9/11: Mental Health in the Wake of Terrorist Attacks ppt

It will become a handbook for all who would research the impact of disaster and terrorism on mental health and well-being.”Yuval Neria is Associate Clinical Professor of Medical Psycholo

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“This is a great and exciting book; a volume filled with stories of endeavour, achievement, appraisal and learning; stories of heroism, challenge and hope It will become a handbook for all who would research the impact of disaster and terrorism on mental health and well-being.”

Yuval Neria is Associate Clinical Professor of Medical Psychology at the Department of Psychiatry at the College of Physicians and Surgeons, Columbia University; and the Department

of Epidemiology, Joseph L Mailman School of Public Health; and Associate Director of Trauma Studies and Services at The New York State Psychiatric Institute.

Raz Grossis Assistant Professor of Epidemiology and Psychiatry, Department of Epidemiology, Joseph L Mailman School of Public Health; and Department of Psychiatry, College of Physicians and Surgeons, Columbia University.

Randall D Marshallis Director of Trauma Studies and Services, New York State Psychiatric Institute; Associate Director, Anxiety Disorders Clinic, New York State Psychiatric Institute, and Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons.

Ezra Susseris Professor of Epidemiology and Psychiatry at the College of Physicians and Surgeons, Columbia University; Chair of the Department of Epidemiology at the Joseph L Mailman School of Public Health, Columbia University; and Head of the Department of Epidemiology of Brain Disorders at the New York State Psychiatric Institute.

9/11: Mental Health in the Wake of Terrorist Attacks

This book is dedicated to those killed in the attacks of September 11, 2001; and is written for those who survived them, and mourned, and to all who have suffered because of what they saw and feared and felt, and lost.

Yuval Neria: For Mariana, Michal, Oren and Maya, who shared this journey and created the safe space which enabled its fulfillment; and for my dear parents and sister with love.

Raz Gross: For Natalie, Roy, Elie, and Daria; for my dear parents; and for my brother Aeyal and my sister Vardit, with great love.

Randall Marshall: For Tessa, Rory and Thalia, and my parents and brother Rodney, who are my teachers on the nature of love; and for Reece Marshal (1971–2001), who would have understood.

9/11: Mental Health in the Wake of Terrorist Attacks

CAMBRIDGE UNIVERSITY PRESS

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo

Cambridge University Press

The Edinburgh Building, Cambridge CB2 8RU, UK

First published in print format

ISBN-13 978-0-521-83191-8

ISBN-13 978-0-511-33385-9

© Cambridge University Press 2006

Every effort has been made in preparing this publication to provide accurate and date information which is in accord with accepted standards and practice at the time ofpublication.Although case histories are drawn from actual cases,every effort has been made to disguise the identities ofthe individuals involved Nevertheless,the authors,editorsand publishers can make no warranties that the information contained herein is totally freefrom error,not least because clinical standards are constantly changing through research and regulation.The authors,editors and publishers therefore disclaim all liability for direct

up-to-or consequential damages resulting from the use ofmaterial contained in this publication.Readers are strongly advised to pay careful attention to information provided by the manufacturer ofany drugs or equipment that they plan to use

2006

Information on this title: www.cambridge.org/9780521831918

This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press

ISBN-10 0-511-33385-4

ISBN-10 0-521-83191-1

Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate

Published in the United States of America by Cambridge University Press, New York

www.cambridge.org

hardback

eBook (EBL)eBook (EBL)hardback

1 Mental health in the wake of terrorism: making sense of mass

Yuval Neria, Raz Gross and Randall D Marshall

Part II The psychological aftermath of 9/11

Ezra S Susser, Yuval Neria, Raz Gross and Randall D Marshall

3 Post-traumatic stress symptoms in the general population after a

Sandro Galea, Jennifer Ahern, Heidi Resnick and David Vlahov

4 Coping with a national trauma: a nationwide longitudinal study

of responses to the terrorist attacks of September 11 45Roxane Cohen Silver, E Alison Holman, Daniel N McIntosh, Michael Poulin,

Virginia Gil-Rivas and Judith Pizarro

5 An epidemiological response to disasters: the post-9/11 psychological

needs assessment of New York City public school students 71Christina W Hoven, Donald J Mandell, Cristiane S Duarte, Ping Wu and

Vincent Giordano

v

6 Historical perspective and future directions in research

on psychiatric consequences of terrorism and other disasters 95Carol S North, Betty Pfefferbaum and Barry Hong

7 Capturing the impact of large-scale events through

Johan M Havenaar and Evelyn J Bromet

8 Mental health research in the aftermath of disasters: using the

Sandro Galea

Part III Reducing the burden: community response and

community recovery

9 Community and ecological approaches to understanding and

Fran H Norris

Mindy Thompson Fullilove and Lourdes Hernández-Cordero

11 Rebuilding communities post-disaster in New York 164

Mindy Thompson Fullilove and Jack Saul

12 Journalism and the public during catastrophes 178

Elana Newman, Joanne Davis and Shawn M Kennedy

Richard E Boyatzis, Diana Bilimoria, Lindsey Godwin,

Margaret M Hopkins and Tony Lingham

14 Guiding community intervention following terrorist attack 215

Stevan E Hobfoll

Part IV Outreach and intervention in the wake of terrorist attacks

Randall D Marshall

Part IV A New York area

16 PTSD in urban primary care patients following 9/11 239

Yuval Neria, Raz Gross, Mark Olfson, Marc J Gameroff, Amar Das, Adriana Feder,

Rafael Lantigua, Steven Shea and Myrna M Weissman

17 Project Liberty: responding to mental health needs after the

Chip J Felton, Sheila Donahue, Carol Barth Lanzara, Elizabeth A Pease and

Randall D Marshall

18 Mental health services support in response to September 11:

the central role of the Mental Health Association of New York City 282John Draper, Gerald McCleery and Richard Schaedle

19 The New York Consortium for Effective Trauma Treatment 311

Randall D Marshall, Yuval Neria, Eun Jung Suh, Lawrence V Amsel,

John Kastan, Spencer Eth, Lori Davis, Marylene Cloitre, Gila Schwarzbaum,

Rachel Yehuda and Jack Rosenthal

20 Evaluation and treatment of firefighters and utility workers

JoAnn Difede, Jennifer Roberts, Nimali Jayasinghe and Pam Leck

21 The World Trade Center Worker/Volunteer Mental Health

Craig L Katz, Rebecca P Smith, Robin Herbert, Stephen M Levin and Raz Gross

22 Child and adolescent trauma treatments and services after

September 11: implementing evidence-based practices into

Laura Murray, James Rodriguez, Kimberly Hoagwood and Peter S Jensen

23 Relationally and developmentally focused interventions with young children

and their caregivers in the wake of terrorism and other violent experiences 402Daniel S Schechter and Susan W Coates

