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U.S. Terrorism Recovery

In the wake of September 11, 2001, HPRT was recruited by the U.S. government to provide technical assistance and support to health care practitioners caring for the survivors and families of victims of the World Trade Center attacks. HPRT has developed a training curriculum for primary care providers, who are treating most of the patients affected by terrorism. This curriculum is currently being deployed to over 70 neighborhood health centers in Massachusetts and the New York metropolitan area.

Terrorism and other forms of extreme violence have an enormous impact on the physical and mental health of the general population. Recent scientific studies have revealed that the psychiatric morbidity associated with mass violence and terrorism can affect large numbers of people, lead to chronic long-term medical and psychiatric illness, and cause premature death among the elderly.The emotional distress of survivors, including feelings of injustice and hatred, can be passed onto future generations as well.

Through two decades of caring for highly traumatized populations in this country and abroad, the Harvard Program in Refugee Trauma (HPRT) has revealed that the primary health care system and its primary health care providers (PCPs) are at the center of recovery and healing for a general population that has been victimized by mass violence and terrorism.

Using our nation’s network of PCPs to support recovery in response to the events of September 11th is the foundation of a program currently being implemented through HPRT, with funding by the Mellon Foundation. This approach is designed, not only to deal with past events, but also to build coping skills against future terrorist threats to our nation’s peace and security. It is based upon the following rationales:

  • PCPs are an essential part of the indigenous healing system of the local population.
  • PCPs can “ask the question” about the patient’s traumatic life experiences, such as those resulting from terrorism, without opening up “Pandora’s box.”
  • PCPs, through implementation of simple concrete steps, can support the healing process of human suffering caused by terrorism.
  • PCPs can inoculate their patients against the potential psychological and physical distress caused by possible future terrorist attacks.
  • PCPs, through taking action today, can assist in ameliorating the detrimental effects of mass violence on future generations.
  • PCPs can provide their care to traumatized persons in a culturally competent way.
  • PCPs can work with their medical colleagues and administrators to reduce their own vulnerability and distress, a necessary secondary step to their care of traumatized survivors.
  • PCPs can actively participate in the larger historical issues affecting their society (e.g., social justice and reconciliation).

Primary Care Practitioners (PCPs) are the local community’s indigenous healers, along with the community’s clergy, traditional healers, family elders, relatives and friends.This is the first line of defense the community turns to, especially at times of national crisis, such as that precipitated by September 11th. PCPs embody the tremendous high demand and respect that is given to them by the general public. HPRT has witnessed in conflict/post-conflict societies throughout the world that traumatized citizens almost exclusively go to their indigenous healers for relief of their physical and emotional symptoms caused by violence. PCPs are trusted by the general public not only because of already established doctor-patient relationships, but also due to the fact that physicians operate in a readily available, non-stigmatizing setting. For example, few survivors are comfortable with the idea of seeking a cure, or even help, from a psychiatric practitioner. Rightfully so, the majority of traumatized people do not consider their emotional and/or physical distress caused by terrorism as a mental illness, but rather as a normal range of responses to a horrific situation.

Many PCPs, however, are afraid to “ask the question,” i.e., ask the patient about their traumatic life experiences. There may be many reasons for this reluctance on the part of PCPs to obtain the patient’s trauma story. Some of these reasons may include:

  • The short amount of time PCPs can allow for a patient visit;
  • Lack of financial reimbursement by managed care insurers for a mental health intervention;
  • Fear of making the patient upset by bringing up their trauma history.

Most importantly, however, it has been HPRT’s experience that PCPs do not “ask the question” because they believe that they are opening up “Pandora’s box.” They fear the possibility that they have very little therapeutically to offer the patient in order to deal with their trauma. Many PCPs believe that they cannot offer much of value within the limited time they have to spend with the patient. In addition, within most primary health environments, there is limited access to health extenders, such as visitors, nurses, social workers and psychiatrists.

The HPRT approach is based upon currently available scientific knowledge and offers the PCPs concrete action steps that can lead to therapeutic outcomes within the current PCP clinical environment. Our approach provides the PCP with a simple detailed method for identifying and treating the medical and psychiatric sequelae of mass violence and terrorism. Therapeutic listening to the patient’s trauma story, in and of itself, may be the only support required for the patient from their PCP. In most cases, the PCP will be actively supporting those measures of coping and self-care that have already been put into place by the patient. Allowing the patient to discuss the impact of terrorism provides an opportunity for the PCP to help the patient, without necessarily taking on the full burden of responsibility for relieving the patient’s distress.

This approach of working within the primary health care system to help survivors of terrorism complements the PCP’s enhancement of the patients’ resiliency to current and future attacks. The PCP’s therapeutic approach, in fact, not only reduces suffering, but also inoculates patients against future distress and loss of medical well-being.

Today, most PCPs practice medicine in culturally diverse communities. As September 11th has revealed, there is no single American response to terrorism; each and every culturally diverse community reacts to terrorism and mass violence in culturally diverse ways. Often, local communities already have an existing problem with neighborhood violence, or the community may consist of refugees who have experienced torture and horrific trauma before arriving in America. Therefore, the PCP needs to provide a basic framework for caring for the survivors of terrorism in a culturally competent and effective way, extending from the proper use of medical interpreters to ethno-psychopharmacology.

