There are many definitions of terrorism. At its core, terrorism is psychological warfare—the use or threat of violence to influence civilian or government conduct.1 When society collectively faces a threat of terrorism, the line between fear and anxiety becomes hazy. The role of mental health professionals becomes prominent and far-reaching. This role is, by necessity, flexible and variable, depending on timing and the exact nature of the disaster resulting from a terrorist attack or threat.
Terrorist attacks, when successful, usually cause mass violence. Mass violence is an “intentional violent criminal act” resulting in “physical, emotional, or psychological injury to a sufficiently large number of people …”2 Examples include the 1995 Tokyo Subway Sarin Attacks, the 1995 Oklahoma City Bombing, and the 2001 September 11 attacks.3
The Merriam-Webster dictionary defines terror as a “state of intense or overwhelming fear.”4 The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),5 distinguishes fear from anxiety by explaining that “fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat.” Terrorist threats and attacks can cause widespread fear and anxiety. Mental health professionals have four main roles: (1) provide immediate psychological first aid to victims; (2) provide ongoing psychological support and treatment for victims, when needed; (3) evaluate or treat the terrorists in correctional settings; and (4) evaluate victims, in a forensic setting, for purposes of assessing claims of psychological damage.
Psychological First Aid to Victims
In the immediate aftermath of any terrorist attack, there will be some degree of chaos. The role of frontline workers, including mental health professionals, varies depending on the specifics of the situation and will change as time passes. The aftermath of a terrorist attack can be looked at in four stages: the impact period, the rescue period, the recovery period, and the return to life period.6
In general, the first 2 days are the “impact” period, and the emphasis is on survival and communication.6 The week after is the “rescue” period, where the emphasis is on adjustment.6 The following few weeks (eg, weeks 1–4) are the “recovery” period, where the emphasis is on appraising the situation and planning.6 Sometime thereafter, the “return to life” period begins; only then does the emphasis shift to reintegration and treatment.6
During the impact period, mental health professionals can provide emotional support by being useful in whatever (safe) way they are needed.7 Although mental health professionals have unique and necessary skills, it is important that they remain flexible and pragmatic. As an on-the-ground professional during a disaster, mental health professionals could reasonably be asked to help by handing out food or water or helping a person who is wounded to the hospital. These are all avenues toward providing emotional assistance (ie, helping fulfill basic needs). This notion is implicit in the idea of psychological first aid. Psychological first aid is defined as “pragmatically oriented interventions with survivors or emergency responders targeting acute stress reactions and immediate needs.”6 This is an old concept that has gained ground in recent years. In 1954, the American Psychiatric Association's Committee on Civil Defense published their “Psychological First Aid in Community Disasters” manual.8 Their advice remains relevant today:
- “Accept every person's right to have his own feelings.”
- “Accept a casualty's [emotional] limitations as real.”
- “Size up a casualty's [emotional] potentialities as accurately and as quickly as possible.”
- “Accept your own limitations in a relief role … [and] examine carefully certain trends in your own ‘normal’ behavior.”
The goal of psychological first aid is “to return moderately disabled persons to reasonably good function in a short time, or to make the more serious casualties as comfortable as possible until more complete care can be arranged.”8 For the mental health professional, the focus is on engagement, recognition of individual differences, and maximization of each person's emotional and practical abilities. These focuses, and the way that they are carried out in the immediate aftermath of a disaster are different than the typical practice of most psychiatrists; it is not just trauma psychiatry.7
After a terrorist attack, many people volunteer to help, including mental health professionals. However, due to disparities in training and competence, the ability to provide psychological first aid can be hampered by difficulties with coordination, licensing, dissemination of information, and supervision.3 This is compounded by the lack of a universally accepted, evidence-based, psychological treatment.3
There is an evidence-informed guide for the immediate aftermath of disasters and terrorism disseminated by the National Child Traumatic Stress Network and the National Center for PTSD (posttraumatic stress disorder).9 The steps are as follows:
Make contact with victims (survivors) and engage them.
Help victims to maintain their own personal safety, disclose relevant information, and provide comfort.
Stabilize and orient emotionally distressed victims; be present and assist them with grounding techniques.
Focus information gathering on directly relevant facts to help with immediate and pressing needs (eg, safety).
