Psychologys Response to Terrorism
Ronald F. Levant
Barbanel, L. Chapter for A.J. Marsella, F. Moghaddam, & A. Bandura (Eds.),International terrorism and terrorists: Psychosocial perspectives. Washington, DC: American Psychological Association, 2003.
President George W. Bush has said that the United States is at war with terrorism. It is clear that Osama bin Laden and the al-Qaeda terrorist network have been at war with us for a decade, going back to the gulf war (Bergen, 2001; Bodansky, 2001). Their intentions have become chillingly clear following the unspeakably barbaric and murderous acts that they perpetrated on us on September 11, 2001. As they are only one of many terrorist organizations at large in the world, it is likely that the war against terrorism could last quite a long time, and perhaps involve us in conflict in and with many other nations, such as those that President Bush has referred to as the evil axis Iran, Iraq, and North Korea. Thus we seem to be facing a threat potentially as serious as the one we faced in World War II.
The nature of this war is fundamentally psychological. This is not stated to minimize the tremendous death and destruction that has taken place, nor the fact of combat in Afghanistan. Rather, this is stated to highlight the fact that the aim of the terrorists is to create crippling fear and psychological debilitation in the populace in order to force the U.S. to submit to the terrorists demands.
The psychological impact has been very significant. We all felt and still feel to some extent the shock and grief that came in the immediate aftermath of the attacks on 9/11. Months after the attack we began to experience the worst of the trauma responses to the attacks. In addition there are continuing fears resulting from the spate of anthrax incidents and the specter of biological and chemical terrorism. We also have the copycats, hoax perpetrators, and domestic terrorists (e.g., the mailing to family planning clinics of suspicious, but thankfully not anthrax infected, envelopes). More recently we have been warned that suicide bombings in public places such as those that occur in Israel will occur here, that our national landmarks may be attacked, as may nuclear power plants, hazardous chemical plants, and the water and food supply. In May 2002, Vice President Dick Cheney told us that it is not a matter of if, but when we will be attacked again. In addition to these very serious threats, the daily fabric of our life is being disrupted. As some have said, the terrorists are putting sand into the gears of every day life. U.S. citizens now have to cope with increased difficulties and disruptions in air travel, postal deliveries, airport and building evacuations, and the like. Clearly, the psychological toll of this war is likely to considerable.
The authors have long argued for psychologys involvement in informing the public policy process on the grounds that we have much science-based expertise to offer to the formulation of public policy on a range of matters, including terrorism (e.g., DeLeon, 1998; DeLeon, in press; DeLeon, Eckert & Wilkins in press; Lorion, Iscoe, DeLeon, & VandenBos, 1996; Martinez, Ryan, & DeLeon, 1995). Given the psychological nature of terrorism, it is clear that psychology has a major role to play in the national effort to counteract it. The American Psychological Association (APA) has been very active in responding to the terrorist attacks of September 11, 2001. In this chapter we will discuss, in turn: APAs efforts to address the threat of terrorism; APAs efforts to address the impact of terrorism; The APA Board of Directors Resolution on Terrorism; Disaster response: A first person account; and Promoting resilience in response to terrorism: A review of the literature.
On September 19, 2001, the APA Board of Directors held a conference call, at which one of the items for discussion was the terrorist attacks on September 11. We noted with appreciation the tremendous efforts of the APA Practice Directorates Disaster Response Network in responding to the needs of both victims and rescue workers. We also expressed appreciation to the staff for all of the wonderful trauma-related materials that were promptly added to APAs website. In tune with the idea that psychology has much to offer the public policy process, the Board then took up the question of what more psychology could contribute to addressing this national crisis. Noting that terrorism is fundamentally a psychological process, and, further, that psychology played significant roles in the war efforts during both World Wars of the last century, the Board of Directors established a Subcommittee on Psychologys Response to Terrorism. The mission of the Subcommittee is to look at what psychologists can contribute to the efforts to address both the threat as well as the impact of terrorism, and thus be a key element of the response. The members of the Subcommittee are Ronald F. Levant, Chair, Laura Barbanel, Nate Perry, Derek Snyder, Kurt Salzinger, Cynthia Belar, Rhea Farberman, Russ Newman, Henry Tomes, Gary VandenBos.
Addressing The Threat of Terrorism
Psychologists, as members of one of the learned professions, have traditionally contributed their expertise to inform makers of public policy. Psychology played significant roles in the war efforts during both World Wars of the last century, contributing scientific knowledge and expertise in such areas as officer-candidate selection, visual perception, and ergonomics. So too, psychology can contribute scientific knowledge and expertise to the goal of ending terrorism. Contributions can be found in the foundational areas of the discipline such as social psychology and its work on malignant attitude formation, such as prejudice and fanaticism. Contributions can also be found in the more applied areas such as international psychology, peace psychology, conflict resolution, multicultural psychology, the psychology of religion, military psychology, and the psychology of criminal justice. The Subcommittee on Psychologys Response to Terrorism has assembled lists of potential contributors and has written to the presidents of APA divisions asking them to help identify their members who might be conducting research which has relevance to the anti-terrorism effort. Dozens of colleagues have written in with offers of help or suggestions of other experts. We also decided that before we go off and write white papers, it would be appropriate to learn what might be of genuine assistance to key policy- and decision-makers. Hence we have been networking with psychologists working in mission critical governmental departments such as Defense, State, the FBI, etc., and have had requests for assistance from several of these agencies. On February 28, 2002 an invitational conference titled Countering Terrorism: Integration of Practice and Theory was held at the FBI academy in Quantico, Virginia with 70 participants, about half of whom were APA member psychologists and half were law enforcement personnel. On March 1, 2002, APA staff arranged for a day of informal meetings between psychological scientists and senior staff of the Senate and House Science committees, to raise awareness of the relevance of psychological science to countering terrorism. The APA Council of Representatives approved funding for additional Congressional Science briefings on terrorism in 2002, so these efforts will continue.