The PCPs’ inoculation of their patients to improve coping skills and resiliency can also benefit future generations. Unfortunately, survivors of mass violence can pass on to their children their upset and sense of fear, hatred, and anxiety. Survivors and their communities are deeply concerned with retribution and obtaining justice for the crimes committed against them. PCPs may not be able to provide justice to their patients—this usually can only be achieved by political and social actions through legislation and the courts. What the PCP can do is monitor and discuss with the patient the impact of their distress on their family and local community. For example, unresolved depression can create chronic irritability with a spouse and lack of quality time and enjoyment with children. The survivor’s distress can even lead to domestic violence and the increase in health risk behaviors, such as increased smoking, drinking, use of drugs and unsafe sexual behaviors. The negative impact on the survivor’s family, especially children, can be enormous.

When dealing with survivors, PCPs are engaged in a historical process. They are historical actors contributing directly to the health and well-being of local citizens. As medical practitioners they also have a unique professional role to play in addressing the larger social issue of social justice and reconciliation.

Ultimately, the stress upon PCPs can be great, especially when they are the victims of terrorism themselves, or have to engage in dangerous activities related to bioterrorism and other types of mass violence. Even within the latter situation, PCPs who do not remain aloof and become directly involved with the traumatic life experience of their patients will absorb some of this pain and emotional upset. PCPs already know the emotional and physical hazards that come with caring for dying patients and other emotionally draining situations. In dealing with terrorism, the PCPs need to work with their colleagues and administrators to engage in activities that reduce “burnout” and promote well-being.

The September 11 attacks, like all terrorism or mass violence, has had a widespread impact on U.S. society. The long-term effects of this event have yet to be realized and accounted for…

This is a National Issue

The effects of September 11, and the continued threat of terrorist acts in the United States, has the effect of eroding the social, economic, mental, and physical health of our nation. For a small percentage of individuals, the psychological effects are a serious problem needing immediate attention. A majority of individuals continue to function, but sustain low levels of anxiety and depression which will accrue more serious effects down the road if not addressed now.

This is a Medical Issue

Recent scientific studies reveal psychiatric morbidity associated with mass violence and terrorism can affect large numbers of people and lead to chronic long-term medical and psychiatric illness and cause premature death among the elderly. Studies also link low-grade depression/anxiety with lower effectiveness of auto-immune system:

  • Chronic depression may lead to diabetes, hypertension, heart disease and stroke.
  • Physical functional disability is associated with psychiatric morbidity in traumatized refugee populations.
  • Chronic medical disability and premature death occur in mentally ill patients cared for by the public system.
  • Depression and social isolation are linked to increased mortality in heart attack and stroke patients.

The Trauma Story

Most people in the U.S. were traumatized during and following September 11 regardless of whether they had direct relationships with victims. Whether they personally survived the attacks, witnessed the events in person, or watched them unfold on television, everyone has a story about their experience. Telling this story helps people heal themselves and leads to affiliative behaviors which sustain and strengthen mental and physical health in the face of continued threats of terrorism.

You, the primary care provider, are the indigenous healer.

Through 20 years of caring for highly traumatized populations in the US and abroad, HPRT has revealed that the primary health care system and its primary health care providers (PCPs) are at the center of recovery and healing for a general population that has been victimized by terrorism or mass violence

You, the primary care provider, can help inoculate society.

The most trusted and appropriate people in US culture to help individuals recover from the trauma, and be healthy in the face of threatened terrorism, are the ones that already attend to the physical, mental and spiritual health of people, including the following:

  • Primary Care Providers
  • Mental Health Workers
  • Clergy
  • Community Elders

What You Can Do

  1. Ask about the patient’s “trauma story”
  2. Identify concrete physical & mental effects
  3. Diagnose & Treat generalized anxiety, depression, PTSD & chronic insomnia
  4. Refer screened cases of serious mental illness
  5. Reinforce & Teach positive coping behaviors
  6. Recommend altruism, work & spiritual activities
  7. Reduce high risk behaviors
  8. Be Culturally-Attuned in communicating & prescribing
  9. Prescribe psychotropic drugs if necessary
  10. Close & Schedule follow up visits
  11. Prevent Burnout by discussing with colleagues
  1. ASK about the patients trauma story. Ask the question:

    How has your life changed since 9-11?

    Have recent events such as September 11th or the anthrax scare caused you any physical or emotional problems?

    Do you think about future attacks?

    Many of my patients have felt that September 11th had a big effect on their health and well-being. Has this been the case for you?Listen to the answer and acknowledge the patient’s trauma story. The trauma of terrorism may occur in addition to other ongoing traumatic life experiences such as poverty or domestic violence. Sometimes an experience of extreme violence such as terrorism will prompt the patient to reveal for the first time prior traumatic experiences that he/she has been reluctant to share with the PCP.

