Dr. Carlos Sluzki - Articles

Advanced draft 9-21-02


Carlos E. Sluzki, MD

Bioterrorism has been announced by government and media as the probable next wave of expression of terrorism. Bioterrorism can be defined as the politically motivated use of chemical, radiological and biological weapons — poisons, poisonous gas, radiation, or disease-bearing agents — targeted on the civilian population, to induce random harm and fear in the citizenry, convey a grievance message from the perpetrators, exert political pressure in a government, and undermine faith in established authority. Until now its utilization has been limited — the 1995 Sarin gas release by the Aum Shinrikyo cult in Japan, the threats of nerve agents (Sarin or equivalent) attack in Israel by Iraq during the Gulf War, the anthrax scare and cases in the US East Coast in 2001. Because of there have been few experiences with bioterrorism and its effects on targeted populations, any speculation about the psychosocial effects of bio-terrorism is based on extrapolations from the effects of natural disasters and of non-biological terrorist attacks as well as other cases of post-violence, more than on actual field experience. However, the 9/11 terrorist attack — remarkable for both its geographic immediacy and emotional impact on a heretofore protected civilian population in the United States — has understandably stimulated renewed efforts at refining forecasting and preventing terrorists (including bioterrorist) attacks, as well as at designing immediate possible responses to those events. It should be added that the boundaries between bioterrorism and other forms of terrorism can be at times blurred and filled with gray zones — as would be, for instance, a (until now hypothetical) case of a suicide-bomber carrying shrapnel tainted with anthrax or HIV virus. However, efforts at drawing these boundaries are necessary in order to be able to be able to develop specific preventive and reparatory strategies for this type of attacks.

Unpredictability as a key factor for terror

Terrorism’s immediate goal is to induce fear (terror) in the general population or a government of a country or region by attacking the innocent. The goals of terrorism are achieved by utilizing means or actions that are unpredictable in terms of:

  • Timing (they may take place at any time, day or night)
  • Location (the target may be a symbolic icon of the country, or a key governmental building in the capital city, or perhaps a small, seemingly marginal town in the heartland, or a market, or a bus),
  • Target (the indiscriminate hit on civilian population is its broad target, but it may aim more specifically at children, at soldiers on leave and their families, at tourists, at an embassy; the attack may aim at disrupting crucial infrastructures — poisoning a city’s water supply, paralyzing a government by contaminating key buildings — or may simply affect individuals), and
  • Means (its vehicle may be a bomb — “clean” or “dirty” — , poisonous gas, airplanes-as-missiles, poisoned drinking water, a tainted mailed package, or an intentionally infected terrorist-traveler).

This proteiform unpredictability is at the center of the effects of the terrorist attack. In fact, the highly pervasive effects of being exposed to any out-of-the-ordinary and extremely threatening situation in which available fight-or-flight skills are useless deserve special emphasis. We expect the world in which we live- both social and natural - to evolve in an orderly and predictable fashion, with random events playing only a minor role. We require time-and-space continuity, we need to be able to predict context, to retain order, to provide causality for events, in sum, to organize coherent narratives, in order to be able to retain a seamless image of self while accounting for the changes in daily living. In this delicate balance between deterministic assumptions and random events there is only a certain margin of “allowable variation” — that is, the amount of variation that can take place without stepping outside of the boundaries of an acceptable or manageable reality, without challenging our ability to organize ourselves-in-context. Any catastrophic event — accidental, “acts of god”, or terrorism — in which we may be a victim occurs outside the parameters of what is predictable or what makes sense, betrays our expectation of order, challenges our very identity and our capacity to account for reality (Langer, 1991; Sluzki, 1993). Violence “destroys the world” of the victims (Scarry 1985).

Hence, when catastrophic events occur, we seek immediate if not urgent reconnection with what we consider the social invariants of our personal world:

  • We may behave for a short while in a routinely manner, as if the event wouldn’t have occurred;
  • We do everything in our means to call and/or seek our family and our friends to assess their wellbeing and exchange reassurances;
  • We turn on TV or radio to evaluate the continuity of the government and of our professional network and to know what to do or expect next;
  • We assess, sometimes with an urgency that is disproportionate with the event, the status of our home, our pets, and other possessions.

