Rocky Mountain Region Disaster Mental Health Conference
February 11-14, 1999
Laramie, Wyoming
CONFERENCE PROCEEDINGS
DAY 2
Terrorism, Disaster Mental Health and PTSD
Day 2 of the Conference began with a presentation by Robert DeMartino, M.D. on
Terrorism and Disaster Mental Health. He spoke about the psychological, social, and
behavioral consequences of natural disasters as being one route toward understanding how
to come to grips with the mental health aftermaths of terrorism. Dr. Renee Garfinkel
provided an account of two studies of elderly civilians living in nursing homes and how
they coped with months of Scud Missile attacks on civilian populations of Israeli cities
during the Gulf War. Patrick Smith, Ph.D. and Kim T. Suda, Ph.D. provided a review of
Mowrer's Two-Factor Theory and how it might be applied to acute intervention following
trauma. Dr. Joseph Sivak presented information about how suicidal thinking often
increases with the presence of PTSD and the prevalence and frequency of suicidal
cognitions and their relation to suicidal attempts. In a presentation that provided
clinical information about the post-traumatic impact and counseling interventions
following the bombing of the Alfred P. Murrah Federal Building, John Jones, Ph.D.
presented a very unique therapeutic approach which is of great value to other clinicians.
PRESENTER: Robert DeMartino, M.D.
Associate Director
Program in Trauma and Terrorism
Division of Program Development
Special Populations and Projects
Center for Mental Health Services
US Public Health Service
rdemarti@samhsa.gov
The psychosocial consequences of natural disasters are an important part of what Disaster
Mental Health deals with. Understanding these are an important component in effectively
dealing with the ramifications of terrorism. Dr. DeMartino talked about the lessons learned
from the experiences of disaster mental health in natural disasters, and how these might be
applied to the aftermath of terrorist acts. He also talked about some of the mental health
issues which are specific to terrorism. His presentation focused on how behavioral and
mental health issues are integral parts of the preparation, mitigation and response for all
disasters. However, they are especially important in bioterrorism events. He emphasized the
fact that, more than any other form of terrorism, biological terrorism will challenge
planners, responders, politicians, health care providers, and the citizens of this country
in ways they have not been challenged in the past. Because of the combination of stealth
and destructiveness, the intent to induce dread and confusion, and the capacity to create
a very prolonged acute crisis, bioterrorist acts create an event which has a very profound
impact.
Dr. DeMartino likened the issue of acute behavioral responses to such events to the early
days of a nuclear Armageddon. He discussed the determinants of some of the potential
consequences of a bioterrorist event. He emphasized risk perception and risk responses as
being essential to any response efforts. He also discussed both pre- and post-interventions
and their potential usefulness.
Dr. DeMartino identified the aspects of terrorist events that could lead to the psychological,
social, and behavioral responses. He said that, as a group, terrorist events have a greater
potential for more severe and longer lasting behavioral/psychosocial sequelae than natural
disasters. He explained the rationale for the expectation that, especially in relation to
terrorist events, the number of psychological casualties will be many times more numerous
than the physical casualties.
Dr. DeMartino identified the following types of expected responses to bioterrorist use of
Biological Weapons:
* Psychological Responses - Anger, Horror, Paranoia, Fear of invisible agents,
Demoralization.
* Social Responses - Damage to community cohesion and infrastructure, hardening of
attitudes with opposition to political reconciliation and support for extreme
countermeasures, doubt of collective security and stability of societal structure
* Behavioral Responses - Panicked evacuation; flouting of quarantine restrictions;
overwhelmed health care facilities; dereliction of jobs and family responsibilities;
behavioral reactions at a distance; repeated acts of terrorism.
Overall, the ultimate psychosocial consequences of Bioterrorism, aside from the inherent
resilience and vulnerabilities of any person or community, rest on the interactions of
four factors: 1) Medical-psychological effects of the biological agent; 2) Stress experience
of the event; 3)Effectiveness of pre-event interventions; and 4) Effectiveness of post-event
response measures.
He described the stress experience as the result of Bioterrorism as dependent upon a
number of factors:
* As a result of the attack, being ill, caring for the ill and being exposed to
the ill
* Geographic and community stigmatization (for those targeted by the attack)
* Individual and community economic loss
* Physical displacement
* Risk Perception, involving -
~ Personal Psychological makeup;
~ The role of the media and what they portray;
~ Behavioral reactions of those affected and citizens in general;
~ Public trust in institutions
~ Influence of crowd behavior in an evolving scenario
Mitigating the medical effects and risk response to a bioterrorist attack
are:
* Pre-event interventions - increasing the public resistance to
fear
* Post-event Responses
~ Bio-social - mass care and return to social roles and supports
~ Debriefing - in its variety of forms
~ Crisis Counseling programs
~ Continued cohesion promoted through shared community activities,
healing rituals, etc.
~ Information Centers - e.g. District Information Centers,
Medical/Psychological information centers
~ Hospital Interventions - triage, information dissemination,
rapid return family, profession referral
~ Community Repair - countering stigmatization, restoring
social, religious and public institutions, restoring
economic infrastructure
Dr. DeMartino provided information about the roles of risk perception, responses and
communication and the media in determining the behavioral responses to bioterrorism.