  2. IDENTIFY concrete physical or mental effects.By identifying the concrete physical and psychological effects of terrorism, the PCP can help the patient to note these effects and be reassured they are normal and usually temporary.
    • Is the patient complaining of any physical symptoms such as:
      • headaches
      • stomach upset
      • back pain
      • fatigue
      • weakness
    • Is the patient exhibiting feelings of:
      • grief
      • anxiety
      • depression or PTSD
    • Have medical or psychiatric disorders worsened?

    Patients with pre-existing psychiatric disorders that worsen following trauma related to terrorism may need adjustment in medications and increased psychosocial support.

  3. DIAGNOSE & TREAT most patients.After a terrorist attack, almost everyone will experience some transient physical or psychological symptoms 85% of patients will not suffer from serious mental illness and will benefit from your counseling on the nature of their symptoms and coping techniques 15% will develop a specific psychiatric disorder including:
    • grief reaction
    • generalized anxiety disorder
    • depression & PTSD
    • chronic insomnia

    Use HPRT’s screening instrument to help you decide if serious mental illness is present.

  4. REFER screened cases of serious mental illness. Many trauma-related mental health conditions will recede with the help of the PCPs reassurance and psychological support. Some will develop into true psychiatric disorders. Screening (click here to download HPRT’s Simple Depression Screen) and referral to a mental health professional should be considered in the following circumstances:
    • Danger to self or others
    • Complicated grief
    • Severe forms of PTSD and/or depression
    • Physical and social disability
  5. REINFORCE & TEACH positive coping behaviors. You can help a patient by simply reinforcing positive behavior and teaching coping techniques. Patients usually hold their PCPs in very high regard. PCPs must take advantage of this positive regard to validate whatever coping strategies are already been used. Affirm behaviors with such phrases as: Keep up the good work! It is good for you and will help you cope. Recommended coping strategies begin with self-care. Remind the patient to build physical, spiritual and mental strength.
  6. RECOMMEND altruism, work & spiritual activities. Scientific studies of survivors of mass violence have repeatedly revealed increased resilience associated with altruism, work and spiritual activities. Engaging in these activities and behaviors appears to prevent mental health problems and promote recovery from existing problems. PCPs should actively recommend these activities: I strongly recommend that you work and keep busy, try to help others and consult with your clergy or engage in spiritual activities such as meditation or prayer. You have the power to recommend a change in behavior!
  7. REDUCE high risk behaviors. Patients often increase their use of cigarettes, drugs and alcohol or become involved in risky sexual behavior during times of crisis. PCPs must be alert for these unhealthy activities. Inquire about high risk behaviors:Have you started to use or increase your use of cigarettes drugs or alcohol? Are you having unprotected sex? If the response is positive, recommend steps to reduce these high risk activities.
  8. BE CULTURALLY ATTUNED to differences. Different cultures have different views of trauma and different ideas about the cause of illness. Literal translation of your questions or diagnosis may be meaningless. The choice of medical interpreters is important – choose someone with both language and context skills.Culturally diverse patients have different reactions to doses and side effects. Consider ethnically-influenced factors such as tolerance levels and body weight (ethnopsychopharmacology is important!) Be aware of a patient’s pre-existing “threshold” for trauma — some patients may have a smaller capacity for additional trauma due to past experiences.
  9. PRESCRIBE psychotropic drugs if necessary Prescribe medication where appropriate. Read XYZ Essay for simple, detailed guides about drugs most commonly used to treat generalized anxiety disorder, depression, PTSD and insomnia.
  10. CLOSE & SCHEDULE follow up visits. PCPs need a method for sensitively closing the interview, especially after a traumatic history has been revealed, such as:Thank you for telling me about these upsetting events. You have helped me to understand your situation better. I know that if we work together, you are definitely going to improve It is important to create a relationship and continuous dialog with the patient – patients value the PCPs reassurance they are going to get better.Schedule follow-up visits & add the diagnosis to the patient’s record (“problem list”). PCPs might say: I want to make a follow-up appointment for 6 weeks from now..just touching base with you to see how you are is important.
  11. PREVENT BURNOUT- discuss w/colleagues. Acts of terrorism and mass violence directly affect the practitioner as well as the patient. Dealing with traumatized patients is stressful in itself. As members of the community, PCPS can suffer similar mental health consequences of terrorism as their patients.PCPs caring for patients affected by terrorism need a systematic, institutionally supported plan for self-care, and time for attention to their own health including diet, exercise and discussion with others – You can prevent burnout by discussing with your colleagues regularly – in the same way a patient benefits from talking to you, you will gain strength from talking with others.

HPRT has developed a training curriculum for primary care providers, who are treating most of the patients affected by the terrorist attacks of September 11, 2001. This curriculum, entitled “Inoculate Against Terror in Primary Care Practice,” is being deployed to over 70 neighborhood health centers in Massachusetts and the New York metropolitan area.
To become a U.S. Terrorism Recovery Project Ambassador or to schedule a U.S. Terrorism Recovery Project, Inoculate Against Terror in Primary Care Practice training at your clinic, contact:

U.S. Terrorism Recovery Project Training Program

Harvard Program in Refugee Trauma Department of Psychiatry Massachusetts General Hospital

22 Putnam Avenue Cambridge, MA 02139 USA

phone 617.876.7879 | fax 617.876.2360