Addressing The Impact of Terrorism
With regard to addressing the impact of terrorism, the APA Practice Directorates Disaster Response Network has been working hand in glove with the American Red Cross in responding to the needs at the World Trade Center, the Pentagon, Pennsylvania, California, and elsewhere across the nation. This effort will be discussed in more detail below, from the perspective of one of the authors who participated as a member of the Disaster Response Network in New York (Barbanel). The APA staff have also posted on APAs website a host of wonderful materials on coping with trauma, stress, anxiety, grief, as well as helping children to cope. There was also information about psychologists self-care, which stressed the need for members to monitor themselves for signs of caretaker trauma. In addition the APA Committee on Colleague Assistance developed a document for the website titled Tapping your resilience in the wake of terrorism, which offers guidance to practitioners on coping with the challenges of working with patients in the aftermath of the terrorist attacks. We have also looked at what psychologists might contribute to addressing the rising number of anti-Islamic and anti-Middle Eastern hate crime incidents, racial profiling and the erosion of civil liberties. The anthrax attack took on the character of workplace violence, and we looked at what psychologists might contribute to address that as well. We are aware that these events have different impacts on different segments of our pluralistic society (e.g., postal and mail-room employees are often ethnic minorities; older adults often have higher degree of resilience, etc.) and will take this into account as we move forward.
The Subcommittee also looked at the possibilities of insuring that psychological services are included in Senator Kennedy's Bioterrorism Preparedness Act and seeking to include psychology as a major participant in the new Homeland Security office.
APA Board of Directors Resolution on Terrorism
To provide authorization for these activities, the APA Board of Directors took emergency action at its December 2001 meeting and adopted the following resolution:
Disaster Response: A First Person Account
This section provides a first person account of the disaster response effort in New York, written by the second author (Barbanel).
APAs Disaster Relief Network (DRN) and the New York State Psychological Associations DRN activated hundreds of psychologists who volunteered and worked on site and in the aftermath of the disaster, counseling families of victims, rescue workers, those who lost homes and those who lost jobs. APA, the National Mental Health Association (NMHA) and the Ad Council put together a series of public service ads such as Talk with Your Kids, which advised parents that children might be frightened and what to do about it.
When the tragedy hit, individual psychologists sought to figure out where they could be of use. There was so much confusion in the first days, which, coupled with difficulties in communication, made it difficult to determine where one could be of use. Depending on the proximity to the WTC, phone lines, email and TV reception were affected in varying degrees. The second author was first asked to go to a police academy in lower Manhattan where there was a need for psychologists, but she could not make contact with them and could not get there. Bridges, tunnels and subways to Manhattan, were closed except to rescue workers. As a member of the DRN for some time and certified by the Red Cross, she was called to register at the Red Cross for this disaster and then told, No, the need is somewhere else. When her email started to function, there were hundreds of emails from psychologists wanting to help. Some were able to get through the confusion and to help. Many were frustrated because they could not get through or, because of the confusion, had been turned down by the Red Cross. Others were looking for support in the form of colleague assistance. Still others were writing of their experiences at the various settings in which they were deployed.
Psychologists ended up working in a number of settings. There were shelters for displaced people, the Compassion Center which was set up for the families of individuals who were lost, Service Centers for people who were working at the WTC who needed economic and other help, as well as for people who were displaced from their homes because of the disaster, and the Missing Persons Hotline, where thousands of people called to find out how to locate people and services.
The breadth of these experiences begins to demonstrate the breadth of this Disaster. The Compassion Center was one of the saddest. Set up in an Armory, here families of victims, people who were last seen in the WTC and were lost, came to look through hospital lists to see if perhaps their loved ones could be found. Rarely was anyone located. The hospitals in NYC had been on alert for emergency care. The doctors waited in vain. There werent many admissions because so many were lost, a euphemism for those who perished.
Psychologists have been involved in the providing of psychological services in disaster for some time. There are psychologists who consider themselves traumatologists and there is a movement to have a new division of APA that is made up of psychologists who study and work in the field of trauma. But the full range of psychologys contribution to this disaster and its aftermath, to the recovery and to the healing, has yet to be recorded.
What did psychologists do? Not therapy as we know it, but emotional first-aid as it came to be named. Some families were very contained and did not wish any emotional help. Others sat down and wept and wanted contact. In the Compassion Center, a man from India asked me if Dr. Barbanel if she could speak to his young, pregnant wife about the loss of her brother. A worker asked Dr. Barbanel to speak to a young African-American man who was looking for a woman who had at the time of the attack fallen down on the ground in front of him, told him she was not going to make it and given him her student ID card and her keys. Weeping, he told Dr. Barbanel that he felt he hadnt helped her enough. He was hoping to find that she had survived. In the meantime he was walking around with her keys and ID card.
In the armory the walls were totally filled with pictures of people who were lost, put up by family members who held out the hope that perhaps their loved ones had been seen by someone else. The pictures were all of happy occasions, a wedding, a boating trip, a father holding a child. They all seemed to be 28 years old. Many of the people looking were the parents of the victims. But there were wives and husbands and girlfriends and boyfriends. There were the representatives of various governments who were looking for their citizens who had been working in one of the towers. It would be their job to inform the families of the deaths.
For psychologists, working in this disaster was different from any work in previous disasters. The scale was larger than anyone had experienced before, the systems set up to deal with it involved more agencies and governmental bodies, both city, state and federal. In places there was overlap of services and in places there were gaps. All of the services were strained. Most importantly, it was clear that the psychologists working in it were affected in a very different way than other kinds of disasters. It was their disaster as well as the disaster of the people they sought to help. Rescue workers began to feel the emotional strain of seeing the gruesome and the macabre. There were bodies falling or jumping out of windows, the smell of incinerated flesh. It was difficult to work on site because communication broke down. Running water was not available at the beginning and there were threats of gas main explosions. The air was thick with smoke and debris. Chaos reigned.