Finally, he discussed why planning for the behavioral and psychosocial aftermath of a
terrorist incident requires a multidisciplinary effort which involves political, medical, and
mental health leaders as well as governmental and social institutions and agencies and
citizens in general. The roles of disaster mental health in planning for pre- and post-event
interventions following terrorist events is extremely important.
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DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond:
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PRESENTER: Renee Garfinkel, Ph.D.
President, Adoption Studies Institute
Editor: "Adoption Quarterly"
Private Clinical Practice
Washington, DC
reneeg@erols.com
Dr.Garfinkel provided an account of two studies of elderly civilians living in nursing homes
and how they coped with months of Scud Missile attacks on civilian populations of Israeli
cities during the Gulf War. These attacks should have led to increased sickness and death
rates. However, Dr. Garfinkel presented information from two studies that found the
opposite to be the case. Not only were morbidity and mortality not increased, but levels
of cooperation, empathy, and civility were seen to increase. Dr. Garfinkel reported that
the studies examined elements of staff behavior, public policy, communications, formal and
informal support, all of which fostered psychological resilience and effective coping when
facing a mass threat. In her presentation she discussed how these elements and principles
could be taught and how they could be integrated into disaster preparation, disaster response,
and staff training.
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DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond:
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PRESENTERS: Patrick O. Smith, Ph.D. and Kim T. Suda, Ph.D.
Associate Professor Postdoctoral Fellow
University of Mississippi University of Mississippi
School of Medicine School of Medicine
Department of Family Medicine Department of Family Medicine
Jackson, MS Jackson, MS
posmith@familymed.umsmed.edu
Smith and Suda (1999) provided a review of Mowrer's Two-Factor theory and its application
to acute intervention following trauma. They identified conditioned fear as variable rather
than universal or automatic. They suggested that acute post-traumatic interventions should
remain flexible while assessing and addressing the different types and levels of
problematic and adaptive reactions. Their discussion presented an interesting application
of a behavioral model for debriefing. Given an assessment and understanding of the
contingencies surrounding an individual conditioned fear response, a debriefer using this
model would be able to provide an individualized intervention to address problem areas.
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References
DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond:
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Joseph Sivak, M.D.
Director of Psychiatric Services
Twin Ports VA Outpatient Clinic
Superior, WI
Clinical Director
Head of the Lakes CISM Program
Duluth, MN
limbicdoc@aol.com
Post traumatic stress disorder is a psychological consequence of a traumatic event. Joseph
Sivak, MD advanced a hypothesis that suicidal thinking often increases when
individuals are afflicted with PTSD. Dr. Sivak presented information from a descriptive
study conducted at the Twin Ports VA outpatient clinic with both combat and non-combat
veterans suffering from PTSD. This study examined the prevalence and frequency of
suicidal cognitions and their relation to suicidal attempts. Dr. Sivak also analyzed Counter
Suicidal Cognitions (CSC) which he defined as the thoughts and related interventions
which individuals use to recover from episodes of suicidal ideation. Dr. Sivak maintained
that a strong focus and distinct understanding of chronic suicidal ideation and CSC in
PTSD can assist mental health professionals in the assessment and development of
prophylactic interventions with this sequelae of PTSD.
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References
DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond:
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John G. Jones, Ph.D., ABPP, ATR-BC
Psychologist, Indian Health Service
Fort Peck Reservation
Wolf Point, MT
jjones@bilb2.billings.ihs.gov
At 9:02 AM on the morning of April 19, 1995 the world changed for the people of Oklahoma
City. In a presentation providing clinical information about the post-traumatic impact and
counseling interventions following the bombing of the Alfred P. Murrah Federal Building,
Dr. Jones presented a very unique therapeutic approach which is of great value to other
clinicians. He describes the use of art therapy as an intervention with victims and
survivors of the bombing. His method and insights provide a valuable guide for clinicians
who may work under similar conditions with the victims and survivors of other disasters
and tragedies.
Dr. Jones reviewed the organizational and clinical issues, general and specific techniques
employed, the impact on survivors of a trauma of this magnitude, and the compassion fatigue
suffered by the caregivers. He also discussed debriefings for survivors and their families,
intervention with bureaucratic managers, coordination of services and networking with other
agencies.
Finally, he discussed specific interventions and their efficacy, including individual therapy,
group therapy, art therapy and traditional healing.
Dr. Jones completed by having attendees do a brief exercise of art therapy. He discussed
this method as a way of expressing one's self in a nonverbal format followed by processing
the art product verbally. He briefly outlined a number of Art Therapy intervention
techniques.
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References
DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
odoc@mailcity.comYour comments will be posted here and others can respond:
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Symposium Panel
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DISCUSSION AND COMMENTS If you wish to make comments or enter
a discussion about the above presentation, topic and/or materials, please email:
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EMAIL: odoc@mailcity.com