Part IV B Washington, DC

24 The mental health response to the 9/11 attacks on the Pentagon 427

Elspeth Cameron Ritchie, Willis Todd Leavitt and Sandra Hanish

25 Learning lessons from the early intervention response to the Pentagon 446

Brett T Litz

Part IV C Prolonged-exposure treatment as a core resource for

clinicians in the community: dissemination of trauma

knowledge post-disaster

26 Psychological treatments for PTSD: an overview 457

Edna B Foa and Shawn P Cahill

27 Dissemination of prolonged exposure therapy for posttraumatic

stress disorder: successes and challenges 475Shawn P Cahill, Elizabeth A Hembree and Edna B Foa

28 Mental health community response to 9/11: training therapists

Lawrence V Amsel, Yuval Neria, Eun Jung Suh and Randall D Marshall

Part V Disasters and mental health: perspectives on

response and preparedness

29 The epidemiology of 9/11: technological advances and conceptual

Naomi Breslau and Richard J McNally

30 Searching for points of convergence: a commentary on prior research

on disasters and some community programs initiated in response to

Krzysztof Kaniasty

31 What mental health professionals should and should not do 543

Simon Wessely

Shira Maguen and Brett Litz

33 Life under the “new normal”: notes on the future of preparedness 592

Irwin Redlener and Stephen S Morse

34 Lessons learned from 9/11: the boundaries of a mental health

The editors thank the dedicated staff of Trauma Studies and Services at The New York State Psychiatric Institute and Columbia University, College of Physiciansand Surgeons who have devoted themselves to our 9/11 work from the very begin-ning: Eun Jung Suh, Larry Amsel, Donna Vermes, Steve Rudin, Gretchen Seirmarco,Helena Rosenfeld-Alvarez, Kimesha Thompson, Arturo Sánchez-Lacay, Smit Sinha,and Jaime Cárcamo, together with Franklin Schneier, Blair Simpson and MichaelLiebowitz and the late Sharon Davies of the Anxiety Disorders Clinic

The editors thank Helena Rosenfeld-Alvarez, the editorial coordinator in New YorkCity; and also thank Alana Balaban for her editorial assistance

Support for this book and for our work described herein has been provided in partfrom the National Institute of Mental Health (Neria, Marshall); The New YorkTimes Neediest Fund (Marshall, Neria); Spunk Fund, Inc (Neria); the New YorkCommunity Trust (Marshall); Project Liberty (Marshall); The Atlantic Philanthropies(Marshall); The September 11th Fund (Neria, Marshall); and The Robin HoodFoundation (Marshall)

ix

Editors brief bio

Yuval Neria, PhD

Dr Neria is Associate Professor of Clinical Psychology at the Departments ofPsychiatry and Epidemiology at Columbia University and Associate Director ofTrauma Studies and Services at The New York State Psychiatric Institute He receivedhis doctorate in Psychology from Haifa University, Israel, in 1994, and subsequentlyserved on the faculty of Tel Aviv University until his recruitment to ColumbiaUniversity in New York City after the attacks of 9/11 He has been working in thearea of trauma, loss and post-traumatic stress disorder (PTSD) both in researchand in treatment over the last 15 years His trauma research is inspired by hisextensive combat experience He was injured in the Yom Kippur 1973 War where he

was awarded Itur Hagevura, the highest medal for bravery that is awarded in Israel.

He has authored numerous publications in the area of PTSD and resilience and hisprojects have been funded by the National Institute of Mental Health (NIMH),National Alliance for Research on Schizophrenia and Depression (NARSAD) andmultiple charity organizations He is currently leading a number of research proj-ects related to the aftermath of 9/11 including a nationwide survey on traumaticgrief and a longitudinal study among low income minority, primary care patientsaffected by the 9/11 attacks Together with Dr Randall D Marshall, he has foundedThe Center for the Study of Trauma and Resilience, aiming to conduct research,training, and educational projects; enhance preparedness for terrorism and massviolence-related trauma; to promote resilient coping with adversities; and to improvethe medical and psychological treatment of individuals affected by trauma of allkinds, including terrorist attacks and major disasters

xi Editors brief bio

Psychiatric Epidemiology at Columbia University He received his Masters degree

in Public Health at the Mailman School of Public Health of Columbia University

Dr Gross is currently Assistant Professor of Epidemiology and Psychiatry atColumbia University He is involved in studies of workers who participated in theclean up and recovery effort at Ground Zero after September 11, and of the men-tal health consequences of 9/11 on primary care patients in Northern Manhattan

Dr Gross is also a member of the core research team conducting a web-based vey on the psychological effects of losing a loved one on 9/11 His other areas ofresearch include studies examining the relationship between psychiatric and med-ical conditions, prenatal and early life risk factors for major psychiatric disorders,and clinical trials

sur-Randall D Marshall, MD

Dr Marshall is Director of Trauma Studies and Services at the New York StatePsychiatric Institute and Associate Professor of Clinical Psychiatry at ColumbiaUniversity He received his degree in Medicine from Johns Hopkins University in

1989, and subsequently trained as a resident and research fellow at the New YorkState Psychiatric Institute, Columbia University He has published over 100 articles,case reports, chapters, and editorials, and received numerous research grants funded

by the National Institute of Mental Health (NIMH), private industry, and multiplephilanthropic sources He is currently conducting a NIMH-funded treatment study

of persons with PTSD related to the 9/11 attacks His research related to psychologicaltrauma has encompassed the role of trauma and dissociation in the anxiety disorders,nosology of trauma-related diagnoses, pharmacotherapy, cognitive–behavioraltherapy, dissemination of evidence-based treatments, the biology of treatmentresponse in PTSD, and most recently, the study of serious mental health complica-tions in bereaved persons Most recently, he and Dr Yuval Neria have founded TheCenter for the Study of Trauma and Resilience, which aims to conduct state-of-the-art research, training, and educational projects to enhance preparedness forterrorism, and mass violence-related trauma; promote resilient coping with adver-sity; and improve the medical and psychological treatment of individuals affected

