Psychological Responses to the New Terrorism: A NATO-Russia Dialogue (Nato Security Through Science Series E: Human Societal Dynamics)

PSYCHOLOGICAL RESPONSES TO THE NEW TERRORISM: A NATO-RUSSIA DIALOGUE

NATO Security through Science Series This Series presents the results of scientific meetings supported under the NATO Programme for Security through Science (STS). Meetings supported by the NATO STS Programme are in security-related priority areas of Defence Against Terrorism or Countering Other Threats to Security. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO STS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action Following a transformation of the programme in 2004 the Series has been re-named and re-organised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Public Diplomacy Division. Sub-Series A. B. C. D. E.

Chemistry and Biology Physics and Biophysics Environmental Security Information and Communication Security Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springeronline.nl http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 3

ISSN: 1574-5597

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue

Edited by

Simon Wessely Department of Psychological Medicine, Institute of Psychiatry, King’s College, London and King’s Centre for Military Health Research

and

Valery N. Krasnov Moscow Research Institute of Psychiatry, Moscow

Amsterdam • Berlin • Oxford • Tokyo • Washington, DC Published in cooperation with NATO Public Diplomacy Division

Proceedings of the NATO Advanced Research Workshop on Social and Psychological Consequences of Chemical and Biological Terrorism Brussels, Belgium 25–27 March 2002

© 2005 IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 1-58603-554-1 Library of Congress Control Number: 2005935644 Publisher IOS Press Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

Distributor in the UK and Ireland IOS Press/Lavis Marketing 73 Lime Walk Headington Oxford OX3 7AD England fax: +44 1865 750079

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

v

Contents List of Contributors Chapter 1. Introduction Simon Wessely and Valery N. Krasnov

vii 1

THE BACKGROUND Chapter 2.Introduction to and Mitigation of Psychological Effects of Weapons of Mass Destruction (WMD) Ross H. Pastel and Elspeth Cameron Ritchie Chapter 3. Emergency, Disaster, and Catastrophe: A Typology with Implications for Terrorism Response Thomas A. Glass Chapter 4. Cultural Precursors and Psychological Consequences of Contemporary Western Responses to Acts of Terror Bill Durodié Chapter 5. Towards a Public Mental Health Approach to Terror Johan M. Havenaar and Evelyn J. Bromet Chapter 6. Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Jennifer S. Lerner, Roxana M. Gonzalez, Deborah A. Small and Baruch Fischhoff Chapter 7. Threats, Chemicals and Bodily Symptoms: A Psychological Perspective Omer Van den Bergh

9

25

37 55

67

81

THE RUSSIAN PERSPECTIVE Chapter 8. Immediate Interventions – The Experience of the Emergency Mental Health Service of EMERCOM of Russia Sergei Aleksanin Chapter 9. Social, Community and Individual Responses to Terrorist Attacks Valery N. Krasnov Chapter 10. Approaches to the Study of Suicide Terrorism: A Perspective from Russia Valery N. Krasnov Chapter 11. Cross-Confessional Investigation of Religious Visions of the World in the Context of the Fight against Terrorism Victor F. Petrenko and Anna I. Yartseva Chapter 12. Special Features of Emergency Psychological Assistance during Acts of Terrorism Yulia S. Shoigu

93 97

107

115

125

vi

Chapter 13. Perception and Experiencing of “Invisible Stress” (in Relation to Radiation Incidents Nadejda V. Tarabrina Chapter 14. Can We Improve the Psychological Tolerance of Populations to Chemical and Biological Terrorism? Vassily Yastrebov Chapter 15. Stockholm Effects and Psychological Responses to Captivity in Hostages Held by Suicidal Terrorists Anne Speckhard, Nadejda Tarabrina and Natalia Mufel

129

137

139

THE AFTERMATH Chapter 16. Tracking the Social Dynamics of Responses to Terrorism: Language, Behavior, and the Internet James W. Pennebaker and Cindy K. Chung Chapter 17. Treatment of Trauma Survivors with Acute Stress Disorder: Achievements of Systematic Outreach Arieh Y. Shalev, Sara Freedman, Yossef Israeli-Shalev, Sarah Frenkiel-Fishman and Rhonda Adessky Chapter 18. Short and Long Term Psychological Reactions to Terrorism: The Role of Information and the Authorities Simon Wessely Chapter 19. Responding to Chemical, Biological, or Nuclear Terrorism: The Indirect and Long-Term Health Effects May Present the Greatest Challenge Kenneth C. Hyams, Frances Murphy and Simon Wessely Chapter 20. Societal Responses to New Terrorism Ben Sheppard

159

171

185

191 205

APPENDICES Chapter 21. Appendix 1. Conclusions of the NATO Advanced Research Workshop on Social and Psychological Consequences of Chemical and Biological Terrorism Brussels, Belgium, 25–27 March 2002 S. Wessely and V. Krasnov Chapter 22. Appendix 2. Guidelines for Communicating the Risk of Chemical, Biological or Nuclear Terrorism: How to Inform the Public, Improve Resilience and not Generate Panic S. Wessely, B. Fischhoff and V. Krasnov Author Index

223

233 243

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

vii

List of Contributors Professor Sergei Aleksanin, Deputy Director, All-Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia Lebedeva str. 4/2, St. Petersburg, 194044, Russia. Professor Evelyn Bromet, Professor of Epidemiology, Department of Psychiatry, State University of New York at Stony Brook, USA. Dr Cindy Chung, Department of Psychology, The University of Texas at Austin, Austin, TX 78712. Bill Durodié, Senior Lecturer in Risk and Security, Resilience Centre, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, Swindon SN6 8LA. Phone: +44 (0)1793 78 5296 (office), +44 (0)7957 559 099 (mobile). E-mail: w.durodie@ cranfield.ac.uk Web-site: http://www.durodie.net Professor Baruch Fischhoff, Howard Heinz University Professor, Department of Social and Decision Sciences, Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213-3890. Thomas A. Glass, Ph.D. Associate Professor, Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street Baltimore, MD 21205. Professor Johan Havenaar, Department of Psychiatry, Vrije Universiteit Amsterdam, The Netherlands, Managing director of adult mental health care, Buitenamstel, Institute of mental health care, Locatie Oldenaller, Oldenaller 1, 1081 HJ, Amsterdam, The Netherlands, Tel +31 00 20 7884 555, Fax +31 00 20 6428 235, e-mail: j.havenaar@ggzba Dr Craig Hyams, Office of Public Health and Environmental Hazards, Department of Veterans Affairs, VA Central Office (13A), 810 Vermont Avenue NW, Washington, DC 20420. Professor Valery Krasnov, Director, Moscow Research Institute of Psychiatry, Poteshnaya v/3, 107076 Moscow. E-mail: [email protected] Dr Jennifer Lerner, Department of Social and Decision Sciences, Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213-3890. Ross H. Pastel, Ph.D. Lieutenant Colonel, Medical Service Corps, U.S. Army Deputy Commander, Safety, Biosurety, Operations, Plans, and Security, USAMRIID, 1425 Porter St, Fort Detrick, MD 21702-5011 and Adjunct Assistant Professor, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. Professor James Pennebaker, Department of Psychology, The University of Texas at Austin, Austin, TX 78712. Victor F. Petrenko, Ph.D., correspondent member of the Russian Academy of Sciences, professor of the Faculty of Psychology in Moscow State University, Moscow, Russia, Phone: (095) 458-75-13, e-mail: [email protected]

viii

List of Contributors

COL Elspeth Cameron Ritchie, MD. MPH, Psychiatry Consultant to the Army Surgeon General, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20901. Dr Yulia S. Shoigu, the chief of the Center of Emergency Psychological Aid of the EMERCOM, Russia. Mr Ben Sheppard, Research Associate, King’s Centre for Risk Management, King’s College London. Professor Arieh Y. Shalev, Professor of Psychiatry, Head, Department of Psychiatry Hadassah University Hospital, Ein Kerem Campus, Jerusalem, 91120, Israel. Anne Speckhard, Ph.D. Adjunct Associate Professor of Psychiatry, Georgetown University Medical Center and Professor of Psychology, Vesalius College, Free University of Brussels. Nadejda Tarabrina, Ph.D., Associate Professor of Psychology and Director of the Traumatic Stress Disorder Laboratory, Institute of Psychology, Russian Academy of Sciences. Dr Omer Van den Bergh, Research Group for Stress, Health and Well-being, Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium. Professor Simon Wessely, Director, King’s Centre for Military Health Research, Professor of Epidemiological and Liaison Psychiatry, Institute of Psychiatry, Weston Education Centre, King’s College London, Cutcombe Rd., Denmark Hill, London SE5 9RJ, e-mail: [email protected] Anna I. Yartseva, psychologist, graduate of the Faculty of Psychology of Moscow State University. Vassily Yastrebov, MD, Professor, Head of Mental Health Support Systems Research Center, Russian Academy of Medical Sciences, 2-2, Zagorodnoje Shosse, 117152, Moscow, Russia, Phone: (095) 952 8929; (095) 952 9201, Fax: (095) 952 8940; (095) 952 9201, e-mail: [email protected]; [email protected]

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

1

Introduction Simon Wessely a,1 and Valery Krasnov b a Institute of Psychiatry, Weston Education Centre, King’s College London, Cutcombe Rd., Denmark Hill, London SE5 9RJ b Moscow Research Institute of Psychiatry, Poteshnaya v/3, 107076 Moscow

Why a Workshop? When President Putin met with NATO Secretary General Robertson in October 2001 it was agreed that one area of co operation between NATO and Russia was studying the effects of terrorism – for reasons that do not need to be spelt out, this was a topic of pressing interest to both Russia and all the NATO nations. The sense of psychological dislocation and disturbance that had echoed around the world in the wake of the television coverage of the events of Sept 11th 2001 were clearly very much in mind, when they identified studying the psychological and social consequences of the new terrorism as a priority. One result was to convene the first ever NATO-Russia Advanced Research Workshop (ARW) on the subject, and indeed to convene it in record time, largely thanks to the unsung efforts of NATO scientists and staff such as Dr Kees Wientjes and Dr Fernando Carvalho Rodriguez. A remarkably diverse group of academics and practitioners made their way to Brussels at the end of March 2002 to discuss the issues, and also to witness the first occasion that the flag of Russia had flown at NATO Headquarters.

What Happened? In the first appendix to this book (Chapter 21) we reproduce the report on the workshop itself. Since then we have also assembled twenty manuscripts developing some of the themes of the workshop, and we are grateful to all the contributors who have provided this material. As frequent attendees at international meetings and workshops ourselves, in which a convivial and successful interaction is blighted by the subsequent request for a chapter for a previously unmentioned publication, we are aware of the efforts required to produce these manuscripts. We also have every sympathy for those unable to fulfil our belated request, and can assure them that they remain very much our friends! Nevertheless, the reader might like to break convention and start with this chapter (Chapter 21) to get an impression of the richness of all the material presented, and the broad scope of the subject. Turning to the contributions, we can discern several themes emerging. First, the universal acknowledgement that runs as a constant theme through each and every contribution of the importance of psychological factors in understanding and mitigating our 1 E-mail: [email protected]

2

S. Wessely and V. Krasnov / Introduction

response to terrorism. The word “terrorism” itself makes its purpose all too clear – it is to create a state of terror, of fear. The killing, maiming and destruction of property that accompanies terrorism is not the end in itself – if that were the case it would have little impact. Terrorism is the creation of states of mind, of reducing people’s resilience and will to resist, and causing such psychological and social pressure that eventually the political aims of a terrorist group will be fulfilled. This book is not about the prevention of terrorism. It is not about better security, increased detection, more sophisticated technology and so on. Nor is about understanding the mind of the terrorist, important though that this (having said that, the rise of suicide terrorism in Russia in the recent past meant that it was felt important to reflect something of this issue – see for example the contribution of Petrenko and Yartseva on religion and terrorism, Chapter 11). This volume is primarily concerned with the consequences of acts of terror, and their impact on populations. And it is concerned with what we are citizens, professionals and governments can do to mitigate these consequences. In general we focussed less on the “timeless” or “universal” trauma reactions captured by labels such as post traumatic stress disorder, but more on culture and place specific reactions (see Havenaar and Bromet, Chapter 5). A comparison of the responses visible in Russia to large scale adversity on a scale unimaginable in the West [1], as well as recent terrorist situations, with the new western cultural shift towards an age of anxiety and risk aversion (see Durodie, Chapter 4, in which he argues that such anxiety and risk aversion is acting as a force multiplier to increase the psychological impact of terrorism) makes this point. We start therefore with a an outline of the problem, provided by Cameron Richie and Ross Pastel, who have written much on the social and psychological consequences of what we have elected to call the “new” terrorism. Their focus, on chemical, biological and nuclear terrorism reflects the broadening of our perception of possible new hazards, risks and opportunities open to terrorist organisations, not least because of the spread of simple new technologies. Nevertheless, we must not forget that in practice most terrorist attacks remain steadfastly conventional. Simple knives are used to convert aircraft into large flying bombs, cars are crammed with explosives, or fanatics seize theatres and schools armed with conventional weaponry. To date, and of course we speak advisedly and almost sotto voce, the examples of the “new terrorism” have been few and far between, and remarkable mainly for their lack of success. The workshop heard accounts of the sarin attack on the Tokyo subway in which the wonder was just how small was the final death toll. We also heard how the cult group responsible had made previous attempts to use other “new terrorist” agents, but failed. The anthrax attacks which convulsed the United States, and remain still unsolved, nevertheless in terms of their direct effects might well have gone almost unnoticed, as indeed did the almost farcical attempts by the Bhagwan cult to use salmonella as a biological weapon. In that instance no one did notice – this was therefore by definition not a terrorist incident, since it failed to cause any terror, only food poisoning. For examples of the possible effects of radiological weapons we were forced to extrapolate from non terrorist events such as the radiation poisoning in Goanna or the nuclear accident at Chernobyl. As Professor Sir Lawry Freedman has said, terrorists remain quintessential risk entrepreneurs, but to date have found conventional means more profitable than the chemical, biological and radiological weapons that we were discussing. Sadly it would be a brave person who would dare to predict that this will not change.

S. Wessely and V. Krasnov / Introduction

3

Emergencies, Disasters and the People Nevertheless, in a contribution that is as arresting on paper as it was in the flesh, American sociologist Tom Glass looks critically at what actually happens in disasters. He reminds us that people are more resilient than we think, and more resourceful than we imagine. Much of the rescue at disasters is carried out not by our trained emergency services, but by bystanders and participants themselves. In particular, he reminds us that if the above paragraph turns out not to be true, and terrorists do acquire the means to generate mass casualties on a scale that defeats the capacity of the system to cope, then we are going to need to mobilise these innate resources and a far greater scale than we have assumed previously.

The Russian Perspective We now turn to the contributions from our Russian colleagues. It will be clear that there are many differences between these contributions and those from the majority of the NATO countries. Exploring the richness of these differences is why we have chosen to call this book a “NATO Russia” dialogue. There are many reasons for these differences. First of all, the classification systems used in Russia for the common psychological disorders are not the same as those used in many Western countries, especially the English speaking world. In fact Russian psychiatric thinking and classification has a very distinguished pedigree, eclipsing our own formulations in the Diagnostic and Statistical Manuals by at least two generations. Likewise, perhaps the greatest Russian scientist of all times, Academician Pavlov, made his presence felt when we came to discuss the problem of how and why people develop chronic and debilitating symptoms after exposure to chemicals at levels which conventional toxicology would suggest harmless (see Chapter 7, Van Der Bergh). The second reason lies in the different political histories of the participant countries, at least in the modern era. Much of the workshop concerned communication and engagement between government and its citizens. We wished for an ideal world in which governments strived to produce rapid, accurate and impartial information in the event of a terrorist incident. Likewise, we wished for a scientifically literate citizenry, but most of all one which trusted its government to be “on the same side”, committed to openness, frankness and transparency. Both of these scenarios are of course mythical. In the United Kingdom communication by government on matters of science is haunted by the spectre of “mad cow disease”. In American there is the Agent Orange saga. Governments have in the past had occasions to be less than open with their citizens, and less than competent in managing public health emergencies. But it is not all one way traffic. Successive governments have been unable to hide their exasperation with citizens as well – the crisis over MMR vaccination in the United Kingdom, in which people seem more willing to allow their children to be infected by agents that definitely do cause disease and even death, whilst avoiding a vaccine which does neither, is at first sight baffling, at least to government. Baruch Fischhoff, who spoke at the meeting and has contributed two chapters to this book, could and did explain this – how lay risk perception is not the same as scientific or statistical risk perception, but one can still sympathise with the difficulties of government when people seem unwilling to listen to, or trust, decent

4

S. Wessely and V. Krasnov / Introduction

scientists whose careers have been spent in protecting the public health, but only too willing to listen to maverick, eccentric and usually misguided scientists who have spent far more time in the TV studio than the laboratory, and whom are far better at writing for the newspapers than the scientific journals. All of these factors are true, and reflect a crisis of confidence in those institutions that we need to trust to defend us against the new terrorism, as political scientist Bill Durodie so elegantly outlines in his dissection of Western responses to terrorism (Chapter 4). But the situation is even more complex in the former Soviet Union. Russian communism, “the God that Failed” as Koestler wrote, did achieve significant social change. But even its most ardent admirers could not claim that a free and democratic press, nor an informed citizenry, were among those achievements. The legacy of communist rule – its hypocrisy and overt manipulation of information, has left a people cynical and disillusioned, with much reason. Communication between government and the people is different when people can recall “Pravda”. All of this is reflected, either spoken or unspoken, in the contributions from our Russian colleagues. Likewise, whilst every contributor constantly referred to the difficulties of co ordination and management of acute crises, the particular legacy of central power in Russia has different problems. There were times when some of those present would have wished for the rigid command and control systems exercised by their Russian colleagues in crisis situations, but there were also times when the disadvantages of these structures were apparent, which is the point made forcefully by Glass when considering what might happen if these centralised emergency management structures were to be overwhelmed by a disaster or catastrophe. We saw some evidence of what Glass is discussing in the ghastly end of the Beslan school siege.

Communication Terrorism is about communication. Without communication there can be no terror, at least other than of those immediately involved. Much attention is being paid, and rightly so, to how terrorists communicate directly with each other, and how they communicate with us. The drawn out torment of videos of hostages in Iraq pleading for their lives before their grizzly executions is an example of the latter. But less attention has been paid to how we communicate with each other about terrorism. Psychological Jamie Pennebaker has made a lifetime study of how people talk to each after disasters in general, and now terrorism in particular (Chapter 16, this volume). People talking to each other in the immediate aftermath of terrorist incidents provides much needed support and reassurance. The conference noted that more attention needed to be given to assisting these normalising processes, and that more needed to be done to safeguard such communications in the immediate aftermath of a terrorist attack. Likewise, it was noted that such communication was an important protection against behavioural panic and disorganisation. The conference also noted en passant the evidence that people talking to mental health professionals, as in so called psychological debriefing or critical incident stress debriefing, did any good, and indeed premature emotional disclosure, especially to strangers or professionals, might actually be harmful (see Chapter 18 and [2,3]). On the other hand, we are now starting to acquire evidence and experience of what treatments do work, especially when focussed not on the majority of people in-

S. Wessely and V. Krasnov / Introduction

5

volved in trauma, most of whom will get better, but on the minority of those who will not (see Shalev, Chapter 17). But what about the authorities talking to the people? The theme of the communication of the risk of terrorism, and of communicating after a terrorist incident, became a leitmotif of the conference, and rightly so. Firstly, because how we prepare populations for the possibility of terrorism is profoundly important in determining our own behaviours in the event of disaster. It may also have crucial political impact on whom we later blame, although that is outside the scope of this volume. Second, if it is indeed the case that, as senior security officials have been saying in Britain and America, it is not “a question of when, but if”, it would be foolhardy to neglect consideration of what is said in the aftermath of an event. Communication matters. The nature of communication has important emotional impacts – people may response to an attack with fear, with rage against the perpetrators, or with rage against their own government for letting it happen, whether justified or not. These emotional consequences themselves affect perception of future risk, and the likelihood of certain behaviours, as Jennifer Lerner and her colleagues demonstrate (Chapter 6). It is not too fanciful to say that the difference between good and bad communication is between a population that responds to terrorism with resilience, courage and a determination to see it through – the Blitz spirit as some contributors termed it – or a population that becomes overwhelmed with anxiety, paralysed with fear, and unable or unwilling to go about its business, thus doing the terrorists’ job for them. We exaggerate, but not by much. The example of Mayor Guiliani in New York who whether by instinct or design managed to mobilise that city’s sense of resilience in the face of disaster is well known. He did so by his behaviour – by speeding to the scene of the disaster he shared the same risks as his citizens, a behaviour that almost cost him his life, but established his courage and credibility [4]. Compare and contrast this with the behaviour of other public figures who are always been moved to a “secure location” at the first sign of trouble. Is it any wonder that in these circumstances people feel less able to tolerate risks or go about their daily business? Actions must match words, and Guiliani’s did that As Aleksanin makes clear (Chapter 8), professionals dealing with emergencies must themselves sometimes accept risk and danger – the same must apply to our leaders as well if they are to provide examples for citizens to follow. If we are to supply examples of responsible bravery, this must start from the top. His words appealed to people’s emotions and sense of shock and pain – as we write in our final chapter on guidelines for communicating the risk of terrorism, public figures have emotions too, and it is not a crime to show them. His words also made it clear what he did and did not know, and established himself rapidly as a source of information that people could trust. The conference also debated the question of not just what should be said, but who should say it. Interesting cross national differences emerged. Powerful civic leaders such as Mayors emerged as important in the USA and Russia, but not in the United Kingdom. Government scientists had less credibility in the UK since the BSE crisis, but were more respected in Scandinavia, and so on. We agreed it was impossible to say who should be the spokesperson, but it was possible to say what qualities this person should have (see Chapter 22).

6

S. Wessely and V. Krasnov / Introduction

They Think it is All Over, and Then... Tom Glass began his presentation by saying one theme of much research about disasters was the fact that afterwards many of those involved often say “well, it could have been worse”. He ascribed this to people being more resilient that we give them credit for, and for the tendency of people to improvise their own solutions when facing adversity. Likewise, we would add the often extraordinary courage and inventiveness shown by emergency workers when really challenged. The conference in general was cautious about some of the apocalyptic “what if” scenarios constructed by some planners concerning CBRN terrorism. We noted that to date terrorism continues to be conventional in its methods, if more indiscriminate and radical in its aims. There is a real danger that we are “scaring ourselves to death” with these scenarios. Likewise, installing more and more elaborate detection systems for less and less likely agents is not only costly, it is also damaging because of the inevitable false alarms, which do not reassure, but only make us more anxious. Some members of the conference also raised fears that these “what if” scenarios did more to reveal to our enemies our own vulnerabilities, and perhaps suggested tactics and opportunities that might not otherwise have occurred to them. So in general the conference, and this volume, concludes that whilst CBRN terrorism provides new threats and challenges, the main threat from global terrorism continues to be conventional. It also concluded that when disasters do strike, especially if man made, there will be death and suffering, often prolonged. But we could also take some comfort from our natural abilities to “muddle through”, our tendencies to react to threats with courage and determination, provided of course that our leaders can provide us with reasons for so doing, and examples of such courage and determination. However, the conference ended on a more ambivalent note. American cultural critic Elaine Showalter spoke about the long term problems that might arise after CBRN terrorism, drawing on the long legacies of Three Mile Island, Chernobyl, the Gulf War Syndrome story and many others [5]. An acute incident may well be managed well but what happens six months later when someone in the affected area develops a cancer, another has a miscarriage, and a third develops strange symptoms. Could this be a lingering legacy of the chemical attack, or the dirty bomb. Official scientists may tell us it is all safe, but there will be the maverick scientist to say otherwise. Rumours and urban legends will flourish. Suspicions will rise. Trust will diminish, and repeated government reassurances will be interpreted as “cover ups”. These problematic long term outcomes are discussed in Chapter 19, and, it is fair to say, whilst we were very much aware of the problem, deciding solutions was more difficult.

References [1] Merridale C. Night of Stone: Death and Memory in Twentieth Century Russia. London: Penguin, 2000. [2] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [3] Gist R, Devilly G. Post-trauma debriefing: the road too frequently travelled. Lancet 2002; 360: 741–742. [4] Boyatzis R, Bilimoria D, Godwin L, Hopkins M, Lingham T. Effective leadership in extreme crisis. In: Neria Y GR, Marshall R, Susser E, ed. 9/11: Public Health in the Wake of Terrorist Attacks. New York: Cambridge University Press, 2005. [5] Showalter E. Hystories: Hysterical Epidemics and Modern Culture. London: Picador, 1997.

THE BACKGROUND

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

9

Introduction to and Mitigation of Psychological Effects of Weapons of Mass Destruction (WMD)1 Ross H. Pastel a and Elspeth Cameron Ritchie b a USAMRIID, 1425 Porter St, Fort Detrick, MD 21702-5011 b Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20901

1. Introduction The importance of the psychological effects of chemical, biological, radiological/nuclear and high explosive (CBRNE) weapons is increasingly being recognized in the post-9/11 era. CBRNE agents are often referred to as “weapons of mass destruction” or “WMD”. However, with the exception of nuclear weapons and high explosives, most of the WMD do not cause large-scale physical destruction. Perhaps a better term would be weapons of mass disruption, as these weapons can cause mass casualties along with extreme psychosocial effects. Some WMDs have been used as agents of war, but all are likely to be effective agents of terror. This chapter will concentrate on psychological effects of chemical, biological, radiological and nuclear (CBRN) weapons. There are critical characteristics of CBRN exposures that differ from conventional weapons (such as bombs or shootings). For example, only a small amount of a biological weapon may be needed and it can be delivered via the air, water or food supply, or by mail. Many CBRN agents are invisible and odorless; thus leading to uncertainties regarding both what kind and what amount of agent a person has been exposed to. In addition, many of the initial or prodromal symptoms are non-specific which leads directly into the problem of differentiating those with direct exposure from those who were unexposed but fear they were exposed. Not knowing who has been exposed thus becomes a central and very important theme for planners, emergency departments, the public health system, and, of course, for the population at large. For example, the sarin attacks in the Tokyo subway system killed twelve, but led 5000 people to seek medical attention [1]. The anthrax in the mail attacks in 2001 caused 23 cases of anthrax with five fatalities, but over 32,000 people with potential exposure sought prophylactic antibiotics (often on the advice of their employer) [2]. In the event of smallpox or pneumonic plague, the threat of contagion is very real, which brings up issues of quarantine and isolation. The recent SARS (severe acute res1 Disclaimer: the opinions expressed are those of the authors and do not reflect the official opinion of the Uniformed University of the Health Sciences, the Department of the Army, or the Department of Defense.

10

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

piratory syndrome) epidemic has demonstrated some of the challenges involved with quarantine. In the event of a smallpox outbreak, isolation of patients, tracing and quarantine of contacts, and vaccination – either ring (i.e., contacts and contacts of contacts) or mass vaccination – will be required to halt an epidemic. Many of the CBRN agents can cause grotesque and disfiguring injuries, which increase the psychological impact both on those affected and on those witnessing the event. For many CBRN agents, special equipment may be needed to detect contamination. For those agents requiring wide-spread environmental decontamination, issues of evacuation from the area or even permanent relocation due to long-lasting contamination (e.g., Chernobyl) require attention. The long-term health consequences of exposures to trace amounts of CBRN agents is controversial: there are many uncertainties whether longterm effects might be psychological, psychophysiological or physiological. Reviewing the literature on “Gulf War Illnesses”, the simplest answer is that there was a combination of all of the above [3]. Health risk communication will be important for both acute and long-term risks. Poor knowledge and public communication will increase psychological ill-effects. For example, information about how to protect oneself from immediate attack is currently scanty or contradictory. In the spring of 2003, the US government advised the population to use duct tape and clear plastic sheeting for protecting themselves at home. This announcement was quickly followed by criticism over questions of efficacy and the dangers of suffocation, as well as many jokes. The loss of governmental credibility, with respect to risk communication was, perhaps, the most serious consequence of his episode (see Appendix this volume). For many years, the military has studied the medical effects of CBRN agents. In July 2000, an international conference on the “Operational Impact of Psychological Casualties from Weapons of Mass Destruction” was held, organized by the first author [4]. There have also been a number of recent reviews on the topic [5–8]. Fortunately, although acute and long-term psychological effects after CBRN events may differ in degree from effects seen after natural disasters or high explosives, they seem to exist on a continuum with no apparent unique psychological disorders [9]. However, it has been postulated that psychophysiologic effects will dominate the long term picture [10]. Although there is historical data about the range of psychological effects, less data is available about the best ways to mitigate expected psychological reactions. Unlike the responses to other episodes of mass violence, we do not have enough information to divide our therapeutic responses into early, intermediate and late phases. Therefore, our response is not delineated in a time-sequenced fashion. In addition, CBRN attacks do not always have a clear end of the attack – long-term contamination may lead to a perceived continuing presence and fear of exposure. There may also be a continuing fear of potential long-term health consequences (e.g., radiation exposure). A brief description of CBRN agents and their medical effects begins the chapter. A historical review of psychological effects following CBRN attacks and accidents follows. The acute and long-term psychological effects of these agents is then summarized. The last section has suggestions for mitigation of these psychological effects.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

11

2. A Brief Summary of Effects of CBRNE Agents 2.1. Chemical weapons Chemical warfare agents (CWA) had their first widespread use in World War I beginning with a German attack with chlorine gas near Ypres, Belgium on 15 April 1915 [60]. The most effective CWA used was sulfur mustard. Chemical agents are reported to have caused one-third of the estimated 5 million casualties of World War I [87]. Fortunately, CWA were not used in World War II. However, they were used again on a large scale in the Iran-Iraq war in the 1980’s, where they reportedly caused at least 45,000 casualties [87]. Five types of CWAs are of most concern: Lung-damaging or pulmonary agents, cyanides, vesicants, nerve agents, and incapacitating agents [60]. Riot-control agents such as tear gas are also chemical agents, but are not considered CWA. Pulmonary agents, such as phosgene and chlorine, are non-persistent gases which produce local pulmonary effects – adult respiratory distress syndrome and pulmonary edema [87]. These agents are toxic industrial chemicals, which are possible terrorist weapons. Cyanides are also nonpersistent gases which can quickly poison cellular metabolism. High exposures cause seizures, and both respiratory and cardiac arrest. Vesicants include sulfur mustard, lewisite, and phosgene oxime and are persistent agents. Vesicants produce delayed effects – blisters (vesicles) – with a latent period of hours following exposure. Depending on exposed areas, the most common effects are on the skin, eyes, and upper respiratory system [60]. Nerve agents (tabun, sarin, soman, and VX) are the most potent CWA. They were invented by the Germans during World War II, but not used until the Iran–Iraq war in the 1980’s. They were also used by Iraq against the Kurdish minority and by a Japanese terrorist cult in the 1990’s. Nerve agents can cause death in minutes by blocking acetylcholinesterase, thus causing excess acetylcholine and a resulting cholinergic crisis. Signs and symptoms vary somewhat after small exposures of vapor vs. small exposures of liquid on skin, but large exposures of vapor or liquids result in sudden loss of consciousness, convulsions, apnea, flaccid paralysis, and copious secretions [60]. 2.2. Biological weapons Biological warfare (BW) is the use of microorganisms or toxins to induce death or disease. Bioterrorism (BT) is the use of biological agents with an ideological motivation (e.g., religious, or political). BW agents (BWA) can be categorized as bacterial agents, viral agents and toxins. BWA differ from CWA in that BWA require an incubation period before they can cause symptoms. Toxins, which are products of living organisms, do not require incubation, but they do have a latent period before they cause symptoms [88]. The Centers of Disease Control (CDC) has differentiated potential biological agents into different categories of concern. Category A agents are of highest concern because of lethality, public fear, and public health requirements. These include the organisms responsible for anthrax, smallpox, plague, tularemia, viral hemorrhagic fevers (e.g., Ebola, Marburg, and Lassa Fever) and botulinum toxin. Typically, BWA initially cause a prodrome with non-specific, flu-like symptoms which can make early diagnosis problematic [89].

12

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

Bacterial agents can be treated with antibiotics, but antidotes to the viral agents and toxins are not available, so supportive care is the only option for treatment. Some BWAs are contagious, meaning that they can be transmitted from person-to-person. Smallpox and pneumonic plague are both contagious through respiratory droplets, while viral hemorrhagic fevers can be transmitted by contact with blood or other body secretions. Licensed vaccines are available for smallpox and anthrax. There has been considerable controversy about the new vaccines however. 2.3. Radiological and nuclear weapons Nuclear weapons can cause death and injury by three mechanisms: blast, thermal and radiation effects [90,91]. Blast and thermal effects are the most prevalent causes of death and injury, but radiation is the most feared effect. Radiological weapons are often referred to as ‘dirty bombs’ or radiation dispersal devices (RDD) and are typically a mix of a radiological source and an explosive. Another type of RDD would be an attack on a nuclear power reactor resulting in a release of radiological material into the environment. In the U.S., the strong containment of nuclear power reactors makes this an unlikely scenario [92]. The acute radiation syndrome (ARS) occurs following exposure to high doses of ionizing radiation. ARS is actually a combination of different clinical syndromes: hematopoietic, gastrointestinal, and a combination of cardiovascular and central nervous system effects. The higher the radiation dose, the shorter the asymptomatic period, and the more intense the initial symptoms. The initial symptoms are non-specific – nausea, vomiting, fatigue, headache and weakness. Radiation is also notorious for causing cancer, perhaps the most feared effect (although actually the contribution of radiation to cancer is relatively small) [93].

3. Historical Examples 3.1. Nuclear and radiological Of all the WMD, nuclear weapons have the greatest destructive impact: they are the quintessential weapons of mass destruction. The atomic weapons dropped on Hiroshima and Nagasaki caused incredible devastation, outbreaks of local fires and large numbers of dead, dying, and injured people [11]. In interviews done after the war, approximately two-thirds described psychological disturbances of intense fear, emotional upset, or depression. Nevertheless there was only a single incident of an apparent mass panic reported at Hiroshima: a large group of frightened people in a park pressed some victims into a river and several died [12]. During the following weeks, survivors continued to witness the sight of severely injured people suffering from burns and blast injuries. In addition, there were outbreaks of acute radiation sickness (ARS). The continued exposures to the devastation and human suffering served as a constant reminder to survivors and reinforced the psychological impact of the original event [11]. Survivors of Hiroshima and Nagasaki were severely stigmatized, especially those with severe burns which resulted in scarring and keloids. Lifton described a ‘Neurasthenic Survivor Syndrome’ characterized by “Persistence of

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

13

symptoms of withdrawal from social life, insomnia, nightmares, chronic depressive and anxiety reactions and far-reaching somatization. . . in addition, fatigue, emotional lability, loss of initiative, and generalized personal, sexual and social maladaptation” [13]. A study of over 7,000 Nagasaki atomic bomb patients done 15 years later showed longterm psychological effects in approximately 7%, with the majority complaining of fatigue, lack of spirit, poor memory and introversion [14]. These symptoms were twice as common in survivors who had shown ARS symptoms and were related to severity of ARS symptoms. The Three Mile Island (TMI) accident in 1979 demonstrated the importance of psychological effects. According to the President’s Commission which studied the accident, the only medical effect documented was mental distress [15]. There were no cases of ARS: the estimated doses for people living within 10 miles of TMI were approximately the dose of an average chest x-ray and much lower than the annual background radiation dose [16]. Populations exhibiting the most distress were TMI workers, families with pre-school-age children, and those living within 5 miles of TMI. Studies of TMI workers reported no long-term effects, only short-term acute effects [16,17]. TMI personnel reported nausea, stomach troubles, headaches, diarrhea, sleep disturbances, and loss of appetite in greater frequency than did control group personnel. (These symptoms are also common in the ARS prodrome, but TMI personnel were not exposed to such doses.) Unlike TMI workers, TMI residents, compared to controls, displayed a significant amount of stress on several measures (performance, self-report measures of anxiety, depression and somatic complaints, physiological measures of urinary norepinephrine, epinephrine, and cortisol, disturbed sleep, and changes in immune system parameters) for up to six years after the accident [18–21]. The TMI symptoms were not the result of exposure to radiation but to perceived radiation threat. Therefore, TMI demonstrates that fear of exposure to WMD can cause significant distress and stress symptoms which can mimic some of the symptoms of actual radiation exposure. Unlike the TMI accident, the Chernobyl accident in 1986 did release significant amounts of radiation. Approximately 135,000 people were evacuated from a 30 km zone in the first two weeks after the accident. Most of these people had to be permanently relocated. In addition, an estimated 600,000 liquidators (i.e., workers involved in the emergency actions on site during the accident and the subsequent cleanup operations) [22]. Acute health effects did occur to liquidators involved in the initial emergency response, including 31 deaths and 140 cases of ARS and other radiation-related acute health effects. An important health effect was widespread psychological distress [22–24]. However, that distress could also have been caused or exacerbated by other factors such as the economic collapse and subsequent breakup of the Soviet Union, evacuation then relocation of communities, distrust in the government, changes in diet (due to contaminated soil), poor nutrition, and other problems [22,24,25]. A study of over 1,400 Latvian liquidators found that 44% had ICD-9 coded mentalpsychosomatic disorders (depression, physiologic malfunction arising from mental factors, or unspecified disorders of the autonomic nervous system) [26]. Due to lack of ICD9 codes, anxiety, post-traumatic stress disorder (PTSD), and sleep disturbances were not diagnosed. A variety of psychoneurological syndromes have been reported as sequelae of Chernobyl in the Russian literature [27–31]. These syndromes are characterized by multiple unexplained physical symptoms (MUPS) including fatigue, sleep and mood disturbances, headaches, impaired memory and concentration, and muscle and/or joint pain.

14

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

These syndromes were reported in both liquidators who had suffered ARS and those who had not [28,30]. No significant correlations were found among physical symptoms, radiation dose and physical examination data [28]. PTSD and PTSD symptoms have been found in two studies [32,33]. An epidemiologic study of over 4,700 Estonian liquidators found an increase in suicide, but no increases in cancer, leukemia, or overall mortality [34]. Suicide accounted for almost 20% of mortality in the liquidator cohort. Reasons for the increased suicide rate are not currently known. Given other studies demonstrating a variety of mental health disorders in Chernobyl liquidators, one could speculate that fear of radiation in these liquidators might cause depression, PTSD, and other disorders which are associated with increased rates of suicide. Interestingly, data from Vietnam veterans with PTSD has demonstrated an increased risk for traumatic deaths, including suicide [35]. The primary toxic agent at Chernobyl appears to be fear, not radiation. 3.2. Biological agents There is emerging data on the potential psychological effects of biological weapons. Smallpox and plague have historically been associated with epidemics and large numbers of fatalities. The most recent smallpox outbreak in a non-endemic country was an outbreak in Yugoslavia in 1972 which caused 175 cases of smallpox with 35 deaths [36]. Containment measures included strict isolation of patients, ring vaccination, prohibition of public meetings, restriction of movement to affected areas, and establishment of checkpoints to check vaccination certificates. A three-week mass vaccination program immunized 18 million out of a total population of nearly 21 million. How the American public would respond to such measures today is unknown. In 1994, there were two outbreaks of plague in India, a bubonic plague outbreak followed one month later by a pneumonic plague outbreak in Surat [37]. There were over 5,000 suspected cases of plague; including 55 deaths [38]. An estimated 400–600,000 people fled Surat, including hospital staff, private medical practitioners, and municipal workers [39–41]. In the city of Delhi, 1200 km from Surat, people used available materials to fashion masks. There was widespread buying and hoarding of tetracycline, which is used to treat plague and is available without prescription in India [40]. The initial government response to the outbreak was denial and officials downplayed the situation. The local press and media helped fuel the anxiety with exaggerated reports [38,41]. In the fall of 2001, the U.S. was shocked by anthrax letters in the mail which led to 23 cases of anthrax [42]. Following September 11, 2001 and prior to the first case of anthrax, there had already been increased purchases of gas masks and ciprofloxacin (“cipro”, used to treat anthrax). After the anthrax mail attacks, there were hundreds of prescriptions for cipro given to people who had no credible exposure [43]. Hospitals reported their already busy emergency rooms were filled with people anxious about anthrax, many demanding treatment. Puzzling long-term effects were seen in the survivors of anthrax. Newspapers reported that survivors suffered symptoms of fatigue, shortness of breath, chest pains, memory problems, nightmares, and rage six–12 months after their illnesses [44,45]. Only one of the inhalational anthrax survivors was well enough to return to work. At this date, no studies have determined whether these symptoms are medical or psychological consequences.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

15

The acute respiratory distress syndrome may be caused by numerous biological weapons. Other infectious disease outbreaks causing this syndrome have been reported to cause both PTSD and a decreased health-related quality of life (HRQL). For example, the majority of survivors of an outbreak of Legionnaires disease reported fatigue, neurologic symptoms, and neuromuscular symptoms 17 months after diagnosis [46]. HRQL was impaired in 7 of 8 dimensions, and 15% of patients experienced PTSD. Similarly, survivors of acute respiratory distress syndrome have also reported decreased HRQL and PTSD [47,48]. 3.3. Chemical agents World War I chemical warfare agents (CWAs) caused 31% of battle injuries, but only 2% of deaths in U.S. forces [49]. In the initial use of chlorine gas on the Western Front by the Germans in 1915, “A full-blown, blind, contagious panic swept portions of the line” [50]. However, there was no panic farther out on the line where there was little or no gas. In the next six gas attacks over the next two months, there were no mass panics, although protective equipment was rudimentary and not widely available. There were only four other gas panics documented in World War I. The psychological impact of CWA casualties was powerful: “A field hospital full of freshly and badly gassed men is. . . the most horrible and ghastly sight of the war. . . to see a hundred or more men, hale and hearty a few hours before, slowly strangling to death from pulmonary edema, with gradually increasing dyspnea, cyanosis and pallor, making futile efforts to expectorate. . .” [51]. Mustard exposure required long convalescence – French mustard casualties at Ypres in 1917 typically required 45 to 70 days before return to duty [52]. Even perceived CWA exposure could cause symptoms. In one incident following desultory gas shelling, 500 battle-tested troops drifted into medical aid stations over a one week period, suffering from chest pain, fatigue, dyspnea, coughing, husky voice, and indefinite eye symptoms [53]. The divisional gas officer found no evidence of gas inhalation or burning. Three years after World War I, approximately one-half of gassed veterans claimed subjective complaints in medical examinations [52]. When there were no objective findings, no compensation or pensions were paid, nor were these included in statistics of permanent disabilities. There were reports of large numbers of men who had recovered from acute gas-poisoning and had good physical examinations, but suffered from serious sequelae, most particularly of easy fatigability and difficulty breathing on exertion [54]. This condition was variously known as effort syndrome, D.A.H. (disordered action of the heart), and neurocirculatory asthenia. In chronic gas cases, there were often acute attacks of breathlessness at night accompanied by nightmares, and patients usually reported insomnia and unrefreshing sleep [54]. PTSD has been reported in World War II American veterans exposed to mustard agent participating in field trials and chamber tests [55]. Sarin, a nerve agent, was used by a terrorist cult in both Matsumoto City in 1994 and in the Tokyo subway in 1995. Over 5,500 people visited 280 medical facilities following the release of sarin in the Tokyo subway [1]. Of these, 1,046 were admitted to the hospital, 20 were treated in intensive care units, and 12 died (10 in the first 48 hours). No extensive mass panic was reported – victims waited in silence both at the subway station and at hospitals. The perplexing silence may have been a sign of psychic numbness [1]. Most admitted patients were hospitalized for a few days. Some reported sleep distur-

16

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

bances, nightmares, and anxiety. Whether these were due to acute stress disorder or to the nerve agent exposure is not known. One study using a post-traumatic symptom scale one month after the event found that hospitalized patients reported fears when approaching the subway (20%), depressed feelings (18%), difficulty sleeping (16%), physical tension (13%), and emotional lability and irritability (7–9%) [1]. A long-term study of sarin patients who had been hospitalized at St. Luke’s Hospital found that somatic and psychological symptoms continued for 5 years after the incident [56]. PTSD was diagnosed in approximately 2–3% and partial PTSD in approximately 7–8%. There was a high rate of reporting of medically unexplained physical symptoms: eye symptoms, fatigue, muscle stiffness, and headache were all reported by more than 10% of the study population.

4. Psychological Effects – Acute and Long-Term Although mass panic is common in disaster movies and media headlines, the evidence from CBRN events and natural disasters suggests that mass panic is very rare [57,58]. What does seem to be common in CBRN events are large numbers of patients reporting to the emergency room with mild exposure or perceived exposure. These patients are not “worried well.” They are worried – possibly with good reason – but they are not well – they have symptoms which cause distress and pain. We advocate that the term “worriedwell” be dropped because it is pejorative and suggests that nothing is wrong with the patient. These patients are certainly worried, but not yet known to be well. Unfortunately, prodromal symptoms of CBRN weapons are often non-specific symptoms; e.g., headache, difficulty breathing, nausea, dizziness, fatigue, and malaise. These symptoms can also be caused by anxiety or by hyperventilation. However, some of the CBRN agents may produce what seem to be psychological effects, but are actually agent-induced effects [59]. In pulmonary agents, respiratory distress may precede measurable physical signs [60]. Symptomatic ambulatory cases with mild or perceived exposures will present difficulties for CBRN event triage. Ubiquitous, non-specific symptoms can also occur with the perception of exposure to a CBRN agent. Outbreaks of these symptoms are often referred to as mass hysteria, mass psychogenic illness, or mass sociogenic illness. However, these terms have a pejorative connotation and should not be used. A more neutral term has been suggested – outbreaks of multiple unexplained symptoms or OMUS [61]. One review found that the most common symptoms included nausea, vomiting, headache, and dizziness or lightheadedness [62]. Not all outbreaks occur in female school-age children! For example, over 1,000 male military recruits reported at least one symptom following a suspected exposure to a toxin in the dining hall [63]. What can be problematic is when an outbreak of multiple unexplained symptoms (OMUS) co-occurs with a CBRN event. Perhaps the most dramatic example occurred following a radiological contamination incident in Goiania, Brazil in 1987 [64]. Four people died, 20 required hospital care and 50 required medical surveillance. However, over 125,000 people demanded to be screened for radiological contamination – only 249 had any radiological contamination. Interestingly, 5,000 of the first 60,000 people screened had symptoms of vomiting, diarrhea, and/or rashes around the face and neck. Although consistent with radiation sickness symptoms, none were contaminated.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

17

The available data suggests that there will be many more patients presenting with mild or psychological symptoms than will be presenting with moderate or severe injury/illness. Unfortunately, when talking with various experts, most disaster exercises have few psychological casualties and what few casualties they have are typically ‘psychotic’, not the expected type of casualty. Furthermore, experience from various disasters, demonstrates that the ambulatory patients show up at the hospital first – before the severely injured can be transported [65]. CBRN victims may present with ill-defined, chronic fatigue-like syndromes with multiple unexplained physical symptoms (MUPS), such as was seen after the first Persian Gulf War in 1991. A full review of Gulf War Illness is outside the scope of this chapter, but may be found elsewhere [3]. Similar syndromes have appeared in veterans following many wars or following infectious diseases, CWA exposures, and nuclear/radiological exposures [14,18,26–28,44,49,54,56,66,67]. These may be stress-related somatization disorders, but at this point, there are no definitive studies. In natural disasters and terrorist attacks with conventional weapons, PTSD, depression, generalized anxiety disorder, and substance/alcohol abuse are commonly seen [68– 70]. We can probably expect similar results from CBRN agents. For example, PTSD has recently been recognized in people recovering from sepsis and acute respiratory distress syndromes [46,48]. PTSD and PTSD-like syndromes were seen following Chernobyl and the sarin attacks in Tokyo [1,25,56,71].

5. Mitigation of Effects 5.1. Preparation in advance Planning before a CBRN event occurs should help prevent and/or mitigate both medical and psychological effects. This should be done in many forms: education of the public, table-top exercises, disaster drills, practice performing tasks in protective equipment, and full scale “mass casualty” exercises [72]. The mass casualty exercises need to be realistic, and they need to role play with large numbers of minimally injured and traumatic stress casualties [73]. The difficulty will be to alert the public to the risks, but not unduly alarm them. Planning and disaster drills should improve the resilience of the public. Accurate information should be released on the effects of the different CBRN agents. Fortunately the Federal and state governments are now implementing disaster planning on a wide scale. In planning for a large-scale disaster, there are numerous scenarios to consider. Is this a chemical or biological or radiological incident? Is it an act of war, terrorism, or an industrial accident? Is there warning, or is it unexpected? Where does it take place? Who is in charge? In all cases, there will be many agencies responding to the attack, as in any disaster (see also Chapter 9 for similarities with Russia). Jurisdictional issues will be paramount. As much as possible, these should be thought through in advance, on the local, state and federal level. For example, in the National Capital Area, deemed a high threat target, there will be the local governments of Northern Virginia, the District of Columbia, and Maryland, plus numerous federal agencies, including the military and the Department of Homeland Security.

18

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

Emergency departments need to be prepared to handle large numbers of people, who are very concerned about exposure. Rather than dismissing concerned citizens by using the pejorative term “worried well”, cases must be taken seriously. A triage area outside the emergency room should be set up, so that many can be screened quickly but thoroughly. Care should also be paid to the concerns of the health care workers. Risks of secondary contagion from chemical agents or infection by biological agents have to be planned for – or else, many health care workers may not show up for work. A number of studies have also demonstrated that victims of a CBRN event consist of more than those on-site during the event. Rescue workers, first responders, healthcare providers, body handlers are also at risk, as are those who lost family or friends to the event [74–76]. The SARS epidemic has demonstrated potential vulnerabilities in our assumption that the health care system is capable of a comprehensive response. The federal government on 10 February 2003 began to issue guidelines for the general public to prepare for a chemical or biological attack. These contained common-sense recommendations, such as, a supply of water, food, flashlights and radios with extra batteries, and mechanical can openers. They also recommended purchasing a roll of plastic, duct tape and scissors for sealing off a room in the home from chemical attacks. This latter recommendation is more problematic, because of the risk of suffocation in complete sealed rooms as was seen in the Scud missile attacks on Israel in 1991 [65]. Training of medical and mental health providers and other associated helping agencies is critical, as has been stressed in other areas of this textbook. Further issues for training of mental health care providers include: the identification of the medical and psychological effects of the different CBRN agents, the differentiation of medical from psychological effects, recognition that infected/injured patients will also suffer psychological consequences and require social support, desensitization of claustrophobia from the protective gear, and other issues as described elsewhere [7,8]. 5.2. Protective equipment issues The protective gear to protect against chemical and biological weapons varies widely, from a simple facemask, to the Mission Oriented Protective Posture (MOPP) gear used by the military, to the self-contained suits used by CDC and HAZMAT personnel. In the past, it was thought that issues of wearing the protective gear were limited to military personnel and first responders trained in use of the equipment. However, increasingly the civilian population may be asked to wear some sort of protective gear. Command and control is an issue in any chaotic situation. In a situation where protective gear is worn, the protective gear will obscure recognition of faces and may garble communication. Therefore labels on the outside of the suits should clearly identify the wearer, and potential communication difficulties should be anticipated. For those who have not worn protective equipment, a brief description of the alienating effects of that equipment may be useful. In the military setting, those who wear the MOPP gear occasionally develop symptoms of claustrophobia, which has been termed “gas mask phobia” [77,78]. This is characterized by feelings of anxiety or panic, which may lead to hyperventilation. In turn, the hyperventilation and anxiety leads to the eyepieces clouding up, and to difficulty breathing, which further contributes to anxiety. In training exercises, occasionally the mask is pulled off, which gives immediate relief. However in the context of a chemical attack, that option may cause death.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

19

Aside from the psychological effects, the equipment is hot and clumsy – even though lighter, improved equipment has been developed. Most equipment allows one to drink through a water bottle, but eating and elimination of body wastes remains problematic. The thermal burden may contribute to the psychological effects described above. “Gas mask phobia” may be treated like other phobias, with the mainstay of treatment being relaxation and desensitization. In practice, that means initially wearing the equipment in quiet situations for short periods of time, and building up to longer periods with more intense activity. Emphasis should be given on activities that replicate the actual duties that a person would perform in the event of an attack. This may include either strenuous activity or working on a computer. Practice of basic activities of daily living, such as eating, drinking and going to the bathroom, should also be practiced. Firefighters and other first responders who routinely train in personal protective equipment are probably self-selected to tolerate the equipment. However, those applicants who are initially unable to tolerate the protective mask should be given a trial of the techniques described above. 5.3. Risk perception and health risk communication In a CBRN event, public health authorities will attempt to calculate the extent of the threat, and doubtless, information will be released via the media. However, it is likely that the extent of the danger will not be known immediately. Typically, initial information is incomplete, fragmented, and sometimes contradictory. As many contributors to this book note, health risk communication will be essential (see chapters 6, 18 and 22). Basic principles of health communication, such as having a consistent message delivered by a knowledgeable and credible official, listening and responding to the concerns of the public, and avoiding the appearance of defensiveness or concealment, should be followed [79]. In the recent past, including 9/11, the anthrax attacks, and the sniper events in the Washington DC area, the value of daily or twice-daily scheduled briefings with the media and the public cannot be understated – even if there is no new information to disseminate. Mayor Giuliani of New York City was extremely effective following the events of September 11. After any toxic accident, there is anxiety about health effects of any toxic release. Such anxieties will be multiplied in the aftermath of a CBRN event. Following 9/11 and the anthrax attacks, the news media was full of devastating descriptions of the results of a potential smallpox attack, and suggested that in the event of anthrax, “Your next breath may kill you.” These kinds of “scare-tactic” information are not helpful – instead the public should be provided with accurate hazard communication and workable solutions, especially with measures that can be taken to protect one’s self and family. According to one approach, risk equals hazard plus outrage [79]. Hazard is the scientifically-based risk-assessment, but outrage is made up of non-quantifiable factors related to the public’s concern and perception of the event. CDC has developed a course on “Emergency Risk Communication Training” which contains more in-depth information on the topic than we have room for here. For more information visit their web site at: http://www.cdc.gov/cdcynergy/emergency/. Outrage following a WMD attack will significantly influence both acute and long-term psychological effects.

20

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

5.4. Triage and issues of differential diagnosis When Israel was attacked with scud missiles during the first Gulf War in 1991, large numbers of people reported to the emergency room for treatment [65,80]. Studies reported that approximately 70–80% of the patients in the early attacks were for stress-related symptoms. Unfortunately, emergency medicine physicians do not spend much time in residency learning how to evaluate psychological casualties [81]. Only recently has there been inclusion of neuropsychiatric casualties in triage [75,82,83]. It will be important for mental health care providers to become better integrated with emergency rooms. An important lesson learned from the Israeli experience is the importance of a separate stress center at hospitals, so that psychological casualties can be removed from the emergency room and taken to a less stressful environment [65,84]. Eleven Israeli civilians who were never in danger of a SCUD missile died because of fear/panic – four by heart attacks, and seven by suffocation (either putting on their gas masks improperly or completely sealing off their room). Initial treatment of psychological casualties may have profound consequences for long-term effects. Military experience dating from World War I demonstrated that “shell shock” casualties needed to be treated near the battle front and be treated when they initially presented with symptoms, rather than after the symptoms had become ingrained [53]. An important part of treatment was the positive expectancy of the staff that the patient would get better, that he was suffering a normal response to an abnormal stimulus. Military experience since then has demonstrated the effectiveness of this treatment, which has been given the acronym PIES – proximity, immediacy, expectancy, and simplicity in reducing PTSD and enhancing the return of soldiers to duty [85,86].

6. Conclusion The use of CBRN weapons may result in mass disruption. There will be a complex of effects which will include acute psychological casualties, long-term psychological casualties, and large-scale psychosocial consequences such as economic disruption, evacuation and/or relocation of portions of the population. The psychological effects will not be unique, but will be similar to those seen after natural and technological disasters, and attacks with conventional weapons. There will likely also be an increase in ill-defined, chronic-fatigue-like syndromes with multiple unexplained physical symptoms. Many of these effects can be prevented or mitigated by proper planning and practice prior to a CBRN event. Mental health care providers will need to become better integrated with disaster response plans and emergency rooms. Early recognition of psychological casualties with prompt supportive treatment in an area separate from medical treatment may be very useful. Health risk communication will be critical.

References [1] Asukai N, Maekawa K. Psychological and physical health effects of the 1995 sarin attack in the Tokyo subway system. In: Havenaar JM, Cwikel JG, Bromet EJ, editors. Toxic Turmoil. Psychological and Societal Consequences of Ecological Disasters. New York City, NY: Kluwer Academic/Plenum Publishers, 2002: 149–162.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

21

[2] Centers for Disease Control. Update: Investigation of bioterrorism-related anthrax and adverse events from antimicrobial prophylaxis. MMWR Morb Mortal Wkly Rep 2001; 50 (44): 973–976. [3] Riddle JR, Brown M, Smith T, Ritchie EC, Brix KA, Romano J. Chemical warfare and the Gulf War: a review of the impact on Gulf veterans’ health. Mil Med 2003; 168 (8): 606–613. [4] Pastel RH, Landauer MR, Knudson GB. International Conference on the Operational Impact of Psychological Casualties from Weapons of Mass Destruction – Proceedings. Mil Med 2001; 166 [Suppl 2]: 1–91. [5] Benedek DM, Holloway HC, Becker SM. Emergency mental health management in bioterrorism events. Emerg Med Clin North Am 2002; 20 (2): 393–407. [6] Holloway HC, Norwood AE, Fullerton CS, Engel CC, Ursano RJ. The threat of biological weapons. Prophylaxis and mitigation of psychological and social consequences. JAMA 1997; 278 (5): 425–427. [7] Ursano RJ, Norwood AE, Fullerton CS, Holloway HC, Hall M. Terrorism with weapons of mass destruction. Chemical, biological, nuclear, radiological, and explosive agents. In: Ursano RJ, Norwood AE, editors. Trauma and Disaster Responses and Management. Washington, DC: American Psychiatric Press, Inc., 2003: 125–154. [8] DiGiovanni C. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry 1999; 156 (10): 1500–1505. [9] Scharf T, Vaught C, Kidd P, Steiner L, Kowalski K, Wiehagen B, et al. Toward a typology of dynamic and hazardous work environments. Hum Ecol Risk Assessment 2001; 7 (7): 1827–1841. [10] Hyams KC, Murphy FM, Wessely S. Responding to chemical, biological, or nuclear terrorism: the indirect and long-term health effects may present the greatest challenge. J Health Polit Policy Law 2002; 27 (2): 273–291. [11] Janis IL. Air War and Emotional Stress. Psychological Studies of Bombing and Civilian Defense. R-212. 6-1-1951. Santa Monica, CA: Rand Corporation. [12] Hersey J. Hiroshima. New York: Knopf, 1946. [13] Lifton R. Death in Life: Survivors of Hiroshima. New York: Random House, 1967. [14] Nishikawa T, Tsuiki S. Psychiatric investigations of atomic bomb survivors. Nagasaki Med J 1961; 36: 717–722. [15] Kemeny JG, Babbitt B, Haggerty PE, Lewis C, Marks P, Marrett CB, et al. Report of the President’s Commission on the Accident at Three Mile Island. New York: Pergamon Press, 1979. [16] Fabrikant JI. Health effects of the nuclear accident at Three Mile Island. Health Phys 1981; 40 (2): 151– 161. [17] Parkinson DK, Bromet EJ. Correlates of mental health in nuclear and coal-fired power plant workers. Scand J Work Environ Health 1983; 9(4): 341–345. [18] Davidson LM, Fleming R, Baum A. Chronic stress, catecholamines, and sleep disturbance at Three Mile Island. J Human Stress 1987; 13 (2): 75–83. [19] McKinnon W, Weisse CS, Reynolds CP, Bowles CA, Baum A. Chronic stress, leukocyte subpopulations, and humoral response to latent viruses. Health Psychol 1989; 8 (4): 389–402. [20] Schaeffer MA, Baum A. Adrenal cortical response to stress at Three Mile Island. Psychosom Med 1984; 46 (3): 227–237. [21] Baum A, Gatchel RJ, Schaeffer MA. Emotional, behavioral, and physiological effects of chronic stress at Three Mile Island. J Consult Clin Psychol 1983; 51 (4): 565–572. [22] Nuclear Energy Agency. Chernobyl. Assessment of Radiological and Health Impacts. 2002 Update of Chernobyl: Ten Years On. 2002. Paris, OECD. Available at http://www.nea.fr/html/rp/reports/2003/ nea3508-chernobyl.pdf [23] Gonzalez AJ. Chernobyl – ten years after. IAEA Bull 1996; 38: 2–13. [24] Ginzburg HM. The psychological consequences of the Chernobyl accident – findings from the International Atomic Energy Agency Study. Public Health Rep 1993; 108 (2): 184–192. [25] Girard P, Dubreuil GH. Stress in accident and post-accident management at Chernobyl. J Rad Protection 1996; 16: 167–180. [26] Viel JF, Curbakova E, Dzerve B, Eglite M, Zvagule T, Vincent C. Risk factors for long-term mental and psychosomatic distress in Latvian Chernobyl liquidators. Environ Health Perspect 1997; 105 (Suppl 6): 1539–1544. [27] Stiehm ER. The psychologic fallout from Chernobyl. Am J Dis Child 1992; 146 (6): 761–762.

22

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

[28] Torubarov FS. Psychological consequences of the Chernobyl accident from the radiation neurology point of view. In: Ricks RC, Berger ME, O’Hara FMJr, editors. The Medical Basis for Radiation-Accident Preparedness III. The Psychological Perspective. New York: Elsevier Science Publishing, 1991. [29] Yevelson II, Abdelgani A, Cwikel J, Yevelson IS. Bridging the gap in mental health approaches between east and west: the psychosocial consequences of radiation exposure. Environ Health Perspect 1997; 105 (Suppl 6): 1551–1556. [30] Novikov VS, Tsygan VN, Borisova ED, Rybina LA. Changes in cerebral bioelectric activity in the Chernobyl NPP accident liquidators. Hum Physiol 1997; 23: 542–546. [31] Pastel RH. Radiophobia: long-term psychological consequences of Chernobyl. Mil Med 2002; 166 (12 Suppl): 134–136. [32] Tarabrina N, Lazebnaya E, Zelenova M, Lasko N. Chernobyl clean-up workers’ perception of radiation threat. Radiat Protection Dosimetry 1996; 68: 251–255. [33] Cwikel J. Comments on the psychosocial aspects of the International Conference on Radiation and Health. Environ Health Perspect 1997; 105 (Suppl 6): 1607–1608. [34] Rahu M, Tekkel M, Veidebaum T, Pukkala E, Hakulinen T, Auvinen A, et al. The Estonian study of Chernobyl cleanup workers: II. Incidence of cancer and mortality. Radiat Res 1997; 147 (5): 653–657. [35] Bullman TA, Kang HK. Posttraumatic stress disorder and the risk of traumatic deaths among Vietnam veterans. In: Fullerton CS, Ursano RJ, editors. Posttraumatic stress disorder. Acute and Long-Term Responses to Trauma and Disaster. Washington, DC: American Psychiatric Press, Inc., 1997: 175–189. [36] Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its Eradication. Geneva: World Health Organization, 1988. [37] John TJ. Learning from plague in India. Lancet 1994; 344 (8928): 972. [38] Mavalankar DV. Indian ‘plague’ epidemic: unanswered questions and key lessons. J R Soc Med 1995; 88 (10): 547–551. [39] Kumar S. Plague in India. Lancet 1994; 344 (8927): 941–942. [40] Ramalingaswami V. Plague in India. Nat Med 1995; 1 (12): 1237–1239. [41] Madan TN. The plague in India, 1994. Soc Sci Med 1995; 40 (9): 1167–1168. [42] Centers for Disease Control. Update: Investigation of bioterrorism-related inhalational anthrax – Connecticut, 2001. MMWR Morb Mortal Wkly Rep 2001; 50 (47): 1049–1051. [43] Steinhauer J. Hysteria can be hazardous. New York Times 2001 Oct 21. [44] Stolberg SG. For anthrax survivors, a halting, painful recovery. New York Times 2002 May 7. [45] Broad WJ, Grady D. Science slow to ponder ills that linger in anthrax victims. New York Times 2002 Sep 16. [46] Lettinga KD, Verbon A, Nieuwkerk PT, Jonkers RE, Gersons BP, Prins JM, et al. Health-related quality of life and posttraumatic stress disorder among survivors of an outbreak of Legionnaires disease. Clin Infect Dis 2002; 35 (1): 11–17. [47] Weinert CR, Gross CR, Kangas JR, Bury CL, Marinelli WA. Health-related quality of life after acute lung injury. Am J Respir Crit Care Med 1997; 156 (4 Pt 1): 1120–1128. [48] Schelling G, Stoll C, Haller M, Briegel J, Manert W, Hummel T, et al. Health-related quality of life and posttraumatic stress disorder in survivors of the acute respiratory distress syndrome. Crit Care Med 1998; 26 (4): 651–659. [49] Gilchrist HL. A Comparative Study of Warfare Gases. Carlisle Barracks, PA: Medical Field Service School, 1925. [50] Hammerman G. The psychological impact of chemical weapons on combat troops in World War I. In: Young RW, Drum BH, editors. Proceedings of the Defense Nuclear Agency Symposium/Workshop on the Psychological Effects of Tactical Nuclear Warfare. Washington, DC: Defense Nuclear Agency, 1987. [51] Norris GW. Some medical impressions of the war. Am J Med Sci 1919; 157: 628–634. [52] Wachtel C. Chemical Warfare. Brooklyn, NY: Chemical Publishing Co., Inc., 1941. [53] Salmon TW, Fenton N. Neuropsychiatry in the American Expeditionary Force. In: Salmon TW, Fenton N, editors. Volume 10. Neuropsychiatry. Washington, DC: Government Printing Office, 1929. [54] Haldane JS. Lung-irritant gas poisoning and its sequelae. J Roy Army Med Corps 1919; 33: 494–507. [55] Schnurr PP, Ford JD, Friedman MJ, Green BL, Dain BJ, Sengupta A. Predictors and outcomes of posttraumatic stress disorder in World War II veterans exposed to mustard gas. J Consult Clin Psychol 2000; 68 (2): 258–268. [56] Kawana N, Ishimatsu S, Kanda K. Psycho-physiological effects of the terrorist sarin attack on the Tokyo subway system. Mil Med 2001; 166 (12 Suppl): 23–26.

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

23

[57] Glass TA, Schoch-Spana M. Bioterrorism and the people: how to vaccinate a city against panic. Clin Infect Dis 2002; 34 (2): 217–223. [58] Quarantelli EL. Images of withdrawal behavior in disasters: some basic misconceptions. Soc Problems 1960; 8: 68–79. [59] Di Giovanni C. Domestic terrorism with chemical or biological agents: psychiatric aspects. Am J Psychiatry 1999; 156 (10): 1500–1505. [60] Chemical Casualty Care Division. Medical Management of Chemical Casualties Handbook. 3rd ed. Aberdeen Proving Grounds, MD: USAMRICD, 2000. [61] Pastel RH. Collective behaviors: mass panic and outbreaks of multiple unexplained symptoms. Mil Med 2001; 166 (12 Suppl): 44–46. [62] Boss LP. Epidemic hysteria: a review of the published literature. Epidemiol Rev 1997; 19: 233–243. [63] Struewing JP, Gray GC. An epidemic of respiratory complaints exacerbated by mass psychogenic illness in a military recruit population. Am J Epidemiol 1990; 132 (6): 1120–1129. [64] Petterson J. Perception vs. reality of radiological impact: the Goiania model. Nuclear News 1988; 31: 84–90. [65] Bleich A, Dycian A, Koslowsky M, Solomon Z, Wiener M. Psychiatric implications of missile attacks on a civilian population. Israeli lessons from the Persian Gulf War. JAMA 1992; 268 (5): 613–615. [66] Ayres JG, Flint N, Smith EG, Tunnicliffe WS, Fletcher TJ, Hammond K, et al. Post-infection fatigue syndrome following Q fever. QJM 1998; 91 (2): 105–123. [67] De Roo A, Ado B, Rose B, Guimard Y, Fonck K, Colebunders R. Survey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences. Trop Med Int Health 1998; 3 (11): 883–885. [68] Norris FH. 60,000 disaster victims speak. Part I: an empirical review of the empirical literature, 1981– 2001. Psychiatry 2002; 65: 207–239. [69] North CS, Nixon SJ, Shariat S, Mallonee S, McMillen JC, Spitznagel EL, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA 1999; 282 (8): 755–762. [70] Brown ES, Fulton MK, Wilkeson A, Petty F. The psychiatric sequelae of civilian trauma. Compr Psychiatry 2000; 41 (1): 19–23. [71] Koscheyev VS, Leon GR, Gourine AV, Gourine VN. The psychosocial aftermath of the Chernobyl disaster in an area of relatively low contamination. Prehospital Disaster Med 1997; 12 (1): 41–46. [72] DiGiovanni C. Pertinent psychological issues in the immediate management of a weapons of mass destruction event. Mil Med 2001; 166 (12 Suppl): 59–60. [73] Campanale RP. Realism in disaster exercises – a true challenge. Mil Med 1963; 128: 418–427. [74] North CS, Tivis L, McMillen JC, Pfefferbaum B, Spitznagel EL, Cox J, et al. Psychiatric disorders in rescue workers after the Oklahoma City bombing. Am J Psychiatry 2002; 159 (5): 857–859. [75] Burkle FM. Triage of disaster-related neuropsychiatric casualties. Emerg Med Clin North Am 1991; 9 (1): 87–105. [76] Fullerton CS, Ursano RJ, Kao TC, Bharitya VR. Disaster-related bereavement: acute symptoms and subsequent depression. Aviat Space Environ Med 1999; 70 (9): 902–909. [77] Ritchie EC. Psychological problems associated with mission-oriented protective gear. Mil Med 2001; 166 (12 Suppl): 83–84. [78] Ritchie EC. Treatment of gas mask phobia. Mil Med 1992; 157 (2): 104–106. [79] Sandman PM. Responding to Community Outrage: Strategies for Effective Risk Communication. Fairfax, VA: American Industrial Hygiene Association, 1993. [80] Rotenberg Z, Noy S, Gabbay U. Israeli ED experience during the Gulf War. Am J Emerg Med 1994; 12 (1): 118–119. [81] Williams ER, Shepherd SM. Medical clearance of psychiatric patients. Emerg Med Clin North Am 2000; 18 (2): 185–98, vii. [82] Burkle FM, Newland C, Orebaugh S, Blood CG. Emergency medicine in the Persian Gulf War – Part 2. Triage methodology and lessons learned. Ann Emerg Med 1994; 23 (4): 748–754. [83] Burkle FM. Acute-phase mental health consequences of disasters: implications for triage and emergency medical services. Ann Emerg Med 1996; 28 (2): 119–128. [84] Rosenbaum C. Chemical warfare: disaster preparation in an Israeli hospital. Soc Work Health Care 1993; 18 (3–4): 137–145. [85] Solomon Z, Benbenishty R. The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon War. Am J Psychiatry 1986; 143 (5): 613–617.

24

R.H. Pastel and E.C. Ritchie / Psychological Effects of Weapons of Mass Destruction

[86] Jones FD. Traditional warfare combat stress casualties. In: Jones FD, Sparacino LR, Wilcox VL, Rothberg JM, Stokes JW, editors. War Psychiatry. Washington, DC: Borden Institute, 1995: 35–62. [87] Newmark J. Chemical warfare agents: a primer. Mil Med 2001; 166 (12 Suppl): 9–10. [88] Kortepeter MG, Christopher G, Cieslak TJ, Culpepper R, Darling R, Pavlin J, et al. USAMRIID’s Medical Management of Biological Casualties Handbook. 4th ed. Fort Detrick, MD: USAMRIID, 2001. [89] Kortepeter MG, Cieslak TJ, Eitzen EM. Bioterrorism. J Environ Health 2001; 63 (6): 21–24. [90] Jarrett DG. Medical aspects of ionizing radiation weapons. Mil Med 2001; 166 (Suppl 2): 6–8. [91] Jarrett DG. Medical Management of Radiological Casualties. Bethesda, MD: AFRRI, 1999. [92] Pastel RH, Kahles GR, Chiang M. Medical and psychological consequences of radiation dispersal devices. SP 01-1. 10-26-2001. Bethesda, MD: AFRRI. [93] Patterson JT. The Dread Disease: Cancer and Modern American Culture. Cambridge, MA: Harvard University Press, 1987.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

25

Emergency, Disaster, and Catastrophe: A Typology with Implications for Terrorism Response Thomas A. Glass Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe Street, Baltimore, MD 21205

1. Introduction The central theme of this chapter is that previous research and theory in the sociological study of natural and technological disasters can inform present policy and research in the area of terrorism (and bioterrorism more specifically) in ways that have yet to be fully appreciated. For the last five decades, the social scientific study of disasters has amassed a large number of case studies, refined a set of useful concepts and theories, and dispelled important myths about the way social groups respond to tragic and lifethreatening circumstances. A better understanding of how the public responds to disasters can inform preparedness and mitigation efforts in the area of terrorism. The dominant theme of the sociological study of disasters has been the observation that social response is less chaotic, less panicked, and more patterned and rule-governed than conventional wisdom has it. However, these insights have been less well articulated and explicated in the area of bioterrorism to date. Therefore, the main goals of this chapter are to provide this explication by: 1) Describing the results of a comparative study of 10 natural and technological disasters done by the author and a team of investigators at Texas A&M University; 2) Propose a typology of mass casualty events (MCEs) in order to formalize a distinction between disasters, emergencies and catastrophes; 3) Develop and explicate the core theme that despite the tendency of planners to think about preparation for a CBW attack in solely professional terms, it would be a terrible mistake to ignore or underestimate the possible role public will likely play in a large scale event; 4) Unpack the implications of this line of research for bioterrorism planning, policy and research.

