care, 445 Milgram’s obedience experiment, 21 National Guard, 357, 438 military National Hurricane Conference, 195 After Action Review protocols, 427 National Incident Management System. See NIMS altruistic suicide, 108 (National Incident Management System) incidence of PTSD, 32 National Institute for Clinical Excellence (UK), 422 and mass psychogenic illness, 158 National Institute of Health, 375 occupation and jujitsu politics, 63 National Institute of Mental Health, 46, 196, 313, 426, personnel studies and CISD, 422 446–447 and the Stafford Act, 442–443 National Institute of Standards and Technology (NIST), studies on satisfaction, 70–71 210, 378 and terrorism, 60–61, 87, 164 National Mental Health Association, 203 training of, 75 National Oil and Hazardous Substances Pollution treatment of psychiatric casualties, 157 Contingency Plan (NCP), 440 Miller, Judith, 368 National Organization for Victims of Crime, minister, 150n1 200–201 Minnesota Multiphasic Personality Inventory (MMPI), National Research Council, 7–8, 367 39, 407 National Resource Coordination Center (NRCC), 442 minority populations, 339, 340–341, 351–353, National Response Plan (NRP), 437, 440–445. See also 388–390, 456. See also CLAS (culturally and Homeland Security Department linguistically appropriate services); individual National Terror Alert System, 362 cultures National Transportation Safety Board (NTSB), 200 Index 485

National Vietnam Veterans Readjustment Study mass panic, absence of, 156 (NVVRS), 32 mass psychogenic illness after, 157–158 National Voluntary Organizations Active in Disaster media coverage of, 81, 125 (NVOAD), 195 mental health treatment after, 6, 146, 304 nationalism, 26, 29 Miami Hispanic study, 341–342 NATO (North Atlantic Treaty Organization), 9, 376 and Mohammed, Khalid Shaikh, 56 Natural Hazards Institute, 195 motivation for, 107 naturalistic decision-making, 237 and Oklahoma City bombing families, 254 Nauru Island, 374 patriotism after, 25–26 Nechaev, Sergey, 94 ‘‘Portraits of Grief’’ series, 180 necrophilia, 393n26 psychological aims of, 3, 19 negative identification, 16 psychological strategy of, 171–172 negativity bias, 122, 124, 127 PTSD levels after, 9, 111, 140, 281, 407–408 New Jersey, 311 public health nurses survey, 299 New Jersey Division of Mental Health Services, 322 religious coping after, 143, 147, 182 New Jersey FEMA project, 322 response to, 378 New Jersey Immigration and Policy Network, 202 risk assessment after, 119 New Jersey Interfaith Partnership for Disaster SPRINT-E assessment, 447 Recovery, 203 suicide rates in United Kingdom, 185 New Life Center, 202 and Terror Management Theory, 375 New Rules Project, 379 therapist training after, 264 New York Academy of Medicine, 274 and Three Mile Island, 82 New York City September 11 Unmet Needs Round- 9/11 United Services Group (USG), 201 table, 203 1993 World Trade Center bombing, 5, 56, 58–62, New York City subway alerts, 368 156, 181 New York Disaster Recovery Interfaith, 203 nocebo effect, 381–382 New York Health Department, 202 Noriega, Manuel, 59 New York Police Department, 201, 208–209, 211. Northern Ireland, 23, 180–185, 259, 264. See also IRA See also first responders (Irish Republican Army) New York Port Authority, 200–201, 210 Northridge earthquake, 294 New York Regional Associations of Grantmakers, 203 Northwestern University Medical School, 378 New York Times, 180 nuclear attacks, 4–5, 155, 162n3, 219, 360–361 New York University Child Study Center, 203 Nuclear Regulatory Commission (NRC), 83 New York University School of Medicine, 349–350 nursing homes, 300, 301 New Zealand, 374–375, 393n27 Nicaraguan hurricane, 38 O’Brian, Nora, 288 Nieman Foundation, 85 Ocalan, Abdullah, 97 Nietzsche, Friedrich, 