The aims of terrorism, it is said, have less to do with causing death and destruction than with instilling fear.
Defeating these aims depends on the extent to which citizens respond with a kind of civic courage: calmly and resolutely taking necessary precautions, caring for friends and neighbors wherever possible, and proceeding with daily routines. For this reason, it would seem that preparing for and responding to the behavioral and mental health consequences of a terrorist attack—whether biological or nonbiological—would be as important as dealing with the physical damage caused by an attack.
In an interview with Psychiatric News, Robert DeMartino, M.D., associate director for the trauma and terrorism program at the federal Center for Mental Health Services of the Substance Abuse and Mental Health Services Administration (SAMHSA), said the government’s efforts in this area build on concepts and specific programs for disaster relief that predate September 11, 2001.
But it is clear that the events of last fall have lent urgency to those efforts and fostered a new appreciation of the importance of preparing for and coping with the fallout of terrorism that affects the mental health of American citizens.
DeMartino said the foundation of disaster preparation is "all-hazards planning," a concept that seeks to encompass preparedness for all possible contingencies and sequelae of a natural or man-made disaster. Yet preparedness for mental health consequences in all-hazards planning has lagged behind other concerns, DeMartino said.
"All-hazards planning has been the norm in disaster planning for a number of years," he said. "It used to be that each state would have plans that would relate to different kinds of events. Over time it became clear that it made more sense to have a single plan encompassing many contingencies and that deviated only when absolutely necessary. But what has also been clear is that states haven’t had the capacity to include mental health specific to disaster."
In response, DeMartino said that SAMHSA is preparing a $4 million competitive grant program for states and localities to hire a "point person" specifically to deal with mental health consequences of disaster relief.
Also critical in the administration’s response is a forthcoming report by the Institute of Medicine (IOM) on the nation’s capacity to respond to the behavioral and mental health consequences of terrorism. Jointly sponsored by the National Institute of Mental Health, SAMHSA, and the IOM, the report will draw on findings by a committee of seven that will be holding a one-day workshop next month in Washington, D.C.
The members of the committee include two psychiatrists with expertise in trauma and disaster issues: Robert Ursano, M.D., a professor of psychiatry and neuroscience and chair of the psychiatry department at the Uniformed Services University of the Health Sciences and director of the center for the study of traumatic stress; and Carol North, M.D., director of the Psychiatry Consultation Service at Barnes Jewish Hospital in St. Louis and a professor of psychiatry at Washington University School of Medicine.
"What this committee will do is try to collect information about the mental health consequences of terrorism, identify vulnerable populations, assess the capacity of the public health infrastructure to respond, and make recommendations on how to optimize the response to the population’s mental health needs," said Adrienne Stith Butler, Ph.D., an IOM project officer.
She said the final report, to be issued next year, would also seek to identify a variety of approaches to intervention that may limit adverse mental health consequences.
Within the encompassing concept of all-hazards planning are two elements that are critical to preparing for and responding to terrorism and that have a special role in the impact on mental health and behavior—"risk perception" and "risk communication."
In the immediate aftermath of a terrorist attack, public officials have the difficult task of conveying accurate information about risks to life and health without frightening the public and without concealing the fact that information may be scant, incomplete, or nonexistent.
"The literature tells us that if you are going to be speaking to people about a topic that involves potential risks, you have to be honest and straightforward about the facts as you know them, and you have to be clear where there are things you don’t know," DeMartino said.
"What is important is to make information accessible enough so that your audience knows and understands the risks, but not so frightening that they reject it because they don’t want to think about it." Knowledge and accurate information give people a "perception of control," critical to wise and cautious action in a stressful time, DeMartino said.
Yet inherent in the nature of terrorism is an element of uncertainty, a feature that is likely to be especially prevalent in the case of bioterror, spreading death and disease through infectious pathogens. "You can’t see it or feel it, so that perception of control is much worse," DeMartino said. "You don’t know where it comes from, so you don’t know how to gauge the risk."
For this reason, the mental health consequences of bioterror may be especially pronounced—or potentially long lasting. At a national summit last year held by SAMHSA on "When Terror Strikes," DeMartino presented a "best-case" scenario for a bioterrorist event. In such a case, there would be a small event involving a noncommunicable disease for which there is some warning and in which the agent was rapidly identified. In that best case, the ratio of behavioral to medical sequelae would likely be 4 to 1.
Far worse scenarios are imaginable, such as the "Dark Winter" exercise by the Johns Hopkins Center for Civilian Biodefense Strategies simulating a bioterrorist attack using smallpox virus, which in a worst-case scenario could result in a million deaths in a matter of months.
In such a scenario, mass panic might be the ultimate behavioral sequela of terrorism. In his presentation last year, DeMartino described the risk factors for mass panic: a belief that there is a small chance of escape from a deadly agent, the perception of a very high risk, limited treatment resources, no effective public response, and loss of credibility by authorities.
Yet the evidence of people’s response to past natural and man-made disasters—not to mention the courage that characterized the response of Americans in New York, Washington, and elsewhere last fall—provide signs of people’s resilience and resistance to panic. ▪