In the midst of all of the chaos and what was described as evil were great acts of kindness and generosity. Food was sent in for rescue workers from all of the finest restaurants in NYC. A Red Cross worker who was at ground zero the day of the disaster described her role, which included passing out on a tray chocolate covered strawberries to rescue workers. She felt a bit odd about that aspect of her role. Clothing was donated by individuals and by shops. Money poured in for the families of the victims.
The headlines told of the large brokerage firms that lost thousands of people. Talking to immigrant parents of an only son who was lost, to the husband of a woman who perished and left three small children all under five, to the brother of a woman whose husband was lost and could not bear to come to this place, gave you yet another picture of this tragedy. Blue-collar workers also suffered. The Central Labor Council began to report that they were getting anxious calls from members who were out of work as a result of the Disaster. These were the cleaners and security guards and data clerks and secretaries. There were people who repair things and who wait outside in the limos that transport others that worked in the towers. There was no class, ethnic or racial group that was not represented. There were the nationals of other countries represented as well.
Responding to disaster was different than the responses psychologists have been typically trained to make. First of all, one needed to be sensitive as to whether to respond altogether. Some people wanted help and could ask for it. Others wanted to be left alone to find their own resources. Many, however, wanted help and could not reach out. To distinguish between the latter two types of people requires sensitivity that psychologists are rarely asked to have.
A young couple that Dr. Barbanel met in the Service Center is illustrative. The young man approached to ask her if there was a psychologist available for his girlfriend who since the disaster had not been able to sleep, and when she slept she had nightmares. She did not eat and was not getting on with her life. She was glued to the TV and watching all of the reports. He thought that she should not be watching TV; that this was retraumatizing her. Dr. Barbanel sat down next to the couple on a group of folding chairs to talk. No real privacy, but somehow everybody in the room respected the island that the three of them created. The young woman was from South America and a recent medical school graduate. The two of them met in NY and have been living together since May. They had just moved into an apartment in the area of the WTC. On the morning of the 11th, the woman was walking out of her apartment when the planes struck. She was frozen to the spot as she watched what transpired. She saw people running and the buildings topple and she began to run also. The scene that kept repeating in her mind and that she described was of a firefighter falling down in front of her. She could not help him but waited with him until the EMS picked him up. She kept saying to herself I am a doctor and I cannot help him. It was this fact that was the most disturbing to her, the feeling of helplessness. She went over the scene several times. Dr. Barbanel pointed out to her that she had indeed helped him by staying with him until EMS arrived. She visibly relaxed. This was not therapy, but certainly therapeutic.
Eventually, one large Service Center was set up at Pier 94 on the Westside of Manhattan. Here a comprehensive set of services was made available. There were services for families of victims, people who lost their homes and people who lost their jobs. There was a special room for children with soft animals and mental health personnel to talk to them. There were chaplains, message therapists, and therapy dogs. As a psychologist on "the floor, the job was to do what somebody characterized as "active lurking". The trick is to be able to talk to somebody and know how to be interested without being intrusive. Not always easy for psychologists who typically have people come to their offices with a clearly defined task on hand.
Family members of the lost were taken on a ferry down to the site where a staging area was set up for viewing the devastation. There were flowers and teddy bears available as well as cards for family members to write notes to leave in the memorial area. As a "worker the task was to hand these items out to the family members and to stop to chat as you did. On the boat one was asked to put on a hard hat and given goggles and a mask should one need it in the area.
At the special platform built at the site to see the devastation, many began to weep. A view of the site made it clear that nobody in there could survive. For families that had not found bodies, this brought both great pain and some kind of closure. There was also a memorial area where the flowers and other items could be left. Pictures, notes flowers and teddy bears were left there. The National Guardsmen that were in the footpath stood at attention and saluted. It was very moving.
Many of the families that were on the boat were extended family or family from out of town that had come in for memorials. They were the parents, aunts and uncles, cousins, friends. It was suggested that one "adopt" a family. Dr. Barbanel spent time with a family that consisted of two male cousins of a young man who was "lost" at ground zero. The three boys, as the wives referred to them, had grown up together and were like brothers. They spoke about many things, from the skyline of NYC to the importance that this trip had to them. When they parted, they hugged Dr. Barbanel, saying that it had been a great "comfort" to them. Not the kind of work psychologists usually do, but definitely therapeutic.
Dr. Barbanel was impressed with the sensitivity and care with which these boat trips were designed, and with the people that executed it. There were boat trips from New Jersey with the families of Port Authority employees who had died and from the Brooklyn Navy Yard with the families of first responders who had perished. A woman who lost her husband of 17 years said after the experience at Pier 94 and the trip to the site, that this place restored her faith in humanity by the kindness that she experienced.
Many heroes emerged. The group that seemed to achieve the greatest reputation for heroism was firefighters. Firefighters, hardly noticed ordinarily by most people, became the symbol of romantic heroism in this tragedy. Dressed in all their gear, they did what they always do; serve the public to put out fires and to protect them. They also displayed support and loyalty to their comrades in a way that is particularly characteristic of firefighters. The romantic figure of the stockbroker or lawyer led way to the figure of the firefighter, prepared to protect and to rescue others. Police officers, who, over the last few years, have not been seen favorably, were admired for their bravery and the challenges of their work.
Less mentioned but certainly worthy, are other heroes such as the teachers and other school personnel who responded to the need immediately and in the post crisis phase. Teachers in the schools closest to the WTC had to lead their children to safety. In a cloud of smoke and debris the teachers of children as young as 4 and 5 linked hands with their students and led them the many blocks to safety. The principal and faculty of Stuyvesant High School, located near the site of the WTC, evacuated all of the 3,000 students from the school. Teachers walked students across the Brooklyn Bridge, the 59th St. Bridge, to Queens, uptown (Deutsch, 2001) The younger students, who had just started high school that week, some from other boroughs of the city, were organized into groups to be helped to find their way. There were 8000 students in eight Manhattan schools that are in that area of the city. All of the children reached physical safety (American Teacher, 2001) The New York City Schools were closed the next day, but school psychologists and other pupil personnel staff attended special sessions on handling the emotional fallout for children, parents and staff. Psychologists in the schools were indeed in the forefront in their roles in the schools, where children and their parents needed help. The threat of bioterrorism and the need to develop resilience in children are issues that continue to need to be confronted.