381 occupational stress, 418–421, 425–427. See also NIMS (National Incident Management System), stress 436–438, 437, 442–443, 457 Office for Victims of Crime, 137, 447 9/11. See also first responders; suicide attacks Office of Emergency Management, 202 and classical conditioning, 165–167 Oklahoma City bombing clinical response to, 282 children’s mental health needs, 311 cognitive behavioral therapy (CBT) treatment, 259 clinical response to, 282 Commission Report, 210, 213 explosives used, 162n1 communication disruptions and, 298 firefighters psychological consequences, 225, 235 and coping skills, 410 Justice Department handbook, 394n34 crime statistics, 130n3, 386, 393n29 justification for, 75 death toll intent, 5 mass panic, absence of, 156 emergency management planning before, 194–196 media and stress after, 378 emergency response and older adult, 297 and 9/11 families, 254 emotions after, 179, 180–182 older adults and PTSD, 293 families, impact on, 311 perpetrators, 181–182 and fear of flying, 23–25 and PTSD, 36–37, 178 GOALs Project, 312–313 religious coping, 137, 409 486 Index

Olberman, Keith, 368 Pearl Harbor attack, 33, 181 older adults Pennsylvania plane crash. See Flight 93 assessment of vulnerabilities, 301–302 Pentagon, 84, 194, 266. See also 9/11 barriers to treatment, 292 perceived deprivation, 70–71 cognitive impairment challenges, 300 Percival, Arthur Ernest (General), 217 conservation of resources theory, 295 peritraumatic dissociation, 275–277, 281–282, 408 crisis intervention, 304 peritraumatic panic emergency response shortcomings, 297 and CISD, 425 English as second language, 344–345 as predictor of pathology, 277–278, 404, 409, 455 immigration and family support, 342 and PTSD, 276, 280–282 linguistic isolation, 343, 347 and trauma, 275, 281 risk factors for psychological consequences, 289 pessimistic ruminations study, 168–169 social support networks, 295–296 pets, 288, 296, 298, 444 studies on and terrorism, 288 Pew Research Center for the People and the Press, 85 vicarious trauma after 9/11, 305 Pi Gilot fuel depot, 5 vulnerability of, 292–293, 456 Pier 94, 201 Olson, Kyle, 84 PIJ, 105–106, 110 OMUS (outbreaks of multiple unexplained symptoms), pituitary gland, 279–280 10, 37, 42, 44, 119 placebo effect, 381–382 On War,60 Plame, Valerie, 368 organizational bias, 207–208, 211–213, 457. See also Pol Pot, 13 organizational practices police officers. See also first responders organizational practices. See also organizational bias; culture of, 39 stress and Lockerbie disaster, 232 communication and naturalistic decision-making, North Tower evacuation, 208–209 237 PTSD study, 229–230, 278, 407 cultural change and terrorism, 241–242 roles of, 419 and postevent stress, 240 and situational awareness, 210 and PTSD, 229–230 political motivations and risk management, 227 anthrax attacks, 394n31 role of during a terrorist event, 232 and mortality salience, 364 simulation training and stress risk, 236 New York City subway alerts, 368 team and interagency operations, 237–240 terror alerts, 357–358, 361, 364–366 turf battles, 238 of terrorism, 359 Orwell, George, 82 and terrorist threats, 368 Oslo Accords, 110–111 Pope, Ken, 392n14 outbreaks of multiple unexplained symptoms. See Popular Front for the Liberation of Palestine (PFLP), OMUS (outbreaks of multiple unexplained 105–106, 108 symptoms) positive emotions, 180, 184 positive identification, 16 Pacific Islanders, 344 postterrorism interventions, 247, 253–256, 259, Pakistan, 71 263–264. See also mental health professionals palancas, 320, 331 posttraumatic growth, 140–141, 143, 147, 149 Palestine, 183, 185, 187, 339, 367–368. See also posttraumatic stress disorder. See PTSD (posttraumatic Hamas stress disorder) Pan