All these efforts aim a assessing the solidity of what was considered social invariants. The stability and continuity of these invariants have a major reaffirming and soothing effect. The inability to make those connections will, on the contrary, enhance the alarm reaction and reduce our capacity to create order in the midst of chaos. Nevertheless, whether we establish those contacts or not, the immediate aftermath of a catastrophic event challenges the coherence of our self, and the solidity of our view of us-in-the-world, will become extremely brittle. Fear will fuel outbursts of anger against the assumed perpetrators and all that remotely resembles them. It may also spill over into bitter recriminations against the government (“You didn’t protect us!”), against loved ones (“You should have taken us away long ago!”) or even against our own self (“I knew that this would happen and didn’t do anything about it!”), hence defining ourselves as perpetrators of our own victimization. It may also turn into depression, despair and hopelessness (“Everything is lost!” “This is the end of the world!”), or into psychological regression and dependence (“Please help me! Without you I am lost!”). Hence the extreme importance, in the aftermath of a catastrophic event, that the authorities — symbols of the social order — , deliver clear, early, realistic messages to the population by the authorities (this will be further discussed later in this chapter): as situations of extreme terror destroy reality-as-we-know-it, they trigger to find signs of normality and reason in the midst of chaos.

It comes in many shapes

There are a variety of potential agents (poisons, toxics, radiation, and disease-bearing organisms) that fit the “bio” label of a bioterrorist attack and contribute to the dread of its multiple potential presentations. In fact, the effects of a bioterrorist attack may be:

  • massive (a “dirty” bomb spreading radiation) or scattered (anthrax) in their impact
  • circumscribed (poison gas in the air conditioning system in a building) or broad and fuzzy (release of a toxic gas cloud, radiations) in relation to the boundaries of their target
  • short-term (nerve gas such as Sarin) or long-term (mad cow disease, radiation) in their expression
  • with high (plague, smallpox) or low (salmonella) penetration and contagion potential.
  • with high (plague) or low (shigellosis) lethality

Terror in the streets

The degrees of panic reaction in the general population will vary with the nature of the agent and the circumstances surrounding the attack. If the impact of the bioterrorist attack is massive — imagine a “dirty bomb” detonated in a major city, or the contamination of the drinking water in a town — , some displacement of populations may be predicted, accompanied, if the bio-agent so warrants it, by quarantine procedures and development of refugees/ temporary camps, disruption of essential services, overload of health facilities, varying degrees of overload of the law-and-order services, and even some pockets of social disruption in socio-economically marginal neighborhoods. However, an acute decay of the social organization and ensuing community chaos, or mass panic, is extremely unusual in the aftermath of a disaster, according to all past evidence, ranging from 9/11 to Hiroshima (Norwood, 2002).

The degrees of terror in the general population will vary also with possible messages from the perpetrators, containing further threats, and with the immediate (counter-) messages and actions by the established authorities of the target region or country after the event. Because of the psychologically regressive, disorganizing impact of those attacks, the eyes and ears of the population will be extremely focused on the people in charge, on the established authorities in their role as protectors of the collective well-being, and much of the collective behavior will be dictated by the presence or absence, and the nature, of their voice.