One of the most touching experiences that Dr. Barbanel had was when she left the Red Cross headquarters late one night and was stopped by a police officer who asked her if she wanted a free taxi ride home. She told him that she was heading for Brooklyn. He said that was fine. In front of the Red Cross headquarters was a line of taxis standing, prepared to take people involved in this effort home. This was their volunteer service. Dr. Barbanel entered a cab driven by a Sheikh driver. His English was broken, but he wanted to tell his story and to hear hers. The Red Cross had debriefed her before that, but this was her real debriefing for the day.
Local universities set up special counseling units and hotlines for students who were displaced from their housing, or their classrooms or who could not get to classes because of transportation difficulties. Faculty at universities were asked to develop programs to help students, both in class and outside of the classroom. Students training to work in schools needed to know how to deal with children in the schools affected by the trauma. Trauma and grief experts were called in to schools, colleges and universities, and to businesses as they reopened. Programs were developed, assistance given, responses improvised. Workshops were developed and provided for students and faculty at colleges. Psychologists who had not been previously trained to respond to trauma asked for training and the wherewithal to cope with the trauma that was all around them as well as their own secondary trauma.
Caretaker trauma began to be discussed. Psychologists started to set up trainings for themselves within weeks. Within days, an impromptu meeting, under the auspices of the New York State Psychological Association, of psychologists working in the disaster was set up. A panel was designed of a number of senior members (Dr. Barbanel included) of the DRN and people had an opportunity to speak and to listen.
Reactions to the attacks varied dramatically. Ayalon (1983), in a description of the Israeli experience of coping with terrorism, points to the dichotomization of response in victims between those who took on an attitude of resentment bordering on paranoid suspicions and those who took an altruistic, self-sacrificing attitude. Here also, for some the response was anger and the wish for revenge. For others an attitude of selfsacrifice and almost spiritual coping was prevalent. The latter seemed to be the more common attitude immediately post 9-11. New York City seemed to become a kinder gentler place. New Yorkers, known for their toughness and almost rudeness to strangers, were observed to be more considerate of each other. On a ride home on a crowded F train, the only one going to Brooklyn in those first days, Dr. Barbanel saw people make room for each other and give directions to other passengers who werent used to this subway line with an attitude of concern rarely demonstrated in the public arena in the city. It is an attitude that reverses the image of victim to one of rescuer. It changes the helplessness into hopefulness.
All disasters have as one of their defining characteristics unpredictability. Floods, tornados and forest fires do not announce themselves. The randomness leaves people surprised, helpless and frequently hopeless. Technological disasters add another dimension of unpredictability, threat, terror, and horror (Austin, 1992). The Disaster of Sept. 11 has no precedent. Victims and others, who might not be at first described as victims, reported classic symptoms of expectable reactions after a terrorist attack. Recurring thoughts of the incident, fears, particularly of leaving home, inability to maintain usual routines, were all reported. A young woman who presented herself for help about a week after the event is an example. She described herself as being unable to resume her activities. She had been in the lobby of the WTC when the attack occurred, having arrived late to work. As debris began to fly around and people around her could not figure out what had happened or what to do, the security guards told them all to stay in the building rather than to leave. She did not feel these instructions were good ones, so she slipped out of the building, and through a series of circuitous adventures, managed to escape. She got home to Brooklyn and although physically safe, could not shake her fears and apprehension, her symptoms of acute stress reaction. Dr. Barbanel pointed out her ability to save herself, her resourcefulness. She starred at her in silence and after a moment said, Thank you. Somehow this recognition of her own active engagement in her flight to safety diminished her sense of helplessness and helped to reduce her symptoms.
In addition to the usual complaints of sleeping and eating problems, grief, emotional numbing depression etc, there is the experience of this trauma as a persistent one. (LeDoux & Gorman, 2001) The magnitude, which has an enormous ripple effect, followed by continued threat of terrorism, including biological terrorism, and of war, and the continued admonishment by the authorities to be on alert has led to the experience of chronic anxiety for many.
The psychological devastation may not be known for months, perhaps years (Everly & Mitchell, 2001). Psychologists and other mental health providers continued and continue to provide counseling services for the victims, their families and others affected by the disaster. All kinds of pro bono and low cost services were set up and continue to operate. FEMA (Federal emergency Management Agency), the Red Cross and the Sept 11 Fund all set up funds and referral networks for victims to access mental health services. The psychological community organized pro bono and low-cost referral networks. Nonetheless, six months after the disaster, there was a newspaper report (Marshall, March 4,2002) of thousands of New Yorkers struggling with the psychological aftermath of the trauma and the difficulty they have had accessing mental health services. Six months after the disaster there is a still a heightened state of alertness with which all New Yorkers, perhaps all Americans live.
We have gone from disaster to anxieties and fears, some nagging and below the surface, others more clearly identifiable. Although there is some semblance of normalcy, there are mental health problems that are apparent and some yet to be seen. Some clinical vignettes that illustrate the state of mind are then the following:
This anxiety cuts across all levels of society, from the young stockbrokers and lawyers who ran from their offices to the security officers in the schools nearby who had to evacuate, to the dishwashers in the restaurants in the area. Undocumented aliens worry about getting deported, as do foreign students, some of whom have the added anxiety of being part of the group that is identified as the group out of which the terrorists came and who are therefore the recipient of rage. The same Muslim and Sheikh cabdrivers who were offering free rides are worried that people will hold them responsible for the attacks. (Purnik, 2001)
In the New York City subways there are ads that read: Its normal to be anxious since Sept 11-lots of people are and then a telephone number is given to get a referral to talk to someone. There are also tips for people, like, Heroes talk or Speaking to family and friends can be helpful.
