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TERRORIST ATTACK: Practical Information for Caregivers

by Mark D. Lerner, Ph.D.

Chairman, The National Center for Emotional Wellness

Today, we are preparing for terrorist attacks. We are developing plans and protocol for addressing the wide spectrum of events that can potentially disable us—including nuclear, biological and chemical attack. We are investing countless hours training and practicing with elaborate equipment and protective gear. Our primary goal ... the stabilization of injury and the preservation of life.

In the event of a terrorist attack, our physical and safety needs must be the priority. As we have learned, physical trauma can destroy many lives. However, we have also learned that a hidden trauma, traumatic stress, can ultimately destroy many more. Traumatic stress refers to the emotional, cognitive, behavioral, physiological and spiritual experience of individuals who are exposed to, or who witness, events that overwhelm their ability to cope.

A terrorist attack will have many direct and indirect victims. Certainly, individuals who are at the scene of a horrific event may experience traumatic stress. However, we must recognize the impact on so many others including, but not limited to, family and friends of victims, emergency responders, and health care providers. We must also recognize the power of the media in affecting people across our nation and around the world. We know that individuals who witness traumatic events on television experience very real traumatic stress reactions.

Traumatic stress, resulting from a terrorist attack, will disable people, cause disease, precipitate mental disorders, lead to substance abuse, and destroy relationships and families. In organizations, traumatic stress will lead to communication breakdowns, a decrease in morale and group cohesiveness, workplace tension and conflict, excessive absenteeism, employee sabotage, an increase in workers’ compensation and disability claims, employee litigation, an inability to retain effective personnel, and ultimately, a decrease in productivity.

Historically, efforts to address psychological needs arrive in the weeks, months and years after a traumatic event—after emotional scars have formed and after people are labeled with a traumatic stress disorder. In recent years, techniques have been developed to demobilize, defuse and debrief people after disengagement from a crisis—following a traumatic event.

Notwithstanding, there is little information offering practical strategies to help people during a traumatic experience ... a time when people are highly suggestible, impressionable and vulnerable.

During and in the wake of a terrorist attack, traumatic stress will be the norm. People will experience overwhelming thoughts and feelings—as well as a host of behavioral and physical reactions. We know that such an event, one of 'intentional human design,' will be particularly difficult for us. Survivors will report feeling stigmatized, marked and different. A deliberately caused tragedy undermines our basic trust in humanity.

How can we keep people functioning and mitigate long-term emotional suffering during, and in the wake of, a terrorist attack?

As caregivers, we must expand our repertoire of helping skills—beyond the physical and safety needs of people, and raise our level of care. During traumatic events, horrible sights, sounds, smells, tastes and physical touch are indelibly etched in our minds. They repeat over and over again, they “play back” in our experience as disturbing “movies,” and they lead to uncomfortable and overwhelming thoughts, feelings, actions and physical reactions. These stimuli, the 'imprint of horror,' are the precipitators of debilitating traumatic stress disorders.

The fact of the matter is that whatever we are exposed to, whatever we focus on during peak emotional experiences in our lives, will stay with us forever. Knowing this, we understand how adversity can disable us. However, in the same way that negative stimuli are etched in our minds during a traumatic experience, so too can a positive, adaptive force. Knowing this, we understand how adversity can propel us to achieve. Look around you. People who have achieved the most in life are often people who have not had the easiest lives. Crises bring opportunities. A positive force, early on, can keep people functioning and lessen the likelihood of long-term emotional suffering.

What is this positive, adaptive force?

In the face of a terrorist attack, one does not need an advanced degree in mental health in order to provide highly effective intervention. In fact, the best help is often rendered by people on the front lines who take the time to listen and say the “right things” at the “right time.” However, one must know what to say and do before a traumatic event. Traumatic experiences, by their very nature, compromise our ability to think clearly and often leave us feeling out-of-control. By having a plan in place, a 'traumatic stress response protocol,' we will be in control and we will know what we need to do. We will be prepared.

How can we prepare to address the emergent psychological needs of others?

In the same way that a high school biology teacher must be knowledgeable about human anatomy, botany and zoology, those who strive to help others exposed to a terrorist attack must be knowledgeable about how people typically react in the face of a tragedy. They must understand what traumatic stress is, who it affects, and how it affects themselves and others.

Caregivers must learn to recognize the emotional, cognitive, behavioral and physiological reactions that people experience during traumatic exposure. And, they must understand that these reactions are normal reactions in the face of an abnormal event. This awareness must come from training prior to a crisis. Beyond understanding traumatic stress and knowing how it affects ourselves and others, caregivers must be equipped with practical tools that they can use to help others during traumatic exposure.

Acute Traumatic Stress Management (Lerner) was developed as a 10 stage model in order to provide structure during an unstructured period of time—and, to enable caregivers to “read off the same page.” For example, if I was helping an individual to remain in a functional state, by focusing on the facts of a given situation, it would would be unfortunate and potentially problematic for another caregiver to walk over and ask, “How ya feeling?” In fact, this situation was described to me by an emergency services police officer in the wake of September 11th. He reported that he was talking with a colleague about extricating bodies when, “...some nut in a red jacket came over and asked me how I was feeling.... I told him to get the ____ out of here. I wanted to kill the bastard!” There is a “right thing” to say, and a “right time” to say it.

Following, is a brief overview of the 10 Stages of ATSM. The first 4 stages are of primary importance to EMS personnel and have to do with considerations surrounding situation management and emergency medical care. The latter stages can be implemented by all caregivers.

It is important to recognize that the nature of the event, time constraints and the intensity of individuals’ reactions, will vary during traumatic exposure. Consequently, appropriate intervention may not fall neatly into a linear progression of stages. You will need to be flexible given the presenting circumstances.

Following is a quick overview of the 10 Stages of Acute Traumatic Stress Management:

1. Assess for Danger/Safety for Self and Others

• Are there factors that can compromise your safety or the safety of others?

2. Consider the Mechanism of Injury

• How did the event physically and perceptually impact the individual?

3. Evaluate the Level of Responsiveness

• Is the individual alert and responsive? Under the influence of a substance?

4. Address Medical Needs

• For those who are specifically trained to manage acute medical conditions

5. Observe & Identify

• Who has been exposed to the event and who is evidencing signs of traumatic stress?

6. Connect with the Individual

• Introduce yourself, state your title and/or position. Once he is medically evaluated, move the individual away from the stressor. Begin to develop rapport.

7. Ground the Individual

• Discuss the facts, assure safety if he is, have him “Tell his story.” Discuss behavioral and

physiological responses.

8. Provide Support

• Be empathic. Communicate a desire to understand the feelings that lie behind his words.

9. Normalize the Response

• Normalize, validate and educate.... “Normal person trying to cope with an abnormal event.”

10. Prepare for the Future

• Review the event, bring the person to the present, describe events in the future and provide referrals.

For comprehensive information about Acute Traumatic Stress Management, see the Infosheet entitled Acute Traumatic Stress Management, A Traumatic Stress Response Protocol. The originator of Acute Traumatic Stress Management, Dr. Mark Lerner, has developed a training program in ATSM. Upon completion, participants will receive a Certificate of participation by The National Center for Emotional Wellness.

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