2. Comparative Study of Mass Casualty Events (MCEs) Between 1989 and 1994, our group, based at Texas A&M University in the United States, initiated a multidisciplinary and comparative study of natural and technological disas-

26

Th.A. Glass / Emergency, Disaster, and Catastrophe

ters funded by the National Science Foundation. This was in response, in part, to considerable interest in disaster research after the United Nation’s decade on disasters. Our goal was to study a range of events comparatively, in order to identify general patterns in response to situations that produce large numbers of casualties, for which some deaths and injuries are assumed to be preventable. This was among the first studies of its kind to be comparative across multiple events, and which brought together engineers, social scientists, epidemiologists and landscape architects. The epidemiologic objective of this project was to understand how deaths and injuries occurred, and what factors mitigated for and against fatal outcomes. Our team developed a quick response field methodology, based in part on over 30 years of study by investigators at the Disaster Research Center at University of Delaware. We deployed a multidisciplinary team to each of 10 MCE’s within 72 hours. Massive amounts of data were collected by our team including building plans, population surveys, press coverage, hospital and emergency medical system data, extensive interviews of professional and non-professional persons involved, and death certificates. The overall goal of the study was to examine factors related to survivability. This was in response to the observation that fatalities and injuries are almost always lower than expected and fewer than initially estimated. The question was: why is this so? What factors are associated with risk of death and injury, and, perhaps more importantly, what factors are associated with protection against these risks? 2.1. MCE’S studied The ten MCE events examined are described in brief detail in Table 1. They included both large and small events, both natural and technological calamity, and “single-site” and “multi-site” events. Table 1 summarizes the casualty figures. In all the events studied, the common refrain from those who examined the epidemiological outcomes was “It’s a miracle that more people weren’t killed.” For example, on August 24, 1992, Hurricane Andrew brought sustained winds of over 140 miles per hour to southern Florida. The best estimates suggest that at least 10,000 residents of Homestead Florida (a community that was especially hard hit) remained during the category five hurricane. Despite almost inestimable wind speeds, and the destruction of approximately 56,000 family dwelling units, Table 1. Summary information on MCE’s studied Location

Event∗

1. Loma Prieta, CA, USA 2. Lugoff, SC, USA 3. LaGuardia Airport, NY, USA 4. Brenham, TX, USA 5. Guadalajara, Mexico 6. Dade Co., FL, USA 7. World Trade Center, NY, USA 8. Tulsa OK, USA 9. Mobile, AL, USA 10. Northridge, CA, USA ∗ “disasters” vs. “emergencies”.

Date

Deaths

Number of injures

Earthquake Train derailment Plane crash Natural gas explosion Underground gas explosion

Oct. 1989 Mar. 1991 Mar. 1992 Apr. 1992 Apr. 1992

62 8 27 3 200+

3757 63 24 18 1400+

Hurricane Andrew Bomb explosion and fire Tornado Train derailment Earthquake

Aug. 1992 Feb. 1993 Apr. 1993 Sep. 1993 Jan. 1994

34 6 7 47 58

1400+ 1042 143 181 9200+

Th.A. Glass / Emergency, Disaster, and Catastrophe

27

along with significant damage to the response infrastructure, only 34 were killed [1]. The critical finding in each of these events was that untrained citizen, victims at the immediate scene, responded to life-threatening circumstances with extraordinary resourcefulness and competence. Importantly, these data also revealed that victims respond collectively, by forming emergent social groups, that avoid death and injury beyond expectation. The explication of these findings and their implications for terrorism response will be the subject of the remainder of this chapter. Other results and conclusions from this study have been published previously [2–6].

3. What Is a Disaster? Among the most important findings of this study, was the realization that the term disaster is problematic and in need of greater clarity of definition. In common language, we have become accustomed to hearing people use the word disaster to refer to everything from a dinner party that goes badly, to an outbreak of terrible disease in a dozen people (e.g., anthrax, U.S.). In the course of our study, our group developed a typology of mass casualty events based on the relative magnitude of two fundamental parameters: a) the demand characteristics of the event (numbers of victims in need or in potential need of extrication, rescue, shelter, and medical intervention), and b) the response capacity available in the immediate environment of the event (including both formal and informal sources of response capacity). This typology is depicted in Fig. 1. The figure posits three qualitatively different types of MCEs: emergencies, disasters and catastrophes. The fundamental insight, drawn from our own studies, and from previous disaster sociology, is that relative scale is of critical importance. That is, a disaster can be more precisely defined as an MCE that generates demands (casualties and damage) in excess of the locally available response capacity. This implies that a small MCE that occurs in a rural or remote area with few formal response resources, can become a disaster, while

Figure 1. Typology of MCEs, making distinctions between disasters, emergencies, and catastrophes.

28

Th.A. Glass / Emergency, Disaster, and Catastrophe

a large MCE (in absolute terms) in a metropolitan city equipped with vast professional and non-professional resources, may not be thought of usefully as a disaster at all. For example, we studied the derailment of the Amtrak sunset limited train in Lugoff, South Carolina. Although this event produced only 64 serious injuries and 8 deaths, we classify it as a disaster because the response capacity was exceeded by the demands. The event itself occurred in a swamp, several miles from the nearest town. The derailment occurred at four o’clock am near a in a small town with a small volunteer fire department. Given the needs of those injured in the dark, local resources were quickly overwhelmed. Alternatively, we also studied the crash of U.S. Air flight 405 on a runway at LaGuardia Airport in New York City in March of 1992. Of the 51 passengers on board, 27 died and 24 were injured after the plane flipped off the runway and into Flushing bay. Ad hoc civilian responders on the plane managed to remove injured passengers from fuelcovered mirky water. In contrast to the circumstances surrounding the Lugoff crash, the US air crash in New York City produced a massive professional response. The EMS and hospital capacity was hardly dented by the demands. This event, in our typology is better classified an emergency. A third relevant example is the Earthquake that struck Kobe Japan in January of 1995 (although well-documented, it was not among the events our group studied). Kobe represents the rare circumstances when the demand characteristics of the event dramatically exceed the response capacity of the formal response system, coupled with substantial direct or indirect damage to the infrastructure upon which that response system depends. In the immediate aftermath of the Kobe (or Great Hanshin) earthquake, roads, bridges, and communications were completely knocked out, hospitals were turned to rubble, firefighters lacked water to battle the 300 fires that broke out due to disruption of the water supply. Tragically, Kobe generated 6,279 deaths, 90% occurred during building collapse, 35,000 injured, and 300,000 lost their homes. In short, the formal response system was massively disrupted. In the first 24 hours, no patients were transported to the local hospitals [7]. Yet despite this, over 1800 persons were extricated from collapsed structures and automobiles and 80% survived despite the lack of a hospital [8]. This points to the importance of non-professional (or informal) response capacity. Kobe is an example of an event that due to the scale of disparity between demands and resources, constitutes a catastrophe. As depicted in Fig. 1 the relationship between demands and resources may not be strictly linear. It has not been possible in the study that we completed to do a comprehensive analysis of the precise threshold points at which an emergency becomes a disaster, or a disaster becomes a catastrophe. We have come to believe however that this typology represents qualitatively different phenomenon with important implications for planning and response. This is the topic of the next section. 3.1. Relevance to terrorism? The two key points made thus far have been: emergencies are qualitatively different from disasters, and that whether an event becomes a disaster depends on the relative scale of resources to demands. To extend these points to a WMD scenario, an event involving 5 thousand victims in New York’s Manhattan may not require the same response strategies as an event involving 500 cases in Manhattan, Kansas (population X). In the U.S., there is a clear preference for thinking in terms of emergencies (albeit large scale ones) in which

Th.A. Glass / Emergency, Disaster, and Catastrophe

29

formal response capacity (hospitals, doctors, nurses, police, EMS) will be sufficient, if severely taxed, to mount a response that results in a minimal reduction in the standard of care afforded to those who are injured. However, beyond the horizon of events that are no larger than the break-even point, where professional responses are adequate, the question becomes: what happens when all the hospitals, clinics, pharmacies, first-aid tents become flooded beyond capacity? What happens when demands exceed that threshold? We rarely entertain this as a possibility, both because these kinds of events are rare and because we tend to presume that available professional capacity is highly elastic. This should not prevent us from thinking about larger scale events where life and death may hang in the balance for large numbers of civilians and for which highly professionalized models are less than adequate. What makes disasters so interesting to study is that from a sociologic approach, human behavior is general highly patterned and structured as a result of the “take-forgranted” nature of everyday life. Sudden disasters (such as an earthquake) cause a rapid dislocation in the integrity of the take-for-granted world of everyday life. By definition, this dislocation is usually on a large or massive scale and by definition, groups and individuals have to create new ways of coping. By definition, what makes a disaster disastrous is that the resources available to respond in the usual taken-for-granted are insufficient for the scale of the crisis. Disasters have this all encompassing quality that transforms and upends routine life sometimes in the blink of an eye. Based on several decades of research, social scientists have come to understand the nature of what happens at the intersection of victim behavior, health system response and the environment as emergent collective behavior. This concept is a rubric, it is a powerful organizing tool and heuristic device. 3.2. A thought experiment The essential argument is that disasters are qualitatively different from emergencies in ways that are quite significant in terms of planning and response. Consider the following simple thought experiment. If a gas attack occurred in the underground below Trafalgar square at this very moment, generating 100 critically injured Londoners, would emergency medical workers arrive quickly and mobilize sufficient resources to respond effectively to the needs of the injured? Would law enforcement be able to establish a secure perimeter and begin an investigation into the identity of the culprit? Would London’s hospital system be able find 100 empty beds to treat victims as they arrived? Would doctors and nurses be able to offer all 100 injured patients state-of-the art care without significant compromise? Could all this be done right now without planning or drilling beyond what has been done so far? Would the number of preventable deaths most likely be kept low? The answer to all these questions is most likely yes. What role would the lay public play in the response: that of victim or bystander. In contrast, what if a dirty bomb in a suitcase exploded in Trafalgar square right now and there were 10,000 seriously injured persons? Would the answer to the above questions still be yes? What is the difference between 100 and 10,000 casualties (other than 9,900 injured persons)? Beyond the obvious differences, previous research suggests that the 100 victim case (a clear emergency in resource-rich London) is qualitatively distinct from the 10,000 victim case. The differences are described in Table 2 below.

30

Th.A. Glass / Emergency, Disaster, and Catastrophe Table 2. Characteristics of emergencies vs. disasters Emergencies

Disasters

Demand Resource Ratio

Demands  Response capacity

Demands  Response capacity

Event perimeter First responders Ideal management model Organizations Preventable death

Well-defined Professionals Command & control Autonomous None to few

Diffuse or none Professionals & Nonprofessionals Emergent resource coordination Convergence Few to large numbers

Crucial mode of care Use of triage∗ Panic

Trauma NO Unusual

Primary care YES Rarer

∗ Triage is used in this context to refer not to the general practice of selecting patients for order of treatment based on urgency of need, but in the more formal, military usage, meaning choosing to withhold care from patients unlikely to survive or the extreme rationing of care under conditions of a shortage of care.

The defining characteristic of a disaster is the relative balance of resources to demands. The other qualitative differences listed in table two arise principally from this. In an emergency, professional responders (fire, police, military, EMS, etc.) seek to establish a fixed event perimeter, often demarcated by the familiar yellow plastic tape. The yellow perimeter establishes the edge of the event itself, but also establishes a dividing line between professionals and the lay public, who are assumed to play no significant role and who are kept on the outside of the perimeter (unless they are victims). In an emergency, the event boundaries are normally easily established and well-defined. Inside the event boundary, professionals conduct search and rescue operations, coordinated from command and control centers located at the event periphery (but inside the yellow tape). Emergency managers tend to assume that all events will be perimeterizable, and hence cordoning the edges of the event is a standard aspect of “disaster drills”. However, in the real world, disasters are distinct in that the perimeter is almost always porous or non-existent. This means that ordinary citizens, who are or the scene, are directly involved in response efforts. Response efforts in a disaster depart from the protocols and procedures of emergencies, due in part to the inherently diffuse or non-existent boundaries of the event. Response to victims tends to emerge as a blend of professional and non-professional action. For example, in the Kobe earthquake, only ¼ of live victim extrications were accomplished by fire, EMS or national-defense forces in 1995 [8]. Due in part to the absence of a defined perimeter, the most common method of victim transport was the private family car, with ambulances transporting only 26% of victims [9]. In our own study, we recorded evidence of emergent patterns of cooperation and mutual aid between civilians, military, and professional responders in the sewer explosions in Guadalajara Mexico in April of 1992. In that event, groups of citizens with no formal training formed search and rescue teams. They used car jacks to lift rubble, and used garden hoses to siphon air to those who were entrapped. This illustrates our third qualitative difference: in disasters, a mix of professionals and non-professionals are the first-responders to the event. In emergency situations, logistical and command and control operations ensure that professional first responders are quickly mobilized at the scene. In disasters, especially ones that are multifocal in nature, professional responders generally have significantly longer response times. In many of the events we studied, disaster conditions cause disruptions in communication, traffic, and in those systems designed to function best in single-location emergencies. During

Th.A. Glass / Emergency, Disaster, and Catastrophe

31

hurricane Andrew for example, the Dade County Fire Department’s disaster response team, which has responded to disasters on the other side of the globe, was not able to respond to an event that occurred in their own jurisdiction. In the U.S., the 9-1-1 system is a good example. During a disaster, the 911 telephone response system becomes quickly flooded with emergency calls. Beyond a certain threshold, the systems ability to maintain protocol is exceeded. In an emergency, a command and control model of event management works well. Adapted from the control of forest fires, the Incident Command System has been the key strategy for emergency response in the United States. In the context of events with a defined perimeter and sufficient professional response capacity, the ICS is especially effective. However, in a disaster context, a single command center with a single incident commander is seldom effective or practical. More importantly, in the disaster context, what is needed more than a vertically hierarchical command and control model, is an emergent systems coordination model, which allows teams using different communication systems, with no or little previous experience working together, and with various levels of knowledge of the local situation to work together in a complex and dynamic environment. Additionally, the ICS is not an effective system for coordinating civilian participants in the response effort, despite substantial evidence that civilians play a critical role in search and rescue, victim extrication, and first aid in disasters. In the U.S., alternatives to a rigid, military style command and control model of disaster planning have yet to be envisioned. As one example, the recommendations of the CDC Strategic Planning Workgroup of preparedness and response for biological and Chemical terrorism provides great detail on the need for professional training, information systems, and infrastructure building, and provides no mention of the role of the civilian population or in the need to coordinate lay and professional first responders [10]. Several examples of alternative approaches can be found in countries that have more experience with large-scale MCEs including Sweden’s “Total Defense” strategy [11] as well as the “community information centers” found in Israel [12]. In most emergencies, there are few or no preventable deaths; the standard of care is maintained even under system stress conditions, and there is no real triage. In a disaster however, because the response capacity is exceeded, the number of preventable deaths can be substantial. 3.3. Summary Among the implications of this distinction is the basic idea that patterns and procedures cannot be generalized from emergencies to disaster situations. For example, numerous American commentators and policy makers including Margaret Hamburg [16], Eric Noji [17], and others, have written articles about lessons learned from recent emergencies and their relevance for disaster response. The events most often used as templates or blueprints for disaster preparedness include the 1999 outbreak of West Nile Virus in New York (62 cases and 7 deaths), the Washington D.C. area sniper case (13 shootings, 10 deaths), the anthrax attacks of 2001 (22 cases, 5 deaths), or the 2002–2003 SARS outbreak in the U.S. (418 total suspect or probable cases [18]). Using emergencies such as these (which admittedly have important lessons to teach and are doubtless of high public opinion visibility and impact) may provide an insufficient basis for designing response patterns for disasters. Next, the implications of these arguments are drawn out more extensively for terrorism preparedness.

32

Th.A. Glass / Emergency, Disaster, and Catastrophe

4. Implications for Terrorism Preparedness 4.1. Implication #1: The civilian public will play a critical role in a disaster Mistrust of the public’s ability to participate effectively in MCE response is widespread. In the United States, disaster planning has tended to emphasize centralized, technology intensive, professionalized response models. In turn, emergency management professionals tend to treat the public as an unwanted nuisance, as panic prone, and as irrelevant to effective response. This is appropriate for emergencies, but not disasters where by definition, formal response systems are overwhelmed and unable to provide adequate response without non-professional assistance. Mutual aid from distant professional agencies is, of course, a component of a complex response, however, the significance of immediate victim/bystander response has been underappreciated and overlooked. Overall, the evidence suggests that victims tend to respond effectively and creatively. In our research, we observed in almost every event, that victims and bystanders tend to form spontaneous groups with roles, rules, leaders and a division of labor. This emergent collective behavior makes it possible for ordinary citizens to do extraordinary things. The Amtrak Sunset Limited derailed and crashed into a bridge near Mobile, Alabama on Sept 22 1993 with 220 passengers and 18 crew members aboard. It was the worst train crash in Amtrak history with 47 fatalities, and over 180 passengers and crew injured. The train crashed at 2:58 in the morning. EMS did not arrive for 1.5 hours and the first patient was not transported until 6:15 AM. All those who died expired within moments. We estimated that 14 additional people would have died if it had not been for other passengers and crew, along with one nurse who was on the train. By the time EMS was able to find the train in the darkness and fog, passengers and victims had been waiting for well over an hour. In most cases, the role of ordinary citizens is under appreciated because the news media arrives with (or because of) formal first-response groups. However, in disasters, the majority of those who will be saved, have been saved prior to the arrival of professionals. In disaster epidemiology, experts often refer to “the golden 24 hours”, or the time when life-saving rescue must arrive before the critically injured are no longer alive or salvageable. Our data show that the vast majority of fatalities in disasters occur instantaneously, or within twenty minutes, not hours. Moreover, the reactions and behaviors of ordinary citizens, who happen by chance to be in the immediate vicinity, and who take actions that have life-and-death consequences for those around them, are a critical and systematically ignored aspect of disaster response. 4.2. Implication #2: Don’t panic about panic In all the events that our team studied, we were struck by the frequency with which victims and responders we interviewed commented on the absence of panic, complaining or irrational behavior. Most described an “eerie feeling of calm” during life and death moments. Panic is a staple of disaster movies, but is quite rare in disasters. It is clear from our research that ordinary citizens are capable of avoiding deadly harm both individually and collectively through astonishing action. Humans may well be evolutionarily selected to respond adaptively, rather than with panic in those situations. There are of course, well documented exceptions, events where panic (defined as irrational flight behavior) is seen. Examples include indoor fires such as the Coconut Grove nightclub fire in Boston in 1942 in which 491 people were killed [19], as well as football stadium “riots”.

Th.A. Glass / Emergency, Disaster, and Catastrophe

33

Although panic is rare, it is not, as some have argued, un-studyable. E.L. Quarantelli, the leading sociologist in this area and founder of the U.S. Disaster Research Center, studied 150 disasters over 50 years and concluded that panic is “extremely rare and almost nonexistent in most disasters” [20,21]. Panic behavior is often portrayed by the media as antisocial behavior, an irrational and ineffective means of escape or collective response. The sociological literature demonstrates that behavior that is described as panic by the press (who have a vested interest in portraying situations as irrational and brutish) is actually adaptive – emergent, not always laudable, but often quite adaptive. Discussions of panic in disasters often lead to the question of looting. Looting is quite common in civil disturbances, but extremely rare in natural disasters. This is because in the latter, powerful norms emerge that protect the idea of private property. At the same time, norms emerge also to support the notion that some property becomes community property when the common good is at stake. In the Guadalajara sewer explosions for example, groups of citizens “broke” into cars and shops to retrieve car jacks to move rubble. This was not looting, but rather a reflection of an emergent norm about how property could be appropriated for collective service. Looting is a response to dissensus and conflict arising from particular social conditions. More often than not, serious scholarship has shown that social response to disasters is based on consensus, rather than dissensus, on cooperation rather than conflict, and on voluntarism that most often goes beyond the call of duty [3,22–26]. Moreover, despite widespread expectations about panic, the most common emergent norm in disasters is altruism. The one event studied by our group where we had expected to see wide spread panic was the first World Trade Center bombing in New York City in February of 1993. With nearly 10,000 people trapped in a vertical column waiting to evacuate the building, all the emergency lighting and public address systems failed (along with elevators); this should have been an ideal mix of ingredients for panic. Hundreds waited as long as six hours slowly descending smoke filled stairwells in the dark. As part of our study, we conducted a random sample of 415 people who were in those stairwells. Our data demonstrated that panic was unusual, and that people were mainly cooperative and calm [5]. The press reported differently but mostly because they interviewed people fleeing the buildings and ignored people who said there was no panic. 4.3. Panic and bioterrorism In regards to the threat of bioterrorism, the question of panic becomes more complex; the lessons of natural disasters clearly have limits. In the case of an intentional outbreak of infectious disease, the problem of emergent norm formation is complicated by the presence of a potentially hidden and contagious threat that cannot be contained. What norms would emerge? How would vaccine stock piles be regarded by organized and spontaneous groups? Would the public trust or reject efforts to enforce quarantine, to institute infection control measures, and ration available treatments? The answers to these questions are not known. One could imagine that the circumstances for panic or other antisocial collective responses could exist. However, historical accounts of the influenza pandemic of 1918, fail to bear this out [27,28]. It is often forgotten that the Great Spanish flu pandemic, which killed over 500,000 Americans, was, according to Alfred Crosby, widely believed to be a biological weapons release – that the Germans had unleashed a new kind of stealth weapon (Bayer aspirin) [27]. Despite those fears, communities across

34

Th.A. Glass / Emergency, Disaster, and Catastrophe

America and throughout the world demonstrated remarkable resilience, resourcefulness, and altruism. The lessons of 1918 however have been lost to the extent that we still lack planning for an outbreak scenario in which the hospitals are filled to capacity, and the outbreak is not yet contained. For this reason, and based on the results of our research, models such as the ‘shielding’ model, which relies on a decentralized, home-based approach to disease surveillance and control should be given stronger funding and support, in addition to current attempts to build a purely hospital/clinic based response capacity (for discussions of shielding, see [29–31]). One thing that is clear is that the term ‘panic’ is used indiscriminately and imprecisely in ways that cloud rather than clarify. For example, after the 2003 U.S. anthrax attack, numerous stories appeared in the press about “panic” buying of antibiotics and gas masks. This hardly amounts to the sort of wholesale abandonment of social order that is implied by the term panic. More to the point, the best survey of post-anthrax behaviors, conducted by Harvard University and Robert Wood Johnson in the three most impacted cities (October 2001), found that only 1% had “purchased a gas mask” and only 5% had gotten an “antibiotic prescription” [32]. Moreover, these behaviors were a symptom of uncertainty, and were medically unwise, but do not constitute evidence of widespread panic. That same survey showed that 44% of the residents of the affected cities reported that they did not trust the secretary of Health and Human Services (T. Thompson), who’s handling of the anthrax crisis was described by John Schwartz of the New York Times as “spin control” rather than sound public health [33]. Overall the lesson is that when people have preexisting social relationships in disasters, then panic is overall quite unusual. This is a lesson that should be considered in disaster preparation.

5. Summary and Conclusions In his recent book Our Final Hour: A Scientists Warning: How Terror, Error and Environmental Disaster Threaten Humankind’s Future in this Century – on Earth and Beyond, Britain’s Astronomer Royal, the Cambridge University Cosmologist Martin Rees says the human species has no better than a 50–50 chance of surviving the 21st century. He has made a 1,000 dollar bet that a biological weapon attack or an error in a lab will kill 1 million before 2020 [34]. Yet, planning and preparation for biological weapons continues to be based on small, contained emergencies. Absent are the plans and preparations for events of super magnitude. The greatest opportunity to invest in strategies that will minimize preventable deaths, however, lies in thinking about and planning for events of this scale. This chapter has attempted to bring needed scrutiny to the problem of how disasters should be defined and how they differ from emergencies and catastrophes. In conclusion, based on this distinction, as well as a large body of sociological research, the following tentative speculations may be useful in guiding policy makers and researchers struggling to plan for the kind of massive event that Rees warns about: 1) During a disaster or catastrophe, victims will circumvent normal routing mechanisms into the hospital and will self-transport, self-triage and to some extent, may self treat. In the 1995 Sarin Gas attack in Japan, for example, 688 people were transported to hospital by emergency medical and fire department authorities. More than 4,000 people found their own way to hospitals and doctors using taxis, private cars, or on foot.

Th.A. Glass / Emergency, Disaster, and Catastrophe

35

2) Hospitals will likely be heavily stressed because the least injured persons will rush to hospital seeking advice and treatment and will clog emergency departments. This will be followed by the press, family members of the injured or infected, and the convergence of all manner of medical personnel. This will, regrettably, create an ideal Petri dish for the transmission of infectious agents. 3) People will form emergent and spontaneous groups. These groups will not be under the direct control of any national agency. The behavior of these groups may make the largest difference in terms of ultimate outcomes. Failure to involve these groups through open and candid release of information, and a sense of collective responsibility will increase the likelihood that destructive social responses emerge. It is critical to develop strategies to pre-engineer the “Blitz spirit” by building trust and local civilian response capacity. Society itself is comprised of interconnected networks of social actors across organizations. This dense network represents an ideal scaffolding for building a civilian based infrastructure that can be harnessed in the event of bioweapon release, pandemic flu, or other emerging infectious threats. 4) The questions around panic and civil unrest after a biological weapons attack depend on what sort of collective definition of the situation emerges. Will norms of mutual dependence and collective resolve emerge and flourish? Will a spirit of esprit d’corps prevail as happened during the Blitz in Britain during World War II? (for an excellent discussion of civilian resilience during the Blitz, see [35]), or as occurred in New York after September 11, or will latent fractures within the social fabric rip open pitting groups against one another in competition for scarce resources? One might postulate that a consensus crisis is more likely as long as the perpetrators are socially external, and as long as information dissemination perceived to be accurate, timely, and free of spin control, and that resource distribution is perceived to be equitable. Finally, the main message of this chapter has been that disasters and emergencies are different classes of events and require different strategies. Qualitative changes occur during crisis situations that exceed the normal range. The surprise: despite what we see in disaster movies, disasters are not, for the most, part chaotic. Instead rules, roles and disaster specific norms of behavior emerge as the event itself collides with the groups and systems it effects. Learning from the lessons of past disasters may have considerable value in improving our preparations for large scale events in the future.

References [1] Anonymous. Preliminary report: medical examiner reports of deaths associated with Hurricane Andrew – Florida, August 1992. MMWR – Morbidity & Mortality Weekly Report 1992; 441 (35): 641–644. [2] Aguirre BE, et al., The Social Organization of Search and Rescue: Evidence from the Guadalajara Gasoline Explosion. International Journal of Mass Emergencies and Disasters 1995; 13 (1): 67–92. [3] Glass TA. Understanding public response to disasters. Public Health Rep 2001; 116 (Suppl 2): 69–73. [4] Glass TA, Schoch-Spana M. Bioterrorism and the people: how to vaccinate a city against panic. Clin Infect Dis 2002; 34 (2): 217–223. [5] Aguirre BE, Wenger D, Vigo G. A test of the emergent norm theory of collective behavior. Sociological Forum 1998; 13 (2): 301–320. [6] Wenger DE, Aguirre B, Vigo G. Evacuation under conditions of uncertainty: The World Trade Center Evacuation of February 26, 1993. In: International Sociological Association (ISA), 1994: ???

36

Th.A. Glass / Emergency, Disaster, and Catastrophe

[7] Nagasawa Y. Earthquake damages to hospitals and clinics in Kobe, Japan. Jpn Hosp 1996; 15: 77–82. [8] Tanaka K. The Kobe earthquake: the system response. A disaster report from Japan. Eur J Emerg Med 1996; 3 (4): 263–269. [9] Tanaka H, et al., Overview of evacuation and transport of patients following the 1995 Hanshin-Awaji earthquake. J Emerg Med 1998; 16 (3): 439–444. [10] Biological and chemical terrorism: strategic plan for preparedness and response. Recommendations of the CDC Strategic Planning Workgroup. MMWR Morb Mortal Wkly Rep 2000; 49 (RR-4): 1–14. [11] Kulling PE, Holst JE. Educational and training systems in Sweden for prehospital response to acts of terrorism. Prehospital Disaster Med 2003; 18 (3): 184–188. [12] Sachs Z, et al., Community coordination and information centers during the Persian Gulf war. Isr J Med Sci 1991; 27 (11–12): 696–700. [13] McNabb SJ, et al., Hurricane Andrew-related injuries and illnesses, Louisiana, 1992. Southern Medical Journal 1995; 88 (6): 615–618. [14] Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 2003; 54 (1): 147–154; discussion 154–155. [15] Bremer R. Policy development in disaster preparedness and management: lessons learned from the January 2001 earthquake in Gujarat, India. Prehospital Disaster Med 2003; 18 (4): 372–384. [16] Hamburg MA. Bioterrorism: a challenge to public health and medicine. J Public Health Manag Pract 2000; 6 (4): 38–44. [17] Noji EK. Introduction: consequences of terrorism. Prehospital Disaster Med 2003; 18 (3): 163–164. [18] Update: severe acute respiratory syndrome – worldwide and United States, 2003. MMWR Morb Mortal Wkly Rep 2003; 52 (28): 664–665. [19] Saffle JR. The 1942 fire at Boston’s Cocoanut Grove nightclub. American Journal of Surgery 1993; 166 (6): 581–591. [20] Dynes RR, Tierney KJ, Fritz C. The emergence and importance of social organization: the contributions of E. L. Quarantelli, in: R.R. Dynes and K.J. Tierney, editors. Disasters, Collective Behavior and Social Organization, 1994, Newark, DE: University of Delaware Press, 1–17. [21] Quarantelli EL. The sociology of panic, in: N. Smelser, P.B. Baltes, editors. International Encyclopedia of the Social and Behavioral Sciences, New York: Pergamon, 2001: 11020–11023. [22] Benedetto R. Poll finds anthrax fear but no panic, in: USA TODAY, 2001, p. A-4. [23] Crocq L. Individual and collective behaviors in earthquakes, fire, and man-made disasters. Psichiatria Ed Ecologia 2001; 37–46. [24] Dynes RR, Tierney KJ, eds. Disasters, Collective Behavior and Social Organization. Newark, DE, University of Delaware Press, 1994: 378. [25] Johnson NR. Panic and the breakdown of social order: popular myth, social theory, and empirical evidence. Sociological Focus 1987; 20 (3): 171–183. [26] McPhail C, Johnson NR. The myth of the madding crowd. Social Forces 1992; 71 (1): 238. [27] Crosby AW. America’s Forgotten Pandemic: the Influenza of 1918. 1989, Cambridge, MA: Cambridge University Press. [28] Schoch-Spana M. Implications of pandemic influenza for bioterrorism response. Clinical Infectious Diseases 2000; 31: 1409–1413. [29] Everly GS, Jr. Responding to bioterrorism and psychological toxicity: an introduction to the concept of shielding. Int J Emerg Ment Health 2002; 4 (4): 231–233. [30] Prior SD, Rowan F, Saathoff G. Foundations of shielding. Int J Emerg Ment Health 2002; 4 (4): 235–238. [31] Saathoff G, Everly GS, Jr. Psychological challenges of bioterror: containing contagion. Int J Emerg Ment Health 2002; 4 (4): 245–252. [32] Blendon RJ, et al., Harvard School of Public Health/Robert Wood Johnson Foundation Survey Project on Americans’ Response to Biological Terrorism, Study 2: National and Three Metropolitan Areas Affected by Anthrax. Boston, MA: Harvard School of Public Health, 2001. [33] Schwartz J. Efforts to Calm the Nation’s Fears Spin Out of Control, in: New York Times, 2001: New York, NY. [34] Rees MJ. Our Final Hour: A Scientist’s Warning: How Terror, Error, and Environmental Disaster Threaten Humankind’s Future In This Century – On Earth and Beyond. New York, NY: Basic Books, 2003. [35] Jones E, et al., Civilian morale during World War Two: responses to air-raids re-examined. J Social History, forthcoming.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

37

Cultural Precursors and Psychological Consequences of Contemporary Western Responses to Acts of Terror Bill Durodié Senior Lecturer in Risk and Security, Resilience Centre, Cranfield University, Defence Academy of the United Kingdom, Shrivenham, Swindon SN6 8LA

Introduction This article explores what the response to the terrorist attacks of September 11th 2001 teaches us about Western society today. There has been a wealth of research examining the purported cultural background and psychology of the perpetrators of those events [1]. That focus has two main rationales; to identify and deal with potential terrorists, and to begin to tackle what are considered to be the ‘root causes’ of terrorism – usually held to stem from poverty and disaffection across the Third World [2]. These approaches offer a somewhat predictable and reassuring explanation of events. They locate the problem of terrorism elsewhere – in the minds, actions and cultures of others. At best, those posing a threat are understood to be reacting in an adverse way to what are held to have been the injustices committed against their forebears during an earlier age of imperial domination. Here, I wish to consider the extent to which some of the issues may be far closer to home, and more contemporary, than we like to envisage. In part, this is due to the particular way in which Western societies perceive and deal with anything that involves risk nowadays [3]. If anything, the actual threats posed could be conceived of as weaker today than those presented throughout most of the Cold War, yet society appears to react as if they were stronger. Why is this? And what does this tell us about ourselves? A focus on our increasingly exaggerated perceptions of risk and the adverse consequences this brings, both to the people of the Third World and for Western societies, is a missing element to our analysis of terrorism that we ignore at our peril. Ultimately, if our responses are shaped, in part at least, through the prism of our own domestic fears and insecurities, then the actions taken will prove limited or ineffective, and may serve to confuse matters more. A mystifying mythology is created, which in its turn demands totemic gestures to reassure the public. This process, readily becomes a self-fulfilling fantasy which – far from assuaging our concerns – will only drive them further. Inverting Questions Just as there are two sides to every coin, so occasionally we need to invert the questions we ask of society if we are to obtain a more balanced and productive take on issues.

38

B. Durodié / Contemporary Western Responses to Acts of Terror

For example, the recent fashion to re-examine Samuel Huntington’s work on, ‘The Clash of Civilisations’ [4], in the light of 9/11, would do well to be moderated with an equally vigorous examination as to the possibility of a clash within civilisation, rather than between differing cultures. This would need to address the radicalisation of Muslims within western societies, but more importantly, for those wanting to get to the real roots of this phenomenon, to assess and analyse the largely Western origins of anti-Western ideas. In this vein, rather than recording so-called anti-American sentiment across the world today [5], we would do well to examine how such attitudes have developed closer to home. After all, more anti-capitalist protestors come from Seattle than from Gaza. The rejection of once core social values, such as ambition, success and development, and their representation as arrogant, selfish and dangerous, reaches its apogee in relation to the US – the most advanced capitalist nation. This rejection is reflected in a growing selfloathing evident in American culture and that of other Western societies, as expressed for instance in Oscar-winning Michael Moore’s best-seller ‘Stupid White Men’ [6]. Another assumption worth exploring in a more rounded way, is that of the need to understand why it is that a small proportion of Asian youth appear to be attracted to fringe Islamist organisations. It may prove more productive to ask, why it is that a small element of Asian youth, and quite a few others beside, fail to find any sense of solidarity or purpose within Western society [7]. Surely, it is an indictment of our own culture that its lack of direction and dynamism, fails to attract and inspire ambitious young people? It is not the magnetism of those who supposedly seek to restore a twelfth-century caliphate in the twenty-first century that should concern us. Rather, it is a failing of our own society that it does not project clearly a vision of its own future to argue against those who would have us live in the past. It fails thereby, to command loyalty, or to impart any sense of mission or meaning. Instead of examining the presumed culture and psychology of those who perpetrate acts of terror, this article focuses upon those selfsame factors in relation to our societies and to ourselves. To what extent are we truly facing a new phenomenon, encompassing new technologies with unforeseen consequences? Or, is it we who have changed – including our individual attitudes to danger, the coherence of our institutions and our sense of social solidarity and resilience?

Diminished Selves The extent to which, once core, social affiliations and bonds have been eroded without replacement over recent decades is striking. We should be alert to the possibility of this producing some unexpected consequences. At the formal level, people in advanced Western societies are increasingly unlikely to participate in the political process. Nor are they as likely to be active – or even passive – members of political parties or trade unions in the same way that their forebears were. There is, of course, more to democracy than merely casting your vote, but even when people do vote, it is often on a negative basis – against an incumbent – rather than for their replacement. These trends are also most marked amongst the young. At the informal level, some changes are even more notable. Many have commented on the growing pressures faced by communities, neighbourhoods and families. In ‘Bowl-

B. Durodié / Contemporary Western Responses to Acts of Terror

39

ing Alone’, the US academic Robert Putnam pointed to the demise of informal clubs and associations [8]. Meeting with friends occurs less frequently than previously, too. This loss of, what has sometimes been coined, social capital, has occurred within a remarkably short period of time. A generation ago it was quite normal to send children to school on their own, assuming that other adults would act in loco parentis – chastising them if they misbehaved, and helping them if they were in need. Today, across many urban areas, this can no longer be assumed to hold. None of us ever signed a contract saying that we would look after other people’s children. It was simply an unstated and self-evident social good. Sadly, this erosion of communal bonds has, in its turn, made the job of parenting harder still [9]. So, as well as being liberated by the erosion of traditional rules and structures over recent decades, we should note that, without anything to replace these, we have also become more isolated from one another and less effective in consequence. Far from this erosion of old community values necessarily giving rise to a new, confident individualism, what we have seen is the emergence of a disconnecting process of individuation. In the past, social networks and norms may have imposed arbitrary or authoritarian structures and rules upon people, but they also provided meaning, conferred identity, and facilitated basic processes, without which we have become greatly diminished as individuals [10]. Being less connected has also left people less corrected. It has allowed their subjective impressions of reality to go unchecked, unmediated or unmoderated through membership of a wider group or association. In the past, when confronting difficulties, people would, through their social networks, have been encouraged to view things more objectively, or at least from a different perspective. They could also have envisaged a collective solution to their problems. Nowadays, personal obsessions readily grow into allconsuming worldviews that are rarely open to reasoned interrogation or resolution. We may be more aware than previous generations, but we are also easier to scare, as we are increasingly alone in facing life’s challenges. Notably, it is this erosion of informal social bonds that has led to their having to be replaced by more formal processes of blaming and claiming [11]. Thus, a narrowly self-oriented personality and culture has emerged alongside a growing sense of isolation and insecurity. In some ways, we have replaced a culture of unthinking deference by one of unnecessary fear. It seems that confident individuals need a coherent society to fall back on, just as much as a coherent society requires confident individuals to build from.

Risk Aversion Above-all though, this process of individuation has encouraged an exaggeration of the threats and challenges posed by everyday life. This has manifested itself as a growing obsession with, and aversion towards, all-manner of risks, both new and old. Risk has become a dominant prism for viewing the world today, as evidenced by the number of courses, conferences and journals now devoted to the concept. This outlook emerged gradually, but was catapulted to prominence through the break-up of the Cold War order, coinciding with the publication of the German sociologist, Ulrich Beck’s book, Risk Society [12].

40

B. Durodié / Contemporary Western Responses to Acts of Terror

The Aids-awareness campaigns of the 1980s were an early indicator of changing perceptions of risk. In the UK, these became much clearer in the debacle over bovine spongiform encephalopathy (or BSE), more commonly referred to as ‘mad cow disease’ [13]. Since that time there have been a steady stream of risk-related issues impinging upon public consciousness. These have included campaigns against the presumed adverse consequences of introducing genetically modified organisms into the environment, and concerns over the use of mobile phones held to have possible effects on the brain through so-called non-thermal radiation [14]. More recently the MMR (measles-mumps-rubella) triple-vaccine, was accused by some, despite a lack of confirming evidence, to be linked to autism in infants [15]. Nor was it just scientific and technological risk-related matters that came to prominence. Age-old activities and problems have also been reinterpreted and reorganised around a heightened consciousness of risk. Bullying in schools, sun-bathing, child abduction, untrustworthy GPs, and the very food we eat, have all, at one time or another, formed part of a growing panoply of issues one can point to, of fears raised over recent years. Risk management as a discipline has therefore become a major discourse and organising activity, in both the public and the private sector [16]. Risk managers sit on the board of major companies [17]. Even relationships are now increasingly viewed through the distorting and stultifying prism of risk. Despite concerns raised as to the broader implications and consequences of this, there is an almost unstoppable trend to reinterpret all issues – whether personal, social or scientific – in this way. But, rather than the world changing any faster today than in the past, or becoming a more dangerous, unforeseeable or complex place, it may be our diminished, and more isolated, sense of self that has altered our confidence in dealing with change and the problems it gives rise to [18]. More on our own, and self-absorbed than previous generations, with an exaggerated sense of threat, it has become normal for people to look for, and expect, professional support in dealing with what would once have been considered to be everyday difficulties. An all-regulating, blame-attaching response to problems and issues ensues that has, in its turn, helped shape a new, more limited, political framework and agenda for a period largely devoid of any broader social vision. In part, this is because a more positive, social and cultural orientation towards change declined over the course of the twentieth century. Radicals who would once have promoted science and technology as a means for challenging vested authority and power, came to associate these with post-war American militarism [19]. Combined with the political defeat and exhaustion of the left, best symbolised internationally by the end of the Cold War, this helped foment a more conservative outlook. In their turn, the old right, briefly triumphal about these developments, soon fell out with one another. The only force to have held them together was the threat posed to their interests by the Soviet bloc externally, and organised labour internally. The convergence of left and right reflects the absence of any broader sense of mission or agreed direction for society. The management of risk fulfills the need for a new organising principle. Politicians, concerned as to their legitimacy have then sought to repackage themselves as societal risk managers. They have also increasingly pursued the centre ground, seeking technical, rather than political, means to enhance turnout in elections. But the demise of any polarised or principled political debate also fed declining interest and engagement in the public sphere. More limited aspirations – to promote voting by

B. Durodié / Contemporary Western Responses to Acts of Terror

41

anyone, for anyone, and to micro-manage the economy, focusing particularly upon privatised concerns such as education and health – have not inspired a new generation of voters. Attempts to include the public more in certain decision-making processes by various means have merely reflected and reinforced declining electoral participation rates [20]. What’s more, whilst a nervous and atomised public is held to expect greater regulation of risk by the authorities in order to feel protected, there is no way of ever satiating this assumed demand. Rather, the failure to do so, appears to confirm a growing sense of human limitations and low expectations. It also feeds suspicion of the very authorities – political, corporate and scientific – that would need to be trusted in order to transcend contemporary difficulties, as well as further undermining social bonds. Increasingly, through these processes, people have learnt and been encouraged to assume the worst or presume a cover-up, even before any crisis has truly emerged.

Cultural Asymmetry It is within this broader cultural context that we need to situate the events of September 11th 2001. Far from being the trigger to a period of insecurity and policy change, these events were a catalyst for wide-ranging trends that lay just beneath the surface of Western society. For the first time, 9/11 allowed Americans en masse to view and perceive of themselves as victims on the world stage. They hardly needed much encouragement. Victims – people who are known by what happens to them – as opposed to heroes – people who are known for what they do – are a key reference point of our times. The fact that the attacks were unprecedented in scale and occurred in the US simply allowed the domestic soul-searching to begin. We should be clear that the real driver for this was the growing sense and exaggeration of risk, caused and accentuated by the individuation of society deriving from a concomitant loss of confidence and purpose. Notably, there has been a shift in conceptualisations of risk in recent years that parallels the demise of active participation in the political sphere. The classical notion of risk comprised an active formulation of ‘taking a risk’, that envisaged positive, as well as possibly negative, outcomes. Contemporary use however, focuses more on the notion of ‘being at risk’, a largely passive viewpoint that externalises threat as somehow being inherently and inevitably out there [21]. This historical shift however, retains an important cultural dimension. Accordingly, there are some who retain an understanding of risk-as-opportunity rather than becoming transfixed by risk-as-threat. It was this cultural asymmetry towards risk-taking, far more than the resource asymmetries other commentators have focused on, that was crucial in facilitating the events of 9/11. In another age, individuals armed with box-cutters might not have been able to achieve what they did. If we are to prevent similar incidents from happening again, we need to become conscious of quite how much we have changed as individuals and as a society over the short period since the end of the Cold War. These changes increasingly play a determining role in world affairs. Some commentators have described this shift as the advent of what they call an ‘age of anxiety’, or ‘culture of fear’. This culture stems from and further encourages a focus on the personal and private over the political and public. Indeed, political life increasingly focuses on personal issues as a consequence. This narrow, privatised introspection emphasises feelings over facts and image over insight, leading to the advent of what

42

B. Durodié / Contemporary Western Responses to Acts of Terror

has also been labeled the ‘therapeutic society’ [22]. Any sense of a collective good, or the need to maintain one’s composure, has been replaced by an increasingly narrow and self-obsessed emotionalism that pours itself out because it fails to perceive any common good worth believing in – still less fighting for. Accordingly, those who do believe in something – no matter what – appear as fanatics to contemporary sensibilities and are labeled ‘fundamentalist’. Ironically, their sense of the possibility and need for social solidarity and sacrifice – irrespective of their limited aims – are important elements of resilience we would do well to learn from, rather than seek to eliminate. What’s more, getting obsessed with – or seeking to moderate – the passions and aspirations of others, evades the urgent need to resurrect our own beliefs and capabilities. Another measure of how much it is we who have changed, can be found by examining the literature on human responses in disasters going back over fifty years. In the past, it was generally assumed that people and systems were fairly resilient and could cope. With few exceptions this was found to be true [23]. Today, experts tend to assume that individuals and institutions can not manage without professional support in a crisis. Accordingly, it is now presumed that humanity and society are always vulnerable and in need of long-term, if not life-long assistance. For nearly fifty years the Western allies stood face to face against an enemy known to have a formidable nuclear arsenal, stocks of, capabilities in, and a significant research programme into, chemical and biological weapons. Yet now, in an age when concepts of belief, truth and sacrifice have been so eroded that they no longer hold any purchase, and when confronted by those who are prepared to commit suicide for their cause, we move to reorganise the world as if we had never faced a greater threat. Surely this tells us more about ourselves than about the enemies we face?

Psychosocial Impacts September the 11th 2001 is testimony to the remarkable strength and widespread prevalence of human resilience. As in most disasters, the orderly evacuation of the World Trade Centre reflected a tendency toward spontaneous, rational, and co-operative behaviour [24]. Yet, the political presumption of social vulnerability and concomitant need for professional support was not long in the offing. Indeed, the dust had hardly settled from the twin towers when a veritable army of counselors, psychologists and other assorted therapists descended on New York to offer their help. Unsurprisingly, according to their own methods and determinations, these experts found an elevated incidence of post-traumatic stress disorder (PTSD) – a term not even listed in psychiatric diagnostic manuals until the 1980s. They also assessed significant rates of depression across the entire population [25]. This was even among those who had only been ‘exposed’ to these events through the medium of television. In this regards, it is worth noting that the very act of searching for, and highlighting, this supposed evidence, itself derives from and ultimately reinforces a culture that effectively encourages people to label themselves as being ill. As Tel-Aviv based psychiatrist, Professor Avi Bleich, has indicated, the reported incidence of trauma appears peculiarly elevated. This is especially so when contrasted to the significantly lower levels amongst an Israeli population who have suffered terrorist

B. Durodié / Contemporary Western Responses to Acts of Terror

43

attacks on an almost daily basis, over a protracted period [26]. All this reinforces the points made as to the determining role of cultural and historical factors in shaping our presumption of vulnerability. But the notion of frail individuals still prevails, shaping both policy and attitudes. Hence, even the Fire Department of New York – who’s firefighters on September the 11th 2001 had been the heroes of the hour – subsequently reinvented themselves according to the dominant social outlook, as forgotten victims in need of support and compensation. By the time the anthrax attacks occurred, Americans had become focused on security issues in general, and their own insecurity in particular. Hence, despite targeting politicians and the media, these incidents led to an unprecedented response right across society. This was manifest by the number of people who handled their mail, quite literally, with gloves, as well as in the demands for ciprofloxacin that inundated doctors across America, from those keen to have what was held to be necessary to treat themselves in the highly unlikely eventuality of being exposed. In the first two weeks of October 2001 alone, there were some 2,300 false anthrax alerts across the United States. A number of these incidents led to cases of what is described in the psychiatric literature as mass psychogenic illness, or in more popular terms, people quite literally worrying themselves sick. One notable case occurred on the Maryland subway where 35 people had to be hospitalised after developing real symptoms including drowsiness, irritability, nausea and vomiting, subsequent to their concerns being alerted to the smell of a strange substance, which later turned out to be window cleaning fluid [27]. Many other similar incidents occured. This was not that first time that mass psychogenic illness or something similar has been observed in populations. It is worth reminding ourselves that due to their fears, combined with a lack of knowledge as to how to use the equipment they had been provided with, a small number of Israelis suffocated themselves to death on their own gas masks during the first Gulf War. The figure was more than had died from being hit by one of Saddam Hussein’s Scud missiles [28]. And, whilst they eventually habituated themselves to the new circumstances, this same population also suffered from an increased incidence of coronary problems in the early days of that conflict. Whether based on a real threat or not, such responses can pose real strains upon society and its resources in an emergency. An incident in Goiana, in North-East Brazil, in 1987, where an inappropriately discarded hospital Cæsium source was stolen by youths is particularly apposite in this regards. Once the incident became known, it led to 100,000 people presenting themselves to the authorities for examination and treatment. Emergency workers had to commandeer a football pitch to sort out the worried-well from the truly exposed, who numbered in the end no more than 244, of which only 54 merited treatment. The point is that people’s concerns, genuine or otherwise, are shaped by the purposes and beliefs of their society and more particularly, those of their social and political leaders. This can have a real impact on the demand for resources and hence the ability of the authorities to cope with any particular incident. By the time an emergency actually occurs, it is too late to change such outlooks. Hence, whilst the numerous training exercises we now witness may serve some limited purpose for the authorities, they will have little impact upon social resilience itself.

44

B. Durodié / Contemporary Western Responses to Acts of Terror

Driving Concerns The actions of political leaders and emergency responders at critical times, especially in the initial stages of any incident, send out important signals to the rest of society as to how they are expected to behave. This can drive public concerns rather than assuaging them. Ambulance personnel, for instance, are trained in an emergency, to calm trauma victims down irrespective of the state of their injuries by downplaying the latter, as such actions save lives. Contemporary culture however, is suspicious of expertise and demands a degree of openness and transparency that increasingly precludes the application of such professional judgment. Few have questioned whether sending people in full chemical and biological weapons suits to handle the numerous incidents of white powder scares that occurred in the aftermath of the anthrax cases, was necessarily the most appropriate action to take. And, in a similar vein, questions could be asked as to the UK government’s decision to place armed police outside mainline railway stations in London in the aftermath of September the 11th , or tanks and troops outside Heathrow airport subsequent to an alleged tip-off as to the possibility of a surface-to-air missile attack. Some commentators have suggested that, far from reassuring the public, such steps are counter-productive and project an image of a society that appears to have lost control, or any sense of perspective and proportion. More recent episodes, concerning the systematic cancellation of flights to Washington DC from London and the release of information surrounding the supposed foiling of a plot to use the little-known chemical osmium tetroxide in an explosive device seem to confirm this trend. This points to a growing confusion, or erosion of the divide, between what ought to remain private intelligence, and what is worth putting into the public domain, based upon an assessment of people’s abilities to take effective action based on the information provided. The British Prime Minister, Tony Blair, countenanced against taking action ‘on the basis of a general warning’, in a speech delivered on the 11th of November 2002 at the Banqueting House in London [29]. He indicated that this could lead to ‘doing their [the terrorists’] job for them’. Yet, the authorities perceive themselves as being under a great deal of pressure to be seen to be acting. Whether their perceptions of the public mood are accurate, or the actions they take are truly effective, remains to be determined. Phrases such as ‘alert, not alarmed’, together with the assumption that a terrorist attack is a matter of ‘when, not if’, or indeed that an attack is ‘inevitable’, are about as general and unspecific as it gets. Such rhetoric presumes itself to be challenging an assumed complacency towards the issue of terrorism, and is presented as, resolute and robust. But the generalised sense of ‘being at risk’ or ‘vulnerable’ that they project reveals an almost resigned air of fatalism towards future events. The use of language to prepare, or alert, the public, also smacks of blame-avoidance rather than determined resolve. It exaggerates the significance of terrorism to society and, in effect, encourages all-manner of potential terrorists, as well as hoaxers, loners and cranks to have a go. It also ignores the understanding the public do have, that determined individuals will always be able to get through, no matter how many technical barriers have been erected against them doing so. Continuously issuing warnings or information that turn out to be factually incorrect, out of date, or too vague to act upon has a number of consequences.

B. Durodié / Contemporary Western Responses to Acts of Terror

45

First, it can literally make people ill. This need not be as dramatic in form as instances of mass psychogenic illness, but it has helped to foment a vaguer underlying anxiety about life and a gradual, passive disengagement from it, that could be tremendously disabling for those seeking to build up social resilience. This is reflected in the large number of surveys that – irrespective of their self-reported basis and the changing basis for assessment – point to increasing levels of stress, depression and trauma, in the aftermath of various incidents. Second, the more likely scenario is that over a period of time, people grow used to ignoring such statements. Again, this could clearly have dramatic consequences. Recent polls suggest that on the whole people are going about their everyday lives ignoring the threat of terror in a pragmatic and resolute fashion. However, this insouciance is likely to be more representative of a growing, broader cynicism and mistrust of authority that now prevails throughout western societies, rather than reflecting any deeply felt inner commitment or resolve. Third, constant warnings readily lead to a self-fulfilling demand for the authorities to do something – distracting them and us from real risks, and diverting social resources accordingly. Amongst other problems, this generates a situation best characterised as information overload. The demand for the public to be vigilant and report any unusual activity, combined with the task of existing and new agencies to sift through these vast amounts of potential intelligence material, clogs up the system, triggering paralysis by analysis, and failing to identify and act upon more plausible threats and risks. Banks, now required to report any ‘suspicious’ transaction to identify possible instances of money-laundering, report a similar trend towards not being able to see the wood for the trees. Sadly, as no serious local authority can afford not to have revised its emergency plans and procedures in the light of these developments, it almost seems that if they do not assess themselves as potentially being on a terrorist hit-list then they can not be taking their responsibilities seriously. A climate has been created whereby whatever measures the government, security and emergency services take, there is an insatiable appetite for more and demands emerging from all quarters, both public and private, to the effect that not enough is being done. The problem is, that many of the measures being put in place are totemic gestures, rather than rational strategies. It is also worth noting the significant element of commercial interests in such matters. Security is big business and indeed, due to our exaggerated sense of insecurity, one of the fastest growing sectors today. Accordingly, there are numerous risk and security consultants, as well as scientists and engineers, of varying abilities and distinctions, who have a financial interest in maintaining both social and individual concern in these matters. These have encouraged companies to develop so-called ‘business continuity strategies’ of dubious worth, focusing particularly on the integrity of their information systems, and the presumed cost of not doing so. All this has led to an inevitable, if perverse, rise of a certain degree of wishfulfillment. One senior executive recently remarked to me that the supply side for respirators or gas-masks was all ready and waiting, what he needed now was for the demand to be ‘stimulated’.

46

B. Durodié / Contemporary Western Responses to Acts of Terror

What if? As all issues are now examined through the prism of risk, there is a growing cultural proclivity to err on the side of caution. This emphasises the negative aspects of particular situations, assuming far-fetched scenarios and acting as if these were true. Extrapolating from worst case evidence, or even uncorroborated data, has become the norm. This has led to a distinctive shift over recent years from asking scientific ‘What is?’ type questions that call for specific evidence, to asking more speculative or anticipatory ‘What if?’ type questions. The latter appeals to a more general, emotionally-driven response. But once we start focusing upon ‘What if?’, an inexorable logic develops. For instance, once we have asked the question ‘What if there were groups or individuals out there who might want to use a biological agent against us?’, then we are led through a convoluted series of further presumptions, ‘What if they had access to such an agent?’, ‘What if they were willing, and capable, of deploying it?’, and so on. Despite the absence of evidence, and the numerous cumulative assumptions, there is little choice, lest they be accused of complacency, but for the authorities to begin to prepare our capacity to cope with such an attack. Thus it was, that smallpox, a disease recognised by the World Health Organisation as having been eradicated in the 1970s, has come back to the fore. Despite the two known repositories of the virus, in the United States and the former Soviet Union, having had no reported breaches of security it was possible to speculate otherwise. In fact, smallpox would not pose particularly great problems, but vaccines were demanded so that public health agencies could establish a protective ring around any incident, just in case. But, the ‘What if’s?’ did not stop there. After all, ‘What if those dispersing the agent had made a point of doing so in a variety of places including airports to ensure effective worldwide dispersal?’. Then, clearly vaccine stocks needed to be sufficient to cover entire populations. In time, we would need to begin a process of actually inoculating first responders and then, in the interest of access and transparency, making the vaccine available to any other person who may wish to have it. Unsurprisingly, what started as a speculative discourse and set of scenarios on one side of the Atlantic, spread like a real disease across to the other side. Other nations followed suit. The next logical step is to ask the same questions with respect to the many other viruses and micro-organisms that could be identified as posing equivalent or significant risks, such as ebola, tularemia, Lassa fever, Marburg fever, e-coli and botulinum, to name but a few. Once the ‘What if?’ questions have started, it is quite literally like knocking over a line of dominoes, except that each step can cost millions, as well as inflicting a tremendous social cost on entire populations who effectively grow accustomed to living in fear. Interestingly, the fear of bioterrorism has tremendous purchase over contemporary society because it also acts as a powerful metaphor for élite concerns as to the corrosion of society from within [30]. Rather than analysing such issues at face value, or in their own terms, as a recent report by the Royal Society did in relation to chemical and biological agents [31], a broader historical and cultural perspective is required to understand why individuals and societies feel so vulnerable to what remain largely speculative scenarios.

B. Durodié / Contemporary Western Responses to Acts of Terror

47

Institutional Distractions Speculation dominates the news after every high-profile arrest or incident. But rather than blaming the media for this, as many are prone to doing – thereby feeding a regulatory response – we would do well to examine the actions and statements of other key public institutions and individuals, ahead of such crises. For instance, after the supposed discovery of the Category B agent ricin, in a flat in north London, the Financial Times reported an official as saying; ‘There is a very serious threat out there still that chemicals that have not been found may be used by people who have not yet been identified’ [32]. This statement of the obvious remains true whether there is a war on terror or not. But, under a banner headline stating; ‘Chemical weapons factory discovered in a London flat’, it helped set the tone of the debate. Yet, whilst the media are guilty of uncritical reporting, thereby enhancing social presumptions, we should be clear that they alone do not set the tone. This latter rather reflects élite fears and the broader cultural perspective that inclines towards believing the worst. Ironically, as more discretely reported in the Sunday Times at a later date, this particular story transpired to be largely false [33]. Analyses by scientists from the UK government’s chemical weapons establishment at Porton Down, found no evidence of ricin manufacture. Yet this aspect of the story was never officially reported or retracted by the authorities and so the assumption amongst the public that it was true, has remained. Presumably, it was felt to be a useful vehicle for keeping the public vigilant. The media both reflect our cautionary climate and, in certain instances, help to amplify it. But it is nervous politicians and officials who are the real drivers as – lacking any vision of their own – they are unable to separate themselves effectively from the broader culture. In the UK for instance, the newly-established Health Protection Agency has issued numerous public health advisories through its ‘cascade system’, to facilitate GPs in the presumed, anticipated task of having to identify the first signs of a chemical or biological attack. This focus not only diverts resources from where they could best be used within the health service, it effectively helps to establish the context and content for future discussion. Worse, the failure to use specific expertise and to assess the real threat posed appropriately, distracts us from the real risks we continue to face, both from terrorism and from other everyday life. As has continuously been demonstrated, real terrorists prefer to use more reliable weapons such as high-explosives and car bombs. Leading scientists continue to identify nature as by far a greater threat to humanity than presumed acts of biological terrorism – although this danger too is prone to being exaggerated. There is little recognition given to the fact that advanced economies are better placed to deal with the consequences and contain the potential of such incidents. Rather, contemporary obsessions prevail, as can be seen by examining new funding priorities and programmes, which dictate an unwarranted distortion of social resources and research priorities towards so-called ‘weapons of mass destruction’.

Psychiatry Lessons Overall, governments have sought to assuage public concerns through the provision of what they consider to be appropriate and accurate information. Ironically, this approach,

48

B. Durodié / Contemporary Western Responses to Acts of Terror

advocated by the new gurus of risk management and communication may serve to make matters worse by feeding the insatiable appetite for fear. It is widely contradicted by a wealth of literature emerging from the field of psychiatry that suggests the provision of information alone – outside an understanding of context and the sense of one’s ability to shape this – can be a potentially futile and counterproductive exercise. It is not so straightforward to reassure anxious people. Even when concerns are correctly identified and targeted, the evidence suggests that – whilst the more extreme manifestation of symptoms may abate temporarily – without tackling the deeper underlying concepts behind them, problems can soon reemerge, manifesting themselves in an exaggerated form [34]. The bottom line is the need to challenge people’s core beliefs about a situation head on. But increasingly over recent years, we have become unwilling to do so. As a society we prioritise consensus-seeking over confrontation. The latter appears too dismissive, or judgmental, to contemporary sensitivities. What’s more, this is not a task that can be achieved by individual psychiatrists or therapists, even in the rare instances where these are not affected by the prevailing norms and values. If the surrounding culture continues to provide signals and messages reinforcing concerns, then the expert is likely to be ignored or questioned anyway. The best that can be achieved in such circumstances is to habituate people to the world they now live in, by encouraging an acceptance of uncertainty. But doing so serves to confirm the dominant social script establishing concern about terrorism. The real task would be to remind people that there is far more to life than terrorism. This has not been addressed by the authorities so far. It requires a focus on ends well beyond dealing with immediate problems. This is a political task that far from distracting us from contemporary issues, should inform the very solutions we seek to put in place. By taking a broader, longer-term view, we would become more conscious of the extent to which trauma itself is a social and historical construct. The widely used terminology of post-traumatic stress disorder did not emerge into professional circles until the mid-1980s. At the time, this was to explain the particular problems faced by certain Vietnam veterans in the US. These suffered not so much from their defeat in South-East Asia, as from rejection by their own communities upon their return home. Shunned as pariahs and labeled psychopaths, the PTSD category eventually offered moral exculpation and access to compensation. But whereas older conditions such as ‘shell shock’ and ‘battle fatigue’ had been held to be specific, relating to a soldier’s background and psyche, the new diagnosis was applied more generally – assumed to derive from the fundamentally traumatising experience of war. Originally framed as applying only to extreme events, PTSD spread rapidly like a disease, to encompass relatively common happenings such as accidents, muggings, verbal or sexual harassment, and even workplace disputes. It finally entered the official Diagnostic and Statistical Manual of Mental Disorders in 1980 and aid agencies now commonly assume whole populations to suffer from it in advance of detailed analysis. Ironically, most veterans diagnosed with PTSD have had no combat experience, pointing to a self-justifying reconstruction of current problems through a narrative of past trauma. Research also suggests that PTSD is more serious and more common among international relief and development personnel, than for the locals they seek to support [35]. These facts indicate the category to be culturally constructed and its causes

B. Durodié / Contemporary Western Responses to Acts of Terror

49

amplified through our particular Western obsession with risk and stress, often in pursuit of remediation or recognition. Studies of those exposed to a range of natural and manmade disasters consistently show that beliefs held prior to an event coupled with one’s understanding of it, account for variation in symptoms far better than the particular characteristics or severity of the experiences encountered. Accordingly, we should also be wary, as indicated earlier, of the figures regularly cited for incidence of trauma amongst the US population post-9/11. These point to the extent to which, even apparently objective data, such as that measuring people’s anxieties in the aftermath of terrorist incidents, is itself a cultural construct based upon assumptions of human vulnerability and their ability to cope. As Furedi has noted, in the past, the dominant social script or narrative would have been one more focused on social and individual resilience and initiative.

Technical Fixations Despite all the evidence pointing to the urgent need for greater clarity of purpose and direction, most activity since 11 September 2001 has focused narrowly upon the technical means to combat terror. The standard fare of conferences and papers revolves around the assumed need for better intelligence, more surveillance, new detection equipment, protective clothing, and computer models to predict behaviour. When the public is engaged it is at the more basic level of identifying means for effectively communicating predetermined messages and information, or to exhort the need for further vigilance under the banal and general slogan of ‘alert, not alarmed’. It is also the case that whatever the government does in these regards there is an insatiable appetite for more. This comes from the posturing of opposition politicians, and the practical demands of emergency responders, as well as the commercial interests of security providers and consultants, who all appeal to the public’s understandable concerns. Some propose the creation of a US-style department of homeland security. Others too, inured by years of cynicism and mistrust in authority are now inclined to assume the worst and presume a cover-up. The urgent need to engage in a broader debate as to social aims and direction, based upon clearly principled beliefs and the desire to engender amongst the population a sense of purpose that would truly make it resilient to acts of terror is continuously put off for some other time, or not even considered. Yet, it is this sense of mission in the world that, having broken down at home, leaves us incredibly unarmed in the face of the limited threat posed by the likes of al Qa’ida and, failing that, what increasingly become labeled as their ‘sympathisers’. If the war on terror was ever hoped to help society rediscover a sense of unity and purpose, then what we are actually witnessing could not be any further from such goals. Far from bringing people together, it has proven deeply divisive and revealed the deep cracks that currently run through society and its institutions. What’s more, technical barriers or solutions to the problem of terror only make things worse as they encourage people to become ever more suspicious and mistrustful as to the activity of their neighbours – rather than bringing people together as the times require. Resilience is not a technology that can be bought. Rather it is an attitude reflecting wider patterns of social development and outlook. Accordingly, attempts to develop

50

B. Durodié / Contemporary Western Responses to Acts of Terror

technical solutions to the problem of terrorism simply end up reflecting and reinforcing existing values. Focusing on the means and losing sight of the ends only builds lack of direction into the system. Presumably, those who are willing to risk their lives fighting fires or combating other emergencies, do so not so that their children can go on to do the same, but for some broader purpose. It is this that we seem to have lost sight of.

Real Resilience The concept of ‘resilience’ – the ability to withstand or recover from adverse conditions – has come of age subsequent to the terrorist attacks of the 11th of September 2001. Politicians, emergency planners and other officials, now talk of the need to ‘build’, ‘engender’, ‘improve’ or ‘enhance’ resilience in society. Unfortunately, by framing the discussion in the fashionable language of ‘risk’, an element of passivity and inevitability has been built into the solutions proffered. The UK Cabinet Office describes the aim of ‘building resilience’ in terms of reducing susceptibility to challenges ‘by reducing the probability of their occurrence and their likely effects’ [36]. The notion that it may be possible to shape conditions, outlooks and perceptions in advance, by setting a clearer political agenda, is not particularly considered. Hence, despite inherent elements of resilience, society continuously seems to down-play such factors, becoming fixated on more immediate problems and undermined by self-doubt. In reality of course, people and systems continue to display a remarkable degree of resilience given the chance [37]. Those directly affected by the events of 9/11 have had little choice but to get on with their lives and, with few exceptions that is what they have done. It is also the case that the total financial cost of these events, both structural and in terms of compensation amounted to less than 1% of US gross domestic product in any one year. To put this into perspective it is worth noting that the Enron saga that followed cost a great deal more. Building on such spontaneous responses, rather than undermining them, requires promoting a clearer sense of who we are and what we are for. This would necessitate truly engaging the public in a political debate as to aims and values. It would also force a need to be more judgmental of others than contemporary society allows. And in turn, this would emphasise the need for collective purpose over individual security in order to achieve predetermined social goals. Sadly, a focus on knowing, engaging, judging and acting is not so straightforward today. Despite this being the real role and responsibility of those in positions of authority, there is good reason to anticipate their reluctance to do so. For if we were to characterise resilient people as their having a greater sense of who they are and of what they can achieve together, along with a willingness to judge others and take action accordingly – it is quite possible to question whether the authorities in the UK, the US, or anywhere else nowadays, would view such a project with any degree of optimism. Resilient people are not necessarily easy to manage. They demand more from those in authority than maybe these latter are willing, or able, to provide. Accordingly, it is likely, for the foreseeable future at least, that there will be much talk about the need to engender social resilience, but very little by way of effective action. It is far easier to make glib references to the need to defend ‘our way of life’, ‘our values’,

B. Durodié / Contemporary Western Responses to Acts of Terror

51

or even ‘freedom and democracy’, than it is to provide real content to such concepts through a concerted campaign to re-engage the public in political discourse. Indeed, few of the authorities concerned with civil defence or homeland security consider it their responsibility to lead on such an agenda. There is, of course, a reason as to why these matters are not being addressed. That is, that there is a failure to recognise that the problem has anything to do with the domestic situation at all. Terrorism is usually perceived as being a problem relating to others, out there. The notion that an absence of direction at home may somehow drive our perception of terrorist acts, as well as undermining resilience and encouraging the perpetrators themselves is a novel one for those in authority. Indeed, there is an even more direct relation between us and the terrorists. That is that terrorism often reflects the dominant forms of social understanding and values it emerges within. When society asserted the need to recognise the independent sovereignty of nation state, terrorists fought politically-motivated national liberation struggles. Now, on the other hand, we live in an age when political debate – beyond the confines of the personal – is weak, or non-existent. One consequence of this is the advent of terrorists without stated aims or goals. What’s more, this nihilistic lashing out against modernity is unrestrained by any sense of moral purpose and draws encouragement from the broader self-loathing evident in western culture. Giving it a name, such as al Qa’ida, rather misses the point. Its perpetrators are as likely to be found at home as anywhere else. They include Timothy McVeigh, the Oklahoma bomber, the Aum Shinrikyo cult, who planted the chemical agent sarin, on the Tokyo subway in 1995, and even the 9/11 hijackers themselves who, far from being poor kids from the Gaza strip were relatively wealthy and well-educated. They had all spent some considerable time attending Western universities and, ultimately reflected our own dominant norms and values. This points to a final problem relating to the war on terror – that is that even if Osama bin Laden and all his acolytes were captured or killed tomorrow, still the problem of terror would not have gone away. This is because a key driver to our perception and response to these events has been our own insecurities. And these are not about to go away. What’s more, by advertising how vulnerable we feel and how frail we have become in relation to any activity, at any time, in any location, we have effectively educated a new generation of the future disaffected, whether terrorists, animal-rights activists, hoaxers, loners or cranks, as to how easy it is to undermine our society using little more than plastic knives and bags of sugar. The sorry truth that lies at the heart of the war on terror is that the West is at war with itself. The acts of 11 September 2001, having been perpetrated by outsiders, served as a useful distraction from addressing where the problems really lie. In fact, those individuals proved so effective because in many ways they reflect our own nihilist culture. It is just that, consciously or not, they have captured this better than we do ourselves. Conclusions From the preceding discussion a number of tentative conclusions can be drawn; 1. A focus on our own societies, psychology and culture is a missing element necessary for understanding both our response to recent acts of terrorism and, the particular salience we attribute to them.

52

B. Durodié / Contemporary Western Responses to Acts of Terror

2. More research is required to explore the largely Western origins of anti-human, anti-modern and anti-Western ideas, as well as how these then become adopted by others. 3. The erosion of social bonds in our society has left a weak, self-centred form of individualism that may be less capable of withstanding difficulties or of perceiving of a greater common good or purpose. 4. A proper understanding of risk perception has to take into account the determining influence of social factors, such as political disengagement and stasis, as well as being grounded in scientific evidence. 5. The key asymmetry used by terrorists is that of our respective attitudes toward risk-taking. We must reassert the inevitability of risk in all activity and highlight the fact that without taking risks nothing can be gained. 6. Government should neither make fatalistic statements about terrorism, nor offer the promise to protect us from all risks. Above-all there should remain a clear distinction between private intelligence and public information. 7. The public are the primary targets of terrorism and accordingly, the real first responders. Their attitudes and values in advance of such incidents are key to shaping outcomes. 8. People and systems are already resilient. Contrary to popular perception, in an emergency, the public rarely panics – displaying both rational and pro-social behaviour – and vital processes continue to function. 9. Real resilience is an attitude, or mindset. It derives from the quiet confidence of having a broader common purpose, combined with a willingness to judge others and to act when necessary. 10. Building real resilience requires re-engaging the public in an active sense, building from their spontaneous co-operative responses, rather than by-passing these using technical means. 11. Technical solutions, when used as an end in themselves – as opposed to a means to a broader end – can push people apart, promoting mistrust and suspicion and thereby further corroding social bonds. 12. Counter-terrorism strategies and national resilience need to be guided by, and embedded within, a broader framework of aims and values for the whole of society. 13. There is an urgent need to restore the centrality of a principled and positive political agenda for society that opposes the use of fear as a vehicle for winning arguments or building coalitions. 14. Social leaders need to focus society on a broader vision, beyond the immediacy of terrorism. It is only through this that they may hope to secure real loyalty and active engagement in achieving their purposes.

