Psychological aspects of terrorism need addressing

An interdisciplinary task force of the American College of Neuropsychopharmacology created in 2003 says our nation’s leaders have taken steps to prepare for future terrorist attacks in the wake of the Sept. 11, 2001, events, but have made far fewer preparations for a pervasive effect of any attack — its psychological impact.

"The goals of terrorism depend on their psychological impact," says task force chairman Steven Hyman, a professor of neurobiology at Harvard Medical School. "The pervasive psychological effects of terrorism demand a public health response, and the inclusion of mental health as an integral part of disaster planning is the first step."

A 2003 poll sponsored by the National Association of State Mental Health and Program Directors, the National Mental Health Association, and the Consortium for Risk and Crisis Communications found that people understand the psychological threat of terrorism and want steps taken to address that threat.

Members of the American College of Neuropsychopharmacology task force are experts in brain and behavior, with a special focus on responses to trauma and risk communication. They evaluated the scientific literature to determine what is known about the psychological effects of terrorism, what is urgently needed to know, and what recommendations should be implemented now.

According to the task force, the risk of developing a long-term mental illness following a terrorist attack is based on two interacting factors: 1) the directness and severity of a person’s exposure and 2) the degree of personal vulnerability. Thus, the more directly a person is affected by a terrorist act, the greater the risk of developing post-traumatic stress disorder or other disorders. Research also shows that some people are more susceptible than others because of genetic risk, past history of trauma, gender (females are more at risk), being evacuated from the site of an attack, and surviving or witnessing an attack. Such personal risk factors apply to too many people and the system could not handle treating everyone with at least one such risk factor.

The researchers say their review of scientific studies leads them to question the merit of a widely used intervention intended to prevent post-traumatic stress disorder. Often mandated for first responders, this intervention, known as psychological debriefing, consists of a single therapy session within days of a traumatic event to allow all involved, whether or not they have symptoms, to vent their emotions and relive the traumatic event.

"While several studies found debriefing to be effective, they were inadequately designed," the researchers say in their report. "When rigorously tested in randomized, controlled clinical trials, the results were quite different. Not only was psychological debriefing found ineffective, but some studies found it can impede recovery."

If the widely used technique of psychological debriefing now is said to be ineffective and potentially harmful, a technique that does work — brief cognitive behavioral therapy — is used very little and should be used more.

Cognitive behavioral therapy involves four to five therapy sessions beginning two to five weeks after a traumatic event. It adopts a problem-solving approach to people with high levels of symptoms, seeking to change their traumatized view of an event and guiding them to more adaptable behavior.

The task force says that one controlled clinical trial found that cognitive behavioral therapy sped up the rate of recovery, although it did not actually reduce the overall prevalence of post-traumatic stress disorder. Another study found that six months after the event, the prevalence of post-traumatic stress disorder was reduced by two-thirds.

Problems hindering broader use of cognitive behavioral therapy are a lack of therapists trained in the technique and the expense and frequency of the sessions needed. "If there was another massive terrorist attack like 9/11," the task force report says, "our mental health system might not be able to handle mass psychological casualties."

One of the areas of research the task force calls for deals with new approaches to prevention of post-traumatic stress disorder, possibly through medications.

Priorities for future research cited in the study include: 1) identifying the minimum treatment necessary to successfully prevent chronic post-traumatic stress disorder and related problems; 2) examining the optimum circumstances for providing interventions, such as time elapsed since a traumatic event and who is most likely to benefit; and 3) validating the efficacy of interventions with a wider range of trauma populations, including victims of terrorist attacks in countries where terrorism is prevalent.

A subset of individuals given special attention by the task force is children. Although children’s reactions to trauma are similar to those of adults, they differ in that they are more susceptible to secondary exposure, that is, exposure through the media or transmitted through the fearful reactions of parents and teachers.

The task force says that understanding the impact of terrorism on children is critical because childhood mental health problems often go unrecognized and if left unattended, their problems can persist and progress, leading to school failure, poor social adjustment, and altered brain development.

Given that terrorism’s effects on children can be indirect, the group says, interventions that improve parental functioning may reduce the psychological impact of terrorism. Studies have indicated it may be more beneficial to target parents and other adults close to children rather than children themselves, particularly because adults can act as a buffer for children and minimize danger. In studies of naturally occurring resilience, effective adults function in a protective capacity for children.

The group notes that one barrier to effective research into terrorism’s behavioral, biological, and psychological effects has been a lack of immediate access to disaster sites and treatment centers. Following major attacks such as the Oklahoma City federal building bombing and the World Trade Center attack, public officials have been reluctant to permit research out of compassion for the victims and a desire not to interfere with logistics. But at the same time, the task force members say, unproven therapeutic interventions such as psychological debriefing have been implemented and may have caused harm. "While excessive intrusiveness should be avoided, it is important for the research community and the disaster response communities to reach accommodations to permit research to proceed, or it will never be possible to improve our preparedness," the scientists say. "Researchers striving to reduce the psychological impact of terrorism should, for example, have the same access that infectious disease researchers have after a biological attack. Policy-makers have a national obligation to be better prepared for the psychological consequences of terrorism and to mitigate its impact."

The task force concludes that if another terrorist attack occurred tomorrow, the U.S. public health and homeland security systems would not be prepared for dealing with its psychological effects because disaster planning does not include science-based approaches to communicate risk to the general public. And mental health planning often is either ignored or separated from general disaster planning.

Steps to be taken immediately, the task force says, include:

  • Working with the news media in advance to promote responsible messages about the risk of a terrorist attack and responsible coverage of an attack. Children’s viewing of TV should be limited in the aftermath of an attack.
  • Putting a risk communication system in place before an attack that promotes adaptive responses by the public, with messages to the public based on the best research about risk communication.
  • Incorporating mental health into all disaster planning.
  • Discontinuing use of psychological debriefing for healthy people and intervening with proven techniques for those who display symptoms or are at highest risk of developing trauma-related disorders.
  • Ensuring more professionals are trained in use of science-based treatments, such as brief cognitive behavioral therapy.

Greater research is needed, the group says, into ways to prevent onset of trauma-related disorders, especially in children; identification of adults and children who are at greatest risk of developing disorders after a terrorist attack; improvement of existing treatments for adults and children with trauma-related disorders; understanding the differences between the impact of trauma and the impact of terrorism; and determination of the long-term effects of terrorism on the brain, on behavior, and on physical health, apart from any physical injuries sustained in an attack.

(A complete report with its underlying component papers is to be published in Neuropsychopharmacology, the journal of the American College of Neuropsychopharmacology. An executive summary is available for download at www.acnp.org.)