Instill empowerment and hope by helping victims identify immediate needs and plan practical steps to fullfil those needs (eg, obtaining shelter, finding a lost family member).
Facilitate the victim's social support system, connecting them with pre-existing or new social supports (eg, family, friends, aid agencies).
Provide information, both about the disaster itself, normal (versus abnormal) postdisaster emotional responses, and healthy coping mechanisms.
Refer victims for more intensive services when needed for urgent medical, psychiatric, and social conditions.
This guide warns mental health providers not to “debrief” victims right after a disaster or terrorist incident.9 This is in direct contrast with another popular intervention strategy, known as critical incident stress management (CISM).10 CISM is controversial and there are valid concerns and data indicating that its debriefing phase might exacerbate symptoms by prematurely forcing survivors to re-experience their trauma.6,11
Ongoing Psychological Support and Treatment to Victims
Psychological first aid, as described above, is meant for the immediate aftermath of a terrorist attack (or other form of mass trauma). It is meant to ensure that victims have their basic needs met, while providing emotional and logistical support. The treatment role is largely limited to emergent concerns. As the dust settles, the mental health professional's role shifts to treatment for those who need and want it. This is particularly true in the “return to life” stage, once the rescue and recovery phases are complete.6
Victim responses to terrorism vary. There seem to be worse outcomes for women and for people with a preexisting psychiatric history.3,12 The level and type of exposure also matters. People who were injured, directly threatened, personally witnessed the event, or lost a loved one tend to have more severe symptoms than the general public.13
To provide support and treatment for victims (including first responders and health care providers, who are a unique subset of victims), it is important to recognize what is normal and abnormal. After a terrorist event, victim responses can broadly be categorized as distress responses, behavioral changes, and psychiatric disorders; these can overlap.3 Distress responses are common and can be normal. They do not necessarily require intervention (unless severe or unless intervention is requested). Distress responses fall into three categories: emotional (shock, denial, fear, anger, irritability), cognitive (difficulties concentrating), and physical (fatigue, headaches, and gastrointestinal upset).14 After a terrorist attack, community and individual behavior changes. These changes are quite variable. They can be adaptive, like volunteering to help other victims. They can also be maladaptive, like increased drug or alcohol usage. Sometimes these behavior changes constitute a worsening or newfound substance use disorder; other times, they are just a nondiagnosable pattern of increased substance use.
Negative psychiatric symptoms that are part of a distress response or behavioral change can overlap with psychiatric disorders. Symptoms typically decrease dramatically over time, even without formal intervention.15 When these symptoms do not decrease, become problematic, or for any other reason assistance is requested, treatment should be provided. Psychiatric treatment should be comprehensive and targeted to symptoms and diagnoses. It should include psychotherapy and, when indicated, pharmacotherapy or hospitalization.6
Acute stress disorder is a trauma diagnosis that occurs in the immediate aftermath of a trauma, like terrorism; it lasts between 3 days and 1 month.5 PTSD is a trauma diagnosis that lasts for at least 1 month; one-half of the people with PTSD initially had an acute stress disorder.4 The symptomatology of both diagnoses is similar. Full descriptions of both diagnoses and their distinguishing features are available in the DSM-5.5 Also, the stress associated with terrorism can precipitate or exacerbate depression and anxiety diagnoses.
Data on psychiatric diagnoses after a terrorist attack often focus on PTSD, depression, and anxiety.13,16 A meta-analysis found that after a terrorist attack 12% to 16% of the population directly affected met criteria for PTSD.17 Some of the studies evaluated in the meta-analysis found much higher rates of PTSD.12,17 Six months after the Oklahoma City bombing, almost one-half of the victims that were directly exposed to the blast had an active psychiatric disorder; approximately one-third met criteria for PTSD.12 Both the Oklahoma City bombing in 1995 and the September 11, 2001 terrorist attack resulted in clinically significant levels of PTSD and impaired functioning. However, the majority “either displayed remarkable resiliency or quick recovery.”18 Resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.”19 It is the ability to return to or near to pre-event functionality even when there are lingering psychological symptoms.
After a terrorist attack, mental health professionals should rely on their typical diagnostic and therapeutic tools. They should not assume that every victim will have long-lasting psychiatric symptoms, although a significant portion will. They should provide therapy and pharmacotherapy as appropriate, use typical clinical guidelines, and recognize the impact and effects of trauma.