References [1] See for example; Reich W. Origins of Terrorism: Psychologies, Ideologies, Theologies, States of Mind, Woodrow Wilson Centre Press, 1998, or Hoffman B. Inside Terrorism, Columbia University Press, 1999. [2] See for example; von Hippel K. The Roots of Terrorism: Probing the Myths, The Political Quarterly, Special Issue, September 2002, or The Roots of Religious Extremist Terrorism, available at; http://www. kcl.ac.uk/ip/andrewsteele/sept11/papers/root.html

B. Durodié / Contemporary Western Responses to Acts of Terror

53

[3] Furedi F. Culture of Fear: Risk-taking and the Morality of Low Expectation, Cassell, 1997, and Continuum, 2002. [4] Huntington SP. The Clash of Civilisations and Remaking of World Order, Simon & Schuster, 1998. [5] See for example; The Pew Global Attitudes Project, available at; http://people-press.org/pgap/ [6] Moore M. Stupid White Men, Penguin, 2002. [7] Durodié B. Sociological Aspects of Risk and Resilience in Response to Acts of Terrorism, World Defence Systems, Vol. 7, No. 1, pp. 214–216, 2004. [8] Putnam RD. Bowling Alone: The Collapse and Revival of American Community, Simon & Schuster, 2000. [9] Furedi F. Paranoid Parenting: Why Ignoring the Experts May be Best for Your Child, Penguin, 2002. [10] Furedi F. Therapy Culture: Cultivating Vulnerability in an Anxious Age, Routledge, 2004. [11] Furedi F. Courting Mistrust: The Hidden Growth of a Culture of Litigation in Britain, Centre for Policy Studies, 1999. [12] Beck U. Risk Society: Towards a New Modernity, Sage Publications, 1992. [13] Durodié B. Poisonous Dummies: Risk Regulation After BSE, European Science and Environment Forum, 1999, available at; http://www.scienceforum.net/pdfs/Durodie1.pdf [14] See for example; Burgess A. Cellular Phones, Public Fears and a Culture of Precaution. Cambridge University Press, 2003. [15] See for example; Fitzpatrick M. MMR and Autism: What Parents Need to Know. Routledge, 2004. [16] Power M. The Risk Management of Everything: Rethinking the Politics of Uncertainty, Demos, 2004, available at; http://www.demos.co.uk/catalogue/riskmanagementofeverythingcatalogue/ [17] Hunt B. The Timid Corporation: Why Business is Terrified of Taking Risk, John Wiley & Sons, 2003. [18] Heartfield J. The ‘Death of the Subject’ Explained, Sheffield-Hallam University Press, 2002. [19] See Durodié B. The Demoralization of Science, paper presented to the Demoralization: Morality, Authority and Power conference, University of Cardiff, 4–6 April 2002, available at; http://www.cf.ac.uk/ dmap/papers/durodie.pdf [20] Durodié B. Limitations of Public Dialogue in Science and the Rise of New ‘Experts’, Critical Review of International Social and Political Philosophy, Vol. 6, No. 4, 2003. [21] Op. cit. Furedi F. 1997. [22] Op. cit. Furedi F. 2004. [23] Quarantelli EL (ed.). What Is a Disaster?: Perspectives on the Question, Routledge, 1998. [24] Furedi F. Heroes of the Hour, New Scientist, Vol. 182, 8 May 2004. [25] Schuster MA, Stein B, Jaycox L, Collins R, Marshall G, Elliott M, Jie Zhou A, Kanouse DE, Morrison JL, Berry SH. After 9/11: Stress and Coping Across America, RAND, 2001. [26] Bleich A, Gelkopf M, Solomon Z. Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel, Journal of the American Medical Association, Vol. 290, pp. 612–620, 2003. [27] Hyams KC, Murphy FM, Wessely S. Responding to chemical, biological or nuclear terrorism: the indirect and long-term health effects may present the greatest challenge, Journal of Health Politics, Policy and Law, Vol. 27, pp. 273–290, 2002. [28] Op. cit. Hyams KC, Murphy FM, Wessely S. 2002. [29] Blair T. Speech at the Lord Mayor’s Banquet, 11 November 2002, available at; http://www.number-10. gov.uk/output/Page1731.asp [30] Durodié B. Facing the Possibility of Bioterrorism, Current Opinion in Biotechnology, Vol. 15, pp. 264– 268, 2004. [31] Royal Society, Making the UK Safer: Detecting and Decontaminating Chemical and Biological Agents, April 2004, available at; http://www.royalsoc.ac.uk/files/statfiles/document-257.pdf [32] Huband M, Burns J, Krishna G. Chemical Weapons Factory Discovered in a London Flat, Financial Times, 8 January 2003. [33] Leppard D. New Government Setback as Ricin Plot Claims Collapse, Sunday Times, 5 October 2003. [34] Durodié B, Wessely S. Resilience or Panic? The Public and Terrorist Attack, Lancet, Vol. 360, pp. 1901– 1902, 2002. [35] Pupavac V. Pathologizing Populations and Colonizing Minds: International Psychosocial Programs in Kosovo, Alternatives, Vol. 27, pp. 489–511, 2002. [36] Cabinet Office, Draft Civil Contingencies Bill, June 2003. [37] Op. cit. Furedi F. 2004.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

55

Towards a Public Mental Health Approach to Terror Johan M. Havenaar and Evelyn J. Bromet

Introduction Since the United States Civil War in the 19th century and the World War I in the early 20th century, it has been recognized that some of the casualties of war are caused by the psychological impact of these experiences rather than just by their physical impact. Similarly, since the seminal descriptions of survivors of the Coconut Grove fire disaster in 1942 [1], many studies of natural and human-made disasters, including toxic exposures, have described their physical and psychological consequences [2]. By their very nature, the recent terrorist attacks are specifically intended to induce fear (terror) in the population in addition to physical casualties and damage. Hence it is useful to consider the lessons learned from research on the diverse catastrophic experiences over the past 50 years. The advent of structured interviews and clinical criteria in psychiatric research during the 1970’s spurred a large number of epidemiological studies that have quantified the impact of disasters on mental health and well-being [3]. The first study to use structured diagnostic interviews focused on the impact of the 1979 accident at the Three Mile Island nuclear power plant on rates of major depression and generalized anxiety disorder [4]. Since then, the DSM classification system officially operationalised Posttraumatic Stress Disorder (PTSD), and the ICD-10 introduced a similar category. Subsequently, much of the research on the psychological impact of disasters has tended to focus more or less exclusively on this PTSD diagnosis, even though it is increasingly recognized that the range of potential negative outcomes is far broader and includes affective, anxiety, substance abuse disorders and non-specific medical symptoms. Thus, while the research over the past decades has produced a wealth of information documenting the prevalence of mental health problems in the aftermath of disasters, and identifying the major risk factors and protective factors determining outcome, the recent work has focused a great deal on PTSD. The terrorist attacks on New York and Washington on September 11th , 2001 have once again given rise to a wave of post-disaster studies. There are both empirical and public health reasons for conducting further descriptive epidemiological studies in the wake of these disasters [5,6]. From a research perspective, the reasons include (a) ascertaining high risk groups among both children, adults, and the elderly; (b) identifying risk and protective factors as well as potential unique etiologic or pathogenic mechanisms; (c) completing the clinical picture beyond people who present for treatment; and (d) identifying new syndromes. Public health reasons include (e) estimating the preva-

56

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

lence of psychopathological reactions in the community for needs assessment purposes; (f) gathering information that can be used for preparing and tailoring response programs; (g) evaluating the effectiveness of interventions; (h) monitoring the long-term health problems, particularly in cases involving exposures with uncertain future effects; (i) addressing public concerns about the health effects of the event; and (j) responding to possible legal challenges. In a recently published review of the disasters literature, we expressed the concern that contemporary disaster research has reached a point where further descriptive studies may be expected to yield little added value to what is already known [7]. We pointed out that recent studies tend to reconfirm findings that are well established. In part, this occurs because the majority of contemporary studies administer a core battery of interview schedules and questionnaires that contain pre-formatted questions and pre-determined answer categories. Thus, we suggested that except for the need for further studies about psychophysiological mechanisms associated with adverse outcomes, especially in cases where the disaster involves exposure to toxic substances with potential negative effects on the central nervous system, the main reasons for doing further disaster studies are likely to be in the public health domain. Conceivably, a merger of quantitative and qualitative methods might yield some significant novel findings about disaster’s impact. Along these lines, funding agencies, such as the National Institute of Mental Health, are in fact more interested in studies designed to develop and evaluate post-disaster mental health interventions than in further descriptive epidemiologic post-disaster research.

Challenges in Designing Disaster Studies Disasters by their very nature are unanticipated. As such a number of challenges arise in designing studies of their mental health sequelae. Assembling a research team The first such challenge is to identify collaborators and organize a research team. Relationships within any research team must be built on mutual trust and respect. In disaster studies, the team is likely to be assembled quickly and at the same time to find itself having to operate under extremely difficult circumstances and with major time constraints. Also, it is not unusual for some members of the research team or their relatives to be directly affected by the event. It is equally important to establish trust between the team and the affected population, as well as between the research team and people involved in relief work in the field. While this may seem obvious, these challenges are not easily achieved when both the research team and the affected population share the shock and devastation of the event. Thus, the research team needs to take stock of their own emotional responses and privacy needs as they consider how to deal with the same issues among potential study participants. Timing The design of an investigation will depend largely on the aims of the study and the conditions under which the study will take place. Most mental health studies will take place after the disaster occurs, and after the physical toll is known. Many recent studies have

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

57

involved cross-sectional surveys, including telephone surveys. These studies try to show differences in rates of symptoms across time, but only longitudinal (follow-up) studies are capable of describing the course and outcome of post-disaster psychological effects, risk and protective factors, and benefits of intervention programs. The timing of the research, as well as of the follow-ups, will be determined by the specific research questions being addressed, as well as by the feasibility and availability of resources available for conducting the study. So far, we have focused on post-disaster research. It is also important to consider the challenges involved in studying “potential” disasters, such as future bioterrorist attacks in which the need for an entirely different type of study may arise. In this scenario, researchers may be confronted with an essentially unique situation, i.e., to design an investigation of whether certain observed health problems are the result of an as yet unknown attack [6]. This was the case in the initial days after the first cases of anthrax were diagnosed in Florida in the fall of 2001 and the source of the infection was unknown. This type of cluster analysis will not be further discussed here, but readers interested in this issue are referred to Fielder and colleagues [6]. Exposure identification The next step is to identify the relevant physical and psychosocial exposures. This issue is critically important because it will determine which end-points are to be assessed, i.e. only psychological or psychiatric sequelae or also global and/or specific physical health outcomes. In the realm of mental health outcomes, it is important to consider a range of potential clinical and subclinical domains, including depression, anxiety, substance use and abuse, somatic symptoms, and PTSD. Recent research has demonstrated that medically unexplained symptoms (MUPS) are an under-researched outcome of disasters [7]. They may occur especially after disasters which involve toxic exposure or in cultural settings where somatic complaints are the normative means for expressing distress. For each of the outcomes to be studied, the relevant competing risk factors, and the potential confounding variables, must be carefully measured as well. Often this means that the interviews or questionnaires will be lengthy, and this too poses a special challenge for disaster studies. One of the important challenges in disaster research, which gives rise to continuous debates at all stages of the research, from design and instrument selection to data analysis and interpretation, is to bridge the gap between the psychological and psychiatric approaches. Psychologists tend to approach research from a dimensional and dynamic point of view whereas psychiatric epidemiologists tend to focus on categorical disease end-points. To some extent, this will influence the sample size needed to achieve a specific result. More than that, these different approaches may give rise to incorrect use of terms, such as “PTSD” which is meant to be a clinical category but is often used to describe individuals with high scores on scales evaluating the intrusion, avoidance and hyperarousal symptoms encompassed by the DSM-IV definition of PTSD. Sample selection Once the aim of the study has been set, and the study design decided upon, the next step would be to define the affected population. This represents one of the most difficult tasks

58

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

in disasters studies. The chaotic situation that occurs immediately after a disaster often makes it impossible to determine who exactly was affected and who was not. Immediately after the crash of the El Al Boeing 747 into a housing block in Amsterdam in 1992, killing 29 residents and 4 crewmembers, the authorities estimated that between 1000 and 1500 persons had directly experienced the crash. This included rescue workers who arrived during the early hours after the event. Six years later, after the endless rumours regarding possible presence of toxic agents in the cargo had finally been proven false, more than six thousand people came for a medical check-up because they feared that their health might have been compromised because of the event [8]. Because of the chaos and the need to maximize the number of people available at the disaster site, even tightly run organizations such as police and fire departments may be unable to produce accurate lists of officers who participated in relief work. Because of the difficulties in defining the sampling frame for a disaster study, many studies turn to convenience samples, such as litigants, web survey responders, telephone responders, insurance claimants, or clinic attenders. Prevalence estimates based on such samples are likely to be unreliable. For example, studies of help-seeking refugees from Cambodia residing in the US produced prevalence rates (of which disorder) varying from 22% to 92% [9]. Once the target sample is defined, it is often extremely difficult to identify an unaffected control group (or groups) who are similar in all respects except for exposure to the disaster. Usually control groups are selected from nearby towns. One obvious problem is that people in nearby towns may in fact be exposed via extensive media coverage, by working in or near the disaster area, or by having friends or family members living or working in the exposure site. For example, in a study of the effects of major floods in southern France, Verger and colleagues found that many control subjects from the unaffected villages nearby had family members or business interests in the flooded villages [10]. In disasters involving toxic exposures, the comparison sites should be screened for other contaminants that could lead to the same end-points. For example, one of the first western epidemiologic studies of the health effects of the 1986 Chernobyl accident, the International Chernobyl Project [11], evaluated the health status of five age-groups living in rural contaminated communities with that of controls from “non-exposed” villages and found no significant differences in physical health (hematological, thyroid, and general health measures). After the report was disseminated in Ukraine, the authorities claimed that the control villages were polluted by dangerous levels of pesticides.

Challenges in Instrument Selection Diagnosis vs. symptom checklists Once the research questions, study design and relevant outcome domains have been determined, the next step will be to translate these into specific measures. A large number of standardized diagnostic and symptom inventories are available, and certain measures, such as Diagnostic Interview Schedule (DIS), the General Health Questionnaire (GHQ), and the Impact of Events Scale (IES), have been administered in many disaster studies. Even though most of these instruments have been shown to have acceptable reliability and validity, it important to realize that when different instruments are used to mea-

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

59

sure the same condition, or even when single instruments are used with different cut-off scores or diagnostic criteria, wide variation in prevalence rates will ensue. More specifically, in the recent National Comorbidity Survey-Replication (N = 9090), a subsample (N = 335) of those initially interviewed with the Composite International Diagnostic Interview (CIDI) were subsequently reinterviewed by clinicians over the telephone with an abbreviated 12-month version of the Structured Clinical Interview for DSM-IV (SCID) [12]. While 7.6% of the sample met DSM-IV criteria for Major Depressive Disorder on the CIDI, 5.2% met the same criteria on the SCID, with a chance corrected agreement which was at best moderate (Cohen’s Kappa = 0.6, 95% CI 0.2–0.6). It is therefore important to keep in mind that the variability in the prevalence rates achieved across different studies is in part attributable to the specific instruments included in the research. Having made the choice between dimensional or categorical (diagnostic) measures, or the choice to use both, the next issue to decide upon is the choice between self-report or interview methods. Self-report questionnaires are convenient and relatively cheap to use. They tend to have good sensitivity, but less favourable specificity. Interviews are more costly, and especially in the case of structured interviews, have reasonable specificity. The cut-points themselves may be culturally specific. For example, in the U.S., when asked to rate your health, the majority of people in the general population answer excellent or very good; few people say moderate, fair or poor. In Ukraine, the normative response is moderate, and the next most popular response is fair. Few people would evaluate their health as very good. In our Chernobyl research [13], it was necessary to extend the low end of the scale by adding a ‘very poor’ category in order to capture the full range of responses in a meaningful way. To date, most disasters studies have been conducted in the West. Whether our measures are equally reliable and valid across race and ethnic groups is a topic that has rarely been studied. Thus, for an event like September 11th that affected a diverse set of cultural and ethnic groups, our lack of knowledge about the cross-cultural validity of western measures and the absence of culturally sensitive measures for most of the affected populations limit what can be learned from current research. Similarly because the majority of the disasters occur in underdeveloped areas of the world, selecting appropriate instruments is a major challenge. Unfortunately, few disaster studies include an examination of cultural variations in idioms of distress or the cross-cultural validity of the instruments and assessment methods that are used [14]. The best way to handle the issue is to include investigators on the research team who are part of the community that was affected by the disaster although even then, the arduous task of establishing cross-cultural reliability and validity may be beyond the grasp of the typical disaster study that is done under both time and budgetary constraints. A further measurement issue is the assessment of the level of personal involvement and incurred stress as a consequence of the disaster. Usually in disaster studies, proximity to the disaster site is used as a proxy for exposure to stress emanating from the event. In addition, usually other information is collected to assess the level of personal involvement, such as whether the subject was injured, lost relatives or property, had to be evacuated, or witnessed dead or injured persons. When the exposure information is subjective (did you feel threatened by the event?), recall bias may be a special problem because the response will be influenced by current affectivity. However, even when the exposure information is presumed to be objective, recall bias is an issue, especially over time. Southwick et al. (1997) interviewed veterans from the first Gulf War about

60

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

their traumatic experiences one month and again two years after their return home [15]. Eighty-eight percent changed their response to at least one item of the questionnaire that asked about their experiences in the field.

Challenges in Executing Disaster Studies Access to remote areas Not only is it difficult to define the affected population, in many cases it may also be difficult to reach the area. Many disasters in developing countries occur in remote areas, but even in areas that might be easily accessible under normal conditions, it might be difficult to get there because of disrupted transportation systems or restrictions imposed by the authorities regarding entry to the area. Conducting telephone surveys may be a way to circumvent these problems, providing telephones are working and telephones are widely available. When the Chornobyl accident occurred in 1986, many people in Kiev had party lines, and thus there was no guarantee that privacy could be achieved. Conditions at the disaster site will also make it difficult to adequately monitor the field work. Another problem is that affected populations or parts of them may have been evacuated or scattered. Response rates Even if eligible subjects can be reached, response rates may be low because people have other priorities and have no time to participate in a mental health study. The post-disaster period is often characterized by great turmoil, food and housing shortages, economic hardships and battles for benefits. These can all lead to relatively low response rates and potentially biased samples. However, this certainly is not always the case, and response rates of over 80% or even over 90% have been achieved (e.g., refs). Response rates from disaster follow-up studies have been disappointing to date. For example, in a 33-year follow-up after a mud slide in Aberfan, South-Wales, which killed 116 children, it was possible to trace 115 of the 145 survivors in the original cohort, but only 41 agreed to participate (28% of the total). Achieving a good response rate in the control group is sometimes more difficult because the motivation for participation is not as obvious. In the Aberfan study, only 19% of controls participated in the follow-up [16]. Informed consent In settings where the population is not literate, or distrust in authorities is the norm, including a western-style informed consent procedure may be challenging. However in our experience studying the effects of Chornobyl, while our colleagues in Ukraine, Belarus and Russia expressed outrage at the concept, virtually everyone whom we studied was happy to hear about confidentiality and related issues and did not hesitate to sign the consent form. A related concern that has been raised is whether trauma victims are able to give valid informed consent, especially during the early phase immediately after the event. DuMont and Stermac (1996) found that 14 out of 15 survivors of sexual assault who had signed consent forms to participate in a trauma study could not remember having

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

61

given consent 10–39 months later [17]. However, in all cases the women reported that they had no problem with being approached by the research team and were willing to participate. Therefore, at this point in time, there is no evidence to suggest that participation has negative effects on participants, even in the immediate aftermath of traumatic experiences. In a similar vein, several authors have suggested that trauma survivors may be too fragile to endure the painful memories and the stress stirred-up by participation in PTSD research [17–19]. These concerns have largely been based on anecdotal evidence. The few empirical studies to investigate this issue found no negative effects of interviews among victims of interpersonal violence [20–22]. In fact in most studies, participants tended to view participation as a positive experience, while only a minority reported that the emotions aroused during the interview were stronger than they expected. In the Bromet follow-up 3 years after the Three Mile Island accident [23], one control mother said that the questions previously asked about her marriage were extremely upsetting and she thus refused to participate again; however, no other respondent refusing the followup interview suggested that her decision was based on the content of the previous assessment.

Challenges in the Analytic Phase Power Many disasters studies are by their very nature designed and implemented at short notice. Usually no power analysis has been done beforehand. Power problems are particularly likely to be problematic in studies focused on clinical diagnoses with relatively low prevalence, such as somatization disorder. Thus, the two published prospective studies in which subjects had by chance participated in a mental health survey and subsequently experienced a disaster had relatively small numbers of subjects [24–27]. While these studies are from a methodological point of view very valuable, their relatively low N’s have made it practically impossible to establish whether disasters have an effect on clinically diagnosable disorders after adjusting for baseline levels, even though symptom counts for these disorders significantly increased. Multiple comparisons An issue that comes up in any study involving extensive testing, and therefore also in disaster studies, is the multiple comparisons problem. This is further compounded by the fact that the measures themselves are highly intercorrelated (e.g., depression, anxiety, PTSD, somatic complaints). To date, very few disaster studies have controlled for multiple comparisons, and it is important that future studies consider this issue when establishing cut-points for establishing statistical significance. False positive responses The widely used Impact of Events Scale [28] or other PTSD scales contain measures of intrusion and avoidance symptoms. It is good to realize that with recurrent images of disasters shown on TV, high scores for intrusion may represent false positive answers, and

62

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

instead may be tapping repeated exposure to images on the news networks. In a recently completed study of the mental health effects of an accident which occurred at an airbase in Lviv, in western Ukraine, where a jet fighter plane crashed into the public gathered to watch an air show, we found a modest but statistically significant correlation between the presence of intrusive symptoms on the IES and watching the event over and over again on TV (unpublished data). If the symptom inventories were not comprehensive in scope, false negatives can occur. Thus, for example, if acting out behaviours or substance abuse problems are not assessed, and anxiety and affective symptoms are evaluated, women will appear to have suffered more in relation to an event than males when in fact, the overall impact on psychological and substance morbidity may be similar. Reporting mental health effects In the situation of disasters, where the stress is collective, a public health perspective should be maintained when reporting on the psychological impact on a stricken community. For example, if the results show an increased rate of panic attacks in exposed vs controls, it is important to clearly communicate that this does not imply that “the population was in a panic.” Indeed, as Glass has indicated in this volume and elsewhere, the findings generally suggest that panic is the exception, not the norm [29]. As responsible citizens, it is our obligation as researchers to present a balanced picture of the impact of the event under study. Rarely do we include “positive” outcomes, rarely do we examine the functional consequences of psychological symptoms, and rarely are we mindful of the limitations of our measures. Thus in our opinion, it is important for investigators not to over-emphasize or over-dramatize the negative findings. Durodie and Wessely, also in this volume and elsewhere, take this point one step further when by suggesting that the strong emphasis placed on the negative impact of terrorist events by media and authorities – who mostly obtain their information from researchers and clinicians – may even be exploited by terrorist groups to their advantage [30,31]. Following these authors line of reasoning, negative findings from disaster studies may send an unintended message to the public that massive psychopathology is likely to ensue. For example, although generalizing from telephone survey research is problematic, the Galea et al. (2002) telephone survey in lower Manhattan in the immediate aftermath of the World Trade Centre attack was used to suggest how many people in the area below 110th street suffered from PTSD and depression at different points in time after the attack [32]. Although the investigators are aware of the study’s limitations (low response rate, generalizability of the findings, use of symptom measures with unknown reliability on the telephone, cross-cultural constraints), the results were reported as if the data provide precise estimates of the numbers of people with symptoms and presumably who might benefit from treatment. As noted above, disaster studies usually do little justice to describing the overall resilience of the population, or the positive effects a disaster can have in strengthening community ties or sense of patriotism. In the worst case scenario studies emphasizing negative outcome may instead strengthen victim identity among the survivors and/or suggest symptoms to future study subjects. In short, disaster research is a form of intervention, and like any intervention, it may have positive as well as negative effects which should be taken into consideration.

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

63

Discussion In recent years many studies have been published about the health effects of disasters. The point has been reached where one might get the impression that every disaster either is or should be followed-up by a mental health study. As we indicated in the introductory paragraph, it is unlikely that studies which continue in the tradition of using the same standardized interviews with prefabricated answer categories over and over again will come up with new, clinically relevant information. Perhaps one of the main reasons that these studies are still being done is that they are a way for society at large, and mental health specialists in particular, to show their concern for the affected community. The study confirms for the victims that the outside world cares about them and may be a way to communicate the outcry of the affected population to the outside world. This raises the issue, however, of whether research is the best way to achieve this goal. From a scientific point of view, it is important that future studies be designed to investigate the effects of large scale mental health interventions. After the September 11th terrorist attacks, numerous support services were set up in the New York area, although reportedly socially underprivileged neighbourhoods received far less mental health support than more affluent parts of the city. As researchers, we are in a position to recognize and address disparities in the provision of mental health care after disasters and other catastrophic events. Indeed, since most disaster studies are epidemiologic in nature, and epidemiology is the scientific arm of preventive medicine, it behoves us as disaster researchers to recognize and address this issue. We also believe that it is timely to reconsider the need for rapid interventions in the intermediate aftermath of a disaster [33]. A number of studies have reported that “crisis support,” i.e., providing people who will listen and give practical and emotional support has positive effects on well-being (e.g. [34]). Undoubtedly people from the affected population will appreciate the attention and support offered to the community from the outside, whether this is provided by mental health professionals, clergy or lay people. It remains to be seen, however, whether providing such support by mental health professionals makes sense from a public health point of view. There have been relatively few studies which have systematically investigated the effectiveness of mental health interventions, such as psychological debriefing, in a randomized controlled fashion. The studies which have been done were unable to consistently show a positive effect of this type of intervention [35,36]. In two trauma studies, in fact, a negative effect of individual and group emotional debriefing were reported [37]. It remains to be further investigated whether these results also hold true in disaster situations. Even less is known about the effects of information provided by authorities in the immediate aftermath of an event. In the Amsterdam airplane crash disaster described above, it was believe that failure of the authorities to credibly falsify rumours about the presence of toxic substances aboard the freighter was one of the crucial factors which fuelled uncertainty and fear in the public. Similar allegations have been made about the way the British government handled the bovine spongiform encephalitis crisis [38]. More research is needed about the most effective strategies for risk communication in the wake of disaster. Despite our lengthy discussion of caveats and potential drawbacks of conducting disaster research, it is our experience that meeting the special challenges that disaster research poses is well worth the effort. Victims of disasters often wish to talk, and re-

64

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

searchers who listen (not just prejudge all the questions and possible answers) may contribute valuable insights about coping with horrific stress. From a scientific point of view, because disasters are independent events, occurring indiscriminately to subjects regardless of their personal histories or personalities, they offer epidemiology the rare opportunity to study the effects of a “natural” experiment. Most importantly, the results of carefully designed and interpreted studies can be used for planning public heath interventions in the future.

References [1] Adler A. Neuropsychiatric complications in victims of Boston’s Cocoanut Grove disaster. JAMA 1943; 123: 113–119. [2] Havenaar J, Cwikel JG, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002. [3] Bromet E, Dew MA. Review of psychiatric epidemiologic research on disasters. Epidemiol Rev 1995; 17 (1): 113–9. [4] Bromet E, Schulberg HC. The TMI disaster: a search for high risk groups. In: Shore J, ed. Disaster Stress Studies: New Methods and Findings. Washington, DC: American Psychological Association, 1986: 2–19. [5] Morris J. The Uses of Epidemiology. 2nd ed. London: Livingstone, 1964. [6] Fielder H, Palmer SR, Coleman G. Methodological issues in the investigation of chemical accidents. In: Havenaar JM CJ, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002: 185–197. [7] Bromet E, Havenaar JM. Mental Health Consequences of Disasters. In: Sartorius N GW, Lopez-Ibor JJ, Maj M., ed. Psychiatry in Society. Chicester: John Wiley, 2002: 241–261. [8] Yzermans J, Gersons BPR. The chaotic aftermath of an airplane crash in Amsterdam: a second disaster. In: Havenaar JM CJ, Bromet EJ, ed. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002: 85–99. [9] Abueg F, Chun KM. Traumatization stress among Asians and Asian Americans. In: Marsella MJ, Gerrity FE, ed. Ethnocultural aspects of Posttraumatic Stress Disorder: Issues, research and clinical applications. Washington, DC: American Psychological Association, 1996. [10] Verger P, Hunault C, Rotily M, Baruffol E. Risk factors for post traumatic stress symptoms five years after the 1992 flood in the Vaucluse (France). Rev Epidemiol Sante Publique 2000; 48 (2): 2S44–53. [11] Association IIAE. The International Chernobyl Project: An Assessment of Radiological Consequences and Evaluation of Protective Measures. Vienna: IAEA, 1991. [12] Kessler R, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush J, Walters EE, Wang PS. The epidemiology of Major Depressive disorder. Results from the National Comorbidity Survey-Replication (NCS-R). JAMA 2003; 289: 3095–3105. [13] Bromet E, Gluzman S, Scwartz J, Goldgaber D. Somatic symptoms in women 11 years after the Chornobyl accident. Environmental Health Perspectives 2002; 110 (Suppl 4): 625–629. [14] Van Ommeren M. Validity issues in transcultural epidemiology. British Journal of Psychiatry 2003; 182: 376–378. [15] Southwick S, Morgan CI, Nicolaou A, Charney D. Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm. Am J Psychiatry 1997; 154: 173–177. [16] Morgan L, Scourfield J, Williams D, Jasper A, Lewis G. The Aberfan disaster: 33-year follow-up of survivors. British Journal of Psychiatry 2003; 182: 532–536. [17] DuMont J, Stermac L. Research with women who have been sexually assaulted: Examining informed consent. Canadian Journal of Human Sexuality 1996; 5: 185–191. [18] Templeton D. Sexual assault: Effects of the research process on all the participants. Canadian Family Physician 1993; 39: 248–258. [19] Drauker C. The emotional impact of sexual violence research in participants. Archives of Psychiatric Nursing 1999; 13: 161–169. [20] Walker ENE, Koss M, Bernsteing D. Does the study of victimization revictimize the victims? Psychiatry and Primary Care 1997; 19: 403–410.

J.M. Havenaar and E.J. Bromet / Towards a Public Mental Health Approach to Terror

65

[21] Newman E, Walker EA, Gefland A. Assessing the ethical costs and benefits of trauma focussed research. General Hospital Psychiatry 1992; 21: 187–196. [22] Griffin M, Resick PA, Waldrop AE, Mechanic MB. Participation in trauma research: is there evidence of harm? Journal of Traumatic Stress 2003; 16: 221–227. [23] Dew M, Bromet EJ, Schulberg HC. A comparative analysis of two community stressors’ long-term mental health effects. Am J Comm Psychol 1987; 15: 167–184. [24] Robins L, Fischbach RL, Smith EM, Cottler LB, Solomon SD, Goldring E. Impact of diaster on previously assessed mental health. In: Shore J, ed. Disaster Stress Studies: New methods and findings. Washington: American Psychiatric Press, 1986: 21–48. [25] Smith E, Robins L, Przybeck T, Goldring E, Solomon S. Psychosocial consequences of a disaster. In: Janes H, Shore M, eds. Disaster Stress Studies: New Methods and Findings. Washington, DC: American Psychiatric Press, 1986: 50–76. [26] Canino G, Bravo M, Rubio-Stipec M, Woodbury M. The impact of disaster on mental health: Prospective and retrospective analyses. International Journal of Mental Health 1990; 19: 51–69. [27] Escobar J, Canino G, Rubio-Stipec M, Bravo M. Somatic symptoms after a natural disaster: a prospective study. American Journal of Psychiatry 1992; 149: 965–967. [28] Horowitz M, Wilner N, Alvarez W. Impact of event scale: a measure of subjective stress. Psychosomatic Medicine 1979; 41: 768–781. [29] Glass T, Schoch-Spana M. Bioterrorism and the People: how to Vaccinate a City against Panic. Clinical Infectious Diseases 2002; 34: 217–223. [30] Durodie W, Wessely S. Resilience or panic: the public’s response to a terrorist attack. Lancet 2002; 360: 1901–1902. [31] Gearson J. The nature of modern terrorism. In: Freedman L, ed. Political Quarterly. Oxford: Blackwell, 2002: 7–24. [32] Galea S, Ahern J, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vlahov D. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine 2002; 346: 982–987. [33] Sensky T. The utility of systematic reviews: the case of psychological debriefing after trauma. Psychother Psychosom 2003; 72: 171–175. [34] Dalgleish T, Joseph S, Thrasher S, Tranah T, Yule W. Crisis support following the Herald of FreeEnterprise disaster: A longitudinal perspective. Journal of Traumatic Stress 1996; 9: 833–845. [35] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [36] Wessely S, Bisson J, Rose S. A systematic review of brief psychological interventions (“debriefing”) for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. In: Oakley-Browne M, Churchill R, Gill D, Trivedi M, Wessely S, eds. Depression, Anxiety and Neurosis Module of the Cochrane Database of Systematic Reviews, Issue 3 ed. Oxford: Update Software, 2000. [37] Carlier I, Lamberts R, Van Uchelen A, Gersons B. The influence of occupational debriefing on post traumatic stress symptomatology in traumatized police officers. British Journal of Medical Psychology 2000; 73: 87–98. [38] Furedi F, Taylor-Goodby P. The assessment of asymmetric threat. Canterbury: University of Kent, 2002.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

67

Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Jennifer S. Lerner a , Roxana M. Gonzalez a , Deborah A. Small b and Baruch Fischhoff a a Carnegie

Mellon University of Pennsylvania

b University

Abstract. The aftermath of September 11th highlights the need to understand how emotion affects citizens’ responses to risk. It also provides an opportunity to test current theories of such effects. On the basis of appraisal-tendency theory, we predicted opposite effects for anger and fear on risk judgments and policy preferences. In a nationally representative sample of Americans (N = 973, ages 13–88), fear increased risk estimates and plans for precautionary measures; anger did the opposite. These patterns emerged with both experimentally induced emotions and naturally occurring ones. Males had less pessimistic risk estimates than did females, emotion differences explaining 60 to 80% of the gender difference. Emotions also predicted diverging public policy preferences. Discussion focuses on theoretical, methodological, and policy implications.

Effects of Fear and Anger on Perceived Risks of Terrorism: A National Field Experiment Terrorist attacks on the United States intensely affected many individuals and institutions, well beyond those directly harmed. Financial markets dropped, consumer spending declined, air travel plummeted, and public opinion toward government shifted. These responses reflected intense thought – and emotion. The attacks – and prospect of sustained conflict with a diffuse, unfamiliar enemy – created anger, fear, and sadness. A growing literature considers the interplay of emotions and risk perception (see [Holtgrave and Weber, 1993 #2073] [Loewenstein, 2003 #2084; Loewenstein, 2001 #2085] [Mellers, 1999 #2086] [Schwarz, 1996 #2089] [Slovic, 2002 #2078]. Its theories can both illuminate current events and be tested by them. Early research found that positive emotions trigger more optimistic risk assessments and negative emotions trigger more pessimistic ones, even if the source of the emotion has no relation to the target risks [1]. Recent research replicates carryover effects of emotion, but demonstrates the importance of examining specific emotions rather than global (positive-negative) feelings [2–6]. Experiments guided by appraisaltendency theory [4,5] have demonstrated that some negative emotions trigger optimism.

68

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Appraisal-tendency theory assumes that emotions not only arise from [7], but also elicit [3–6] specific cognitive appraisals. Such appraisals, although tailored to help the individual respond to the event that evoked the emotion, persist beyond the eliciting situation – becoming an implicit perceptual lens for interpreting subsequent situations. For example, fear arises from [7] and evokes appraisals of uncertainty and situational control [4], two central determinants of risk judgments [8], whereas anger is associated with appraisals of certainty and individual control [4,7]. Consistent with appraisal-tendency theory, laboratory studies have found that anger triggered in one situation evokes more optimistic risk estimates and risk-seeking choices in unrelated situations. Fear does the opposite, evoking pessimistic estimates and risk-averse choices [5]. Appraisals of certainty and control moderate and (in the case of control) mediate these effects [4,5]. If these findings generalize to the risks of terrorism, then an angry country could endorse different policies than a fearful one. The existing evidence, however, comes almost exclusively from experiments with controlled conditions and college-student samples. The present study tested whether these patterns would hold with a nationally representative sample that received emotion inductions and answered questions at home. No previous emotion experiment has used a national sample; few have used a topic so inherently salient that respondents already have strongly held beliefs. To further test generality, the study measured risk perceptions with different response modes (verbal, numeric), while considering both naturally occurring and experimentally induced emotions. Members of a nationally representative sample vary in many ways. Our analyses focus on age and gender. Compared with women, men generally report lower risk estimates [9]. Given the many factors that covary with gender in a national sample (e.g., income, longevity, social status), a gender difference in risk estimates may be multiply determined. One intriguing (but previously untested) explanation implied by appraisal-tendency theory is that gender differences in emotional experience will account for differences in risk estimates. Drawing on the demonstrated effects of fear and anger on risk perception [5] and men’s tendency to report experiencing less fear and more anger than women [10,11], we predicted that women would perceive greater risks than men and that differences in experienced fear and anger would mediate this result. Conventional wisdom holds that adolescents have a sense of invulnerability that encourages risky behaviors. However, studies have found similar risk perceptions for adolescents and adults [12]. A recent study of a nationally representative adolescent sample measured predications of life events (e.g., pregnancy, school completion, violent crime) and found accurate to optimistic predictions, except for exaggerated estimates of premature mortality [13]. We oversampled adolescents, in order to have the statistical power to detect age differences. The tragic terrorist attacks provide a unique opportunity for testing psychological theories and laboratory findings, using experimental methods with a nationally representative sample and considering issues of intense interest. In addition, the results may also help citizens and policy makers understand the complex emotions and cognitions evoked by the attacks.

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

69

Method1 Overview Our two-part field experiment drew a random sample from Knowledge Networks’ nationally representative panel, originally recruited through random-digit dialing. Individuals agreeing to participate in this panel receive a WebTV and free interactive Internet access, in return for completing occasional surveys. Characteristics of the 75,000 households in the panel closely match the U.S. Census (for details on the Knowledge Networks panel, see http://www.knowledgenetworks.com/ganp/). For the present study, respondents received an e-mail message announcing the survey’s availability. Respondents agreeing to participate received the survey and provided informed consent. Survey alerts were sent on two dates: September 20th and November 10th, 2001. Each time, respondents had approximately 14 days to respond. September 20th procedure (Time 1) A random sample of 1,786 Knowledge Networks panel members (ages 13–88) answered questions about the attacks and completed several psychosocial scales, two of which are relevant here: (a) the five-item Anxiety Subscale from the Stanford Acute Stress Reaction Questionnaire [14] (α = .78) and (b) a four-item face-valid Desire for Vengeance Scale [15] (α = .69). We performed a principal-components factor analysis on each question set (no rotation), then used regression scores from the factor in subsequent data analyses. November 10th procedure (Time 2) The same 1,786 panel members received a message describing the second study and inviting those who could spend 20 uninterrupted minutes alone to participate. The survey was opened by 1,030 people. The study sample included the 973 who completed almost all the survey questions. Sample Preliminary analyses separated adolescents (N = 143) and adults (N = 830). Demographics for each subsample roughly matched Census figures.2 Both were 49% male. The mean ages were 45.9 (SD = 16.8, range: 18–88) and 15.3 (SD = 1.15, range: 13–17). Across the sample, self-reported ethnic-group membership was as follows: 12% African American, non-Hispanic; 12% Hispanic; 8% other, non-Hispanic; and 68% White, nonHispanic.3 Among the adults, 14% reported not completing high school, 31% said they had graduated high school or received a general equivalence diploma, 23% reported having some college education but no degree, 23% said they graduated from a 2- or 4-year college, and 9% had advanced degrees. 1 Given space constraints, methodological details could not be included in this report. This information is available on-line (http://computing.hss.cmu.edu/lernerlab/papers.php) or by request from the authors. 2 Weights adjusted for variable number of telephone lines per household and oversampling of some geographical areas. They included a nonresponse adjustment and poststratification weighting to demographic benchmarks from the Current Population Survey. For sampling details, see http://www.knowledgenetworks. com/ganp/. 3 When an adolescent did not identify his or her race, we inferred it from parental race. When parental race was missing, race was randomly assigned according to the proportions in the cases for which race was known.

70

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Experimental manipulation As respondents opened the second survey, a computer algorithm randomly assigned them to one of three emotion conditions. Respondents answered questions about their mood, then received a two-part emotion induction. The first part presented text like the following, followed by a box for typing a response: The terrorist attacks evoked a lot of emotion in Americans. We are particularly interested in what makes you most ANGRY about the attacks. Please describe in detail the one thing that makes you most ANGRY about the attacks. Write as detailed a description of that thing as possible. If you can, write your description so that someone reading it might even get ANGRY from learning about the situation. • What aspect of the terrorist attacks makes you the most ANGRY? • Why does it make you so ANGRY?

The other two conditions replaced “ANGRY” with “SAD” or “AFRAID.” Respondents in each condition then saw a picture and heard an audio clip about terrorism that had, in pretests, evoked the target emotion more than the other two emotions. (We focus in this report on fear and anger; the sadness manipulation will be reported elsewhere.) In order to evaluate the effects of actual media portrayals, all stimuli came from major media outlets, primarily CNN and the New York Times. The anger text and picture involved celebrations of the attacks by people in Arab countries. The fear text warned of anthrax and bioterrorism; the picture showed postal workers wearing flimsy masks. Measures of risk perception Each respondent judged risks in three ways, differing in response mode, focal event, and risk target. For the first set of questions, respondents judged the likelihood of future events for the United States, on a verbal response scale anchored at 0 (extremely unlikely) and 8 (extremely likely). Typical items were, “Safety in airline travel will improve dramatically as a result of the terrorist attack,” “Another major terrorist attack will occur within the next 12 months” (reverse-scored), and “The United States will be able to capture Osama bin Laden.” Analyses of this Risk of Future Events for the United States scale used mean responses to the nine items (α = .73). It is possible that placing greater analytic demands on respondents might diminish emotion effects. In order to test this possibility, we included two other risk scales that asked respondents to generate precise probabilities. First, the Risky Events and Precautionary Actions for Self scale asked respondents to indicate the probabilities that they themselves might experience eight risky events and precautionary actions within the next 12 months. Then, the Risky Events and Precautionary Actions for Average American scale asked respondents to indicate the probabilities that the average American might experience the same eight events and actions within the next 12 months.4 The anchors for these scales were 0% (the event is impossible) and 100% (the event is certain to happen). Five items concerned terrorism; three concerned routine risks (α = .74 for Self, 4 Judgments may be subject to a self-enhancement bias wherein respondents believe that they face less risk

then the “average American” [19,20]. We examined whether this bias persists despite the sense of vulnerability potentially instilled by the terrorist attacks.

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

71

α = .85 for Average American). Item-level responses were negatively skewed (toward low probabilities). Averaging items on each scale produced more normal distributions. Policy preferences Finally, respondents evaluated four “possible government policies” on a 4-point Likert scale anchored at 1 (strongly opposed) to 4 (strongly support). Manipulation checks At the end of the survey, respondents reported how they felt while writing about their feelings, viewing the picture, and hearing the audio clip. They rated five-item scales for each focal emotion (fear: α = .94, anger: α = .94). Response scales ranged from 0 (do not feel the emotion the slightest bit) to 8 (feel the emotion even more strongly than ever before). We averaged responses on each scale for subsequent analyses.

Results5 Are teens different from adults? The data for teens and adults were consistent with recent findings (B. Fischhoff et al., 2000) in that the teen and adult samples revealed the same patterns on all analyses. Therefore, we collapsed the samples, weighting teens proportional to their representation in the U.S. Census data. Self-reported emotions Across the fear and anger conditions, the mean self-report for anger was 5.06. The mean for fear was 3.46. Analyses of variance (ANOVAs) indicated that the emotion primes significantly increased the target emotion. Respondents reported more anger in the anger condition (M = 5.39) than in the fear condition (M = 4.73), F (1, 649) = 13.55, p < .001. They reported more fear in the fear condition (M = 3.72) than in the anger condition (M = 3.22), F (1, 649) = 9.18, p < .01. As anticipated, females reported less anger than men, F (1, 645) = 6.16, p < .05 (Ms = 4.84 vs. 5.29) and greater fear, F (1, 645) = 21.43, p < .001 (Ms = 3.84 vs. 3.08). There was no interaction between emotion condition and gender. Thus, the emotion primes increased the target emotions, for males and females. Nonetheless, anger was the dominant emotion across conditions.6 5 Although doing so weakened the experimental effects, we included every respondent for whom we had data, regardless of whether the respondent followed instructions to (a) be completely alone during the survey (75.6% complied), (b) write feelings corresponding to the emotion prime (81.4% complied), and (c) complete the survey in one sitting (87% completed within the same day). Comprehensive statistics on response and completion rates are available from the authors. 6 It may have been socially undesirable to admit feeling fear while the United States president called for courageous and retaliatory responses. In pilot tests with the same stimuli conducted 4 weeks before Time 2, reported fear was higher.

72

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Risk perceptions Do experimentally primed emotions affect risk perceptions? We predicted opposite effects on risk perceptions for fear and anger. In order to test for generality, we elicited judgments of 25 risks, over three scales, with two response modes. The Risk of Future Events for the United States scale was a nine-item Likert scale, with verbal response options. The two eight-item Risky Events and Precautionary Actions scales (Self and Average American) used a numerical probability scale. As expected, each risk scale showed more optimistic (i.e., lower) estimates in the anger condition than in the fear condition (see Fig. 1). For the Risk of Future Events for the United States scale, the mean response was 3.38 in the anger condition and 3.62 in the fear condition, F (1, 644) = 7.93, p < .01. Similarly, on the Risky Events and Precautionary Actions for Self scale, the mean estimated probability was 30.5% in the anger condition and 35.2% in the fear condition, F (1, 644) = 8.25, p < .01. The highest mean was for fear-condition females (37.7%), and the lowest was for anger-condition males (27.3%). The same pattern emerged with the Risky Events and Precautionary Actions for Average American scale (Manger = 48.1%, Mfear = 52.0%), F (1, 644) = 4.55, p < .05. Thus, experimentally priming emotions triggered global effects on risk perceptions, well beyond the specific foci of the stimuli and even with the more analytic probability response scale. Gender differences As predicted, males were more optimistic than females, an effect that did not interact with emotion-condition effects (see Fig. 1). Females’ risk estimates were higher than males’ for risks to the United States (Mfemale = 3.65, Mmale = 3.34), F (1, 640) = 18.28. Similar patterns appeared for risks to the self (Mfemale = 35.92%, Mmale = 29.61%), F (1, 640) = 18.04, and for risks to the average American (Mfemale = 53.29%, Mmale = 46.51%), F (1, 640) = 15.97, all ps < .001. On the latter two scales, the difference in mean probability judgments ranged from 1.0% to 14.9% across the 16 items, with an overall mean difference of 6.4%. Mediators The foregoing results are consistent with emotion manipulations having causal effects on risk judgments. However, the condition differences might also reflect aspects of the manipulations other than the emotions they evoked. We evaluated the possibility with two analyses. Why do the fear prime and anger prime have opposite effects on risk estimates? A multivariate analysis of covariance (MANCOVA) tested whether controlling for respondents’ self-reported emotions would diminish the relationship between emotion condition and risk perception.7 The MANCOVA included the three risk scales as dependent measures, the self-report scales for fear and anger (respectively) as covariates, and emo7 A multivariate analysis was warranted (rather than nine ANOVAs), given the similar patterns for the three scales. In addition, this analysis reduced the chance of Type 1 error.

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

73

Figure 1. Mean perception of risk as a function of emotion condition, separately for males and females. Results are shown for the three scales, which measured (a) perceived risk to the United States (nine items), (b) probability of risky events and precautionary actions for oneself (eight items), and (c) probability of risky events and precautionary actions for the average American (eight items).

74

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

tion condition (anger, fear) as the independent variable. Results supported the hypothesis. Significant associations appeared between the fear covariate and higher risk perceptions, F (3, 640) = 48.08, Wilks’s λ = .82 (η2 = .19), as well as between the anger covariate and lower risk perceptions, F (3, 640) = 11.35, Wilks’s λ = .95 (η2 = .05), both ps < .001. When these covariates were considered, the once-significant effect of emotion condition, F (3, 640) = 5.30, p = .001, Wilks’s λ = .98 (η2 = .02), no longer predicted risk perceptions, F (3, 640) = 1.86, p = .14, Wilks’s λ = .99 (η2 = .01). Do emotions experienced shortly after September 11th predict risk estimates 6 to 10 weeks later? The second analysis examined whether naturally occurring fear and anger showed the same patterns as experimentally primed fear and anger. At Time 1, 9 to 23 days after September 11th, respondents completed the Desire for Vengeance Scale and the Anxiety Subscale of the Stanford Acute Stress Reaction Questionnaire. If emotion has lasting effects on risk perceptions, respondents who were more anxious shortly after the attacks should have made more pessimistic risk estimates at Time 2, 6 to 10 weeks later, compared with respondents who were less anxious; similarly, respondents who were initially more angry (as measured by their desire for vengeance) should have made lower risk estimates at Time 2 than respondents who were less angry. We tested these predictions by calculating partial correlations between Time 1 self-reported emotions and Time 2 scores on the three risk measures, controlling for the nonfocal emotion.8 Table 1 displays the results. As predicted, naturally occurring emotions shortly after the attacks reliably predicted risk estimates for diverse events 6 to 10 weeks later; this was true for both of the response scales (verbal, probability). Moreover, although both anxiety and vengeance are negative feelings, they had opposite correlations with risk perceptions. Greater anxiety predicted higher risk estimates; greater desire for vengeance predicted lower risk estimates.9 The results in Table 1 and the experimental effects provide convergent evidence for fear and anger having significant and distinct effects on risk perceptions. Why do men and women view risks differently? A MANCOVA tested the hypothesis that self-reported emotional experience mediates the gender difference in risk estimates. Consistent with the hypothesis, the data Table 1. Partial correlations between naturally occurring anxiety and desire for vengeance (measured soon after September 11th ) and risk perceptions (measured 6–10 weeks later) Risk perception Risk of future events for the United States

Anxiety

Desire for vengeance

.10∗

−.16∗∗

.24∗∗

Risky events and precautionary actions for self −.07+ Risky actions and precautionary actions for average American .13∗∗ −.07+ Notes. These correlations control for the nonfocal emotion (anxiety or vengeance, respectively), pre-existing anxiety disorders, and political ideology. All p values are two-tailed. + = p  .08. ∗ = p  .05. ∗∗ = p  .001. (N = 973). 8 In previous research, desire for vengeance correlated positively with conservative attitudes [21]. Therefore, we controlled for political ideology in all our analyses involving vengeance. 9 Two of the correlations for vengeance fell just short of significance with a two-tailed test, but achieved significance with a one-tailed test. The lower reliability of these results may reflect imperfect measurement of the underlying concept of anger. The scale alpha was only .69, and item content did not address anger exclusively.

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

75

Table 2. Relationships between gender and risk estimates

Risk of future events for the United States Relation to gender Risky events and precautionary actions for self Relation to gender

Pearson correlation

Semi-partial correlation

% Variance explained

squared

squared

by emotion

.018

.007

.611

.037

.007

.811

Risky actions and precautionary actions for average American Relation to gender .018 .007 .611 Notes. The semi-partial correlations control for participants’ self-reported experience of fear and anger.

showed significant associations between the fear covariate and higher risk perceptions, F (3, 635) = 45.45, Wilks’s λ = .82 (η2 = .18), as well as between the anger covariate and lower risk perceptions, F (3, 635) = 11.06, Wilks’s λ = .95 (η2 = .05), both ps < .001. The original gender difference, F (3, 637) = 10.10, p < .001, Wilks’s λ = .96 (η2 = .05), was weaker, but still significant, when these covariates were taken into account, F (3, 635) = 4.14, p < .01, Wilks’s λ = .98 (η2 = .02). In order to determine how much emotions mediated the gender difference in each outcome, we calculated the semi-partial correlations between gender and risk outcomes, controlling for self-reported emotion during the study. We then calculated the squared semi-partial correlations, which represent percentage of variance explained (see Table 2). The results were consistent with the MANCOVA. Controlling for self-reported emotions did not fully explain the gender difference in risk perception, but self-reported fear and anger explained 81% of the variance in risk estimates on the Risky Events and Precautionary Actions for Self scale and 61% of the variance on the other two scales. How realistic are lay risk perceptions? As in previous research, respondents assigned each negative event a lower probability of occurring to them than to the average American (see Table 3). For example, they saw a mean 20.5% personal chance of being hurt in a terrorist attack within the next year, but a 47.8% chance for the average American to be hurt. Because respondents estimated the chance that each event would occur within the next year, it is now possible to evaluate the accuracy of their predictions, and we are undertaking a study to do this. In the meantime, a few aspects of the data merit note. If probability judgments are interpreted literally, then the mean probability judgments should equal the relative frequency of the associated events occurring. In this light, the flu-risk judgments would be accurate if, in the ensuing year, about 50% of the respondents had a disease that they considered the flu. Compared with the historical flu rates, this mean judgment is moderately elevated, for both the Risky Events and Precautionary Actions for Self and Risky Events and Precautionary Actions for Average American scales [16]. The average estimated personal probability of being a victim of violent crime (other than a crime of terror) also agrees with historical statistics [17], if one uses the median to represent the skewed distribution. However, the 43% estimated probability for the average American to be the victim of violent crime (other than a crime of terror) is much higher than official estimates, as is the mean for dying from any cause. These high estimates could reflect an availability bias, with media reports exaggerating other people’s apparent

76

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Table 3. Respondents’ probability estimates that within the next 12 months they and the average American would experience risky events and take precautionary actions Event or action

Scale

Mean

S.D.

Median

probability estimate Being hurt in a terror attack Having trouble sleeping because of the situation with terror Traveling less than usual Screening mail carefully for suspicious items Taking antibiotics against anthrax Getting the flu Being the victim of violent crime (other than terror) Dying from any cause (crime,

Self Average American Self

20.5 47.8 23.5

22.5 35.7 29.5

10.0 50.0 10.0

Average American Self Average American Self Average American Self

44.0 34.0 53.9 53.6 60.0 22.1

27.6 36.2 25.3 38.8 29.6 30.3

45.0 20.0 50.0 50.0 60.0 5.0

Average American Self Average American Self Average American Self

39.3 46.8 59.5 22.0 43.0 35.0

30.2 31.3 29.2 22.9 30.1 34.3

35.0 50.0 50.0 10.0 40.0 25.0

illness, accident) Average of all items (N = 973)

Average American 52.6 35.2 50.0 Self 32.3 18.7 30.4 Average American 50.1 21.3 50.0 Notes. All t values for paired comparisons were significant at p < .001. The distribution of the individual items (excluding the average of all the items) were negatively skewed. A Wilcoxon sign-rank test was therefore performed, and the results were equivalent to the parametric results.

vulnerability [18]. They could also reflect sporadic problems with translating beliefs into probability judgments, especially regarding risks for average Americans.10 Nonetheless, the judgments in Table 3 suggest that respondents perceived unrealistically high rates of risks for themselves and even more elevated risks for the average American. Does emotion affect policy preferences beyond risk perceptions? Finally, we expected that responses to two of our “possible government policies” would show effects of fear and anger. Table 4 displays the items and results. Compared with fear-condition respondents, anger-condition respondents supported the (vengeful) deporting policy more strongly and the (conciliatory) contact policy less strongly. Selfreported emotions from Time 1 (vengeance) and Time 2 (fear, anger) showed a similar pattern. Regardless of emotion, respondents supported providing Americans with honest, accurate information. Unexpectedly, an emotion difference emerged for investing in general capabilities over specific solutions; fearful respondents showed modestly more 10 One difficulty with open-ended probability response modes is that respondents may use “50” to express

uncertainty (i.e., “fifty-fifty”), rather than a numerical probability [22,23]. Saying “50” when one cannot resolve one’s beliefs inflates summary statistics for risks typically assigned much lower probabilities. Such a “50 blip” occurred for the estimates of personal risk for two events: being injured in a terror attack and taking antibiotics against anthrax. Removing all “50%” responses for the former event reduces the mean probability estimate from 21% to 12% and the median from 10% to 5%. Removing all “50%” responses for the latter event reduces the mean probability estimate from 22% to 17% and the median from 5% to 3%.

Table 4. Emotion and policy preferences Partial correlations

Means for

Test for

with selfreported affect at Time 1a

with selfreported emotion at Time 2b

experimental condition at Time 2

mean difference between fear and anger at Time 2

Anxiety

Vengeance

Fear

Anger

Fear

Anger

t (df)

.02

.02

−.01

.09∗

3.47

3.43

−0.68 (634)

.05

−.02

.09∗

.02

3.58

3.47

−2.19∗ (635)

−.06

.28∗∗

−.12∗∗

.26∗∗

3.48

3.63

2.52∗ (634)

General policy preferences Provide Americans with honest, accurate information about the situation, even if the information worries people Invest in general capabilities, like stronger public health, more than a specific solution like smallpox vaccinations Emotionally-responsive policy preferences Deport foreigners in the U.S. who lack valid visas Strengthen ties with countries

−.02 −.09∗ 3.23 3.08 −2.17∗ (631) in the Moslem world −.02 −.13∗ Notes. Policy response scales ranged from 1 (strongly opposed) to 4 (strongly support). a Time 1 emotions represent individual differences shortly after September 11th . Partial correlations between Time 1 emotions and policy questions control for the non-focal Time 1 emotion (anxiety or vengeance, respectively), pre-existing anxiety disorders, and political ideology. b Time 2 emotions represent self-reported feelings in response to the emotion manipulations. Partial correlations between Time 2 emotions and policy questions control for the non-focal emotion (fear or anger, respectively). All p values are two-tailed. ∗ = p  .05. ∗∗ = p  .001. (N = 973).

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

Partial correlations

77

78

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

support for this policy than angry respondents did. In sum, emotion primes significantly shifted views on terrorism policies; naturally occurring emotions showed corresponding patterns.

Conclusions A field experiment, using a nationally representative sample and a multimethod approach, found that fear and anger altered beliefs and attitudes regarding matters of national interest. Experiencing more anger triggered more optimistic beliefs; experiencing more fear triggered greater pessimism. These effects held across a range of risks (terror and non-terror related) and with both a verbal response scale and a more analytical probability response scale. Thus, two negative emotions had consistently divergent effects on risk estimates, providing additional evidence for the importance of examining specific emotions, rather than just global moods. Across all risks, males expressed less pessimism than did females. Differences in reported emotion explained 60% to 80% of the variance in these effects. As has been found previously, respondents saw themselves as less vulnerable to risks than the average American, and less likely to take precautionary measures. However, these judgments of relative risk did not reflect unrealistic optimism, in an absolute sense. Some risk estimates (e.g., for the average American being a victim of violent crime) reflected pronounced pessimism, considering historical risk rates. Other risk judgments (e.g., being injured in a terror attack) can be evaluated only now, when the actual risk is known because a year has passed since completing the survey. Given the events (or lack thereof) in the year since the survey, respondents appear to have been deeply pessimistic when estimating a 20% chance of being hurt in a terror attack for themselves and a 48% chance for the average American. Although our comparisons between fear and anger focused on risk estimates, emotions also influenced public policy preferences. As expected, experimentally primed anger activated more punitive preferences, and fear enhanced preferences for conciliatory policies and investment in broadly applicable precautionary measures. Extrapolating results from an experiment to a real-world setting requires matching conditions between the two. Our study used television (WebTV) to focus respondents on an all-too-familiar topic for 15 to 20 min. The manipulation involved activities that one might encounter in everyday life. Specifically, respondents were asked to dwell briefly on a common emotion, then experience a related picture and text from the news media. Thus, the effects we observed might resemble those evoked by comparable news reports and periods of reflection. A more sustained focus (e.g., a crisis, intense political debate, memorial period) could be expected to increase the effects. Similar emotional manipulations (by experimenters, politicians, etc.) should have similar effects, proportional to their emotional power. Citizens need to understand these processes in order to apply their hearts and minds to what might be a protracted struggle with the risks of terror.

Authors’ Note Originally published in Psychological Science, 14, 144–150. Copyright © 2003, Blackwell Publishing. Reprinted with permission.

J.S. Lerner et al. / Effects of Fear and Anger on Perceived Risks of Terrorism

79

National Science Foundation (SES-0201525), National Institute of Mental Health (MH62376), and American Psychological Association (Division 9) grants supported this research. We thank David Fetherstonhaugh, Mike Dennis, Bill McCready, Justin Malakhow, Bill von Hippel, Shelley Taylor, Dan Martin, George Loewenstein, and Steve Klepper. Correspondence address: Jennifer Lerner, Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, 15213. Phone: 412-268-4573; E-mail: [email protected]. References [1] Johnson EJ, Tversky A. Affect, generalization, and the perception of risk. Journal of Personality and Social Psychology 1983; 45: 20–31. [2] DeSteno D, Petty RE, Wegener DT, Rucker DD. Beyond valence in the perception of likelihood: The role of emotion specificity. Journal of Personality & Social Psychology 2000; 78: 397–416. [3] Keltner D, Ellsworth PC, Edwards K. Beyond simple pessimism: Effects of sadness and anger on social perception. Journal of Personality and Social Psychology 1993; 64: 740–752. [4] Lerner JS, Keltner D. Beyond valence: Toward a model of emotion-specific influences on judgment and choice. Cognition and Emotion 2000; 14: 473–493. [5] Lerner JS, Keltner D. Fear, anger, and risk. Journal of Personality and Social Psychology 2001; 81: 146–159. [6] Tiedens LZ, Linton S. Judgment under emotional certainty and uncertainty: The effects of specific emotions on information processing. Journal of Personality & Social Psychology 2001; 81: 973–988. [7] Smith CA, Ellsworth PC. Patterns of cognitive appraisal in emotion. Journal of Personality and Social Psychology 1985; 48: 813–838. [8] Slovic P. Perception of Risk. Science 1987; 236: 280–285. [9] Slovic P. Trust, emotion, sex, politics, and science: surveying the risk assessment battlefield. Risk Analysis 1999; 19: 689–702. [10] Biaggio MK. Assessment of anger arousal. Journal of Personality Assessment 1980; 44: 289–298. [11] Grossman M, Wood W. Sex differences in intensity of emotional experience: A social role interpretation. Journal of Personality & Social Psychology 1993; 65: 1010–1022. [12] Quadrel MJ, Fischhoff B, Davis W. Adolescent (in)vulnerability. American Psychologist 1993; 48: 102– 116. [13] Fischhoff B, Parker A, Bruine de Bruin W, Downs J, Palmgren C, Dawes RM, et al. Teen expectations for significant life events. Public Opinion Quarterly 2000; 64: 189–205. [14] Cardeña E, Koopman C, Classen C, Waelde LC, Spiegel D. Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): A valid and reliable measure of acute stress. Journal of Traumatic Stress 2000; 13: 719–734. [15] Skitka LJ. The desire for vengeance scale: University of Illinois at Chicago, 2001. [16] Adams P, Marano, M. Current estimates from the national health interview survey. Hyattsville, MD: National Center for Health Statistics, Vital and Health Statistics, 1995. [17] RAND. National Crime Victimization Study. Santa Monica, CA: RAND, 1998. [18] Kahneman D, Slovic P, Tversky A, eds. Judgment under uncertainty: Heuristics and biases. New York: Cambridge University Press, 1982. [19] Taylor SE, Brown JD. Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin 1988; 103: 193–210. [20] Weinstein ND. Unrealistic optimism about future life events. Journal of Personality and Social Psychology 1980; 39: 806–820. [21] Skitka LJ, Tetlock PE. Providing public assistance: Cognitive and motivational processes underlying liberal and conservative policy preferences. Journal of Personality and Social Psychology 1993; 65: 1–19. [22] Bruine de Bruin W, Fischbeck PS, Stiber NA, Fischhoff B. What number is “fifty-fifty”?: Distributing excessive 50% responses in elicited probabilities. Risk Analysis 2002; 22: 713–723. [23] Fischhoff B, Bruine de Bruin W. Fifty-fifty = 50%? Journal of Behavioral Decision Making 1999; 12: 149–16.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

81

Threats, Chemicals and Bodily Symptoms: A Psychological Perspective Omer Van den Bergh Research Group for Stress, Health and Well-being, Department of Psychology, Tiensestraat 102, B-3000 Leuven, Belgium Abstract. Terrorism caused by chemical, biological or nuclear agents differs from terrorism using explosive forces. It is argued that ideal situations are created to attribute a wide variety of vague, systemic symptoms to environmental stimuli. A series of laboratory studies is discussed showing symptom learning in response to odorous chemical substances: the experience of a few symptom episodes in association with such substances is sufficient to subsequently feel symptoms upon perceiving the substances alone. This is more likely when the substances are foul smelling or endowed with negative meanings. Persons tending to negative moods and emotions appear more vulnerable to these processes. Implications for medically unexplained symptoms are discussed.

1. Explosives and Chemical, Biological and Nuclear (CBN) Agents Terrorism using guns, bombs or missiles (or civilian airplanes turned into missiles, for that matter) is psychologically devastating for many reasons, the major ones being: 1. unpredictability of the threat in time and space; 2. lack of controllability of both its occurrence and its effects; and 3. the seriousness of its potential effects, namely the loss of lives and the destruction to property, housing and personal environment. Life threatening events that are highly unpredictable and uncontrollable almost prototypically represent the most powerful stressors for living organisms. Numerous studies have tried to create laboratory conditions with similar characteristics in order to investigate their psychobiological effects under controlled conditions. Obviously, animal studies have been going farther along that road than human studies [1,2]. Human studies have mostly relied on “naturally” occurring circumstances. Overall, it is hard to find a relevant psychobiological parameter in living organisms that is not affected by a deep sense of continuous threat of life and insecurity [3]. Terrorism using chemical, biological or nuclear/radioactive agents (CBN) shares many characteristics with terrorism using explosive forces, but diverges from it as well. The occurrence of an explosive event may be unpredictable, but once it occurs it has a clear spatio-temporal structure, that is, both its location and its time course are defined. In addition, its immediate destructive effects on humans and material goods can readily be circumscribed, and mostly, there is a clear and understandable way how to deal with them. This is different for terrorism involving CBN agents. Many agents may be hard to perceive and/or understand and their impact may be spread out in space and time. Therefore, it is not only unpredictable where and when CBN agents might be encountered,

82

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

but it might even be unpredictable whether they are there at all (“Isn’t this some kind of powder? Is this powder anthrax or not? Is there nuclear fall out around here or not? Is the drinking water deliberately polluted or not?”). This makes them extremely capable of creating stress and anxiety [4–9]. In addition, unlike an explosive attack, their effects, time course and ways to handle them are much more difficult to define. Rather than a sudden and often ferocious disruption of one’s bodily integrity, bodily harm may be more subtle and spread out throughout the body and over time. For example, vague, systemic symptoms may be the result of exposure to some kind of toxic agent and prelude a fatal course only in the long run. As a result, such symptoms may become a source of uncertainty, severe concerns and stress, persisting long after a CBN event. In other words, the spatio-temporal and causal structure of a CBN event and its effects are more difficult to grasp compared to those of an explosive event, and, as a consequence, are even more difficult to handle and to clearly communicate as well.

2. Learning Associations One way to reduce unpredictability is trying to detect stable relationships between events, such that one event can be used to predict another. This may also increase controllability, because if an event can be predicted, it may possibly allow for actions influencing its course. Learning associations between events can therefore be seen as an adaptive process in situations of unpredictable threat and can help to transform a general and undefined sense of anxiety into a focused fear [10]. In fact, one of the basic elements of the psychobiological make up of most organisms is the orienting response towards new and unpredictable events, which can be considered some kind of “what’s that?” question [11], facilitating learning of predictive and causal relationships between events. The (potential) occurrence of aversive events of major importance that lack a clear, phenomenal cause-effect structure such as CBN terrorism may have some important psychological implications. First, the chronic state of apprehensive anticipation of future negative events may by itself induce vague, arousal related bodily symptoms that are amenable to interpreting them as effects of CBN agents. Second, as there may be no clearly defined and perceivable threat, the range of potential threathening stimuli in the environment to alert to may become extremely wide. For example, salient odors or chemical products with unnatural colors, or even normal air conditioning systems may become suspicious environmental stimuli. Third, without a clearly defined cause-effect structure of the event, spurious correlations between events may easily be perceived as cause-effect relationships, especially when pre-existing beliefs about such relationships exist [12]. In sum, threats of CBN terrorism may facilitate attributing a wider range of health effects to a wider range of environmental stimuli. It may be obvious that this analysis does not only apply to threats caused by potential CBN attacks, but also to other subjectively experienced health threats caused by environmental stimuli that are difficult to predict and control. For example, similar characteristics may emerge from the conviction that one is gradually being poisoned by the ubiquitously present chemical pollution in our modern way of life, a conviction that is prominent among patients that suffer from Multiple Chemical Sensitivity (chemical intolerance, or environmental illness) [13]. Or the conviction may arise that radiation from secretly transported radioactive goods in a crashed airplane is causing health problems in

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

83

people living in the crash area [14]. Or the belief may emerge that exposure to the fumes and dust from collapsed buildings or in war zones is detrimental for one’s health because they contain toxic elements [15]. These examples do not intend to suggest that health problems with clear and measurable biomedical abnormalities may not have been caused by the events mentioned. We only argue that either or not on top of those, medically unexplained symptoms may emerge and attributed to environmental stimuli.

3. Learning Associations Between Chemicals and Bodily Symptoms Subjective health symptoms are by definition psychological events: bodily signals have to be sensed, perceived, appreciated and interpreted, put into language and expressed. Thus, signals from bodily dysfunction are but one, yet an extremely important source of information, but psychological processes related to each of the information processing steps can seriously influence and bias subjective health symptoms [16]. No wonder that correlations between subjective symptoms and objective signs of pathology can vary anywhere from zero to almost one [17]. The previous analysis of a potential CBN threat suggests that such a situation creates ideal conditions to perceive subjective health symptoms and attribute them to toxic agents in the environment. In order to investigate processes of symptom perception in response to chemicals in greater detail, we developed a respiratory symptom learning paradigm and ran a series of laboratory experiments with the following general features: Subjects were invited to take part in a study, investigating the effect of different air mixtures on subjective health and well-being. It was told that some air mixtures might cause health complaints that would quickly disappear after a trial. The basic model implied the administration of a number of breathing trials of two minutes each (Fig. 1). Air enriched with CO2 (ranging between 5.5% to 10%, depending on the study) served as a respiratory

Figure 1. Schema of a respiratory conditioning paradigm and a typical result (means ± SD) [12].