As many people continue to experience chronic anxiety, psychologists will need to know how to respond to this need, and to think about the impact of the aftermath on their work more broadly. We will need to respond to the chronic anxiety and fear in a way that is different than our more traditional work. It will involve developing greater understanding of resilience and how to foster its development.
Promoting Resilience in Response to Terrorism
Like the schoolyard bully, terrorism depends for its effect on being able to induce fear in its intended victims. To the extent that psychology can contribute to enhancing the resilience of our citizenry so that we react with less fear when terrorism strikes, we reduce not only the impact of terrorism but also the incentives for terrorists to engage in violent acts. Hence, there is a need for good information on psychological resilience, coping with disasters, and programs designed to help citizens deal with the continuing threat of terrorism.
It is vital that when we give psychology to the public that it is based on sound psychological research and good clinical judgement. We believe that our current situation is unprecedented and do not expect to find any studies addressing it directly. We have been advised by our science colleagues to look at the literature on psychological resilience, as well as the literature on terrorism in other countries (e.g., Northern Ireland, Israel) and on the response to natural disasters like hurricanes and earthquakes. In addition, stress inoculation programs and programs for dealing with acute and chronic stress and anxiety are likely to be of significant help in coping with threat of terrorist attack. We are also aware that different segments of our diverse society have different methods of coping and managing stress. Hence we need to keep the diverse needs of our pluralistic society uppermost in its mind as we develop information on programs.
Funding was recently approved for collaboration between APA and the American Psychological Foundation on an Integrated Science-Practice Task Force on Promoting Resilience in Response to Terrorism. The Task Force would develop information for psychologists and graduate students, State Psychological Associations, and external groups such as the National Mental Health Association on psychological resilience, coping with disasters, and on programs that are most likely to help our citizens deal with the stress, anxiety and fear caused by terrorism. The work product would present a range of approaches/materials/information, leaving it up to the clinician to determine what fits best under the circumstances he or she faces. The focus would be on programs aimed at building strengths and promoting resilience and health.
To provide a scientific foundation for this effort, we conducted a literature search using APAs on-line search services in January, 2002, on the following topics: Terrorism, ethno-political warfare, ethnic or religious conflict or war; disasters; defining and measuring resilience and hardiness; resilience, hardiness, and promoting or enhancing resilience or hardiness; preventing PTSD, stress inoculation programs, and the efficacy of stress management programs. We will briefly summarize the salient findings.
Terrorism, Ethno-Political Warfare, Ethnic or Religious Conflict or War
The psychological literature on terrorism, ethno-political warfare, ethnic or religious conflict or war is sparse. Apart from the recent volume published by the American Psychological Association on ethnopolitical warfare (Chirot & Seligman, 2001), we were able to identify only a handful of articles and very little empirical research. We could only find several studies, and these were on the Oklahoma City bombing (e.g., Pfefferbaum, Gurwitch, McDonald, Leftwich, Sconzo, Messenbaugh, & Schultz, 2000; Pfefferbaum, Nixon, Tivis, Doughty, Pynoos, Gurwitch, & Foy, 2000). Most of the articles were review or conceptual papers dealing with such matters as the Holocaust (Suedfeld, 2000), the conflict in Northern Ireland (Cairns & Darby, 1998), the Israeli-Palestinian conflict (Rouhana & -Bar-Tal, 1998), terrorism in Guatemala and Peru (Comas-Diaz, Lykes, & Alarcon, 1998), ethnic conflict in Sri Lanka (Rogers, Spencer, & Uyangoda, 1998) and global psychology (Mays, Bullock, Rosenzweig, & Wessels, 1998; Mays, Rubin, Sabourin, & Walker, 1996). Needless to say this is an area in great need of research and development.
The psychological literature on disasters is much larger. The psychological sequela of natural disasters has been studied with regard to hurricanes (Anthony, Lonigan, & Hecht, 1999; Bernard & Rothgeb, 2000; Dudley-Grant, Mendez, & Zinn, 2000; Jones, Frary, Cunningham, Weddle, & Kaiser, 2001; LaGreca, Silverman, Vernberg, & Prinstein, 1996; LaGreca, Silverman, & Wasserstein, 1998; Norris & Kaniasty, 1996; Thompson, Norris, & Hanacek, 1993; Vernberg, La Greca, Silverman, & Prinstein, 1996); tornadoes (McMillen, Smith, & Fischer, 1997); earthquakes (Knight, Gatz, Heller, & Bengtson, 2000; Nolen-Hoeksema & Morrow, 1991; Wiess, Marmar, Meltzer, & Ronfeldt, 1995; Wood, Bootzin, Rosenham, & Nolen-Hoeksema, 1992); and floods (Phifer, 1990). In addition human-made disasters have also been the subject of psychological study, including airline disasters (Butcher & Hatcher, 1988; Dougall, Herberman, Delahanty, Inslicht, & Baum, 2000; Jacobs, Quevillon, & Stricherz, 1990; McMillen, Smith, & Fischer, 1997; Williams, Solomon, & Bartone, 1988), bus accidents (Turner, 2000), ship sinkings (Lindeman, Saari, Verkasalo, & Prytz, 1996; Rosen, 1995), and mass killings (McMillen, Smith, & Fischer, 1997). Finally technological disasters and toxic accidents have also been the subject of study (Baum & Fleming, 1993; Baum, Gatchel and Schaeffer, 983; Kronik, Akhmerov, & Speckhard, 1999). For an excellent overview of the development of the field of disaster mental health see Jacobs (1995).