by trauma of all kinds, including terrorist attacks and major disasters

Ezra Susser, MD, DrPH

Ezra Susser is the Anna Cheskis Gelman and Murray Charles Gelman Professorand Chair of the Department of Epidemiology at the Mailman School of PublicHealth of Columbia University, and Head of the Department of Epidemiology ofBrain Disorders at the New York State Psychiatric Institute Much of his researchfocuses on the developmental origins of health and disease throughout the lifecourse He heads the Center for Developmental Origins of Health, a collaborative

birth cohort research program in which epidemiologists seek to uncover the causes

of a broad range of disease and health outcomes, including psychiatric and rodevelopmental disorders, obesity, cardiovascular disease, reproductive perform-ance, and breast and ovarian cancers Elsewhere in his research, he has taken anactive role in using epidemiology to better understand social inequalities of health

neu-by focusing in the health of inner city populations He has studied the tionships between homelessness, HIV, and psychotic disorders and was formerlydirector of the Center for Urban Epidemiologic Studies at the New York Academy

interrela-of Medicine Following September 11, 2001, he worked in close partnership withthe New York State Office of Mental Health and the New York City Department ofHealth and Mental Hygiene to coordinate the research and services response of thepublic and academic sectors He lead the preparation of a broad needs assessmentsubmitted by New York State to the federal government estimating the scope andcosts of mental health needs arising from the terror attacks He also received fund-ing for and implemented a free and confidential mental health services program, ACommon Ground, for the union workers who participated in the World TradeCenter (WTC) rescue and recovery effort This program provided psycho-education,outreach, and group, family and individual counseling and psychiatric services tothousands of union members and their families

List of contributors

Jennifer Ahern, MPH

Senior Research Analyst

Center for Urban Epidemiologic

Studies

New York Academy of Medicine

1216 Fifth Avenue, Room 553

New York, NY 10029, USA

Columbia University College of

Physicians and Surgeons

Director of Dissemination Research for

Trauma Studies and Services

New York State Psychiatric Institute

Associate for Medical Education

Hasting Center for Bioethics

245 West 107th Street, Suite 14-F

New York, NY 10025-3064, USA

10900 Euclid AvenueCleveland, OH 44106-7235, USATel:
216-368-2115

Fax:
216-368-6228E-mail: dxb12@po.cwru.edu

Richard E Boyatzis, PhD

Professor and ChairDepartment of Organizational BehaviorCase Western Reserve University

10900 Euclid AvenueCleveland, OH 44106-7235, USATel:
216-368-2055

Fax:
216-368-4785E-mail: reb2@weatherhead.cwru.edu

Naomi Breslau, PhD

ProfessorDepartment of EpidemiologyMichigan State UniversityB645 West Fee Hall

xiii

East Lansing, MI 48824, USA

SUNY at Stony Brook

Putnam Hall-South Campus

Stony Brook, NY 11794-8790, USA

Cathy and Stephen Graham Professor

of Child and Adolescent Psychiatry

Director, Institute for Trauma and Stress

Child Study Center

New York University School of Medicine

215 Lexington Avenue 16th Floor

New York, NY 10016, USA

Fax:
212-580-1423E-mail: swcl@columbia.edu

Roxane Cohen Silver, PhD

Professor, Department of Psychologyand Social Behavior

Professor, Department of Medicine

3340 Social Ecology IIUniversity of California, IrvineIrvine, CA 92697-7085

Tel:
949-824-2192Fax:
949-824-3002E-mail: rsilver@uci.edu

Amar Das, MD, PhD

Assistant ProfessorStanford Medical InformaticsDepartments of Medicine and ofPsychiatry and Behavioral SciencesStanford University School of MedicineMSOB X-233

251 Campus Drive Stanford, CA

94305, USATel:
650-736-1632Fax:
650-725-7944E-mail: akd@SMI.stanford.edu

Joanne L Davis, PhD

Assistant ProfessorDepartment of PsychologyUniversity of Tulsa

600 South College308C Lorton HallTulsa, OK 74104, USATel:
918-631-2875Fax:
918-631-2833E-mail: Joanne-Davis@utulsa.edu

Lori Davis, Psy D

107 West 82nd Street, Suite P106

New York, NY, USA 10024

Director, Program for Anxiety and

Traumatic Stress Studies

Payne Whitney Clinic, Department of

Psychiatry

Weill/Cornell Medical College

New York Presbyterian Hospital

New York, NY, USA

Center for Information Technology

and Evaluation Research

New York State Office of Mental Health

44 Holland Avenue

Albany, New York, USA 12229

E-mail: coevsad@omh.state.ny.us

John Draper, PhD

Director of Public Education and the

LifeNet Hotline Network

Mental Health Association of

New York City, Inc

666 Broadway, Suite 405

New York, NY 10012, USA

Tel:
212-614-6309 (direct/voice mail)

1051 Riverside Drive, Unit 43New York, NY 10032, USATel:
212-543-5688, 212-543-5725Fax:
212-781-6050

New York Medical CollegeMedical Director and Senior Vice President

Behavioral Health ServicesSaint Vincent Catholic Medical Centers

144 West 12th StreetNew York, NY 10011, USATel:
212-604-8195Fax:
212-604-8197E-mail: seth@svcmcny.org

Adriana Feder, MD

Assistant ProfessorDepartment of PsychiatryMount Sinai School of MedicineOne Gustave L Levy Place, Box 1218New York, NY, USA 10029

Tel:
212-241-1563Fax:
212-824-2302E-mail: Adriana.feder@mssm.edu

Chip J Felton, MSW

Senior Deputy Commissioner andChief Information Officer Center for

Information Technology and

Mindy Thompson Fullilove, MD

Professor of Clinical Psychiatry and

New York State Psychiatric Institute

1051 Riverside Drive / Unit 24New York, NY, USA 10032Tel:
212-543-5849Fax:
212-568-3534E-mail: gameroff@childpsych

columbia.edu

Virginia Gil-Rivas, PhD

Assistant ProfessorDepartment of PsychologyUniversity of North Carolina, Charlotte

9201 University BoulevardCharlotte, NC 28223 0001, USA

Vincent Giordano, PhD

New York Academy of Medicine,Office School Health Programs,Senior Consultant National Center forSchool Crisis and Bereavement,Advisory Board Member Denizen Consulting, Partner Association for Supervision andCurriculum Development