Treatment or Evaluation of Terrorists in Correctional Settings
Most terrorists are not mentally ill. They do not necessarily have more psychological flaws than other criminals.20 Nonetheless, like members of the general population, people accused of or convicted of terrorism sometimes require mental health services. Mental health professionals provide these services in either a treatment role or an evaluation role. After a terrorist is arrested, the person is usually placed in jail; once convicted, the person is moved to prison. If a person accused of or convicted of terrorism has a suspected psychiatric condition, mental health professionals (eg, a correctional psychiatrist or psychologist) can be asked to provide treatment. The treatment is similar to what would be provided in regular settings, although there are peculiarities in correctional settings, like limitations on medications (particularly controlled substances).
A mental health professional's primary obligation remains to the well-being and treatment of their patients, even if the patient is accused of committing or convicted of a terrorist act. Accordingly, a treatment role does not include assisting in an interrogation or facilitating torture.21 Mental health professionals must be mindful of their ethical and professional duties. Although flexibility is encouraged when dealing with the victims of terrorism in the immediate aftermath of an attack (eg, offering logistical as well as emotional support), this same flexibility is not appropriate in a correctional setting. For example, a mental health professional in a correctional setting should not disclose their patient's medical records to someone conducting an interrogation. Nonetheless, as in normal practice, disclosure is permitted and appropriate for urgent safety concerns (eg, a credible and imminent threat of self-harm or of violence toward staff or other inmates).
A separate role for mental health professionals is the evaluation role. When a person accused of terrorism has a suspected mental illness, questions can arise as to whether that mental illness legally interferes with the person's ability to be tried or convicted or should influence sentencing once convicted. These questions require an evaluation, usually by a forensic psychiatrist or psychologist, assessing competence to stand trial, criminal responsibility (eg, a not guilty by reason of insanity plea), and/or sentencing. The specifics of these questions, and associated evaluations, are beyond the scope of this article.
Forensic Evaluation of Victims
After a terrorist attack or other mass violence event, victims, or their families, often file lawsuits. In these situations, mental health professionals can be asked to serve in an evaluator role for a victim of terrorism, eg, to perform a psychiatric disability evaluation. This is a subspecialized area of mental health, taught in forensic psychiatric and psychology training programs. Interested readers should, prior to performing such an evaluation, consider reviewing the American Academy of Psychiatry and the Law practice guidelines on the forensic evaluation of psychiatric disability.22
Terrorism is a form of psychological warfare. When a terrorist accomplishes their goal, a man-made disaster can ensue. As part of that disaster, there is mass violence—physical and/or emotional. Mental health professionals play a prominent role in the aftermath. That role varies depending on the specifics of the situation. In the immediate aftermath the primary focus is on first aid, including psychological first aid. Mental health professionals need to be flexible and pragmatic. Mental health professionals can provide necessary hands-on support, engaging and connecting with victims by assisting with basic needs.
As time goes on, mental health professionals can return to a treatment role, focusing in on full evaluations and standard of care treatment for specific symptoms and diagnoses. This treatment role extends beyond victims, to people in a correctional setting who are accused of or convicted of terrorism. It can also involve the treatment of health care professionals who were first responders after a terrorist attack; they are considered a special type of victim (exposed to both the aftermath of the attack, and vicariously, the trauma of their patients).
Alternatively, mental health professionals, especially those trained in forensics, can serve in an evaluation role. Forensically trained mental health professionals can be called upon to evaluate people accused of or convicted of terrorism for competency to stand trial, criminal responsibility, or sentencing considerations. Similarly, they can be called upon to evaluate victims, related to legal claims of psychological damage.
- Federal Bureau of Investigation. General functions, 28 CFR § 0.85 (l) (1969). Updated August 2015. Accessed August 17, 2020. https://www.govinfo.gov/content/pkg/CFR-2019-title28-vol1/xml/CFR-2019-title28-vol1-sec0-85.xml
- Office for Victims of Crime. Helping victims of mass violence & terrorism: glossary. Accessed August 5, 2020. https://www.ovc.gov/pubs/mvt-toolkit/glossary.html
- Institute of Medicine. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. The National Academies Press; 2003.