84

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

challenge to induce symptoms and two odorous chemicals were used as harmless cues, for example dilute ammonia and niaouli, a mixture containing mainly eucalyptus oil. In the learning phase, subjects breathed one odor mixed with CO2 (called a CS+ trial), and the other odor mixed with room air (called a CS− trial).1 In the test phase, the CO2 was not administered anymore and the breathing trials contained only the odorous chemicals. Respiratory frequency, tidal volume, end-tidal fractional concentration of CO2 and heart rate were measured throughout the experiment and subjective symptoms were registered after each trial. This experimental laboratory model has important features that are relevant for medically unexplained symptoms in response to chemicals: (1) it involves human subjects; (2) the major dependent variable consists of a wide variety of subjective symptoms; (3) CO2 inhalation may represent a conceptual laboratory analogue for a toxic exposure; and (4) harmless odoring chemicals are introduced to serve as cues for or elicitors of the symptoms. In addition, both bodily responses and subjective symptoms are measured, allowing to investigate the concordance/divergence among the two sets of responses. An important methodological advantage is also that the associative learning effect can be tested both within subject and within odor, meaning that both the subjects and the odors serve as their own controls. As a result, any difference in symptom reports among the two chemicals in the test phase can unequivocally be attributed to the formed association between an odor and symptoms, in other words, to learning. Admittedly, the emotional distress created in such laboratory conditions is minimal and remote from real threats caused by terrorism or disasters involving potential releases of CBN agents. Nevertheless, a quite consistent and compelling set of results were obtained in a series of experiments: 1) After a few symptom experiences induced by the odor mixed with CO2 , the odor alone altered respiratory behavior and induced elevated levels of somatic symptoms “as if the subjects were still breathing CO2 ”. In other words, symptoms had been learned [18–22]. 2) The symptom learning effect was selective: when one odor was foul smelling and the other was neutral to pleasant, symptom learning occurred only in response to the foul smelling odor (see Fig. 1). When both odors were foul smelling (e.g. irritant ammonia and nonirritant butyric acid) learned symptoms emerged to both, suggesting that the unpleasantness of the odors was the critical variable for the selective association effect [18–21]. 3) The symptom learning effect was specific: no effects appeared for symptoms usually not provoked by CO2 (“dummy symptoms”) and the effects could not be explained by learned arousal/anxiety in response to the odors: We never observed a conditioned heart rate increase and the effects were largest for the subset of symptoms that is typically elicited by CO2 , namely the respiratory subset [19–21]. 1 Technically, this is a differential Pavlovian conditioning paradigm in which the CO enriched air is an 2 unconditional stimulus (US) and the odors are conditioned stimuli (CS). The odor mixed with CO2 enriched air is called a CS+, whereas the odor mixed with regular room air is called a CS−. Both odors are administered to the same subject (within subject design), but the specific odor used in each trial type (CS+ or CS−) is counterbalanced between subjects. The test phase consists of presenting both the CS+ and CS− without the US. Typically, a difference is found between measures of the response to the CS+ and the response to the CS−.

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

85

4) Learned symptoms were quite persistent: it did not matter for the size of the learning effect whether the test phase was run immediately after the learning phase or one week later [22]. 5) A straightforward extinction procedure, involving a series of unreinforced exposures of the odor only after learning had occurred, readily reduced the learned symptoms [21]. 6) Once symptoms were learned to one odor, they generalized to newly presented odors but only when these odors were also foul smelling. For example, subjects conditioned to have symptoms to ammonia showed elevated symptoms also to (first time presented) foul smelling butyric acid and acetic acid, but not to fresh smelling citric aroma [22]. 7) Mental thoughts and images can also serve as cues for symptoms: Merely evoking an image of a situation that had previously been paired with the experience of CO2 -induced symptoms elicited those symptoms and altered respiratory behavior. Again, unpleasantness of the the imagined situations appeared to be an important variable because learning effects only showed up when the imagined situations were stressful [23]. 8) Important individual differences occurred. The level of neuroticism or negative affectivity (NA) in normal subjects facilitated the learning effects: Learned symptoms and their generalization to new odors were overall more elevated in a group of subjects scoring high for negative affectivity [20,22]. Similarly, the learning effects on symptoms were overall stronger in a group of “psychosomatic” patients. This suggests that neurotic and psychopathological groups are more vulnerable to learning medically unexplained symptoms [19]. 9) Although both (respiratory) symptoms and altered respiratory behavior were learned, the symptoms in the test phase were not a reflection of the actual (learned) physiologic responses. Rather, the symptoms were relying on an activated memory representation of the symptoms experienced in the acquisition phase. This activation process was automatic, in that it required little or no conscious mental resources [20]. Other recent evidence was in accordance with this finding: Within-subject correlations between self-reported respiratory symptoms and a objective measures of respiratory behavior were significantly lower in persons with high negative affect, in particular when they were in an unpleasant situation [24]. In other words, under the same circumstances that led to optimal learning, they were interoceptively less accurate. 10) Manipulations of a priori beliefs about the health effects of chemical pollution had quite important effects on symptom learning. In one study [25], half the subjects were given information to read in the waiting room before participating, describing the so-called wider context of the experiment, whereas the other half was given irrelevant reading materials. The relevant text was mainly copied from websites warning against the ever increasing chemical pollution of our environment that may make some people oversensitive so as to cause chemical intolerance, environmental illness and multiple chemical sensitivity. In addition, a case story of a MCS patient was given to read (see appendix). This manipulation of a priori beliefs facilitated symptom learning in two ways: only one learning trial (instead of three) was sufficient to cause symptom learning and it now occurred also in response to fresh smelling odors. This suggests that not the

86

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

unpleasant perceptual quality as such, but the negative meanings evoked by the unpleasantness of the chemical is an important variable in symptom learning. 11) In several studies, we also collected contingency awareness data. In other words, we measured whether subjects were aware of the relationship between a particular chemical and the occurrence of CO2 induced symptoms during the learning phase. Although we have previously reported in several individual studies that contingency awareness did not matter for symptom learning, a recent investigation pooling data from several studies showed that contigency awareness was critical indeed [26]. That is, only subjects who could verbalize which particular odor (CS+) had been “causing” most symptoms during the learning phase showed elevated symptoms towards the same odor during the test phase. However, contingency awareness was necessary but not sufficient, because not all aware subjects showed learning. Also other variables (see the previous points above, such as unpleasantness of the chemicals, situations, etc.) were additionally important. 12) The importance of contingency awareness was further demonstrated in a study using butyric acid and ammonia as odors. Although the data of the learning phase showed most symptoms to emerge in response to the CS+ odor, the contingency awareness measure showed an erroneous contingency awareness in several subjects: there was a bias towards indicating butyric acid as the odor that had been causing most symptoms in the learning phase, when, in fact, it had been ammonia. In subjects with a reversed contingency awareness, also a reversed symptom learning effect occurred, that is, they reported more symptoms to butyric acid than to ammonia consistent with their erroneous retrospective belief [27]. The above are all laboratory findings and little is currently known about their ecological validity. However, apparent similarities with real life phenomena suggest they may have an important heuristic value to understand medically unexplained symptoms. For example, persons with medically unexplained symptoms score generally higher for neuroticism or negative affectivity, which parallels the finding that persons with high NA and psychosomatic patients are better symptom learners. Also, medically unexplained symptoms seem to occur more likely in adverse or stressful circumstances, which resembles better symptom learning in response to unpleasant stimuli or situations. In addition, in our laboratory studies no correspondence was found between physiologic responses and subjective symptoms, which is also typically observed in studies with high symptom reporters [28].

4. Symptom Learning and Medically Unexplained Symptoms The existence of medically unexplained symptoms and syndromes promotes two extreme positions. One is that some specific explanatory mechanism of dysfunction in the body must exist that has yet to be discovered. The other assumes that such symptoms are mainly the result of perceptual-cognitive processes, amplifying (relatively minor) bodily sensations resulting from stress and anxiety. Several investigators hold positions inbetween these extremes, but common to both views is a static model, that is, symptoms of a particular illness are considered as invariantly determined by the same set of processes.

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

87

An important implication from the above findings is, however, that symptom perception is a dynamic process, implying that the relative importance of several mechanisms and sources of information may change over time within an individual. This means that we do not subscribe to the view that symptoms have either a biomedical or a “psychological” basis, but can have both in varying degrees, depending on the circumstances. Indeed, the basic message of the above set of findings is that the simple experience of a few symptom episodes caused by a “true” source in association with a harmless odorous chemical is sufficient to induce symptoms when subsequently perceiving the chemical only. In other words, symptoms that could be called “medically unexplained” were learned, implying a shift from relatively accurate interoception of true changes in the body in a first phase to a biased and inaccurate perception in a later phase. The latter situation reminds of the concept of “somatovisceral illusion” [29]. The above paradigm allows to investigate biased interoception and attribution of symptoms to internal and external stimuli after experimental induction of symptoms. However, it remains silent as to the source of the symptoms in real life in the first place. We believe that any symptom episode without a clear explanation (e.g. stress-induced hyperventilation, chronic fatigue syndrome, fybromyalgia, see Sharpe & Bass [30]) may easily be perceived in contingency with or attributed to the presence of harmless environmental cues. The psychosocial context, including the government and the media, may contribute to making specific biochemical cues more salient and induce beliefs facilitating false attributions of normal stress reactions and normal disease symptoms (such as the flu) to such contamination, as might happen in cases of ‘mass psychogenic illness’ [4, 6,25,31–33]. In that respect, threats of CBN attacks may create ideal conditions for mass psychogenic illness to emerge. The present perspective is also consistent with the view advocated by Wessely, Nimnuan and Sharpe [34]. They consider the so-called functional syndromes, (e.g. chronic fatigue syndrome, fibromyalgia, MCS, but also irritable bowel syndrome, Gulf War syndrome, etc.) as basically having a common ground. Indeed, patients show considerable symptom overlap, share the same non-symptom characteristics (e.g. predominance of women, elevated psychiatric co-morbidity) and respond to the same therapies. The authors assume that the different diagnostic categories mainly reflect differences in attributions of symptoms to sources. Symptom perception processes and patient’s causal attributions of symptoms to cues may determine which particular physician will be consulted, and depending on the specialty of the consulted physician, different illness labels may be applied. Obviously, both patients and physicians may reinforce each other in selective perceptions and specific causal attributions. Once a causal structure has been established in the patient’s mind, subsequent confrontations with the environmental cue alone may trigger anticipatory processes at several levels of functioning, both physiological and perceptual-cognitive, subserving the experience of subjective symptoms. One potential physiological source of symptoms, the importance of which may be underestimated, is hyperventilation-induced hypocapnia. This may be a particularly relevant source because of its strong link with stressful arousal [35], its wide range of systems in the body that may be affected [36], its episodic nature and – therefore – the difficulty to diagnose it in typical laboratory conditions. It may be either the main and primary source of symptoms or a secondary one on top of other less transient sources, contaminating the clinical picture. When occurring in a “chemical context”, it may act in the same way as the CO2 -induced hyperventilation in

88

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

our studies. This was recently shown in an experiment using the same symptom learning paradigm with odors, but now with voluntary hyperventilation rather than CO2 inhalation to induce symptoms in the learning phase. It was found that typical sensations of hyperventilation, such as lightheadedness, were being reported in response to sensing the odor that had been associated with voluntary hyperventilation [37]. This view may explain a number of observations in functional syndromes, such as MCS. First, (1) the origin of MCS appears in some cases to be linked to episodes of stress and not to toxic exposures; [39] (2) there is a substantial overlap among the symptoms of MCS and those of hyperventilation, such as intermittent flares of fatigue and weakness, dizziness or light-headedness, cognitive difficulties (concentration and memory), shortness of breath, sore throat, dry mouth, palpitations and “racing heart”, gastro-intestinal problems and feelings of anxiety or depression [18,40–42]; (3) Leznoff [43] observed that exposure of MCS patients to their chemical trigger induced hyperventilation in 73% of them. Also in a recent study with Gulf War syndrome patients [44], particularly strong tendencies to hyperventilate were observed in response to sensing diesel vapors in the laboratory, that reminded to diesel exposures during active duty in the Gulf. One can easily imagine cases in which both hyperventilation and toxic exposures are involved. For example, a toxic exposure may be a primary source of symptoms, causing learned symptoms and anxiety to odoring substances or specific “contaminated” environments. Subsequent exposures to those environments may induce hyperventilation as part of anticipatory anxiety and in this way become a secondary source. Occasional episodes of hyperventilation may intermittently reinforce learned symptoms, making the source of symptoms quite variable and elusive. In that respect, hyperventilation may not just be some epiphenomenon in several stress-related conditions, but act as an important source of symptom learning. Because this may loosen the link between symptoms and their physiological correlates (see above), a one-to-one relationship between hypocapnia and the presence of symptoms should not be considered critical for the hypothesis [38].

Conclusion Subjective symptoms are inherently plastic. The occurrence of symptom episodes in association with environmental cues, such as odors, may easily give way to symptom learning, implying attributing and experiencing symptoms to such cues. Threats of CBN terrorism may create ideal conditions for symptom learning. Both real toxic exposures and several stress related sources of symptoms, among which hyperventilation may be a prominent one, may act as initial causes of symptom episodes. Learning mechanisms may further shape perceptual-cognitive mechanisms and trigger additional physiological stress responses to form a dynamic state, characterized by negative affectivity, interoceptive vigilance, catastrophic expectancies and medically unexplained symptoms.

Acknowledgement I am indebted to Johan Bresseleers for his help and comments on earlier versions of the chapter.

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

89

References [1] Mineka S, Kihlstrom JF. Unpredictable and uncontrollable events: a new perspective on experimental neurosis. J Abnorm Psychol 1978; 87 (2): 256–271. [2] Mineka S, Hendersen RW. Controllability and predictability in acquired motivation. Annu Rev Psychol 1985; 36: 495–529. [3] Melamed S, Shirom A, Toker S, Berliner S, Shapira I. Association of fear of terror with low-grade inflammation among apparently healthy employed adults. Psychosom Med 2004; 66: 484–491. [4] Alexander DA, Klein S. Biochemical terrorism: too awful to contemplate, too serious to ignore. British Journal of Psychiatry 2003; 183: 491–497. [5] Stamm BH, Tuma F, Norris FH, Piland NF, Van der Hart O, Fairbank JA, Stamm IV HE, Higson-Smith C, Barbanel L, Levant RF. The terror part of terrorism: The role of human infrastructure in terrorism risks and responding. IEEE Engineering in Medicine and Biology Magazine 2004; 23 (1): 149–161. [6] Wessely S, Hyams KC, Bartholomew R. Psychological implications of chemical and biological weapons: Long term social and psychological effects may be worse than acute ones. British Medical Journal 2001; 323: 878–879. [7] Hasset AL, Sigal LH. Unforeseen consequences of terrorism: Medically unexplained symptoms in a time of fear. Archives of Internal Medicine 2002; 162: 1809–1813. [8] Hyams KC, Murphy FM, Wessely S. Responding to chemical, biolocial, or nuclear terrorism: The indirect and long-term health effects may present the greatest challenge. Journal of Health Politics, Policy and Law 2002; 27 (2): 273–291. [9] Durodie B. Facing the possibiliy of bioterrorism. Current Opinion in Biotechnology 2004; 15: 264–268. [10] Grillon C. Startle reactivity and anxiety disorders: aversive conditioning, context, and neurobiology. Biol Psychiatry 2002; 52 (10): 958–975. [11] Bradley MM, Codispoti M, Cuthbert BN, Lang PJ. Emotion and motivation I: defensive and appetitive reactions in picture processing. Emotion 2001; 1 (3): 276–298. [12] Davey GCL. A conditioning model of phobias. In: Davey GCL, editor. Phobias: a handbook of theory, research and treatment. Chichester: John Wiley & Sons Ltd.; 1997, p. 301–322. [13] Graveling RA, Pilkington A, George JPK, et al. A review of Multiple Chemical Sensitivity. Occup Environ Med 1999; 56: 73–85. [14] Boin A, van Duin M, Heyse L. Toxic fear: the management of uncertainty in the wake of the Amsterdam air crash. J Hazard Mater 2001; 88 (2–3): 213–234. [15] Lange JL, Schwartz DA, Doebbeling BN, Heller JM, Thorne PS. Exposures to the Kuwait oil fires and their association with asthma and bronchitis among gulf war veterans. Environ Health Perspect 2002; 110 (11): 1141–1146. [16] Pennebaker JW. The psychology of physical symptoms. New York: Springer; 1982. [17] Van den Bergh O, Winters W, Devriese S, Van Diest I. Learning subjective health complaints. Scand J Psychol 2002; 43: 147–152. [18] Van den Bergh O, Kempynck PJ, Van de Woestijne KP, Baeyens F, Eelen P. Respiratory learning and somatic complaints: A conditioning approach using CO2 -enriched air inhalation. Behav Res Ther 1995; 33: 517–527. [19] Van den Bergh O, Stegen K, Van de Woestijne KP. Learning to have psychosomatic complaints: Conditioning of respiratory behavior and somatic complaints in psychosomatic patients. Psychosom Med 1997; 59: 13–23. [20] Van den Bergh O, Stegen K, Van de Woestijne KP. Memory effects on symptom reporting in a respiratory learning paradigm. Health Psychol 1998; 17: 241–248. [21] Van den Bergh O, Stegen K, Van Diest I, Raes C, Stulens P, Eelen P, Veulemans H, Van de Woestijne KP, Nemery B. Acquisition and extinction of somatic complaints in response to odors: a paradigm relevant to investigate Multiple Chemical Sensitivity. Occup Environ Med 1999; 56: 295–301. [22] Devriese S, Winters W, Stegen K, Van Diest I, Veulemans H, Nemery B, Eelen P, Van de Woestijne KP, Van den Bergh O. Generalization of acquired somatic symptoms in response to odors: A pavlovian perspective on Multiple Chemical Sensitivity. Psychosom Med 2000; 62: 751–759. [23] Stegen K, De Bruyne K, Rasschaert W, Van de Woestijne KP, Van den Bergh O. Fear-relevant images as conditioned stimuli for somatic complaints, respiratory behavior, and reduced end-tidal pCO2 . J Abnorm Psychol 1999; 108: 143–152.

90

O. Van den Bergh / Threats, Chemicals and Bodily Symptoms

[24] Van den Bergh O, Winters W, Devriese S, Van Diest I, Vos G, De Peuter S. Accuracy of Respiratory Symptom Perception in Persons with High and Low Negative Affectivity. Psychology & Health 2004; 19: 213–222. [25] Winters W, Devriese S, Van Diest I, Nemery B, Veulemans H, Eelen P, Van de Woestijne KP, Van den Bergh O. Media warnings about environmental pollution facilitate the acquisition of symptoms in response to chemical substances. Psychosom Med 2003; 65: 332–338. [26] Devriese S, Winters W, Van Diest I, De Peuter S, Vos G, Van den Bergh O. Perceived rather than actual contingencies between odors and symptoms determine learning of symptoms in response to chemicals. Int Arch Occ Envir Health 2004; 77: 200–204. [27] Devriese S, Winters W, Van Diest I, Van den Bergh O. Contingency awareness in a symptom learning paradigm: Necessary but not sufficient? Consciousness and Cognition 2004; 13 (3): 439–452. [28] Houtveen JH, Rietveld S, de Geus EJ. Exaggerated perception of normal physiological responses to stress and hypercapnia in young women with numerous functional somatic symptoms. J Psychosom Res 2003; 55 (6): 481–490. [29] Cacioppo JT, Tassinary LG. Inferring psychological significance from physiological signals. Am Psychol 1990; 45 (1): 16–28. [30] Sharpe M, Bass C. Pathophysiological mechanisms in somatization. Int Rev Psychiatry 1992; 4: 81–97. [31] Bartholomew R, Wessely S. Protean Nature of Mass Sociogenic Illness: From Possessed Nuns to Chemical and Biological Terrorism Fears. Br J Psychiatry 2002; 180: 300–306. [32] Romano JA, King JM. Chemical warfare and chemical terrorism: Psychological and performance outcomes. Military psychology 2002; 14 (2): 85–92. [33] Donovan S. (2002). Bioterrorism Summaries from Annual Session 2002: Recognizing and treating the psychological effects of terrorism. American College of Physicans. [34] Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet 1999; 354 (9182): 936–939. [35] Van Diest I, Winters W, Devriese S, Vercamst E, Han JN, Van de Woestijne KP, Van den Bergh O. Hyperventilation beyond fight/flight: Respiratory responses during emotional imagery. Psychophysiology 2001; 38: 961–968. [36] Gardner WN. The pathophysiology of hyperventilation disorders. Chest 1996; 109: 516–534. [37] Van Diest I, De Peuter S, Vos G, Devriese S, Van de Woestijne KP, Van den Bergh O. Conditioned lightheadedness in response to odors using hyperventilation as unconditional stimulus. Paper presented at the Fifth Conference on Psychology & Health organized by the Research Institute for Psychology & Health 2004 May 10–12, Kerkrade, The Netherlands. [38] Hornsveld HK, Garssen B, Dop MJ, et al. Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome. Lancet 1996; 348: 154–158. [39] Schottenfeld RS. Workers with multiple chemical sensitivities: a psychiatric approach to diagnosis and treatment. Occup Med State Art Rev 1987; 2: 739–753. [40] Shusterman DJ. Critical review: The health significance of environmental odor pollution. Arch Environ Health 1992; 47: 76–87. [41] Lehrer PM. Psychophysiological hypotheses regarding multiple chemical sensitivity syndrome. Environ Health Perspect 1997; 105: 479–483. [42] Pearson DJ. Psychologic and somatic interrelationships in allergy and pseudoallergy. J Allergy Clin Immunol 1988; 81: 351–361. [43] Leznoff A. Provocative challenges in patients with multiple chemical sensitivity. J Allergy Clin Immunol 1997; 99: 434–437. [44] Fiedler N, Giardino N, Natelson B, Ottenweller JE, Weisel C, Lioy P, Lehrer P, Ohman-Strickland P, Kelly-McNeil K, Kipen H. Responses to controlled diesel vapor exposure among chemically sensitive Gulf War veterans. Psychosom Med 2004; 66: 588–598.

THE RUSSIAN PERSPECTIVE

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

93

Immediate Interventions – The Experience of the Emergency Mental Health Service of EMERCOM of Russia Sergei Aleksanin All-Russian Center of Emergency and Radiation Medicine, EMERCOM of Russia, Lebedeva str. 4/2, St. Petersburg, 194044, Russia More than 100 years ago the famous Russian surgeon Dr. Pirogov first suggested that among other things war is an epidemic of traumatism. Similarly, it is no exaggeration to state that modern emergencies, be they terrorist acts, technological accidents or natural disasters, can cause mental trauma on an epic scale. Our experience at EMERCOM in Russia, confirms this fact. It is not by accident that only ten years ago the Ministry decided to create in 1998 a Psychological Support Service to assist the work of EMERCOM. We did so because of the increasing need for systems of psychological support and assistance both to those injured in emergencies, and also to the emergency workers themselves. Such an organizational structure allows: • A wide network of regional services for day to day management; • Mobile groups of psychologists from the personnel of the Emergency Psychological Help Center (Moscow branch of ARCERM) and the Department of Medical Psychological Problems of ARCERM; • Psychological support for the activities of emergency workers (professional selection, preparation, monitoring and correction of condition) linked to an agreed set of standards. In the past three years Service experts have accompanied emergency workers to attend the earthquake on Sakhalin island, the flood on Lena river in Lensk, have rendered psychological help to the relatives of the victims of air catastrophes, the “Kursk” submarine, and also during recent terrorist acts in Moscow. In this paper I will report on some of our experiences giving emergency psychological help to the victims of terrorist acts. Emergency psychological help is an independent area of psychological practice. It has two unique elements: • The index events and its effects on emotions, cognitions and the personality of those affected almost by definition is unexpected; • Emergency psychological help needs to be given rapidly. Despite the above, emergency psychological help is governed by conventional principles. However, the emergency situation does give certain special challenges.

94

S. Aleksanin / Immediate Interventions

1. There is a different relationship between the psychologist and the emergency victim to that between the psychological and the normal client seen in clinical practice. The latter has specifically requested psychological help for a defined problem, the former has not. Looking after the needs and privacy of any client is always important for all psychologists wherever their work, but these issues are different for the psychological outreach that is the sine qua non of emergency psychology. 2. The principle of “first do not harm”: must be born in mind in these situations, particularly because time is short, and interventions rarely prolonged. It may not be possible or desirable to address long standing pre emergency problems within the client. 3. Voluntary consent remains important, even if in the emergency situation is the psychologist who makes contact with the client, rather than vice versa. 4. Confidentiality: must also be respected in emergency circumstances, with the rare exception of when the psychologist considers the behaviour of the client to be dangerous to the client or other people. In this ethical emergency psychological help does not differ from psychological assistance in non emergency situations. 5. Professional motivation: becomes especially important in the emergency situation, since there can be other strong motives (self-statement, social acceptance, etc.). 6. Professional competence remains critical, even in the demands of an emergency. The expert rendering the emergency psychological help must have appropriate and relevant professional qualifications, and must also be acting for professional, as opposed to personal, motives. The professional must also be prepared to work in demanding, and even occasionally dangerous, situations. Emergency psychological help can be divided into three stages. I. Preparatory stage The purpose of a preparatory stage is the detailed plan of the emergency psychological help. Information should be gathered concerning psychological aspects of the emergency as follows: • To find and secure a secure setting for psychological help – which needs to be located in proximity to wherever the injured are being managed, and their relatives are assembling. It should also be near facilities that have to deal with victim identification and the inevitable interactions between the bereaved and the authorities; • To have an approximate assessment of the numbers of people needing help; • To have a realistic appraisal of the resources needed in terms of expert numbers, time, equipment and other resources. This information is necessary for the optimal organization of the emergency psychological help. II. A basic stage At the basic stage of the emergency psychological help there are two basic directions of activities of the specialist-psychologists: to help emergency workers participating in the

S. Aleksanin / Immediate Interventions

95

mitigation of consequences of the emergency and to help injured. The content of activity of the psychologists depends on the specific situation encountered. III. A closing stage In the final stages of emergency psychological help the tasks are as follows: • • • •

Psychological help for those in need; Psychological support of the emergency workers; Analysis of information obtained during the emergency psychological help; Some forecast on future developments and needs based on available data.

Approaches to the Emergency Psychological Help All the methods of emergency psychological help should be short-term, namely: neurolinguistic programming, body-oriented therapy, arttherapy, short-term positive therapy, suggestive technology, relaxation methods and methods directed on self-regulation, rational psychotherapy and others. Emergency psychological help is a system of short-term individual or group measures to restore the psychological/psychophysiological state of the victims of a crisis or extreme event and mitigation of negative emotional experiences. The choice of measures is determined by the resources available and the individual situation.

Examples of Work on Rendering Emergency Psychological Assistance Psychologists from the ARCERM of EMERCOM of Russia participated in the aftermath of the terrorist acts in Moscow (Guryanova street, 17 and Kashirsky highway, 6) during the period from 9.09 to 17.09.99. The basic themes of the work undertaken by the psychologists were: • Prevention of potential mass negative emotional responses from interfering with emergency activities (see Krasnov Chapter 9 as well); • Determining which victims needed emergency medical psychological help (i.e. those in high risk categories); • Definition of specific tasks requiring participation of experts-psychologists in the mitigation of consequences of the emergency situation, including search and rescue activities, medical and social help to the population and keeping order in the affected area. Psychologists used such methods as psychological observation and interview. To restore mental health the techniques of rational psychotherapy and decreasing the level of psychological strain were selected. As it turned out, panic attacks and other negative responses were observed during the first hours of emergencies due to acute emotional shock state and also lack of information. Some injured needed urgent psychotherapy alongside pharmacological therapy. Individuals who become caught up in disaster situations can be grouped as follows:

96

S. Aleksanin / Immediate Interventions

• The injured, their relatives and intimate friends (this group is at the highest risk of stress responses and consequently requires urgent medical psychological help); • Bystanders – the inhabitants of the nearest houses, etc. (whose actions might interfere with emergency service activities); • Individuals arriving at the emergency area (maladaptive psychological responses are less probable). Our experience of emergency scenes suggests the following priorities: 1. Giving emergency individual psychological help to the injured. 2. Identification of those requiring emergency psychiatric help. 3. Identification of those liable to spread panic and engaging them with the psychological intervention. 4. Selection of those capable of prevention of mass negative psychological responses (panic) among the population. 5. Psychological correction and medical psychological rehabilitation of personnel of search and rescue detachments.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

97

Social, Community and Individual Responses to Terrorist Attacks V.N. Krasnov Moscow Research Institute of Psychiatry

1. Introduction Terrorism has been accompanying mankind for centuries. It shows itself in purposeful, usually planned aggression against group of persons, or organization or specific country, and implemented actually with military means at the time of peace. The principal aim of terrorists is to bring fear and demoralization to as many people as possible. This aim reflects the psychological basis of terrorism – namely acquiring irrational power, as a rule, bye frustrated persons with an inner conflict between high selfesteem and insignificant actual achievements. Extremism (including political extremism and separatism) is not always associated with terrorism, but in the absence of humanitarian values, extremists sometimes commit acts of terror in order to draw public attention or use them as their “last argument”. A terrorist finds his identity in an act of terror, and he is unable to find it in everyday life. This aspect of terrorism is associated with another danger. I mean creating the halo of heroism and romanticism around terrorists among young people and in certain groups with low ability for self-actualization and lack of humanitarian values. Threat to life is the major destructive psychological factor that influences the population, even if it is not the only one. Threat to life is characteristic that puts acts of terror in line with other emergency situations, including natural and technological disasters. Therefore the experience of “Disaster psychiatry” can be used as model of care in terrorist attacks and their aftermath. Disaster psychiatry is developing last years very intensively in Russia [1,2,5,9,12] alongside with other countries [3,4,10,11,13]. Disaster psychiatry or as it is sometimes known, the psychiatry of catastrophies or extreme situations, is a relatively new area of psychiatric knowledge which development does require close connections with clinical and social psychology. The subject matter of this branch of psychiatry is the mental health consequences of technological catastrophies, floods, earthquakes, terrorist attacks, ethnic clashes, military actions, etc. The practical issues of disaster psychiatry concern, first of all, developing the optimal forms of rendering psychological and psychiatric aid to communities that find themselves in these extreme situations. Russia has the National Service for Disaster Medicine under the Ministry of Public Health, which is also in contact with the Ministry of Emergency (Table 1) (see also Chapter 8, Aleksanin). This service deals with the management of medical consequences and provision of medical care in natural disasters, major accidents, catastrophes, epi-

98

V.N. Krasnov / Responses to Terrorist Attacks Table 1. Organizational structure of the national service for disaster medicine

All-Russian Center of Disaster Medicine “Zaschita” (“Protection”) • Clinic with a multiprofile field hospital, including a psychiatric (psychotherapeutic) unit • Institute for Disaster Medicine and Special Professional Training • Center for medical evaluation and rehabilitation (intended mainly for rescue workers) • Department of medico-technical problems of emergency care • 7 regional branches In the Center for Disaster Medicine, there is always psychiatric team on duty. Besides, the Ministry of Emergency has the All-Russia Center for Extreme Medicine in St. Petersburg, and the Department in Moscow with the psychological rescue team.

Table 2. The structure of the network on rendering psychiatric and psychological aid to people in extreme situations Organizational lever

Team

On the alert

Federal

2 teams at Moscow Institute of Psychiatry and at the State Research Center for Social and Forensic Psychiatry being ready

1 person constantly available at the Field General Hospital

Regional

Local

to be deployed to a disaster site 2–3 teams at leading psychiatric institutions of a regional being ready to be deployed to a disaster site Teams on request at leading psychiatric institutions

1 person constantly available at the Regional Centre for Disasters Medicine None

demics, local military conflicts, terrorist attacks and other emergencies. The Center organizes and provides emergency and consultative medical care in emergency situations. It has 7 branches in the different regions of Russia. Local centers are organized alongside the emergency medical care stations. Special psychiatric teams are integrated into general medical institutions of the service for Disaster Medicine (Table 2). In all the recent terrorist incidents in Moscow the specialized Moscow Psychotherapeutic Polyclinic has taken the leading role in service provision, together with the Center of Disaster Medicine and other institutions. Regrettably in recent years we have gained considerable knowledge from studying a wide variety of extreme situations, terrorist attack and catastrophes as well as their consequences. Our observations suggest that the following issues should be specifically considered: 1. The associations of psychological and psychopathological features of responses to extreme situations; 2. The distinction between individual and group responses to extreme situations;

V.N. Krasnov / Responses to Terrorist Attacks

99

Table 3. Mental reactions in exreme situations • 0.5–5% – reactive psychotic disorders (the number depends not only on the casual threat, but also on specific environmental circumstances, interpersonal and informational influences, additional exhaustion factors and physical condition); • 70–80% – acute situational reactions, mostly psychologically understandable and physiologically adaptive: anxiety, fear, tension, vegetative arousal; • in 30–35% these reactions meet the criteria of “acute stress reaction” and require psychological care (psychological counseling, short-term psychological intervention), otherwise they develop into affective (depressive, anxiety) disorders or post-traumatic stress disorder; and at delayed stage and under the influence of unfavorable factors there appear cognitive and personality problems. Table 4. Development stages of mental disorders (changes) in people under extreme situations • Changeable combinations of adaptive and maladaptive forms of situational responses. • Synergetic influences between somatic (vegetative), and psychological components of situational responses. • Combination of individual and group forms of responses. • The disorders either diminishing or getting complicated (from asthenic and psychovegetative forms to the affective forms). • If the unfavorable situation is maintained there are tendencies to personality changes such as hostility, social escape, substance abuse and so on; • If there are additional noxious factors (intoxications, brain traumata, severe somatic illnesses) then cognitive changes may lead to the development of psychoorganic syndromes. • Low threshold for coping with subsequent extreme situations as well as in facing with the events or objects symbolizing an extreme situation.

3. The way in which the delivery of care is altered as the psychological reactions change with the passage of time. In addition to the traditional knowledge of psychology and psychopathology of disasters, certain tendencies have been evident during the last decades. These include a decrease in the frequency of psychotic reactions, with a corresponding increase in the number of somatoform, affective spectrum, adjustment disorders and PTSD (Tables 3, 4). We also need to take note of the multifactorial nature of the psychosocial consequences of disasters (Table 5). Another new development is recognition of the informational component of terrorist activities. It is very clear that the speed, growth, sophistication and variety of modern information technologies acts to substantially increase the negative potential of terrorism, not least by gaining access to an almost limitless audience. The mass media, especially television, afford organizers and perpetrators almost unlimited opportunities for strengthening the impact of terrorist acts and for spreading the propaganda measure of the terrorists themselves. The dramatic and perverted aesthetics of modern terrorism are used in a very sophisticated way when planning terrorist actions, anticipating the inevitable global audience for the events. Emphatic examples of this were the events on September 11, 2001 in the USA and the capture of hostages in a Moscow theater, October 23–26, 2002. Yet at the same time, the mass media have huge, though still little used, possibilities to neutralize the immediate fear inducing and propaganda influence of terrorist activities: introducing agreed ethical standards during news coverage; giving well balanced information on the events; deheroization of terrorists while bringing to light instances of constructive and rational behavior of individuals who became victims of terrorist actions.

100

V.N. Krasnov / Responses to Terrorist Attacks Table 5. Factors of extreme situation

External • Response due to a direct threat to life • Short-term situational threats • Long-term unfavourable situations • Additional noxious influences (intoxications, traumata, etc.) Internal • Particular personality traits (anxiety, histrionic components, emotional instability) • Passive or active personal position in response to the extreme situation • Poor somatic (physical) conditions • Residual cerebral (organic) dysfunctions Informational environment • Availability or absence of information that explains the emergency situation and predicts its development • Availability or absence of communication and chance for interaction with the relatives, acquaintances, as well as officials involved in the situation • The media showing the images of the catastrophe and naturalistic pictures (negative information environment), or providing balanced information including, besides threat and damage, also pictures of rational and constructive behavior, positive activities and mutual support

Such objectives are all attainable by the mass media and do not contradict the general standards and ethics of journalism in open societies. The undoubted impact of the media and information technology also mandates the careful preparation and training of official “spokepersons”, who will be called upon to represent the authorities and rescue agencies and sanctioned to inform the population about the course of events (see Appendix to this volume). The competence with which this is done can lead to either public reassurance or public anxiety. The main factor of fighting terrorism is to uncover and to support natural psychological resilience, either at the individual or group level. Actual instances of resilience in the face of terrorist threat, examples of self-control and mutual help, of resisting panic are not only worthy of being covered by mass media, but they should also become a subject of scientific analysis with a view to developing evidence based recommendations to prevent social and psychological consequences of terrorism. Almost all persons exposed to the extreme life-threatening situations are potentially participants in group disorganized behavior, yet so called mass panic is in practice a rare reaction of people in extreme situations (see Glass, this volume). More predictable negative reactions are either hostility or apathy-like states, sometimes associated with varying degrees of antipathy towards the rescuers. For some victims, the threat to their ethnic identity (threat directed against specific ethnic group) m a be more important that threat to their life and losing their family members. Some regressive forms of reactions with transient cognitive disturbances and difficulties in the performance of simple tasks are very frequent, especially in a prolonged life-threatening situation. However most persons involved in extreme situations are still able to show rational and constructive behavioural responses regarding their own safety, provided they receive equally rational and constructive information about the real threat and the ways to avoid or minimize it. Long-term consequences of terrorist attacks include not only mental health problems in the victims but also limitations in their social functioning, which, in turn, impact on the social environment of the victim and influence social processes at large.

V.N. Krasnov / Responses to Terrorist Attacks

101

Table 6. Structure of psychiatric care in emergency • First aid + psychological care • Immediate medical care • Secondary medical care with elements of specialized care • Specialized care (psychiatric, psychotherapeutic) • Rehabilitation of victims (medico-psychological and social, organization of social support) • Psychoeducation (including training for managers, persons in charge and officials)

On the basis of our long history of organizing care in emergency situations we can summarise some of the main organizational issues as we perceive them (Table 6).

2. Preventing and Overcoming the Consequences of Emergency Situations 2.1. Terroristic act in Moscow theatre centre, October 23–26, 2002: Main events and the organization of psychological and psychiatric aid to the victims At 9 P.M. October 23, a terrorist group captured a theater in Moscow during the performance. The performing actors were taken hostage, with many children and adolescents among them. The terrorist demanded an end to the war in Chechnya and threatened to begin killing hostaged unless Russian troops were immediately withdrawn from Chechnya. If an assault on the building was made they threatened to blow themselves up with the hostages. The captives were mainly held in the music hall under the threat of death with a few demonstrative gunshots fired. Several people attempting to escape were shot. For two and a half days the unsteady communication between the hostages and the outer world was maintained first via mobile phones and later with the aid of some members of parliament, popular artists and doctors who were admitted to the negotiations. Through their mediation, several groups of young children (under the age of 12) and some seriously sick hostages were released. Early in the morning, October 26, the hostages were released, as result of the assault made by Russian Special Forces. Before the assault a neurotropic “soporific” gas was pumped into the building through ventiducts. During the assault, 36 terrorists were killed and several hostages died of gunshot wounds. Along with this, about 70 hostages died of cardiopulmonary decompensation. Some more captives died in hospitals in the following days. The overall dead toll among the hostages was 129. After relatively short-term treatment, 499 people were discharged from hospitals. The Medical headquarters of Moscow government gave medical and medicalpsychological help. The headquarters started working as early as 10 P.M., November 23, very soon after the main Government headquarters dealing with the security situation was established. A medical rehabilitation center for aid to the victims was organized in the War veterans’ hospital located in the vicinity of the theater. During the first day, aid was primarily given to the relatives of the hostages and resident of the neighborhood. It is important to note that the relatives and friends of the hostages started to gather near the theater from the first hours of the capture. Some of them needed medical and psychological assistance. A number of individuals created a psychologically tense atmosphere with their behavior. In order to minimize their activities either psychological aid or other means were required.

102

V.N. Krasnov / Responses to Terrorist Attacks

Dr. Yu. Boiko, head psychotherapist of Moscow, was on the staff of the Medical headquarters for the aid to victims from the first hours after the terrorist attack. More than 40 specialists (mostly psychiatrists with a psychotherapeutic training and clinic psychologist) worked under his supervision. They counseled those who sought help at the above-mentioned rehabilitation center, as well as those among the crowd of the relatives who gathered near the captured building. Their objective was to discover individuals who needed medical-psychological help, and to reveal “negative leaders” who disorganized the crowd with their overly expansive and provocative actions. After the organization of the Medical headquarters, the staff from other institutions joined that team. One of them was a group supervised by Z. Kekelidze that consisted mainly of psychiatrists from the Center of Social and Forensic Psychiatry Psychotherapists and psychologists from several state institutions joined as well. Two groups of psychologists (from the Ministry of Emergency Situations and the Ministry of Internal Affairs) worked relatively independently but in coordination with the main headquarters. Their work mostly involved psychological support for the members of trained rescue units and special forces. The activities of psychiatrists, psychotherapist, and psychologists were not limited to the period of the capture of hostages and their release as a result of the assault on October 26. Their work continued and is still in progress in a number of hospitals where the hostages were sent. Psychotherapeutic counseling rooms were set up. Where experts aided everyone who sought help, as well as advised medical doctors on the state of health of individual patients. Besides, counseling rooms were organized at several institutes and outpatient hospitals, where psychological, psychotherapeutic and comprehensive psychiatric aid was offered. Several counseling centers still continue to assist the victims who seek help. All such treatment is carried out free of charge at these state institutions. Some of the victims needed hospital examination and treatment. They were sent mainly to the Moscow specialized “Clinic of neurosis” or to special unit for the victims of emergency situations at the Center of Social and Forensic Psychiatry, as well as to other clinics of Moscow. Some individuals are treated at the Speech Pathology and Neurorehabilitation Clinic of the Moscow Research Institute of Psychiatry. They manifest more complex organic disturbance of the central nervous affect than was expected, due to fact that captives were weakened by hypodynamia, food and water shortage, and were in state of long-term psychological stress. The mental state of many victims was manifested in complex of anxiety-depressive, asthenic, and cognitive disorders, which testifies to the multifactorial nature of these victims – the former hostages and their relatives. 2.2. Current experience with terrorist attacks Many emergencies of recent years require attention in order to specify the notion of their psychological psychiatric consequences, as well as the possibilities of assistance to the victims. Accumulated experience shows the necessity for further careful study of the challenges and problems of psychological psychiatric assistance during emergencies, though these problems are not new: there already exist some definite organizational approaches and working principles for their solution. Nevertheless, each new emergency raises further questions that require clarification. We can single out the following organizational problems, related to assistance in emergencies:

V.N. Krasnov / Responses to Terrorist Attacks

103

1. The need for active cooperation between various specialists, organizations, services and departments (sectors) during the emergency; this kind of cooperation must be provided by central administration responsible for elimination of emergency and its consequences. 2. The readiness of multidisciplinary professional teams and specialists (psychiatrists, interns and psychologists) to work in the conditions of emergency. This readiness should be provided in each region, city and district on the basis of particular institutions’ specialists’ functional duties, which usually work with regular “routine” schedule of clinical and counseling psychological practice. 3. The clarification of the professional status of people, who work during emergency (presence of certificate confirming their proficiency to work during emergencies), including their affiliation to state institution with corresponding authority. 4. Distribution of functions between various specialists (clinical diagnostics and therapeutic help, psychotherapeutic help, psychological counseling, psychological help, psychologist’s participation in psychotherapy, social support, etc.). 5. Development, substantiation and approval of ethical deontological and legal norms of medical psychological and psychosocial “interferences” as assistance to the victims. Principles of partnership should extend to all work during emergencies, however due to the situation and the possible poor condition of some victims as seen in the Moscow Theatre siege, paternalism and assertive measures and variants of help are unavoidable and should be foreseen. 6. Provision of adequate informational support for all rescue measures. Those aspects of work can be illustrated in Table 7. Each emergency has its own particularities and circumstances, so, correspondingly, the reactions of victims are different. These differences help to see not only the role of the stressor itself (threat of death, realization of loss) but also the role of preceding factors, various biological and psychological premises in the mechanisms of response. Of course, there are common patterns of psychic (and psychosomatic) response and development of psychological and psychiatric consequences of emergencies. As far as the mechanisms are concerned – there is no reason to question the traditional and much confirmed division of response into acute and prolonged. The psychopathological manifestations of the former appear in various guises ranging from stupor to “storms” of movement, though in modern conditions those reactions are rare. In both cases there are elements of confusion, intellectual failure, helplessness, though their short term nature and tendency to recover do not always provide grounds for psychiatric interference. At more distant stages together with disorders of the affective spectrum (including anxious and somatoform disorders) there are regressive forms of psychic response. They mostly appear in exaggerated intellectual failure and excessive exhaustion after psychic effort. Table 7. Operational tasks to provide medical psychological help in emergencies 1. Cooperation of services and specialists. 2. Functional readiness. 3. Status of specialists. 4. Distribution of functions and tasks. 5. Ethical and legal regulation. 6. Informational support.

104

V.N. Krasnov / Responses to Terrorist Attacks

What is important to note as a general pattern requiring attention while evaluating the condition and assistance is the somatic autonomic expressions of acute response to stress. Somatic autonomic shifts are non specific as well, but they are mostly related to cardio-vascular system and reflect sympaticotonic shifts of autonomic regulation up to hypertension crisis, episodes of stenocardia, etc. The kind of contrreaction or delayed reactions like hypotonia or vascular regulation disbalance with hypotonic crisis and the threat of cordial or cerebral ischemia are no less dangerous. Somatic vulnerability which appears at the acute stage requires systematic control, because at further stages it often leads to long term disorders in cardio-vascular and other physiological systems. However such outcome is not inevitable, and timely adequate help at early stages prevents the development of the pathological changes previously mentioned. Rescuers, including all participants in rescue operations and the provision of help, are also affected by many different special factors. Psychological and physical involvement in rescue operations can itself mobilize psychological resources, and assist in coping with the inevitable impact of the work and the sheer weight of the work load. But, no doubt, rest is required after that, and sometimes even medical and psychological help, without which somatic and psychic health of the rescuers is in danger. It was confirmed by the experience of assistance to the victims during the explosion in the metro on February 6, 2004 and during roof collapse in the aqua park on February 14, 2004. Once again, acute responses to stress, despite their diversity, are well described and in theory at least should not present any difficult in diagnosis. However, one problem is that this diagnostic function is the responsibility of the medical teams, because it is important to keep in mind combined lesions in the complex mixture of understandable psychological responses and psychopathological symptoms (barotrauma during the explosion in the metro, commotions, contusion in both cases, cold trauma in the case of roof collapse, etc.). At the same time it is important to take into account that offering psychological help must always on a voluntary basis. People are not always ready to accept help, so it should be offered in different forms. Until now some of the types of help that have been given to victims are ill defined, and may not even have names. For example, a group of colleagues from Moscow Research Institute of Psychiatry offered psychological support to the relatives of the deceased during the identification of body remains – this work is vital, but does not fit easily into our existing classifications and structures. Such work required not only psychological sympathy and emotional support, but also primary medical help related to cardiovascular and other responses and the worsening of somatic illnesses. At the same time it was necessary to keep some distance yet be ready to offer help without imposing it in this tragic procedure. But most of all what is needed is more study relating to the cooperation or otherwise between the different services. This may be the most crucial area of further work related to emergencies. Joint efforts of medical and psychological community with the involvement of lawyers are necessary to deal with the dilemma of legal norm of medical aid appealability and the ethical impulse to provide help when it really is necessary. On another level the relationship between professional prerogatives of a psychiatrist (as a diagnostician, pharmacotherapist and psychotherapist), an internist (as an “urgent” diagnostician and general therapist) and a clinical psychologist should also be clarified.

V.N. Krasnov / Responses to Terrorist Attacks

105

In foreseeing emergencies of different kinds (including the regrettably low probability that terrorism will disappear on the global stage) it seems important not only to organize help to the victims but also to raise people’s vitality, their resistance to terrorism and to stressors and survival in tragic circumstances. Recent emergencies give impressive examples of people’s vitality and constructive behavior in circumstances which might otherwise have provoked panic and helplessness. This experience is worth studying and evaluating from both psychological and social point of view in order to mobilize such evidence for psychoeducational activities. Reserves of vitality – at the individual, group and population level, with all associated their gender, age and culture aspects – require studying no less then pathological phenomena.

References [1] Aleksandrovsky Yu, et al. Psychogenias in emergency situations. Moscow: Meditsina, 1991, 97 p. (in Russian). [2] Boiko Yu. Antistress medical care in emergency situations and after them. Social and Clinical Psychiatry 2003; 13 (2): 60–67 (in Russian). [3] Cohen R. Mental Health services for victims of disasters. World Psychiatry 2002; 1 (3): 149–152. [4] Individal and community responses to trauma and disaster: the structure of human chaos, Ursano RI, Caughey BG, Fullerton CS (eds). Cambridge, New York. Melbourne: Cambridge University Press, 1994, 422 p. [5] Kekelidze Z, Morozova I. Psychiatry of emergency situations. In: Dmitrieva B. (ed.), Handbook of Social Psychiatry. Moscow: Meditsina, 2001, pp. 415–446 (in Russian). [6] Kokhanov V, Krjukov V, Kibrik N. Specific features of mental disorders in the victims of the terroristic act in Budennovsk. Disaster Medicine 1995; 11–12 (3–4): 64–67 (in Russian). [7] Kokhanov V, Goncharov S. Vital problems of organization of psychiatric aid in emergencies (the system of the All-Russian Service of Disaster Medicine). Disaster Medicine 1997; 17 (1): 7–15 (in Russian). [8] Kokhanov V, Krasnov V. Psychiatric aid for victims of emergency situations. Concise guide for medical practitioners. Moscow: Zashchita, 1997, 46 p. (in Russian). [9] Krasnov V. Methodological and organizational aspects of disaster psychiatry. Disaster Medicine 1997; 17 (1): 21–24 (in Russian). [10] Lopez-Ibor JJ. The Psycho(patho)logy of Disasters. In: XII World Congress of Psychiatry. Plenary Lectures, Yokohama, 2002, pp. 3–11. [11] Responding to disaster. A guide for mental health professionals. Austin LS (ed.). Washington: American Psychiatric Press, 1992, 256 p. [12] Smirnov V, et al. Psychiatry of disasters. Military Medicine Journ 1990; (4): 49–56 (in Russian). [13] Terrorism and disaster. Individual and community mental health intervention. Ursano RI, Fullerton CS, Norwod AE (eds). New York: Cambridge University Press, 2003, 348 p.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

107

Approaches to the Study of Suicide Terrorism: A Perspective from Russia V.N. Krasnov Moscow Research Institute of Psychiatry The attempts to explain suicide terrorism from the perspective of view of individual psychology or psychopathology show little promise to date. In contrast, there are good reasons to believe that cultural psychological research into the long standing and stable systems of clan up-bringing by North Caucasian people may be more informative. However, during the Soviet period the psychological study of these problems was ideologically forbidden, whilst also not forbidden by contemporary Russian psychology it was not possible because of the particular security circumstances in North Caucasus. Of course, it is possible to make some inferences regarding the personality of the terrorist from individual biographies, but the contribution of individual biography is likely to be very small in comparison to socio-psychological, political, ethnocultural factors. As we have no opportunity to study terrorists, let alone any possibility of studying a representative group using sound methodology, instead we must rely on what are admittedly generalizations from available data sources, no matter how imperfect. The data we have comes from our work of many years, made in collaboration with psychiatric and psychological specialists from the Chechen Republic and international organizations, such as World Health Organization (WHO) and Medecins du Monde, who took care of Chechen people, especially in refugees’ camps on the territory of Ingush Republic. The current press sources, and some recent books [2,6,7] have been also used for the analysis of behavioral appearance and possible motives of terrorists actions. Our point of view can be only tentative. But we should take into account the obvious difficulties on the way of the systematic study of terrorism. For example, in 2002 one thousand citizens from two cities (Grozny and Gudermes) and two country regions of Chechen Republic were studied with the methodological assistance of the Moscow Research Institute of Psychiatry and the technical assistance of a group of Chechen specialists under the supervision of Dr. K.A. Idrissov [4]. The goal of the study was to reveal the extent to which psychiatric disorders were spread among different groups of people and to define the needs for psychiatric assistance and counseling. The main instruments used were General Health Questionnaire (GHQ-28) (D. Goldberg) and the München Scale of Posttraumatic Stress Disorder. The Diagnostic Research Criteria for ICD-10 and the Hopkins Symptom Check List (SCL-90) were used as additional instruments. The studies reported a high prevalence of mental disturbances (86.3%) according to the GHQ-28 criteria, mostly stress related disorders. For example, probable posttraumatic stress disorder (PTSD) was found in 31.2% of all examined people. PTSD was less common in the youngest age group (10.6% at the age of 18–25 years), but increased with age (51% at the age of 46 and more).

108

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

Kh. Akhmedova [1] has carried out psychological research with the methodological assistance of the Moscow Research Institute of Psychiatry in the refugee camps in the Northern Caucasus. She has reported that the setting of long term trauma is fertile ground for the growth of responses such as fanaticism with ideas of revenge, particularly amongst young people. Fanaticism is characterized by an unshakable and unchangeable certainty about the necessity of revenge and the associated narrowing of a person’s value systems.. The events of the past are viewed in a narrow, one-sided way. Motives of revenge become stronger and stronger, and more reasons for revenge are found [1,3]. Not only personal experience, but also the experience of the family or even the whole people (ethnic group) plays a major role. It is important to notice that in conditions of both long-term social instability and continuing military operations with all their consequences any conflicts with representatives of administration and/or government are always associated with national identity. It is necessary to keep in mind that these tragic events can occur during the period of a teenager’s self-identification, and this can also influence the development of terrorist’s personality. Due to immaturity, youthful suggestibility and lack of personal life experience these young people easily fall under the influence of older “mentors”. Religious fanatics, such as vakkhabites, are especially dangerous because they emphasize and use the theme of outward aggression, traumatization of people and the threat of destruction of the Chechen ethnos and identity. As an alternative to this they promote the idea of national and supranational (Islamic) resistance as a heroic life path. Fanaticism can be regarded as a shift of personality or a change of personality, which strongly disposes towards terrorism. The development of fanaticism is accompanied by the growth of aggressivity. According to Kh. Akhmedova [1], but perhaps not surprisingly, such people are inclined0 to refuse any psychological help. Suicide terrorism involving women (for example, Chechen women who took part in terrorist attacks in Russia) requires special attention. For the development of female suicide terrorist the concurrence of 3 main factors is required: 1. Frustration experience with depressive features – loss of meaning, aversion to life; suicidal thoughts; 2. Religious and the strict ethnocultural prohibition of suicide in traditional family way of life of North Caucasian people; 3. Consistent “mentor’s” training or direct coercion to sacrificial terrorism proceeding from an older relative, usually an older brother but occasionally an older women.

Commentary on Factor 1 Ideologists of Chechen separatism try hard to create and promote the image of a desperate widow, avenging her husband’s death. But in practice most of the young women suicide terrorists are not widows. However, it is true that often some of their both close and distant relatives, have died or disappeared. This is important in the development of a psychological readiness to terrorist actions, but alone is probably not sufficient. What is also needed is for these immediate or recent losses to be linked with the long term ethnocultural perception that these are insults that require a response, invariably a violent response – in other words revenge. Thus any discussion of aggression towards the

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

109

Chechen people is perceived within the language of insult and revenge. The actual circumstances of any tragic event are usually viewed one-sidedly. The legend or mythology of widowhood is particularly wide-spread because it naturally invokes sympathy and compassion. In some cases personal crisis directly related to the death of relatives or threat to the individual’s life can be linked to the development of depression. But in the atmosphere described above this crisis gradually acquires “causal” connection with not only the family’s experience of such tragic events, but also with the wider military and political situation. Finally we must not forget the archaic but still persisting concepts of “blood revenge” as a natural response to the murder of one of family members.

Commentary on Factor 2 The conflict between the depressive negation of life or desire to die and the ethnocultural ban on suicide is solved in the form of sacrificial revenge. The traditional culture of North Caucasian people condemns suicide not only as an act of an individual but also because of the shame it brings to her family and the whole clan. It is stigmatized alongside the stigma of mental disorders. Suicide is usually covered up as an accident, and mental disorders are often kept in secret even from the wide circle of relatives, let alone neighbors and acquaintances.

Commentary on Factor 3 Suicide terrorists from Chechen Republic, especially women – are mostly natives from the countryside. As such they tend to have a lower level of education and narrower world outlook. Many of them have never left Chechnya. There is some preliminary evidence to infer the presence of dependence and suggestibility, which is also associated with depression. These traits are exploited by more experienced and educated “mentors” – who are usually not only supporters of Chechen separatism but also adherents to Islamic extremism, the so called vakkhabism. The latter usually do not take part in terrorist attacks that involve a threat to the terrorists’ life. Young women experiencing a psychological crisis or a protracted frustration with depressive features are isolated by older “mentors” from outward contacts – for example by moving to remote villages, to an environment of multiple religious rituals, endless reading of suras and so on. This occurs alongside the persistent repetition of the theme of revenge to the enemy for all the perceived disasters and insults to national dignity. The women become a kind of hostage and become more and more psychologically submissive to the mentor. After that comes practical training in the mechanics of suicide terrorism – learning to use weapons, explosives, how to navigate through the city that is the chosen target of the terrorist operation. The last stage of training can take place close to the intended place of operation. From our modern perspective it is hard for us to imagine that it is possible to recruit a significant number of young people, including women, ready to die in an act of sacrificial revenge. The process of training of a suicide terrorist is well beyond our own experiences and imagination, and cannot be understood outside the framework of the traditional, archaic system of family and clan upbringing. This is the system of values which maintains a strict hierarchy of submission and obedience: “the older – the younger”, “man –

110

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

woman” (at least in the outward rituals of behavior), “clan – family – individual”. The value of individual’s life is very small in comparison to the significance of the clan as an integrated formation. In such conditions a young woman not only has to submit to older women in her family or to a brother of her own age, but all her upbringing in a traditional “village” family is a preparation for sacrificial revenge for the honor of her family and clan. These traditional upbringings also cultivate heroic ideals related to the history of family, clan and ethnic group. These ideals reflect the readiness to sacrifice oneself for the good of the family and clan. We can suppose that they oppose the hedonistic culture of modern civilization. It is also likely that these cultural values are weakened by urbanization – hence the predominance of rural communities and individuals in known cases of suicide terrorism. The use of the symbolic “black widows” dresses by the female terrorists who took part in the Moscow theatre siege in 2002 can be regarded as the reduction of ideal heroism to its theatrical forms. This subterfuge with its ostensible heroics could be seen as appealing for the suggestible young women not acquainted with outward effects of urban life. On the other hand this subterfuge was intended to influence the audience (in the theatre hall) and especially Russian and international TV audience. Religiousness, including Islam, does not have deep roots in the post-Soviet culture of the North Caucasian people, at least among the majority. Religiosity became the ideological form of opposing mind and opposing behavior. The clan ideology of serving one’s family is more traditional, and it can be a foundation for the purposeful development of readiness for sacrificial quasiheroic behavior – combatant, “partisan” terrorism among teenagers and young people, suicide terrorism among young women. “Jihad” permits suicide as a sacrifice for the sake of the Islamic idea and of one’s people. Mentors and ideologists of terrorism, who are often psychologically sophisticated, find young women who are experiencing life crisis, depression and/or, suicidal feelings. At the same time mentors, usually older brothers, use their clan position of superiority to its full extent, up to and including blackmail and intimidation. Male teenagers, on the other hand, are offered a more “masculine” kind of sacrificial heroic – namely participation in military operations as members of armed units.

The Importance of the Aesthetics of Terrorism Terrorism has aesthetics of its own which seem to form not spontaneously but systematically, taking into account modern forms of informational influence upon people. Visual means of influence, first and foremost the TV, are used above all. Written and oral statements in the conditions of relative freedom of speech decrease in value and do not lend people’s credibility. That is why the written and spoken word is more and more often replaced by bright spectacular images on TV. It combines the aesthetics of destruction with the sight of large-scale explosions, fires, building crashes and the aesthetics of theatric tragedy. One example of this is the attack on World Trade Center in New York on September 11, 2001, which was clearly intended to be broadcast all over the world, as indeed it was. It caused the unwilling, but revealing, amoral utterance by the famous composer, Karl Heinz Stockhausen, who said that “I am delighted with the beauty of this attack.” Another example is the subtly organized “show during the show” – the taking of

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

111

hostages in the theater in Moscow, October 23–26, 2002. Firstly this was a re-enactment of familiar scenarios or symbols familiar to us from disaster films. Secondly, it contained allusions to theatrical sacrificial rituals, influenced by historical costume dramas. The main characters were elegantly dressed young women in the costumes of mourner, nun or secret cult follower. The “producers” of the action or drama not only have the possibility of showing themselves to the world but even have the possibility of constantly correcting or refining the images of themselves that they would like to project on the world screen. The power of such suggestive methods of terrorists has been described by many witnesses, even by persons with very analytical and critical attitude [7]. Comparing the terrorist acts, conducted by the same center, 7 years after the capture of big hospital in North Caucasus in 1995 we can see considerable changes in the “asthetical” arrangement of the brutal performance [5,7]. In connection with the hostages’ taken during the musical “Nord-Ost” in Moscow we would like to consider the informational component of the terrorist attack. • The event itself had clearly been planned as a broadcast televisual event, with transmission via the broadcast networks was a certainty. • As a broadcast event the terrorist attack showed a certain cynicism of the Russian TV channels, because alongside with reports, surveys and discussions of the event they did not drop their regular advertisement or commercial breaks. This combination of real time tragedy and commercial advertisement however may have reduced the impact of the terrorists actions or intentions, who may have expected to see continuing extreme dramatization of the event, with the consequent intimidation of the population and pressure on politicians. Almost certainly inadvertently, the decision to continue commercial breaks, whilst made for cynical reasons, may have added an air of normality to the televising of the siege.

Conclusion Suicide terrorists are not typologically uniform. We can single out two types of Chechen suicide terrorists: 1. Young women: a) Mostly dependent introverts, with occasional elements of psychological immaturity, who have a lack of social experience. They are mostly villagers with ordinary intelligence, relatively low levels of education, who may be experiencing depressive spectrum disorders. b) They have been exposed to traumatic experiences, although this may not have been very personal in all instances, instead involving their family or immediate social networks. They idea of revenge, often itself a replacement for direct suicidal action, rarely is self generated but comes from the influence of older people. c) They receive intensive training in special conditions, for example in the family of distant relatives, or (rarely) close relatives, in small camps with groups of other young women. Here they are taken care of for several months by older women or men and undergo an intensive religious and simplified military training. It is noticeable that well-educated, active, often extravert women

112

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

with significant social experience, who also had traumatic experiences and also become fanatical in the pursuit of revenge, yet do not strive to sacrifice themselves, instead actively recruit others from the population of more vulnerable women as described above. These more extravert women can and do participate in the psychological and technical preparation of other more vulnerable women for suicide terrorism and martyrdom. 2. Men. In general males rarely become suicide terrorists, who are more typically young women and teenagers. Men become suicide terrorists in extraordinary cases, and each case requires its own explanation. There is some indirect data to suggest that a psychological trauma is an obligatory component. The trauma should be related not only to the death of relatives and/or personal threat to life but also to humiliation, personal but most particularly to a perception of national dignity. In such cases we need to address the traditional codes of upbringing of highlander peoples: in the codes of honour of the clans the male is attributed some chivalrous qualities. Under such codes the male cannot be wrong and cannot be humiliated. It follows that the feeling of guilt is not formed culturally, the place of selfcriticism is given to the ideas of man’s valor, protection of one’s honour, which can not be separated from the protection of family’s and clan’s honor. This is one of the key moments of ethnic self-identification. Humiliation from outsiders, especially wounding of ethnical affiliation feelings, is intolerable. And from this comes ideas of revenge. The psychological mechanisms of revenge, and its links with fanaticism and aggression were studied by K. Idrisov [3] and Kh. Akhmedova [1]. A kind of ethnic hyper-identification was revealed recently in the study of forced migrants [8]. If revenge is impossible to achieve in open combat (which would be the preferred option for a male brought up in traditional highlanders’ behavior codex) another option in such “desperate” circumstances can be suicide terrorism. Then children, women, hospital patients, chance passengers and people of one’s own ethnicity can all become victims: fanatism destroys all ethical barriers in fulfillment of the goal of revenge. Suicide terrorism acquires irrational forms – it offers a macabre escape from intolerable feelings of offended dignity, and affirms the person’s sense of right, and of course the “other’s” wrong. This fanatical blindness is the principle difference between modern suicide-terrorist and Japanese kamikadze of World War Two, who directed their planes only to military objects.

References [1] Akhmedova Kh. Fanaticism and idea of revenge in persons with post-traumatic stress disorder (PTSD). Social and Clinical Psychiatry 2003; 13 (2): 15–23 (in Russian). [2] Chlebnikov P. The talk with barber. Moscow: Detective-Press, 2004, 282 p. (in Russian). [3] Idrisov K. PTSD dynamics in civilians that experienced life-threating situations in a local military conflict. Social and Clinical Psychiatry 2002; 12 (3): 34–37 (in Russian). [4] Idrisov K, Krasnov V. Mental health of the Chechen Republic population in the long-term emergency situation. Social and Clinical Psychiatry 2004; 14 (2): 5–12 (in Russian). [5] Kokhanov V, Krjukov V, Kibrik N. Specific features of mental disorders in the victims of the terrorostic act in Budennovsk. Disaster Medicine 1995; 11–12 (3–4): 64–67 (in Russian). [6] Olshansky D. The psychology of terrorism. S-Petersburg: Piter, 2002, 286 p. (in Russian).

V.N. Krasnov / Approaches to the Study of Suicide Terrorism

113

[7] Popova T. Nord-Ost in the eyes of hostage. Moscow: Vagrius, 2002, 238 p. (in Russian). [8] Soldatova G, Shaygerova L. Psychological adaptation of forced migrants. Psychol. Journal 2002; 23 (4): 66–81 (in Russian).

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

115

Cross-Confessional Investigation of Religious Visions of the World in the Context of the Fight against Terrorism V.F. Petrenko a,1 and A.I. Yartseva a Russian Academy of Sciences, Faculty of Psychology, Moscow State University, Moscow, Russia

Religion and Terror This article discusses the project of a cross-confessional investigation of religious mentalities and values in the context of extremism and terrorism. September 11, 2001, became a turning point in the history of human civilization and revealed a crisis in value systems as well as in humanitarian, cultural and religious identity. A well-known, but officially unrecognized during the Soviet period, Russian historian B.F. Porshnev once expressed a paradoxical idea that cannibalism had not existed in the history of mankind (though this contradicts anthropological investigations) because those who had eaten other human beings never considered their victims as humans – i.e. as self. This idea has resonances with the phenomena of genocide and terrorism because extreme nationalists and proponents of ‘class despotism’ and religious fanatics responsible for acts of extremism do not consider their victims as equal to themselves and their culture. The issue of genocide and terrorism can be analyzed from the point of view of terrorist’s identity and his national, clan or religious grounds and lack of internalized common human values. Terrorism and genocide, which is close to it, had existed long before the 21st century. However, the terrorism of the 21st century has a number of characteristics that establish a new phenomenon – namely, a mutated religious consciousness and religious values. The majority of world religions have developed in the course of overcoming tribal and clan identity. The idea of “One God” carries the implication, overtly or not, of uniting mankind on basis of religious belief. The Christian principle ‘there’s no Greek and no Jew but a Christian’ is known in other formulations in both Buddhism and Islam. The rise of world religions was associated with rise of huge empires and states where various ethnic groups coexisted, not only on the basis of force alone, but also on basis of common religious belief and value systems imposed by religious ideology. Governing polyethnic territories, developments in economy and trade and consistent humanization of human spirit resulted in the development of common human values. Mankind started perceiving itself as a single species sharing a common world history. The concept of ‘mankind’ came to unite people irrespective of their race, religion and nationality. And, finally, modern science and advances in evolution biology and genetics indicate population unity and 1 E-mail: [email protected]

116 V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World

common genetic stock, when diseases that emerge at one part of the world can be easily transported by modern transport to other parts of the world. Before September 11, industrially developed countries emphasized the importance of security, but with the emphasis on national defence against external aggressors, principally other state actors. And for the superpowers the main symbol of overwhelming and unanswerable state power was possession of the nuclear bomb. Possessing nuclear weapons seemed to be a reliable guarantee of the military safety of the country within the framework of state alliances and the doctrine of MAD (“Mutally Assured Destruction”). However, advances in modern technology, and our dependence on the same technologies in hierarchical functional systems, mean that a minor mishap can disrupt a whole system (for instance, electricity supply or Internet communication). Likewise, the high density and mobility of modern populations create conditions for small groups or even single individuals to ‘privatize’ the possibility of a large-scale destruction, for example by biological terrorism. The ‘sick mind’ of the fanatic becomes a real source of danger. For these reasons we propose that the role of the humanities in understanding terrorism has never been more important. Philosophy, psychology, sociology, ethnology and ethnography, religious disciplines, cultural anthropology, pedagogics, ethics and aesthetics not only study consciousness and cultures but also formulate and promote new, also futurological, ideas concerning being in this complicated world. The tragic events of autumn 2001 showed that even the United States, the now dominant world power, is vulnerable to international terrorism. This attack caused an emotional shock all over the world, not just within the confines of the United States. Besides the large number of victims and material damage involved, it was also a challenge to democratic values and the open society, and also to values of religious consciousness. These events reflected the civilization break predicted by Samuel Huntington and changed the geopolitical map of the world. The shock was also partially associated with the fact that in the new self written history of the civilized world it was believed that the variability of value/morals systems could be, and indeed had been, restricted by the framework of so-called common human values presented explicitly in the Universal Declaration of Human Rights. Different civilizations had been interacting in a globalised world on basis of certain moral standards and common human values. This basis was destroyed by the acts of terrorism on September 11, which were also an example of a pathogenic mutation of the now non shared value systems. Terrorism as a social and cultural phenomenon has a long history. Some authors trace its episodes back to the Bible while the majority tends to date it to the 19th century. However, the acts of terrorism on September 11 have certain characteristics that point to a new phenomenon – a pathogenic mutation of religious ideology and culture. In our opinion, they can be described as follows: 1. Those acts were not directed at individuals (usually a political leader) but at innocent and peaceful populations. In Russian history, the assassination of czar Alexander II by Russian terrorists or the assassination of Indian Prime Minister Gandhi by a terrorist from the “Tigers of Liberation of Tamile Ilama” were acts against specific persons and their policies. 2. Those acts were anonymous. No political organization claimed responsibility for the attacks. Russian terrorists of the past did not disappear from the crime scene and did their best to turn the resulting trial into a political performance.

V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World 117

3. Those acts strongly resembled religious sacrifice because they inevitably included the death of the terrorist. They were not associated with revenge motives or vendetta. Terrorists had enjoyed the hospitality of the country they attacked and even studied there. Terrorist acts rather resemble stories from the Old Testament, such as ‘Abraham sacrificing his son’. In this case the ‘son’ was not represented by numerous innocent victims but by terrorists themselves. Islam, like other religions, rejects suicide, but on the other hand ‘changing’ one’s own life into many others’ can be interpreted as ‘death in combat’ – in other words martyrdom. Thus the shahid is not carrying out an act of suicide, which would be seen as selfish, but acting altruistically for the community – an act of martyrdom. 4. For the first time, an aircraft was used as a direct means of terrorism – the aircraft, instead of delivering the “bomb”, became itself the bomb. It was the end, not the means. Such conscious use of usually peaceful technological achievements for killing other humans indicates the technological “know how” of modern terrorists, and confirms Freedman and Durodie’s view (Chapter 4) of the terrorist as a modern risk entrepreneur. Any glance at history shows that the use of air power for bringing destruction to civilians is nothing new – the change is using civil aircraft for that purpose, and also for using the aircraft as a “suicide” weapon. Analysis of the differences between modern suicide terrorism and the Japanese kamikaze movement might prove instructive here. 5. Those acts were not a form of protest against specific political or military developments. We can compare it with a certain form of institutional advertising or image promotion, which is not aimed at promotion of a specific product but at promotion of a certain lifestyle. In this sense, we can speak about ‘institutional terrorism’ which is directed against a particular value system, such as the so-called American way of life. The twin towers of the World Trade Center are one key symbol of the latter, and indeed a wider Euro-American civilization. In our analysis, we presume that terrorist attacks of September 11 ideologically constitute a pathogenic mutation of Islam. Islam is a world religion and is based on certain common human values. Mutation can occur in any (quasi)religious consciousness. Take, for instance, Aum Shinrikyo. Members of this sect committed a number of terrorist attacks in the Tokyo Metro though its ideology was based on the largely pacifist religion of Buddhism. In order to defend society against religious fanatics and ideological extremists from the standpoint of a free and open democratic society, we need to reconstruct their vision of the world and, specifically, their value systems. The importance of the programme Russian psychological science has been actively working in the field of experimental psychosemantics (Petrenko, 1982, 1988, 1997) which can be traced back to Kelly’s personal constructs theory and Osgood’s semantic space investigations. We use the semantic space technique for the analysis of political and religious mentalities. We describe the dynamics of changes in public consciousness by means of analysis of semantic space transformations. We develop the typologies of respondents, political parties and ethnic cultures on basis of similarities in their semantic space. And, finally, by applying determinant analysis (Chesnokov, 1982), we distinguish the respondents’ characteristics (or

118 V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World

determinants) that determine their belonging to a specific mentality or specific vision of the world. In our previous publications on the ethnic and political mentality of the inhabitants of Russia (Petrenko & Mitina, 1997; Petrenko & Mitina 1985, 1997, 2001), we described our methods and techniques used for analysis of public consciousness and generalization of dynamics. This research did not concern directly the religious consciousness of the inhabitants of Russia or their attitude to religion. However, it did provide interesting data concerning religious aspects of life. Thus, when we studied the attitude of the population towards reforms in the economy and politics, a relatively weak factor of religious consciousness showed up, specifically, the influence of the Russian Orthodox Church in Russian political space. Another investigation dealt with geopolitical views of the Russians (Petrenko, Mitina & Bertnikov 2003) and their perception of other countries, and it also detected the presence of religious factor. So far, the analysis of current mentality and political consciousness of the Russians inevitably brings us to the subject of religious consciousness and specific confessions. Objective of this study: cross-confessional investigation of value systems in religions spread in Russia and establishing to what extent they are spiritually acceptable to Russians. Methods: psychosemantic methods close to those of Kelly’s ‘repertory grid method’ and Osgood’s semantic differentiation and G-sorting. Material: 300 fragments of religious canonical texts containing moral judgements (Russian Orthodoxy, Catholicism, Protestantism, Judaism, Buddhism, Islam and Hinduism presented by Krishna Consciousness) and representative texts of communist and fascist ideologies, which claimed in the 20th century quasi-religious status. These texts will be evaluated by priests, pastors, rabbis, muftis etc. and form the basis for a multidimensional axiological semantic space, which will reflect respective (quasi)-religious values and show similarities and differences between them. Afterwards, the same descriptors will be used on the population in different regions of Russia – both believers and non-believers – and in ethnic territories in order to establish the ‘density’ of followers and analyze tolerance for other people’ religious views. We expect that on major factors the positions of religions in axiological semantic space will be close, and they will oppose the commonplace consciousness and totalitarian ideologies i.e. spiritually world religions will be close to each other. One can also expect spiritual closeness of Russian Orthodoxy, Catholicism and Protestantism, all being Christian confessions, and their connection with Judaism within the frames of the Judaic-Christian culture. Finally, we have to expect a rather flat axiological semantic space for religious fanatics and proponents of totalitarian ideologies (cognitive simplicity) and their ‘blackand-white’ (Manichean) consciousness.