Terror in the soul

Orthogonal to the collective impact of the bioterrorist attack, the impact on individuals and on families will depend on many idiosyncratic variables. In fact, as it has been witnessed during and immediately after the Twin Towers and Pentagon attacks of September 11, 2001, and has been witnessed in prior disasters such as the Oklahoma bombing or even accidental ordeal such as the sinking of the Titanic or of the Andrea Doria, collective threats bring out the best (and occasionally the worst) of people. We can safely assume that, at the level of the individual, factors that will compound the effect of the experience and after-effects of terror include:

  • surprise: The less the attack is expected (and expectations may vary from individual to individual, regardless of any prior collective campaign of awareness), the higher the experience of terror
  • initiative: The lesser the individual’s experience of agency or initiative (and the less action-oriented the individual) , the higher the negative effects of the terrorist act
  • social isolation: The lower the individual’s social capital, that is, his or her commitment with civic issues and connection and involvement with the community, the higher the negative effects of the act of terrorism
  • personal isolation: The more the fragmentation of the individual’s personal social network — disconnection from family and friends — , the more traumatic will be the ordeal
  • risk for self or family: The higher the perceived risk for self and kin, the higher the alarm reaction
  • ordeal: The more harrowing the ordeal after the attack (hunger, thirst, inability to sleep, actual risks of exposure and/or of attacks by third parties, or of life-threatening events such as risk of drowning while crossing waterways), the higher the effects of the act
  • exposure: The longer the exposure to the stressors, even indirectly (via media), the higher the likelihood of psychosocial-post-effects
  • loss of property: The greater the loss of property, the higher the trauma
  • receptivity of the community post-attack: The more receptive/ supportive/ organized the community during the ordeal and at any reception center, the lesser the effect of the stress.

In sum, the more unexpected, unpredictable, intense, prolonged, isolating and risky the event, the more the potential for short- and long-term trauma for the population, as these effects reduce the individual’s capability for decision-making process and adaptation to new circumstances and context.

Adding to the above some preventive/therapeutic implications, it can be expected that, the higher the stress experienced:

  • the higher the need for a recognizable environment to reduce the cognitive dissonance entailed in the experience of the event and its aftermath
  • the lower the individual’s ability to assess his/her options, beyond the immediate future
  • the more labile and brittle will be the affected individual
  • the more the probability of a syndrome within the PTSD spectrum (which seals-in the traumatic experience)

However, it should be highlighted that resilience is the norm: even in most severe disasters, only a fragment of the population exposed to that event will present lasting signs of psychopathology (mainly PTSD symptoms — avoidance and numbing, intrusive recall, hyper-arousal.) While a substantial number of persons may respond with stunning to a catastrophic or disorganizing event, the recovery is generally quick and is followed by self-preservation behavior as well as by displays of solidarity and collective responsibility.

Terror in the body

Needless to say, an intervening variable that may take central stage is the neurotoxic effects of bio-weapon, which have the potential of affecting the mental status of the victims. Specifically, toxic gases and toxins in general may trigger deficits in attention, concentration, and memory, overall psychomotor retardation, depression, hallucinations, and agitated delirium, which may require specific symptomatic attention.

While all exposure to terror-generating events triggers bodily alarm responses, bioterrorist attacks present an important idiosyncratic trait: the weapon goes into our body undetected and insidiously, and expresses itself only when our body has been victimized. There are few if any external evidences of a radioactive environment, of an epidemic, of a tainted drinking water supply; we know of its existence when it affects our organism; it signals its presence by our experiencing symptoms. Sometimes there will be no symptomatic expression, but the doubt may linger whether the body is carrying within itself a long-term “time bomb” such as an increase chances of cancer in years to come, or a genetic defect introduced by the exposure to the attack. Sometimes the symptoms may appear in a few days, but when they do it is already too late to do something about it. Sometimes the symptoms are very specific, but frequently they simply imitate, in their initial stage, one of those many minor discomforts of our daily bodily living, discomforts that we ignore…and they go away by themselves, or with an analgesic or antacid or a nap. However, when we are in an environment that has been potentially tainted, each and all of those minor nuisances become a potentially ominous sign of doom and source of dread. The collaborative, familiar relationship that we had with our body is placed in doubt, as the enemy may have infiltrated it. This is yet another potential betrayal of the established order of things discussed above: our narrative of us-in-the-world, our self (which includes the body), is shaken to the core. Therefore, it can be safely predicted that people will flood emergency services with a range of symptoms and signs that may or may not fit the profile of the specific biological, chemical or nuclear agent used in the terrorist attack.

