Terrorism and other forms of extreme violence have an enormous impact on the physical and mental health of the general population. Recent scientific studies have revealed that the psychiatric morbidity associated with mass violence and terrorism can affect large numbers of people, lead to chronic long-term medical and psychiatric illness, and cause premature death among the elderly.The emotional distress of survivors, including feelings of injustice and hatred, can be passed onto future generations as well.
Through two decades of caring for highly traumatized populations in this country and abroad, the Harvard Program in Refugee Trauma (HPRT) has revealed that the primary health care system and its primary health care providers (PCPs) are at the center of recovery and healing for a general population that has been victimized by mass violence and terrorism.
Using our nation’s network of PCPs to support recovery in response to the events of September 11th is the foundation of a program currently being implemented through HPRT, with funding by the Mellon Foundation. This approach is designed, not only to deal with past events, but also to build coping skills against future terrorist threats to our nation’s peace and security. It is based upon the following rationales:
Primary Care Practitioners (PCPs) are the local community’s indigenous healers, along with the community’s clergy, traditional healers, family elders, relatives and friends.This is the first line of defense the community turns to, especially at times of national crisis, such as that precipitated by September 11th. PCPs embody the tremendous high demand and respect that is given to them by the general public. HPRT has witnessed in conflict/post-conflict societies throughout the world that traumatized citizens almost exclusively go to their indigenous healers for relief of their physical and emotional symptoms caused by violence. PCPs are trusted by the general public not only because of already established doctor-patient relationships, but also due to the fact that physicians operate in a readily available, non-stigmatizing setting. For example, few survivors are comfortable with the idea of seeking a cure, or even help, from a psychiatric practitioner. Rightfully so, the majority of traumatized people do not consider their emotional and/or physical distress caused by terrorism as a mental illness, but rather as a normal range of responses to a horrific situation.
Many PCPs, however, are afraid to “ask the question,” i.e., ask the patient about their traumatic life experiences. There may be many reasons for this reluctance on the part of PCPs to obtain the patient’s trauma story. Some of these reasons may include:
Most importantly, however, it has been HPRT’s experience that PCPs do not “ask the question” because they believe that they are opening up “Pandora’s box.” They fear the possibility that they have very little therapeutically to offer the patient in order to deal with their trauma. Many PCPs believe that they cannot offer much of value within the limited time they have to spend with the patient. In addition, within most primary health environments, there is limited access to health extenders, such as visitors, nurses, social workers and psychiatrists.
The HPRT approach is based upon currently available scientific knowledge and offers the PCPs concrete action steps that can lead to therapeutic outcomes within the current PCP clinical environment. Our approach provides the PCP with a simple detailed method for identifying and treating the medical and psychiatric sequelae of mass violence and terrorism. Therapeutic listening to the patient’s trauma story, in and of itself, may be the only support required for the patient from their PCP. In most cases, the PCP will be actively supporting those measures of coping and self-care that have already been put into place by the patient. Allowing the patient to discuss the impact of terrorism provides an opportunity for the PCP to help the patient, without necessarily taking on the full burden of responsibility for relieving the patient’s distress.
This approach of working within the primary health care system to help survivors of terrorism complements the PCP’s enhancement of the patients’ resiliency to current and future attacks. The PCP’s therapeutic approach, in fact, not only reduces suffering, but also inoculates patients against future distress and loss of medical well-being.
Today, most PCPs practice medicine in culturally diverse communities. As September 11th has revealed, there is no single American response to terrorism; each and every culturally diverse community reacts to terrorism and mass violence in culturally diverse ways. Often, local communities already have an existing problem with neighborhood violence, or the community may consist of refugees who have experienced torture and horrific trauma before arriving in America. Therefore, the PCP needs to provide a basic framework for caring for the survivors of terrorism in a culturally competent and effective way, extending from the proper use of medical interpreters to ethno-psychopharmacology.
The PCPs’ inoculation of their patients to improve coping skills and resiliency can also benefit future generations. Unfortunately, survivors of mass violence can pass on to their children their upset and sense of fear, hatred, and anxiety. Survivors and their communities are deeply concerned with retribution and obtaining justice for the crimes committed against them. PCPs may not be able to provide justice to their patients—this usually can only be achieved by political and social actions through legislation and the courts. What the PCP can do is monitor and discuss with the patient the impact of their distress on their family and local community. For example, unresolved depression can create chronic irritability with a spouse and lack of quality time and enjoyment with children. The survivor’s distress can even lead to domestic violence and the increase in health risk behaviors, such as increased smoking, drinking, use of drugs and unsafe sexual behaviors. The negative impact on the survivor’s family, especially children, can be enormous.
Ultimately, the stress upon PCPs can be great, especially when they are the victims of terrorism themselves, or have to engage in dangerous activities related to bioterrorism and other types of mass violence. Even within the latter situation, PCPs who do not remain aloof and become directly involved with the traumatic life experience of their patients will absorb some of this pain and emotional upset. PCPs already know the emotional and physical hazards that come with caring for dying patients and other emotionally draining situations. In dealing with terrorism, the PCPs need to work with their colleagues and administrators to engage in activities that reduce “burnout” and promote well-being.