Am 103. See Lockerbie plane crash posttraumatic thriving, 403 Pan American Health Organization, 384 potentially traumatizing events (PTEs), 39 Panama invasion, 59 pothole rescue in Rome, 385 panic attacks. See peritraumatic panic poverty, 377 Pape, Robert, 62 Preparing for the Psychological Consequences of Terrorism: paramedics, 427 A Public Health Strategy, 448 Parisian subway attack, 261 principal federal official (PFO), 440 Passions within Reason,16 prison experiment, 171 Patriot Act, 362 Project Liberty, 46, 179, 256, 259, 265–267 patriotism, 25–26, 28–29, 60 Project Phoenix, 322 Index 487

Project School Emergency Response to Violence research priorities for, 282–283 (SERV), 447 risk assessment after attacks, 35 prolonged exposure (PE), 51 risk factors for, 39–40, 46–47, 278–279, 281–282, propranolol, 51, 276 302, 455 protective services professionals, 225, 227, 229, screening assessment, 304, 428 231–232, 241–243. See also first responders social support and risk, 257–258, 411 Provisional Irish Republican Army. See IRA suicide attacks and, 111–112 psychic numbing, 367 survivor education, 257 psychological contamination, 37, 44 and traumatic grief, 249, 251 psychological distance, 75–76 VA National Center for PTSD, 446 psychological first aid (PFA) variables contributing to, 229–230 after disasters, 378, 385, 393n23, 449 and veterans, 138–139, 406, 411–412 Haddon matrix, 350 public health nurses, 299 and older adults, 298 and resiliency, 283, 427–428 Quest Scale, 143 in stepped care, 253–256, 456 Substance Abuse Mental Health Services Adminis- rage, 368 tration (SAMHSA), 447 Rahman, Omar Abdul, 58 as treatment for PTSD, 47–48, 50, 455 RAND survey, 137 WHO statement, 382 rape. See sexual assault psychopathology, 15, 273–274. See also PTSD Reagan, Ronald, 88 (posttraumatic stress disorder) recovery PTSD (posttraumatic stress disorder). See also CISD defined, 184 (critical incident stress debriefing); cognitive trajectories of, 403–404, 428 behavioral therapy (CBT); trauma and trauma, 41–42, 137–138, 145, 455 and ASD, 70, 273, 277 Red Army Faction, 94, 102 biologic markers for, 279–281 Red Brigade, 17, 19, 94 care limitations for, 264 Red Cross. See also relief organizations and CISD review, 6–7 Boston disaster training, 200–201 coping skills and, 261 disaster welfare information (DWI), 445 delayed-onset, 277 fact sheet, 392n14 and depression, 40 and family assistance centers, 201 diagnostic criteria, 42, 177, 273–274 and the Federal Emergency Response Plan, evidence-based treatment for, 248–249 195, 439 and fear, 228, 263–264 geographical information system (GIS), 349 and the GOALs Project, 315–316 Mass Bay, 200 group stress debriefing, 254 Montana management meeting, 194 and immigrant populations, 341, 347, 352–353 and the National Transportation Safety Board incidence of after 9/11, 9, 32, 362 (NTSB), 200 interventions for, 247 and National Voluntary Organizations Active in National Center for PTSD, 267, 375 Disaster (NVOAD), 195 occupational stress and, 420 and 9/11, 197, 202–205 older adults, 292, 302 older adults and, 297, 298 and peritraumatic dissociation, 275 sex toy donations, 393n27 and peritraumatic hyperarousal, 408 volunteers and risks, 200 and peritraumatic panic, 275–276 Red River flood, 294 physical injury as predictor, 37 reexposure therapy, 49–50 postterrorism care model, 266–267 refugees. See immigrants predictors for, 256, 406–407 regional resources coordination center (RRCC), 443 and psychological first aid, 428 region-beta paradox, 180, 183 rates of in Israel, 9, 47, 111–112, 183 Reinecke, Mark, 378 rates of in U.S., 177 relative deprivation, 71 rates of in younger adults, 293 relevant arguments theory, 21–22 recovery from after 9/11, 274–275 