The purpose of our research has been to document the variability in acute and ongoing responses to the largest community-based trauma in recent US history across a nationally representative sample of individuals. Specifically, we have sought to understand psychological responses to the September 11th attacks and their aftermath across the USA, and identify specific personal, social, and psychological factors that predict differences in outcomes over time. Our work is informed by decades of research on stress and coping that suggests a dynamic process in which responses to events are influenced by both individual and social variables. The accumulated data in the stress and coping field present a wide variety of relations among psychological responses and psychiatric symptoms (e.g., distress, positive affect, depression, PTSD), social and psychological variables (e.g., social support, worldviews), and behaviors (e.g., coping strategies). However, integrating these findings has been hindered by the lack of methodological consistency across studies that examine adjustment to different events, using different measures, and sampling different populations. This prior work has nonetheless provided empirical and theoretical foundations for a comprehensive and rigorous examination of adjustment processes in a social context. Since September 2001, we have conducted a longitudinal panel study of responses to the terrorist attacks of September 11 in a national probability sample of Americans. The national scale of the terrorist attacks allowed us to examine the emotional, cognitive, and social impact of a single event within a representative sample of individuals. Early results indicated substantial variability in response. One goal of our ongoing research is to examine factors that may account for this variability, and to identify early predictors of long-term adjustment to this traumatic event. Tracking the interplay of social and psychological factors in responses to the terr

If terrorism creates lingering anxiety and worry about the potential for future malicious mass violence, then terrorism is effective. As a result, the goal becomes to increase effective coping and reduce incapacitating and disabling fears among citizens. We know very little about how people cope with the unique possibility of future terrorist attacks, although we know something about the mental health impact of direct and indirect exposure to terrorism in different contexts (e.g., Oklahoma City, 9/11). With respect to theory and research depicting risk and resilience factors that contribute to the mental health impact of trauma and traumatic loss, the field of traumatic stress has evolved considerably, and research on the threat of terrorism will likely continue in this tradition. In this chapter we argued that long-term adaptation to terror requires a paradigm shift away from psychopathology and toward coping and functional impact in the face of concerns about future terrorism, and we presented a conceptual framework based on this argument. As evidence accumulates in this important research area, we expect our working conceptual framework to be modified considerably. In order to test the validity of various risk and resilience indicators, causal modeling studies are needed. Our hope is that research examining key elements of the model will reveal information that will guide future terror-related educational and clinical intervention efforts. [Text, pp. 586-587]

Disasters, whether unintentional acts of nature or human-made terror, can have profound effects on those who experience them. Research conducted after various types of disasters (the Oklahoma City bombing, Hurricane Andrew, the Three Mile Island nuclear accident, the Loma Prieta earthquake, the terrorist attacks on September 11, 2001) has demonstrated that adults and children show a wide range of reactions. Some suffer distressing worries, difficulty sleeping and concentrating, and bad memories that, while disturbing and impairing, most often fade with good emotional support and the passage of time. Others are more deeply affected and experience long-term problems such as depression, PTSD, and other anxiety disorders. Research focused on the effects of terrorism can provide important information that may improve long-term survival, help prepare for subsequent incidents, aid in assessing the physical and emotional needs of a population, impact on planning and provision of mental health services for victims and other disaster-affected persons, and increase understanding of the human response to trauma more broadly. Prior studies involving trauma and disaster-affected populations have identified some of the special issues that exist for research in the unique circumstances of terror, but concerns about magnitude of risk to participants of research post-disaster are largely undocumented. Some question whether witnesses to or victims of extreme trauma may be able to anticipate the degree of distress that will accompany research participation. The process of institutional review and approval is intended to ensure that adequate procedures are in place to address this and other issues. However, beliefs and knowledge about the potential of these studies to traumatize or upset participants varies greatly among individual investigators and members of review bodies. Although the risks and benefits of participation in disaster-focused research are not fully understood, most woul

