No study to date has investigated the effects of the World Trade Center disaster in primary care patients. A greater understanding of the risk and protective factors for the development of PTSD in an exposed low-income immigrant primary care population will facilitate planning for targeted primary care-based interventions. The aim of the study described in this chapter was to study a systematic sample of low-income, mostly Hispanic patients attending an urban general medicine clinic in New York City. The specific aims of this study were to: (1) estimate the current prevalence of patients who receive positive screen results for current 9/11-related PTSD; (2) compare demographic, 9/11 trauma exposure, clinical, treatment, and service use characteristics of patients who screen positive for current PTSD with those who do not; and (3) report on comorbidity, impairment, and health functioning of screen positive patients. [Text, p. 241]

In this chapter, the focus is on the considerations surrounding efforts to conduct research on the effects of disasters and terrorism within school settings. Schools are a logical setting in which to evaluate children's disaster reactions, because most children are enrolled in school, and thus schools provide an opportunity to obtain community estimates of the effects of disasters and terrorism on children. Many studies of the effects of natural disasters on children have, in fact, been school-based studies of children and adolescents. Similarly, studies of children's and adolescents' reactions following the 1995 bombing of the Federal Building in Oklahoma City and some of the key studies emerging from the 2001 terrorist attack on the World Trade Center have evaluated children and adolescents in school settings. This approach to child disaster research is extremely common and valuable. This present chapter is designed to highlight several key issues that are pertinent to study design and implementation. It is organized as follows. The first section discusses the types of disaster-related research questions that are well suited to a school-based approach, and also describes some of the potentials and challenges associated with conducting disaster research in school settings. The second section focuses on issues related to study design, including sampling strategies for selecting schools and assessment strategies for evaluating children and adolescents. The third section deals with selected issues in study implementation, and especially the recruitment and retention of participants and considerations for training research assistants. The final section provides a brief summary and conclusion. [Adapted from Text, p. 142]

This chapter is designed to describe findings from a study with 226 individuals closely affected by the Oklahoma City bombing 7 years after the event and to provide personal examples of survivors' thoughts and feelings during the recovery process. This chapter will offer some of the major findings relevant to the study of posttraumatic growth (PTG) with a terrorist attack. The responses given by subjects in this study tend to validate Tedeschi and Calhoun's premise that cognitive processing is an essential component of building new schemas and acquiring PTG. The data also indicate that PTG and psychological distress can coexist and demonstrate how additional acts of terrorism can trigger significant distress and feelings similar to those experienced in the original trauma. The information derived from this study offers evidence of significant "constructive" PTG [and] raises questions about the role of forgiveness in growth outcomes with survivors of a mass terror attack. [Text, p. 313]

The terrorist attacks of September 11, 2001, generated acute and ongoing concerns regarding the capacity of federal, state, and local mental health systems to address the psychological consequences of terrorism. It has become increasingly recognized that disasters, especially those involving mass casualties, have various adverse effects on mental health that necessitate the provision of crisis intervention services to survivors of these events. Disaster mental health services thus have emerged as an integral component of federal and local emergency management. The response to the attacks of New York's mental health system was multifaceted, with Project Liberty, a federally funded crisis counseling program, at its heart. Federal disaster areas are eligible for a wide range of services, including the Crisis Counseling Assistance and Training Program. Funded by the Federal Emergency Management Agency (FEMA) and administered by the Center for Mental Health Services (CMHS), the crisis counseling program (CPP) is designed to address short-term mental health needs of communities affected by disasters through public education, outreach, and crisis counseling. Because the CCP was designed primarily for natural disasters, it was not clear how well its guidelines would match the needs of New York. Our case study was conducted to learn lessons from New York's experience that could be useful to other communities that must respond to major disasters and terrorism. The purpose was not to evaluate the impact or effectiveness of Project Liberty but rather to document the challenges it faced. [Text, pp. 343-344]

The design and implementation of research following major disasters and terrorist attacks present formidable scientific and logistical challenges, many of which result from the fundamental unpredictability of these events. This chapter addresses the use of Internet-based approaches to community epidemiological studies following such events. Although clearly not a cure-all, use of Internet-based methods provides at least partial solutions to some of the important challenges. In what follows we identify some critical challenges for epidemiological studies of major disasters or terrorist attacks, discuss how Internet-based studies can reduce them, summarize briefly some of the advantages and drawbacks of Web-based sampling and data collection, and provide some details of how Internet-based studies can be implemented. [Text, pp. 129-130]