37 Mount Tom RoadNew Rochelle, New York, NY 10805 USATel:
914-654-8897

Fax:
914-654-8897Cell:
914-393-4541E-mail: vgiordano@verizon.net

Lindsey Godwin, Doctoral Candidate

Department of OrganizationalBehavior

Weatherhead School of ManagementCase Western Reserve University

324 E 310 Street

Willowick OH, USA 44095

Psychiatric Clinical Nurse Specialist

Walter Reed Army Medical Center

Pentagon/Operation Solace

Johan M Havenaar, PhD

Managing Director of Adult Psychiatry

Buitenamstel Institute of Mental

Health Care; Department of Psychiatry

Vrije Universiteit Amsterdam

Amsterdam, The Netherlands

Mount Sinai School of MedicineNew York, NY 10029, USAE-mail: robin.herbert@mssm.edu

Columbia University

1051 Riverside Drive, Box 78New York, NY 10032, USATel:
212-543-6131Fax:
212-543-5966E-mail: Hoagwood@childpsych.columbia.edu

E Alison Holman, FNP, PhD

Health Policy and ResearchUniversity of California, Irvine

100 Theory, Suite 110Irvine, CA 92697-5800, USATel:
949-824-6849

Case Western Reserve University

Weatherhead School of Management

Community Research Group

Mailman School of Public Health

513 West 166th Street, 3rd floor

New York, NY, USA 10032

1051 Riverside Drive, Unit 43New York, NY 10032, USATel:
212-543-5688Fax:
212-781-6050E-mail: HOVEN@childpsych

1051 Riverside Drive, Unit No 78New York, NY 10032, USATel:
212-543-5334Fax:
212-543-5260E-mail: pj131@columbia.edu

Krzysztof Kaniasty, PhD

ProfessorDepartment of PsychologyUhler Hall, 1020 Oakland AvenueIndiana University of PennsylvaniaIndiana, PA 15705-1068, USA

Mount Sinai School of Medicine

President, Disaster Psychiatry Outreach

1100 Park Ave., Suite 1B

New York, NY 10128, USA

Professor of Clinical Medicine

Director, General Medicine Outpatient

Services

Director, Columbia Center for theActive Life of Minority Elders (CALME)Columbia University Medical Center

622 West 168th Street, VC2-205New York, NY, USA 10032Tel:
212-305-6262Fax:
212-305-6279E-mail: ral4@columbia.edu

Carol Barth Lanzara, MS, JD

Research ScientistCenter for Information and EvaluationResearch

Evaluation Research BranchNYS Office of Mental Health

44 Holland AvenueAlbany, New York, USA 12229Tel:
518-408-2042

Fax:
518-474-7361E-mail: clanzara@omh.state.ny.us

Willis Todd Leavitt, MD

LTC, MC, USAPsychiatry Consultant, Great PlainsRegional Medical CommandCombat/Operational Stress ControlProgram Manager

Tel:
210-221-8235Fax:
210-221-7235E-mail: Willis.Leavitt@cen.amedd.army.mil

Tel:
212-746-0554Fax:
212-746-8552E-mail: pal2002@med.cornell.edu

Stephen M Levin, MD

Associate Professor

Department of Community and

Preventive Medicine

Mount Sinai School of Medicine

New York, NY 10029, USA

E-mail: stephen.levin@mssm.edu

Tony Lingham, PhD

Case Western Reserve University

Weatherhead School of Management

Department of Organizational Behavior

2040 Stearns Road, Apartment No 1

National Center for Posttraumatic

Stress Disorder / Behavioral Science

Division (116-B5)

Boston Department of Veterans

Affairs Medical Center

150 South Huntington Avenue

Donald J Mandell, PhD

Professor, State University of New YorkResearch Scientist, New York StatePsychiatric Institute

1051 Riverside Drive, Unit 43New York, NY 10032, USATel:
212-543-5688 (main)E-mail: mandell@child.cpmc

columbia.edu

Randall D Marshall, MD

Associate Professor of Clinical Psychiatry,Columbia University College ofPhysicians & Surgeons

Director of Trauma Studies & Services,New York State Psychiatric Institute,New York Office of Mental HealthCo-Director, Center for the Study ofTrauma & Resilience,

New York State Psychiatric Insitute and Columbia University

Associate Director, Anxiety DisordersClinic,

New York State Psychiatric Institute

1051 Riverside Drive, Unit 69New York, NY 10032, USATel:
212-543-5454Fax:
212-543-6515E-mail: Randall@nyspi.cpmc

columbia.edu

Gerald McCleery PhD

Associate Executive DirectorMental Health Association ofNew York City

666 Broadway, 2nd floorNew York, NY 10012, USA

Mailman School of Public Health

Center for Public Health Preparedness

722 West 168th Street, Suite 522C

New York, NY 10032, USA

Fax:
212-543-8793

E-mail: ssm20@columbia.edu

Laura Murray, PhD

Center for the Advancement of Children

Columbia University/New York State

Psychiatric Institute

1051 Riverside Drive, Unit 78

New York, NY 10032, USA

Associate Director, Trauma Studies and Services

New York State Psychiatric Institute

1051 Riverside Drive / Unit 69New York, NY USA 10032Tel:
212-543-6061Fax:
212-543-6515E-mail: ny126@columbia.edu

Elana Newman, PhD

Associate ProfessorDepartment of Psychology, Lorton HallUniversity of Tulsa

600 South College AvenueTulsa, OK 74104 3189, USATel:
918-631-2836Fax:
918-631-2822E-mail: elana-newman@utulsa.edu

Fran H Norris, PhD

Research ProfessorDepartment of Psychiatry,Dartmouth Medical School andNational Center for PTSDVeterans’ Administration MedicalCenter 116D

215 North Main StreetWhite River Junction, VT 05009, USA Tel:
802-296-5132

Fax:
802-296-5135E-mail: fran.norris@dartmouth.edu

Carol S North, MD, MPE

Professor of Clinical Psychiatry

Columbia University and New York

State Psychiatric Institute

New York, NY, USA

Chairman, Department of Psychiatry

and Behavioral Sciences

Director, Terrorism and Disaster

Center of the National Child

Traumatic Stress Network

University of Oklahoma Health

Beverley Raphael, AM, MBBS, MD, FRANZCP, FRCPsych., FASSA, Hon MD (Newcastle, NSW)