relief organizations, 195–201, 204–206, 456. See also and religious coping, 142 Red Cross 488 Index religion. See also faith-based community; fundament- and fear, 118–119 alism; spirituality and heuristics, 121–122 American Psychological Association Division 36, and hyperarousal, 36 Psychology of Religion, 393n20 media and fear, 123–126 as coping mechanism, 137–138, 142–145, 147, 390, negativity bias, 122 409, 456 recommendations for public education, 8 definition, 138 research, 267 financial assistance after 9/11, 203 and terrorism, 35–36, 39 Maori spirituality, 383 treatment model, 41 minister, 150n1 risk management. See also stress multicultural community aid resource, 352 in crisis, 199–200 and Northern Ireland bombings, 180 and gender, 406 and older adults, 298, 304–305 paradigm for stress management, 226–227 and political opposition, 18–19 postevent stress, 240–241 and recovery, 182, 265 stress and interagency cooperation, 240, 457 Religious Commitment Inventory, 149 terrorism and stress, 232–234 South Pacific disasters, 388–390 Robespierre, Maximilian, 3, 90 and suicide attacks, 105–106, 110 Rockefeller Foundation, 203 and terrorism, 95–96, 98n7 role rigidity, 171 and violence, 390 Roman Catholic Church, 18, 178, 203. See also religion relocation shock, 343 Rothschild, Michael, 120 Remarque, Eric Maria, 220 Rove, Karl, 368 repressive coping, 184 rumination scale, 144 Rescorla, Rick, 156 Rwandan genocide, 127 resiliency after trauma, 42, 175, 313, 455 Safe and Drug-free Schools Programs, 447 coping skills for, 260–262 Safe Horizon, 201, 202 definition, 403 Safe Return, 298 and first responders, 418, 425–427, 429–430 Salameh, Mohammed, 58 GOALs Project training, 327 Salvation Army, 179, 201–203, 298. See also relief individual characteristics and, 404–406 organizations in individuals, 221–222 Sands, Bobby, 109 in Israel studies, 9 Saudi Arabia, 71, 73, 400 mental health professionals role, 10 schema, 89, 98n3 in minority populations, 347 schizophrenia, 184 and national security, 153 Scibilia, John, 203 and older adults, 293–294, 304 Sears Tower, 172 and peritraumatic panic, 409 security (national) positive emotions and, 180, 184 after 9/11, 374 and posttraumatic growth, 140–141 at airports, 24–25 and problem-focused coping, 411 depression rates in U.S., 167 as process, 403–404, 429 financial cost of, 22 and protective services professionals, 241 personnel and stress, 170–171 research, 267, 282, 401–402, 412–413 and psychological threats, 164–165 underestimation of in populations, 161–162 role rigidity dangers, 171 Reuters News Service, 85n1 Seligman, Martin, 144 Revere, Paul, 357, 359 Sendero Luminoso. See Shining Path revivification, 424 Seneca, 220 Revolutionary War, 357 sensemaking (situational awareness), 210 Rhode Island nightclub fire, 447 sensitization, 176–177, 183, 185–186, 455 Ridge, Tom, 360, 368 September, 11, 2001. See 9/11 risk assessment September 11 Fund, 199, 202–203 and communication, 128–129 sex toy donations, 393n27 disproportionate and terrorism, 120–121 sexual assault, 248, 253, 406 and experiential risk assessment, 35 shahid (martyrs), 110, 111 Index 489

Shamir, Itzhak, 14 and CBR attacks, 231–232, 260 Shia Muslims, 3 in Chinese calligraphy, 376 shift work, 230, 232 and command structure, 212, 231 Shining Path, 19, 97–98 and emergencies, 225 sicarii, 3, 102 impact on security personnel, 170–171 Sikhs, 26 and information sharing, 208 Sitting Bull, 218 inoculation training, 248, 258 situational awareness, 208–210, 231, 237 management of acute reaction, 255–256 skin conductance, 278 national impact of, 367 Slavic Americans, 351 and neurochemicals, 276–277 sleep disorders, 43 as normative response, 274 slippery slope, 21–22 and performance guilt, 235 