Narrative Exposure Therapy (NET) is a treatment approach that was developed for the treatment of PTSD resulting from organized violence. NET was developed by vivo as a standardized short term approach based on the principles of cognitive behavioral exposure therapy and testimony therapy by adapting it to meet the needs of traumatized survivors of war and torture. In NET, the patient repeatedly talks about the worst traumatic event in detail while re-experiencing the emotions associated with this event. In the process, the patient constructs a narration of his life, focusing on the detailed report of the traumatic experiences. The majority of persons habituate and lose the emotional response to the traumatic memory, which consequently leads to a remission of PTSD symptoms. [Text, p. 24]

TOPICS TREATED: Terrorism event characteristics; Psychological reactions to be anticipated; Unique challenges to mental health professionals in weapons of mass destruction and terrorist events; Psychological impact; Oklahoma City Federal Building bombing; Impact of the September 11, 2001 terrorist attacks; CODE-C: a model for mental health response to terrorism; National recommendations for early psychological intervention for victims and survivors of mass violence.

This chapter deals with the plague of terrorism and its impact on a great number of people who are caught up in the traumatic ripple effects, forming ever-widening "circles of vulnerability", including families, friends, peers, eyewitnesses, rescuers, and mental health workers. Based on 35 years of research, the author analyzes the impact of terrorism on child victims or survivors in terms of the main feature of trauma: the rupture of continuity in time, in relations and attachments, in perceptions of self and others, in basic assumptions about the world, in future expectations, and, above all, in ruptures in one's fabric of meaning and belief systems. The growing number of children involved in terrorist victimization in Israel and other countries prompted the formation of new, age-appropriate methods that focus on the need to establish the survivor's sense of continuity of experience. This chapter describes the author's internationally used Community Oriented Preventive Education (COPE) program for dealing with disaster and trauma by enhancing six channels of coping resources. It advocates the children's right to grow and to actualize their full potential in a safe environment. [Author Abstract]

We enter a new century already marked by the devastating effects of terrorist violence. For mental health professionals, this state of affairs, of necessity, widens the scope of their focus and skills. The anxiety, helplessness, and sense of meaninglessness that patients increasingly complain about are found to derive not merely from their psychic reality but, more and more, from the deterioration and collapse of their external environments, environments on which they can no longer rely for security and support. In this chapter, we present a new diagnostic entity that we call the syndrome of anxiety by disruption (AbD) to address the clinical picture of growing numbers of patients and nonpatients who struggle with life under the threat of environmental violence in the form of terrorism and social or economic devastation. We describe the clinical manifestations, treatment implications, and imminent significance of these conditions. [Author Abstract]

The writing of this book was spurred by the dramatic escalation in brutal terrorism toward the start of the third millennium, and especially the catastrophic events of September 11, 2001 in the United States, as well as the relentless wave of suicide bombers in Israel during the ensuing period. The urgent need to address the psychological aftermath of these events and to ensure better preparation for any future eventuality has become of paramount importance. Naturally, many of the issues discussed in this book were written with these events in mind. The scope of this book, however, is not limited to dealing with school-based responses to the aforementioned or similar acts of terror, but rather aims to tackle a wider spectrum of traumatic experiences. To elucidate the best intervention practices, we will draw both on theory and research, as well as from our experience both through preventive interventions in the school system and through clinical practice. Although recommendations based on empirical research data are most valuable, research in the area of trauma response is limited and problematic, given the complex and unique conditions and the various operational pressures involved in each disaster. To address these limitations, we will propose that situation-specific interventions be creatively tailored on the basis of principles drawn both from research and from prior experiences in crisis intervention. We attribute great value to the extensive experience accumulated by professionals involved in crisis interventions around the world and especially in trauma-stricken areas, even if this experience is not accompanied by clear research evidence. Such professional experiences may include case material, anecdotes, media reports, professional· observations, as well as accounts of interventions with schoolchildren following large-scale disasters by our colleagues in Israel and elsewhere. If examined in light of existing theorizing and research, these accounts may