- Merriam-Webster. Terror. Accessed August 5, 2020. https://www.merriam-webster.com/dictionary/terror
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
- National Institute of Mental Health. Mental health and mass violence: evidence-based early intervention for victims/survivors of mass violence. A workshop to reach consensus on best practice. NIH Publication No. 02–5138 Published 2002. Accessed August 5, 2020. https://www.hsdl.org/?view&did=441844
- Kantor EM, Beckert DR. Preparation and systems issues. In: Stoddard FJ, Pandya A, Katz CL, eds. Disaster Psychiatry: Readiness, Evaluation, and Treatment. American Psychiatric Publishing, Inc; 2011:3–17.
- American Psychiatric Association. Psychological First Aid in Community Disasters. American Psychiatric Association; 1954.
- Brymer M, Jacobs A, Layne C, et al. Psychological First Aid: Field Operations Guide. 2nd ed. National Child Traumatic Stress Network and National Center for PTSD; 2006. Accessed August 5, 2020. https://www.nctsn.org/sites/default/files/resources//pfa_field_operations_guide.pdf.
- Everly GS Jr, Flannery RB Jr, Mitchell JT. Critical incident stress management (CISM): a review of the literature. Aggress Violent Behav. 1999;5(1):23–40. doi:10.1016/S1359-1789(98)00026-3 [CrossRef]
- Mansdorf IJ. Psychological interventions following terrorist attacks. Br Med Bull. 2008;88(1):7–22. doi:10.1093/bmb/ldn041 [CrossRef] PMID:19011264
- North CS, Nixon SJ, Shariat S, et al. Psychiatric disorders among survivors of the Oklahoma City bombing. JAMA. 1999;282(8):755–762. doi:10.1001/jama.282.8.755 [CrossRef] PMID:10463711
- Stoddard FJ Jr, Gold J, Henderson SW, et al. Psychiatry and terrorism. J Nerv Ment Dis. 2011;199(8):537–543. doi:10.1097/NMD.0b013e318225ee90 [CrossRef] PMID:21814075
- Katz CL. Psychiatric evaluation. In: Stoddard FJ, Pandya A, Katz CL, eds. Disaster Psychiatry: Readiness, Evaluation, and Treatment. American Psychiatric Publishing, Inc; 2011:3–17.
- Substance Abuse and Mental Health Services Administration. Disaster technical assistance center supplemental research bulletin: mass violence and behavioral health. Published September 2017. Accessed August 5, 2020. https://www.samhsa.gov/sites/default/files/dtac/srb-mass-violence-behavioral-health.pdf.
- Norris FH, Friedman MJ, Watson PJ, Byrne CM, Diaz E, Kaniasty K. 60,000 disaster victims speak: part I. An empirical review of the empirical literature, 1981–2001. Psychiatry. 2002;65(3):207–239. doi:10.1521/psyc.220.127.116.1173 [CrossRef] PMID:12405079
- DiMaggio C, Galea S. The behavioral consequences of terrorism: a metaanalysis. Acad Emerg Med. 2006;13:559–566. doi:10.1111/j.1553-2712.2006.tb01008.x [CrossRef]
- Delahanty DL. Are we prepared to handle the mental health consequences of terrorism?Am J Psychiatry. 2007;164(2):189–191. doi:10.1176/ajp.2007.164.2.189 [CrossRef] PMID:17267775
- American Psychological Association. Building your resilience. Accessed August 5, 2020. https://www.apa.org/topics/resilience
- Gill P, Corner E. There and back again: the study of mental disorder and terrorist involvement. Am Psychol. 2017;72(3):231–241. doi:10.1037/amp0000090 [CrossRef] PMID:28383976
- American Psychiatric Association. Position statement on psychiatric participation in interrogation of detainees. Approved by the Board of Trustees, December2019. Accessed August 5, 2020. https://s3.amazonaws.com/PHR_other/APA-2006-stmt-enhanced-interrogation-doc-participation.pdf
- Gold LH, Anfang SA, Drukteinis AM, et al. AAPL practice guideline for the forensic evaluation of psychiatric disability. J Am Acad Psychiatry Law. 2008;36(4)(suppl):S3–S50. PMID:19092058