Tasks for Future Investigations A. Cross-confessional investigation of values, including the development of axiological semantic space based on judgements of priests, pastors, rabbis, mullahs, lamas, etc. on respective scriptures, as well as specific ideologies – communism and fascism (the proponents of the latter are extreme nationalist groups). The data matrix will be subjected to factor and cluster analysis in order to determine the categorical structure of the worldview for every religion. The positions of re-

V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World 119

ligions in the value space will show similarities and differences in value orientations, common human values (as invariants) and specific traits. This is important for constructive inter-confessional communication and interaction of different cultures. B. Determining moral values in the Russian population, in different regions and national republics by finding out the attitudes of people towards the same fragments of canonical religious texts and placing them in the axiological semantic space. High concentration of respondents by a confession/ideology shows the density of followers. C. Establishing social and demographic determinants of the confession/ideology. Chesnokov’s ‘determinant analysis’ will allow to determine age, social and national characteristics of the followers of a confession/ideology. D. Investigation of religious and ideological roots of fanaticism and extremism. This is an extra task because its implementation, specifically, working with representatives of extremist groups and religious fanatics require special experience. In this investigation, we intend to outline the methods and approaches to studying totalitarian consciousness and religious extremism. Pilot study of the Russian population’s views concerning values of world religions The above mentioned psychosemantic approach towards values was previously applied in our pilot investigation performed on 200 respondents. All respondents were highly educated and volunteered to participate in this study because of their interest in religious subjects. They were asked to complete the so-called reflective matrices i.e. they put themselves in the shoes of a ‘Russian Orthodox’, a ‘Catholic’, a ‘Buddhist’, a ‘Krishna’ follower, a ‘Judaist’, a ‘Moslem’, and also from their own point of view, from the points of view of a ‘common person’ (‘person from the street’), a communist and a fascist. Naturally, this pilot investigation does not reflect the ‘objective’ position of different religions but respondents’ ideas about these religions. A more objective picture will be obtained in the course of the main study involving the immediate proponents of religious mentalities (priests, mullahs, rabbis, lamas, etc.). Therefore, here we deal with role positions or ‘social representations’ (Moskovici, 1998). Such an investigation is also important for psychologists because besides checking on value judgements they give information about the population’s views on specific confessions and ideologies. Method: Semantic space development on the basis of canonical religious texts containing value and normative statements from the Old and New Testaments, Bhagavat Gita, Moslem Hadith, Koran, The Book of Exodus) and some texts reflecting communist and fascist ideologies. Procedure: Respondents were asked to express their agreement/disagreement on the texts or statements using a 7-point scale (from +3 ‘agree completely’ to −3 ‘absolutely disagree’). They received in total 160 religious and ideological statements. They were not informed about the sources of these statements though some of them were easily recognized. Data processing: Individual matrices with 10 role positions on 160 statements (or descriptors) were brought together and formed one group matrix which was subsequently analyzed by means of factorial analysis with the help of SPSS. As a result, four factors were selected that explained 42%, 27%, 8% and 6% of total variance.

120 V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World

Factor 1 (F1) had on one axis statements like: • Do not murder (Exodus) • Love your enemies, and pray for those who persecute you (The Gospel according to Matthew) • Hate shall never stop hate in the world but it stops in the absence of hate (The Dhammapada) • Do not resist him who is evil; but whoever slaps you on your rights cheek, turn to him the other also (The Gospel according to Matthew) • Wars cannot be conducted for the sake of gaining territory (Hadith). The other axis contained the following statements: • He is unworthy who is unable to revenge (Nietzsche) • Those who want to live have to fight and those who keep away from fight do not deserve to live (Hitler) • The stronger shall rule the weaker (Hitler) • One shall be punished by death for the crime committed (The Book of Deuteronomy) • A soul for a soul, an eye for an eye, an ear for an ear, a tooth for a tooth and wounds shall be avenged (Koran) • If a man does evil but for the sake of loyal faithfulness, he shall be as righteous as he is in the right way (Bhagavat Gita). Thus, on one axis we have here the judgements that forbid violence even with best intentions. Many of these statements contain a negation. In its strongest expression, it demands love for enemies. On the opposite axis we have the statements that belong mainly to Nietzsche and Hitler that emphasize the right of the strong. There are also statements from the Old Testament and the Koran about the right to retribution. We can see the locations of representations of religions in semantic space (Table 1). From the point of view of our respondents, Christianity, Buddhism, Krishna Consciousness preach forgiving, tolerance and no evil deeds even for the sake of good purpose. On the opposite axis, we find representations concerning fascism. It is known that fascists strove to prove their racial superiority in every possible way including genocide. Representations on communism are close to those on fascism though communism practiced genocide not for racial reasons but for ‘class reasons’, with certain exceptions. So far, this opposition between religions and ideologies looks rather logical. There is but one exclusion. That is Islam. In axiological space, it opposes other religions. It could be explained by its rigid norms and by associations with fundamentalism and negative experiences with the war in Chechenia. Neutral happen to be representations on Judaism. Perhaps, the respondents are not well informed about this religion. Rather neutral are ‘common persons’ representations while representation of ‘myself ‘ are shifted in direction of tolerance. Thus, the first factor has been interpreted in the following way: “Violence forbidden ↔ Violence for the sake of a good purpose (or ‘The end justifies the means’)”. Factor 2 (F2) included statements like: • Do not take gifts (The Book of Exodus)

V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World 121

Table 1.

• Whoever exalts himself shall be humbled, and whoever humbles himself shall be exalted (The Gospel according to Matthew) • No piece for those who strive to satisfy their wishes (Bhadavad Gita) • The love of money is a root of all sort of evil (First Timothy) • Wealth gives rise to immoderate desires (Islam Nadjul Balagha) • Wine and gambling are great sins (Koran) • If you want to live quietly, learn to do without things which are unnecessary (Tolstoj) • Pride precedes death and arrogance precedes fall (The Book of Proverbs). On the opposite axis we have the following statements: • Follow your passions, good or evil (Nietzsche) • Evil instincts serve their purpose as they preserve the species (Nietzsche). The contents of factor 2 can be expressed as “Control of passions and desires ↔ Selfindulgence”. Almost all religions demand self-restriction and humility (see Illustration 1). On the opposite axis we find the representations of ‘myself’ and ‘common person’s’. Religion establishes a certain ideal towards which one should strive. However normal people are disposed to passions, pride, bodily desires and attractions. Communist ideology also imposes some limitations (‘communal is more important than individual’). As for fascism, according to our respondents, it is neutral on this issue. Factor 3 (F3) had to do with the pair “Rigid norms of behavior ↔ Possibility to choose”. On the one hand, we offered strictly normative statements like: • The thief’s hand shall be cut off as retribution for his gain (Koran) • Man is responsible for all sins of the woman (Nietzsche)

122 V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World

• People must not eat the meat of animals (Bhagavad Gita) etc. There were also statements that left the choice with man: • As your soul wants it, you can get and eat meat (The Book of Deuteronomy) • Church belief is slavery (Tolstoj), etc. On factor 3, Judaism and Islam, being strictly normative religions, oppose Christianity (Russian Orthodoxy and Catholicism) that allow more freedom of choice, as well as communism with its conscious choice (Table 2). Weak Factor 4 (F4) included the statements interpreting being as illusion and those on primacy of individualism (a kind of moral solipsism) like the following: • Ruler of death does not see those who see the world as mirage (The Dhammapada) • Living means permanently pushing away things that have to die (Nietzsche). The other axis presented the statements that emphasize involvement in the world of people: • Man finds happiness only in serving others (Tolstoj), etc. On factor 4, role representations of Buddhists and the followers of the Krishna Consciousness (both being individualistic religions), are away from Christianity, Islam and Judaism while representations referring to ‘myself’, a ‘common person’ and a ‘communist’ are neutral (Table 2). Factor 4 can be interpreted as “Illusive nature of being ↔ Inclusion in the world of people”.

Table 2.

V.F. Petrenko and A.I. Yartseva / Cross-Confessional Investigation of Religious Visions of the World 123

We would like to stress that these results are not based on profound religious analysis but reflect our respondents’ representations concerning religions. However, we plan to work with those who are professionally involved in religious activities, i.e. priests, pastors, mullahs, rabbis, lamas etc. and with proponents of the two mentioned ideologies (fascism and communism). Semantic space based on their judgements, together with representations of the population will provide a picture of religious views and show common people’s attitudes to specific religious confessions or ideologies. Psycho-semantic analysis exposes the deepest religious and moral feelings of persons while sociological surveys reflect only conscious reactions of respondents and are not free from ‘social desirability’, ethnic influences and social conformity with religious rituals. Such an investigation will make it possible to determine an approximate percentage of true believers and those who claim to be believers, as well as the percentage of people oriented at specific religious values. As for the extra task formulated as the “Investigation of religious and ideological roots of fanaticism and extremism”, we have to work among extremists. Naturally, what we aim at is not a psychodiagnostic method that would allow to control any presumed ‘terrorist mentality”, whatever that may be, nor to be used as a means of control by security agencies, as by George Orwell’s ‘thought police’. Those who do not want to show their attitudes, can imitate some social wishes. However, in order to develop counterpropaganda and ideological weapons against extremism, we have to reconstruct its ideology. Psychosemantic investigation has to resolve this issue. Besides, data on positions of different religions in axiological semantic space will contribute to our understanding the status of these religions in the interconfessional communication.

References Kelly GA. A theory of personality. The psychology of personal constructs. N.Y. 1963. Osgood Ch. Dimensionality of the semantic space for communication. Scand J of Psychology (Stockholm) 1966; 7 (1). Moscovici S. The machine that makes Gods. Moscow, 1998 (in Russian). Petrenko VF. Introduction to experimental psychosemantics: investigation of representations of common consciousness. Moscow, 1982 (in Russian). Petrenko VF. Psychosemantics of consciousness. Moscow, 1988 (in Russian). Petrenko VF. Basics of psychosemantics. Moscow, 1997 (in Russian). Petrenko VF, Mitina OV. Psychosemantic analysis of the dynamics of public consciousness. Moscow, 1997 (in Russian). Porshnev BF. Social psychology and history. Moscow, 1979 (in Russian). Huntington SP. The clash of civilizations and the remaking of world order. London, etc.: Touchstone Books, 1998. Chesnokov SV. Determinant analysis of socioeconomic data. Moscow, 1982 (in Russian). Petrenko V, Mitina O, Brown R. The semantic space of Russian political parties on federal and regional levels. Europe-Asia Studies 1995; 47 (5). Petrenko V, Mitina O. The psychosemantic approach to political psychology: Mapping Russian political thought. States of Mind: American and post-Soviet perspectives on contemporary issues in psychology. New York: Oxford Univ. Press, 1997, p. 19–48. Petrenko V, Mitina O. A psychosemantic analysis of the dynamics of Russian life quality (1917–1998). Europ. Psychologist 2001; 6 (I): 1–14. Petrenko V, Mitina O, Bertnikov K. Russian citizens’ representations of the country’s positions in the geopolitical space of the Commonwealth of Independent States, Europe and the world. Europ. Psychologists 2003; 8 (4): 238–251.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

125

Special Features of Emergency Psychological Assistance during Acts of Terrorism Y.S. Shoigu Center of Emergency Psychological Aid of the EMERCOM, Russia The threat of terrorism is becoming ever more evident in recent years. This can be seen both from the context of Russia and in the wider world. Terrorism is becoming an inescapable phenomena of modern society, and it cannot but tell upon mental health and psychological condition of people. These pressures can also be amplified by the inevitable role of the mass media, which, while highlighting tragic events and providing information about them, also can place additional stressors on victims of terrorism. All this makes psychological help necessary for people who have suffered in emergency situations, including terrorist attacks. There are three main tasks which psychologists fulfill while providing emergency psychological help: • Exposure and timely correction of unfavorable psychological reactions, which appear in response to a particular situation and to maintain optimal psychological and physiological condition of the victim. • Prevention of unfavorable mass reactions among the victims. • Precautions against delayed consequences for the victims hurt in the incident. It is important to notice, that these tasks are characteristic of emergency help, that is, short-term help, which is provided immediately after the event, accident or terrorist attack. There are three main stages in the provision of emergency help: the preparatory stage, the main stage and the final stage. The first task of a specialist at the preparatory stage is to obtain essential information about the number of victims and their psychological state, about the peculiarities of medical aid organization and social conditions (is there hot food, tea, adequate provision for rest, etc.?) and to make this data the basis for building the system of assistance optimal for these conditions. During the main stage the fundamental task is the provision of emergency help to victims and staff. The longer the situation lasts, the more help will be needed by the staff, who can easily be overlooked. At the final stage the specialists’ tasks are to make a prognosis about the future consequences of the incident, and to give the victims information concerning where they can obtain help in the future. The term “victims” requires explanation and elaboration. In a broad sense, victims are all the people who receive psychological help after the event. We can single out five groups of victims: victims, relatives, witnesses, spectators, secondary victims. It is necessary to briefly describe each of these groups (Table 1).

126

Y.S. Shoigu / Special Features of Emergency Psychological Assistance Table 1.

Name and short definition of the group

Peculiarities of behavior and psychological response

Peculiarities of emergency help provision

Victims – people physically hurt during the event

This group has the broadest range of psychological response to traumatic experience from the absence of unfavorable response up to the extreme forms of its expression

Relatives of the victims who were physically hurt or people who lost their property as a result of emergency

Victims of this category gather in locations where information is available or as near as possible to the places of tragedy. There can be different kinds of response to traumatic situations (weeping, hysterical reactions, aggression, etc.). Unlike the first group, nearly everyone in this category shows some psychological consequences. The appearance of mass reaction is possible They can be usually found in the same locations as the second group. As they were not involved in the event, but it happened very close to them, they often start repeating in their minds different variants of the situation’s development. This can lead to strong psychological trauma. The stage of shock lasts comparatively longer with this group. Phobic disorders can be found comparatively more often They can be found in locations with best views to the site of occurrence. The appearance of mass reactions is possible

If victims of this group are in hospital, it is appropriate if specialists from this medical institution provide psychological assistance. A smooth transition from emergency psychological help to rehabilitation recovery work is desirable It is possible to achieve maximum efficiency of help when work is based on the principle of individual short-term sessions. The choice of particular method depends on the peculiarities of the situation, the victim’s response and his or her personal circumstances

The provision of emergency help is often organized according to the principle of control aimed to prevent mass reactions

They rarely seek specialists’ help. They usually have phobic response to traumatic situation

The provision of emergency help is possible through various kinds of hot lines

Witnesses – people who became indirect participants of the situation: neighbors, witnesses

Spectators

Secondary victims – people, whose psychological problems are connected to receiving information about the event through mass media

Medical assistance to this group can be provided in groups of different sizes. While treating this group it is necessary to pay special attention to the prevention of delayed responses

It is possible to single out one more category of people who may need help from psychologists – the specialists of various emergency services, who perform their official duties at emergency sites: rescuers, firefighters, policemen, social services, etc. The assistance to this group can be built on the principle of creating the most optimal conditions of work and rest, as well as the organization of group sessions aimed at peer support and recovery – sleep deprivation can create severe psychological pressures that should be watched for. Specialists working at emergency sites often do not have special training for this kind of work, for instance, those working in the social services. In this case

Y.S. Shoigu / Special Features of Emergency Psychological Assistance

127

psychological response is similar to the one of “witnesses”. It is necessary to keep this in mind while providing emergency psychological help. The approach used to provide emergency psychological help can be called eclectic. To provide assistance of this kind methods from different areas of modern psychological science and practice are used: body oriented approach, gestalt-therapy, art-therapy, rational approach, cognitive approach, neurolinguistic programming, short-term positive therapy and others. However, some conditions restrict the application of this or that method in provision of emergency assistance. The most important of these conditions are: 1. Limit of time – the assistance must be provided quickly, so the method must be short-term; 2. Lack of conditions (separate room, silence, etc.) for individual work, so the method should not require the isolation of psychologist and his patient. In conclusion, it is important to notice some special circumstances which influence emergency help after terrorist attack. Unlike natural and technological catastrophes, the terrorist attack is the result of purposeful criminal activities. This fact has a particular meaning to people. A terrorist attack is even less predictable than many other situations. This leads to the uncertainty in the future, defenselessness, inability to protect oneself and one’s relatives, the feeling that tragedy can occur in any place at any time. These emotional experiences are more intense after a terrorist attack than in any other situation. The second peculiarity of people’s experience after a terrorist attack is the appearance of ethnical, political or any other intolerance. “They” come in – the outcast group which is to blame for the tragedy. “They” are associated not only to particular criminals who organized the terrorist attack, but with all representatives of their nationality (or even the group of nationalities), political party etc. The widest range of expression of this kind of intolerance ranges from fear of members of that community to aggressive actions against them. Those specific issues should be taken into account while providing psychological help during such emergencies as a terrorist attack. Thus, the provision of emergency psychological assistance after terrorist attacks is an important element of mental health protection and prevention of delayed response of victims.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

129

Perception and Experiencing of “Invisible Stress” (in Relation to Radiation Incidents) N.V. Tarabrina Traumatic Stress Disorder Laboratory, Institute of Psychology, Russian Academy of Sciences

Introduction Sixteen years have passed since the Chernobyl catastrophe. Although a great quantity of scientific research has been done and published during this time period, there have been only a few psychological studies. The quantity of publications in the popular press is enormous. However it’s important to mention, that journalists sometimes make negative contributions to elucidating the Chernobyl tragedy, such as promoting “radiation hysteria,” especially during the first several years after the catastrophe. There are still diverse and often contradictory points of view on the problem of delayed consequences of radiation on human health. Academician Ilyin, a member of the Central International Committee for radiation defense who personally took part in liquidation of the consequences of the Chernobyl disaster, has clearly shown that 7 years after the catastrophe there has been NO increase of general oncological morbidity and mortality among surrounding population exposed to radiation. These results were in accordance with the prognosis of the International Consulting Committee (ICC) that was formed the auspices of the International Chernobyl Project. The results of the ICC activities created an ambivalent reaction including direct accusations that the scientists were a part of the “atomic mafia”, the ICC proceedings were repeatedly criticized not only by journalists and writers, but by professionals as well. This criticism arose because the Chernobyl catastrophe had acquired unique social and political resonance. Certainly, it is too early to come up with final conclusion about such an important questions. For instance, the scientific report by World Healh Organization in 1996 demonstrated an increase in thyroid gland cancer among children living in the polluted Chernobyl areas. As early as in 1993 professor Gus’kova, medical director of the Institute of Biophysics Hospital, where the first victims of the Chernobyl catastrophe were treated, published a review paper that considered various methodological approaches to research involving the consequences of radiation. In this review studies were divided into two groups: those that meet and those that do not meet criteria for scientific research. For example, examining the studies from the second group, Gus’kova demonstrated how easily one could come to a wrong conclusion about the influence of radioactivity on the development of various diseases. These analyses led Gus’kova to the unambiguous con-

130

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

clusion that “only the scientists who have no expertise in the field of radiation consequences explain various biological and medical deviations by exposure to radiation. One cannot ascribe these deviations to radiation especially if the normal rate of morbidity is not known, and those diseases are most likely the result of psychological factors and stresses. It is most difficult to estimate the role of radiation exposure per se in the development of mental and psychosomatic disorders in individuals, exposed to radiation. To date the findings have been very contradictory. Loganovsky in 1999 published the results of clinical and epidemiological research examining the mental health of survivors of the Chernobyl disaster. He found “dramatic deterioration of mental health”, especially in the personnel, who had worked at Chernobyl between 1986 and 1987. The origins of those mental disorders were attributed to a combination of unfavorable factors related to a radioactive, as well as non-radioactive nature. It is difficult to disagree with in such an explanation; however it provides little clarification in the complex picture of psychological consequences of radioactive impact. In the above-mentioned ICC report on the International Chernobyl project, the experts presented posttraumatic stress disorder as one of psychological consequences of the Chernobyl catastrophe. The emotional impact on human mind of such traumatic events as violence, armed conflicts, and various industrial and natural disasters have been extensively studied. These kinds of psychological trauma have common etiology: so called “acute” stress due to a specific traumatic event. On the other hand, survivors of the “invisible stressors,” such as threats of radioactive, chemical, bacteriological, and other similar contaminations have received very little attention. The “invisible stressors” do not visible affect one’s environment, therefore their perception and estimation of possible harmful effects are based on individual’s knowledge of their presence as well as on the unconscious or partly conscious fear of their detrimental impact on one’s life and health. Several years ago my laboratory at the Institute of Psychology of the Russian Academy of Sciences in collaboration with the Psychophysiology Laboratory of the Harvard Medical School carried out a study of psychological effects of the stressful experience of possible radioactive contamination in workers (military, fire-fighters, etc.) who participated in containing the disaster at the Chernobyl Atomic Power Station. I would like to express my gratitude to our American colleagues, Drs. Roger Pitman, Scott Orr and Natasha Lasko, for their continuous generous support of our scientific endeavors. As it was mentioned above, the traumatic effects of work in the disaster area on the psychological health of disaster workers (known under the general name of “liquidators”) in general, and development of PTSD in particular, have not been extensively studied. After the Chernobyl disaster from 200 to 600 thousand “liquidators” were employed at different times to do the clean up, making clear the necessity of studying the consequences of the radiation threat experienced by the liquidators. The goal of our research was to examine workers’ characteristics of perception of the radiation threat and to establish the nature of emotional and personality changes that occurred in those who survived a radiation threat crisis.

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

131

Subjects and Methods Subjects (N = 65) were male ex-disaster workers who participated in the Chernobyl reactor clean-up. Excluded were subjects with a radioactive illness in any stage, medication free, or any kind of a cerebral pathology. Demographic and psychometric data appear in Table 1. All subjects experienced a similar, allegedly traumatic event, viz., one to two months’ exposure to radiation during clean-up of the nuclear power station in Chernobyl in 1986. Russian-language versions of following instruments were administered to each subject: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Structured Clinical Interview for DSM-III-R (SCID) [7] Clinical-Administered PTSD Scale (CAPS) [8] Mississippi Scale for Civilian PTSD [9] Impact of Event Scale [10] Minnesota Multiphasic Personality Inventory – MMPI State Trait Anxiety Inventory – STAI [11] Beck Depression Inventory – BDI [12] Symptom Check List 90-revised – SCL90-R [13] Radiactive Threat Perception Questionnaire (RTPQ) [14]

Results and Discussion Results of t-test comparisons between the PTSD and non-PTSD groups for the various psychometric measures are presented in Table 1. Both diagnostic groups were similar in regard to their mean ages and education levels. The PTSD group scored significantly higher than the non-PTSD group on all the measures of PTSD and general psychiatric symptomatology, state and trait anxiety, depression. Our diagnostic assessment involving the use of the SCID (structured clinical interview) revealed prominence of symptoms of physiological arousal as specific to a clinical picture of PTSD in the liquidators. In follow-up interview, some “liquidators” who had not met criteria for PTSD at the time of initial observation, but manifested some PTSD symptoms, reported that with the passage of time and especially when they did not feel well or heard about other Chernobyl liquidators becoming ill or dying, they’d have increasingly frequent intrusive memories of their experience at Chernobyl. Meanwhile, they began to attribute most of their emotional problems, such as irritability, insomnia, and unpleasant life events in life (e.g., divorce) to Chernobyl. Thus Chernobyl became a new point of reference in the liquidator’s life, which divided it into what life was like before the disaster and how life changed after it. In our study, the “liquidators” suffering from PTSD reported a much higher degree of psychological discomfort than the “PTSD-free” group (the differences between the two groups are statistically significant and consistent along all the psychometric scales used). MMPI has been shown to produce discrimination between PTSD and non-PTSD populations [9,15–19]. Several studies have suggested that the clinical scale configurations associated with PTSD diagnosis include: F-2-8/8-2 [9,19,20], 8-2-7 [21], 2-8-7, and F-8-7 [22]. In the present study, the PTSD group scored significantly higher on the MMPI F-scale and most of the clinical scales. The three-point MMPI code configuration

132

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress” Table 1. Demographic and psychometric data PTSD n = 21

non-PTSD n = 44

t

p

M

SD

M

SD

35.4 12.1

5.8 2.5

38.3 12.9

7.2 2.6

1.6 1.1

0.1 0.3

47.5 84.6

10.3 20.0

49.2 69.1

7.2 10.0

0.7 3.8

0.4 <0.001

K MMPI Clinical Scales Hs [1] D [2] Hy [3] Pd [4]

48.6

9.2

50.2

7.5

0.7

0.4

83.9 89.5 73.5 74.5

14.2 16.3 11.7 11.6

68.3 73.0 61.8 60.1

18.4 17.0 12.4 13.6

3.3 3.6 3.5 3.8

0.002 <0.001 <0.01 <0.01

Mf [5] Pa [6] Pt [7] Sc [8] Ma [9] Si (0)

63.9 74.3 83.1 90.7 71.4 61.5

7.7 13.0 12.7 19.4 12.2 8.3

63.3 59.8 67.9 69.3 63.9 58.1

11.2 10.7 13.3 15.0 12.0 8.7

0.2 4.6 4.3 4.7 2.3 1.5

0.83 <0.001 <0.001 <0.001 0.03 0.4

PK PTSD Keane PS PTSD Schlenger

75.6 73.1

15.4 11.8

62.7 61.5

14.1 12.6

3.3 3.5

0.02 0.001

Other Psychometrics IOES Intrusion Avoidance

5.9 8.0

3.9 6.7

2.5 2.9

2.6 3.9

4.1 3.8

<0.001 <0.001

Mississippi Scale for Civilian PTSD CAPS Frequency Intensity Total STAI State Trait

95.2 23.3 23.9 47.2 46.0 52.5

13.9 6.2 6.4 12.5 8.8 7.9

81.6 6.0 6.2 12.3 41.0 44.9

14.3 5.7 6.4 12.1 8.9 7.4

3.6 11.1 10.4 1.4 3.7 3.7

<0.001 <0.001 <0.001 <0.001 0.03 <0.001

SCL-90-R GSI Beck Depression Inventory

1.0 17.3

0.5 7.4

0.6 9.9

0.4 7.4

3.4 3.7

0.001 0.001

Demographics Age Education MMPI Validity Scales L F

was 8-F-2 for the entire profile, and 8-2-7 for the clinical scales. So, the MMPI profile of the Chernobyl PTSD group is in accord with previously published data on PTSD. Furthermore, this profile bears a striking similarity to that reported by Orr et al. [15] for Vietnam combat veterans with PTSD; the only notable differences are found on the F and Hs scales, on which the Chernobyl subjects were more elevated. The Hs elevation suggests that Chernobyl PTSD subjects were manifesting substantial concern about their physical health, not surprising given their exposure to a serious radiation hazard with its associated health implications. Using a newly developed PRTQ questionnaire, we established that the PTSD group had additional characteristics that distinguished it from the non-PTSD group. Specifi-

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

133

cally, the majority of the liquidators with PTSD viewed themselves as having been “heavily contaminated” with radiation while working at the site. This view was based on: (1) feelings of physical and psychological discomfort that had developed since the Chernobyl disaster; (2) perception that they had changed in their behavior, mood, state of mind, and attitude towards themselves, others and life in general. Compared to their non-PTSD counterparts, liquidators with PTSD gave a higher estimate of their radiation exposure expressed through their self-reported perception that they had: (1) worked in the immediate vicinity of the primary source of high-level radiation, (2) gone out there to work more often than other liquidators, (3) more often than others, been in highly radioactive areas for periods longer than was permitted by the safety standard. Starting from the beginning of their tour of duty in the disaster area, the liquidators with PTSD reported experiencing more tension, anxiety, and health-related fears, compared to others. This led to a chronic concern that there would be negative consequences in the post-Chernobyl life as a result of the radiation exposure. Another characteristic feature of this group of liquidators included their using every opportunity to discuss their health problems thereby re-living their past traumatic experiences. They also consulted physicians more frequently because of fear that any symptom was indicative of the negative effects of radiation. As would be expected, the liquidators with PTSD witnessed consequences of radiation exposure (burns on skin, syncope, hemorrhages, etc.) more often than the average person. Overall, our research pointed to a central role played by the “subjectivepersonal” factor in the development of the radiation-related traumatic stress. That factor also determines many specific features of this kind of stress. The results of our research indicate that conditions under which the decontamination of the Chernobyl site took place can best be viewed as traumatic because the primary stressor was the direct threat to human health and life posed by radiation exposure. This threat to life enables us to include participation in the decontamination of the Chernobyl disaster among traumatic situations that meet DSM IV and ICD-10 A criterion for PTSD. Consequently, it is reasonable to assume that, the liquidators experienced traumatic stress, even though most of the stressors encountered by them while working in the disaster area, were “invisible.” In other words, the stressors were being perceived, estimated, and interred even though the actual threat was not visible. The above-listed factors, along with other events that arose in the process of the decontamination operations, can be described as the primary stressors. Upon return from Chernobyl, the liquidators were exposed to secondary stressors. Information received subsequent to working at Chernobyl was an especially important secondary stressor. As demonstrated by our findings as well as those obtained from research conducted by other investigators, most of the liquidators who worked at Chernobyl knew little or nothing about the possible effects of radiation, or their knowledge was distorted and incomplete, while at Chernobyl. The situation was made worse by the fact that they were deliberately kept in the dark about the true dimensions of the catastrophe.

134

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

The dramatic changes in socio-political climate in Russia that followed soon after their return brought about an informational explosion in the mass media. This information included data on the actual dimensions of the disaster and the harmful effects of exposure to radiation, and became the principal secondary stressor. The release of new or additional information continues to cause severe emotional distress in the liquidators. Additional secondary stressors include: (1) deteriorating health that is subjectively attributed, primarily, to one’s personal participation in the decontamination operations; (2) fear of developing radiation sickness and, as a consequence, having a life expectancy shorter than normal; (3) increased hypervigilance at work caused by overestimation of the possibility of industrial accidents (i.e., fear that accidents happen more often, have more disastrous effects, and cause more serious injuries than usual); (4) family problems related to childbirth such as the possibility of becoming sterile or having children with birth defects. The clinical and psychological analysis of individual life stories, as well as data obtained in the course of psychotherapeutic intervention, confirms the important role of the secondary stressors in the etiology of PTSD. We hypothesized that the mechanism by which “invisible stressors,” such as the threat of radiation sickness, lead to the development of PTSD, differs from that associated with easily perceptible and specific event-based traumatic experience as combat, violence, natural disasters, etc. The primary difference is in the degree of perception and internalization of the traumatic experience. Our findings suggest that the psychological impact of the radiation threat depends, most of all, on the individual’s knowledge of the possible harmful effects of radiation, and one’s ability to internalize that information, both being subjective personality factors. In addition, the impact of this information may be intensified by negative emotions caused by the traumatic experience, e.g. another subjective personality factor. Our research has also shown that the level of conscious realization of the radiation threat was not very high, even though it certainly varied from individual to individual.This discrepancy led us to an assumption that the primary stressor – viz. the threat to human life presented by radioactive contamination – was perceived and realized mainly at the subliminal level of consciousness. The amount of realization increased later, as the liquidators, during the post-Chernobyl period of their lives, gradually acquired knowledge about the harmful effects of radiation on the human organism. This accumulation of data by no means presupposes an accurate insight into the facts acquired. Even having sufficient data at their disposal, people tend to internalize them through the “prism” of their individual (personal, intellectual, emotional and other) characteristics. Those characteristics, in the long run, determine either the subsequent development of PTSD or the emergence of defense and coping mechanisms capable of neutralizing the post-traumatic symptoms. We believe that research of “invisible” stressors such as radiation threat, have important scientific and practical value. First, this work has shown that PTSD occupies a prominent place in continuum of negative psychological consequences of Chernobyl disaster. Taking into account that PTSD may develop at any time following a traumatic experience, correct diagnosis of this disorder and subsequent intervention, may substantially decrease level of the social-psychological tension caused by the Chernobyl accident.

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

135

It is worth noting that during the post-Chernobyl years the role played by mental stress caused by exposure to radiation is recognized not only by physicians and psychologists, but also by representatives of power structures which gives us some hope in regard to our ability to overcome negative consequences of Chernobyl accident. On the other hand, there are other sources of “invisible stress” beyond that of radiation, e.g. threat of biological and chemical warfare. It is likely that the psychological mechanisms of developing post-traumatic disorders from these threats are similar. Unfortunately, we are faced with the fact that compared to research on traditional sources of posttraumatic stress disorders, mechanisms of development of PTSD related to “invisible stressors” has so far received very little attention in the scientific community. Even so after publishing our findings, the diagnosis of PTSD related to the radiation stress has become a medical reality, and provided practical benefit for the development of preventive, medical and rehabilitation measures. This problem acquired even greater significance today in the post-September 11 era when the modern world woke up to a new life under constant threat of terrorism, including threats of biological and chemical weapons. We now come to the painful realization that a terrorist attack can take place at any moment, in any place, and each of us (ordinary people) might become a victim. The reality, unpredictability, and “invisibility” of such a threat forces individuals to be in a constant state of hypervigilance, which in turn promotes the development of distressing and anxious states. Psychological consequences associated with a threat of terrorism are capable of attaining the character of mental epidemic. In this regard it becomes obvious, that there is an acute necessity for the fundamental clinical-psychological research on specific characteristics of subjectivepersonal experience of threat of terror, as well as on predictors of the development of posttraumatic stress disorder, caused by this specific stress.

Literature Loganovsky KN. Clinical and epidemiological aspects of psychiatric aftermath of the Chernobyl disaster. Social and Clinical Psychiatry 1999; 9 (1): 5–18. Dyachenko AA, Graboboi ID, Ilyin LN. Chernobyl: Disaster. Exploit. Lessons and Conclusions. Moscow, Inter-Vesy, 1996; p. 784.

References [1] Viner HM. The Psychological Dimensions of Health Care for Patients Exposed to Radiation and the Other Invisible Environmental Contaminants. Social Scientific Medicine 1988; 27 (10): 1097–1103. [2] Dew MS, Bromet EJ. Predictors of temporal patters of psychiatric distress during 10 years following the nuclear accident at Three MIle Island. Social Psychiatry and Psychiatric Epidemiology 1993; 28: 49–55. [3] Collins DL, de Carvalho AB. Chronic Stress from the Goiania 137Cs radiation accident. Behavioral Medicine 1993; 18: 149–157. [4] Alexandrovski JA, Rumjanzewa GM, Jurow WW, Martiuschow AA. The dynamics of psychological maladjustment states of chronic stress in inhabitants of areas involved in the Czernobyl nuclear accident. Psychiatrische Praxis 1992; 19: 31–34. [5] Torubarov FS, Chinkina OV. Psychological aftereffects of the disaster at the Chernobyl NPS. Klinicheskaya Medicina (Moscow) 1991; 69: 24–28. [6] Simon GE, Katon WJ, Sparks PJ. Allergic to life: psychological factors in environmental illness. American Journal of Psychiatry 1990; 147: 901–906.

136

N.V. Tarabrina / Perception and Experiencing of “Invisible Stress”

[7] Spitzer RL, Williams JBW, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R. Washington: American Psychiatric Press, 1989. [8] Blake DD, Weathers FW, Cook, et al. Assessing current and lifetime PTSD status with a CAPS. National Center for PTSD, 1990. [9] Keane TM, Malloy PF, Fairbank JA. Empirical development of an MMPI subscale for the assessment of combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 1984; 52: 888–891. [10] Horowitz MJ, Wilner NJ, Alvarez W. Impact of event scale: A measure of subjective stress. Psychosomatic Medicine 1979; 41: 209–218. [11] Spielberger CD, Gorsuch RL, Lushene RE. Manual for the State-Trait Anxiety Inventory (self-evaluation questionnaire). Palo Alto: Consulting Psychologists Press, 1970. [12] Beck AT, Ward CH, Mendelson M, Mock JE, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry 1961; 4: 561–571. [13] Derogatis LR. SCL-90-R: Administration, Scoring & Procedures Manual-II for the R(evised) Version. Towson, M.D., Clinical Psychometric Research, 1983. [14] Tarabrina NV, Petrukhin EV. Psychological features of radiation danger perception. Psychological Journal 1994; 15 (1): 27–41. [15] Orr SP, Claiborn TM, Altman B, Forgue DF, de Jong JB et al. Psychometric profile of PTSD, Anxious and Healthy Vietnam Veterans: Correlations with psychophysiologic Responses. J of Consulting and Clinical Psychology 1990; 58 (3): 329–335. [16] Fairbank JA, Keane TM, Malloy PF. Some preliminary data on the psychological characteristics of Vietnam Veterans with PTSD. J of Consulting and Clinical Psychology 1983; 51: 912–919. [17] Merbaum M, Hefez A. Some personality characteristics of soldiers exposed to extreme war stress. J of Consulting and Clinical Psychology 1976; 44: 1–6. [18] Roberts WR, Penk WE, Gearing ML, Robinowits R, Dolan MP, Patterson ET. Interpersonal problems of Vietnam combat veterans with symptoms of posttraumatic stress disorder. J of Abnormal Psychology 1982; 91: 444–450. [19] Wolfe J, Quinn S, Stewart J, Vielhauer M, Clum G, Kamen D, Brown P. MMPI-2 profiles in males and females with PTSD: A Retrospective analysis. International Society for Traumatic Stress Studies, San Antonio, October, 1993. [20] Blanchard EB, Hickling EJ, Taylor AE, Loos WR, Gerardi RJ. The psychophysiology of motor vehicle accident related posttraumatic stress disorder. Behavior Therapy 1994; 25: 453–467. [21] Burke HR, Mayer S. The MMPI and the post-traumatic stress syndrome in Vietnam era veterans. J of Clinical Psychology 1985; 41: 152–156. [22] Blue BA, Fama-Collins L, Blake DD, Gusman F. Psychometric norms for a combat-related PTSD inpatient sample. International Society for Traumatic Stress Studies, Los Angeles, October, 1992. [23] Petrukhin EV, Kharkovskaya TA, Selkova V, Tarabrina NV, Lasko NB. Chernobyl disaster workers’ perception of the radioactive threat. International Society for Traumatic Stress Studies Annual Meeting, San Antonio, Texas, October 1993. [24] Tarabrina NV, Lazebnaya EO, Zelenova ME. Psychological features of post-traumatic stress states among Chernobyl disaster workers. Psychological Journal 1994; 15 (5): 67. [25] Tarabrina NV, Lazebnaya EO, Zelenova ME, Lasko N. Chernobyl clean-up workers’ perception of radiation threat. Radiation Protection Dosimetry. Nuclear Technology Publishing 1996; 68 (3/4): 251–255.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

137

Can We Improve the Psychological Tolerance of Populations to Chemical and Biological Terrorism? V. Yastrebov Mental Health Support Systems Research Center, Russian Academy of Medical Sciences, 2-2, Zagorodnoje Shosse, 117152, Moscow, Russia The challenge thrown down by terrorism to society is based on the demonstration of its aggressive, destroying force. One of the most important consequences of terrorism is the deliberate attempt to create a state of mass fear and panic. Chemical or biological, terrorism has specific features, different from the feature of other forms of terrorism: (1) simplicity of use; (2) cheapness; (3) difficulties of detection; (4) increased dimensions of destruction; and (5) the possibility of mass casualties. If one makes an analogy with the classification of infectious diseases, then biological terrorism is a particularly lethal strain of terrorism. The characteristic feature of the threat of chemical and biological terrorism is a prolonged state of anxiety and fear within the at risk population because of the continuous expectation of tragedy and the state of uncertainty, which can create a prolonged mass acute psycho-emotional disorders. The aim of terrorist acts is to cause emotional experience of terror, fear, horror, to humiliate, to make victims agonize, to suffer. We can consider “terror” as the most strong negative emotion, manifesting its destructive effect on all levels: psycho-physiological, psychological, emotional, personal and social. Of these the psychological component is the most important. And although terrorism can be classified and labeled as biological, chemical, etc., it remains at heart a psychological weapon. Before we can consider how we can increase public tolerance to biological and chemical terrorizm we require an adequate definition of “tolerance” as a socio-biological term. “Tolerance“ is the ability to become less sensitive to a certain stimulus, especially during prolonged exposure to that stimulus. We also have to define of significance and dimensions stimulus. It is clear that our actions to improve how society tolerates unfortunates such as those with mental illness or physical disabilities is very different to how we can improve how society “tolerates” threatening situations – we are really talking about resilience rather than tolerance, for different processes are involved. Practically it is sufficient to define two levels of tolerance: psycho-physiological and social-psychological. The psycho-physiological level of tolerance is more responsible for the stability of the human constitution, with it’s systems and functions. The socialpsychological level is more responsible for a stability of a person as a member of society, as a social unit, representing aggregate public relationships. Acts of terror are aimed at frightening, integrating all levels – from vital to ideological. The psycho-physical level of the experience of fear is characterized by fear for one’s life and biological future. The social-psychological level of the experience of fear is characterized by fear of the threat

138

V. Yastrebov / Psychological Tolerance of Populations Terrorism?

to personal-social identity. The terrorist act is aimed at ideological terror, destruction of ideals, moral principles and cultural values of the person, and at splitting public cohesion. Amplification of ideological tolerance to the act of terror in general is connected with forming maximum harmonious relations under the heading of “personality-society”, and with buttressing such socio-personal characteristics as maturity, independence, social networks and support, etc. It is clear that public information is a powerful psycho-physiological factor. In order to make it positive and to contribute to improving resilience, anti-terror education should be highly-professional. Only very tested, adapted, professionally designed and actually effective programs and training should be used. Psychologists and social workers should play an important role in developing these programs. But for provision of professional presentation of information it is important that advice is sought from medical professionals including mental health specialists. Psychiatrists should be responsible for checking the adequacy of programs, the training of personnel and their delivery. Looking for new, “non traditional” ways of raising tolerance should not be substituted by adventurism, naivety or insufficient professionalism. Incorrectly designed or applied programs and trainings can become not only ineffective, but what is more they can decrease tolerance by so called “sensitisation” of society. Among possible negative consequences of incorrectly applied programs we can single out the provocation of “neurotic readiness”, panic and phobic reactions, inductive mental disorders, decompensations of personality disorders, exacerbation of psychotic (including depressive and delusional) disorders and other psychopathological states. In connection with this the following factors are extremely important – intensity, objectivity and the content of material presented by mass media. So, two main directions of amplifying of public tolerance to chemical and biological can be named: 1) Conducting special educational courses, popular lectures about possible consequences and measures of prevention for special categories of staff and for population of different age groups. 2) Cooperation with mass media concerning forms and methods of presentation of this kind of information (about the possible threat of terrorism).

Conclusion 1. The list of necessary measures should first of all include preventive (explanatory and educative) activity. 2. We need more information on how populations react to acts of terror. 3. It is also very important that different specialists – medical professionals, chemists, radiologists, sociologists, representatives of mass media – should participate in this complex program. 4. It is also necessary that representatives of local and national government structures engage in this effort, since little can be achieved without the input of policy makers and decision formers. In other words any program of training of population for threat of biological and chemical terrorism should be multi-disciplinary, multi faceted and multi dimensional, and developed from a broad knowledge base.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

139

Stockholm Effects and Psychological Responses to Captivity in Hostages Held by Suicidal Terrorists Anne Speckhard a,1 , Nadejda Tarabrina b and Natalia Mufel c a Georgetown University Medical Center and Vesalius College, Free University of Brussels b Traumatic Stress Disorder Laboratory, Institute of Psychology, Russian Academy of Sciences c Belarusian State University Abstract. October 2002, 800 plus hostages were held for three days in a Moscow theater by suicidal terrorists armed with bombs. The stand-off ended when Russian Special Forces gassed and stormed the theater. One hundred thirty of the hostages died. The authors – an American psychologist and colleagues from the Russian Academy of Sciences began to collaborate soon after the event. This article reports on eleven hostage interviews regarding their psychological responses to captivity including their expressions of Stockholm syndrome.

On the evening of October 23, 2002, the audience in the Moscow Dubrovka House of Culture suddenly found their entertainment interrupted as masked Chechen terrorists stormed across the stage. “Hands behind your heads!” the terrorists shouted, waving their guns. Bombs strapped around their waists and toting automatic rifles they barked out commands to the uncomprehending audience that this armed takeover of the theater was not part of the performance, but an action by a terrorist group. Some of the stunned theatergoers complied, while up in the balcony titters of laughter mixed with disbelief rippled down over the railings. More shouts, as the Chechens stormed up the aisles and rapid firing of their automatics. Suddenly silence fell as the audience realized this was not a joke – it was a terrorist takeover of an entire theater involving approximately 800 persons. The siege lasted three days and was ended by introduction into the theater air vents of an unidentified “sleeping” gas that caused most of the inhabitants to fall unconscious. At this moment the Russian Special forces stormed the theater during which all forty Chechen terrorists were killed. The unconscious hostages were carried out of the theater and placed into buses that took them away to hospitals where the majority of them were revived. However, over one hundred died or were pronounced dead on arrival from the effects of the unidentified gas. Many more would have lasting health effects. The total death toll would later be 130 hostages, only five of which died directly at the hands of the terrorists. 1 E-mail: [email protected] or [email protected]

140

A. Speckhard et al. / Stockholm Effects & Psychological Responses

Five weeks later the author, an American researcher and two Russian colleagues from the Russian Academy of Sciences began meetings with Russian hostages in Moscow to assess their psychological responses and states following the event. Additionally four hostages from Minsk, Belarus were interviewed four months after the event. The hostages were each interviewed individually (in Russian) in an open ended format and with questions pertaining to their experiences in the theater, their observations of the suicide terrorists, their feelings about the terrorists, the event and its end, their levels of stress and attempts at coping during the event, and their acute and posttraumatic responses to it. Given the unexpected nature of the event it was impossible to quickly procure funding for a larger sample, although the authors did apply to NIMH to carry out a larger randomized study. The lack of rapid funding available to study such events limited the scope of this study, yet despite the small and nonrandomly selected sample, it was rich in detail and provides a spectrum of psychological issues and processes that need to be considered when working with victims of terrorism or captivity. If we wish to understand terrorism better, given the unpredictability of terrorist acts we need to have funding mechanisms available to quickly put in place and fund studies shortly after the fact. Acute and posttraumatic stress responses were common as were Stockholm effects. Preliminary findings from interviews with eleven of these hostages are presented here with an in-depth analysis of the results pertaining to coping with the captivity stress of being a victim of suicidal terrorist hostage-taking. Due to space limitations, in-depth analysis of longer-term psychological effects and of the hostages’ reports of their observations and interactions with the terrorists aside from those pertaining to Stockholm effects are reported elsewhere (Speckhard, Tarabrina, Krasnov & Akhmedova, 2004; Speckhard, Tarabrina, Krasnov & Mufel, 2004).

Adaptations to Captivity Stress The practice of taking of hostages for ransom or for political gain has existed since recorded history. It is only in modern times that we have begun to understand that hostages and prisoners of war undergo a specific type of stress often referred to in the literature as “captivity stress” (Bower, 1981). During any period of forced captivity, a captive suddenly finds that his will falls under the control of his captor, that he must control his emotions and that indeed his behavior must resemble, if not become, an act of submission (Lassagne, 2001). Early research on adaptation to and recovery from captivity stress identified six stages of adaptation: startle-panic; disbelief; hypervigilance; resistancecompliance; depression; and gradual acceptance, as well as six stages of recovery: brief euphoria; hyperarousal; compliance-resistance; denial; restitution; and gradual readjustment. (Rahe & Genender, 1983). Other researchers have described the process of captivity to begin with a period of initial shock accompanied by extreme fear and anxiety, followed by a phase characterized by outward acceptance of the perpetrator’s control, after which gradually the internal state of extreme fright is replaced by a phase of adaptation in which captives resort to a number of coping strategies (Corrado & Tompkins, 1989). The pathogenic factors in the hostage-terrorist experience have been identified as sudden loss of control, helplessness, total loss of familiar routine and relationships, imminent threat to life, and the psychological transformation of the terrorist captor into

A. Speckhard et al. / Stockholm Effects & Psychological Responses

141

an all-powerful protector against perceived danger from the authorities (Simon & Blum, 1987, pp. 194). The coercive control over hostages is often oppressive and when combined with terrorizing actions requires on the part of the hostages strong efforts of selfcontrol, self-soothing and coping strategies. Face to face with the terrorist, each hostage must make multiple decisions and analyses of risk regarding the situation, how much he can withstand, and how great the risks are for protest or resistance. Since communication between hostages is often strictly controlled, these decisions are often made without the ability to consult others. As is almost always the case, when passivity is the demanded outcome the hostage must choose strategies to restrain himself from protest behaviors, hysteria, and emotional outbursts that if indulged can become the basis for his or her victimization: even death.

Initial Responses: Disbelief, Shock and Terror All of the hostages in this sample reported extreme shock or disbelief when the Chechen terrorists appeared on the stage. The timing of the terrorist takeover was at a point in the well-known “Nord Ost” drama in which military figures in uniform were expected to appear on stage, an expectation that caused confusion for the audience. One hostage recalls, “It happened so fast. . . They came (onto the stage) in military uniforms, with masks and automatics. We thought it had to be a joke. They started to scream ‘hands behind your heads!’ Many people put their hands up but we thought it had to be a joke. We sat laughing. Then we saw it was terrorists. Then we believed! At that moment we felt terrible terror. It was like a nightmare, a child’s terrifying dream of being without help.” Disbelief and desynchronized responses were common. One hostage reported, “I realized what it was in almost the first moment. My husband said, ‘Don’t worry, it’s the script.’ But I told him it’s not the script; please don’t do anything. When we saw one of the Chechens use his automatic rifle to beat the head of disbelieving man nearby we realized immediately.” Another hostage states, “I understood immediately, it was shooting. They (the terrorists) ran into all areas of the theater.” Her friend however did not comprehend the shooting of their automatics recalling, “. . . it was like a motor at the airport, I didn’t understand for awhile that there can be Chechens on the stage.” Another hostage states, “The first feeling was that it’s part of the act. Many teenagers were laughing like it was a joke or maybe the operations of the special services police, a special operation? But then the Chechens beat first one and then another person on the neck and shoulders just to show it’s the truth. Then we understood.” The hostages’ responses moved quickly from disbelief to shock and terror. A hostage recounts, “There was some hysteria at first. Some cried, others held their hearts.” Another hostage, a physician recounts, “There were some hysterical reactions – with the young, and a heavy woman who found it hard to breath.” In the first moments of the siege the Chechens swept over the theater asserting their control over the hostages while announcing to the stunned crowd that they were not planning to return home, that theirs was a suicide mission. They warned that they would shoot the hostages one by one if necessary. The terrorists were all armed, the men with automatics and grenades, the women with bombs strapped to their bodies and grenades. The hostages understood that they would not be released until all

142

A. Speckhard et al. / Stockholm Effects & Psychological Responses

Russian forces had left Chechnya – a demand that both parties knew was unlikely to be met. The terrorists were highly synchronized in their takeover sweeping up and down the aisles ordering the hostages to organize according to their demands. One hostage recounts, “We kept our hands behind our heads only in the first moments. We passed our telephones to the aisles and then we divided men from women. After that we sat normally. Foreigners were also divided to their own section.” The terror of being held captive was clearly palpable in the hostages’ accounts of their first hours of captivity. One woman recounts how she realized that she must recover her heart medicine from her purse that lay in a large pile of bags that had been taken from the hostages. “They gave me permission to look for my medicine. But he had a gun near my head as I looked in the pile. In one hand he held a grenade with one finger in the ring and in the other hand he had a pistol with his finger on the trigger. They were ready always, at every moment ready to fire.” A mother recalls the response of one of the children in her group to the machine gun fire at one point early on in the standoff, One of our girls got scared and we called her “scared poodle”. She got under the chair right away (when they started shooting) and didn’t want to get out, the shooting was over and everyone sat down again but she was lying down there. I told her, “An’ka, get out.” (laughs) She said, “No! I’m not going to!” “An’ka get out.” She is a big girl and lying there. There are six people sitting next to her with their legs up like grasshoppers. An’ka is lying there. Of course there is not enough space. Later we understood that we can take off the seats and then we could sit on the floor. But at first it was really uncomfortable. And one of our girls. . . we even started giggling. She is sitting there and saying “An’ka we will all get out of here and get medals for bravery. But you won’t get one because you are absent. So get out.” And then I said, “An’ka why are you lying there?” She answered, “I’m passing on this one.” I told her, “Turn your head this way and look.” She turned her head and I said, “Here can you see the guy with the automatic gun coming toward us?” She said, “Yeah, I see him.” And I told her, “He can see your back too.” The girl was thinking about it for a minute and then she moved from under our feet and crawled under the chairs themselves!

In the first moments of the takeover many of the hostages witnessed violence. One hostage recalls that when the Chechens were first entering the theater a man in the balcony who thought it was a joke “stood up and started to smile. He was sitting on the chair by the door. The Chechen beat him on the shoulder and bloodied his face with the butt of his automatic rifle.” Another remembers, “One of the Chechens broke the glass (windows) of the technical operators. One of these broken windows cut the back of a hostage badly causing him to bleed heavily.” Bombs were quickly positioned around the theater. As one hostage recalls, “Using three to four plastic chairs they put plastic explosives on the stage. . . I was afraid they would put people in those chairs.” Another recalls, “It was very frightening their shouting in their language.” Another explains, “There was nothing to drink, bad water, hysterical atmosphere. A few women lost consciousness right in front of my eyes.” Another states, “The first days were awful, no information. After, there was a radio. I wondered maybe no one knows about us. Psychologically the first day was very difficult.”

A. Speckhard et al. / Stockholm Effects & Psychological Responses

143

Initial Features of Captivity Stress Losing a sense of time As with nearly all situations of captivity, the hostages state that they began to lose their sense of time. In their case this was exacerbated with the constant use of bright lights in the theater hall. One hostage explains, “We couldn’t understand the passage of time, only by our watches. Until now I hate halogen lamps. You can close your eyes and still feel them shining on you.” Another adds, “We lost the sense of time. The lights burned above us all the time. There was no daylight and no night.” Loss of normal role functioning A dentist recalls her feelings of powerlessness. “It is my nature, I love people and (in my work) I must take away pain, but I could not help anyone. It was awful there.” Two doctors recall their fear to identify themselves. “We had a really big fear to stand up. When they asked for doctors we didn’t stand. If there was a big problem we will help, of course, but we didn’t.” Although later on in the siege, one of these doctors noticed that another hostage was acutely ill, and at that moment she moved immediately back into her usual role without any thought to the dangers to herself. “. . . when something was wrong with one of the women’s breathing, by instinct I stood up and ran to her to help her. When I was running near the Chechen I bumped him and his gun. I realize now he could have shot me. He asked, ‘Where are you going?’ I didn’t stop only answered, ‘I am a doctor.’ ” Parents of small children perhaps felt the deepest stress of being forced out of their normal protective behaviors and into choices that went against their normal instincts. One mother recalls in a fragmentary manner allowing her small daughter to join a group of young children to be released, We decided to give away a little child. He (the Chechen terrorist) said ‘I need a little child.’ Some mothers from that main hall started to hold up their children and scream, ‘Mine! Mine! My child! Look mine is little!’ One little girl was passed down the rows toward him. He said, ‘Yes, yes, yes.’ Then he turns and points with his automatic (to me and says) take out yours. She was sleeping there. He actually didn’t point with the gun, just his hands were on the gun, and it was just a move to point. I’m taking her out of there; he held her up on his arms, so that people from the stage can see her. They have a short dialogue in their language and he says (to me), ‘We are releasing her.’ You know, for me, a lot of people are asking me about it, if it was terrifying or horrible. For me the most terrifying was not what is happening here, but the question if they decide to release someone who it will be. I understood that my little girl will be released and the oldest one (her older son) will stay here. I got hysterical. You understand why I started to react this way, not according to the situation.

Loss of normal routines The inability to function normally and the complete loss of daily routines was the hardest on those who were ill. One hostage recalls, “On Friday my husband felt sick. He became ill with his kidney. We had tablets from the doctors that he took.” In his case he still had his medications and was able to get water. With hundreds of hostages it was inevitable that some of the woman would menstruate and be in need of feminine care

144

A. Speckhard et al. / Stockholm Effects & Psychological Responses

products as another hostage recalls, “On the second day I was getting sick and I began my period. Fatima (another hostage entrusted with the duty of dispensing supplies) was giving medicine. I asked her for help. She gave me sanitary napkins.” Smokers and coffee drinkers longed for their normal routines. One hostage recalls hearing, “Aslan. . . talked about Saturday. I thought we can’t stay until Saturday, I need a cup of coffee!” Another states, “I smoke. I wanted to smoke. Some people did smoke in the toilet.” Thoughts of family and death With little to occupy their time the hostages found that they frequently considered their fates and if they would ever see family members again. One hostage recalls, “I thought of my children, co-workers and patients. I really tried to say goodbye to them but it made me hysterical.” Another states, “I saw my work, how much I love people. I had ambivalent feelings too. At first I could only see the end. I will never see my job, never see my children.” Another recalls, “I thought about my kids without their mother, awful.”

Dissociative Responses As is often common with traumatic events some hostages reported dissociative responses and emotional numbing. One hostage states, “I was surprised at my reactions. I prefer to cry usually but I had no tears. I had only one thought – how are my children?” Another recounts, “It seemed like a movie. You never see a person beaten or shot. In real life it’s very unnatural to see it.”

Self Soothing and Adaptive Strategies to Captivity Stress As the first day wore on the hostages began to understand the limitations of their situation, to habituate to the terror of being held hostage and to make adaptations to captivity. These adaptations came mainly in terms of basic needs – finding out how to get food, use the toilet and become more comfortable in their situation. One hostage recalls, “The first night we tried to sleep in our chairs. It hurt your back. People started to take the seat cushions off and to sleep on the floor. But on the floor you couldn’t see anything. As a result we didn’t see much.” This inability to see created a psychological barrier as well – the hostages heard shooting but as they couldn’t see what was happening and it did not come near them they felt more removed from it.

Attachment Attachments were important in calming oneself during the times of high terror. One hostage recounts, “Since I was with my husband, I felt better. We were divided on different sides (due to the separating of men and women by the captors) and we couldn’t really move. But I could stand up in my seat a teeny bit and he moved the same and I felt connected to him across the balcony. . . When they allowed me to unite with my husband on Thursday and Friday I slept at his knees.” This husband reports, “I tried to

A. Speckhard et al. / Stockholm Effects & Psychological Responses

145

be supportive of my wife. She has heart problems. I tried to understand if she was okay. I wondered if I could find a safer place to sit. Later I asked Aslan if I can go to my wife and he agreed. . . I couldn’t find a place by her so we went and sat near the bomb. There were more free places there.” Another hostage recalls how she pretended to faint in order to move closer to her boyfriend and be comforted by him. “Men and women were divided so I sat apart from my boyfriend, but later I got up and went near his seat. I pretended to lose consciousness. Many people caught me and saw me fall down next to him but then when I came too we sat next to each other. I was afraid the doctor will come to help me.” One of two friends recalls, “We were together all the time.” The other recalls how she kept calming her friend saying, “Tanya it will all be okay.” The depth of these women’s attachment to each other extended to Tanya’s refusing to be released early without the other. “I went to the toilet. They asked if I was pregnant, I said, ‘Yes.’ I ended in the foreigner’s section (where she was slated to be released shortly).” But she explains why she returned to her original seat, “I couldn’t leave Olga.” Likewise the hostages report strong connections springing up between former strangers. These too were helpful to soothe emotions under duress. “At the first moment people were really hysterical and then that passed and people became very supportive to each other.” One woman gives an example, “A girl behind us had asthma or bronchitis. They gave her water. . . She gave the others water after drinking only a small amount. She said, ‘You didn’t drink all day and I have had water to drink, take it.’ These actions touched us and connected us to each other. Another hostage recalls, “We spoke with each other.” Reassuring one another, “There are too many people here for the government to forget about us. If they really wanted to shoot us they would have done it the first day.” Mobile telephones One aspect of this event that is unique from the many hostage-taking events preceding it is that the hostages had mobile phones that they were allowed to use to contact loved ones. Naturally the terrorists used these devices to their own advantage urging the hostages to call their governments, embassies and loved ones to create a furor over their captivity and to tell their loved ones to come out to Red Square in protest. Despite this most hostages report being able to call out of the theater as a very positive aspect as it allowed them to make use of their attachment relationships to calm themselves and often to calm their family members by at least telling them they were still alive. One mother recalls, “I really wanted to hear my child. At first my husband didn’t want to call them. Maybe they didn’t know we were in the theater.” A young woman calling home recalls that her mother was much more upset than she and that the phone calls were very useful to try to calm her mother and reassure her that at least for the present moment everything was okay.

Moments of Acute Terror One of the hostages recalls the siege this way, “I’ve been asked, ‘Was it terrifying or not?’ We couldn’t stand up, go freely to the toilet or get water, but you adapt.” In general most of the hostages found ways to self soothe and adapt to the stress of captivity although

146

A. Speckhard et al. / Stockholm Effects & Psychological Responses

there were moments of acute terror throughout the siege, particularly when anyone of the hostages lost control. According to the hostages the terrorists shot one of the hostages after she became hysterical, Then after the night, the next day, they were shooting in the night. They shot that girl practically in front of our eyes, not really in front of our eyes. They pushed her between the rows, and then shot, actually you could see it. You could understand it. Everyone could see very well from the corner of the second floor. . . .I remembered while they are taking the girl out she was screaming something, the girl’s behavior was not correct. There was a rumor that she was drunk. It seemed to me that she’s just hysterical, she was screaming, squealing really aggressively, and very aggressively expressing her anger. The Chechens told her to shut up and if she would cry it would be the end of it.

This hostage describes her dissociative self-numbing response to the event. I just remember her hysteria, they are taking her out, pushing her through the rows and right away you can hear the automatic firing there. Barking, barking the firing of the automatic guns. Fast, three or four times in a row. I remember that before this firing the last I remember is the voice saying, ‘Shoot her in the head.’ It’s clear and then the sound of the shooting and right away they shoot and I think I even saw the shadow of the body falling to the floor. Maybe it came to me afterwards, but this fact, can you imagine did not scare me at all. Maybe because I was in the balcony and everything that happened downstairs seemed unreal.

Another hostage recounts, “We often heard shooting in the corridor – maybe to scare us.” Among the hostages there was a lot of confusion about how many people were shot, probably due to the fact that most were resting on the floor where they could not see well and no one was allowed to stand up. One hostage recounts, “At 5 am the first day they shot a hysterical woman. At night they shot an old man who was trying to find his son. Later a man ran. . . they shot him. They wounded two persons.” The official figures are that five persons were shot by the terrorists. Throughout the siege the hostages explain, “We were afraid of death. The button and battery or the two wires (alluding to the strapped-on-bombs and wires rigged to the larger bombs placed about the theater).” Another hostage describes his terror from the suicidal nature of the hostage-taking mission, “On the third day they started putting iron connectors from the bombs so that they can detonate them from a distance. The psychological environment became so pressurized.” Another recounts, “When I understood that they are suicidal I understood they will die and we will die with them. They announced it, they said that we will all die together.” Another observes, “It was very clear that they were ready to die.” Shooting also erupted during the day as one hostage recalls, “Two women in the balcony went to the toilet and escaped out the window. The terrorists shot at their backs and legs.” Another recalls, “When they started to connect the bombs it was very difficult. From time to time there was shooting in the halls. We didn’t know if it was the storm (the takeover by special forces). The Chechens would go and check in the ventilator system with guns.” Another hostage speaks about the increasing terror that came with recognition of the reality of their situation, “When they connected the bombs, the whole period before there was the question of are they real or not? The guns I knew were real, as were the grenades, pistols, plastic explosives and the automatics – all were real. At that moment when they connected the bombs, I realized they are real.”

A. Speckhard et al. / Stockholm Effects & Psychological Responses

147

Building tension “Everyone, they and we felt something will happen on the third day. The storm maybe. . . There were people in the street? They started to put armchairs to cover the windows and moved all the (terrorist) men down in the front of the balcony section by us. When the men moved they kept chairs near them to lie behind. They began to shout. We laid down under our armchairs, there we felt more safe, that we won’t see reality.” By the third day one hostage recounts, “We were all afraid and tired! They were tired too and nerves frayed. They didn’t sleep and they must control our actions.” Calming & self protective strategies One hostage recounts how some people tried to make sure they would not go hungry while she thought it better to avoid the dangers of having to walk through the theater taking her children to the toilet, “Many of the people demanded for chocolate. I think that people felt it’s for a long time and wanted to have like the chipmunk some food saved up in his cheek to be fed later. You could see that, and you know that some people had during the break time, drank coffee or had food; I don’t think the most were so starving. But when food was brought into the balcony, a lot of people started to ask for me, for me, for me. I didn’t give it to my children, because if you eat chocolate it means thirst and drink means going to the toilet and going to the toilet is a whole adventure. I decided it’s better that they will be hungry. You cannot die from it, from not having food for a short time.” Another hostage describes clinging to the will to live during the moments of terror and fears of death in various times throughout the siege, “I was not terrified there. I knew things were out of my control, and what happens will happen. I had only one thought – to live.” Two physicians recount that being in charge of medicines allowed them to self regulate by medicating themselves. One recalls, “We took barbitol to sleep.” A man remembers, “I’ve been asked, ‘Was it terrifying or not?’ We couldn’t stand up, go freely to the toilet or get water, but you adapt.” The hostages stated that they expected a rescue attempt and were waiting for it, but only one hostage, of those we interviewed, had made any real preparations for it. I was trying not to sleep. I was expecting and waiting for the storm and I wanted to be ready. . . I knew there was no clear plan for how long they would hold us if their first goal cannot be reached and that they were ready to die. I was sure that the special services are working and the only possibility is a storm. That is why I made wet all my handkerchiefs – because they will use gas. . . . I was trying to find the most safe place to in the balcony. We were seated on the corridor but behind us were two women with explosives and a man with an automatic. Without the storm we were okay, but if there was a storm I knew we were in the most unsafe place. I asked them if we could move, saying that we were too cold. I didn’t sleep for twentyfour hours all three days, just daydreaming, but I did not sleep. I heard some shooting and a man went out. I smelled a sweet smell and then I gave a wet cloth to my wife to cover her mouth and nose. I put my wife to her knees and put our clothes over our heads. I covered us with our coats and the armchair cushions over us. According to my calculations the wet cloth became dry very fast. I made them wet again. It was 5:30 a.m. At 9:00 a.m. I became conscious again at the hospital.

148

A. Speckhard et al. / Stockholm Effects & Psychological Responses

Stockholm Syndrome The Stockholm Syndrome, first reported upon following a Stockholm bank robbery in which hostages were observed to have developed bonds of attachment to their captors seems to be an automatic, probably unconscious emotional response to the traumatic experience of being a victim (Ochberg & Soskis, 1980; Strentz, 1979). According to the syndrome, under a siege environment, hostage and hostage-taker alike become united in a positive emotional bond against outsiders, which may serve to save the life of victim and captor alike. It is anecdotally credited with enhancing the hostage’s ability to cope with captivity and minimizing the chances of violence directed at the hostage (Harnischmacher & Muther, 1987). The syndrome is believed to occur when hostage takers have refrained from overly abusive behaviors and have had ongoing personal contact with their hostages. Evidence for the syndrome consists largely of interview data from former hostages and observations of their behavior after being freed and as a theory it has never been tested in a naturalistic event. The positive bonds that arise during captivity are strong and appear to endure over time. Strentz (1979) for example writes that some victims felt such sympathy for their former captors that they visited them in jail. Eitinger & Weisaeth (1980) writes that when under the affective influence of the Stockholm syndrome “victims exhibit sympathy and positive bonding towards the captors while fear, distrust, and even hostility may be directed against the authorities negotiating for their lives.” The Stockholm effect was observed in this group of hostages despite their being held only seventy-two hours. That it occurred is indeed quite interesting given general negative Russian attitudes toward Chechens. One hostage observes, “When I came to (from the gas) I felt very sorry that they were all killed. The young one she never took a baby in her hands, ever.” Another expresses similar regret; “At first I was happy about the storm, at first. But there is a different face of the terrorist and the face of those soldiers (who stormed the theater). I like the face of the terrorist better. I think of it a lot, especially of the old, calm and kind terrorist (Aslan). . .” Another states, “I feel sorry for them (that they died).” Not all the hostages developed Stockholm effects. Despite successfully negotiating with the terrorists to change his seats and care for his wife, one hostage states that he felt no relationship with the terrorists. “I am not sorry that they died. If they were afraid of death then I am sorry, but they were not.” The Stockholm syndrome functions similar to defenses engendered by traumatic stress. Similar to peritraumatic dissociation, it appears to arise as an automatic, perhaps unconscious emotional response to the trauma of being held captive in a barricade environment where death appears as likely to come as a result of actions of outsiders, as from those actions of the captor. The attachments that arise in response to the terror of being held hostage are also similar to the traumatic attachments found in victims of domestic abuse who frequently cling to and attempt to protect their abusers from outside interventions. The “trauma bond” that occurs both in Stockholm Syndrome and in situations of domestic abuse is engendered from the hostage’s (or the abuse victim’s) assessment that the life threat as well as the potential for protection are for the time being under the nearly complete control of the captor (or abuser). Lassagne (2001) writes, that on a psychodynamic basis, the hostage goes through an experiment in which the possibility of death occurs with violence. To cope with this many hostages develop an unconscious

A. Speckhard et al. / Stockholm Effects & Psychological Responses

149

psychological strategy: to identify with the aggressor which can help them to cope with the distress of sitting silent; and being passive for long stretches of time; as well as the need to contain strong emotions of fear, anger, and sadness. Hence during captivity even the hostages’ thoughts can come under the influence of their captors. In this case the Chechen terrorists were quick to address the hysteria induced by the takeover by instructing the audience calmly, saying as reported by one hostage, “Don’t be afraid. You won’t be hurt if you follow all of our orders and will be quiet. We want only for the Russian military to go out of Chechnya.” At the same time they made clear that hysterical responses would not be tolerated as one hostage recalls, “The terrorists warned the crowd, ‘If you will be hysterical we will shoot you.’ So we tried very hard to support each other.” In the first hours the atmosphere of terror was replaced by relative calm as the terrorist began to create order among their captives and set up the necessities of support designating the opera pit as the toilet for those in the main hall, and setting out food and water to be dispensed to the hostages. One hostage recalls, “They tossed food to us like monkeys from time to time. Some couldn’t catch it. They behaved in a better way with children. They gave better cakes to the children.” Another recounts, “Aslan said that doctors can get up and go from person to person. There was a box of medicine. All the doctors could take medicines as needed.” Another recounts, People started to get used to the situation, were less afraid and relaxed somewhat. The terrorist didn’t allow them to totally relax, when there was some activity or talking or turning about, they interrupted it by shooting into the air. But the situation was more relaxed in itself and people started to talk with him. The first question was always, “Why did you come here?” and “How long are we going to be here?” a little bit hysterical questions. I had only one thought on my mind – that it’s forbidden to speak about this, forbidden, forbidden, forbidden to ask about these topics, we must speak about normal things that he can answer.