Professor Population Mental Healthand Disasters

University of Western SydneyParramatta Campus

Locked Bag 1797Penrith South, NSW DC 1797AUSTRALIA

Tel:
61-2-9685-9575Fax:
61-2-9685-9554E-mail: b.Raphael@usw.edu.auand

Professor of Psychological MedicineAustralian National University

Heidi Resnick, PhD

ProfessorNational Crime Victims Research andTreatment Center

xxiii List of contributors

Department of Psychiatry and

Behavioral Sciences

Medical University of South Carolina

165 Cannon Street, PO Box 250852

Weill/Cornell Medical College

New York Presbyterian Hospital

Tel:
212-746-6167

Fax:
212-746-5418

E-mail: jroberts@med.cornell.edu

Jim Rodriguez, MSW, PhD

Research Scientist, Department of

Child Psychiatry, Columbia

University and New York

State Office of Mental Health

229 West 43rd StreetNew York, NY, USA 10036Tel:
212-556-1091 Fax:
212-556-4450E-mail: rosebud@nytimes.com

Jack Saul, PhD

Assistant Professor of ClinicalPopulation and Family HealthDirector, International TraumaStudies Program

Mailman School of Public HealthColumbia University

155 Avenue of the Americas, 4th FloorNew York, NY 10013, USA

Tel:
212-691-6499Fax:
212-807-1809E-mail: js2920@columbia.edu

Richard Schaedle, DSW

The Mental Health Association ofNew York City

666 Broadway, 4th FloorNew York, NY 10012, USADirector of the Crisis Resource Center

at LifeNetWork: 212-614-6345Home: 718-834-6061E-mail: rschaedle@mhaofnyc.org

Daniel S Schechter, MD

Assistant Professor of Clinical Psychiatry

in Pediatrics, College of Physicians and Surgeons, Columbia UniversityNew York, NY, USA

Tel:
1-212-543-6920Fax:
1-212-463-0702E-mail: dss11@columbia.edu

xxiv List of contributors

Gila Schwarzbaum, MBA

Mount Sinai School of Medicine

Bronx Veterans Affairs

130 West Kingsbridge Road

526 Office of Mental Health PTSD 116/A

Bronx, NY 10468, USA

Arieh Y Shalev, MD

Professor of Psychiatry,

Head, Department of Psychiatry

Hadassah University Hospital,

Hamilton Southworth Professor of

Medicine and Professor of Epidemiology

Chief, Division of General Medicine

Vice Dean of the Faculty of Medicine

and Senior Associate Dean for Clinical

Assistant Professor of Psychiatry

Mount Sinai Hospital and Medical

School

Staff Psychiatrist, Disaster Psychiatry

Outreach

World Trade Center Volunteer, Rescue

and Salvage Worker Screening Program

1200 Fifth Avenue, First FloorNew York, NY 10128, USATel:
212-241-9057E-mail: Rebecca.smith@mssm.edu

Eun Jung Suh, PhD

Instructor in Clinical PsychologyDepartment of PsychiatryColumbia University College ofPhysicians and SurgeonsNew York State Psychiatric Institute

1051 Riverside Drive, Unit 69New York, NY 10032, USAE-mail: ejs161@columbia.edu

Ezra S Susser, MD, DrPH

Anna Cheskis Gelman and Murray Charles Gelman Professor and Chair

Department of Epidemiology Mailman School of Public Health,Columbia University

Professor of Psychiatry andDepartment Head,

Epidemiology of Brain DisordersNew York State Psychiatric Institute

722 West 168th Street, Room 1508New York, NY, USA 10032Tel:
212-342-2133Fax:
212-342-2286E-mail: ess8@columbia.edu

David Vlahov, PhD

DirectorCenter for Urban Epidemiologic studiesProfessor Department of EpidemiologyMailman School of Public Health,Columbia University

Center for Urban EpidemiologicStudies

Professor of Epidemiology in Psychiatry

Columbia University College of

Physicians & Surgeons

1051 Riverside Drive Unit 24

New York, NY, 10032

King’s College London

Weston Education Centre

Fax:
212-781-6050E-mail:

wup@child.cpmc.columbia.edu

Rachel Yehuda, PhD

Professor of PsychiatryMount Sinai School ofMedicine/Bronx Veterans Affairs

130 West Kingsbridge Road

526 Office of Mental Health PTSD116/A

Bronx, NY 10468, USATel:
718-584-9000; ext: 6964 or 6677Fax:
718-741-4775

E-mail: Rachel.yehuda@med.va.gov

A number of themes thread their way through this book: The enormity, pectedness and uniqueness of what happened; not only was America assaulted, butthe world saw, and felt what happened Courage, the “democracy” of distress, resolve,resilience – the coming together of peoples: ranging from the comforts of strangers,

unex-to the convergence of those who would provide help, all attested unex-to the wish unex-torepair, to undo the damage, to make the world right and safe again, to heal There

is the acknowledgment and measurement of the research reported: the ical injuries experienced by many, and, as well, the stressors that arose subsequentlyand made further burdens for those fighting to recover There is a suffering revealedvividly when we listen to the words of those most directly affected Recognition ofthe extent of the catastrophe, and its possible effects, the “global distress”, as well asthe individual pathology, has led most contributors to talk of the public healthissues There is documentation of need for the “population injury” to be dealt with,

psycholog-as well psycholog-as the clinical psychological injury; and many of the diverse concepts,

xxvi

initiatives and research mobilized to address these, including those of powerful munity driven responses This recognition also demonstrated the need for a coher-ent population health framework for such an approach for mental health, includingthe importance of core baseline data and surveillance programs (Commonwealth ofAustralia, 2000) There is also the pluralism which is so essentially American; themultiplicity of approaches which has been creative and productive – yet the need forconsistency and coordination of response – all most obvious is the convergence ofagencies, ideas and methodologies, which demonstrate the need for the reassurance

com-of governance, coordination and structure in the face com-of chaos and uncertainty.Researchers and commentators highlight the vital importance of evaluation, notonly of individual treatments, but also of organizational response of the public health

as well as the clinical initiatives The aims to provide the “highest quality based practice” and “rigorous outcome evaluations” are important but extremely dif-ficult to achieve at most times, let alone in the face of catastrophe Further researchquestions are also seen as relevant; for instance, what are the exposures of “terrorism”and its aftermath; what is resilience; how are interventions to be really targeted tothose with greatest need related to their experience of this incident; what is the nature

evidence-of “psychological trauma” and “collective trauma” and how can we better deconstructthese scientifically to research their etiological significance; and how can excessive

“trauma expectations” be avoided? There is also the need for better scientific appraisal

of ethno-cultural “trauma” impacts

Sophisticated science for “ecological assessment” to inform learning from theseresponses; for instance, how positive dynamics can be supported and negativechanges mitigated is also important Changes such as those associated with socialnetwork damage, splitting, fear and rejection of those who are different, perhaps interms of ethno-cultural distinctions, need to be better understood This shouldinclude an understanding and tracking of what happens to the anger and rage insuch settings and the complex social consequences, the coming to terms with the

“darker side of human nature” – both in our attackers and ourselves

What are the effects of no clear end points to an event, and more specifically ofongoing terrorism “threat” – what changes occur socially, personally, and individ-ually and politically as a consequence? How do individual and collective percep-tions and realities interact? How can beliefs that have attached to models ofresponse, for instance, debriefing and screening, be changed by evidence and howcan evidence inform the realities of care in such circumstances? How do individualsand communities live with, prepare for a threat, with individual and communityplans, that will be of wider value, that will promote well-being, even if the eventdoes not occur, while preparing for effective response if it does?