Some will access emergency hospitals in extreme distress, desperately searching of loved ones with whom they were accidentally disconnected, fearing that they may be among those brought to the hospital, or to the morgue.

Many will present with symptoms that in fact will require a differential diagnosis to define whether they have been tainted by the terrorist tool or not (is it bronchitis or mustard gas? Are they exhausted by the ordeal or have they been poisoned by radiation? Et cetera).

Many more will present without symptoms, but requesting being medically cleared, as they fear they have been reached by the bioterrorist hazard.

Others will present a variety of somatic symptoms that are clearly unrelated to any possible bioterrorist agent, but triggered by their fears and their wish and need to be immersed in what they perceive as being a safe heaven where care is provided, namely, a hospital setting.

And there will be also an increase in the number of patients presenting psychiatric symptoms, as life-threatening events are positively associated with relapses of major psychiatric disorders (e.g., Boudreaux et al., 1998).

The need for emergency service that meet a difficult equilibrium of efficacy and kindness in these type of extreme health crisis, while obvious given the multiple needs of a population in fear and under attack, will be discussed below.

Soothing the collective: Making predictable the unpredictable

One of the main ways of reducing the psychosocial impact of acts of terrorism is to make them predictable. This shift into predictability may take place spontaneously: after a series of random bomb attacks, populations exposed to them expect their random occurrence (defeating thus the inherent contradiction in terms of the formulation), and go on with their lives in spite of the threats. Such is reported to have been the case in Sri Lanka in the year 2000 — where a “good day” was defined not by the lack of Tamil Tigers’ terrorist attempts through car-bombs and grenade explosions in public markets but by the low number of victims — and is reported by many to be the case in Israel 2002. Predictability may also be facilitated by design by the target country’s government. Such is the case of the systematic public awareness campaign waged by the US Government after 9/11, when, for an extended period, it communicated through weekly official announcements the possibility of imminent terrorist attacks, thus keeping the theme alive while reducing the unpredictable nature of any terrorist attack in the post 9/11 environment — a desirable effect regardless of whether that was the intent of the Government.

The response by the government and its representative agencies to the acute situation will set the tone for the societal response. If the government implements a rapid, transparent, un-mystified transmission of information to the general population about the event, its origin, possible immediate consequences, and informs the public about measures being taken (some of which discussed below), and has an adequate preparedness and well planned, rehearsed and executed community-oriented reaction, then the chances are increased of reducing the impact of a terrorist attack with biological weapons of mass destruction on individuals and on the citizenry, and it will facilitate a more rapid recovery and an increased chances of continuity in the general population’s experience of “community”. In this regard, “well-developed and well-executed communication strategies” are strongly recommended (USUHS, 2000). More specifically, it is imperative that people in charge, and all levels — from governmental to organizational to familial:

  • Make sure that the general population receives information about the threat or the actuality of a bio-agent or weapon that is as accurate as possible, is disseminated as early as possible, and is easily accessible to the population at large.
  • Offer as soon as possible a clear contextual (socio-political, ideological) frame about the perpetrators
  • Provide quick, clear information about the chain of command of government and agencies
  • Provide emotional and physical safe heavens to those who need them
  • Create centers or contact points for temporarily disconnected family members and friends
  • Re-establish and/or organize social networks

Soothing the soul and the body: Bio-psycho-social treatment in action

Planning for treatment services for victims of these attacks as well as for incidental casualties resulting from panic and for potentially displaced segments of the population requires the assumption of a multi-level scenario, drawn in advance and with personnel thoroughly educated about those emergencies:

  • An immediate response, “frontline” set of mobile, in situ, personnel and services, including hotlines, EMTs, emergency room — stable or makeshift — , in addition to pre-designated networks of emergency hospitals and of trauma centers well versed in infectious diseases, radiation/burns management, poisons differential diagnosis and treatment, and psychiatric emergencies;
  • Medium-level services to cover needs of the general population — people who are unlikely to have been immediately affected by the weapon — , both in established hospitals and at secondary “refuges” or displaced persons shelters; and
  • Services organized for the management of long-term, persistent effects both on returnees and on those who never left, both direct victims of the chosen mean for the terrorist attack or indirect victims of the emotional impact of the attack — a process which puts in motion the slow and complex process of treating victims of violence.