The hostages soon realized that their captors would provide their basic needs and were kind as long as everyone remained under their strict control. One hostage notes, “The relationship to the children, you understand, I liked that they didn’t treat them like everybody else. They treated them . . .(her voice fades away). And everybody else they treated normal. If you did everything they asked for they were decent to you.” As the hostages began to feel some connection with their captors they began to negotiate in behalf of the weaker hostages. “We were asking about pregnant women and children, to let them go out. They answered us that children already thirteen are soldiers.” “There was a pregnant woman there,” one gynecologist relates. She was in her twentyfourth week. She cried the whole time. The Chechens said, “It doesn’t show, we don’t let her go.” One hostage recalls, “The first woman who went to the terrorists was a teacher of a class of adolescents. She wanted to take the children out.” Normally Russians hold a dim outlook of Chechens, viewing them as uncivilized, uneducated and wild mountain people; but as their situation dictated relatedness the hostages began to drop their prejudices and search for commonalities between themselves and the terrorists. One hostage recalls, “I asked the Chechen woman, ‘Do you have children?”’ Another hostage recalls being surprised by the Chechen men after they removed their masks, “I was looking at him and seeing oh my God his face is gorgeous. If I would meet a man like this on the street, my eyes would stop on him. In truth those Caucaus guys usually have uncivilized, wild faces. But he did not. Some of them when

150

A. Speckhard et al. / Stockholm Effects & Psychological Responses

they started to take off their masks, I cannot say they looked not necessarily intelligent, but how to say it, they had a seal of civilization on their faces.” Another recalls, “Aslan was the Chechen in charge of our section. He had intelligent eyes. He talked fast in English on the phone, long distance.” Another recalls this leader as well, “We had Aslan in charge of our section. He was more calm for us. We were very afraid of those on the first floor, they gave us a real feeling of fear. When they took off their masks you could see that Aslan was very handsome. All the women noticed him. With him we felt secure.” Another recalls this leader as well saying, “Sometimes I felt that I can speak directly to Aslan and the others.” One hostage recalls how she began to relate to the two terrorists in her section, striking up a tentative attachment with the second terrorist. The second terrorist had a bandage on his hand and it was bleeding the whole time. He was bleeding from breaking the glass. When the action started the terrorists broke all the glass up above the balcony where the (theatrical) lights came from. There was a line of dark glass there that they broke so that they could shoot from there. He cut his hand. They asked for a doctor when he cut his hand and the doctor bandaged it. The second guy came up to sit by the first and I could see that his hand hurt. He was holding it and. . . sitting with closed eyes. He opened his eyes and he was looking in my direction and he said I’m sick. I told him, ‘You need to drink more water and eat chocolate.’ He asked ‘Why?’ I told him ‘Because you are losing alot of blood and you must drink more water to replenish your body.’ . . .He asked me, ‘Are you a doctor?’ I said, ‘No.’ But I told him I learned it. That was this kind of conversation. I tried to talk about something that he was interested in. Because conversation about what is happening now won’t result in any answer. I saw this with the first one. We talked from time to time, or looked at each other or exchanged some words. Sometimes he even tried to calm me. I even allowed myself a few times to ask him what will happen to the children, especially at night when they started to collect and move the children out of the theater hall below us. . . .‘Look they are taking out those teenagers – but when will our little lambs be taken out?’ He answered, ‘Wait, wait wait.’ (She relays his words in a tender voice speaking in the informal tense). When he said ‘wait wait wait’, I didn’t insist because I cannot. Later there were a few times, where I felt I am somehow special but not because I am so beautiful and intelligent and my children are so wonderful. I think it was because he was not really taking care of me but because he had somehow singled me out. When he went out from time to time he always returned and had a cookie for the children and hands it to my children. I hand it to somewhere else and he and asks “Why don’t you eat it?” I say “No, no.” He answers “Okay, it’s up to you.”

Relating to the terrorists was generally calming although the conversations inevitably touched on the suicidal nature of their mission stirring up anxiety for the hostages and challenging them with another worldview. One hostage recalls, My boyfriend and I hardly talked to each other. The young Chechens talked to us saying, ‘It will be okay.’ I talked quite a bit with one. A Muslim woman in the audience, Fatima and I talked with him quite a lot. He was religious. We together talked to this boy. He had a very nice face, but he didn’t formulate his thoughts well. He had a different mentality – he was not educated. He went only to a few grades of school, but he dreamed of graduating from the institute. He told us, ‘The most important thing for me is to die a martyr.’ He said, ‘I feel myself a martyr.’ I saw that it was important for him to die this way, to die for ideas, but at the same time he could not formulate his ideas well. He didn’t want to change, for him it was like an instinct. He seemed almost like an animal – without civilization. But we felt terror only at first. Possibly all the time he sat nearby.

A. Speckhard et al. / Stockholm Effects & Psychological Responses

151

As the siege wore on one hostage recalls that the terrorists called them to retrieve their coats from the coat check in order to sleep more comfortably and when doing so fed them from the buffet nearby. Another recalls the barriers falling between hostages and the terrorists, “On the second day, they took their masks off. One Chechen sat on a stool by the bar. . . his face was typical (for a Russian) – round. You had to ask him to go to the toilet. He had cigarettes from the bar and invited whoever needed to smoke. I was not afraid of him at all. One woman got a bottle of whiskey from the bar. She began to drink. It’s a big sin for them to smoke and drink. He told her, ‘No don’t, it’s a sin!’ But she did.” By the third day one hostage recounts, “We were all afraid and tired! They were tired too and nerves frayed. They didn’t sleep and they must control our actions.” Another recalls, “For the first day the Chechen near us held her gun ready, then after a few days they were in the same condition as us – lazy.” As the barriers fell between them the hostages remained terrified of their situation, but became less afraid of the terrorists, “I was afraid of them at first but later no.” The hostages understood that they must be careful as one hostage notes, “I knew I must not get nervous and that we must not argue with them, then they can become nervous too.” Overtime the hostages began to make positive attributions to the terrorists such as, “I realized after that they had a habit. If they got a direct order to bomb us, otherwise no, they won’t willfully hurt us.” Another states that she realized, “If they really wanted to shoot us they would have done it the first day.” Another recalls, “I didn’t hate them.” At first the hostages were afraid to respond positively to their captors, “Only one woman answered to being a doctor in the beginning.” The terrorists used this doctor, a surgeon and later others who identified themselves to care for the medical needs of the audience. She “was free to pass to everyone.” Likewise the boundaries between captive and captor became blurred as the captors too began to show signs of distress and also needed medical care. “One Chechen was wounded and this doctor treated his hand.” One hostage recalls how in speaking to the Chechens their common plight was pointed out vis a vis the Russian government, “We were speaking with one of the Chechens saying we can understand their position and their pain, that their children are in war, but at the same time we said these methods are not good to solve war. The Chechen told us the that our government feels nothing for us and doesn’t care to save us.” Another hostage recalls that the terrorists even began to say hopeful things about future relations such as, “They told us about beautiful things in their country and that we can go to each other like guests.” The fact that the terrorists did take care for the hostages created a potential chink in their armor as one hostage noted when a Moscow doctor was allowed into the theater to access the medical needs of the hostages and to return with medicines. “He didn’t take any pills or medicines at first. I know that he was counting people and where the bombs were located. Two times he came to the theater. Many people had problems with their stomachs, kidneys and without eating. Many asked for activated charcoal but he didn’t even hear what he was being told. He was more interested in who is where and the locations of the bombs.” Some researchers have suggested, based on case studies, that in preparing their populations for these types of terrorist events, authorities should encourage the formation of the Stockholm syndrome to assist in safeguarding the lives of hostages (Turco, 1987). While this suggestion may be worthwhile no one has empirically tested it in a real setting nor is much known about long-term effects. Afterward for instance, this strategy

152

A. Speckhard et al. / Stockholm Effects & Psychological Responses

and the paradoxical friendliness the ex-hostage felt toward his kidnappers – which may have contributed to his survival – may be retrospectively reassessed as negative, causing psychological distress. Passivity, silence, containing emotions, failing to act protectively or pro-actively can have different meanings depending upon the person’s gender, life circumstances, responsibilities and life history. For instance men, especially those in military service may later reassess their passive hostage behaviors as unmanly, cowardly, unprotective, disloyal, or find that others do so. Indeed, in December 2002 shortly after the event, a former member of the KGB stated to the interviewers that he found it unbelievable that military service men had sat passively and done nothing to try to fight with the terrorists. He described this as their greatest shame. Despite the increasing timeliness and importance of these questions of how hostages cope and how they relate to their captors and how these variables impact their longterm adjustments, little empirical research has focused on how subjective appraisals of the other persons who are part of a threatening environment influence one’s ability to cope with that environment, and how use of the Stockholm Syndrome as a means of coping, may relate to long-term psychological outcomes. The only study that has tested the Stockholm syndrome’s protective effect on hostages during a terrorist event is an empirical test of a simulation of captivity (Auerbach, Kiesler, Strentz, Schmidt & Serio, 1994), albeit a highly realistic and stressful simulation. In this research the investigators used FBI agents as “terrorists” and airline employees as hostages to simulate an event in which hostages were taken captive under highly stressful circumstances for four days. In the simulation the hostage were not allowed to communicate with each other and had pillowcases continuously placed over their faces. Each day they were observed and taken out of the situation for a brief interview in which the degree to which they had oriented to their captors was assessed. In the simulation it was found that hostage adjustment and emotional distress levels were consistent with the theoretical aspects of Stockholm syndrome showing that the relatedness was two-sided as well. Hostages who found captivity most aversive and who adjusted poorest to captivity were those who perceived the terrorist as most dominant and least friendly (and who were perceived as least friendly by the terrorist). Whereas those who perceived the terrorist as less dominant and more friendly adjusted better. These who adjusted best tended to show the closest complimentary match to the terrorist interpersonal behavior – that is the hostages were submissive in reaction to the dominant presentation of the terrorists, and developed a friendly stance toward their captors. The researchers were also able to test if prior training in a randomly controlled trial would enhance Stockholm effects and adjustment in the simulated setting. These findings were also positive. Training that emphasized the use of avoidant coping strategies and that legitimized the submissive position of the hostage, versus training that emphasized active problem solving, and that implicitly fostered defiance, had more positive results. Hence the researchers concluded that adapting a stance in which hostages either attends carefully to the behavior of the terrorist and modulates their behavior accordingly (which could be attributed to Stockholm Syndrome effects), or detaches from the controlling person, while focusing on feelings inconsistent with stress, are most protective (Auerbach et al., 1994). In a naturalistic setting this latter strategy could be a consciously initiated defense, to remain passive, or also be unconsciously initiated, as in a dissociative defense.

A. Speckhard et al. / Stockholm Effects & Psychological Responses

153

Advice of the Hostages When asked what advice they would offer to hostages held in situations similar to what they face the hostages were generally without a response, throwing their hands up in the air or shaking their heads. One hostage answered, “I cannot advise others, each person is different. I am against terrorism.” A physician answered, “Psychologically it might be good to see scary and violent films because in them you will see models of good behavior, good responses to violence and they all have good ends. It can prepare you.” Two others cited the fact that people somehow manage to adapt to stressful situations including captivity stress, the first saying, “My experience is that in every situation a person can adapt.” The second recounts, “It’s amazing how people can get used to the situation, like they got used to this situation. People can live in every situation, even this, they adapt.”

After-the-Event Responses After-the-event responses can only be noted in brief here and are examined more deeply in another paper (Speckhard, Tarabrina, Krasnov & Mufel). All of the hostages that we interviewed had posttraumatic responses to their ordeal after it was over and most were still struggling with symptoms of acute or posttraumatic stress disorder (PTSD). Some had sought psychotherapy and others sought support from family members. All of them had begun to isolate themselves from prying journalists and voyeuristic acquaintances to avoid triggering painful memories and feeling like an object of other’s curiosity. Grief, shock and anger were also after-the-event responses. The hostages felt grief and guilt for having survived when so many all around them had died, even feeling grief over the death of the terrorists. The hostages remarked that it seemed strange to say they felt grief for the terrorists but most expressed regrets that they had been killed. Anger and shock were common responses to how the Russian government had handled the crisis. While they were grateful for the rescue they generally had concerns about the lack of care shown in refusing information to the hospitals about the gas and not having ambulances and medical personnel ready to take the hostages to hospital after the storming of the theater. While Russians are used to decades long tradition of their government placing little value on individual life, many still felt deep shock at how the hostages had been removed from the theater and treated. This upset their world assumptions, as did becoming a hostage in the middle of Moscow – a city felt by most to be relatively safe up till then.

Summary Faced with suicidal terrorists in a captivity situation a hostage must decide how to respond. Clearly these terrorists were willing to sacrifice their lives for the principal they were fighting for and this creates a dilemma for the hostage. Is it better to be passive and cooperate with suicidal terrorists knowing they are ready and willing to die for their cause, or to try to find ways to resist? In this case the terrorists controlled nearly every aspect of the hostages lives and those who resisted did so at grave danger to themselves.

154

A. Speckhard et al. / Stockholm Effects & Psychological Responses

One hysterical woman was shot when she refused to calm herself, and two girls who escaped out of the bathroom window were shot at as they ran to safety. Men who stood up and resisted the takeover in the first moments – in this case from disbelief – were beaten into submission. In the 9–11 plane crashes the passengers were hostages for a very short time until the planes were crashed into preplanned terrorist targets. In three planes passengers were passive going to their deaths as well as the destruction of others. In the one plane in which the hostages resisted they also died, but the plane crashed before it reached its target preventing the deaths of others. In this standoff it was clear that hostages who interacted positively with the terrorists gained negotiating power for many small concessions and even some larger ones – including release in the case of one mother with her children. Unfortunately suicidal terrorism is on the rise the world over: witness events in Russia, Israel, Iraq, Pakistan, Turkey and so on. Hostage taking events by suicidal terrorists are likely events in the future and those who are in risk-taking positions must be prepared. How best to prepare for this type of terrorism is a complex question. The research simulation demonstrating that passive cooperation and Stockholm effects are protective is likely an accurate assessment. In advising an individual on how best to behave as a hostage it seems wise to teach that positive attachments and passivity are likely to arise in this terrifying state of captivity and that if one can recognize this reaction when it is occurring and keep it within control it is likely most protective. An individual that can act the part of a cooperative and friendly hostage while keeping some level of objective detachment – while searching for safe ways to communicate meaningfully to the outside, to safely escape, and to prepare oneself for the inevitable attempts of rescue or release – gains the most negotiating power without sacrificing objectivity. Certainly in this case it appears that the Stockholm effects were not harmful and even protective to a degree for the hostages. As far as treatment for hostages goes it is important for clinicians to realize that hostages often bond to their captors and feel conflicting feelings of grief over their demise, and guilt for having bonded to them. If one understands that Stockholm effects are common in hostages then clinical interventions can take this into account, educating the hostage about his unconscious attempts to protect himself by creating a “trauma bond” with his captor and helping the hostage to release himself from guilt and confused feelings over having done so. Likewise hostages, like other trauma survivors, often feel deep feelings of guilt over having survived when others have not and men especially, although women as well, felt guilt over having failed to act. In this case the woman in charge of so many children felt that she had failed the children she was unable to remove from the theater and felt deeply guilty for abandoning some of them. Likewise another hostage felt deep alienation from others, especially when she learned some acquaintances did not believe she had even been in the theater. All of the hostages also needed help protecting themselves from intrusive press coverage and the gratuitous curiosity of acquaintances that often just stirred up traumatic recall. In general a supportive cognitive therapy model that assists the hostage in working through whatever aspects of acute and posttraumatic stress they may have and the specific issues of having been a hostage is what is often needed.

A. Speckhard et al. / Stockholm Effects & Psychological Responses

155

Sadly as current events in Iraq make clear, these types of terrorist events are likely to be with us in coming years and as suicidal terrorism elevates the level of terror involved for the hostages this is a phenomena that we would do well to study further.

References Auerbach SM., Kiesler DJ, Strentz T, Schmidt JA, et al. The Hostage Crisis Simulation. Journal of Social & Clinical Psychology 1994; 13 (2): 207–221. Bower B. Consequences of captivity. Science News 1981; 119 (12): 188–191 (March 21). Corrado RR, Tompkins E. A comparative model of the psychological effects on the victims of state and antistate terrorism. International Journal of Law and Psychiatry 1989; 12 (4): 281–293. Eitinger L, Weisaeth L. Stockholm-syndromet (translated – The Stockholm syndrome). Tidsskrift for den Norske Laegeforening 1980; 100 (5): 307–309. Harnischmacher R, Muther J. Das Stockholm-Syndrom: zur psychischen Reaktion von Geiseln und Geiselnehmern (Translated as – The Stockholm syndrome: on the psychological reaction of hostages and hostage-takers). Archive für Kriminologie 1987; 180 (1–2): July–August, 1–12. Lassagne M. Le syndrome de Stockholm: une influence sur le debriefing (translated – The Stockholm syndrome: the influence it has on the psychological debriefing). Revue Francophone du Stress et du Trauma 2001; 1 (2): February, 83–90. Ochberg FM, Soskis DA (eds.). Victims of terrorism in Ochberg, Frank M, Soskis DA (eds.). Victims of terrorism. Boulder, Colorado: Westview Press, 1980, pp. 137–148. Rahe RH, Genender E. Adaptation to and recovery from captivity stress. Military Medicine 1983; 148 (7): July, 577–585. Simon RI, Blum RA. After the terrorist incident: psychotherapeutic treatment of former hostages. American Journal of Psychotherapy 1987; 41 (2): April, 194–200. Speckhard A, Tarabrina N, Krasnov V, Akhmedova K. Observations of suicidal terrorists in action: The psychology of suicidal terrorism. Journal of Terrorism and Political Violence, 2004, accepted. Speckhard A, Tarabrina N, Krasnov V, Mufel N. Posttraumatic and acute stress responses in hostages held by suicidal terrorists in the takeover of a Moscow theater. Journal of Traumatolgy, 2004, submitted. Strentz T. The Stockholm Syndrome: Law enforcement policy and ego defenses of the hostage. Annals of the New York Academy of Sciences 1979; 347: 137–150. Turco RM. Psychiatric contributions to the understanding of international terrorism. International Journal of Offender Therapy & Comparative Criminology 1987; 31 (2): 153–161.

This page intentionally left blank

THE AFTERMATH

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

159

Tracking the Social Dynamics of Responses to Terrorism: Language, Behavior, and the Internet James W. Pennebaker and Cindy K. Chung The University of Texas at Austin Abstract. The Social Stage Model of Disasters is examined as a parallel to natural responses to terrorism. After a shared upheaval, people tend to go through an emergency phase when they talk about the event, followed by a drop in talking during a longer inhibition phase. Thoughts of the event still weigh heavily on people’s minds until the adaptation phase when social and physiological patterns stabilize. New methodological and analytical tools have enabled the study of immediate reactions to natural disasters, collective trauma, and terrorist attacks. These include the Electronically-Activated Recorder (EAR), which captures how people congregate and talk to or avoid others. Also, Linguistic Inquiry and Word Count (LIWC), a software program that analyzes psychological states through linguistic markers, has been applied to language samples from various internet forums for communication before, during, and after shared upheavals. A review of the research using these recent technological developments suggests that terrorism can have the unintended effects of encouraging affiliation, strengthening values, and reaffirming identities. The findings further suggest that distancing, a natural phase in the course of crises and challenges, may be helpful when faced with terrorism. The Internet will continue to be a valuable venue for both victims and researchers.

On September 11, 2001, almost 3,000 people were killed in a series of suicide attacks in the United States. In over three years since that day, only a handful of Americans have died in terrorist attacks in the United States, while tens of thousands of Americans have died from murder, suicide, and a host of preventable diseases. Nevertheless, the fear of future terrorist attacks continues to plague the media and the minds of Americans. It has changed the country – economically, politically, and socially, in ways that no other groups of illness or deaths have. Beyond any immediate physical damage, threats of terrorism instill a lingering sense of fear and anxiety which can have insidious effects on human behavior. As social scientists, we need to explore the natural unfolding of events that are associated with fear, loss of life, and terrorism. Our first line of defense in overcoming terrorism is to understand its psychological mechanisms, along with adaptive responses to it.

1. Social and Behavioral Effects of Fear and Anxiety Fear and anxiety are common emotions among most vertebrates in response to threat. It is beyond the scope of this chapter to outline the biological changes that occur in the brain and body during and following the arousal of extreme fear [1,2]. Concurrent

160

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

with biological upheavals, most social organisms also change in their social behaviors during fear arousal. For example, one of the most common behavioral changes seen in nonhuman primates in response to fearful stimuli is increased contact with family members through touching or grooming [3,4]. Fear can serve to teach younger animals how to respond to fearful stimuli through affiliation. At times, it can also serve to inhibit social exploration and sexual behavior [5]. Events that provoke fear and anxiety in the non-human animal kingdom are generally short-lived. The predator either eats the prey or goes away hungry. The lightening storm that produced the clap of thunder that frightens dissipates. Perhaps through some basic mechanisms of classical conditioning, the animals will more readily experience fear in the future when similar conditions arise. Otherwise, however, longterm anxiety or stress is not the norm for most animals. Humans are another story. We have the unique ability to learn about a fear-related object or event, mull it over, and live with it for days, weeks, or years. Research on fear and anxiety in humans has been conducted primarily in highly controlled laboratory studies. In some of the classical studies in social psychology, for example, people who fear they will receive a painful shock opt to wait with others as opposed to alone [6]. Other work suggests that people who become highly anxious are more compliant with attitudinal messages [7], more uncritically accepting of information [8], and poorer information processors in general [9]. Laboratory studies on fear and anxiety provide only a hint of what might happen to people in the real world who collectively must cope with a terrorist threat. There have, of course, been several studies that have described people’s reactions in the aftermath of highly threatening events. Baum and his colleagues have evaluated the psychological consequences of technological catastrophes, including toxic waste spills and nuclear accidents (e.g. [10,11]). Most studies have relied exclusively on self-reports, tests of cognitive performance, or interviews several weeks or months after the event; virtually none have focused on terrorism. What happens to groups of people when faced with unpredictable upheavals? Acts of terrorism, natural disasters, and man-made upheavals all have the potential to instill long-lasting fear and to change the ways people think, feel, and behave. Particularly interesting are the questions concerning the social dynamics of upheavals. For example, in the wake of a novel life-threatening event, how do people talk with one another, where do they go, what do they do, and how do they make decisions? Further, how do these processes change over time – from the first hours after the event to the next days and months? These questions have been at the heart of our research for the last two decades. Our findings are based on multiple methodologies including surveys, monitoring of natural behaviors, archive analyses of health and crime data, and linguistic analyses of Internet usage. Because of our interest in both individual and collective traumas, we have studied natural disasters (Mount St. Helen’s Volcano eruption in 1981; Loma Prieta Earthquake in the San Francisco area in 1989), public human tragedies (death of Princess Diana in 1997; Texas A&M Bonfire tragedy where 12 students died during the building of the annual bonfire in 1999), and the general population’s responses to war (Persian Gulf War in 1991; September 11, 2001 attacks). In all cases, this research has focused on people who may have been emotionally touched by the events but not directly victimized. Our

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

161

interests, then, have been on how the average person reacts on learning of a profoundly upsetting event. The purpose of this chapter is to summarize the results of these projects and to generalize to possible scenarios of terrorism in the future. Although we have not studied bioterrorism directly, any research on the social dynamics of terror can be potentially valuable in the creation of contagion and information dispersal models.

2. Social Stages of Disasters: An Overview Perhaps the most frustrating aspect of studying disasters is their unpredictability and inherent chaos. Unlike most other research topics, the conventional scientific niceties such as experimental control, random selection of participants, pre-measures, approval to conduct research from ethics committees, and even the ability to select the location for research are simply not available. Consequently, most solid large-scale studies of disasters generally begin several weeks or months after they have occurred. The problem is that the ways people think about and deal with an upheaval unfold over time. Across several studies, we have been able to detect important social changes in the aftermath of an upheaval. Using weekly random digit dialing telephone surveys with hundreds of people following the Loma Prieta Earthquake and the beginning of the Persian Gulf War, we discovered three identifiable shifts that occurred. During the first 2– 3 weeks after the events, people reported talking, hearing about, and thinking about the events at very high rates. However, for both the earthquake and the outbreak of war, there was a dramatic drop in talking about the event starting about three weeks after their occurrence. Although their talking rates dropped considerably, they continued to think about the events at very high rates. In both cases, it took at least 8 weeks after the events until people reported not thinking or talking about them [12]. As depicted in Fig. 1, the first stage, referred to as the “emergency phase,” is characterized by high rates of thinking and talking about the upheaval. During this time, people’s physical health is surprisingly good, and self-reports of hostility and aggression towards family and coworkers are low. However, during the subsequent inhibition

Figure 1. Rates of thought and talking following upheaval.

162

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

stage when talking rates are low but thinking rates are high, a number of interesting phenomena emerge. During this period, people report heightened rates of physical symptoms, more nightmares about the upheavals, and higher rates of fights with friends and coworkers. Indeed, analyses of aggravated assault rates in the San Francisco area in the years surrounding the earthquake revealed that assaults increased starting 2 weeks after the earthquake and continued at this elevated rate for about a month in comparison with the year before the earthquake [13]. We have speculated that these effects occur because individuals are still concerned about the upheavals, but are likely to misattribute this diffuse anxiety to other sources (e.g. [14]). Finally, by the adaptation phase, people are no longer talking or thinking about the event, and markers of distress return to baseline. Why do these social stages occur? In the earthquake project, we asked people how much they would like to tell others about what happened to them during the earthquake and also asked them how much they would like to hear other people’s earthquake stories. Across all time periods, people said they would enjoy telling others about their own stories. However, beginning about three weeks after the earthquake – coinciding with the inhibition stage – people reported that they did not want to hear other people’s stories. In fact, about a month after the earthquake, t-shirts began appearing in San Francisco that proclaimed, “Thank you for not sharing your earthquake experience.” The inhibition phase may well be a subtle social defense that members of the society all erect about the same time. Hearing other people’s upsetting experiences is itself distressing. To avoid unneeded reminders of the earthquake, everyone tacitly agrees to stop talking. In the years since the development of our social stage model, two shortcomings have become apparent. First, the time estimates of the various stages clearly vary as a function of the upheaval. For the death of Princess Diana among people in the United States, analyses of online discussions of her death dropped to very low rates by approximately a week afterwards [15]. The events of September 11 (9/11) suggested a much longer time span in the ways people talked about the event [16]. Taken together, it appears that the more powerful the personal and cultural impact, the longer the emergency phase appears to last. A second shortcoming of the social stage model is that it fails to address the social dynamics in the first hours or days after a disaster occurs. The initial model was based on weekly assessments of people’s reactions to an event. Only recently have we been able to evaluate psychological changes in a more fine-grained way using the day-by-day web postings of individuals. As will be described below, large-scale changes in emotional expression, self-focus, and collective focus occur during the first few days after an upheaval – many of which return to baseline by the end of the first week. In short, future social stage models must focus on the immediate reactions of people after an event.

3. Immediate Reactions: Hours, Days, and Weeks after a Disaster In many ways, the 9/11 attacks coincided with a number of technological developments that have allowed us to look at upheavals with new sets of eyes. One system that we were testing before and during the months preceding 9/11 was a digital tape recorder that periodically captured people’s auditory worlds several times a day. Coincidentally, we had started a study the day before the attacks and were able to track a small group of individuals as 9/11 unfolded. A second methodology we had been working on for several

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

163

years was a computerized text analysis program that allows investigators to quickly and efficiently analyze large corpora of text files. In the months after 9/11, we were able to obtain a massive data set of over 1,000 people who were high users of online diaries. By analyzing their writings before and after 9/11, we monitored how a broad sample of people were thinking and writing on a daily basis. 3.1. Tracking real world behaviors: the EAR In the late 1990s, we developed a specially-engineered digital voice recorder that was designed to record for 30 seconds once every 12–13 minutes. The Electronically-Activated Recorder, or EAR, was created so that we could capture snippets of people’s everyday lives in as unobtrusive ways as possible over several days [17]. In early September, 2001, two EAR projects were underway. One was a personality study wherein we asked people to wear the EAR for two days so that we could see how their social behaviors and natural language were correlated with self-reports (e.g. [18]). A second project, begun on September 10, involved a group of 5 participants who were to wear the EAR and an ambulatory blood pressure monitor for 48 hours. On the morning of September 11, they were to report to the laboratory where they would write about emotional upheavals. In Austin, Texas, where the study was being conducted, the first 9/11 attacks were announced around 8:00 AM. The first World Trade Center building collapsed a little after 9:00 AM, just about the time participants arrived at the lab. Rather than have them write about previous traumatic experiences, we asked all participants to go about their daily lives and to continue wearing the EAR for the next 10 days and blood pressure machines for the next 24 hours. An additional 6 participants who had worn the EAR earlier in the month were recruited to also wear the EAR for the next 10 days. Overall, then, 11 individuals wore the EAR 24 hours per day for 1–2 days prior to 9/11 and for 10 days thereafter. The participants were either current or recentlygraduated students with a mean age of 20. Seven were female and four were born in countries outside the United States [19]. Analyses of the EAR data indicated that in the days after 9/11, people changed in their patterns of social interactions. Overall, there was a reduction in the amount of time that people spent in groups of three or more whereas a corresponding increase in dyadic interactions occurred. In other words, in the 5–6 days after the attacks, people spent more time at home with one other person rather than congregating in large or moderate-sized groups. Interestingly, the more that people deviated from this social profile, the less welladjusted they appeared to be two weeks later. These statistical patterns matched our field observations as well. In the two days after 9/11, we periodically walked along a set path around the university campus with a tape recorder to capture ongoing social interactions. In the first 3 hours after the Tuesday morning attacks, students were congregating in large groups with a high degree of nervous laughing. By four hours after the attacks, the campus was almost deserted. Although classes continued to be held throughout the week, attendance was down and students did not mass in the typical indoor (cafeterias) or outdoor (patios) locations. The following weekend, movie theaters were virtually empty, restaurants deserted, and public parks devoid of people. There is every reason to think that the social patterns in Austin – a city of almost one million people – were similar to cities elsewhere in the United States. Modern-day urban

164

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

humans, it seems, evidence a distinctive social process in the face of a large-scale ambiguous threat. Rather than congregating in large social groups during periods of threat, we seek the quiet refuge of family and very close friends. This social patterning may be good news for bioterrorism experts. Should an infectious toxin be released and its effects made known quickly, individuals appear to naturally move into smaller units that are in contact via phone and computer rather than in person. 3.2. Tracking thoughts and feelings over the internet Beginning in the mid-1980s, we began studying how people deal with personal upheavals in their lives. Early findings suggested that those people who have had a traumatic experience were much more likely to suffer subsequent health problems if they kept the trauma secret than if they could openly talk about it to others (e.g. [20]). Part of this research asked participants to either write about their traumas or, for those assigned to a control condition, to write about superficial topics for 3–4 days, 15–20 minutes per day. Multiple studies eventually found that writing about traumatic experiences was associated with improvements in physical and mental health over the next several months (e.g. [21,22]). By the early 1990s, a number of research teams began exploring why expressive writing was effective. One strategy to answer this question was to analyze people’s writing samples – a surprisingly complicated undertaking. To simplify this task, we developed a computerized text analysis program that simply counted the number of different types of words in any text file – emotion words, cognitive words, pronouns, etc. The computer program, Linguistic Inquiry and Word Count, or LIWC, calculates the percentage of words in each of 72 different categories [23]. In the years since LIWC was first developed, we have found compelling evidence to suggest that the ways people use words in daily conversation and writing can provide rich insights into their thoughts and feelings [24]. The LIWC methodology is ideally suited to the analysis of large groups of text files. With the rapid development of the Internet, finding text samples to address psychologically important questions has been made considerably easier. In various ways, millions of people around the world are constantly posting their personal stories and observations on the web. Some electronic strategies include standard emails or list-serves that go to selected friends of the writer. Other strategies are more dynamic wherein individuals enter a “chat room” where individuals “talk” to one another in real time communications that all members of the chat room can read. Another popular forum is the use of weblogs or “blogs” where people post their personal diaries for the world to read. By collecting this public information, we have begun to track how people are thinking and communicating with others before, during, and following an upheaval. Our most promising approach to date has been to analyze a select group of people who post their daily diaries on the website www.livejournal.com. LiveJournal has over 5 million members who post at the rate of 2300 posts per hour. In their blogs, people write about all aspects of their lives from experiences at work, to love concerns, to lists of favorite songs or things they have just bought at the grocery store. Several months after 9/11, we worked with LiveJournal to download the blogs of high users who posted blogs in the two months before 9/11, and who posted at least 14 out of a possible 17 time frames in the two months after 9/11. The sample was restricted to self-identified U.S.

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

165

Figure 2. Positive and negative emotion word use before, during, and after 9/11.

citizens over the age of 18 with equal numbers of males and females and stratified by age groups. The final sample included 1,084 participants who posted a total of 71,800 blogs between July 11 and November 11, 2001. The beauty of a sample such as this is that we were able to track people’s natural blogs on a day-by-day basis following 9/11 and compare their postings from before the attacks. The results have been striking along several dimensions. In terms of simple volume of writing, individuals drastically increased the number of words that they wrote for each post. Prior to 9/11, for example, the average post was 348 words. In the week after 9/11, the average post increased to 390 words. In wasn’t until late October that words per post returned to baseline. Interestingly, this increase in writing volume was not just writing about terrorism. Even those who wrote virtually nothing about the attacks increased in their writing rate. More striking, however, were the changes in how people expressed themselves. Ironically, very few emotion researchers have ever been able to measure how long emotions last – especially real world emotions. By calculating the percentage of positive and negative emotions used by participants, we see that the 9/11 attacks provoked large increases in negative emotions and a suppression of positive emotions in daily blogs. More impressive is how short-lived these effects were. As depicted in Fig. 2, negative emotion words increased from a base rate of 2.1 percent of total words to 3.2 percent in the two days after 9/11 but then returned to 2.2 percent by 9/15, and back to baseline in less than a week. Positive emotion words paint a more intriguing picture. They dropped from a baseline rate of 2.6 percent to 2.1 percent on 9/11 and returned to baseline on 9/15. By September 18 – one week after the attacks – positive emotion word use was slightly (but significantly) higher than baseline for the remainder of the study. What accounts for this peculiar positive emotion shift? The analysis of pronouns adds another piece of the puzzle. Across multiple studies, we have discovered that the use of first person singular pronouns – especially the word “I” – is associated with self-focus, depression, low self-esteem, and low dominance [24–26]. Use of first person plural (we, us, our), on the other hand, serves multiple purposes. It often signals group solidarity (“we love one another”) and can also reflect emotional detachment (“we need to take out the trash” (translation: you need to take out the trash)). It is not uncommon for people to switch from the detached “we” to the personal “we” during emotional upheavals [27].

166

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

The LiveJournal sample evidenced a large drop in “I” usage – from 7 percent of all words at baseline to 5.9 percent for 3 days immediately after the attacks. Interestingly, “I” continued to be suppressed for the next two months of data collection averaging 6.6 percent the entire month of October and early November. Corresponding with drops in “I”, there was a significant increase in “we” usage. In the months before 9/11, mean “we” usage was 0.63 percent of all words. Between 9/11 and 9/14 this rate increased to 1.05 percent. Indeed, the rate of 1st person plural remained elevated above baseline until midOctober. Interestingly, this elevated use of “we” words was not reflecting nationalistic fervor. Rather, people were talking about “my boyfriend and me” or “our family.” In short, a personalized “we” rather than a detached one. Taken together, the pronoun data suggest that people became less self-absorbed after the 9/11 attacks and focused more on other people. Implications for mental and physical health are discussed in the next section. A third linguistic finding deserves mention. Certain types of cognitive words have been found to be related to higher level cognitive processing. For example, exclusive prepositions and conjunctions (except, without, but, exclude) are used at higher rates among people who are attempting to make distinctions between categories and ideas. We have found these words to be related to honesty, better grades on exams, and more cognitively complex ideas. Similarly, the use of certain types of cognitive words associated with thinking (sometimes referred to as ontological verbs: think, believe, wonder, know) have been linked to better health outcomes among people writing about emotional upheavals [28]. Analysis of exclusive words and other cognitive words evidenced an important pattern: immediately after 9/11, people drastically increased in cognitive word usage for about a week. Soon thereafter, cognitive word usage dropped below baseline, and continued to drop for the remainder of the study in early November. The longterm drop in cognitive word usage suggests a certain passivity or reduction in critical thinking skills in the wake of a disaster. These findings are reminiscent of the lab studies by Glass and Singer [29] on psychic cost. In their studies, people were exposed to bursts of loud, unpredictable noise while working on tasks. Surprisingly, performance during the noise was not affected; however, after the noise stopped, people’s subsequent task performance greatly diminished. Later studies with children living next to expressway traffic showed the same aftereffects of unpredictable and uncontrollable stressors [30].

4. The Terrorism Paradox: When Good Things Come from Horrible Experiences The events of 9/11, the death of young students, and the effects of large scale natural disasters all extract an unforgiving human toll. In addition to the pain of the immediate survivors, these events arouse feelings of anxiety, fear, and of terror among the populace. Despite these powerful effects, a recurring series of positive effects have been emerging in our studies and others. The linguistic analyses of 9/11 suggest that people felt more positive and were more psychologically connected with others in the weeks and months after the attacks compared with before the attacks. Similarly, the EAR data showed an increase in dyadic interactions with others. Even the earthquake and Gulf War study found drops in aggravated assaults in the first weeks after the events (although these rates increased to above

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

167

baseline levels about a month afterwards). Markers of mental and physical health show similar benefits. In the 6 months after the Texas A&M Bonfire tragedy, the A&M students visited the student health center for illness 40% less than they had a year before – whereas these numbers remained unchanged at its sister school, the University of Texas at Austin some 150 km away [31]. Note that there were similar reports of drops in suicide rates among Londoners during the Nazi blitz [32]. Terrorism has the unintended effect of bringing people together, making us feel more connected and appreciated. This is not a new idea, of course. Ernest Becker [33] argued that thoughts of death caused people to embrace their cultural values. Dozens of studies by Pyszczynski, Solomon, and Greenberg [34] have found that reminders of death cause people to believe more firmly in the principals that guide their lives. Oftentimes these principals include deeper beliefs in the correctness of their religion and their nation. How can we reconcile the well-publicized findings of the high rates of anxiety, physical symptoms, and symptoms of Post-Traumatic Stress Disorder (PTSD) in the general population after 9/11 (e.g. [35,36]) with these puzzling positive effects? The reality is that most people felt both anxious and socially integrated – both bad and good. Largescale surveys placed a frame on people’s lives to focus on the negative side of the 9/11 attacks. When any of us are asked about our reactions to a tragedy, the question automatically triggers tragedy-related schemas – thoughts of sadness, pain, loss. For most of us, the thought that a horrible event could be associated with love and meaning is disrepectful and downright inappropriate. This is where measures such as the EAR and online text analysis strategies can provide a more “frame-free” assessment of people’s lives. Note that we are not arguing that a cultural disaster is not like a dark storm; rather we argue that there are many silver linings. Indeed, these silver linings should be integrated into our thinking about and approaches to coping with terrorism and other disasters in the future.

5. Psychological Distancing and Implications for Interventions Across multiple studies, it is clear that most people who deal with traumatic experiences ultimately cope quite well. Those who are most adversely affected by upheavals are the very people who were coping most poorly with life prior to the upheavals [37]. The linguistic analyses surrounding 9/11 and other cultural upheavals undoubtedly reflect the ways that healthy people deal with disasters. When the upsetting events occurred, most adopted a coping strategy characterized by psychological distancing. That is, they dropped in their use of first person singular pronouns, they started using bigger words, and were more concrete and cognitively complex in their posts. Although they exhibited brief increases in negative emotions, these returned to baseline within a week or so of the attacks. Compare the 9/11 posts with writing samples of individuals who are chronically depressed. In both lab studies (e.g. [25]) and blogs on depression websites in English [38] Spanish [39], people who are depressed use far higher rates of first person singular pronouns and tend to use shorter words in less concrete and complex sentences. Individuals who are depressed have difficulty emotionally distancing themselves from whatever topics they are addressing. Non-depressed individuals, including those dealing with an inherently upsetting topic such as 9/11, are quickly able to distance themselves from the

168

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

event and seek out the companionship of others. Indeed, our data show that the more people write about the terrorist attacks, the more they distance themselves linguistically [16]. These findings have clear implications for potential interventions. Any short term, broad-based intervention strategies should probably reinforce distancing rather than demand people process their emotions and thoughts. This may explain the spectacular failure of debriefing strategies such as Critical Incident Stress Debriefing in the wake of a disaster [40]. Most debriefing techniques require that people who have witnessed a traumatic experience to emotionally process the event within 72 hours of its occurrence [41]. Instead of asking people to get closer to the trauma, our data suggests that any techniques to help people avoid the thoughts about it might be helpful immediately after the event occurs. Ironically, these data – together with those associated with the social stages model – hint that interventions that encourage emotional processing may be best suited to people several weeks or months after the event. Perhaps the earliest point at which emotional processing interventions would be appropriate would be when the social environment begins to actively discourage people from talking about the event. At the point that people feel no one wants to listen is the time that therapists should become available. Because terrorism touches everyone in the culture, there are obviously large individual differences in how people respond. Realistically, most people probably need to be able to talk with close friends or family members. Others may simply not want to talk to anyone. For those who don’t have access to a social network, the development of terrorism-related blog sites might be a good idea. By the same token, a small group of people – perhaps those most vulnerable to any kind of upheaval – will require hand holding and additional support. Whether immediate therapy is beneficial to them is simply not known at this point. We would hope that this is an area where future research efforts are focused.

References [1] LeDoux JE. The Emotional Brain. New York: Simon and Shuster, 1996. [2] LeDoux JE. Fear and the brain: Where have we been, and where are we going? Biological Psychiatry 1988; 44: 1229–1238. [3] Moodie EM, Chamove AS. Brief threatening events beneficial for captive tamarins? Zoo Biology 1990; 9: 275–286. [4] Wiener SG, Levine S. Behavioral and physiological responses of mother and infant squirrel monkeys to fearful stimuli. Developmental Psychobiology 1992; 25: 127–136. [5] Salzen EA. Imprinting in birds and primates. Behaviour 1967; 28: 232–254. [6] Schachter S. The Psychology of Affiliation: Experimental Studies of the Sources of Gregariousness. Oxford: Stanford University Press, 1959. [7] Leventhal H. Fear: For your health. Psychology Today 1967; 1: 54–58. [8] Cacioppo JT, Petty RE. The elaboration likelihood model: The role of affect and affect-laden information processing in persuasion. In: Cafferata P, Tybout AM, editors, Cognitive and Affective Responses to Advertising. Lexington: Lexington Books/D. C. Heath and Com, 1989, p. 69–89. [9] DeBono KG, McDermott JB. Trait anxiety and persuasion: Individual differences in information processing strategies. Journal of Research in Personality 1994; 28: 395–407. [10] Gatchel RJ, Schaeffer MA, Baum A. A psychological field study of stress at Three Mile Island. Psychophysiology 1985; 22: 175–181. [11] Wroble MC, Baum A. Toxic waste spills and nuclear accidents. In: La Greca AM, Silverman WK, Vernberg EM, Roberts MC, editors, Helping Children Cope With Disasters and Terrorism. Washington, DC: American Psychological Association, 2002, p. 207–221.

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

169

[12] Pennebaker JW, Harber KD. A social stage model of collective coping: The Loma Prieta Earthquake and the Persian Gulf War. Journal of Social Issues 1993; 49: 125–145. [13] Pennebaker JW. Inhibition as the linchpin of health. In: Friedman H, editor, Hostility, health, and coping. Washington: American Psychological Association, 1992, p. 127–139. [14] Zillman D. Sequential dependencies in emotional experience and behavior. In: Kavanaugh RD, Zimmerberg B, Fein S, editors, Emotion: Interdisciplinary Perspectives. Hillsdale: Lawrence Erlbaum Associates, Inc., 1996, p. 243–272. [15] Stone LD, Pennebaker JW. Trauma in real time: Talking and avoiding online conversations about the death of Princess Diana. Basic and Applied Social Psychology 2002; 24: 172–182. [16] Cohn MA, Mehl MR, Pennebaker JW. Linguistic Markers of Psychological Change Surrounding September 11, 2001. Psychological Science 2004; 15: 687–693. [17] Mehl M, Pennebaker JW, Crow DM, Dabbs J, Price J. The Electronically Activated Recorder (EAR): A device for sampling naturalistic daily activities and conversations. Behavior Research Methods, Instruments, & Computers 2001; 33: 517–523. [18] Mehl MR, Pennebaker JW. The sounds of social life: A psychometric analysis of students’ daily social environments and natural conversations. Journal of Personality and Social Psychology 2003; 84: 857– 870. [19] Mehl MR, Pennebaker JW. The Social Dynamics of a Cultural Upheaval: Social Interactions Surrounding September 11, 2001. Psychological Science 2003; 14: 579–585. [20] Pennebaker JW. Psychological factors influencing the reporting of physical symptoms. In: Stone AA, Turkkan JS, Bachrach CA, Jobe JB, Kurtzman HS, Cain VS, editors, The Science of Self-Report: Implications for Research and Practice. Mahwah: Erlbaum Publishers, 1999, p. 299–316. [21] Lepore SJ, Smyth JM. The Writing Cure: How Expressive Writing Promotes Health and Emotional WellBeing. Washington, DC: American Psychological Association, 2002. [22] Pennebaker JW, Graybeal A. Patterns of natural language use: Disclosure, personality, and social integration. Current Directions in Psychological Science 2001; 10: 90–93. [23] Pennebaker JW, Francis ME, Booth RJ. Linguistic Inquiry and Word Count (LIWC 2001). Mahwah: Erlbaum, 2001. [24] Pennebaker JW, Mehl MR, Niederhoffer K. Psychological Aspects of Natural Language Use: Our Words, Our Selves. Annual Review of Psychology 2003; 54: 547–577. [25] Rude SS, Gortner EM, Pennebaker JW. Language use of depressed and depression-vulnerable college students. Cognition and Emotion, in press. [26] Weintraub W. Verbal Behavior in Everyday Life. New York: Springer Publishing Corp, 1989. [27] Pennebaker JW, Lay TC. Language use and personality during crises: Analyses of Mayor Rudolph Giuliani’s press conferences. Journal of Research in Personality 2002; 36: 271–282. [28] Pennebaker JW, Mayne TJ, Francis ME. Linguistic predictors of adaptive bereavement. Journal of Personality and Social Psychology 1997; 72: 863–871. [29] Glass DC, Singer JE. Experimental studies of uncontrollable and unpredictable noise. Representative Research in Social Psychology 1973; 4: 165–183. [30] Cohen S, Glass DC, Singer JE. Apartment noise, auditory discrimination, and reading ability in children. Journal of Experimental Social Psychology 1973; 9: 407–422. [31] Gortner EM, Pennebaker JW. The archival anatomy of a disaster: Media coverage and community-wide health effects of the Texas A&M Bonfire Tragedy. Journal of Social and Clinical Psychology 2003; 22: 580–603. [32] Silke A. The psychological cost of terrorism. Forensic Update 2003; 72: 23–29. [33] Becker E. Escape from Evil. New York: Free Press, 1975. [34] Pyszczynski T, Solomon S, Greenberg J. In the wake of 9/11: The psychology of terror. American Journal of Psychiatry 2003; 160: 1019. [35] Schlenger WE, Caddell JM, Ebert L, et al. Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. JAMA 2002; 288: 581–588. [36] Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002; 288: 1235–1244. [37] Miller MW. Personality and the etiology and expression of PTSD: A three-factor model perspective. Clinical Psychology: Science and Practice 2003; 10: 373–393. [38] Davison KP, Pennebaker JW, Dickerson SS. Who talks? The social psychology of illness support groups. American Psychologist 2002; 55: 205–217.

170

J.W. Pennebaker and C.K. Chung / Social Dynamics of Responses to Terrorism

[39] Ramirez-Esparza N, Pennebaker JW, Garcia FA, Suria R. Un programa de ordenador que analiza textos en Inglés y Español: Su aplicación con personas deprimidas en Internet (A Computerized Text Analyses in English and Spanish: Its Application with Depress People in the Internet). Psicothema, under review. [40] McNally RJ, Bryant RA, Ehlers A. Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest 2003; 4: 45–79. [41] Mitchell JT, Everly GS. Critical incident stress debriefing (CISD): An operations manual. Ellicott City: Chevron, 1996.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

171

Treatment of Trauma Survivors with Acute Stress Disorder: Achievements of Systematic Outreach Arieh Y. Shalev 1 , Sara Freedman, Yossef Israeli-Shalev, Sarah Frenkiel-Fishman and Rhonda Adessky The Center for Traumatic Stress Studies, Hadassah University Hospital, Jerusalem, Israel

Introduction The early identification and treatment of individuals who express post-traumatic stress disorder (PTSD) symptoms at the aftermath of a traumatic event is a matter of controversy. Indeed, this issue has been obscured by unwarranted claims of effective ‘screening,’ and ‘prevention’ among survivors ‘at risk’ – often by single session interventions [1]. Notwithstanding, some survivors are severely distressed and disabled at the early aftermath of traumatic events, and many of those remain distressed for months and years [2]. Therefore, whilst a general stance to ‘treat everyone at risk’ is certainly erroneous (and impractical) – the needs of the few who continuously express severe anxiety or depressive symptoms are all too real to be ignored. Large-scale terrorist attacks and industrial disasters may create numerous cases with severe initial reactions. Their early treatment might be beneficial – but often hampered by poorly defined threshold criteria for defining a clinical case, and survivors’ reluctance of survivors to seek help [3]. This chapter addresses one possible solution of the latter: systematic outreach and identification of highly distressed survivors. It reports data from an ongoing outreach program in the terror-prone city of Jerusalem.

Why Treat the Early Response to Traumatic Events? Recent reviews indicate that the psychological effects of terror, road traffic accidents and disasters on exposed populations are deleterious and far-reaching [4,5]. Research conducted after September the 11th revealed significant levels psychological distress and frequent expression of post-traumatic stress disorder (PTSD) symptoms [6,7] – but limited help seeking [8]. Evidence from epidemiological and clinical studies suggests that the likelihood of recovery from PTSD decreases with time [9–11]. However, this might be due to the per1 Corresponding author: Arieh Y. Shalev, M.D., Professor of Psychiatry, Head, Department of Psychiatry, Hadassah University Hospital, Ein Kerem Campus, Jerusalem, 91120, Israel.

172

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

sistence of the disorder among survivors who, because of uncontrollable factors (e.g., genetic, biographic, event-severity) were prone to develop PTSD [12]. In such case treatment can only accelerate the recovery of those who will anyhow recover – but cannot reduce the incidence of chronic PTSD [9]. Contrasting with this view, Brewin et al., [13] has shown that risk factors that follow traumatic events contribute to subsequent PTSD. Within the latter, the duration of expressing early PTSD symptoms might have a pathogenic effect. This idea is subsumed under Antelman’s [14] “time-dependent sensitization” model, Post’s [15] kindling model and McEwen’s [16] allostatic stress model. In such is the case then early treatment may truly prevent chronic PTSD. Support for the sensitization model of PTSD comes from the Shalev et al., [17] prospective study of auditory startle in PTSD, in which a typical non-habituating autonomic response to loud tones was not present one week after a traumatic and developed within the following four months in survivors who had PTSD. Further support to this idea comes from a recent twin study of heart rate responses to loud tones [18], which showed that larger heart rate HR responses to tones are acquired and not inherited. Together, these studies suggest that the first four months that follow a traumatic event constitute a sensitive period during which irreversible alterations of the CNS might occur in survivors who have PTSD. This view predicts that early interventions have inherent advantage. Similar argument has been advanced in support of early treatment of budding schizophrenia [19]. The case of PTSD may or may not be different – but the possibility of a difference, and the potentially chronic course of PTSD make a compelling argument for studying the effect of early treatment. Acute stress disorder and chronic PTSD Whilst scholars’ opinions about the meaning and the prognosis of early PTSD symptoms differ (e.g., [20]), acute stress disorder (ASD) is a major – if not inclusive risk indicator of PTSD [21]. Table 1 summarizes nine studies of ASD. It shows that PTSD develops in 30% to 83% of trauma survivors with ASD, but also in many survivors who do not have ASD. This implies that in order to effectively prevent PTSD, one has to address both survivors with fully expressed ASD and others who do not meet all the disorder’s diagnostic criteria. Table 1. Summary of prospective studies of acute stress disorder (adapted from Bryant, Biol Psych. 2003) Trauma type

Study

Follow-up

Proportion of ASD who developed PTSD

Proportion of PTSD who had ASD

MVA Brain injury

Harvey and Bryant (1998) Bryant and Harvey (1998)

6 months 6 months

78% 83%

39% 40%

Assault MVA MVA MVA Typhoon MVA

Brewin et al. (1999) Holeva et al. (2001) Creamer et al. (in press) Schnyder et al. (2001) Staab et al. (1996) Harvey and Bryant (1999)

6 months 6 months 6 months 6 months 8 months 2 years

83% 72% 30% 34% 30% 82%

57% 59% 34% 10% 37% 29%

2 years

80%

72%

Brain injury Harvey and Bryant (2000) MVA = motor vehicle accidents.

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

173

Evidence of effective treatment of PTSD Cognitive behavioral therapy (CBT) has been studied in numerous well-designed randomized controlled studies (RCTs); (e.g., [22–27]). RCTs have found that CBT leads to clinically significant reductions in PTSD and associated features such as depression. The components of CBT that have been associated with the largest effects in the treatment of PTSD are cognitive therapy (CT) and prolonged exposure (PE) [28]. Several studies compared the two with fairly consistent results. Marks et al., [25] found equivalent reductions in PTSD symptoms in CT alone, prolonged exposure (PE) alone, and CT-PE combined. Similarly, Tarrier and colleagues [26] found equivalent reductions in PTSD symptoms in imaginal exposure and a CT. Resick et al. [27] found equivalent reductions in PTSD symptoms in cognitive processing therapy and PE. Foa and colleagues [23] compared PE to stress inoculation training (containing CT) and found no difference between the treatments in reduction of PTSD severity. Pharmacological therapy: Large-scale RCTs have shown that SSRIs effectively reduce the prevalence of PTSD and the intensity of PTSD symptoms [29–33]. SSRIs also have a potential use for co-occurring conditions such as depression, other anxiety disorders, and impulsivity. Early psychological interventions: Studies of early CBT (reviewed in [34,35]) have shown promising results on selected samples. Three published RCTs involving early CBT [36–38] found clear superiority of CBT in reducing PTSD symptoms as compared to a control group, whereas one [39] did not. In addition, a controlled (but not randomized) comparison of CBT versus an assessment-only condition in the acute phase posttrauma found fewer PTSD symptoms in the CBT group at a 5.5-month follow-up [40]. Importantly, the studies by Bryant and colleagues [36,37] concerned individuals with a DSM IV diagnosis of ASD. They indicate that structured CBT intervention administered approximately 2 weeks after serious trauma reduces the likelihood that participants will develop full-blown PTSD. A four years follow up of this work [41] found that participants who received CBT show less intense (although not less frequent) PTSD symptoms. The results provide preliminary evidence that early CBT for survivors with ASD is associated with long-term benefits. More recently, Ehlers et al. [42] compared cognitive therapy (CT; n = 28) with a self-help booklet (n = 28) and repeated assessment (n = 29) in motor vehicle accident survivors. The intervention began two months after a traumatic event. CT, but no other condition, significantly reduced the rate of PTSD and the severity of PTSD symptoms nine months later. Zatzick et al. [43], however, evaluated the effect of a composite package of interventions (“Collaborative Care”) in 120 injured surgical patients. They showed no reduction in the percentage of patients who met DSM IV criteria for PTSD 12 months following the intervention. The non-intervention group showed 6% increase in the rate of PTSD. Early pharmacological interventions: Only one RCT has documented the use of psychopharmacological interventions for acute stress responses in adults. Pitman and colleagues [44] conducted a randomized, double blind pilot study in which they administered Propranolol within 6 hours of a traumatic event. While the Propranolol group did not appear to exhibit decreased PTSD symptoms 3 months later, it did exhibit reduced physiological reactivity. Few other studies have been conducted. A review of medical records [45] found that low doses of Risperidone given to patients at an average of five

174

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

days following a traumatic event was associated with a decrease in sleep disturbance, nightmares/flashbacks and hyperarousal. In contrast, a case-control study [46], found that prescribing of benzodiazepines within days of a traumatic event increased the likelihood of subsequent PTSD.

Questions Left Open by Previous Studies At this point, CBT has the strongest empirical support as an early intervention that might prevent PTSD. CBT, however, has not been studied in unselected cohorts of survivors. Research has to examine the efficacy and the effectiveness of CBT in among larger cohorts of survivors. Since CBT requires expertise and often missing resources, pharmacotherapy should be studied as well. Many exposed survivors show PTSD symptoms shortly after a traumatic event – but these symptoms subside with time in most of them, hence their low predictive power [10,11]. ASD is highly predictive but too restrictive. In the absence of clear riskindicators the accuracy of identifying survivors at risk requires further study. There is controversy regarding the optimal timing of interventions after mass violence or disaster, but there is no data comparing an early with a delayed implementation of treatment. Further research is needed to compare similar interventions at varying time intervals in terms of their efficacy, tolerability, and acceptability to survivors. CBT is still a relatively rare resource and its implementation on a large scale is expensive and arguably might drain scarce community resources. However, the burden of chronic PTSD on individuals and communities [9] is also expensive and draining. A recommendation to regularly offer CBT for secondary prevention of PTSD requires solid evidence of effectiveness. During the years 2000–2004, Jerusalem has been the site of repeated acts of terror against civilians [47] (e.g., Shalev et al., 2004). Hadassah University Hospital is the city’s largest receiving hospital. A follow-up study of terror survivors showed that 38% of developed PTSD [48]. The availability of psychological team at the hospital ER and the access to patients at the early aftermath of traumatic events provided an optimal opportunity to systematically address the prevention of PTSD by early treatment and address the questions mentioned above. Specifically, the feasibility of large – scale outreach had to be tested, as well as survivors’ willingness to respond to an outreach – and eventually come for assessment and therapy. Since no one really knows whether predictions made by clinicians on the basis of early symptoms are accurate – we also had to test them, prospectively. Survivors’ unwillingness to attend therapy might be a healthy instinct – or severe miscalculation – and this also had to be evaluated. Finally, different forms of therapy were offered and compared, in order not to reject a priori potentially effective therapy. Indeed, the outreach project consisted of large-scale follow-up project with embedded early therapy for survivors with outstanding symptoms.

Design Subjects: Inclusion in this projected encompassed was every adult residing in the larger Jerusalem area who had been admitted to the ER for car accidents, terrorist attacks,

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

175

work accidents, home accidents, army combat or training incidents, poisoning, drowning, burns, public riot, assault, or rape. The telephone interviews assigned to clinical interviews every survivor with significant initial distress. Treatment was recommended to every survivor with full or partial ASD. Survivors with injury requiring hospital admission and survivors with head injury, loss of consciousness or survivors in coma were not included Survivors with current or past psychosis, bipolar disorder, current substance abuse/dependence or survivors who reactivated, following trauma, a DSM IV axis I disorders that require dedicated treatment were included in this work, but were assessed and referred to treatment for their respective disorders. Interventions: these included the following: CBT – according to Foa et al., Prolonged Exposure (PE) protocol [49]. The treatment consisted of twelve weekly 90-minute sessions. Pharmacotherapy with escitalopram 10 to 20 mg per day with weekly visits to a psychiatrist for the first four weeks, and biweekly visits from week four to twelve. Cognitive therapy followed a protocol developed by Isaac Marks [25]. Survivors assigned to the WL control immediately received an appointment for treatment 12 weeks later and the clinician who interviewed each survivors followed him or her biweekly, evaluated their condition and assisted them in any possible way. Assessment: We used The Clinician-Administered PTSD Scale (CAPS; [50]) and the Structured Clinical Interview for DSM-IV (SCID; [51]) to evaluate current and lifetime (pre-event) Axis I mental disorders. Survivors also completed several self-report instruments including the Post-traumatic Symptom Scale – revised (PSS-SR; [40]), the acute stress disorder scale (ASDS; [52]), The K6 – a short, six questions screening scale of psychological distress, the Beck Depression Inventory (BDI; [53]) an Event Severity Scale (e.g., [44]). Additionally clinicians filled the Clinical Global Impression (CGI; [54]). Procedure: Potential trauma survivors were identified via Hadassah University Hospital ER computerized records. The project’s dedicated software downloaded all ER ‘trauma’ records to the project’s dedicated server. The software assigned a number to each survivor, to be used for subsequent treatment allocation, and applied preliminary inclusion criteria of age, injury and residency (see below). Following manual ascertainment of survivors’ details and willingness to be called by telephone, telephone interviews were conducted within a week of the traumatic event with each potentially traumatized survivor. The interviewers identified themselves as working at Hadassah Trauma Center, explained the purpose of the call and obtained subjects’ consent to continue the interview. They then enquired about subjects’ health and well being, obtained information about the potentially – traumatic event, thanked survivors who had events that did not meet threshold criteria for a traumatic event, and continued the interviews, assessed ASD symptoms and depression in those who had a traumatic events. Survivors with qualifying event and intense reactions of fear and horror, and every survivor who said that he/she wanted to see a psychologist were invited to attend a free assessment session, within two weeks of the interview. In the clinical assessment session, clinical psychologists greeted subjects, explained the choice of treatment and obtain a written informed consent. They then evaluated the subject condition using psychometric instruments and structured clinical interviews as below. Survivors with ASD – and those with partial ASD (that is, ASD without the dissociation or ASD without the avoidance criterion) were allocated to one of four treatment options: early PE, early cognitive therapy (CT) early SSRI (escitalopram) or delayed PE

176

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

Figure 1. A project designed to address these questions.

(that is – three months later). Survivors could decline one or more treatment options, following which they were randomized into one of the options that they have accepted. Survivors started early treatment within four weeks of the traumatic event and delayed treatment within four months of the traumatic event. Successive clinical evaluations were conducted four and seven months following trauma, and a telephone interview took place seven months following the traumatic event. Dedicated software A project of such magnitude requires, organization and monitoring. Special challenges include time constraints and routing decisions taken by several agents (e.g., clinicians, interviewers and patients) at several time points. Other challenges are monitoring of activities, oversight and quality control. Responding to these challenges, we borrowed and

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

177

Figure 2.

further developed software used in the industry for streamlining and quality assurance of productions that involve serial, interdependent steps. This software has been tested in a series of pilot studies. As shown in Fig. 2, the software uploaded data from ER and admission records. It than screens for primary inclusion and exclusion criteria, creates a daily printout of subject candidates, assists the coordinator of telephone interviews to assign daily work to interviewers. Records and updates data from telephone and clinical interviews, assists the administrators to schedule interviews and treatment within the required time frame, and keeps track of completion and delays. The software greatly facilitated the smooth pursuit of this work.

The Project’s Achievements During nine months (from August 1st 2003 to May 30th 2004) we recruited every survivor of potentially traumatic event, as above. Three terrorist attacks occurred in Jerusalem during this period: The Café Hillel suicide bombing (9/9/2003), the suicide bombing of bus #19 (1/29/2004) and suicide bombing of bus #14a (2/22/2004). There have been 4513 ER admissions for potentially traumatic events during nine months – including major and minor injuries, accidents and incidents. 1598 of those met inclusion criteria and 1234 (77%) were reached for telephone interviews. Only 72 survivors (5.8%) declined the telephone interviews and 1162 were successfully interviewed. The telephone interviews took place 7.43 ± 2.69 days after a traumatic event. Survivors who were interviewed by telephone (n = 1163) did not differ in age and gender distribution from those who were not. Terror survivors were more frequently reached by telephone (113 of 124) (Table 2).

178

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder Table 2. Comparison of survivors interviewed by telephone with those not were not Reached (n = 1162)

Gender (M/F) 685/477 Age 33.4 ± 11.60 Trauma type 113/874/175 (terror/MVA/others) MVA = motor vehicle accidents.

Not reached (n = 436)

t-test/Chi square

p

279/157 33.2 ± 11.97 11/321/104

3.37 0.43 60.65

.07 n.s 0.0001

Table 3. Comparison of survivors who accepted clinical assessment with those who declined Accepted (n = 233)

Declined (n = 174)

t-test/Chi square

p

Gender (M/F) Age

128/105 33.37 ± 12.01

90/84 30.97 ± 10.81

0.413 2.084

.547 .038

Trauma type (terror/MVA/others) CGI

65/157/11

35/129/10

10.07

.260

4.78 ± 1.19

4.50 ± 1.15

2.36

.019

Table 4. Comparison of survivors invited for early intervention with those not invited

Gender (M/F) Age Trauma type (terror/MVA/others) PTSD criteria met

Invited (n = 119)

Not invited (n = 59)

t-test/Chi square

p

62/57 35.44 ± 11.31 36/75/8

35/24 33.69 ± 11.88 15/42/2

.829 .952 8.72

.425 .343 .190

104 (87%)

8 (14%)

103.73

.0001

Mean PSS-SR 25.70 ± 12.74 10.47 ± 9.45 8.133 .0001 CGI 4.68 ± 1.20 2.71 ± 0.89 11.16 .0001 BDI 19.70 ± 10.76 5.66 ± 4.07 9.59 .0001 MVA = motor vehicle accidents; PSS = PTSD symptom scale – revised; CGI = clinical global impression; BDI = beck depression inventory.

The telephone interviews revealed exclusion criteria in 60 survivors as follows: 509 had no qualifying trauma, 172 had a traumatic event, but no qualifying symptoms, and 418 (35%) had a traumatic event and qualifying symptoms and were referred to clinical assessment. Of those offered clinical assessment 174 (42%) declined, 233 (56%) accepted and came for assessment. Survivors who have agreed to attend the clinical assessment were somewhat older and more distressed than those who declined (Table 3). The Clinical assessments took place 18.39 ± 5.15 days from the traumatic event. Exclusion criteria were found in six survivors, 47 had another mental disorder (psychosis, exacerbated substance abuse, OCD) and were referred for treatment of their respective disorders. Of the remaining 178, 59 (33%) did not have ASD/partial ASD, and 119 (67%) had qualifying symptoms and were invited for treatment. Survivors with qualifying symptoms and those without them had similar age, gender distribution and trauma type (Table 4). As expected, the former had more symptoms.

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

179

Table 5. Comparison of survivors who started an intervention with those who declined

Gender (M/F) Age Trauma: (terror/MVA/others) PTSD criteria met

Accepted (n = 77)

Declined (n = 42)

t-test/Chi square

p

40/37 37.59 ± 11.75 21/49/5

22/20 32.29 ± 9.48 15/24/3

.032 2.50 4.62

.014 .464

65 (86%)

37 (88%)

0.56

.753

Mean PSS-SR 27.52 ± 12.03 22.43 ± 13.69 2.09 .039 CGI 4.64 ± 1.25 4.76 ± 1.14 0.52 .603 BDI 19.65 ± 10.51 19.63 ± 11.45 0.011 .991 MVA = motor vehicle accidents; PSS = PTSD symptom scale – revised; CGI = clinical global impression; BDI = beck depression inventory.

Table 6. Prevalence of PTSD, partial PTSD and no PTSD before and after treatment PTSD before treatment

PTSD at four months

PTSD

Partial PTSD

No PTSD

All (intent to treat) (n = 24) Completers (n = 19)

21

3

0

17

2

Waitlist (n = 18)

16

2

PTSD

Partial PTSD

No PTSD

6

4

14 (58%)

0

5

4

10 (53%)

0

10

4

4(22%)

Early treatment: Forty-two (35%) survivors who were invited for treatment declined, and 77 (65%) started treatment. They were randomized into prolonged Exposure (PE), n = 29 (M/F = 18/11), Cognitive therapy (CT), n = 15 (4/11), escitalopram (SSRI), n = 11 (8/3) and wait list (WL), n = 22 (11/11). Survivors who accepted treatment were somewhat older and had more PTSD symptoms than survivors who declined. The groups did not differ otherwise (Table 5). Only one of 119 survivors declined to be on WL. 98% and 97% of subjects accepted PE and CT, respectively. The SSRI was accepted by 63% of those to whom it has been offered (n = 67). The second clinical assessment took place 136 ± 27 days from the traumatic event and the second telephone interview took place 212 ± 30 days from the traumatic event. Only 13% of those invited for clinical interview and 11% of those contacted for telephone interviews declined. Data is currently available for 24 subjects assigned to active treatment and 18 in the WL (Table 6). The groups had similar age (respectively 40.8 ± 12.8 viz. 35.2±10.11; t = 1.54, ns), similar gender distribution (11 (45%) vs. 8 (44%) males), and similar PSS scores before treatment (respectively 29.65 ± 9.5 and 28.33 ± 9.65). Four months’ PSS scores were smaller among those who started treatment, compared with WL (12.45 ± 10.10 vs. 20.69 ± 14.55; t (df = 36) = 2.06, p. < 0.05). Five subjects in the active treatment group (21%; 2 males, 3 females) did not complete the treatment. Fourteen (58%) of 24 survivors who started therapy and four (22.2%) survivors on the WL had no PTSD at four months. As in Ehlers et al., (2003) intent to treat and completed treatment had similar outcome. Contrasting all those who started treatment with WL controls on all three levels of PTSD yields a X-sqr (df = 2) = 5.82; p. = 0.055.

180

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder Table 7. Attrition rates summary Attempted

Not reached

Declined

Completed

Second clinical interview

162

2

22

138∗

Second telephone interview

100.00% 172 100%

1.25% 5 2.91%

13.75% 19 7.66%

85.00% 153∗∗ 88.95%

∗ Data entered and cleaned at the time of writing: 132 clinical interviews, 141 phone interviews.

Conclusions Preliminary results of this work clearly show that comprehensive outreach program effectively identifies numerous survivors with high levels of initial symptoms, recommends professional evaluation to a reasonable numbers of survivors (n = 418 or 9.2% of all ‘trauma’ admissions), offers professional interventions to a manageable number of highly symptomatic survivors (n = 119 in nine months of comprehensive outreach) and can generate pertinent data on treatment choice, treatment effect and adherence. Specifically this work clearly suggests that: (a) A project of this size is feasible. (b) Most survivors accept telephone interviews. (c) Despite reaching out there is significant reluctance to meet clinicians for interviews or therapy. (d) Treatment completion is reasonably good (79%). (e) Professional interventions yielded promising results. (f) There is limited attrition rate between successive evaluations (Table 7). Technical, social and cultural difficulties might affect the success of similar approaches in other societies. Nonetheless, even within reasonable acceptance rates, the number of professional treatment episodes required to cover thousands of traumatic incidents is not forbidding. These findings should encourage training and systematic implementation of the more advanced treatment techniques for the few survivors of events who are persistently distressed. A question regarding the optimal timing of treatment is left open by these findings, but should receive an answer in the future. Importantly, whilst this program seems to be costly and somewhat complex, it actually better manages the allocation of resources, making treatment available to those who specifically need it, and providing shorter contact and follow-up to survivors with lesser needs. Ultimately, if the promise of early intervention is supported by this and other studies, then programs such as this might prevent a frequently occurring, disabling and resource-draining disorder, and thereby justify an initial investment by saving on subsequent health care costs.

References [1] Rose S, Bisson J, Wessely S. Psychological debriefing for preventing posttraumatic stress disorder (PTSD). The Cochrane Library, Issue 2: Update Software Ltd., 2002. [2] Shalev AY, Freedman S, Peri T, Brandes D, Sahar T, Orr SP, et al. Prospective study of posttraumatic stress disorder and depression following trauma. American Journal of Psychiatry 1998; 155: 630–637. [3] Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine 2004; 351: 13–22.