All these are important questions for future research But such research shouldlearn from the rich contributions of this volume and the further work to come,

from what Yuval Neria, Raz Gross, Randall D Marshall have so powerfully drawntogether, and from all the excellent contributions that comprise this work Thereviews of previous research, the science and actualities of response so comprehen-sively documented and the unflinching critiques provide a valuable resource We willall learn from it in terms of research, but also in policy and planning ahead: much ofwhat has been learned can also enrich planning and research agendae world wide,including those such as WHO–AIMS–E, (WHO, 2005) and other guidelines Theneed for core minimum data sets is critical for future research so that the knowledgebase can be built (Consensus Conference December 2005 Sydney, Australia), so that

we can compare what we do; and share and learn from others, including other tures and worlds This book is a foundation stone for such future endeavors.With this volume, and with the story of 9/11, there are other powerful themes thatshadow response One is the theme of grief, grief for the multiple losses, the terribledeaths, but also the consequent losses of the sense of invulnerability, trust in safe, con-trollable worlds Grief is touched upon for instance in describing Guliano’s leader-ship, symbolized by how he “turned the grief and shock into action and compassion”(this volume, p 193) It is noted in the risk associated with the loss of a loved one, theloss of social network, place of work, the loss of community, “of a place to collectivelymourn” (this volume, p 343) As suggested in the contribution about the Pentagon,those in the services, and Americans generally, had to prepare for war, and indeedthere is the documentation of the many subsequent challenges of the anthrax attacks,wars in Afghanistan and Iraq, terrorist attacks elsewhere, and of course more recently

cul-by international and national natural disasters of catastrophic proportions, theTsunami, Katrina, Pakistan earthquake to name a few The shadows of grief, the sad-ness of lost pasts, and future fears reflect changed worlds That such challenges will becourageously met is attested to by this volume, but is not easy, it is sad, sadness, that is

a human grief requiring recognition, comfort, memorialization and commitment tovalue our loved ones and to make strong compassionate futures for our worlds

As is so well evidenced by this magnificent work:“to come to terms with catastrophemust reinforce human values of family and society, of love and hope, and of passion-ate commitment to life, its value, and its preservation” (Raphael, 1986, p 311)

Part I

Mental health in the wake of terrorism:

making sense of mass casualty trauma

Yuval Neria, Raz Gross and Randall D Marshall

1

On the morning of September 11, 2001, with the attacks on the World Trade Center(WTC) and the Pentagon, the world that many of us thought we knew, was altered.While thousands of people were directly exposed to or witnessed the attacks fromclose proximity, millions around the globe watched the events in real time or repeat-edly over time on news channels The attacks of 9/11 will likely be the most witnessedterrorist acts in modern history

The events that unfolded on and after 9/11, and the subsequent terrorismaround the globe have created a climate of fear and anxiety These are the psycho-logical outcomes that terrorists seek to inflict Terror can only be effective if itleaves lingering concerns about safety; if it disrupts the most basic ways citizensmanage and control their lives

The overall goal of this volume is to document and critically examine the prehensive and wide-ranging mental health response after 9/11 Specifically, thisvolume aims to examine:

com-(1) Whether the research on the psychological consequences of 9/11 suggest aunique and substantial emotional and behavioral impact among adults andchildren

(2) In what way the impact of these attacks exceeded the individual level, affectedcommunities and specific professional groups, and tested different leadershipstyles

(3) How professional communities of mental health clinicians, policy makers andresearchers were mobilized to respond to the emerging needs post-disaster.(4) What are the lessons learned from the work conducted after 9/11, and theimplications for future disaster mental health work and preparedness efforts

Contemporary terrorism: a psychological warfare

While early definitions of disasters typically implied a single “event” that affected asingle “social group” and was usually limited to a specific point of “time” or “location”

(see Quarantelli, 1998; Lopez-Ibor, 2005), the scale of the 9/11 events, occurringsimultaneously in two major urban centers, challenges early concepts of disasters Theunfolding series of post-9/11 al-Qaeda assaults (e.g., March 11, 2004 in Madrid; July

7, 2005 in London) has impacted enormous numbers of people sending a clear sage that terrorism is primarily psychological warfare rather than conventional mili-tary warfare, aimed at causing fear and disarray in large populations

mes-More than 25 years ago, before suicide terrorism had become a worldwide cern, Mengel (1977) distinguished between terrorism that seeks to discriminate itstarget selection and terrorism that involves random acts While the first type of ter-rorism has a political agenda and uses bargaining to maximize its political power,the second type, rooted in an extreme ideology, aims to create global conflicts, and

con-to maximize the destruction of its “enemy” In the pre-9/11 era terrorist activitiestargeted mostly narrow and specific objectives, were limited to specific geographicalareas (e.g., Israel, Lebanon, Indonesia), and the terrorists benefited from relativelylimited media coverage Contemporary terror campaigns, however, target majormetropolitan areas with vast geopolitical and economic significance, threateninglarge masses, relying on wide media coverage, and benefit from worldwide attention

to accomplish their agenda

9/11 and the following stream of terrorist attacks demonstrate that rary terrorism has an extremely effective capacity to impact the psychological andsocial well-being of citizens in places never before disrupted by security problems.Large urban cities are especially vulnerable to terrorist assaults because they areopen, easy to infiltrate, and easy to hit

contempo-More than seven decades ago, Carr (1932) conceptualized a disaster not only as

an “event” but rather as the collapse of a community’s “cultural protections”.Accordingly, large-scale, unanticipated, incidents such as the orchestrated attacks

of 9/11, or for that matter any large-scale unpredicted disaster, has the potential tointimidate large communities causing them to doubt whether they are able toeffectively defend themselves and to guarantee their own existence