smallpox, 85, 155 and physical illness, 177–178 social categorization, 75–76 reactions to, 303 social comparison theory, 22 reintegration and organizational culture, 241–242 social deterioration model, 295 and resiliency, 406 social identity theory, 358, 363–364 resistance, 401 social influence campaigns, 87–88, 90–93, 96–98, 454 runaway response, 279 social support sexual assault, 248 coping behavior, 227–228, 261 and situational awareness, 237 and group therapy, 250–251, 254 and survivor education, 257 and mental health, 410–411, 455 terror alerts and, 361–363 minority communities, 342 traumatic, 220–221 occupational stress, 427 women and after 9/11, 362 older adults and stress, 295–296 substance abuse. See alcohol/substance abuse and PTSD, 229–230, 281 Substance Abuse Mental Health Services Administra- as risk factor after terrorism, 276, 408 tion (SAMHSA), 446, 447 for survivors, 257–258 success kits, 320 and traumatic grief, 252 suicide attacks. See also fear; terrorists Sociological Practice Association, 420 Beirut Marine base bombing, 14 Solomon Asch Center for the Study of Ethnopolitical cell structure of organizations, 74–75 Conflict, 25 common characteristics of, 102 Somalia, 220, 341 demographic characteristics, 105–106, 453–454 South Pacific islands, 388–390 detection of, 9 Southern Baptist and Church of the Brethren, 201 differences with 9/11 attackers, 17 spirituality, 138–139, 143–144, 201, 383, 456. education levels of Palestinian attackers, 106 See also religion and inhibitory mechanisms, 76 SPRINT-E assessment, 447 logic of, 10 St. Vincent’s Hospital, 330 and the media, 82, 124–125 Stafford Act, 200, 438–439, 442–443 moral trajectory of, 453 Stalin, Josef, 13 numbers of by country, 102, 104 Stanford University prison experiment, 171 personality and psychopathology, 107–109 State Child Health Insurance Program (SCHIP), 345 political motivations, 101 State Hope Scales for Children, 331 profile of terrorists, 103–105 stereotyping, 27–28 psychological effects of, 111–113 Stern, Jessica, 155 psychological preparations for, 109–110 Stern Gang, 13 psychological profile of, 4 Stevens, Robert, 84 public support for, 110–111 stovepipe situational awareness. See situational revenge as motivation, 107 awareness successes of, 117 Strategic National Stockpile, 444 by year, 103 stress. See also occupational stress; risk management; Sun Tzu, 217–218 trauma Super Bowl games, 443 and acculturation, 343–344 swoop in factor, 199 anticipation period, 339 symmetric war. See warfare 490 Index

Taliban, 23, 62. See also Afghanistan Office for Victims of Crime Handbook for Coping Tamil Tigers (LTTE) after Terrorism, 137 constituency of, 92 older adults, effects on, 289–292 gender and age of attackers, 105 origins of in the Muslim world, 18–19 group commitment of attackers, 110 as politicized term, 4 political motivations, 19, 96 and positive emotions, 180 and suicide attacks, 102, 117 preparations strategies for, 186–187 Tanzania bombings, 87 Preparing for the Psychological Consequences of telephone/cell phones Terrorism: A Public Health Strategy, 448 AT&T Language Line, 349 prevention of, 9–10, 76–77 CLAS (culturally and linguistically appropriate psychological aims of, 3–4, 400 services) guidelines, 345–346 psychological responses to, 33–36, 38 GOALs Project outreach, 316 pyramid of terrorism, 23, 92 hotlines, 201, 258, 266–267 ratio of psychological to physical casualties, 5–6, and information dissemination, 348–349 288–289 and mental health services, 258–259, 265 reactions to, 302–303 survey of psychological consequences of 9/11, 362 and relief organizations, 195 television. See also media research issues, 7–8, 10–11, 452 Al Jazeera interview, 5 responses to as compared to