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

181

[4] Katz CL, Pellegrino L, Pandya A, Ng A, DeLisi LE. Research on psychiatric outcomes and interventions subsequent to disasters: A review of the literature. Psychiatry Research 2002; 110: 201–217. [5] Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981–2001. Psychiatry: Interpersonal and Biological Processes 2002; 65: 207–239. [6] Schlenger WE, Caddell JM, Ebert L, Jordan BK, Rourke KM, Wilson D, et al. Psychological reactions to terrorist attacks: Findings from the national study of Americans’ reactions to September 11. Journal of the American Medical Association 2002; 288: 581–588. [7] Centers for Disease Control and Prevention. Community needs assessment of lower Manhattan residents following the world trade center attacks-Manhattan, New York City, 2001. Journal of the American Medical Association 2002; 288: 1227–1228. [8] DeLisi LE, Maurizio A, Yost M, Papparozzi CF, Fulchino C, Katz CL, et al. A survey of New Yorkers after the Sept. 11, 2001, terrorist attacks. American Journal of Psychiatry 2003; 160: 780–783. [9] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic stress disorder in the national comorbidity survey. Archives of General Psychiatry 1995; 52: 1048–1060. [10] Rothbaum BO, Foa EB, Riggs DS, Murdock T, Walsh W. A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress 1992; 5: 455–475. [11] Freedman SA, Peri T, Brandes D, Shalev AY. Predictors of chronic PTSD – A prospective study. British Journal of Psychiatry 1999; 174: 353–359. [12] True WR, Rice J, Eisen SA, Heath AC, Goldberg J, Lyons MJ, et al. A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms [see comments]. Archives of General Psychiatry 1993; 50: 257–264. [13] Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical Psychology 2000; 68: 748–766. [14] Antelman SM. Time-dependent sensitization as the cornerstone for a new approach to pharmacotherapy: Drugs as foreign/stressful stimuli. Drug Development Research 1988; 14: 1–30. [15] Post RM, Weiss SRB, Smith MA. Sensitization and kindling: Implications for the evolving neural substrates of post-traumatic stress disorder. In: Friedman JM, Charney DS, Deutch AY (Eds.). Neurobiological and Clinical Consequences of Stress. Philadelphia, PA: Lippincott Williams & Wilkins, 1995: 203–224. [16] McEwen BS. Allostasis and allostatic load: Implications for neuropsychopharmacology. Neuropsychopharmacology 2000; 22: 108–124. [17] Shalev AY, Peri T, Brandes D, Freedman S, Orr SP, Pitman RK. Auditory startle in trauma survivors with posttraumatic stress disorder: A prospective study. American Journal of Psychiatry 2000; 157: 255–261. [18] Orr SP, Metzger LJ, Lasko NB, Macklin ML, Hu FB, Shalev AY, et al. Physiologic responses to sudden, loud tones in monozygotic twins discordant for combat exposure: association with posttraumatic stress disorder. Archives of General Psychiatry 2003; 60: 283–288. [19] McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Archives of General Psychiatry 2002; 59: 921–928. [20] North CS, Pfefferbaum B. Research on the mental health effects of terrorism. Journal of the American Medical Association 2002; 288: 633–636. [21] Bryant RA. Early predictors of posttraumatic stress disorder. Biol Psychiatry 2003; 53: 789–795. [22] Bryant RA, Moulds M, Guthrie R, Nixon RDV. Treating acute stress disorder following mild traumatic brain injury. American Journal of Psychiatry 2003; 160: 585–587. [23] Foa EB, Dancu CV, Hembree EA, Jaycox LH, Meadows EA, Street GP. A comparison of exposure therapy, stress inoculation training, and their combination for reducing posstraumatic stress disorder in female assault victims. Journal of Consulting and Clinical Psychology 1999; 67: 194–200. [24] Foa EB, Hearst-Ikeda D, Perry KJ. Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology 1995; 63: 948–955. [25] Marks I, Lovell K, Noshirvani H, Livanou M, Thrasher S. Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: A controlled study. Archives of General Psychiatry 1998; 55: 317–325.

182

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

[26] Tarrier N, Pilgrim H, Sommerfield C, Faragher B, Reynolds M, Graham E, et al. A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic post traumatic stress disorder. Journal of Consulting and Clinical Psychology 1999; 67: 13–18. [27] Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol 2002; 70: 867–879. [28] Bryant RA, Moulds ML, Guthrie RM, Dang ST, Nixon RDV. Imaginal exposure alone and imaginal exposure with cognitive restructuring in treatment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology 2003; 71: 706–712. [29] Brady K, Pearlstein T, Asnis GM, Baker D, Rothbaum B, Sikes CR, et al. Double-blind placebocontrolled study of the efficacy and safety of Sertraline treatment of posttraumatic stress disorder. Journal of the American Medical Association 2000; 283: 1837–1844. [30] Davidson J, Pearlstein T, Londborg P, Brady KT, Rothbaum B, Bell J, et al. Efficacy of Sertraline in preventing relapse of posttraumatic stress disorder: Results of a 28-week double-blind, placebo-controlled study. American Journal of Psychiatry 2001; 158: 1974–1981. [31] Davidson JRT, Rothbaum BO, van der Kolk BA, Sikes CR, Farfel GM. Multicenter, double-blind comparison of Sertraline and placebo in the treatment of posttraumatic stress disorder. Archives of General Psychiatry 2001; 58: 485–492. [32] Marshall RD, Beebe KL, Oldham M, Zaninelli R. Efficacy and safety of Paroxetine treatment for chronic PTSD: A fixed-dose, placebo-controlled study. American Journal of Psychiatry 2001: 158: 1982–1988. [33] Tucker P, Zaninelli R, Yehuda R, Ruggiero L, Dillingham K, Pitts CD. Paroxetine in the treatment of chronic posttraumatic stress disorder: Results of a placebo-controlled, flexible-dosage trial. Journal of Clinical Psychiatry 2001; 62: 860–868. [34] Ehlers A, Clark DM. Early psychological interventions for adult survivors of trauma: A review. Biological Psychiatry 2003; 53: 817–826. [35] Litz BT, Gray MJ, Bryant RA, Adler AB. Early intervention for trauma: Current status and future directions. Clinical Psychology: Science and Practice 2002; 9: 112–134. [36] Bryant RA, Harvey AG. Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry 1998; 155: 625–629. [37] Bryant RA, Harvey AG, Dang ST, Sackville T, Basten C. Treatment of acute stress disorder: A comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology 1998; 66: 862–866. [38] Echeburua E, de Corral P, Sarasua B, Zubizarreta I. Treatment of acute posttraumatic stress disorder in rape victims: An experimental study. Journal of Anxiety Disorders 1996; 10: 185–199. [39] Brom D, Kleber RJ, Hofman MC. Victims of traffic accidents: Incidence and prevention of post-traumatic stress disorder. Journal of Clinical Psychology 1993; 49: 131–140. [40] Foa EB. Posttraumatic Stress Diagnostic Scale. Minneapolis, MN: National Computer Systems, Inc., 1995. [41] Bryant RA, Moulds ML, Nixon RVD. Cognitive behavior therapy of acute stress disorder: A four-year follow-up. Behaviour Research and Therapy 2003; 41: 489–494. [42] Ehlers A, Clark DM, Hackman A, McManus F, Fennell M, Herbert C, et al. A randomized controlled trial of cognitive therapy, a selfhelp booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Archives of General Psychiatry 2003; 60: 1024–1032. [43] Zatzick D, Roy-Byrne P, Russo J, Rivara F, Droesch R, Wagner A, et al. A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry 2004; 61: 498–506. [44] Pitman RK, Sanders KM, Zusman RM, Healy AR, Cheema F, Lasko NB, et al. Pilot study of secondary prevention of post-traumatic stress disorder with Propranolol. Biological Psychiatry 2002; 51: 189–192. [45] Eidelman I, Seedat S, Stein DJ. Risperidone in the treatment of acute stress disorder in physically traumatized in-patients. Depress Anxiety 2000; 11: 187–188. [46] Gelpin E, Bonne O, Peri T, Brandes D, Shalev AY. Treatment of recent trauma survivors with benzodiazepines: A prospective study. Journal of Clinical Psychiatry 1996; 57: 390–394. [47] Shalev AY. The Israeli experience of continuous terrorism (2000–2004). In: Lopez-Ibor JJ, Christodoulou G, Maj M, Sartorius N, Okasha A. (Eds.). Disasters and Mental Health. London, UK: Willey & Sons, 2004.

A.Y. Shalev et al. / Treatment of Trauma Survivors with Acute Stress Disorder

183

[48] Shalev AY, Freedman S. PTSD following terrorist attacks: A prospective evaluation. American Journal of Psychiatry, in press. [49] Foa EB, Hearst DE, Dancu CV, Hembree E, Jaycox LH. Prolonged exposure (PE) manual. Unpublished manuscript, Medical College of Pennsylvania, Eastern Pennsylvania Psychiatric Institute, 1994. [50] Blake DD, Weathers FW, Nagy LM, Kaloupek DG, Klauminzer G, Charney DS, et al. A clinician rating scale for assessing current and lifetime PTSD: The CAPS-I. Behavior Therapist 1990; 13: 187–188. [51] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders. Washington, D.C, American Psychiatric Publishing Inc., 1997. [52] Bryant RA, Moulds ML, Guthrie RM. Acute stress disorder scale: a self-report measure of acute stress disorder. Psychological Assessment 2000; 12: 61–68. [53] Beck AT. Beck Depression Inventory. New York: Psychological Corporation, 1988. [54] Endicott J, Spitzer RL, Fleiss JL, Cohen J. The global assessment scale: A procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry 1976; 33: 766–771.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

185

Short and Long Term Psychological Reactions to Terrorism: The Role of Information and the Authorities Simon Wessely 1 Dept. of Psychological Medicine, Institute of Psychiatry, King’s College London

Introduction In this paper I shall specifically considered the role of information and the authorities facing the possibility of a CBW terrorist incident. I shall make four essential points in considering the psychological and social responses to a CBRN attack. 1. Panic – and why people usually don’t. 2. Why reassuring an anxious population does not work. 3. Why practical support linked to accurate/timely information is a more effective short term mental health intervention than formal psychological interventions such as debriefing. 4. And why we will manage the short-term consequences well, and be caught short by the long-term consequences.

Panic and why People Usually Don’t There is a general and repeated perception that facing severe and overwhelming adversity, people will panic. But what has happened in the past? Take the example of the London Blitz during the Second World War. Beforehand every expert, psychiatrist, planner and government official was firmly convinced that the “bomber will always get through”, and that civilian morale would rapidly crack, with populations fleeing to the country in panic. Yet it didn’t happen, except in a few very specific circumstances, such as a crowd surge in a crowded subway entrance. The myth of “London can take it” is in fact no myth. London did take it [1]. Likewise, it seems clear from the research on 9/11 that panic was conspicuous by its absence during the evacuation of the World Trade Centre. A building on fire, about to collapse, and the emergency services not yet present. And yet there was no panic, but an orderly evacuation perhaps aided by pre existing social networks [2]. Why not? There are many reasons. First of all, people can and do become habituated to great hardship. Initial responses such as anxiety can decrease over time as the threat continues, 1 E-mail: [email protected]

186

S. Wessely / Short and Long Term Psychological Reactions to Terrorism

and assist people in gradually habituating to the new anxiety, as seen in Israel during the 1991 SCUD missile attacks [3]. The population of Israel, whilst clearly experiencing significant psychological distress as a result of the current suicide bomb campaign, nevertheless continue to go about this business (see Shephard, this volume). Second, during the period of the London Blitz civic leadership was strong, and examples of leadership common. Likewise in modern times there was the example of the civic leadership role of Mayor Giuliani after 9/11 and his unequivocal assumption of the basic resilience of those affected. But there are also instances in which this has not been forthcoming. Compare and contrast to the initial reactions of the US leadership to 9/11 and anthrax, with Vice President Cheney moving to yet another undisclosed location (see Chapter 2 and 20). People were entitled to say “well, if they can’t protect him, what chance have I got? And why should I stay put if he doesn’t?”. Compare and contrast also the risk messages in the UK, which, whether by accident or design, by appealing to national stereotypes of resilience (the Blitz, the IRA campaign in London), in which civic society had coped, made it clear that panic was a concession to our enemies, whilst avoiding Corporal Jones’ famous injunction “don’t panic!”. One difference between then and now was the collective purpose – by 1944 perhaps 80% of the UK adult population were involved in some form or other in the war effort, either in the Armed Forces or the voluntary sector. Compare and contrast with the so called “war on terror”, which there is no clear role for civilians, other than to submit to ever more ingenious ways of being humiliated and harassed at modern airports. Finally, risk in the London blitz was arbitrary. The leadership were almost as much at risk from the bombing as those rather lower down the social order, at least it seemed that way. On the other hand, during the 2001 anthrax crisis in Washington there was a perception that officials reacted more vigorously to the threat to Congress than to the postal workers, who were more likely to come from disadvantaged ethnic minorities. The consequences of that misjudgement are still being felt. Historians have also suggested that one of the many reasons why the Vietnam war seemed to lead to far greater long term psychiatric illness in those who served there, in contrast to the Second World War in which casualties and the chance of combat exposure were much higher, was because the military itself was no longer as representative of the citizenry as it had been. Said one historian “Vietnam was the war our servants fought” [4]. I conclude that people are more resilient than we give them credit for, and our leaders can trust their populations more than they sometimes seem to do.

The Uses and Abuses of Reassurance People are more resilient than you think, but we often try and reduce that resilience by increasing our natural anxieties. Of course people are anxious about the threat from CBRN terrorism for many reasons. True. And so, if people are anxious, we should reassure them. Or should we? We need to consider some basic psychology and learning theory. Imagine a patient who is phobic about going on the subway. Everytime it is mentioned he develops panic attacks. A very common situation indeed. And how is this person treated? Do we agree with him that the subway is a dangerous place? Make sure you don’t go near the tube if you are that worried, even though there is nothing to worry about. Do

S. Wessely / Short and Long Term Psychological Reactions to Terrorism

187

we reassure? Discuss the tube safety statistics? No. Do we go over the tube evacuation plans? No. Why not? Because reassuring anxious patients does not reduce anxiety, because the true cause of the anxiety has not been addressed. Far from reducing anxiety the act of reassuring fears that are out of proportion to the threat involved merely increases them [5]. Instead the treatment of choice is exposure – exposing the person to their fears, by making them travel on the tube, and confront their fears. And it is incredibly successful. Exposure encourages habituation, avoidance increases fear. Now let us consider this at the level of society. The more we spend on reassuring the public about increasingly implausible threats, the more anxious they become, and the more convinced that the implausible is just around the corner. Likewise, the more we clean up the environment, and introduce increasingly stringent chemical regulation – parts per billion rather than million – the less people seem to trust. Few people say – “OK, that’s all right then, now I feel safe”. More often, they demand more and more in response too less and less threat. As Durodie has argued in this volume, the precautionary principle makes more political than psychological sense. Excessive reassurance about increasingly virtual risks does not work. Reassurance must be accurate and specific, or it may be counter productive.

Short and Long Term Responses We are constantly told that with terrorism it is not a question of “when, but if”. So let us now consider the scenario that an attack has indeed happened. What happens next? Short term I predict that the acute scenario will be relatively well managed. Contrary to the gloomy predictions beloved on BBC docudramas, there will be little panic. Heroism and altruistic behaviour will be commoner than we imagine. We will muddle through, creating a new set of cultural heroes and stereotypes as we do. And that in itself is important – populations under stress need heroic models to pattern their own responses and behaviours. Afterwards there will be an orgy of “lessons learned” papers and meetings, but the theme will be “things could have been worse”, or as Tom Glass puts it in his contribution (Chapter 3) – “it’s a miracle more people weren’t killed”. But what about the psychological consequences – are there things we should be doing that will decrease psychological distress? We will certainly try. Whether we like it or not, almost before the blue lights stop flashing, the call will go out for counsellors, or “trained counsellors” as they are inevitably called. And they will respond with the usual intervention – some form of rapid psychological debriefing. Which would be fine if it works, but unfortunately it doesn’t. Randomised controlled trials leave little doubt that immediate post trauma counselling does not reduce psychological distress [6]. And indeed there is some evidence that it may make some people worse [7]. Perhaps by promoting the idea that without it large numbers of people will develop psychiatric disorder, or by impeding our natural methods of coping by talking to family and friends. Or perhaps it is not always “good to talk” – some

188

S. Wessely / Short and Long Term Psychological Reactions to Terrorism

find it too painful or intrusive, others prefer emotional reticence over disclosure, even if that is currently unfashionable. The reason for the failure of debriefing perhaps does not matter – what matters is to recognise that immediate counselling of normal people who have been exposed to adversity does not promote resilience. Instead, emotional support comes from a person’s own social networks – family, friends, colleagues, family doctor, priest etc. These are people who knew us before the trauma, and will know us afterwards. It is the task of authority to facilitate, not replace, this. So should we do nothing? No. There is much that can be done to reduce psychological distress and promote resilience/coping. In brief, however, these interventions are always more practically than emotion based. The account given by Cameron Ritchie of immediate support in the aftermath of the Sept 11th attack on the Pentagon gives an elegant description of the provision of practical help. Cam Ritchie’s account of the response to the Pentagon attack describes how each bereaved family was assigned a “casualty assistance care officer (CACO)”, who stayed with the family to help them negotiate all of the financial and other issues related to sudden death [8]. It is this type of “nuts and bolts” help which is the immediate and most pressing priority, and is itself a mental health intervention in all but name. First and foremost comes the provision of information. Lack of information promotes anxiety, knowledge promotes coping. Rumour, myth and panic flourish in information vacuums. Few will need persuading that the provision of timely and accurate information is vital – but many may be unaware that is in itself a powerful mental health intervention. Second, mental health support also comes indirectly from practical support. In the immediate aftermath what people need is security, warmth, shelter, and most of all, communication, as Jamie Pennebaker described in his contribution to the meeting. Communication from the authorities, but also communication with their own social networks. Anything that can be done to maintain these will foster social resilience, reduce panic and protect mental health. We know that the first response most people make to an acute adverse event is to attempt to communicate with their loved ones. Research from Israel on behaviour after terrorist incidents shows that provided this happens, people then are able to continue their lives, but if it is blocked, then they become more anxious and behave differently. There are some reasons why the authorities might wish to reduce the public’s use of communications, especially mobiles, in the after math of a terrorist incident, but the advantages of this should be set against the disadvantages in terms of promoting resilience. We can also be fairly confident that the majority of those seeking medical aid after a CBRN incident will not directly require medical attention, but are doing so because of anxiety, uncertainty over perceived symptoms, or general health concerns. Estimates vary, but most assume that these numbers will exceed those directly affected by an order of magnitude [9]. It is very unlikely that stretched emergency services will be able to cope with these numbers, especially if the hospital services themselves are in “lock down” because of contamination risk. These people also have information needs, which are unlikely to be met unless preparations have been made. Thought should be given to stockpiling simple information cards to be available via (or perhaps outside) hospitals with information on likely emotional reactions and how people can manage these themselves.

S. Wessely / Short and Long Term Psychological Reactions to Terrorism

189

Longer term And then what? Things settle down. Buildings are decontaminated. The tube is reopened. The vaccination programme is no longer needed. And so on. A collective sigh of relief all round. And then someone in the affected area has a miscarriage, gives birth to a handicapped child, develops a cancer, or just starts to feel unexpectedly exhausted. And here we go again. What are they not telling us? Is it really safe? Can we trust the government scientists? Or should we trust that charismatic maverick scientist who tells us that the levels aren’t safe at all, and who now seems to be commanding almost unlimited coverage? Is there a cover up? It’s happened before, people say. Remember Gulf War Syndrome, MMR, BSE, the Amsterdam El Al crash, Camelford, Chernobyl and so on and so forth, going back to Agent Orange or the alleged cover up of nuclear test volunteers. And now up goes anxiety, down goes confidence, up goes symptoms and down goes trust This is the scenario that myself and others have discussed in our contribution and elsewhere [10–12]. There is no simple solution to this scenario. It will be easy to manage however if i) During the acute crisis the authorities were perceived as being as open as possible commensurate with security. ii) That whatever the risk, it is seen as being equitable – that the authorities are responding fairly – and not, for example, seeming to discriminate between poor postal workers and comfortable information rich Congressional staff. iii) That at least some attempts were made during the acute incident to maintain a register of who was, and who was not, exposed (see Havenaar and Bromet, Chapter 5). iv) That the authorities have a programme of sensible research in place from an early period, and not in response to later public/media pressure. It is this situation that most taxes the authorities. So my prediction is that after a CBW attack the acute effects will be less than you fear, and the long term effects more insidious and difficult to manage than you imagine.

References [1] Jones E, Woolven R, Durodie W, Wessely S. Public panic and morale: a reassement of civilian reactions during the Blitz and World War 2. Journal of Social History 2004; in press. [2] Glass T, Schoch-Spana M. Bioterrorism and the People: how to Vaccinate a City against Panic. Clinical Infectious Diseases 2002; 34: 217–223. [3] Solomon Z. Coping with War-Induced Stress: The Gulf War and Israeli Response. New York, NY: Plenum Press, 1995. [4] Shephard B. A War of Nerves, Soldiers and Psychiatrists 1914–1994. London: Jonathan Cape, 2000. [5] Warwick HM, Salkovskis PM. Reassurance. British Medical Journal 1985; 290: 1028. [6] Wessely S, Bisson J, Rose S. A systematic review of brief psychological interventions (“debriefing”) for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. In: Oakley-Browne M, Churchill R, Gill D, Trivedi M, Wessely S, eds. Depression, Anxiety and Neurosis Module of the Cochrane Database of Systematic Reviews. Issue 3 ed. Oxford: Update Software, 2000. [7] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [8] Ritchie C, Leavitt F, Hanish S. The Mental Health Response to the 9/11 Attack on the Pentagon. In: Neria Y GR, Marshall R, Susser E, ed. 9/11: Mental Health in the Wake of a Terrorist Attack. New York: Cambridge University Press, 2005.

190

S. Wessely / Short and Long Term Psychological Reactions to Terrorism

[9] Stein B, Tanielian T, Eisenman D, Keyser D, Burnam M, Pincus H. Emotional and behavioral consequences of bioterrorism: planning a public health response. Millbank Quarterly 2004; 82: 413–455. [10] Hyams K, Murphy F, Wessely S. Combatting terrorism: recommendations for dealing with the long term health consequences of a chemical, biological or nuclear attack. Journal of Health Politics, Policy and Law 2002; 27: 273–291. [11] Engel C, Adkins J, Cowan D. Caring for medically unexplained symptoms after toxic environmental exposure: the effect of contested causation. Environ Health Persp 2002; 110 (Suppl 4): 641–647. [12] Hassett A, Sigal L. Unforseen consequences of terrorism: Medically unexplained symptoms in a time of fear. Archives of Internal Medicine 2002; 162: 1809–1813.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

191

Responding to Chemical, Biological, or Nuclear Terrorism: The Indirect and Long-Term Health Effects May Present the Greatest Challenge1 Kenneth C. Hyams a , Frances Murphy a and Simon Wessely b a Department of Veterans Affairs b Guy’s, King’s, and St. Thomas’s School of Medicine and Institute of Psychiatry, London

Introduction The possibility of terrorists employing chemical, biological, or nuclear/radiological (CBN) materials has been a concern since 1995 when sarin gas was dispersed in a Tokyo subway. Contingency planning almost exclusively involved detection, containment, and emergency health care for mass casualties. However, it is clear that even small-scale CBN incidents – like the 2001 spread of anthrax spores through the mail – can cause widespread confusion, fear, and psychological stress that have lasting effects on the health of affected communities and on a nation’s sense of well being. More emphasis therefore needs to be placed on indirect effects and on the medical, social, economic, and legal consequences that follow months to years afterwards. To respond effectively to CBN attacks, a comprehensive strategy needs to be developed that includes not only emergency response but also long-term health care, risk communication, research, and economic assistance. Organizing an effective response challenges government institutions because the issues involved – eligibility for health care, the effects of low-level exposure to toxic agents, stress-related illnesses, unlicensed therapeutics, financial compensation – are complex and controversial. Few can doubt the enormous importance now being given to the possibility that future terrorism using chemical, biological, or nuclear/radiological (CBN) materials could cause mass numbers of casualties [1,2]. For example, it has been estimated that 100,000 deaths could result from an airborne release of anthrax spores over a large urban area [3]. As a consequence, the USA now devotes considerable funding, resources, and training to the rapid detection and containment of a CBN attack and to the provision of emergency health care. Although a catastrophic attack is conceivable, it is more likely that limited casualties would result from direct exposure to CBN agents because of technical difficulties in 1 An earlier version of this paper was published in the Journal of Health Policy and Law, and is reproduced by kind permission of the editors.

192

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

using these weapons against civilian populations [4]. Nevertheless, the confusion, fear, and long-term health consequences still may be severe. As demonstrated by the events of 2001 involving letters containing anthrax spores, even a small-scale attack with CBN materials can have a profound impact on the health of a community and a nation’s sense of well-being [5,6], and lead to protracted social and economic problems [1]. Why are terrorist attacks using CBN materials so devastating? As Ritchie and Pastel have already pointed out in the opening chapter, terrorism already is frightful, but the use of unconventional weapons is even more so. CBN agents are terrifying because they cause injury and death in strange and prolonged ways [2]. In addition, we feel more vulnerable to these weapons than conventional explosives because they can harm large numbers of ordinary citizens in places generally considered safe, like at the workplace and in residential neighborhoods. Other characteristics of CBN weapons place them in the category of health hazards that are likely to cause both public fear and heightened anxiety [7,8]. A large body of research has indicated that the following features of a health threat are associated with prolonged effects: 1) involuntary threats that occur without warning (as opposed to personal choices like cigarette smoking); 2) man-made threats versus natural disasters (“acts of God”); 3) unfamiliar threats with unknown health effects; and, 4) threats that pose a danger to children and future generations [9,10]. It is clear that CBN weapons fulfill all of the criteria for creating a major catastrophe. Not only are these weapons intended to cause death and terror, but a CBN incident has the characteristics of disasters that induce lingering medical, psychological, and social reactions. In order to combat acts of mass terror, contingency planning has to involve more than just emergency response. An effective strategy will have to consider a broader array of immediate and long-term consequences, which will arise regardless of the type of toxic exposure or number of casualties [11,12].

Immediate Harm The first casualties of a terrorist attack result from the direct effects of the CBN agent. Emergency response training is ongoing for this eventuality. This aspect of medical care may appear clear-cut but could cause immediate controversy. Prophylactic measures that have been used to protect against biological and chemical warfare agents – like the anthrax vaccine and pyridostigmine bromide pills – have been postulated to cause chronic medical problems [13,14]. Attempts to use these problematic drugs and vaccines fuel controversy and add to an affected community’s health concerns [15] – the direct effect of the 1991 Gulf War in terms of conventional casualties was thankfully light, but the indirect effect of the health effects arising around the so called Gulf War Syndrome continue to confound and dismay. In addition to direct harm from a CBN agent, the impact on those not exposed may be almost as traumatic, as amply demonstrated since the terrorist attacks on the World Trade Center and Pentagon. In the immediate aftermath of a large-scale CBN attack, there is fear and bewilderment [11]. Everyone involved worries about his or her families and friends. Accidents can occur from people fleeing the disaster area. Essential hospital employees may be incapacitated by secondary exposure to the CBN agent or leave work out of personal concerns [5]. The normal reaction to an unfamiliar, life-threatening event – fear, confusion, and flight – could cause greater damage than the attack itself [16].

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

193

Until the nature of the CBN exposure is clearly determined, uncertainty and fear would be present even among skilled rescue and medical personnel [11]. Although prophylactic drugs and vaccines and the use of gas masks and protective clothing help alleviate anxiety among “first responders,” dramatic and hurried activities of rescue workers frighten residents of the disaster area [17]. The perceptions of a much larger population can be affected by television and newspaper reports of emergency medical care and decontamination efforts [18]. Media images of spacesuit-clad investigators unsettled a worldwide audience during the 2001 anthrax scares [19]. With uncertainty about the identity of the perpetrators and extent of anthrax contamination, no person is certain they will not be involved in a terrorist attack. Following reports of a CBN attack, health care facilities can become quickly overrun by both medical and psychological casualties, and concerned citizens [1]. For example, after the anthrax deaths, it has not been possible to satisfy public demand for ciprofloxacin, an antibiotic approved for the treatment of anthrax; patients have inundated emergency rooms seeking reassurance; and, the public health system has been stretched to the limit trying to screen populations that may have been exposed to contaminated letters [20,21]. For another example, after the “Goiania” incident in Brazil, in which accidental exposure to a medical radiation source led to several hundred casualties and four deaths, 10 percent of the population (more than 100,000 people) sought medical checks [22,23]. Urgent questions can be expected about the causes of common physical (somatic) complaints because non-specific symptoms are often the first manifestation of injury from CBN agents [15,24]. However, somatic symptoms are frequently reported in healthy populations of adults and become even more prominent under stressful circumstances [25,26]. We know that general distress rose after the Sept 11th attacks, including sleeplessness, headaches, palpitations, and so on [27]. Common flu-like symptoms, like cough and feverishness, are particularly frightening after an attack with anthrax spores. Symptoms that arise from normal fear and uncertainty in a chaotic emergency, like headaches and difficulty concentrating, are indistinguishable from the early effects of nerve gas exposure [16]. The non-specificity of these symptoms and the resulting difficulty in rapidly determining their causes, can misdirect and deplete emergency medical care and containment resources. Even though there has been acknowledgement that the indirect consequence of a CBN incident will be substantial [1], official planning may nevertheless underestimate the potential scale of the response. With uncertainty about who was exposed and whether further exposures were occurring, large numbers of both endangered and unaffected residents will present to medical care providers with health concerns, as occurred after the release of sarin in a Tokyo subway [28] and again in 2001 following potential exposure to anthrax spores [21]. Additionally, stress, fear, worry, and grief can exacerbate existing medical and psychological problems in the entire community. As one example of indirect outcomes, a widely reported CBN incident could act as a powerful trigger for outbreaks of “mass sociogenic illness”. In fact, several outbreaks have occurred in the aftermath of recent terrorist attacks [29]. These episodes of physical symptoms suggestive of acute injury, which have been misleadingly called “mass hysteria,” can be set off by toxic exposures, unusual odors, or even rumors of contamination [30]. The immediate response to multiple casualties, such as the arrival of emergency workers wearing decontamination clothing and television cameras, accelerates the spread

194

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

of this illness [31,32]. It is important to realize that mass sociogenic illness can affect any population, given the appropriate circumstances of stress, fear, and confusion [30]. Because there is limited understanding of this phenomenon, symptoms of mass sociogenic illness frequently are medicalized rather than treated with education and reassurance, which subsequently leads to protracted controversy in affected communities. In addition to increased demands for health care after a CBN attack, immediate changes in reproductive behavior may occur. Following the Chernobyl radiation disaster there was a decrease in the birth rate across Western Europe and an increase in induced abortions [33,34]. More recently, abortions and delayed pregnancy became an issue in the Balkans during aerial bombing of chemical plants [35]. Similar fears about birth defects were expressed by victims of the 1995 Tokyo sarin attack [36]. Whether recent terrorist attacks will affect reproductive behavior is not yet known, but numerous “anthrax hoaxes” were perpetrated against abortion clinics in the United States immediately following reports that anthrax spores were being spread through the mail [37]. For the emergency response to a major CBN event, planning therefore has to take into account two different health care scenarios. The first relates to managing the deaths and injuries caused directly by the attack. The second involves dealing with the fears, health concerns, and psychological reactions that normally arise in disasters. Because enormous numbers of people will feel at risk before the extent of exposure can be determined, these indirect consequences may pose the greater challenge to authority, acute health care, and public confidence. After the emergency response, many of these initial health problems may have prolonged consequences.

Long-Term Consequences As natural and man-made disasters have shown, the long-term effects can be substantial. Experience indicates that following a CBN attack there would be four major health concerns: 1) chronic injuries and diseases directly caused by the toxic agent; 2) questions about adverse reproductive outcomes; 3) psychological effects; and, 4) increased levels of somatic symptoms [26,38,39]. Acute injuries caused by a particular CBN exposure are manageable because they can be identified and treated according to established guidelines. As during the emergency response, more difficulties may result over the longer term from harder to prove or disprove health outcomes. For instance, cancer, birth defects, and various neurological, rheumatic, and immunological diseases are increasing being attributed to diverse types of chemical and radiation exposures [40]. There are many social, historical, and cultural reasons why these health concerns would be prevalent after a CBN attack. Everyone has been sensitized by the AIDS epidemic, mad cow disease, and numerous environmental tragedies. The scientific debate over the health effects of pesticides, genetically modified foods, electrical power lines, and cellular telephones also has influenced public perceptions. The result is a heightened sensitivity over environmental exposures. A terrorist attack not only would create new fears but would surely amplify existing concerns about the safety of our food, water, and air. For instance, residents downwind of an anthrax-contaminated building in Florida have been concerned about the possibility of infection [20]. The current scientific uncertainty over the chronic health effects of low level exposure to toxic agents will further increase anxiety in the affected communities [41].

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

195

Because health officials cannot give blanket assurances that no harm will result from brief or non-symptom producing exposure to chemical, biological, or radiological materials [14], distrust of medical experts and government officials may result. Furthermore, unconfirmed and controversial hypotheses about the health effects of exposure to CBN materials can become contentious scientific and legal issues [42]. One contemporary example demonstrates the potential long-term impact of environmental concerns. Residents in a market town in the west of England have blamed a variety of health problems on “germ warfare experiments” that involved aerial spraying of bacteria 30 years ago during the Cold War [43]. What is noteworthy is the wide range of conditions attributed to the experiments – cancers, cerebral palsy, Down’s syndrome, miscarriages, learning difficulties, autism, skin ulcers, to name a few. The result has been “an entire Dorset village torn apart.” The aftermath of the 1992 El Al crash in an Amsterdam suburb has led to a decade of unexplained health concerns, conspiracy theories and mistrust [44]. The long-term psychological consequences of a CBN incident also can be substantial. Post-traumatic stress disorder (PTSD) affects victims, witnesses, and rescue workers most directly involved in the initial exposure. However, PTSD will be only one of the mental health problems facing a community, as demonstrated in Japan following two terrorist attacks with the chemical nerve agent, sarin [36,45]. The anthrax episode in the United States caused routine activities that once felt familiar and safe, like visiting the post office, to seem threatening and strange [46]. The general level of fear and anxiety will remain high for years, exacerbating pre-existing psychiatric disorders [47,48]. While we have considerable information about high background levels of physical symptoms in adult populations, there is less understanding of the causes of more complex symptoms and of the factors that affect the experience and reporting of distress [49,50]. As a consequence, when clusters of unexplained symptoms have been observed following toxic exposures [44,51], there is often heated debate over the role of psychological stress in causing or contributing to reported health problems [13,52–54]. These controversies are difficult to resolve because stress is an inevitable aspect of any life-threatening experience. A population exposed to a terrorist attack experiences both direct injuries and numerous physical symptoms due to prolonged stress, muscular tension, and sleep deprivation [55,56]. As noted in the discussion of emergency medical care, public concern can arise from well-intended health care decisions. The non-standard, off-label, and even investigational drugs and vaccines that may help save lives in a CBN attack can become protracted health and legal issues. In particular, therapeutic agents that have not received official approval, like licensing from the U.S. Food and Drug Administration (FDA), are distrusted [57]. Increased symptoms and illnesses reported long after a terrorist attack may be attributed to side effects of medical interventions [14]. A misunderstanding of the nature of “off label” prescribing was one more factor contributing to the Gulf War Syndrome controversy. It has been difficult to obtain FDA approval for many potentially useful therapeutic and prophylactic measures because CBN materials are too toxic to expose human volunteers in required efficacy studies [12]. To address this problem, the FDA is considering a different standard – the use of animal studies – for the approval of new vaccines and pharmaceutical products to counter chemical and biological warfare agents [58]. These rule changes will directly impact the development of a new generation of vaccines for

196

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

anthrax and smallpox because it is not ethically feasible to expose study subjects to these deadly diseases in order to demonstrate protection. Controversy over the health effects of hazardous exposures and therapeutic interventions may impede other aspects of the recovery effort. As in any disaster, government assistance will be required to rebuild communities and restore the local economy. However, the issue of compensation for personal injuries could have a damaging effect on public faith in government [38]. The reason is that many health claims will be hard to prove or to relate to the CBN incident, and the field will be open to contested or even “junk” science [59]. The fear of “cover up” may surface, and litigation will lead to an adversarial relationship between the public and government. Assigning blame and legal liability could become the focus of acrimonious public and political debate, which hinders public health efforts, public trust, confidence and ultimately health [54,60]. The nature of the particular terrorist weapon also has a consequential impact on recovery efforts. For example, chemical nerve agents dissipate rapidly and would not pose a long-term health risk [12]. In contrast, anthrax spores and radiological material can persist in the environment for decades, which would make decontamination efforts problematic and lead to persistent health concerns. The demographic and cultural characteristics of an affected community, as well as the availability of public transportation and medical and social services, further influence recovery efforts [56]. Less well-off communities need greater medical, social, and economic assistance. In wealthy communities, however, it is difficult to monitor the health impact of the attack because residents have greater mobility and access to a diversity of health care services. The economy of a community may be permanently harmed because of fears that locally produced agricultural and manufacturing products may be contaminated with harmful CBN agents [23]. For the same reason, the value of individual homes and commercial property could drop precipitously, which will engender feelings of hopelessness in the community [23].

Recommendations A community attacked with a CBN weapon will need both emergency intervention and long-term health care, extensive medical and risk assessment information, and economic support. Also, multiple challenges to the credibility of governmental and scientific authority could hamper recovery efforts. The following recommendations can be made for dealing with these consequences.

Health Care Emergency response teams already train for acute medical care of mass casualties. What remains to be decided is how long health care should be provided and whether health care should be comprehensive or restricted to the probable toxic effects of the CBN agent. These are critical questions in countries like the United States, which does not have universal health care. In the event of a large-scale CBN attack, there are compelling reasons for offering comprehensive health care over an extended period of time. For one,

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

197

readily available clinical care would ensure that an affected community’s health care needs are met, which is arguably a prime responsibility of the government after a disaster. In addition, provision of medical care represents one of many tangible indications that the government is committed to recovery, and as such helps restore confidence in public institutions. The need for readily available health care and specially trained providers cannot be underestimated. The “Gulf War syndrome” controversy demonstrates how complex health issues can become after a possible CBN attack and how important it is for health care providers to have up-to-date information [61]. When a traumatized population cannot obtain answers to health questions from knowledgeable providers, misinformation fills the void, and concerns multiply. Moreover, specially trained providers could maintain standardized medical records, which are important for scientific and medical-legal purposes. Although it can be argued that freely available health care will foster the sick role and prolong disability, properly trained health care providers can help patients work through their health problems and grief, with restoration of function as the primary goal of treatment. Although offering mental health care after an act of mass terror is important, immediate grief counseling or psychological debriefing is not be the most effective approach [62,63], may waste scarce resources on the vast majority who whilst distressed are certain to recover, and finally divert attention and the resource from the small minority who do need long term help and care [64]. There is a concern that mental health resources and enthusiasm will be dissipated providing short term care, and then no longer be available in the long term. This would be an error, since whilst there is little to no evidence that short term interventions do prevent psychiatric morbidity and more worryingly, increasing evidence that they do harm [63], in contrast there is powerful evidence that mental health interventions do improve outcomes with established disorders such as post traumatic stress disorder.

Risk Communication and Management A concerted risk communication and management effort is critical after a CBN attack in order to keep the public informed and to promote recovery [65]. In the immediate aftermath of a terrorist attack, the primary method for rapidly disseminating information is through the popular news media. Accordingly, public officials and scientific experts have to be as open, clear, and forthcoming as possible with the press and the development of an adversarial relationship avoided. (see Appendix 2) After a community’s sense of well-being has been shattered, there is a tendency for information and reassurance to be met with disbelief and anger [38,66]. A frustrated press corps only makes communicating with the public harder. These issues are addressed further in Appendix 1. To enlist the help of the press, health officials have to provide the press with the best available information. It is important for crisis managers to work cooperatively with the press to discourage the reporting of false rumors and inaccurate information, while at the same time not providing false reassurance [67]. The press also has to educate itself about a new health threat in order to accurately report the news, as exemplified recently by early media reports that did not distinguish between anthrax exposure and infection. Over time, diverse methods have to be developed for communicating with the affected

198

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

population [68]. These include mass mailings, use of the internet (see Chapter 13), and community meetings. In some cultures, but not necessarily all, open meetings may help disseminate useful information and involve the public in the recovery process, which speed recovery and increase confidence in governmental actions [11]. Effective risk communication is a long-term process that requires a two-way exchange of information with the affected population (see Appendix 2). Public concerns should also be addressed by working closely with community leaders [69]. Maintaining credibility over the long-term will be one of the most difficult challenges for government institutions. Precipitous decisions made in a crisis to care for casualties and to prevent further injury will be judged later in a deliberative manner using more complete and accurate information. Mistakes will be identified. The government should take responsibility for its mistakes and clearly explain the reasons for critical decisions in order to maintain trust. As noted, unsupported health claims could become a problem. There will be nonorthodox views and hypotheses on events and scientific issues [13,70,71]. These ideas cannot be ignored but public health policy and medical care cannot be based on unsubstantiated opinion. A successful risk communication strategy has to deal fairly and openly with unproven assertions and new hypotheses, not least because the existence of dissident views appeals to the popular media’s commitment to balanced reporting [72– 74]. Nevertheless, it cannot be denied that maverick scientific opinion will play an important part in reducing public confidence and trust after a CBRN incident, and that as yet there is no clear guidelines on how this should be managed. For recovery to work, risk management efforts have to prevent demoralization and ensure that members of the affected population are ultimately characterized as “survivors” rather than as “victims.” A shift in thinking from vulnerability and dependency to pride in overcoming adversity will do more to overcome long-term health problems in both the targeted community and the nation at large than any other health measure [75, 76]. Even after a devastating disaster, communities display substantial resilience when not rendered helpless and passive in the recovery process [55]. Additionally, rapid financial assistance and the rebuilding of the community’s economy provide substantial health benefits [77].

Surveillance and Research An extensive surveillance and research effort is important following a major CBN attack. The identification of persons injured or killed by a CBN weapon will be a priority during the emergency response. Accurate detection requires the establishment of a “case definition,” of affected individuals [78]. This case definition should be based primarily on the objective characteristics of the injury caused by the particular CBN exposure [2]. Diagnostic criteria should not rely on non-specific symptoms that become prominent in a highly stressful situation and may be related to mass sociogenic illness [18]. Misclassification of unaffected communities as exposed to a deadly CBN agent will not only misdirect emergency efforts but confuse the public and result in protracted scientific and legal disputes about who was injured. The recent confusion over who may have been exposed to anthrax spores from contact with contaminated mail could easily lead to prolonged controversy.

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

199

After a major CBN attack, longitudinal surveillance studies should be initiated. Evidence-based answers have to be available for questions that will arise after a toxic exposure about increased rates of various diseases, birth defects, physical and mental symptoms, and psychiatric disorders. Failure to conduct epidemiological surveillance is likely to lead to accusations of government insensitivity, incompetence, and cover-up [26]. Delaying sound research also opens the door to unsubstantiated claims and may eventually preclude the initiation of definitive research studies because accurate data becomes less accessible over time [14,79]. Although a concerted research effort may be misinterpreted as evidence of more widespread harm than officially acknowledged [18], it is better for the responsible authorities to initiate scientific investigations rather than to be pushed into them by public and media criticism [38]. By being able to respond to the public’s legitimate need for answers, fear and anxiety can be lessened and credibility of responsible authorities improved. Research is necessary, not only to answer pressing health questions but as part of the risk management process itself. To implement the preceding set of recommendations, a high degree of communication, coordination, and cooperation is required among governmental and social institutions. To organize an effective response is difficult given the many different groups involved, such as: the civilian government agencies at the local, state, and national level; law enforcement; the military; emergency response teams; community health care providers; social services; local business interests; the court system; and, the news media [80]. Because most of these organizations are not accustomed to working together and have different priorities, conflicts arise. Therefore, clear lines of authority are essential to guide an effective response and recovery effort [81].

Conclusion Because of the success of recent terrorist attacks, concrete steps have to be taken now to better prepare for further threats. Along with efforts to prevent acts of mass terrorism and to mount an effective emergency response, greater discussion and awareness are needed about the potential for indirect and long-term consequences. Without a comprehensive plan of action that considers all eventualities, government agencies are more likely to respond ineffectually or to over-react, creating unnecessary panic and infringing on basic civil liberties [5,82]. Thorough preparedness could also aid deterrence efforts. In the future, terrorists may be dissuaded from attempting to use these technically demanding and unpredictable agents if they think the government’s responses will minimize widespread injury and fear. Responding to an actual CBN attack is an even more daunting task because many of the issues involved – eligibility for health care, the effects of low-level chemical and radiation exposure, stress-related illnesses, unlicensed therapeutics, financial compensation – are complex and controversial. Only government institutions that maintain credibility with the public will be capable of dealing effectively with the broad range of problems that evolve after a terrorist attack. A successful recovery effort must provide for long-term health care, risk communication, and surveillance. Although advanced technologies help in the emergency response, there is a greater need for a general plan of action, central coordination, and basic

200

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

education [83]. Not just the medical community but government officials, the press, and the general public have to be more fully informed about the nature of this threat. Moreover, additional research is necessary concerning the best methods of risk management and communication [84]. Future chemical, biological, or nuclear terrorism should be anticipated. In preparing for these attacks, we have to walk a fine line between lack of preparedness and creating undue fear in our daily lives [85]. Terrorism is not simply about killing people, it is also about destroying our sense of well-being and trust in government. This outcome cannot be allowed to happen either before or after a terrorist attack. References [1] Falkenrath R. Confronting Nuclear, Biological and Chemical Terrorism. Survival 1998; 40: 43–65. [2] Franz D, Jahrling P, Friedlander A, McClain D, Hoover D, Bryne W. Clinical Recognition and Management of Patients Exposed to Biological Warfare Agents. JAMA 1997; 278: 399–411. [3] Inglesby T, Henderson D, Barlett J, Ascher M, Eitzen E, Friedlander A, Hauer J, McDade J, Osterholm M, O’Toole T, Parker G, Perl T, Russell P, Tonat K, and the Working Group on Civilian Biodefense. Anthrax as a Biological Weapon: Medical and Public Health Management. JAMA 1999; 281: 1735–1745. [4] Betts R. The New Threat of Mass Destruction. Foreign Affairs 1998; 77: 26–41. [5] Guillemin J. Anthrax: The Investigation of a Deadly Outbreak. Berkeley: University of California, 1999. [6] Okie S. Use of Anti-Anxiety Drugs Jumps in U.S. Washington Post 2001 14th October; A08. [7] Renn O. Health impacts of large release of radionuclides. Mental health, stress and risk perception: insights from psychological research. CIBA Foundation Symposium 1997; 203: 205–231. [8] Renn O. Mental Health, stress and risk perception: insights from psychological research. Health Effects of Large Releases of Radionucleotides. Chichester: John Wiley, 1997: 205–231. [9] Bennett P. Understanding responses to risk: some basic findings. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford: Oxford Medical Publications, 1999: 3–19. [10] Smith E, Robins L, Przybeck T, Goldring E, Solomon S. Psychosocial consequences of a disaster. In: Janes H, Shore M, eds. Disaster Stress Studies: New Methods and Findings. Washington, DC: American Psychiatric Press, 1986: 50–76. [11] Holloway H, Norwood A, Fullerton C, Engel C, Ursano R. The threat of biological weapons: prophylaxis and mitigation of psychological and social consequences. Journal of the American Medical Association 1997; 278: 425–427. [12] Medicine Io. Chemical and Biological Terrorism: Research and Development to Improve Civilian Medical Response. Washington, DC: National Academy Press, 1999. [13] Presidential Advisory Committee on Gulf War Veterans’ Illnesses. Final Report, December 1996. Washington, DC: US Government Printing Office, 1996. [14] Medicine Io. Gulf War and Health: Volume 1. Depleted Uranium, Sarin, Pyridostigmine Bromide, Vaccines. Washington, DC: National Academy of Sciences, 2000. [15] Rosen P. Coping with Bioterrorism: Is Difficult, but May Help Us Respond to New Epidemics. British Medical Journal 2000; 320: 71–72. [16] Bleich A, Kron S, Margalit C, Inbar G, Kaplan Z, Cooper S, Solomon Z. Israeli Psychological Casualties of the Persian Gulf War: Characteristics, Therapy, and Selected Issues. Israel Journal of Medical Sciences 1991; 27: 673–676. [17] Barker P, Selvey D. Malathion-Induced Epidemic Hysteria in an Elementary School. Veterinary and Human Toxicology 1992; 34: 156–160. [18] Jones T, Craig A, Hoy D, Gunter E, Ashley D, Barr D, Brock J, Schaffner W. Mass Psychogenic Illness Attributed to Toxic Exposure at a High School. New England Journal of Medicine 2000; 342: 96–100. [19] Dobbs M. Anthrax Scare Spreads Around the World. Washington Post 2001 October 18; A15. [20] Firestone D. In Florida, an Anthrax Outbreak Turns the Air into a Terror Suspect. New York Times 2001 October 12. [21] Prial D. New Yorkers Flood Hospitals after Anthrax Case Reported. New York Times 2001 13th October. [22] Collins D, Carvalho A. Chronic stress from the Goiania 137 Cs radiation accident. Behavioral Medicine 1993; 18: 149–157.

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

201

[23] Petterson J. Perception vs. reality of radiological impact: the Goiania model. Nuclear News, 1988: 84–90. [24] Bleich A, Dycian A, Koslowsky M, Solomon Z, Wiener M. Psychiatric implications of missile attacks on a civilian population. Israeli lessons from the Persian Gulf War. JAMA 1992; 268 (5): 613–615. [25] Barsky A, Borus J. Functional somatic syndromes. Annals of Internal Medicine 1999; 130: 910–921. [26] Schwartz S, White P, Hughes R. Environmental threats, communities and hysteria. Journal of Public Health Policy 1985; 6: 58–77. [27] Galea S, Ahern J, Resnick H, Kilpatrick D, Bucuvalas M, Gold J, Vlahov D. Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine 2002; 346: 982–987. [28] Woodall J. Tokyo Subway Gas Attack. Lancet 1997; 350: 296. [29] Wessely S, Hyams K, Bartholomew R. Psychological Implications of Chemical and Biological Weapons. British Medical Journal 2001; 323: 878–879. [30] Boss L. Epidemic Hysteria: a review of the published literature. Epidemiologic Reviews 1997; 19: 233– 243. [31] Krug SE. Mass illness at an intermediate school: toxic fumes or epidemic hysteria? Pediatr Emerg Care 1992; 8: 280–282. [32] Selden BS. Adolescent epidemic hysteria presenting as a mass casualty, toxic exposure incident. Ann Emerg Med 1989; 18: 892–895. [33] Bertollini R, Di Lallo D, Mastrolacovo P, Perucci C. Reduction in births in Italy after the Chernobyl accident. Scandinavian Journal of Work and Environmental Health 1990; 16: 96–101. [34] Knudson L. Legally induced abortions in Denmark after Chernobyl. Biomedicine and Pharmacotherapy 1991; 45: 229–232. [35] Fineman M. Yugoslav City Battling Toxic Enemies. Los Angeles Times 1999 6 July. [36] Watts J. Tokyo Terrorist Attack: Effects Still Felt 4 Years On. Lancet 1999; 353: 569. [37] Booth W. Bioterror Takes on Another Face. Washington Post 2001 21st October 2001; A08. [38] David A, Wessely S. The Legend of Camelford: Medical Consequences of a Water Pollution Accident. Journal of Psychosomatic Research 1995; 39: 1–10. [39] Nakajima T, Ohta S, Fukushima Y, Yanagisawa N. Sequelae of sarin toxicity at one and three years after exposure in Matsumoto, Japan. Journal of Epidemiology 1999; 9: 337–343. [40] Neutra R, Lipscomb J, Satin K, Shusterman D. Hypotheses to explain the higher symptom rates observed around hazardous waste sites. Environ Health Perspect 1991; 94: 31–38. [41] Brown M, Brix K. Review of Health Consequences from High, Intermediate, and Low-Level Exposure to Organophosphorus Nerve Agents. Journal of Applied Toxicology 1998; 18: 393–408. [42] Birchard K. Does Iraq’s Depleted Uranium Pose a Health Risk? Lancet 1998; 351: 657. [43] Townsend M. What Has Caused These Tragedies? Western Morning News 1997 October 16. [44] Yzermans J, Gersons, BPR. The chaotic aftermath of an airplane crash in Amsterdam: a second disaster. In: Havenaar JM CJ, Bromet EJ, eds. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002: 85–99. [45] Ohbu S, Yamashina A, Takasu N, Yamaguchi T, Murai T, Nakano K. Sarin Poisoning on Tokyo Subway. Southern Medical Journal 1997; 90: 587–593. [46] Whoriskey P, Jenkins, Chris. Mailbox Trip Meets with Trepidation. Washington Post 2001 October 24th. [47] Davidson L, Baum A, Collins D. Stress and Control-Related Problems at Three Mile Island. Journal of Applied Social Psychology 1982; 12: 349–359. [48] Prince-Embury S, Rooney J. Psychological symptoms of residents in the aftermath of the Three-Mile island nuclear accident in the aftermath of technological disaster. Journal of Social Psychology 1988; 128: 779–790. [49] Roht L, Vernon S, Weir F, Pier S, Sullivan P, Reed L. Community exposure to hazardous waste disposal sites: assessing reporting bias. American Journal of Epidemiology 1985; 122: 418–433. [50] Shusterman D, Lipscomb J, Neutra R, Satin K. Symptom prevalence and odor-worry interaction near hazardous waste sites. Environ Health Perspect 1991; 94: 25–30. [51] Hyams K, Wignall S, Roswell R. War syndromes and their evaluation: from the U.S. Civil War to the Persian Gulf War. Annals of Internal Medicine 1996; 125: 398–405. [52] Joseph S, Hyams K, Gackstetter G, Mathews E, Patterson R. Persian Gulf War Health Issues. In: Rom W, ed. Environmental and Occupational Medicine. 3rd ed. Philadelphia: Lippincott-Raven, 1998: 1595– 1610.

202

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

[53] Stiehm E. The Psychologic Fallout from Chernobyl. American Journal of Diseases of Children 1992; 146: 761–762. [54] Engel C, Adkins J, Cowan D. Caring for medically unexplained symptoms after toxic environmental exposure: the effect of contested causation. Environ Health Persp 2002; 110 (Suppl 4): 641–647. [55] Bravo M, Rubio-Stipec M, Canino G, Woodbury M, Ribera J. The Psychological Sequelae of Disaster Stress Prospectively and Retrospectively Evaluated. American Journal of Community Psychology 1990; 18: 661–680. [56] Nakano K. The Tokyo Sarin Gas Attack: Victims’ Isolation and Post-Traumatic Stress Disorders. CrossCultural Psychology Bulletin 1995; 29: 12–15. [57] Berezuk G, McCarty G. Investigational drugs and vaccines fielded in support of Operation Desert Storm. Mil Med 1992; 157: 404–406. [58] Zoon K. Vaccines, Pharmaceutical Products, and Bioterrorism: Challenges for the U.S. Food and Drug Administration. Emerging Infectious Diseases 1999; 5: 534–536. [59] Huber P. Galileo’s Revenge: Junk Science in the Courtroom. New York: Basic Books, 1992. [60] Hassett A, Sigal L. Unforseen consequences of terrorism: Meducally unexplained symptoms in a time of fear. Archives of Internal Medicine 2002; 162: 1809–1813. [61] Murphy F, Allen R, Kang H, et al. The health status of Gulf War Veterans: lessons learnt from the Department of Veterans Affairs Health Registry. Military Medicine 1999; 164: 327–331. [62] Wessely S, Bisson J, Rose S. A systematic review of brief psychological interventions (“debriefing”) for the treatment of immediate trauma related symptoms and the prevention of post traumatic stress disorder. In: Oakley-Browne M, Churchill R, Gill D, Trivedi M, Wessely S, eds. Depression, Anxiety and Neurosis Module of the Cochrane Database of Systematic Reviews, Issue 3 ed. Oxford: Update Software, 2000. [63] Emmerik A, Kamphuls J, Hulsbosch A, Emmelkamp P. Single session debriefing after psychological trauma: a meta analysis. Lancet 2002; 360: 736–741. [64] Wessely S, Deahl, M. Psychological Debriefing is a Waste of Time. British Journal of Psychiatry 2003; 183: 12–14. [65] Bennett P, Coles D, McDonald A. Risk communication as a decision process. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford: Oxford Medical Publications, 1999: 207–221. [66] Brewin T. Chernobyl and the media. British Medical Journal 1994; 309: 208. [67] Modan B, Tirosh M, Weissenberg E, et al. The Arjenyattah Epidemic: A Mass Phenomenon: Spread and Triggering Factors. Lancet 1983; ii: 1472–1475. [68] Neutra R. Epidemiology for and with a distrustful community. Environmental Health Perspectives 1985; 62: 393–397. [69] Coote A, Franklin J. Negotiating Risks to Public Health – Models for Participation. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford: Oxford Medical Publications, 1999: 183–194. [70] Glassner B. In the Culture of Fear: Why Americans Are Afraid of the Wrong Things. New York: Basic Books, 1999. [71] Havenaar J, Cwikel J, Bromet J, eds. Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters. New York: Plenum, 2002. [72] Ferreira C. Risk, transparency and cover up: media narratives and cultural resonance. Journal of Risk Research 2004; 7: 199–211. [73] Slovic P. Trust, emotion, sex, politics, and science: surveying the risk assessment battlefield. Risk Analysis 1999; 19: 689–702. [74] Singer E, Endreny P. Reporting on Risk. New York: Russell Sage Foundation, 1993. [75] Giel R. The Psychosocial Aftermath of Two Major Disasters in the Soviet Union. Journal of Traumatic Stress 1991; 4: 381–393. [76] Summerfield D. War and Mental Health: A Brief Overview. British Medical Journal 2000; 321: 232–235. [77] Summerfield D. A critique of seven assumptions behind psychological trauma programmes in war affected areas. Social Science and Medicine 1999; 48: 1449–1462. [78] Brennan R, Waeckerle J, Sharp T, Lillibridge S. Chemical Warfare Agents: Emergency Medical and Emergency Public Health Issues. Annals of Emergency Medicine 1999; 34: 191–204. [79] Engel CJ, Adkins A, Riddle J, Gibson JR, Can We Prevent a Second ‘Gulf War Syndrome’? PopulationBased Healthcare for Chronic Idiopathic Pain and Fatigue after War. Advances in Psychosomatic Medicine 2004; 25: 102–122. [80] Tucker J. National Health and Medical Services Response to Incidents of Chemical and Biological Terrorism. JAMA 1997; 278: 362–368.

K.C. Hyams et al. / Responding to Chemical, Biological, or Nuclear Terrorism

203

[81] Prevention CfDCa. Biological and Chemical Terrorism: Strategic Plan for Preparedness and Response. Morbidity and Mortality Weekly Reports 2000; 49: 1–14. [82] Stern J. The Prospect of Domestic Bioterrorism. Emerging Infectious Diseases 1999; 5: 517–522. [83] Sharp T, Brennan R, Keim M, Williams R, Eitzen E, Lillibridge S. Medical Preparedness for a Terrorist Incident Involving Chemical or Biological Agents during the 1996 Atlanta Olympic Games. Annals of Emergency Medicine 1998; 32: 214–223. [84] Bennett P. Research Priorities. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford: Oxford Medical Publications, 1999: 9–30. [85] Shalala D. Bioterrorism: How Prepared Are We? Emerging Infectious Diseases 1999; 5: 492–493.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

205

Societal Responses to New Terrorism Ben Sheppard 1 King’s Centre for Risk Management, King’s College London

Introduction With much of the homeland counter terrorism effort post 9/11 directed towards enhancing physiological preparation and response mechanisms (decontamination equipment, vaccine stockpiles, etc.), the psychological angle (communicating the terrorism threat, and engaging with the public, etc.) has arguably not been fully explored with the same urgency by governments. Understanding the psychological and behavioural responses of citizens is important for anticipating how the general public may respond to pre and post incident planning. Gaining a proficient understanding of this process is essential for devising and implementing effective communication and emergency response strategies, be they for a large scale conventional strike on the scale of 9/11 or an attack entailing the detonation of a chemical, biological, or a radiological (CBR) device.2 If we do not know where people are coming from with their probable behavioural patterns and existing knowledge base, it is very difficult to get them to another place.3 From the stand point of strategic studies from which this chapter is written from their arguably lacks a proficient understanding of the terror of terrorism on population centres, together with a common assumption that the public can easily panic. For instance Walter Laqueur believes that from “the single successful [WMD] one could unleash far greater panic than anything the world has yet experienced”.4 In addition assessing the impact of terrorism on society is often neglected leading to Paul Wilkinson to observe that: “quantifying the terror of terrorism is a complex issue because of its subjectivity – a possible reason to why other commentators have not focused on the fear and anxiety of terrorism”.5 This chapter suggests that the terror caused by suicide terrorism, mass casualty and CBR terrorism (sometimes referred to as new terrorism) is less than commonly assumed, but that it can lead to a large segment of the targeted populace to change their daily routines (behaviours and attitudes) to reduce the risk of being personally threatened by an act of terrorism. Secondly, this chapter will demonstrate that panic is rare following an attack with the public generally reacting in a calm and calculated way, but this is partly 1 E-mail: [email protected] 2 The devastation caused by a nuclear device requires separate consideration in view of the magnitude of the problems that would be caused. 3 Baruch Fischhoff, “Assessing and Communicating the Risks of Terrorism”, in A.H. Teich, S.D. Nelson, and S.J. Lita (eds.), Science and technology in a vulnerable world (Washington DC: AAAS, 2002), p. 52. 4 Walter Laqueur, ‘Postmodern Terrorism’, Foreign Affairs (September/October 1996), p. 36. 5 Paul Wilkinson, Terrorism and the Liberal State’ (Macmillan Press: 1977), p. 47.

206

B. Sheppard / Societal Responses to New Terrorism

dependent on the effectiveness of the information provided by authorities and their level of engagement (e.g. emergency first responders strategy) with the public. Panic occurs in situations where there is the perception of close physical space, in which there is an immediate and clear threat of death, and in which escape routes will not accommodate all those in danger in the minutes before death comes to those left behind.6 To investigate these strands this chapter will examine the psychological and behavioural responses of the public to four terrorist incidents: The 1995 sarin attack on Tokyo’s subway system, September 11 attacks on the World Trade Center and the Pentagon, the subsequent anthrax attacks, and the current Intifada in Israel. To assess how societal responses may differ from attacks entailing conventional and non-conventional (CBR) devices, the paper will first look at 9/11 and the Intifada followed by the 1995 sarin attack and the 2001 anthrax attacks. The second half of this paper focuses on what lessons could be learnt and applied to civil defence preparation and response mechanisms (for instance threat advisory systems and public health response strategies).

Case Studies Conventional – September 11 Since 9/11 a number of mental health studies have been published providing valuable empirical evidence on the extent a major mass casualty conventional attack can have on a targeted populace and the nation as a whole. Evidence suggests that there was no overt panic in the self-evacuation of the World Trade Center although this might have been because the people concerned largely knew each other beforehand.7 Furthermore very few of those trapped above the impact zone, believing they had a chance of making their way out alive of the WTC, exhibited panic.8 While Americans believed that ordinary citizens behaved responsibly rather than panicked,9 the attacks left a psychological scar that exhibited itself with many changing their behaviour to minimise the risk of terrorism to themselves, as will be discussed later. There are also likely to be long-term mental health problems for a segment of the populace suffering from conditions including depression and PTSD. 9/11 caused an increase in levels of depression, stress and in many cases PTSD among New Yorkers and to a lesser extent the rest of the nation. According to a mental health study by Schlenger et al. the prevalence of PTSD 1–2 months after the attack in the New York City metropolitan area was 11.2%, in Washington DC 2.7%, and the rest of the country around 4%.10 To make a direct comparison between the PTSD levels in New York and the rest of the nation requires taking into account the socio-demographic 6 Dennis S. Mileti and John H. Sorensen, Communication of Emergency Public Warnings: A Social Perspective and State-of-the-art Assessment, a report prepared for the Federal Emergency Management Agency, August 1990, pp. 3–2. 7 “Resilience or panic? The public and terrorist attack”, The Lancet, Vol. 360, 14 December, 2002, p. 1901. 8 Jim Dwyer, Eric Lipton, Kevin Flynn, James Glanz and Ford Fessenden, ‘Fighting to Live as the Towers Dies’, The New York Times, 26 May 2002 [www.nytimes.com]. 9 Baruch Fischhoff, et al., “Evaluating the Success of Terror Risk Communication”, p. 257. 10 William E. Schlenger, et al., “Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans’ Reactions to September 11”, Journal of American Medical Association, Vol. 288, No. 5, August 7, 2002, pp. 581–588.

B. Sheppard / Societal Responses to New Terrorism

207

conditions of the New York area compared to the national average. Once this is factored in, the New York PTSD level declines to 9.4% – still significantly higher than the rest of the nation of around 3–4%.11 Research by Galea et al. calculates PTSD levels in New York at 7.5% and those expressing symptoms of depression at 9.7%.12 Based on the number residing in Manhattan within seven miles from the WTC, it is estimated that 67,000 persons had PTSD and 87,000 depression.13 Therefore ‘probable PTSD’ is associated with direct exposure to the terrorist attacks among adults.14 The prevalence of PTSD in New York is not unexpected given that a study of natural disasters and terrorist acts like the Oklahoma City bombing confirms that PTSD is a probable outcome for many people who were directly exposed to the events of September 11.15 The levels of clinically significant distress meanwhile were far higher than PTSD where they were measured from early October to early November at 16.6% for New York, 14.9% for Washington DC, and around 12% for other major metropolitan areas and the remainder of the US.16 These levels of stress are similar to those uncovered by the Silver et al. who recorded stress nationally at 17% two months after the attacks.17 However, as expected these levels were significantly higher in the week after the attack with a nationally representative survey observing that 44% of respondents reported a substantial stress reaction (symptoms including insomnia and being upset) declining to around 20% by November 2001.18 These figures suggest that stress could reach around 40% nationally in the week following a major conventional attack on the scale of 9/11 to then decline to around 10– 20% in the second month. Levels of PTSD could expect to be around 7–11% for the city 11 Although the original figure in the survey was 11.2%, the researchers had to adjust this downwards in view that examination of the socio-demographic structure of New York City Metropolitan residents (race/ethnicity, age, sex, and education characteristics that were distinct from the national average) revealed they were 2.9 times more likely to be probable cases of PTSD than those elsewhere that day. William E. Schlenger, et al., “Psychological Reactions to Terrorist Attacks”, p. 581. 12 Sandro Galea, et al., “Psychological Sequelae of the September 11 Terrorist Attacks In New York City”, The New England Journal of Medicine, Vol. 346, No. 13, March 28, 2002, p. 982. The survey entailed randomdigit dialling to contact a representative sample of adults living south of 110th Street Manhattan, 7 miles north of where the WTC stood. 13 Sandro Galea, et al., “Psychological Sequelae of the September 11 Terrorist Attacks In New York City”, p. 982. 14 William E. Schlenger, et al., “Psychological Reactions to Terrorist Attacks”, p. 581 The term ‘probable’ was used because the PTSD diagnosis were made on the basis of screening instruments, not comprehensive clinical evaluations. The research was based on a sample of 2,273 adults including over samples of the New York, NY, and Washington DC and other major metropolitan areas. The epidemiological survey were webbased and used a cross-sectional sample. The surveys were sent via e-mail from October 12 through to November 12, 2001. 15 Robert J. Ursano, “Post Traumatic Stress Disorder,” The New England Journal of Medicine, Vol. 346, No. 2, January 10, 2002, p. 131. 16 William E. Schlenger, et al., “Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans’ Reactions to September 11”, Journal of American Medical Association, Vol. 288, No. 5, August 7, 2002, p. 585. 17 Roxane Cohen Silver, et al., “Nationwide Longitudinal Study of Psychological Responses to September 11”, Journal of American Medical Association, Vol. 288, No. 10, p. 1235. 18 Mark Schuster, “What we know about public opinion post September 11,” paper presented to the NATORussia Advanced Scientific Workshop on the Social and Psychological Consequences of Chemical, Biological and Radiological Terrorism, March 25–27, 2002.

208

B. Sheppard / Societal Responses to New Terrorism

that is targeted and around 4% for the rest of the nation. While levels of stress decline and PTSD barely reach double figures for the targeted area, fears of further attacks could initially be considerably high to then decline in subsequent months. A study by Silver et al. found that two months after the attacks nearly two thirds (64%) of the national populace reported fears of future terrorism at least sometimes and 59% reported fear of harm to family as a result of terrorism. Six months after 9/11 these levels declined to 37% and 40% respectively.19 A separate national survey by Huddy et al. conducted October 2001–March 2002 found that 50% of Americans were very concerned that there would be another attack on US soil in the near future and 11% not very or not at all concerned, while 31% were very concerned of becoming a victim of terrorism and 31% not very or not at all concerned. This suggests that Americans believed the risk of further attacks against the nation was greater than being personally threatened by terrorism.20 In addition only 18% believed the attacks had shaken their sense of personal safety and security a great deal while 47% thought the attacks had little or no effect on their sense of safety and security. Therefore the perceived risk of further terrorism was far more widespread than the emotional responses of fear and anxiety.21 As could be expected, the levels of risk appraisal of further attacks was more prevalent among those residing around New York with 82% of respondents in three New York counties 6 weeks after the attacks reporting they were very or somewhat concerned about another major terrorist attack in the future, and 81% concerned about a chemical or biological attack.22 Of particular interest is how the perceived personal risk noted in the surveys manifested itself into changing Americans behavioural patterns. A survey of three counties in New York (October 20–November 11) revealed that a large number changed their everyday lives after 9/11: • • • •

26% had delayed or cancelled plans to travel by air 7% had changed their upcoming holiday plans 18.5% were driving into Manhattan less often 17% using mass transportation into Manhattan less often.23

A separate survey of national trends discovered that in January 2002 13–14% of Americans had altered their travel plans since 9/11 and 5–7% had “stopped flying altogether out of fear.”24 The US Air Transport Association revealed after the re-opening of US airspace after 9/11, passenger traffic was down by almost 40% on the same period the year before, to then gradually recover to 19.8% in November and then 14% in Janu19 Roxane Cohen Silver, et al., “Nationwide Longitudinal Study of Psychological Responses to Septem-

ber 11”, p. 1240. 20 Leonie Huddy, Stanley Feldman, Charles Taber, Gallya Lahav, “The Politics of Threat: Cognitive and Affective Reactions to 9/11”, paper presented at the annual meeting of the American Political Science Association, Boston, 29 August–1 September 2002. 21 Ibid. 22 Leonie Huddy, Stanley Feldman, Theresa Capelos, and Colin Provost, “The Consequences of terrorism: Disentangling the Effects of Personal and National Threat”, Political Psychology, Vol. 23, No. 3, 2002, p. 494. 23 Leonie Huddy, et al., “The Consequences of terrorism: Disentangling the Effects of Personal and National Threat”, p. 505. 24 Erica Goode, “Now, Fear of Flying is More Than a Phobia,” New York Times, January 29, 2002, p. 1. The survey quoted was compiled by Mercer Management Consulting’s global aviation division.

B. Sheppard / Societal Responses to New Terrorism

209

ary 2002.25 A year after the attacks a survey conducted by the New York Daily News in August 2002 found that almost a year on New Yorkers continued to alter their daily lives. 11% were making an effort to avoid potential terror targets, such as subways; 23% avoiding tourist sights, and 20% tall buildings.26 Israel and the second Intifada Research on the psychological reactions of Israelis to the second Intifada is less extensive than that of 9/11, but studies that have been undertaken show a remarkable level of adaptation among Israelis. Key among them is a survey conducted by Bleich et al. in the Journal of American Medical Association published in August 2003.27 Although those surveyed showed distress and lowered sense of safety, they did not develop high levels of psychiatric distress, which may be related to a the populace getting use to the attacks and developing effective coping mechanisms. The survey was conducted in April–May 2002, by which time since the start of the uprising in 2000 there had been 472 persons killed (318 civilians) and 3,846 (2,708 civilians) injured representing 0.067% of Israel’s population of 6.4 million. The research found that 9.4% were found to have PTSD and 58.6% reported feeling depressed. Interestingly the PTSD level is about the same as that found in New York after 9/11. One third (37.4%) reported having at least one traumatic stress related symptom for at least one month. Arguably this is similar to the stress level detected after 9/11 where 44% of respondents reported a substantial stress reaction in the first week declining to around 20% by November 2001.28 What is striking about the study is the high level of confidence found among Israelis. 82.2% expressed optimism about their personal future and 66.8% expressed optimism about the future of Israel. This is despite that 60.4% had a low sense of personal safety and 67.9% low sense of safety for their relatives. Whenever an attack occurred over three quarters (80%) had phoned to check on the whereabouts of family and friends and a third always use this method of coping. Just under three quarters (72%) believe an effective way of coping is to accept and come to terms with the situation as it is. Despite the high levels of confidence, those directly exposed to terrorism have shown symptoms of acute distress in the hours following an attack. 60% of terror-related emergency room admissions to Israel’s Hadassah University Hospital in the first 24 hours of a terrorist attack have been psychological.29 Hadassah Hospital has taken care of more terror victims than any other hospital in Israel. To reduce the psychological impact of terrorist attacks, Israeli authorities are quick to remove the scares on the physical environment following an attack including the re25 Erica Goode, “Now, Fear of Flying is More Than a Phobia,” p. 1. 26 Russ Hoyle, “A year later, a city is still on edge”, New York Daily News, September 1, 2002, p. 1. The poll interviewed 503 adults in New York City on August 20–21 by Blum & Weprin Associates. The margin for error was plus or minus 4.5%. 27 Avraham Bleich, Marc Gelkopf, Zahava Solomon, “Exposure to terrorism, Stress-Related Mental Health Symptoms, and Coping Behaviors Among a Nationally Representative Sample in Israel,” Journal of American Medical Association, 6 August, 2003, Vol. 290, No. 5, pp. 612–620. 28 Mark Schuster, “What we know about public opinion post September 11,” paper presented to the NATORussia Advanced Scientific Workshop on the Social and Psychological Consequences of Chemical, Biological and Radiological Terrorism, 25–27 March, 2002. 29 Arieh Y. Shalev, “Continuous Terrorism in Israel, 2000–2004,” p. 6. Forthcoming.