Therefore, it is of extreme importance to provide, in a coordinated fashion, a range of integrated bio-psycho-social services for children and adults in which the staff may treat physical and emotional wounds with equal weight and expertise. Simulations (rehearsals) of catastrophic bioterrorist emergencies should be regularly conducted by emergency health services; liaison — including hot lines and emergency codes — should be established and frequently tested among all regional services and agencies and with centralized resources such as the Center for Disease Control and Poison Information Centers. While emergency services will operate necessarily with stipulated criteria of priorities (critical injuries and life threatening emergency first, then the rest), bio-psycho-socially integrated services will care for all emergencies as legitimate: every crisis involves people-in-context, not merely wounded bodies. Therefore, the personnel should be thoroughly trained in the sensitive art of differential diagnosis and gentle triaging during emergencies.

As mentioned at the beginning of this chapter, all these scenarios are by necessity speculative, as the experience of bioterrorism worldwide has been rather circumscribed. Nevertheless, current evidence strongly suggests that to assume that these attacks will remain in the realm of speculation is mere wishful thinking. While most local, national and international efforts should be devoted to ameliorating the structural causes of terrorism — those stemming from socioeconomic unevenness, oppression and hopelessness — , it is nonetheless reasonable to expand our preparedness to react in the event of those attacks, in order to maximize our resilience as a society and minimize the suffering of the innocent.



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  • Macilawain, C. (1993): Study proves Iraq used nerve gas. Nature, 363:3.
  • Norris, F.H. (2001): 50,000 Disaster Victims Speak: An empirical review of the empirical literature, 1981-2001. http://obssr.od.nih.gov/Activities/911/disaster-impact.pdf
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  • Pfefferbaum, B. (2002): The Children of Oklahoma. (Book in preparation)
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Presented on June 27, 2002, at the Organizational and Planning Workshop “Perceived Threat and the Public Health Response to Bioterrorism,” School of Public Policy, George Mason University, Fairfax VA. The author wishes to thank Professors Sara Cobb and Arthur Malmed for their constructive suggestions of the original manuscript.