Among the findings most relevant to our focus, namely promoting resilience in the face of terrorism, a number of variables have been identified as predictors of post-disaster symptomatology. Weiss, et al. (1995) found that post-disaster symptomatology in adults (emergency service personnel) can be predicted by exposure to trauma, social support, experience (years on the job), locus of control, and dissociative tendencies. Dougall, et al. (2000) found that prior exposure to trauma that was dissimilar to the current trauma resulted in greater post-disaster symptomatology in adults (disaster personnel). Nolen-Hoeksema & Morrow (1991) found that post-disaster symptomatology in adults (college students) could be predicted by exposure, prior symptomatology, and a tendency toward rumination. Norris & Kaniasty (1996) found evidence for their social support deterioration deterrence model, which stipulates that post-disaster mobilization of support counteracts the deterioration in expectations of support often experienced by disaster victims. McMillen, et al. (1997) found that perceived benefit 4-6 weeks following exposure to disaster predicted post-traumatic stress disorder 3 years later, and moderated the effect of severity of disaster exposure. With regard to children, LaGreca, et al. (1996) found that post-disaster symptomatology can be predicted by a model that includes five factors: Exposure to traumatic events during and after the disaster, demographic characteristics, occurrence of major life stressors, availability of social support, and coping strategies. Hence, although a range of predictive factors have been identified, the literature suggests that degree of exposure to the disaster, prior symptomatology, occurrence of major stressors in the aftermath of the disaster tend to be related to greater post-disaster symptomatology, and that personality resources and social support tend to ameliorate post-disaster symptomatology.
For the most part the literature on demographic differences in responses to disaster is contradictory and inconclusive. For example, Lindeman, et al. (1996) found that women experience more post-disaster symptomatology than men; however, in an older adult sample, Phifer (1990) found men experience more post-disaster symptomatology than women. Clearly the relationship between gender and post-disaster symptomatology is quite complicated, reflecting the complexity of the larger relationship between gender and mental health (c.f. Levant & Kopecky, 1995). Jones, et al. (2001) examined levels of self-reported post-disaster symptomatology among African American, Hispanic, and Caucasian elementary and middle school children, finding no differences with regard to race/ethnicity. On the other hand LaGreca, et al. (1998) found that race predicted self-reported post-disaster symptomatology seven months after the disaster, with African Americans faring worse than other children. Hence, the relationship between race/ethnicity and post-disaster symptomatology also appears to be quite complicated. Focussing on older adults (who have been found to have lower levels of post-disaster symptomatology than their younger counterparts), Knight, et al. (2000) found that older adults greater resilience is more likely the result of inoculation due to prior experience with disaster than the result of maturation.
Defining and Measuring Resilience and Hardiness
Ego-resiliency. J.H. Block and Block (1980) defined ego resiliency as an individual difference variable, with the following characteristics:
Bloch (1978) developed a Q-sort procedure performed by multiple observers, the California Adult Q-Set (CAQ), to measure the ego resiliency construct. Although the CAQ is a reliable and valid measure, Q-Sorts are very time consuming. Hence, Klohnen (1996) developed a self-report Ego-Resiliency (ER) scale, which was found on exploratory factor analysis to include the following components: Confident Optimism, Productive and Autonomous Activity, Interpersonal Warmth and Insight, and Skilled Expressiveness. In terms of construct validity, Klohnen, Vanderwater, and Young (1996) studied midlife adjustment in women longitudinally and found that ego resiliency (using both observer-based and self-report measures) predicted successful midlife adjustment.
Hardiness. Kobasa (1979) defined hardiness as a personality style that consists of three beliefs about the interaction between self and world: A sense of control over ones life, commitment as a result of finding meaning in ones existence, and viewing change as challenge. Hardiness is thought to buffer against the negative effects of stressful life circumstances. Maddi and Kobasa (1984) developed a set of self-report scales to measure hardiness. Bartone (1989) factor analyzed these scales and found three factors in a 45-item scale that corresponded to the hypothesized beliefs (Commitment, Control, and Challenge). Bartone (1999) subsequently further condensed the scale to 15 items, but the internal consistency of two of the subscales was marginal (with Cronbachs alpha coefficient in the high .60s). Maddi (1996) developed a 50 item scale (the Personal Views Survey) with a better internal consistency of (alpha coefficients in the .70s).
Resilience, Hardiness, and Promoting or Enhancing Resilience or Hardiness
This literature breaks out into several areas: Stress-resistant children, resilience to family, medical, and economic stress, resilience and hardiness in response to occupational stress, resilience and hardiness in response to military stress, and miscellaneous.
Stress-resilient children. Garmezy (1986) noted that constructs such as risk, vulnerability, stress, coping, and protective factors are central themes in understanding developmental psychopathology. Rutter (1995) suggested that the protective factors for children and adolescents fall into five categories: Reduction of the personal impact of risk experience, reduction of negative chain reactions, promotion of self-esteem and self-efficacy, opening up of positive opportunities, and positive cognitive processing. Garmezy (Garmezy 1993, Masten, Best, & Garmezy, 1990) and Rutter (1979, 1987) used the term resilience to describe children who appeared to function surprisingly well under adverse and even harmful environmental conditions. Masten (2001, Masten & Coatsworth, 2001), in two recent reviews of the literature found that resilience is quite common in children, and that such naturally occurring resilience serves as a protective factor among children at risk because of disadvantage or trauma. Masten and Coatsworth (2001) identified three sets of characteristics of resilient children and adolescents: Individual Traits (good cognitive functioning, good disposition, self-confidence, talents, and faith); Family Characteristics (good attachment to parental figure, authoritative parenting, socioeconomic advantages, and functional extended family network); Extrafamilial Resources (bonds to prosocial non-family adults, involvement in prosocial organizations, enrolled in effective schools).