disasters, 33, 39, and anticipatory fear, 339 119–120 and information dissemination, 348–349 risk perceptions of, 122 Project Liberty education, 265 state, 13–14, 90 viewing and stress after 9/11, 362–363, 378 as strategy, 22–23, 96 Templeton Prize, 139 study of, 373 Tepeyac, 202 and violence, 13 terror alerts, 357–359, 361–367, 374. See also terrorists. See also suicide attacks; terrorism color-coded terror alert system goals of, 62–63 Terror Management Theory, 358, 363–364, 375, 383, and moral disengagement, 73–74 393n25 moral trajectory of, 19–22 terrorism. See also criminal justice; fear; terrorists motivations of, 8–9, 14–15, 359, 367, 453 barriers to research, 375 organizational structure of, 74–75 characteristics of event, 407–408 as propagandists, 94 CLAS (culturally and linguistically appropriate psychological profile, 3–4, 17, 70, 126–127, 373 services) guidelines, 345–346 and the pyramid of support, 23 contemporary, 4–5 and Reuters, 85n1 declaration of war, consequences, 60 staircase metaphor, 70–76 defined, 3, 69, 87, 98n1, 219–220, 358, 375 and technology, 376 as disaster, 375 and terror alerts, 361–363 federal response to, 438–440 as videographers, 124 and fraternal deprivation, 71 The China Syndrome,83 frustration and insult as motivating factor, 16–17 The Culture of Fear, 121 future targets in the U.S., 172, 185–186 The Deadly Ethnic Riot,16 goals of, 10, 164 theta EEG, 280 government sponsored, 373–374 Thornburg, Richard, 83, 86n4 and group dynamics, 29 thought field therapy (TFT), 50 Haddon matrix, 350 Three Mile Island, 37, 82–83 hatred as motivating factor, 15–16 Time magazine survey, 368 historical survey, 93–96, 181–182 Tokyo subway attacks. See Aum Shinriky[o] Institute of Medicine´s Committee on Responding TOPOFF (1–3), 195, 231, 237–239 to the Psychological Consequences of torture, 22 Terrorism, 351 trauma. See also CISD (critical incident stress de- and media relationship, 81 briefing); GOALs Project; PTSD (posttraumatic and mental health, 225 stress disorder); resiliency model for understanding, 221–222 alcohol/substance abuse, 252–253 number of attacks, 377 disillusionment stage, 330 Index 491

extinction learning, 276 risk for trauma event, 177 medicalization of, 424–425 security costs, 22 and older adults, 301 as target for CBRNE terrorism, 155 organizational factors and stress, 236 as target for Muslim terrorists, 18 outcomes after adversity, 402–403 terror alerts effectiveness, 359–360 and peritraumatic panic, 275, 281 United Way GOALs Project, 314 pre-traumatic stress syndrome, 401 University of Medicine and Dentistry of New and psychopathology, 273–274 Jersey, 312 reactions to, 176 unknown risk, 35–36 recovery from, 41–42, 137–138, 145, 180–181 U.S. Attorney General, 438 and resiliency, 401–402 U.S. Census Bureau, 339–341 as response to different incidents, 32–33 U.S. Civil War, 216–217, 219, 384. See also warfare risk factors for, 404–407 U.S. Department of Defense, 427, 444 and terrorism, 401 U.S. Department of Education, 447 threat assessment model, 41 U.S. Department of Health and Human Services types of after terror attacks, 42–44, 119 (DHHS), 345–346, 440–441, 443–445, 456 UCLA Trauma/Grief Psychotherapy Program, 331 U.S. Department of Justice, 377, 394n34 vicarious after 9/11, 305 U.S. Department of Transportation, 444 and vulnerability, 227–228 U.S. Department of Veterans Affairs, 375 Trauma Center, 200 U.S. Government Interagency Domestic Terrorism traumatic grief, 9, 249–253 Concept of Operations Plan (CON_PLAN), 440 traumatization, 36–39 U.S. National Comorbidity Survey, 167 triage, 255–256, 299, 381, 444 U.S. Postal Service, 84 turf battles, 211, 238, 329–330 Turkish Revolutionary People´s Liberation Front, VA National Center for