The September 11 attacks, like all terrorism or mass violence, has had a widespread impact on U.S. society.
The long-term effects of this event have yet to be realized and accounted for…
This is a National Issue
The effects of September 11, and the continued threat of terrorist acts in the United States, has the effect of eroding the social, economic, mental, and physical health of our nation. For a small percentage of individuals, the psychological effects are a serious problem needing immediate attention. A majority of individuals continue to function, but sustain low levels of anxiety and depression which will accrue more serious effects down the road if not addressed now.
This is a Medical Issue
Recent scientific studies reveal psychiatric morbidity associated with mass violence and terrorism can affect large numbers of people and lead to chronic long-term medical and psychiatric illness and cause premature death among the elderly. Studies also link low-grade depression/anxiety with lower effectiveness of auto-immune system:
- Chronic depression may lead to diabetes, hypertension, heart disease and stroke.
- Physical functional disability is associated with psychiatric morbidity in traumatized refugee populations.
- Chronic medical disability and premature death occur in mentally ill patients cared for by the public system.
- Depression and social isolation are linked to increased mortality in heart attack and stroke patients.
The Trauma Story
Most people in the U.S. were traumatized during and following September 11 regardless of whether they had direct relationships with victims. Whether they personally survived the attacks, witnessed the events in person, or watched them unfold on television, everyone has a story about their experience. Telling this story helps people heal themselves and leads to affiliative behaviors which sustain and strengthen mental and physical health in the face of continued threats of terrorism.
You, the primary care provider, are the indigenous healer.
Through 20 years of caring for highly traumatized populations in the US and abroad, 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 terrorism or mass violence
You, the primary care provider, can help inoculate society.
The most trusted and appropriate people in US culture to help individuals recover from the trauma, and be healthy in the face of threatened terrorism, are the ones that already attend to the physical, mental and spiritual health of people, including the following:
- Primary Care Providers
- Mental Health Workers
- Clergy
- Community Elders
What You Can Do
- Ask
about the patient's "trauma story"
- Identify
concrete physical & mental effects
- Diagnose & Treat
generalized anxiety, depression, PTSD & chronic insomnia
- Refer
screened cases of serious mental illness
- Reinforce & Teach
positive coping behaviors
- Recommend
altruism, work & spiritual activities
- Reduce
high risk behaviors
- Be Culturally-Attuned
in communicating & prescribing
- Prescribe
psychotropic drugs if necessary
- Close & Schedule
follow up visits
- Prevent Burnout
by discussing with colleagues
- ASK about the patients trauma story.
Ask the question:
How has your life changed since 9-11?
Have recent events such as September 11th or the anthrax scare caused you any physical or emotional problems?
Do you think about future attacks?
Many of my patients have felt that September 11th had a big effect on their health and well-being. Has this been the case for you?
Listen to the answer and acknowledge the patient's trauma story.
The trauma of terrorism may occur in addition to other ongoing traumatic life experiences such as poverty or domestic violence.
Sometimes an experience of extreme violence such as terrorism will prompt the patient to reveal for the first time prior traumatic experiences that he/she has been reluctant to share with the PCP.
- IDENTIFY concrete physical or mental effects.
By identifying the concrete physical and psychological effects of terrorism, the PCP can help the patient to note these effects and be reassured they are normal and usually temporary.
- Is the patient complaining of any physical symptoms such as:
- headaches
- stomach upset
- back pain
- fatigue
- weakness
- Is the patient exhibiting feelings of:
- grief
- anxiety
- depression or PTSD
- Have medical or psychiatric disorders worsened?
Patients with pre-existing psychiatric disorders that worsen following trauma related to terrorism may need adjustment in medications and increased psychosocial support.
- DIAGNOSE & TREAT most patients.
After a terrorist attack, almost everyone will experience some transient physical or psychological symptoms
85% of patients will not suffer from serious mental illness and will benefit from your counseling on the nature of their symptoms and coping techniques
15% will develop a specific psychiatric disorder including:
- grief reaction
- generalized anxiety disorder
- depression & PTSD
- chronic insomnia
Use HPRT's screening instrument to help you decide if serious mental illness is present.
- REFER screened cases of serious mental illness.
Many trauma-related mental health conditions will recede with the help of the PCPs reassurance and psychological support. Some will develop into true psychiatric disorders. Screening (click here to download HPRT's Simple Depression Screen) and referral to a mental health professional should be considered in the following circumstances:
- Danger to self or others
- Complicated grief
- Severe forms of PTSD and/or depression
- Physical and social disability
- REINFORCE & TEACH positive coping behaviors.
You can help a patient by simply reinforcing positive behavior and teaching coping techniques. Patients usually hold their PCPs in very high regard. PCPs must take advantage of this positive regard to validate whatever coping strategies are already been used. Affirm behaviors with such phrases as:
Keep up the good work! It is good for you and will help you cope.
Recommended coping strategies begin with self-care. Remind the patient to build physical, spiritual and mental strength.
- RECOMMEND altruism, work & spiritual activities.
Scientific studies of survivors of mass violence have repeatedly revealed increased resilience associated with altruism, work and spiritual activities. Engaging in these activities and behaviors appears to prevent mental health problems and promote recovery from existing problems. PCPs should actively recommend these activities:
I strongly recommend that you work and keep busy, try to help others and consult with your clergy or engage in spiritual activities such as meditation or prayer.
You have the power to recommend a change in behavior!
- REDUCE high risk behaviors.
Patients often increase their use of cigarettes, drugs and alcohol or become involved in risky sexual behavior during times of crisis. PCPs must be alert for these unhealthy activities. Inquire about high risk behaviors:
Have you started to use or increase your use of cigarettes drugs or alcohol? Are you having unprotected sex?
If the response is positive, recommend steps to reduce these high risk activities.
- BE CULTURALLY ATTUNED to differences.
Different cultures have different views of trauma and different ideas about the cause of illness. Literal translation of your questions or diagnosis may be meaningless. The choice of medical interpreters is important - choose someone with both language and context skills.
Culturally diverse patients have different reactions to doses and side effects. Consider ethnically-influenced factors such as tolerance levels and body weight (ethnopsychopharmacology is important!) Be aware of a patient's pre-existing "threshold" for trauma -- some patients may have a smaller capacity for additional trauma due to past experiences.
- PRESCRIBE psychotropic drugs if necessary
Prescribe medication where appropriate. Read XYZ Essay for simple, detailed guides about drugs most commonly used to treat generalized anxiety disorder, depression, PTSD and insomnia.
- CLOSE & SCHEDULE follow up visits.
PCPs need a method for sensitively closing the interview, especially after a traumatic history has been revealed, such as:
Thank you for telling me about these upsetting events. You have helped me to understand your situation better.
I know that if we work together, you are definitely going to improve
It is important to create a relationship and continuous dialog with the patient – patients value the PCPs reassurance they are going to get better.
Schedule follow-up visits & add the diagnosis to the patient's record ("problem list"). PCPs might say:
I want to make a follow-up appointment for 6 weeks from now..just touching base with you to see how you are is important.
- PREVENT BURNOUT- discuss w/colleagues.
Acts of terrorism and mass violence directly affect the practitioner as well as the patient. Dealing with traumatized patients is stressful in itself. As members of the community, PCPS can suffer similar mental health consequences of terrorism as their patients.
PCPs caring for patients affected by terrorism need a systematic, institutionally supported plan for self-care, and time for attention to their own health including diet, exercise and discussion with others
– You can prevent burnout by discussing with your colleagues regularly - in the same way a patient benefits from talking to you, you will gain strength from talking with others.