Resilience to family, medical, and economic stress. Snyder, Mangrum, and Wills (1993) found that psychological resilience was a factor in predicting the outcome of marital therapy. Marsh and Johnson (1997) suggested that family resilience can be an important factor in coping with the stress of serious mental illness afflicting a family member. Costigan, Floyd, Harter, & McClintock (1997) found evidence in their study of family problem-solving interactions that resilience helped family members cope with the stress of having a mentally retarded child. Perlesz, Kinsella, and Crowe, in a review of the literature on family psychosocial outcome after traumatic brain injury, suggests that future research focus more on the resilience of families and their ability to work toward positive outcomes. Horton and Wallander (2001) found that hope and social support served as resilience factors against distress in mothers of children with chronic illnesses. Cowen (1991) suggested that resilience was one of the cornerstones of new psychology of wellness. Conger, Rueter, and Elder (1999) found that higher degrees of marital support provided couples with resilience against economic stress, reducing the association between economic pressure and emotional distress.
Resilience and hardiness in response to occupational stress. Williams and Cooper (1998) reported the development of a reliable measure of occupational stress that also includes a measure of resilience. Kobasa (1979) found that hardiness differentiated managers who experienced high levels of stress but low illness.
Resilience and hardiness in response to military stress. King, King, Fairbank, Keane, and Adams (1998) used structural equation modeling to examine the relationship among war zone stressor variables, resilience and recovery factors and post traumatic stress disorder symptoms in a national sample of Vietnam-era war veterans. The resiliencerecovery factors included postwar structural and functional social support and hardiness. Hardiness was found to have both a direct negative relationship with PTSD, and an indirect relationship through the variable of functional social support, for both men and women. However, of the resilience-recovery factors functional social support had the largest total effect on PTSD for both men and women. In addition, support was found for strong mediation effects of additional negative life effects in the postwar period. In a subsequent report, King, King, Foy, Keane, and Fairbank (199) found that while war-zone stressors appeared preeminent for PTSD for men, posttrauma resilience-recovery factors were more salient for women.
Bartone (1999) studied the effects of hardiness on war related stress in army reserve forces, and found that hardiness protects against the ill effects of war related stress, particularly under high- and multiple- stress conditions. Aldwin, Levenson, and Spiro (1994) found among male combat veterans that appraisals of the desirable and undesirable effects of military service mediate the effects of combat stress on PTSD symptoms in later life, with undesirable effects increasing the relationship and desirable effects decreasing it. Finally, Vasterling, Duke, Brailey, Constans, Allain, and Sutker (2002) found among Vietnam veterans that although the extent of combat experience was the most important predictor of the severity of PTSD symptoms, the estimated premilitary IQ appeared to help buffer the veterans from developing PTSD symptoms.
Miscellaneous. Wandersman and Nation (1998) examined the impact of neighborhood characteristics on mental health outcomes, as well as the characteristics of both individual and neighborhoods that encourage resilience. They proposed interventions at the neighborhood level to ameliorate or prevent distress. Montgomery, Miville, Winterowd, Jeffries, and Baysden (2000) studied a small sample of American Indian college students and found that their resilience was imbedded in their cultural traditions. Major, Richards, Cooper, Cozzarelli, & Zubek (1998) found that more resilient women appraised their abortion as less stressful and had greater self-efficacy for coping with abortion.
Risk and Protective Factors in a Stage Model of Disasters
Pann (2001), building on the work of Zinner and Williams (1999), identified the unique risk and protective factors at both the individual and community levels across a series of stages from the pre-trauma period to the post-trauma period.
Pre-trauma period. In addition to factors already noted, several personality traits are associated with resilience to traumatic stress. One such variable is coping styles, which can be emotion-focused or problem-focused, or oriented toward approach or avoidance. These different coping styles can have different outcomes depending on the situation. For example emotion-focused coping can helpful if it helps focus on the managing of distressing emotional reactions, but can be maladaptive if it leads to excessive rumination. So too, problem-focussed coping can aid in the adjustment process, but if used excessively relative to emotion-focussed coping or denial may lead to greater anxiety levels. Hence people may be better served by learning a range of coping responses and being flexible in their use. Another variable is cognitive appraisal of stress or threat. A tendency to appraise events as unpredictable and threatening can increase vulnerability to deleterious effects of trauma. Attributional style is a related variable, which has three dimensions: Locus (the tendency to assume an internal vs. an external locus of causality of a traumatic event), stability (the tendency to assume that the traumatic event will continue vs. viewing it as temporary), and globality (refers to the degree to which events are seen as affecting ones entire life or only specific aspects of it). An attribution style consisting of an internal locus, stability and globality would increase ones vulnerability to post-traumatic symptoms. Self-efficacy, or the view that one can cope with stressful events, is a protective factor, as is psychological stability (in contrast to neuroticism). In addition to personality variables, several community-level variables are important risk and protective factors during the pre-trauma period. Risk factors included past unresolved traumas and previous losses. Protective factors include a psychological sense of community, belonging and cohesion, levels of support structures in place, and the ability to mobilize for emergencies.
Trauma period. Individual risk factors include sense of threat (to life, limb or family member), sense of helplessness, loss of significant others, bereavement, injury to self or family member, loss of possessions, significant property damage, dislocation, displacement, sense of personal responsibility, sense of inescapable horror, sense of human malevolence, panic during the disaster, exposure to media coverage of the disaster, and level of symptomatology exhibited during the early phases of disaster recovery (especially avoidance and numbing symptoms). Risk factors at the level of the community include human- caused disasters, extreme destruction, great injury and death, serious financial impact and degree of dislocation of community functions.
Primary intervention period. This can be described as a heroic period, in which large amounts of time and energy are directed toward rescue operations and stabilizing the situation. In the acute phase of recovery, individual risk and protective factors include: social support, information (or lack) about the disaster, presence of other stressors, presence of resources (higher income and education, recovery services), and successful mastery of past traumatic events. Community factors include leadership, communication, and the provision of trauma resources to victims.
Secondary adjustment period. Key individual factors include the restoration of normality and a sense of security. At the community level, large-scale devastation can impair the quality of life for a considerable time. Rituals and memorials can assist communities in coping with losses.
Post-trauma period. Most individuals return to their pre-disaster level of functioning in six months to three years after the event. Those most directly exposed to life threat are at greatest risk for adverse effects. Hard hit communities may struggle for quite some time to return to a sense of normalcy.