PTSD, 446 102, 106 veterans. See also warfare Tuvalu Island, 388–389 Department of Veterans Affairs, 200–201 TWA 847, 88 National Vietnam Veterans Readjustment Study Twenty-first Century Foundation, 203 (NVVRS), 32 twins studies, 278 and PTSD, 138–139, 406–407, 411–412 2002 Olympics, 443 U.S. Department of Veterans Affairs conferences, 375 undocumented aliens, 341, 347 Veterans Administration, 139, 444 Unification Church, 20 victims, 381, 384 unified command model, 207, 212–214 Vietnam War. See also veterans; warfare United Kingdom, 46, 59, 85n1, 185. See also London boat people, 347 bombings; Northern Ireland casualties, 217–218 United Methodist Committee on Relief (UMCOR), 203 CBT as treatment for PTSD, 248 United States as conflict, 59, 95 adaptation after terrorism, 185 end of, 63 anti-Muslim prejudice in, 339 psychological defeat, 219–220 census statistics, 339–341, 343 vigilance, 170, 185–186 color-coded terror alert system, 358 violence crime statistics, 182 Buddhist beliefs, 367 death statistics, 374 habituation to, 182–183 depression rates in U.S., 167–168 impact on population, 184–185 disaster victims mental health, 446 Mental Health and Mass Violence, 448 health literacy report, 344 National Institute of Mental Health report, 196 intelligence failures before 9/11, 374 and terrorism, 13, 281–282, 454 interventions after terrorism, 311 volcanic eruption, 376 Libya raid, 367 von Clausewitz, Carl, 60, 93 minority populations interventions, 353–354 vulnerability motivations for the war on terror, 21 and CISD, 424 psychological impact of 9/11, 362 and cultural diversity, 338 race riots and psychiatric services, 185 economic disadvantage, 348 492 Index vulnerability (continued) WHO (World Health Organization), 351, 382–384, 422 first responders and, 229 WMDs (weapons of mass destruction), 5–6, 155, 168, older adults and, 292–295, 301–302, 456 195, 233. See also CBRNE attacks and postevent stress, 240–241 Wolfenson, James D., 377 and resiliency, 402 World Economic Forum, 16, 377 and terror alerts, 359 World Financial Center, 209 and trauma, 227–228 World Terrorism and Political Violence¨ Implications for New Zealand, 374 Wake Island attack, 217–218 World Trade Center, 208–210. See also 1993 World Walter Reed Army Medical Center, 221 Trade Center bombing; 9/11 ‘‘War of the Worlds’’ broadcast, 34, 156 World War I. See also warfare warfare. See also individual wars and the British monarchy, 59 asymmetric, strategies for, 165–171 casualties, 216, 218 declarations of, 59 end of, 63 Douglas MacArthur’s message, 61 poison gas attacks, 154, 160–161 and the enemy, 60 World War II. See also warfare kamikaze pilots, 110 absence of mass panic during, 156 psychological nature of, 218–219 end of, 63 and PTSD, 139 Nazi occupation of Paris, 220 purpose of, 216–217 psychological research after, 19 as response to terrorism, 64, 454–455 psychological resiliency of population, 162, 184 and risk assessment, 57–58 radar operators, 170 and suicide rates, 109, 185 reconstruction after, 374 Sun Tzu on victory, 217–218 Singapore attack, 217 symmetric, defined, 165 terrorism after, 94–95 and vigilance, 170 V2 rocket attacks, 159 Washington, DC, 32, 185–186, 378 Wake Island attack, 217–218 Washington, George, 219 Washington Post,84 Yale model (social influence), 88–89, 97, 454 Washington Quarterly,4 Yamashita, Tomoyuki (General), 217 Weapons of Mass Destruction. See WMDs (weapons Yasin, Abdul Rahman, 63 of mass destruction) YMCA, 314 Weather Underground, 17 yohimbine, 280 Weick, Karl, 210 Yousef, Ramzi, 56, 58, 155 Weill Medical College, 363 Weiss, Rick, 84 Zaoui, Ahmed, 374–375, 393n18 Welles, Orson, 156 Zawahiri, Ayman, 96 Werner, Emmy, 405 Zealots, 3, 93–94 Wessely, Simon, 9–10 Zionists, 85n1, 95