Significant research and clinical interest in the role of mental health interventions in circumstances of terrorism and mass violence has increased, especially since the terrorist attacks of September 11, 2001. The opportunity for early intervention exists and is now a focus, as discussed and concluded in the recent consensus conference on mass violence (U.S. Consensus Workshop on Mass Violence and Early Intervention, 2001). This chapter will consider some of the options for early intervention with civilian populations, focusing on the first month, but taking into account the special constraints and requirements of the immediate days or weeks post-incident as well as the acute reaction phase of the first month or so. Humanitarian aid, prevention of post-incident psychiatric morbidity, and treatment of those who decompensate are among the many aims of intervention. Group focus is a way of providing for the large numbers involved, and because people so often come together spontaneously at such a time. Nevertheless, the efficacy of formal group interventions in the prevention and treatment of initial acute reactions among civilian populations has yet to be established. The use of group intervention for response to such initial acute reactions will be considered, taking into account the potential for interventions to assist both formal and informal groups, the rationale for possible effect, and what is known about outcomes. [Text, pp. 482-483]

This chapter will review the history of research on disasters and terrorism leading up to the state of the field at the time of the September 11th terrorist attacks and the methodological challenges faced in responding to this unprecedented event. This chapter will also discuss translations of empirical data to clinical intervention and policy, and the ramifications of disaster studies for future research and disaster planning. [Text, p. 95]

Terrorism, and its threat, poses several conundrums for mental health care providers. It is generally concluded that the experience of terrorism is so horrific that traumatization follows. Accordingly, comprehensive intervention programs are needed. It is, therefore, essential to ascertain how these threats affect us and to develop appropriate and effective psychological interventions. This chapter will explore what happens to people who live under the constant threat of terrorist attacks over a prolonged period. It will also examine the specific characteristics of clinical issues related to ongoing terrorist threats and review appropriate psychological interventions. [Text, p. 34]

This chapter outlines three service models commonly applied in situations of mass violence -- combat psychiatry, disaster mental health response, and high-risk occupation support -- together with two additional models of early care -- the rape crisis counseling model applied with numerous survivors of sexual violence, albeit on a sequential basis, and an evolving cognitive-behavioral model of early intervention with assault and accident survivors who receive hospital emergency medical care. Key issues in providing early intervention for survivors of mass violence are explored, in terms of the common assumptions of existing models of care, the nature and importance of "natural" recovery processes, range of potential targets of early intervention efforts, and ways of achieving target behavior change. [Adapted from Text, p 16]

In the aftermath of September 11, we developed a study to assess the potential mental health consequences of the September 11 attacks in the general population of the New York City (NYC) metropolitan area. Underlying this work was the premise that all residents of the NYC metropolitan area were potentially exposed to the September 11 attacks, and could plausibly develop post-traumatic stress symptoms related to the attacks. There were three key research questions guiding this work. First, it was considered of paramount importance to determine the burden of post-traumatic stress in the general population a month after the September 11 attacks; this could both contribute to public mental health planning and also add new insight to the literature where there were no peer-reviewed papers documenting the early prevalence of PTSD in the general population. Second, it was considered equally important to document the course of PTSD in the general population in the months after September 11. Third, we wanted to identify specific groups that were at high risk of post-traumatic stress symptoms in the general population after the terrorist attacks and who would, as such, benefit from targeted public mental health interventions. This research group conducted a number of studies to address these questions in the NYC metropolitan area. We discuss here the rationale behind the studies conducted and the study design chosen, evidence about post-traumatic stress in the general population in the first 6 months after September 11, and the implications of this work for public health planning after major disasters in densely populated urban areas. [Text, pp. 20-21]

Psychological First Aid is an evidence-informed modular approach to help children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism. Psychological First Aid is designed to reduce the initial distress caused by traumatic events and to foster short- and long-term adaptive functioning and coping. Principles and techniques of Psychological First Aid meet four basic standards. They are: (1) Consistent with research evidence on risk and resilience following trauma; (2) Applicable and practical in field settings; (3) Appropriate for developmental levels across the lifespan; (4) Culturally informed and delivered in a flexible manner. Psychological First Aid does not assume that all survivors will develop severe mental health problems or long-term difficulties in recovery. Instead, it is based on an understanding that disaster survivors and others affected by such events will experience a broad range of early reactions (spiritual, physical, psychological, and behavioral). Some of these reactions will cause enough distress to interfere with adaptive coping and recovery may be helped by support from compassionate and caring disaster responders. As a community religious professional, you may work primarily with people you know well. However, while delivering Psychological First Aid, you will be meeting new people continuously, working in diverse settings, and encountering unfamiliar situations and circumstances. This is a very demanding and draining experience. Psychological First Aid will give you a particular set of skills and procedures that will allow you to minister safely and effectively to survivors of disasters and terrorist events. [Text, p. 7]