Preventing PTSD, Stress Inoculation and Stress Management Programs
Preventing PTSD. Bryant and Harvey (2000) have suggested that Acute Stress Disorder (ASD) is a precursor of PTSD. Hence, they argue, PTSD can be prevented by identifying and treating (with cognitive behavioral therapy) trauma victims who suffer from ASD. Bryant, Harvey, Dang, Sackville, and Basten (1998) found that brief cognitive behavioral therapy of ASD resulted in significantly fewer cases of PTSD at post-treatment and 6 month follow up, as compared with a supportive counseling condition. Foa, Hearst-Ikeda, and Perry (1995) found that a brief (4-session) cognitive behavioral program aimed at arresting the development of PTSD in female victims of assault significantly reduced the severity of PTSD symptoms as compared to an assessment control group two months post-assault.
Stress Inoculation Training. Stress inoculation training (SIT), according to Meichenbaum (1993), is a flexible, individually-tailored, multifaceted form of cognitive behavioral therapy. The concept of inoculation is borrowed from both medicine and social psychological research on attitude change. The underlying concept is that by enhancing a persons coping responses to mild stressors through skills training and development, one can reduce the likelihood of developing symptoms in the face of severe stress. Meichenbaum described three phases to SIT. SIT begins with a conceptualization phase through which the problem is assessed and clients are taught that their appraisal of stressful events mediates their reaction to them. The second phase focuses on coping skill acquisition and rehearsal. The final phase, application and follow through, involves exposure, in which the client is encouraged to apply their coping skills to gradually increasing levels of stressful situations. SIT has been applied to a wide range of stressful situations: Medical problems such as preparation for surgery or other stressful medical procedures; reducing the stress associated with mental illness; treatment of performance anxiety; adjustment to life transitions such as unemployment or entering military service; helping occupants of high stress occupations, such as first responders to disaster; and helping victims of trauma.
Stress Management Programs. A literature search on the outcomes of stress management programs found that there are studies demonstrating efficacy in several areas: Workplace/job stress (Adams, 1981; Bunce, 1997; Bunce & West, 1996; Murphy, 1986; Stensrud & Stesnsrud, 1983; ), medical illness (Baum, Herberman, & Cohen, 1995; Heinrich & Schag, 1985; Ludwick-Rosenthal & Neufeld, 1988), life transitions (Schinke, Schilling, & Snow, 1987), and family stress (Falloon, 1985; Schinke, Barth, Gilchrist, & Maxwell, 1986; Weinberg, 1999).
The literature suggests that several variables are associated with post-disaster psychological status. Pre-disaster psychological vulnerability (e.g., prior episodes of PTSD), degree of exposure to the traumatic event during and immediately after the disaster, and the occurrence of major life stressors (e.g., loss of home, unemployment) are associated with poorer post-disaster adjustment. On the other hand, personality resources such as resilience or hardiness and social support are associated with better post-disaster psychological status. Stress Inoculation and stress management programs might be of considerable help in preparing some citizens to cope with the threat of terrorist attack. Very little is known about how different demographic groups respond to disasters and hence more research is needed in this area. One challenge for the future is to design and evaluate psychoeducational programs aimed at enhancing the factors of resilience (Confident Optimism, Productive and Autonomous Activity, Interpersonal Warmth and Insight, and Skilled Expressiveness) and hardiness (a sense of Control over ones life, Commitment as a result of finding meaning in ones existence, and viewing change as Challenge).
As one of the nations learned professions, psychology has always possessed the potential to contribute meaningfully to society. As active participants within the APA governance for over a quarter of a century, we have collectively been very pleased with the extent to which our profession has gradually accepted this important societal responsibility in an increasingly wide range of areas. The tragic events of 9-11 have brought psychologys unique expertise to the forefront, and we are genuinely proud of how our Association and colleagues across the nation spontaneously responded to this crisis. This is truly the mark of a maturing profession.
The essence of the War On Terrorism is, above all else, that of a psychological conflict. Immediately following the totally unprecedented attack, our clinical colleagues reached out to provide high quality health care fully realizing that individuals are different, that children are not merely little adults, and that those closest to the horror would most likely respond differently than those farther away. An impressive range of psychological expertise was demonstrated, including informing the media and developing databased responses to real-life psychological experiences. At both the national and state association level, psychologists were absolutely critical in shaping our nations response. There can be no question that we really do know a tremendous amount about the underlying experiences our citizens faced and fortunately our voice was heard. The behavioral sciences are the key to survival and flourishing in the 21st Century.
Our nation is now entering another phase in this War: How to deal with continuous vague and often unsubstantiated threats on our daily lives. To many, this goes to the essence of the American dream. Once again, psychologys calm and thoughtful voice is being heard -- in the media and at the highest levels of public policy leadership. And, from a public policy perspective, we must soon expect the emergence of yet another phase: How to aggressively address the underlying causes of the seemingly irrational hatred and violence that is being targeted towards our citizens and our fundamental way of life. Fortunately, our discipline has a long and rich history of scientifically addressing highly related issues.
We fully expect that throughout these challenges, we shall once again witness the best and brightest of our nations behavioral scientists unselfishly, if not enthusiastically, contributing to the ongoing national (and international) debate as it unfolds. In time, we further expect that our professions educators will become extraordinarily involved in crafting creative solutions. And, in our judgment, this is as it should be. The key to the future is quality education for all individuals and this simply cannot be accomplished without the active engagement of our worlds educational institutions. Our planet is becoming increasingly interdependent, with physical distances having increasingly little significance. Daily we are faced with a virtual explosion in technological advances; international, if not instant, communications; and virtually unforeseen transportation capabilities that we have now almost come to expect. As we enter the 21st Century, all nations and their enlightened citizenry must come to appreciate the extraordinarily globalization that our world faces today. The different facets of psychology all reflect one family. Our collective world is exponentially becoming smaller and smaller. This is the challenge of the 21st Century.
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