  1. The CDC definition narrow of bioterrorism is “Intentional or threatened use of viruses, bacteria, fungi or toxins from living organisms to produce death or disease in human, animals or plants”. Terrorism in turn has been the subject of many definitions. The United Nations ODCCP cites as “Academic Consensus Definition” the following: “Terrorism is an anxiety-inspiring method of repeated violent action, employed by (semi-) clandestine individual, group or state actors, for idiosyncratic, criminal or political reasons, whereby - in contrast to assassination - the direct targets of violence are not the main targets. The immediate human victims of violence are generally chosen randomly (targets of opportunity) or selectively (representative or symbolic targets) from a target population, and serve as message generators. Threat- and violence-based communication processes between terrorist (organization), (imperilled) victims, and main targets are used to manipulate the main target (audience(s)), turning it into a target of terror, a target of demands, or a target of attention, depending on whether intimidation, coercion, or propaganda is primarily sought” and is attributed to Schmid, 1988. The FBI in turn defines terrorism as “the unlawful use of force or violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives”.
  2. While the overwhelming majority of terrorist, including bioterrorist, attacks have been politically motivated, there is always the possibility that the source may be simply a disgruntled sociopath or an otherwise mentally deranged individual, as was the case of the so called “Unabomber” in the late 1980s, and may even be the case of the anthrax — by-mail spread of late 2001.
  3. This threat was credible given the knowledge that in 1988 Iraq used poison gas to terrorize when not to exterminate the Kurdish civilian population within that country’s own frontiers. (Macilwain, 1993).
  4. The 1984 episode in which Rajneesh cult followers spiked with salmonella the salad bars in 10 local restaurants in The Dalles, Oregon, cannot be classified as bioterrorism, as the intent was not to engender fear in the general population but to reduce the number of voters in a local election in order to improve the electoral chances of a cult-affiliated candidate. However, it is a clear case of the use of biological agents with the intent to harm indiscriminately a civilian population — among the 740 people affected were adults and children, locals and visitors. (Vetter and Perlstein, 1991)
  5. This is described of mothers who continue attending in a motherly fashion an infant who has just died, and of severely wounded people and even of people receiving a catastrophic new, who continue doing what they were doing “in automatic pilot” until reality sinks in.
  6. Post 9/11/01 there has been a media documentation of a resurgence of acts of violence in the U.S. against people perceived as Arab-looking.
  7. The ones with maximal bioterrorist potentials are the agents that transmit anthrax, botulism, plague, smallpox, tularemia and viral hemorrhagic fevers.
  8. While follow-up care is recommended because of possible delayed peripheral neuropathy, the peak toxicity of these gases takes place within minutes and up to a few hours. (Ohbu et al., 1997, Su and Hoffman, 2002)
  9. Cf. in this regard the stress/performance bell curve discussed by Dr. Peter Bergethon in chapter ?? of this book.
  10. This assertion has received confirmatory evidence from the exemplary studies by Pfefferbaum (2002) on the effect of the Oklahoma bombing on children and adolescents. That author also notes that the psychopathological effect of the exposure to the traumatic event is significantly higher in those subjects who subsequently followed those events in their countless iterations by the television news coverage (Pfefferbaum, 2001). For a thorough review of the literature on victims of disaster, cf. Norris,2001.
  11. Cf. DiGiovanni, 1999, for a richly exemplified discussion of the neurotoxic effect of chemical and biological agents and the psychological impact of collective fear of these effects.
  12. “Somatization” of terror or anxiety is frequently considered a nuisance in emergency room settings during times of crisis, when patients with life threatening conditions are treated or expected. However, the well-trained and sensitized emergency professional knows that these patients deserve, and frequently respond rapidly to, a modicum of TLC, including a careful “translation” of somatic symptoms into legitimate psychosocial concerns and, if needed, a non-mystifying (i.e., realistic) reassurance, to be then referred to the appropriate resource.
  13. Even though it has not been classified as terrorism, the massive Blitzgrieg over London by the Luftwaffe during WWII was specifically aimed at terrorizing the civil population with the intent to undermine the collective morale, in preparation for a never carried out invasion of England by the German armed forces. For the matter, that is the intent of all bombing of civilian populations during wars. Prime examples of the case are Warsaw, Stalingrad, and so many other cities in the Eastern front by the Nazis, and many German cities by the allies, as well as Hiroshima and Nagasaki during WWII, as well as, years later, Hanoi, with varying degrees of overall success in overwhelming what was at that moment defined as the enemy.
  14. According to recent evidence (van Emmeril et al. 2002), “debriefing”, that is, providing a service aimed at offering immediate conversational spaces where people exposed to the emotional impact of the attack may vent feelings and emote, may not have the expected impact of reducing long-term potential PTSD-like effects, perhaps with the exception of a vulnerable 10% of the population. As noted in the The Lancet’s Editor’s Comment that accompanies van Emmeril et al.’s meta-analysis, an estimated 9000 “purveyors of debriefing and other popularized interventions” swarmed the World Trade Center’s area immediately after 9/11, advocating interventions for any person remotely connected to the tragedy. It may be hence advisable to centrally coordinate the thousands of Good Samaritans and hundreds of NGOs and other organized groups that — responding in good faith to their need to express support and “be part of the action” — tend to flood the scene of any major disaster with their offers of help.
  15. The literature on approaches to the treatment of traumatized populations and for training personnel to help that population is currently vast and will not be discussed here. The interested reader may consult, among many others, Herman, 1997; USIP 2001; and Yehuda, 2002, and several of the references to this chapter.