As previously discussed elsewhere (Neria et al., 2005) a major aim of

contempo-rary terrorism, especially in its suicidal form, is to ignite a worldwide clash betweenideological and religious groups: to create a division between “good” and “evil”,between “true believers” and “infidels” and to stigmatize people who don’t believe

in a certain divinity as sinners doomed to be rebuked and eventually exterminatedfrom the earth

Continuous exposure to this sort of stress might result in a wide range of ioral changes In several urban centers around the globe, citizens are voluntarilylimiting their actions, avoiding public transportation, changing social habits such

behav-as entertainment in crowded spaces In Jerusalem, for example, many people havedeveloped the so-called “security zones”, where they can socialize freely, creating

the illusion of security or invulnerability In other cities (e.g., New York City), zens are being monitored, their bags checked, and they are being questioned andasked to show identification papers more and more often.

citi-Sadly, these are the calculated consequences of terrorism as warfare (see Levy &

Sidel, 2003; Post, 2003; Susser et al., 2002; Yehuda & Hyman, 2005) Terrorism’s

objective is emotional and behavioral modification of entire populations throughwidespread dissemination of fear and psychological distress (Velez, 2005) Terroristsaccomplish their goals by inducing instability and distress, violating the underpin-

nings of daily life (Fullerton et al., 2003) and inflicting changes to the ordinary routines

of the general population (Holloway & Fullerton, 1994) Although typically, terrorismdoes not pose existential danger to nations due to its lack of significant militaryimpact, it is effective in attacking the public’s morale, reducing trust in democraticprocesses, and eventually eroding resilience in continuously exposed communities

Individual and community sequelae of disaster trauma:

vulnerability and resilience

Terrorism is often perceived as a “pervasive generator” of psychopathology (Fullerton

et al., 2003; p 4 Holloway et al., 1997; North et al., 1999; North & Pfefferbaum,

2002) However, research on the mental health consequences of terrorism, with the

exception of the Oklahoma City bombing (e.g., North et al., 1999; Pfefferbaum,

1999), has been relatively scant

In the immediate aftermath of a disaster, affiliative, attachment-motivated iors such as bonding, caring, and collaborating were suggested to be common amongvictims and rescue forces (Mawson, 2005; Raphael, 2005) Indeed the extreme expe-riences of disasters often bring people together with altruistic intent to help victims,directly, or indirectly (e.g., making or raising donations) These types of behaviorsmay be common in the first and the second post-disaster phases referred to respec-tively as the “rescue” and the “honeymoon” phases (Raphael, 2005) However, whenthe hard facts about the toll of the disaster sink in (e.g., scale of loss and destruction),and penetrate the “denial shield” typical to the immediate aftermath of the disaster,

behav-a “disillusionment” phbehav-ase often tbehav-akes plbehav-ace, behav-and fbehav-atigue behav-and berebehav-avement tbehav-ake over.Previous research has underscored the role that immediate responses to traumaplay in the long-term adjustment of the exposed individuals, suggesting thatuncontrolled behaviors are powerful predictors of chronic post-traumatic stress

disorder (PTSD; e.g., Neria et al., 2000a) Similarly, 9/11 studies have shown that

the experience of panic during the attacks is strongly associated with PTSD in

people exposed to the WTC attacks (Galea et al., 2002).

The nature and the impact of the immediate response of the public to disastersare yet to be understood and so far the findings are not conclusive (see Mawson,

2005; Raphael, 2005) Early reports on Londoners in the aftermath of the attacksduring the summer of 2005 suggest that panic was uncommon in the immediateaftermath of the attacks (Wessley, 2005) However, images of people running fromthe WTC site during the morning of the 9/11 attacks suggest that many peopleexperienced acute and intense fear and horror The images recently received fromHurricane Katrina sites (September 2005) similarly suggest intense anger and panic-type responses in neglected neighborhoods, rescue sites and temporary sheltersespecially among people caught in extreme conditions waiting for rescue and helpthat are late to come Dysfunctional behaviors (e.g., people who engaged in aim-less, dissociative and stunned behaviors) have also been observed when disastersstrike (Tyhurst, 1951; Weisath, 1989), and it has been suggested that bio-terrorist

events may further escalate fears of chemical or biological agents (see Ursano et al.,

2004) Differences in the collective, immediate responses in affected populationsmight be accounted for by specific characteristics of the exposure (e.g., whetherthe way out of a building is cleared), availability of help, and social support andcultural differences

Research on the long-term effects of extreme traumatic events has provided ful information, enabling disaster clinicians and policy makers to make inferencesabout risk and vulnerability among affected populations Traumatic events

use-are common (Kessler et al., 1995) and most of the individuals exposed to trauma

effectively cope with such events, even if they experience significant adversities

(Bonanno, 2005; Bonanno, et al., 2005; Neria et al., 1998, 2000b) At the same time,

disaster research has systematically documented that a significant minority willexperience functionally impairing distress, especially in the immediate aftermath;some are likely to manifest behavioral and cognitive changes; and others willdevelop long-term trauma-related psychiatric disorders such as PTSD, trauma-

related depression and substance abuse (e.g., Norris et al., 2002a&b).

The severity of a post-disaster psychopathology is associated with various riskand protective factors including type, intensity and duration of exposure, level ofresource loss, social support, sense of community and meaning making (e.g., Norris

et al., 2002a) Sociodemographic factors such as previous trauma history, mental

health problems, age, gender and education might also play a role in onset and

per-sistence of psychiatric symptoms (Brewin et al., 2000) The interaction of human

loss and trauma exposure may be particularly powerful in post-traumatic

adapta-tion (Neria & Litz, 2004; Neria et al., this volume) At the same time, traumatic

experiences may serve as an opportunity for positive growth, an enhanced sense ofpurpose, and an opportunity to reprioritize everyday life goals Persons who areable to draw positive appraisals of their adversities were found to grow personallyfrom traumatic experiences, as compared to those who do not, even if they suffer

symptoms of PTSD (Dohrenwend et al., 2004).