210

B. Sheppard / Societal Responses to New Terrorism

pair of buildings, the removal of gruesome reminders and even the replacement of trees within hours of an event.30 In addition the public are kept fully informed within minutes to hours and days following an attack to include casualty rates, road access, sources of advice, and receiving hospitals. According to Ariah Y. Shalev this is ‘extremely important psychologically since for most of the population the information provided signals the absence of proximal threat, and therefore constitutes a safety signal.’31 Assessing the behavioural changes in the Israeli populace reveals a number who have altered their daily routines. For instance the Israeli bus system has seen a major reduction in usage. Prior to the Intifada it was extremely popular and well organized, but bus travel has declined a great deal with the less well off and soldiers now using it the most. While Israelis at the initial stage of the Initifada avoided public places like shopping malls at certain times, this has become less prevalent with evidence suggesting Israelis are adapting to the situation and returning to a near normal lives much as possible although families still report of being on a roller coaster ride of when and where not to go to public places like the mall, restaurants, and cinemas. Many of those who used not to go anywhere during the early days of the uprising now do, although there are those who still avoid certain public places. In addition many large-scale public events like Independence Day celebrations and annual big parades cancelled in the early period of the Intifada have in the past year been re-instated. What appears to be happening is that Israelis are adapting to the terrorist threat in their own ways and accepted the situation as part of every day life. Some increasingly venture out to public places as they would normally, while a minority have taken to avoiding certain places at certain times. There are occasions when events cause Israelis to become increasingly risk conscious, for instance the assassination of Sheik Ahmed Yassin in March 2004, the founder and spiritual leader of Hamas. With Israelis expecting a reprisal attack, public places in Jerusalem for instance were very quiet immediately afterwards.32 Although 80% of Israelis polled believed the assassination would lead to more attacks, this did not prevent near normality returning.33 In the following month Prime Minister Aerial Sharon’s counter terrorism advisor believed Israelis were becoming too complacent. In April 2004 the advisor warned Israelis that their alertness had ‘dwindled a bit’ and advised for greater vigilance.34

Chemical, Biological and Radiological Attacks The belief held in some quarters that CBR terrorism can easily frighten and panic the public is similar to the debate that occurred in Britain during the 1930s over the concern that bomber aircraft would always get through to attack cities causing panic and a break down in society. The Blitz on London and other cities during World War Two 30 Ibid., p. 4. 31 Ibid., p. 5. 32 Molly Moore, “Fear of Reprisals Casts a Pall on Jerusalem: Israelis Desert Restaurants and Buses”, Washington Post, 24 March, 2004, p. A01. 33 Ibid. 34 Arieh O’Sullivan, “Anti-terror advisor: Israelis too complacent about security,” Jerusalem Post, [www.jpost.com], 8 April, 2004.

B. Sheppard / Societal Responses to New Terrorism

211

proved civilians to be more resilient than planners had predicted largely because they underestimated their adaptability and resourcefulness.35 Chemical, biological and radiological weapons are traditionally viewed as destroying an individual’s sense of security and trust in their environment, causing shock, horror, helplessness, and panic.36 The fear of the unknown caused by a CBR device with often the inability to see or smell the agent may exacerbate this. Thus the mere threat by terrorists to use such weapons is viewed as potentially breeding ‘panic’.37 Assessment of the 1995 sarin attack in Tokyo and 2001 anthrax attacks suggests that systemic fear and anxiety, let alone panic did not occur following these events. The 1995 sarin attack on Tokyo The religious cult Aum Shinrikyo successfully released sarin against its own people with their attacks on Matsumoto on June 27, 1994 and Tokyo’s subway system on March 12, 1995. The latter injured 3,796 and killed 12 and is the focus of attention in this paper. From the personal accounts given by those in the contaminated subway carriages and stations, there was no real sense of panic from the attacks. Individuals responded in an orderly fashion as they were evacuated from the affected areas. A commuter on the Marunouchi line when asked by the police if people panicked recalled “Everyone was so silent. No one uttered a word.” Even though she knew it was sarin poisoning having read before the symptoms of pupil contractions from sarin attack victims in Matsumoto the previous year, she felt “extremely calm”.38 Similarly a passenger on the Hibya Line remarked that as he walked through the station with collapsed people lying around not knowing if they were alive, “I still didn’t sense any danger. I don’t know why. In retrospect that seems odd – why wasn’t I afraid? – but then neither was anyone else.” Another passenger on the Hibya line reported that when someone came walking from the next carriage where the gas had been released shouting “sarin sarin”, those around him stood up but were not running to escape. When the public address system announced that poison gas had been detected and passengers were advised to head for the safety of above ground, “passengers stood up and got off the train, but still there wasn’t any panic. They walked a little faster than normal, but there was no pushing or anything. Some put handkerchiefs to their mouths or were coughing, but that’s all.”39 Above ground a firefighter who attended the incident later recalled that people coming out of the contaminated subway remained silent. He had never experienced such 35 Edgar Jones, Robin Woolven, Bill Durodie and Simon Wessely, “Civilian Morale during World War Two: responses to air-raids re-examined”, American Journal of Psychiatry [forthcoming]. 36 Carol S. Fullerton, George T. Brand, Robert J. Ursano, “Chemical and Biological Weapons: Silent Agents of Terror”, p. 123, in: Robert J. Ursano and Ann E. Norwood, Emotional Aftermath of the Persian Gulf War: Veterans, Families, Communities, and Nations (Washington DC: American Psychiatric Press Inc., 1996). 37 Robert Kupperman and Darrell Trent, Terrorism: Threat, Reality, Response (Stanford: Hoover Institution Publication, 1979), p. 62. 38 Haruki Murakami, Underground: The Tokyo Gas Attack and the Japanese Psyche (London: The Harvill Press, 2000), p. 99. Haruki Murakami interviewed 60 victims of the subway attack including a relatives of the deceased. 39 Ibid., p. 161.

212

B. Sheppard / Societal Responses to New Terrorism

a scene: “just victims’ coughing heard in the perplexing scene”. The same scene was reported to have occurred in hospitals where victims waited patiently to be treated.40 The only time the victims noted they felt considerable fear was when they had difficulty in contacting the emergency services and the long time it felt for first responders to arrive on the scene. A commuter on the Marunouchi Line platform recalled that only when nobody answered the emergency phone to call for assistance did she then “feel real fear”, adding, “Everything I had believed up until then just crumbled. From that moment on it was total chaos.”41 The delay in the arrival of first responders to treat the injured presented its own problem with passers-by wanting to assist in the rescue operation. In Tokyo a number of the general public assisted in the recovery operation in ferrying the injured to hospital in their own cars and at one subway station flagged down passing cars to speed up the process of getting the injured to hospital. 88% of the 541 who arrived at St Lukes hospital which received the majority of the casualties in the first four hours were brought in by non-medical motorists.42 This large number demonstrates how the general public can voluntarily get heavily involved in a CBR incident in the absence of sufficient first responders or direction, potentially causing problems of secondary contamination. Despite the lack of panic, a large number of passengers incorrectly believed they had been exposed to sarin (what is sometimes called the worried well), and a significant proportion who although were exposed to the sarin did not require hospitalisation. In all around 5,500 people went to 280 medical facilities in the days following the attack. The total number of poisoned victims, as summed up in the police record, came to 3,795 of which 1,046 required hospitalisation – some for no more than a few hours, some for many days.43,44 12 were killed. This left over 1,200 (22%) who arrived at medical facilities believing they had been exposed to sarin, but physiologically they did not require treatment for exposure, and 2,749 (50%) categorised as ‘poisoned’ by the police but not requiring hospitalisation. The number of casualties could have been greater had the sarin been more than 30% pure. This lower concentration was due to production difficulties Aum encountered in manufacturing the chemical. The Tokyo sarin attack suggests that a CBR attack in a densely populated area could lead to only 20–25% of those arriving at medical establishments requiring treatment, half exposed to the agent but not requiring hospitalisation, and a fifth falsely believing they had been exposed. With 72% of arrivals in Tokyo not classified as requiring hospitalisation, suggests that medical establishments could easily be overwhelmed in a major CBR incident when faced with the difficulty of identifying and treating those most in need. 40 Nozomu Asukai and Kazuhiko Maekawa, “Psychological and Physical Health Effects of the 1995 Sarin Attack in the Tokyo Subway System”, in: Johan M. Havenaar and Julie G. Evelyn J. Bromet, Toxic Turmoil: Psychological and Societal Consequences of Ecological Disasters (New York, Kluwer Academic/Plenum Publishers: 2002), p. 153. 41 Haruki Murakami, Underground: The Tokyo Gas Attack and the Japanese Psyche, p. 100. 42 Tetsu Okumura, “Report on 640 Victims of the Tokyo Subway Sarin Attack”, Annals of Emergency Medicine, Vol. 28, No. 2, August 1996, p. 130. 43 Kyle B. Olson, “Aum Shinrikyo: Once and Future Threat?”, Emerging Infectious Diseases, Vol. 5, No. 4, July August 1999, p. 514. 44 Nozomu Asukai and Kazuhiko Maekawa, “Psychological and Physical Health Effects of the 1995 Sarin Attack in the Tokyo Subway System”, p. 151.

B. Sheppard / Societal Responses to New Terrorism

213

A survey of 610 victims (who were hospitalised) conducted within weeks of the incident revealed that 60% of the 475 respondents reported symptoms of PTSD.45 Symptoms victims noted included nightmares, numerous flashbacks that included unusual odours, ambulance sirens, and the sound of coughing of neighbours. This was augmented when using the subways, seeing depictions of the attack on television, and news of other terrorist attacks.46 20% had fears of using the subway.47 The 2001 anthrax attacks The use of the US postal system to attack media and government institutions with anthrax, killing five people in October to November 2001, exposed America to a type of threat they were not fully prepared for or fully understood. At first the authorities believed that the attacks were part of a second wave of al-Qaeda strikes federal authorities had warned of or a diversion for an attack of far greater magnitude. During the anthrax attacks Americans remained calm and resolute while concerned about personal safety – in contrast to some public officials’ expectations of panic. The large-scale public-health campaign was orderly, with hundreds and sometimes thousands of people waiting in line for long periods.48 Despite reports by the media of a reactive and hysterical public, the populace exhibited steadfastness in an environment of uncertainty.49 A series of Gallup polls taken during 2001 suggests that Americans level of perceived personal risk from terrorism did not increase during the anthrax attacks. Gallup asked Americans whether they were worried that they, or a family member, would become a victim of terrorism. While concerns jumped from 49% to 59% after the first reported anthrax case in early October equalling the level recorded just after 9/11, concern dropped steadily to 35% in late November. This was despite that there were three more anthrax deaths in early November, two Department of Justice threat advisory warnings of further terrorist attacks in October and November, and the initiation of hostilities against Afghanistan. To put these concerns into perspective, Americans believed they were five times more likely to get flu than anthrax and almost three times more likely to be injured in a car accident.50 Proximity to the reported anthrax cases influenced the risk perception of contracting anthrax with 26% of Washington DC residents whose workplaces had been closed believing it was likely they would contract the disease, compared to 15% of area residents without any direct experience of the threat, and 9% and the general US population.51 45 Kanzo Nakano, “The Tokyo Sarin Gas Attack: Victims Isolation and Post-Traumatic Stress Disorders”, Cross-Cultural Psychology Bulletin, December 1995, p. 13. 46 Ibid., p. 13. 47 Nozomu Asukai and Kazuhiko Maekawa, “Psychological and Physical Health Effects of the 1995 Sarin Attack in the Tokyo Subway System”, p. 154. 48 Monica Schoch-Spana, “Educating, informing, and mobilizing the public”, in: Barry S. Levy and Victor W. Sidel (eds), Terrorism and Public Health: A balanced approach to Strengthening Systems and Protecting People (New York, Oxford University Press: 2003), p. 122. 49 Ibid. 50 R.J. Blendon, J.M. Benson, C.M. Des Roches, et al., Harvard School of Public Health/Robert Wood Johnson Foundation Survey project on Americans’ responses to biological terrorism. Study 2: national and three metropolitan areas affected by anthrax, November 29–December 3, 2001. 9 December 2001. 51 Ibid.

214

B. Sheppard / Societal Responses to New Terrorism

Nationally 57% of Americans changed their behaviour to minimize their risk of contracting anthrax. Behavioural changes included 12% avoiding public events, one-third exercised caution when opening mail, including 30% who washed their hands afterward, and 6% who wore gloves.52 In the New York area 55% reported handling the mail at home more carefully as a consequence of the news of anthrax contamination.53 A common perception of America’s reaction to the anthrax attacks is the large number who acquired a prescription for antibiotics. The Center for Disease Control (CDC) recommended three antibiotic drugs that could each treat anthrax: ciprofloxacin, doxycycline and amoxicillion. In all CDC advised 10,000 people who were potentially exposed to anthrax in Connecticut, Florida, New Jersey, New York City and Washington DC to take the 60 day treatment. A comparison of the national prescription levels to these drugs in October to November 2001 with the same period in 2000 demonstrates that only a small number of the public purchased these drugs when compared to the size of the US populace. Compared to 2000 levels, ciprofloxacin prescriptions were 40% higher in October 2001, doxycycline increased by 30% during October–November. This corresponded to an increase of 160,000 prescriptions to ciprofloxacin in October, and 216,000 to doxycycline during October–November.54 Overall this represented a total of 376,000 extra prescriptions during October–November 2001 over the year before – representing only 0.13% of America’s population of 290 million. These figures do not include the 10,000 prescriptions prescribed by CDC which came from the National Pharmaceutical Stockpile. In addition a series of Gallup polls taken in mid October 2001 concluded that 70% of respondents reported not having thought of purchasing an antibiotic prescription or a gas mask, and only 2–3% of adults reporting to have done so.55 After the death of two postal workers this increased to 5% reported having obtained the drug, and 1% a gas mask or protective clothing.56 Although 5% reported having obtained antibiotics, only 1% in the survey reported taking the medication. Therefore while a considerable number of Americans were troubled by the anthrax attacks, only a small proportion felt sufficiently concerned to embark on a 60-day medication despite the known side effects. There was however a strong increase in the demand for information by the public as to what measures they could take to reduce the risk of exposure. In a survey by the Harvard School of Public Health 12% of respondents consulted a website for guidance on personal protection, 6% spoke to their physician, 4% 52 R.J. Blendon, J.M. Benson, C.M. DesRoches, et al., Harvard School of Public Health/Robert Wood Foundation survey project on Americans’ response to biological terrorism, tabulation report, October 24–28, 2001. 31 October 2001. [http://www.hsph.Harvard.edu/press/releases/blendon/report2.pdf]. 53 Leonie Huddy, et al., “The Consequences of terrorism: Disentangling the Effects of Personal and National Threat”, p. 497. 54 Douglas Schaffer et al., “Increased US prescription trends associated with the CDC Bacillus anthracis antimicrobial postexposure prophylaxis campaign”, Pharmacoepidemiology and Drug Safety, Vol. 12, No. 3, pp. 177–182. The differing prescription peaks of ciprofloxacin followed by doxycycline are consistent with the CDC’s initial choice of ciprofloxacin followed by the preferred use of doxycycline once susceptibility patterns for anthrax were known. The use of the third drug, amoxicillin increased only marginally (by 12,000 in October). 55 J.M. Jones, “Nine in 10 Americans are going about their business as usual”, Gallup News Service, October 26, 2001. [http://www.gallup.com/poll/releases/pro11026.asp.] Cited in Monica Schoch-Spana, “Educating, informing, and mobilizing the public”. 56 R.J. Blendon, et al., Harvard School of Public Health/Robert Wood Foundation survey project on Americans’ response to biological terrorism, tabulation report.

B. Sheppard / Societal Responses to New Terrorism

215

telephoned the health department and 1% telephoned the CDC.57 While analysts may point to the purchase of Cipro and gas masks by Americans as signs of panic, these reactions were reasonable in view of the lack of consistent advice Americans received from the authorities.58

Terrorism and Risk Perceptions Although mental health data and research surveys can explain to some extent the terror of terrorism through measuring the levels of fear and anxiety, and for a minority mental health problems like depression, stress, or even PTSD, this does not provide sufficient explanation for the behavioural changes observed in the rest of the populace. For instance, the fear of flying, taking extra precaution when opening mail during the anthrax attacks, or avoiding taking the bus and visiting shopping malls during the Intifada. Although behavioural changes are recognized as one of the symptoms of certain mental health disorders (for instance the avoidance symptomatology criteria of PTSD)59 , changes in an individual’s daily routine or attitude does not necessarily mean they have a mental health problem – however there is arguably no distinct line between clinically diagnosed psychological disorders and those changing their behaviours to reduce the risk of terrorism to themselves, in view that certain behavioural changes are classed as one of several symptoms of psychological disorders. What can help to explain these actions is individuals taking actions to reduce the risk to themselves not because they are irrational or panicking, but an instinct to reduce risk through making reasonable choices. To investigate this we need to look at the different risk perceptions of terrorism. An individual’s perception of personal risk by terrorism is likely to be influenced by the perceived level of certainty and control they have over a situation.60,61 Lack of certainty over when, where and by what means an attack could take place leads to the perception of unknown risk involved in carrying out their daily lives. For instance, Tokyo citizens were concerned over taking the subway following the sarin attack fearful of further strikes by Aum, and Americans taking precautions when opening their mail during the anthrax attacks. Lack of control is the belief that one lacks the ability to influence a situation imposed by terrorism. This causes individuals to change their routines to ones that they believe they have greater control over. For instance Israelis chose to avoid taking 57 J.M. Jones, “Nine in 10 Americans are going about their business as usual”. 58 Thomas Glass, “Emergent Collective Behaviour: Lessons Learnt,” paper presented to the NATO-Russia Advanced Scientific Workshop on the Social and Psychological Consequences of Chemical, Biological and Radiological Terrorism, March 25–27, 2002. 59 According to the Diagnostic and Statistical Manual of Disorders four edition text revision (DSM-IV-TR) there are six criterion that must be met for an individual to be categorised as having PTSD. The avoidance symptomatology (Criteria C) is divided into two primary categories: effortful avoidance and numbing/dissociation. See Diagnostic and Statistical Manual of Disorders (American Psychological Association, Washington D.C.: 2000) 4th edition test revision. 60 Jennifer S. Lerner and Dacher Keltner, “Fear, Anger, and Risk”, Journal of Personality and Social Psychology, Vol. 81, No. 1, p. 146. 61 David Ropeik and Paul Slovic, “Risk Communication: A Neglected Tool in Protecting Public Health”, Risk in Perspective, Vol. 11, No. 2 (Harvard Center for Risk Communication, Cambridge, Mass. 2003), p. 2. Other factors that influence risk perception include dread, if children are involved, if the risk is new, if the risk is natural or human made, awareness, risk benefit tradeoff, and trust.

216

B. Sheppard / Societal Responses to New Terrorism

the bus at the start of the second Intifada in preference of driving and Americans changed their travel plans to avoid flying after 9/11 believing this gave them greater control over their situation. Risk avoidance tends to be prevalent among those who believe they are personally at risk of terrorism rather than those who believe their country is at risk of terrorism. For instance, while around 50% of Americans in the months after 9/11 were very concerned their country would be attacked, only around 30% believed they personally could be exposed to an attack. Personal threats – especially threats that involve physical danger – is much more likely than remote national threats to elicit fear and anxiety. Consequently personal threat and fear can lead to a change in personal behaviour designed to minimize exposure to a risk.62 A populaces behavioural change following a terrorist attack is similar in vain to crime victimization where individuals who perceive themselves as the likely victims of crime tend to change their behaviour in ways to minimize their risk.63,64 While to some observers these behavioural and attitude changes may bear little resemblance to the statistical likelihood of becoming the victim of a terrorist attack or crime and could be interpreted as being over sensitive or even irrational in their actions (purchasing Cipro, gas masks, avoiding taking the bus), to the individuals concerned these actions are reasonable choices designed to minimize the risk to themselves based on their pre-existing understanding of a risk. While fearful people believe they are faced with a sense of enforced situational control and uncertainty from terrorism, expressing this as pessimistic risk estimates, there is another category to consider here: those who are optimistic about their future and thus express positive risk estimates believing they have more individual control and certainty.65,66 This could arguably include the 80% of Israelis who in the height of the Intifada expressed optimism over their personal future and conducted their lives as normal as possible. For instance, many of those who used to avoid public places like shopping malls during the early days of the uprising now do not, resumption of many public events, and visiting holiday destinations previously avoided. The importance for understanding these different types of responses to terrorism is to enable the development of effective pre and post incident risk communication and civil defence planning to terrorism. People rarely panic, but a segment can change their behaviours and attitudes to reduce their perceived risk to terrorism. Given that these are not ones of ‘panic’ but of reasonable actions based on individual’s pre-conceived ideas of minimizing risk, the development by authorities of effective communication and understanding of likely behavioural actions is recommended. There is a danger of a self-fulfilling prophecy in not providing adequate information leading to behavioural changes by the public that could then be interpreted by authorities as a ‘panic’ response. But then the public seeing inadequate directions or engagement from authorities due to a lack of understanding of their responses could then become increasingly fearful and anxious, reducing their trust in their leaders and willingness to co-operate thus undermining an effective national response to terrorism (eg. greater de62 Leonie Huddy, et al., “The Consequences of terrorism”, p. 487. 63 Leonie Huddy, et al., “The Politics of Threat”, p. 7. 64 K.A. Ferraro, “Women’s fear of victimisation: Shadow or sexual assault?” Social Forces, Vol. 75, pp. 667–

690. 65 Jennifer S. Lerner and Dacher Keltner, “Fear, Anger, and Risk”, p. 146. 66 Leonie Huddy, et al., “The Politics of Threat”.

B. Sheppard / Societal Responses to New Terrorism

217

mands on limited medical resources, implementing effective decontamination or vaccination strategies). With this in mind, it would be prudent to provide an overview of what characterizes effective risk communication.

Communicating the Risk of Terrorism Human risk perception is both analytical and affective, which offers an explanation of why the public’s fears sometimes do not match the facts with people commonly more afraid of some relatively small risks, and less afraid of some that in certain ways cause greater harm. Western society has come to perceive itself as increasingly vulnerable to life’s hazards and to believe that the land, air, and water are more contaminated by toxic substances than ever before.67 In some instances polarized views have developed with the public demeaned by the experts as being hysterical, while the experts are vilified as being evil.68 The perception of activities by the public like taking cipro during the anthrax attacks, fear of flying after 9/11, or Israelis avoiding taking the bus are not irrational actions but reasonable based on their level of understanding and perception of the risk.69 The perceived risks of terrorism can be amplified or attenuated by social institutions and structures (for instance government, media, and the emergency services).70 Understanding and respecting the ways people make risk judgments together with the levels of fear and anxiety caused by terrorism can help governments assist their populace in keeping their sense of risk in perspective and enable effective engagement with the public following an attack. Calculated pre incident communication to the public on measures that they could embark on in certain scenarios is unlikely to cause panic, but create a forewarned and forearmed populace with a pre-developed base line knowledge that could be worked with effectively during an incident. Effective risk communication could be of significant importance when dealing with a CBR attack where the fear of the unknown and high degree of uncertainty surrounding the lethality of the agent combined with a lack of understanding by the public of the nature of the risk could greatly complicate the execution of an effective response and advise to the public on what actions they should take. A crucial ingredient for effective pre and post incident risk communication is public trust in the communicators. If the public trust the risk manager, communication is relatively easy. If trust is lacking, no form or process of communication will be satisfactory and people would be unlikely to change their behaviour.71,72 Risk research shows that on the whole transparency and openness increases trust, while secretiveness leads to distrust.73 Added to this is the 67 Paul Slovic, “Perceived Risk, Trust, and Democracy”, Risk Analysis, Vol. 13, No. 6, 1993, p. 675. 68 Baruch Fischhoff, “Risk Perception and Communication Unplugged: Twenty Years of Process”, Risk

Analysis, Vol. 15, No. 2 (1995), p. 144. 69 Paul Slovic, “Perceived Risk, Trust, and Democracy”, p. 677. 70 Roger E. Kasperson and Jeanne X. Kasperson, “The Social Amplification and Attenuation of Risk”, The Annals of the American Academy and of Political and Social Science, Vol. 545, May 1996, pp. 95–105. 71 Paul Slovic, “Perceived Risk, Trust, and Democracy”, p. 677. 72 L.J. Frewer, C. Howard, D. Hedderley, R. Shepherd, “What Determines Trust in Information About FoodRelated Risks? Underlying Psychological Constructs”, Risk Analysis, Vol. 16, No. 4, 1996, p. 473. 73 Ragnar E. Lofstedt, “Science Communication and the Swedish Acrylamide ‘Alarm’,” Journal of Health Communication, Vol. 8, p. 417.

218

B. Sheppard / Societal Responses to New Terrorism

fact that negative events are more likely to have a powerful effect on trust than positive events.74 Except during extreme situations (for example rapid evacuation), authorities should seek partnership with the public, provide measured facts for them to make independent choices rather than providing information that is believed what they should hear.75 For instance, some US government officials believe providing too much information to the public regarding terrorism threats could result in public panic and disorganization.76 However, it is arguably not the amount of information that causes the public to respond inappropriately to warnings or threats, but rather, the adequacy of the information provided that will determine the public’s response.77 Effective communication would then enable people to make more informed choices about the risks they face. Should the American populace be representative of the public’s demand for information, a national US survey on the public’s priorities regarding the receipt of terrorrelated information suggests that the public wants honest and accurate information about terror-related situations (65% strongly supported and 24% slightly supported), even if that information worries them.78 Where possible terrorism advisory warnings should include specific, accurate, consistent and clear information at hand including known location, and threat time frame. In some instances this cannot be fully achieved either because the identified threat is general or there are limitations on what can be released in view of the sensitivity of the intelligence. Without adequate threat information, the public may ignore the threat or engage in inappropriate actions, some of which may compromise rather than promote the public’s safety.79 Despite the publicity and public health information provided, one year after first reported anthrax case 47% of American’s still believed anthrax was contagious: a sign that this fact was either a) simply missing in messages reaching the public, b) lost in the clutter of messages, or c) communicated poorly.80 Arguably the US authorities did not prepare the public for the threat, did not assess the threat quickly, and continually had to rescind statements and policies.81 Failure to implement sound risk communication following an attack could serve to heighten fear and anxiety among the targeted populace.82 This could then lead to individuals taking actions that could endanger their health or place pressure on limited resources (e.g. medical supplies). For instance, just under 90% of respondents to a survey in the US when questioned on what they should do in the event of a dirty bomb being detonated 74 Paul Slovic, “Perceived Risk, Trust, and Democracy”, p. 678. 75 Baruch Fischhoff, “Assessing and Communicating the Risks of Terrorism”, p. 54. 76 Senior Advisor for Public Health Risk Communication at the Department of Health and Human Services,

cited in “Risk Communication Principles May Assist in Refinement of the Homeland Security Advisory System”, General Accounting Office, Washington DC, 16 March 2004, p. 10. 77 “Risk Communication Principles May Assist in Refinement of the Homeland Security Advisory System”, General Accounting Office, Washington DC, 16 March 2004, p. 11. 78 Baruch Fischhoff, et al., “Evaluating the Success of Terror Risk Communication,” p. 256. 79 “Risk Communication Principles May Assist in Refinement of the Homeland Security Advisory System”, General Accounting Office, Washington DC, 16 March 2004, p. i. 80 Baruch Fischhoff, et al., “Evaluating the Success of Terror Risk Communication”, p. 257. 81 Lester Lave, “View Point: Risk Analysis and the Terrorism Problem”, Risk Analysis, Vol. 22, No. 3, 2002, p. 403. 82 Paul F. Deisler, “A Perspective: Risk Analysis as a Tool for Reducing the Risks of Terrorism”, Risk Analysis, Vol. 22, No. 3, 2002, p. 408.

B. Sheppard / Societal Responses to New Terrorism

219

releasing radioactive material replied that they should get away as fast as humanly possible. While under some circumstances this could be true, staying indoors would reduce dermal exposure and inhalation. Unless the public recognizes this possibility, ahead of any incidents, authorities may face great difficulty credibly recommending it under crisis conditions.83 An example where poor understanding of the risk and use of protective equipment has led to death and injury is Israeli reactions to Iraqi Scud missile strikes during the 1991 Gulf War. 230 Israelis falsely injected themselves with atropine (anti nerve agent) believing there had been a chemical-biological tipped missile strike nearby and seven died from suffocation caused by wearing their gas mask with the air type cap on.84

Conclusion Understanding the psychological and behavioural responses of the public could play a crucial role in devising and testing the robustness of civil defence planning and response measures to various types of incidents in field and tabletop exercises. Often terrorism exercises portray the general public in one-dimensional roles as mass casualties and panic stricken crowds who flee from affected areas or resort to violence to gain access to hospitals or to obtain scarce antibiotics and vaccines, thus precluding a constructive engagement with the public.85 As shown above the robustness of these assumptions of a panic prone public is questionable and could be shown to have major implications in the way emergency first responders and authorities have planned to react to a major incident: particularly one involving a CBR device. Authorities cannot develop an effective intervention strategy if it is defined merely in terms of physical procedures and knowledge.86 In view that major terrorist attacks can stretch the resources of the emergency services and civil defence planning beyond their actual capabilities, governments should seek to constructively engage with the public as part of pre and post incident emergency planning rather than excluding them due to their assumed lack of resilience and capacity to respond effectively.

83 Baruch Fischhoff, et al., “Evaluating the Success of Terror Risk Communication”, p. 257. 84 Zahava Solomon, Coping with War Induced Stress: The Gulf War and the Israeli Response (Plenum Press) 1995, p. 49. 85 Monica Schoch-Spana, “Educating, informing, and mobilizing the public”, p. 119. 86 David Alan Alexander and Susan Klein, ‘Biochemical terrorism: too awful to contemplate’, British Journal of Psychiatry (2003), 183, p. 494.

This page intentionally left blank

APPENDICES

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

223

Appendix 1. Conclusions of the NATO Advanced Research Workshop on Social and Psychological Consequences of Chemical and Biological Terrorism Brussels, Belgium, 25–27 March 2002 S. Wessely and V. Krasnov When President Putin met with NATO Secretary General Robertson in October 2001 it was agreed that one area of co operation between NATO and Russia was studying the effects of terrorism, with the intention of mitigating them. In response to this call, a joint Workshop was organised at short notice, bringing together international experts from Russia, the NATO countries and other relevant nations to discuss the social and psychological implications of the new terrorism. The workshop was held at NATO Headquarters between the 25 and 27th March 2002, and generated interest, activity, enthusiasm and no shortage of questions that need to be addressed. As an indicator of the seriousness of the topic, and also the importance placed by both the NATO nations and Russia on the subject, and on their desire to work together on this issue, there were many indicators of the high level of importance placed by senior officials on this co operation. The workshop was opened by the NATO Assistant Secretary General for Scientific and Environmental Affairs, was the guest of his Excellency the Russian Ambassador at a formal reception, and was closed by the NATO Deputy Secretary General.

Proceedings of the Workshop The workshop was organised and co chaired by Professor Valery Krasnov (Moscow) and Professor Simon Wessely (London) and was divided into several themes.

Case Studies of Relevant Episodes On the first day the theme was what can be learned from previous episodes of Chemical, Biological and Radiological (CBR) terrorism, and also from non terrorist incidents. The radiation disaster at Goiania (Brasil) was discussed by Dr Brian Dadd of the International Atomic Energy, whilst the long term consequences of the Chernobyl disaster were addressed by Dr Nadezhda Tarabrina (Russia) and Professor Lars Weisath (Norway). The dread in which the public view radiation threats were repeatedly emphasised. Although

224

S. Wessely and V. Krasnov / Appendix 1

in the Brasil incident control over the exposure was achieved rapidly, the impact on the local population was immense, with enormous numbers arriving for medical checks and screening. The clear up took many months, with a significant cost and impact. Social and psychological pressures added to the cost. The impact was so great that the international radiation sign has now been added to the State flag, demonstrating that a radiological disaster can lead to permanent changes in the way in which the inhabitants view themselves. The impact of the Chernobyl disaster is too well known to bear repetition, but evidence heard by the workshop once again confirmed that its long term health impact relates primarily to its social and psychological consequences. Again, people’s views of themselves in the affected areas have changed dramatically and irreversibly, to the extent that Chernobyl is now blamed for all the ills and problems of the regions, even those unlikely to be associated with the disaster itself. The Workshop also heard some candid admissions of the failure of communication between the authorities and the people, and that these had resulted in an increase of the impact of the disaster. One nation that has lived for many years under the threat of CBR is Israel. Professor Avi Bleich (Tel Aviv), ably assisted by Professor Arik Shalev (Jerusalem) described this, focussing on the particular case of the Israeli response to the SCUD missile attacks during the 1991 Gulf War. Detailed and compelling statistics were produced. First, it was clear that the side effects of some of the counter measures taken should never be underestimated. Despite much preparation of the population, there were still more deaths from misuse of the gas masks than from the direct attacks of the missiles themselves. Second, psychological casualties more than out number the physical casualties, and planning needed to take this into account if emergency services were not to be overwhelmed. Efficient triage was necessary. Third, habituation to the attacks came very quickly, and the surge of psychological casualties soon subsided. Fourth, any population based civilian planning needs to be repeated on a regular basis. The 1991 Gulf War also had long term effects on members of the Armed Forces of the Coalition nations that participated. Professor Simon Wessely (London) described a programme of research into the health of the UK Armed Forces. The key lessons were that the fear of exposure to CBW weapons was a major factor in the subsequent health of individuals, but this interacted with unexpected side effects of the measures taken to protect the Armed Forces against these weapons. A third strand were the problems in the political responses to the emergence of symptoms amongst veterans, and the media handling of the issues. Professor Wessely concluded that unexplained medical symptoms must be anticipated after any future CBW threat, and may not be preventable, but that current management to minimise their impact remained fragmented. Dr Craig Hyams (Washington, DC) showed how the long term impacts of any CBR episode may prove more problematic than the short term. The maintenance of trust between those affected and those in authority was a fundamental goal, a theme that was echoed throughout the workshop. The so called Gulf War Syndrome demonstrated that the issues with which we are concerned may take many years to develop, and many more to alleviate, but Professor Ben Nemery (Belgium) showed that events can also develop in hours. In his review of the Coca Cola incident in Belgium, now seen as principally an episode of mass psychogenic illness, and the psychological responses to the use of possible chemical agents in Tbilisi, Georgia, during the Soviet era, he showed that psychogenic transmission of illness was indeed a factor, but that management of such episodes were impeded by the lack of an

S. Wessely and V. Krasnov / Appendix 1

225

acceptable linguistic term which both acknowledged the psychological origin of symptoms, without denying its seriousness and reality. He proposed the term Catastrophic Reaction Syndrome as an cceptable term. Professor Stephen Palmer (Cardiff) discussed the problems posed by chemical pollution and leakages. By comparing and contrasting those incidents in which there had been no long term impact with those in which long term social and psychological impacts persist, he demonstrated the importance of community participation in determining responses, and how this was not the same as scientific or epidemiological responses, echoing Raymond Neutra’s classic descriptions of epidemiology “for and with a distrustful community”. He delineated the learning processes that medical and political agencies go though with each new episode. Two seminal CBW attacks were discussed in much detail. Professor Nozumu Asukai (Japan) discussed the infamous Sarin attack on the Tokyo subway. New information from his work showed first the need for a planned response from the emergency services, since without that rescue workers soon turned into victims themselves, and second, that long term symptoms have indeed emerged after the attack. A question that has yet to be answered is if these are psychological responses, as some evidence indicates, but the possibility of long term central nervous system involvement cannot be discounted. It is perhaps too early to appreciate the full story and impact of the US anthrax attacks, but Lt Col Ross Pastel (Fort Detrick) made a valiant effort. He showed how medical responses improved rapidly, and that early detection appeared to save lives. He also showed how confused and uncertain political responses added to confusion and uncertainty. The need for credible scientific communication was emphasised, but the difficulties also, since it became clear during the attack that the medical understanding of anthrax transmission needed to be revised. Many speakers alluded to the various physical, social and psychological mechanisms that might underly the emergence of long term symptoms after CBR episodes. Dr Omar Van der Bergh (Belgium) described some elegant experiments showing how classic Pavlovian conditioning could result in the amplification of symptoms after toxic exposures. This was particularly relevant to the development of so called “chemical sensitivity” which has been observed after many “toxic” exposures.

Psychological and Social Perspectives on Reactions to CBR A challenging overall view of these individual episodes was provided from the sociological perspective by Professor Thomas Glass (Baltimore). Professor Glass drew attention to what became an developing theme – the resilience of people. He reminded the workshop that during the World Trade Centre attack of September 11th , the evacuation of the Twin Towers was not accompanied by the panic that one might have predicted. He drew attention to the role of social networks, and individual resilience. Although panic in its classic sense has occurred after disasters, these examples were outnumbered by instances in which bystanders provided the primary rescue services. Community involvement was needed prior to a disaster in terms of planning, and was inevitable after a disaster. Professor Glass urged authorities and planners to make the public allies in the process, and to harness their resources. Professor Havennar (Utrecht) provided a counter balancing psychological understanding bringing together the collective experience of such disasters. He demonstrated

226

S. Wessely and V. Krasnov / Appendix 1

clearly how man made, technological disasters were associated with greater long term disruption and psychological sequelae than natural disasters, even if the physical destruction of the latter might outweigh the former. The continuing uncertain nature of a CBW threat was central to understanding these greater consequences, as was the often “invisible” nature of the threat. Several speakers were concerned with the overall impact of mass terrorism. Dr Mark Schuster (RAND, USA) described a nationally representative survey carried out in the USA after Sept 11th . There was no doubting that this episode had engaged the American public like nothing before. A substantial minority of the public reported significant distressing symptoms in the aftermath. A variety of coping methods had been used by the public. Professor Valery Mansurov (Moscow) described a similar survey carried out in Russia. Whilst anger and outrage at the attack was a common feature of both surveys, and fear of future attacks was also a common finding (as indeed has been the case world wide) there was also substantial differences in the popular understanding of the reasons for the terrorism between the two countries. The Workshop concluded that Sept 11th had indeed had a profound psychological impact world wide. Professor Jennifer Lerner (Pittsburgh) showed that a substantial minority of the US population now expected to be a victim of CBR terrorism in the future, an alarming finding which only added to the importance of the issues that were the subject of this workshop. On the second day of the workshop we addressed the more general psychological and social issues raised by the various case histories. Professor Krasnov (Moscow) began with a review of the known psychological and social consequences of mass terrorism. Whilst acknowledging that people were resilient, he also reminded us that some were not, and that long term psychiatric illness and personality change could be anticipated in many. Behavioral changes, such as increased substance abuse, were also likely. However, he reflected the theme of the conference by concluding that terrorism was fundamentally an attack on the community rather than individuals. Dr Giovanni (Washington) showed how far reaching the psychological consequences could be, and how large were the areas of uncertainties. Like Professor Krasnov, he emphasised the importance of families, but made the additional point that we cannot be sure what effect the views of families would have on, for example, the willingness of emergency workers to expose themselves to continuing risk exposure after radiological or biological terrorist incidents. Dr Craig Hyams (Washington) pointed to the difficulties that any health care system would face after a CBR episode in avoiding being overwhelmed by demand.

Post Disaster Behaviours What do people do after a disaster was a theme of several presentations. Professor Jamie Pennebaker (Texas) produced some imaginative data from his work on the responses of normal individuals caught up in unexpected disasters, culminating, as so many other speakers did, with the experience of September 11th . He showed how individual responses followed certain predictable patterns. The initial response was a massive increase in mobile phone traffic, then the coming together in groups, and finally the use of internet for communication and information. However, there was a limit to how much (and more pertinently how long) people were willing and able to share experiences. He concluded that interventions should be targeted not on the immediate post disaster phrase, but per-

S. Wessely and V. Krasnov / Appendix 1

227

haps in the following weeks, when those affected still wanted to “tell their stories” but no longer could find a willing audience. Other speakers noted that one consequence of Professor Pennebaker’s research was that in a future attack on a subway system, a central feature of modern cities, and a planner’s nightmare, then one way of reducing fear and panic, and encouraging cooperative behaviours, would be to ensure that mobile systems work in subway systems. Dr Arnon Rollnick (Israel) drew on the Israeli experience of the “Sealed Room” to remind the workshop of the unharnessed power of the Internet. This would provide, all speakers agreed, an increasing important way for individuals to communicate. It could also provide access to suitable and relevant information – the opportunities missed by the British government to utilise the Internet to communicate with the farming community during the Foot and Mouth crisis was mentioned in discussion. Dr Rollnick also pointed out the potential of the Internet for delivering self administered anxiety management interventions. The workshop also was reminded of the importance of other cultural factors in shaping responses to terrorism. Professor Victor Petrenko (Moscow) showed the importance of a factor too often neglected, namely religion and values, in determining responses. The role of religious beliefs in the genesis of terrorism is obviously a topic of intense scrutiny elsewhere, but relevant to this workshop was the problem that different religious communities reacted to the threat of terrorism in different ways. Likewise, communicating with groups with differing values was likely to prove a challenge.

Interventions Interventions provided a major challenge. It is fair to say that no consensus was reached on this question, which remains a pressing issue for research. There was consensus that certain high risk groups existed, who would be expected to develop acute psychological problems in the aftermath of being exposed to CBR episodes. For example, those with pre existing psychiatric disorders, or those who showed immediate and obvious acute, overwhelming distress. Other options for immediate interventions were also discussed. Professor Sergei Aleksanin discussed the Russian policy on early psychiatric interventions, again emphasising those at high risk. Dr Anne Speckhard (Brussels) talked about another group often overlooked – diplomats or other small groups who find themselves exposed to extreme risks in isolated surrounding as part of their profession. Dr Bernd Wilkomm (Germany) described his experience dealing with the victims of disasters, including those after Sept 11th . However, Professor Robert Ursano (Washington DC) drew attention to the difficulties posed by the evidence we have. The Critical Incident Stress Debriefing (CISD) literature provides no support for the routine use of early interventions such as CISD. Professor Ursano also reminded the Workshop of the need to recall the axiom “first do no harm”, whilst other speakers emphasised natural recovery and resilience, and the dangers of professionalisation and intruding on natural networks of coping. Lt Col Cameron Ritchie (Washington DC) discussed the results of the recent Consensus Conference on early interventions held in the aftermath of Sept 11th and involving many of the participants in the current workshop.

228

S. Wessely and V. Krasnov / Appendix 1

Communication On the third day communication was the big idea. Professor Fischhoff (Pittsburgh) took the workshop though the science of risk communication. He echoed the practical observations of Professor Palmer on the rather predictable ways in which authorities approached the need for risk communication of scientific issues to exposed populations. Dr Lerner (Pittsburgh) presented the results of some elegant research carried out in the immediate aftermath of September 11th . Her research showed that the perception of risk was strongly influenced by emotional factors, and that people were likely to make judgements on risk influenced by whether or not they were in states of anger or fear. She also provided an empirically based understanding of why there were such marked gender differences in the responding to terrorism threats. Dr Igor Linkov (Harvard and Russia) showed how the modern science of risk analysis, developed in response to communities threatened by real or perceived environmental contamination, could be adapted to the modern CBR threat environment. Authorities need to know more about risk communication, but those who in practice communicate risk are the media. A panel discussion chaired by Mark Laity, ex BBC defence correspondent and now NATO Deputy Director of Communications discussed the issues involved, concluding that it could not be assumed that media actions would be aimed at reducing public disquiet, nor increasing confidence, and occasionally the reverse could be expected. Nik Gowing (Main Presenter, BBC News, London, attending in a personal capacity) showed how the speed of response was crucial, and ever increasing. After a CBN incident the news agenda would be determined within the first hour, and accurate information would be required from the authorities within that time frame. He also drew attention to the numerous other media players, few of whom would now be expected to maintain the same ethical and professional standards as the more established news organisations. Modern media technologies also allowed for much faster transfer of images, and much easier distortion of images, practices that would be used by those with powerful, and sometimes hostile agendas. However, Mr Gowing also showed that governments’ themselves had been guilty of clear image distortion, even if such practices backfired. The animated discussion confirmed that the moment the “event” happens and the crisis begins, governments, authorities, scientists confront the ‘tyranny of real time’ in handling information. (The dictionary definition of ‘tyranny’ is cruel and arbitrary.) Recent crisis management experience shows this information will cascade at an overwhelming rate that defies government instinct to control all data, especially in the first few hours. There will be both information overload and inertia, which will lead to uncertainty and confusion. Mr. Gowing argued that the key challenge will be the surge as the crisis begins. This surge will overwhelm all attempts to organise spontaneously. Therefore it is vital to plan for every eventuality well in advance. Plans should be exercised regularly in advance and include a cadre of acceptable, plausible spokespeople. Many contributors confirmed that research shows that neither experts, scientists nor politicians can assume they will be viewed as plausible. It is vital to have a reliable (probably non-expert) figure who becomes the core anchor figure of trust in public minds, but it is also clear that the identity and background of such a person will differ from culture to culture. That person must have the projection and personality both to convince the public, have the absolute confi-

S. Wessely and V. Krasnov / Appendix 1

229

dence of the political leaders/security chiefs. He or she must also the robustness to fight what will be inevitable instincts of obstruction and obfuscation within the machinery of government at a time on acute fear and probably institutional confusion. Dr. Mils Hills (DSTL/Cabinet Office) spoke on the need for government to build competitive, sustainable and resilient approaches to the assessment, communication and management of risk. Correctly engaged, civil populations can be a source of great resilience in times of increasing uncertainty. This requires creative and innovative approaches to be adopted, not least for anticipating the needs of various constituencies of our citizens. Terrorists and other asymmetric actors aim for disproportionate effect, generated through the use of the emotions. We need to recognise this, and out-compete such activities.

Rumours and Myths The need for fast but accurate information, no matter how difficult the task, was emphasised by Professor Frank Furedi (Kent, UK), who discussed the little addressed topic of rumours, myths and hoaxes. It is clear that in our post modern, high communication age, rumours are dispersed around the globe within hours of terrorist outrages, as exemplified by September 11th . Profesor Furedi concluded that many of these rumours were relatively harmless, and served some social cohesive role. People did not want only to know what happened, the purpose of media communication, but to give events some meaning. It is the latter that is served by the creation of rumours and myths. However, some rumours and myths are more corrosive and damaging. Rumours and myths provided a link between the three sessions of the Workshop. Effective, accurate and timely communication from government is the best antidote to the spread of socially damaging rumours, emphasising the need for early and measured risk communication. If this does not happen, or trust and confidence is endangered by other means, then the scene is set for the propagation of misinformation. Misinformation and mistrust are the soil from which spring many of the difficult, complex and chronic medically unexplained syndromes, such as Gulf War Syndrome, which are one long term debilitating outcome that we can expect from CBR episodes.

Scenarios The workshop included a realistic threat scenario organised by a team from DSTL (London). The results of this simulation will be posted separately.

Overviews The workshop concluded with two broad perspectives. Professor Vassily Yastrebov (Moscow) took us through the historical background to terrorism, and the fundamental challenges it poses to our societies. He outlined ways of taking a population based approach, with the aim of increasing resilience, a central theme of the workshop. Professor Yastrebov took the view that most shared – in our complex, fragmented and unstable world future attacks by terrorists groups were near certain, and the probability that these

230

S. Wessely and V. Krasnov / Appendix 1

would include CBR weapons was high. Security measures could reduce this risk, but never eliminate it. Hence education and planning were central to reducing the impact on the population. Professor Showalter (Princeton, USA) concluded the workshop by looking at the way in which terrorism has become part of our culture. She drew attention to the little studied role of popular literature in defining our responses – not Tolstoy, but Tom Clancy. Like Hollywood, these reflected our views, but also shaped them. For her, as for so many others, Sept 11th had been a turning point. She described the many ways in which Americans were coming to terms with this change, pointing out that the extraordinary wave of displaying the American flag was not, as some far away observers interpreted it, a signal of increased bellicosity, but a demonstration of a need for reassurance. It took a literary critic to remind an audience of many psychologists and psychiatrists the importance of the “comfort blanket”. However, again echoing a repeated theme, Professor Showalter was concerned that the post Sept 11th unity and support seen in the American communities at home and abroad, might not be maintained, and there was another cultural theme or script, that of mistrust, suspicion and “cover up” which might supervene, and for which there were many historical precedents.

Cross National Perspectives It was heartening to see the many points of agreement between all the national groups that participated in the conference. All delegates from Russia and the NATO nations agreed on the crucial importance of monitoring, providing early timely and accurate information, offering assistance to those most distressed, involving families at an early opportunity, and the need to learn from others. On the other hand, it was also clear that major differences exist between societies in their anticipated reactions to CBR, and the expectations of governments in dealing with these reactions. It was clear that there is no single solution to these issues that would be applicable across NATO nations and/or Russia. National factors will also have strong impacts on policy. For example, in the United Kingdom long experience of IRA terrorism has failed to bring about significant social change, and may have increased population resilience. On the other hand, the BSE crisis has reduced public confidence in expert scientific opinion, which may not be reflected in other countries. Twenty years of Civil Defence planning and rehearsal means that the Israeli population now have a greater level of information and preparedness than most others. The very different recent history of Russia, and the differing expectations of individual and state, mean that a greater reliance is needed on pre defined emergency planning. Numerous examples of differences in approach and expectation across all the participant nations were observed, emphasising the need to learn from, but not slavishly imitate, each others experiences.

Conclusions Certain themes dominated the Workshop. 1. CBR episodes have not so far been sui generis different from previous man made or technological disasters, which therefore have much to teach us.

S. Wessely and V. Krasnov / Appendix 1

231

2. Most people involved in such episodes can be expected to cope. People are more resilient than we give them credit for. Except in certain circumstances, classic panic should not be anticipated. 3. Although all those involved in a CBR episode can be expected to show emotional reactions, those who develop longer term psychiatric or psychological consequences will be the minority. 4. In a modern technological society people will communicate immediately after any CBR episode. Authorities wishing to disseminate information on counter measures, decontamination, future risk and safe behaviours will need to do so very rapidly indeed. 5. People should be encouraged to talk to people after an episode, since this may provide strong social cohesion, and promote co operative behaviours. 6. There is still no consensus on the role, if any, of very acute interventions. Classic CISD debriefing can no longer be recommended. The balance between getting people to talk to people, and getting people to talk to professionals, has not been established. 7. It may be that the best time for interventions is not in the immediate aftermath of an attack, but in the following weeks, when people have stopped telling their own stories, but some, those perhaps most distressed, still require empathic audiences. 8. Authorities must understand the basic principles of risk communication. 9. Communication depended upon the public trusting the person conveying the information. There is no consensus on who is the best person to deliver the necessary messages, and a probability that will differ from nation to nation. 10. Given the speed required, more work must be done preparing communication messages and strategies for possible CBR scenarios. 11. Rumours, myths and legends will develop after any episode. These may serve a social purpose, but if there is a major failure in risk communication, these may in turn form the soil from which post exposure unexplained syndromes develop. 12. Monitoring and surveillance of those involved in a CBR episode will be necessary. This will detect the emergence of later medical problems such as cancer or premature death, but also serve as an important public reassurance if no such increases are noted. During an acute episode it will be an imperative to document those affected, and an early priority to establish an appropriate control group. 13. Maintaining public confidence is a long, and not just a short, term task. The recent events post Sept 11th have demonstrated that populations are resilience, and may react to assaults with cohesion rather than panic, even if many individuals will experience some psychological distress. Increased communication opportunities, especially those that are initiated by the public themselves, may add further protection against anxiety and distress. 14. On the other hand, the nature of modern societies can also amplify the impact of terrorism. The same easy communications provides opportunities for the propagation of myth and rumour. Discrepancies between government statements,. and between scientific experts, can be easily exploited. Access to the media of maverick scientific opinions will reduce confidence. Memories of previous accepted misgovernance reduce confidence, and create societies in which rumours of conspiracy and cover up can flourish.

232

S. Wessely and V. Krasnov / Appendix 1

15. The role of precaution in determining policy remains controversial. At the workshop views were expressed that only by showing caution and minimising risk would the public feel protected against the consequences of CBW. On the other hand, excessive caution can induce not resilience, but anxiety, perpetuating a cycle of increasing risk aversion and increasing anxiety. There is no consensus yet on how, or indeed if, the precautionary principle should operate after a serious CBR attack.

Further Work In the next few weeks there will be further work on defining research questions and priorities, which will be communicated via this website. A fuller summary of the conference proceedings will be produced in book form for publication in 2003. Further working groups will be meeting to consider next steps.

Summary Most societies vulnerable to CBR terrorism have now well developed disaster management plans in place. Whilst no plan will cover all eventualities, and few plans survive “contact with the enemy”, it is still expected that rational planning will reduce acute casualties, reduce the possibility of panic, and provide populations with reassurance. Likewise, the repeated demonstrations of popular resilience and coping, and of people making their own solutions, gives grounds for optimism that societies are well equipped to resist the acute effects of mass terror. On the other hand, the Workshop concluded that in the longer term, there was less reason for optimism. More research is needed on maintaining long term confidence and trust. The workshop concluded with a strong reaffirmation that the purpose of CBN terrorism is not to take lives or destroy property. These are the mechanisms by which the terrorist seeks to achieve his or her goal, but it is not the goal. The goal is to weaken the sense of cohesion that binds communities together, to reduce its social capital, and to sow distrust, fear and insecurity. Asymmetic terrorism is thus fundamentally a method of waging social and psychological warfare. The Workshop concluded that we need to pay more attention to understanding how these disruptions are instigated, and how they can be better managed.

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

233

Appendix 2. Guidelines for Communicating the Risk of Chemical, Biological or Nuclear Terrorism: How to Inform the Public, Improve Resilience and not Generate Panic S. Wessely, B. Fischhoff and V. Krasnov

Introduction The purpose of this document is to provide simple assistance in the construction of messages to communicate the risk of chemical, biological and nuclear (CBN) terrorism to the public. We envisage two scenarios. The first concerns communication about future risk – the intention being is to educate and inform the public, and to increase vigilance, but without increasing anxiety or reducing resilience. The second concerns communications after a terrorist incident, in which the primary purpose is to convey information as rapidly as possible, but again without increasing anxiety any more than is warranted, and continuing to maintain resilience. Risk communication related to the problem of terrorism is always going to be crucial to maintain public health and morale. Creating effective communications requires acknowledging the properties of these risks that make them potent sources of risk. Chemical, biological or nuclear (CBN) terrorism fits all the characteristics of risks, which are known to be particularly potent in raising people’s fears. They are involuntary. They result from man made, rather than natural, events. The agents are often invisible. All evoke feelings of “dread”. The risks are difficult to quantify, unfamiliar and associated with scientific uncertainty. There are potential hazards to the unborn child. There are no discernable benefits. For these reasons communicating with the public both before, and after any CBN event could hardly be more important. People need to prepare themselves practically and psychologically, for this long term threat. They need to respond effectively when it is realised, or even when they worry that something might be happening. What are the purposes of communications with populations affected, or potentially affected, by acts of terrorism? Three aims can be identified. 1. Information – the public has a right to receive accurate and timely information – modern States are obliged to provide this; 2. Psychological – minimizing the immediate psychological stress of victims and their relatives caused by terrorist activities and preventing the spread of longer term psychological consequences; 3. Operational – preparing and informing the public

234

S. Wessely et al. / Appendix 2

for measures needed to be implemented by those who duty it is to prevent or manage acts of terrorism and maintain public security. This might include effective operational planning, or enlisting the public to assist the maintenance of security by, for example, maintaining vigilance. An informed, as opposed to an ignorant, audience, possessing as much knowledge as is compatible with genuine security needs, may be the best form of “chaos control”, minimising panic reactions and unexpected disorganized behaviour of individuals or groups, and hence minimising the impact of the terrorist act. Some member states may also wish to use communication with at risk populations to counter over heroic representations of terrorists, neutralizing their ideological aims, explaining to the public necessary security measures, and promoting resilience in the audience. This goal may not apply to all States – depending on particular circumstances and backgrounds. What does not differ between States and cultures is the fundamental goal of terrorism, which is to create terror, a psychological state, extending far beyond the direct damage. As a result, how people respond determines the damage that terrorism inflicts on society. The underlying theme of risk communication should be that we must, and can, mobilize ourselves, as individuals and communities, to minimise the harm that terrorism can cause. Because the risk of terrorism is intimately related to the response of the public to it, the way it is communicated has an important influence on damage that a terrorist incident can inflict on society. A key task of risk communication in this sphere is to transmit, a) the idea that terrorism has become a part of our life and b) precisely because it has become a part of our life, we need to take steps as a community to minimise the harm it can cause. Every incident is different. Every country has different experiences and histories. No organisation asked to respond to the challenge of terrorism is the same. But there are principles, which can be followed in crafting communication messages, and certain well known mistakes that it would be prudent to avoid. What follows is a guide to sensible practice in this area. What will not be considered are the communication issues around quarantine and possible mass population movements that pose specific and special questions that need to be addressed separately.

Summary Points • Decide who shall deliver the message. • Always begin by acknowledging the gravity of the events and tragedy of those who have suffered. • Know your audience(s). • Recognize the public’s concerns, emotions, and efforts to manage the risk. • Assure the audience that the relevant officials are doing all that they can – and make sure that is true. • Express a coherent, consistent communication philosophy (for all risks). – We will do all we can to help you to make responsible decisions for yourself and your loved ones.

S. Wessely et al. / Appendix 2

235

– To that end, we will provide you the best, relevant information that we can, along with an idea of how good that information is. – We will not engage in speculation. – We may need to withhold information that may aid or comfort terrorists. – Provide quantitative risk estimates, including the attendant uncertainties. • Avoid educating our enemies about our worst fears. • Provide summary analyses of possible protective actions, considering all the expected effects. • Lead by example, showing possible models for responsible bravery. • Make sure scientific advice is credible, fast and coherent. • Always tell the truth, or explain why you cannot. • Be quick. • Don’t try and be funny. • Be aware of rumours, legends and urban myths. • Commit to earning and keeping the public trust.

Explanation and Elaboration Decide who shall deliver the message There is no single template for a media spokesperson. This will differ from situation to situation and state to state, but certain guidelines can be given. People will first question your empathy, trust, competence, fairness and credibility before they listen to your statistics and details. Credibility is essential for any spokesperson. Charisma can be helpful. Sometimes a senior authority figure has these abilities, but sometimes they do not. Training may help, but cannot create these qualities if they are not already there. Sleep deprivation does not help – make sure your spokesperson is adequately supported physically and psychologically. Organisations likely to be called on to communicate with the public after a terrorist incident should identify their spokesperson beforehand. Doing so after the incident may be chaotic, and undermine confidence, until a single voice emerges. If the spokesperson has sufficient power or authority to be able to deliver on any commitments made, so much the better in maintaining trust. Acknowledge the gravity of the events and tragedy of those who have suffered After a tragedy, people are dealing with their emotions as well as the practical challenges facing them. Be sensitive to the public’s specific concerns on a human level. Statistics and probabilities don’t necessarily answer all questions. Having an official position does not preclude acknowledging the sadness of illness, injury or death. Do not overstate or dwell on tragedy, but do empathize with the public and provide answers that respect their humanity. Bear in mind that regardless of the specific target, the entire community is the target of terrorism.

236

S. Wessely et al. / Appendix 2

Know your audience(s) These guidelines are being provided for dissemination within the NATO member states. However, it must be recognised that the circumstances and histories of different states will have major impacts on the way in which risk messages are received. For example, populations in the Transition States of Eastern Europe and the Former Soviet Union have a different memory of statements made by authorities than those in Western States. Previous lack of candour over, for example, Chernobyl, creates suspicions that need to be overcome. There remain major credibility gaps between the public and the authorities. On the other hand in the United Kingdom there are lasting concerns over the BSE (“Mad Cow”) crisis and Foot and Mouth disease, which have created a credibility gap around official scientific advice. One should also beware of assuming there is a single “audience” out there, any more than there is a “general” public. Instead there are many audiences, facing different problems and bringing to them different backgrounds, views and values. Future communication might be strengthened if research is conducted now on those publics’ knowledge and views about the risk and consequences of terrorism. Recognize the public’s concerns, emotions, and efforts to manage the risk Everyone is needed to keep society functioning in time of stress, and should be rewarded for doing the best that they can. Emotions are an important and legitimate part of responding to extreme events. Recognizing their existence creates a human bond with the audience. Recognizing the legitimacy of emotions can help people to take the steps needed to manage them. Individuals needing special attention, for example those with existing mental health problems, should be afforded ready access. However, the tenor of the communication should be adult to adult, assuming the ability to cope. Assure the audience that the relevant officials are doing all that they can The communicator cannot vouch for the competence of all officials or for the adequacy of the resources at their disposal. However, it should be possible to attest to their commitment. Express a coherent, consistent communication philosophy (for all risks) • We will do all we can to help you to make responsible decisions for yourself and your loved ones. • To that end, we will provide you the best, relevant information that we can, along with an idea of how good that information is. • We will not engage in speculation. • We will admit when we do not know something. • We may need to withhold information that may aid or comfort terrorists. The commitment is to a partnership, with officials attempting to empower citizens to master difficult, and potentially protracted challenges. The communicator will leave speculation to others (e.g., news media, ordinary citizens), knowing that many ideas will

S. Wessely et al. / Appendix 2

237

be discussed in a democratic society, preserving the role of being the definitive source for vetted information. Be exceptionally cautious about withholding information that you feel might cause panic. The disaster literature predicts little mass panic, unless officials behave in ways that erode trust in them. Withholding vital information might be construed as such behavior. People do not want to learn that they have exposed themselves and their loved ones to risks because they were not trusted to act like adults. Avoid educating our enemies about our worst fears Terrorism by definition aims to strike at our psychological vulnerabilities. Avoid revealing these in risk communication messages – “at least our children are safe”. It is important not to treat a terrorist act as if it is beyond the capacity of a society to manage its effects. Terms like ‘unimaginable’, ‘beyond comprehension’ and ‘incalculable’ should be avoided. Provide quantitative information – but carefully Provide quantitative risk estimates, including the attendant uncertainties, but be careful about the “numbers game”. People need to know how big risks are, in order to decide what to do about them. Often, those numbers are missing, because the experts have not produced them or have not disseminated them. Sometimes, the numbers are incomplete, as when people see the death toll, but not the total number of people exposed. An intuitively appealing message is “the risk of X is smaller that being struck by lightning.” However, this is the wrong message in many ways. It often offends people, by trivializing their concerns. It misrepresents the risk, by ignoring the many ways in which X differs from lightning (e.g., the associated uncertainty), especially when, unlike lightning, X is poorly understood, and may increase, or decrease, in the future. It often appears manipulative, undermining the credibility of the source. It is safer just to give the numbers, and uncertainties. Doing so requires the staff work needed to produce those estimates. If you are going to compare risks, make sure that they are similar. Compare well understood voluntary risks with other well understood voluntary ones, or involuntary risks with other involuntary risks. Do not compare the risk of being killed by a lone gunman to the risk of being involved in a road accident. Numbers are a problem. Do not use percentages if you can avoid it. Say “1 in a million”, not 0.0001%. Large numbers are also a problem. Illustrate a number by comparing it to something familiar. Compare one million to the population of Glasgow or Samara, or 2,000 would be the size of a secondary school. People may however need to be reminded that there are risks with every action, and also inaction. They may need tactful reminders of the extreme cost and also impossibility of seeking complete safety. It is sometimes useful to consider the consequences of not taking risks. For example, outside the terrorism field, it may be useful to remind audiences that “if society demanded 100% certainty, many normal activities would be curtailed and new drugs and vaccines would never reach the public.” Just because something is risky does not mean it is not very useful. Understanding the impossibility of total security is important, so as to avoid viewing every successful terrorist act as a major failure, which will only serve the interests of terrorists. Societies can learn to live with surprising levels of risk, if they trust their leaders.

238

S. Wessely et al. / Appendix 2

Provide summary analyses of possible protective actions, considering all the expected effects, positive and negative Messages that provide means for effective public action reduces distress more than those that simply list risks and issue warnings. One reason why popular morale was maintained in the United Kingdom during the civilian bombings in Second World War was the very high level of public participation in the war effort, with most civilians having some role in civil action or civil defence. It is also important to emphasis both the risk and benefits of suggested actions, or indeed actions that people are already taking on their own initiative, particularly when the risk facing them is low. People may ignore the fact that actions reducing one risk may increase other risks. They may not recognize the psychological costs and benefits of risk-reduction actions. They may not see the things that they are losing (i.e., “opportunity costs”) when they forgo activities, in order to reduce risks. They may not be able to estimate the effects of their actions, exaggerating some, underestimating others. Presenting the best available understanding of these issues, in a standard format, should help people to develop coherent decision-making strategies. By offering alternatives, one respects individuals’ right to make different choices, reflecting their personal values. We must however also acknowledge that differences exist in the relationship between public and state agencies in differing States. Countries differ in their recent histories of “self help” and community based actions or decision making. Some authorities may prefer to advise people against independent, spontaneous “rescue” activities, emphasizing that these activities are prepared or carried out by professional services. Lead by example, showing possible models for responsible bravery People expect leaders to conduct themselves professionally, including their own exposure to risk. Such behavior can have a calming effect and model the sort of quiet “soldiering on” that many people want to show, in their own way, appropriate to their own circumstances. Do not avoid personalising the message, as long as one recognises peoples’ right to reach different conclusions. For instance, “I will not stop doing ‘something’ because of some terrorist activity”. Explaining that action (e.g. “I will not stop doing a particular action because of some terrorist activity”) offers alternative perspectives in a noncoercive fashion. One important perspective is that continuing with life represents an act of defiance/bravery on the part of the individual. Avoid messages that may appear inconsistent or hypocritical. Do not ask the public to go about their own business as usual, whilst taking elaborate steps to protect senior officials. People may think, “if they can’t protect senior officials, what chance have I got?” or “why aren’t they as worried about me?” The apparent double standard for protecting different people appears in retrospect to have played a part in the perception of poor management of the anthrax episode in the United States. Don’t be afraid to appeal to the public’s sense of courage and pride even in the face of severe adversity. Consider Mayor Guiliani’s appeal to the pride of fellow New Yorker’s following the Twin Towers disaster contrasted with official pronouncements around the anthrax letter bombs. Communities can display great resiliency following a disaster when

S. Wessely et al. / Appendix 2

239

given the opportunity. Public pronouncements should encourage a community to view itself as a survivor of adversity, and not a helpless victim. Make sure your scientific advice is credible, fast and coherent There is any number of scientific “experts” out there. Not all are equal, and you can be sure that, particularly if a situation/emergency is prolonged, attention will eventually shift to maverick scientists simply because they give different information to you – the media always look for discord, argument and discrepancies. Be prepared for this. Identify serious scientific opinion early, whilst also avoiding over confident pronouncements that may backfire later. Always tell the truth, or explain why you cannot Be honest and open. Once lost, trust and credibility are almost impossible to regain. Never mislead the public by lying or failing to provide information whenever it is possible to do so. When in doubt share your uncertainty. Admit that you do not know when this is the case. Be prepared to issue new information, or correct information that turns out to be inaccurate, as soon as possible. There are also genuine and legitimate concerns about security issues. Many agencies will have information which, for understandable and logical reasons, should not be communicated to the public because of potential security risks. The public accept that there is some information which should not be given because it assists the terrorists or endangers life. Be firm with media representatives who seem not to understand this, because the public will be on your side. On the other hand, do not be secretive about being secretive – explain that there is information that you cannot divulge, rather than ignoring the question or saying “no comment”. Again, experience with, and experience of, the media, differs across member states. In tense, uncertain, and highly dangerous circumstances, some States will request mass media to coordinate their broadcasts about the incident with the objectives of crisis resolution, and refrain from presenting their own “versions” or unverified information. In other States, with different historical experiences of the relationship between State and media, such requests may prove counter productive. Nevertheless, enlisting media support, and involving them in crisis planning and disaster management exercises should be encouraged. Be quick: be prepared After any terrorist incident the window of opportunity for communication is short. Governments no longer have the monopoly of communication. Numerous media actors have come into existence, some of them more responsible than others. Some may actively serve the agenda of the perpetrator of the incident. There is rarely enough time to compose considered messages, sanctioned by superior officials, in the aftermath of an incident. It is better to be prepared by considering likely scenarios, identifying and training spokespersons, and prior rehearsal. Humour – avoid it If used, direct it at yourself. Don’t use it in relation to others’ safety, health, or risk.

240

S. Wessely et al. / Appendix 2

Be aware of rumours, legends and urban myths Rumours and urban myths arise rapidly in the context of major public crises such as would be generated by a CBN terrorist incident. In so far as it is possible, authorities should be aware of these rumours as they arise, and use the (trusted) spokesperson to directly dispel them if possible. Commit to earning and keeping the public trust Your purpose is to achieve market share as the source of unbiased information. Having such a source is essential for social coordination, in both the long and short run. Communication processes should be evaluated to ensure their continued success. They should solicit continuing input from the public to ensure their relevance. Furthermore, after a terrorist incident agencies should continue a public, accountable and rational critical analysis of the incident, as part of strengthening trust and confidence in state agencies as preparation for the future.

The Five Minute Guide You have been given five minutes notice that you have to communicate on a sensitive risk issue. Here is a check list to go through in that five minutes, taken from ILGRA, 2001. – Minute 1: What is your target audience? Clarify your objective – what do you want the public to know after the interview/meeting? – Minute 2: How are you going to come across? Don’t be afraid of showing emotion. Think of the opportunity to explain, rather than be defensive. Be committed and sincere – you are probably an expert in this area, who cares strongly about the issues. Say so. Respect other people’s perspectives, though – try to understand and explain, not defeat others in any argument. – Minute 3: What are you going to say? Decide your key message(s). Write it down. Try and relate this to you as a citizen. What do you want people to do afterwards? Try and be practical. – Minute 4: There will be difficult questions. What might they be? Always show respect to other’s people’s concerns. Be prepared to admit uncertainty. Come back later with answers if you can. – Minute 5: Relax, deep breath, and remember your key points.

Further Reading Bennett P. Understanding responses to risk: some basic findings. In: Bennett P, Calman K, eds. Risk Communication and Public Health. Oxford: Oxford Medical Publications, 1999: 3–19. See also www.doh.gov. uk/pointers.htm Durodie W, Wessely S. Resilience or panic: the public’s response to a terrorist attack. Lancet 2002; 360: 1901– 1902. Communicating Risk in a Soundbite. A Guide for Scientists. Science and Media Centre, Royal Institution. www. Sciencemediacentre.orfg/aboutus/risk.html

S. Wessely et al. / Appendix 2

241

Fischhoff B. Assessing and communicating the risks of terrorism. In: Teich A, Nelson D, Lita S, eds. Science and Technology in a Vulnerable World. Washington: American Association for the Advancement of Science, 2002. http://www.aaas.org/spp/yearbook/2003/stvwch5.pdf Fischhoff BBA; Quadrel MJ. Risk perception and communication. In: Detels R, McEwen R, Beaglehole R, Tanaka H, eds. Oxford Textbook of Public Health. London: Oxford University Press, 2002: 1105–1123. Hassett A, Sigal L. Unforeseen consequences of terrorism: medically unexplained symptoms in a time of fear. Archives of Internal Medicine 2002; 162. Inter-departmental Liaison Group on Risk Assessment. Risk Communication: A Guide to Regulatory Practice. London, Health and Safety Executive. Saathoff G. What is to be done? Emerging Perspectives on Public Responses to Bioterrorism.

This page intentionally left blank

Psychological Responses to the New Terrorism: A NATO-Russia Dialogue S. Wessely and V.N. Krasnov (Eds.) IOS Press, 2005 © 2005 IOS Press. All rights reserved.

243

Author Index Adessky, R. 171 Aleksanin, S. 93 Bromet, E.J. 55 Chung, C.K. 159 Durodié, B. 37 Fischhoff, B. 67, 233 Freedman, S. 171 Frenkiel-Fishman, S. 171 Glass, T.A. 25 Gonzalez, R.M. 67 Havenaar, J.M. 55 Hyams, K.C. 191 Israeli-Shalev, Y. 171 Krasnov, V.N. 1, 97, 107, 223, 233 Lerner, J.S. 67 Mufel, N. 139

Murphy, F. 191 Pastel, R.H. 9 Pennebaker, J.W. 159 Petrenko, V.F. 115 Ritchie, E.C. 9 Shalev, A.Y. 171 Sheppard, B. 205 Shoigu, Y.S. 125 Small, D.A. 67 Speckhard, A. 139 Tarabrina, N.V. 129, 139 Van den Bergh, O. 81 Wessely, S. 1, 185, 191, 223, 233 Yartseva, A.I. 115 Yastrebov, V. 137

This page intentionally left blank

This page intentionally left blank

This page intentionally left blank

This page intentionally left blank

This page intentionally left blank