To date, the effects of large-scale disasters on communities and individuals have

been focused almost entirely on natural disasters (Norris et al., 2002a&b) However,

when a community is struck by terrorism, the experience is likely to differ from that

of a natural disaster Natural disasters (Kaniasty, this volume; Kaniasty & Norris, 2004;Norris, this volume) are usually limited to time and space, are often expected (e.g.,hurricanes) and their pace usually enables some coordination of rescue efforts,sheltering and deployment of medical services Terrorism, however, usually occursrandomly and unexpectedly with regard to place and time Accordingly, the psycho-logical impact is likely to be accumulative, wide, non-specific and enduring, affect-ing how whole communities cope with subsequent threats and demands (Shalev,2005; Maguen & Litz, this volume)

Indirect exposure and post-disaster psychopathology

The nature of the psychological effect of disasters, especially man made, may exceed

the scope of the particular epicenter where the impact occurred (see Schlenger et al., 2002; Galea et al., this volume; Silver et al., this volume) The magnitude of this kind

of exposure might not be necessarily limited to the well-documented dose responseassociations of trauma and effect The studies presented in this volume provide a rare

opportunity to address this topic For example, while Neria et al in their study of

pri-mary care patients exposed to the 9/11 attacks in Northern Manhattan did not find

indirect exposure to WTC attacks by itself to be related to PTSD (Neria et al., this ume), other studies conducted in national samples after 9/11 (Schlenger et al., 2002; Silver et al., 2002; Stein et al., 2004; Silver et al., this volume) or in distant population areas after the Oklahoma City bombing (Pfefferbaum et al., 2000) or in Israel after the 1991 Scud missile attacks (Bleich et al., 1992) provide some evidence for proba-

vol-ble relationships of indirect exposure and PTSD These kinds of findings may lenge the core definition of PTSD They lead to the question whether a person whowas not directly exposed to trauma, witnessed it, or lost a loved one, might be trau-matized by this type of exposure and would be eligible for a positive Diagnostic andStatistical Manual for Mental Disorders (DSM) Criteria A of PTSD

chal-Instead of direct exposure to the attacks of 9/11 most of the persons interviewed

in post-9/11 national surveys reported indirect exposure (e.g., watching live andretransmitted coverage on TV) The inclusion of this type of exposure is certainlynew to the discipline of trauma research and brought experts to doubt its reasoningand validity (e.g., Southwick & Charney, 2002; McNally, 2003; Breslau & McNally,this volume) The events of 9/11, the subsequent wars in Afghanistan and Iraq, andterrorist events in Europe and recent major natural disasters provide a furtheropportunity to examine whether direct exposure to trauma is a necessary conditionfor PTSD, or alternatively an interaction between a “sufficient” level of exposure and

certain risk factors (e.g., genetic susceptibility) can result in post-exposure psychopathology even via indirect exposure.

Post-disaster outreach and intervention

It was suggested that most of the people exposed to 9/11 attacks did not seek mental

health care (e.g., Stein et al., 2004) The degree to what other sorts of care (e.g., from

friends, colleagues, employers or clergy), often mentioned in the media, are utilized inthe face of disasters is not clear and has never been systematically studied Indeed,people exposed to traumatic experiences often remain in isolation due to shame andguilt associated with the trauma, stigma associated with treatment of mental healthproblems, and the social context (Litz, 2004) However, when trauma has occurred inthe public domain (e.g., national disasters) and is associated with a public emergency,large and varied groups of professionals are likely to intervene at the disaster sites inattempts to aid affected populations during, immediately or soon after the incident.Most early responders (e.g., firefighters, police officers, medical teams, NationalGuard, Red Cross) are not qualified or trained to provide mental health care They arefocused on providing for the safety and basic needs of victims and evacuees However,some first responders may also be required to address the mental health needs of vic-tims, especially in the acute phase when fear and terror are prevalent It is especiallyimportant to address immediate interventions aimed at high-risk groups such as theinjured children and the elderly (Litz, 2004) To date little is known about the emo-tional care, screening or triage conducted in the immediate phase after impact.Schechter and Coates (this volume) provide a rare opportunity to learn about imme-diate intervention provided to children in the immediate aftermath of the WTCattacks

Despite emerging evidence that did not provide any support for the effectiveness

of psychological debriefing post-exposure (Bisson et al., 1997, 2000; Mayou et al., 2000; Rose et al., 2002), this type of intervention was still common among people

involved in 9/11 rescue and recovery efforts (http://edition.cnn.com/2002/US/07/20/wtc.police/?related) Randomized clinical trials conducted in the last decade con-sistently support the use of cognitive behavioral treatment (CBT) post-exposure(Foa & Cahill, this volume) The differences between these two modalities are sub-stantial Psychological debriefing was originally conceptualized to be implemented bynon-clinicians, immediately but not only after the exposure, consisting of a single andlong meeting, and without a clinical evaluation either before or after the intervention

On the other hand, CBT programs are initiated at least 2 weeks after the exposure,implemented only by clinicians, usually consist of 4–12 sessions, and entail a system-atic pre- and post-intervention evaluation While the efficacy and effectiveness of CBT

was consistently proven (Foa & Cahill, this volume), debriefing was found to be either

not effective in preventing PTSD (Bisson et al., 2000; Rose et al., 2002) or delayed recovery (Bisson et al., 1997; Mayou et al., 2000) Several explanations were suggested

to explain the poor performance of debriefing (e.g., for a review see Friedman et al.,

2004) such as that debriefing interferes with habituation and cognitive changes thatare beneficial for recovery (Foa & Cahill, this volume); that a focus on acute post-traumatic symptoms may foster negative cognitions about oneself and the world(McNally, 2003); and that the timing of the intervention in psychological debriefing istoo early and impedes normal remission and normal recovery (Ehlers & Clark, 2003).The terrorist attacks of 9/11 had an enormous impact on the mobilization of the

professional community in the New York area (Marshall et al., this volume; Felton

et al., this volume) Large-scale training programs aiming at dissemination of knowledge of trauma treatment were offered to clinicians (Amsel et al., this volume); treatment programs for adults (Katz et al., this volume; Difede et al., this volume; Marshall et al., this volume) and children (Hoven et al., this volume; Murray et al.,

this volume; Schechter & Coates, this volume) were developed; and statewide

out-reach (Draper et al., this volume) and counseling programs (Felton et al., this

vol-ume) were rapidly developed and employed

Drawing quality lessons from horrific experiences such as 9/11 attacks is central

to the future work mental health professionals will conduct before (e.g., ness), during (e.g., management and triage), and after (e.g., long-term care; trainingand dissemination) the next mass casualty trauma This volume was created tofacilitate this learning process Clinicians, researchers and policy makers who areinvolved in this work devote their best intellectual and emotional resources.Effective and meaningful disaster research relies on reliable observations and theability to update the questions asked, and the tools selected to answer them (Galea

prepared-et al., this volume) We hope that this volume will contribute to all domains of

dis-aster and terrorism-related mental health knowledge

R E F E R E N C ES

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R Gross & R.D Marshall Cambridge, UK: Cambridge University Press.

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10 Yuval Neria et al.