On September 11, 2001, three planes attacked the two World Trade Towers and the Pentagon. Watching the horrific pictures of
disaster on TV while listening to students and staff express their shock and horror, I experienced a feeling of déjà vu.
As a former Medical Social Worker in Israel, a memory came back to me of seeing oncology patients hooked to chemotherapy IVs
watching continuous TV footage on the latest terrorist attack of a blown up city bus filled with passengers going about their
business in downtown Tel Aviv. It was an incongruent image of patients attempting to survive cancer while concentrating on
blood spattered chaotic scenes of death. I tried to think professionally about how I was going to deal with the shock and
identification of the patients, some of whom were Holocaust survivors who were dealing with the possibility of death a second
time through their illness. I worried about how to assess their reactions and prepare them for whatever they might have to
face when returning home to possible news of friends and loved ones who had been wounded or had died in the attack. Now,
five years later, in the middle of a university in Kansas, I was experiencing the effects of terrorism again. Faculty and
students around me were stunned and trying to process what had happened halfway across the country. A few turned to me, knowing
of my prior residence in Israel for so many years, and in an expression of emotion asked, "But, you must be used to this?"
Professionally and personally, I don't think anyone ever gets used to being a victim of terror.
When a traumatic event occurs that is out of our control, we become the victims of others' harmful intentions. We must recover
our balance and our sense of living while experiencing grief and loss. Social workers need to understand how they can help
themselves and others to get through this period and to emerge on the other side. The reason for the sharing of this author's
past memories and explain the dynamics of terror is to aid professional practitioners in coping with and assisting victims
The Psychology of Terror, Crisis Intervention,
and Post-Traumatic Stress Disorder
How do terrorist incidents impact on its victims? From a professional view, Albert Bandura in his article "Mechanisms
of moral disengagement" describes several side effects (Bandura, 1998). Because an aim of terrorist acts is to create
widespread public fear, these incidents are designed to cause its victims deep feelings of loss of control, lack of self-efficacy,
shock, and fear of being killed or maimed for life. Psychologically, the mind initially cannot absorb being the central target
of an attack. In addition, anxiety for family, friends and associates welfare becomes overwhelming. The stress of the trauma
takes over that can produce lasting psychological consequences of hyperactivity, depression, anxiety, sleeplessness, and other
symptoms of Post-Traumatic Stress Syndrome.
Immediate response, therefore, by an organized group of professional practitioners is critical. The unpredictability of
terrorist attacks creates strong feelings of vulnerability and helplessness. During an attack anything can occur, and people
are liable to react in a number of unexpected ways.
Communities need an overall response plan that will be able to deal with primary and secondary victims, for example, family
members with feelings of "confusion, fear, anger, guilt, lack of insight, and feelings of powerlessness" (Rackley,
1998, 94). A first priority is that any strategy of intervention must be designed to provide an environment of safety while,
at the same time, succeed in minimizing the sense of threat. Social workers must be prepared to attend to the unusual degree
of clients experiencing a "disrupted state" and inability to activate effectively their "normal coping methods
to reduce stress" (94). A major goal of practitioners will be first, through debriefing, to increase the person's ability
to endure and survive his or her feelings of stress. Ventilation, appropriate tactile comforting, and the provision of opportunities
to make small decisions (e.g. whom to contact) can allow victims in small ways to gradually regain a sense of control in light
of what has happened. In follow-up, social workers will need to monitor and assess continuing client reactions. In light of
the multitude of people's individual and personal contexts, practitioners will need to concentrate on individual styles of
methods chosen to cope with ongoing side effects to better understand the personal meanings that have been assigned by victims
to having been caught in a terrorist event. Given a period of time, after the event, it is essential for a strengths perspective
to be employed during the assessment and intervention. To help clients to maintain themselves, social workers must go on the
assumption that people bring themselves into the story of what happens to them. Almost all clients can recall in detail modes
of coping in the past with crisis events even though they are most likely not comparable to the trauma of terrorism. However,
in order to identify clients' strengths, social workers must be able to distinguish between the behaviors they are viewing
as a continuation and intensification of prior problems or if they are directly related to and derived from the terrorist
incident itself in order to provide appropriate forms of intervention. Continued offers of long-term intervention and support
to victims and their families may be necessary who may be undergoing "fear, anxiety, re-experiencing, urges to avoid,
and hyperarousal" (National Center for PTSD, 2001, December 16).
"Practice, Practice, Practice"
In a telephone interview with Ms. Jenny Posen, LMSW, co-author of "Mass casualties: an organizational model of a
hospital information center in Tel Aviv", and an Israeli Medical Social Worker at Ichilov Hospital in Tel Aviv, she stressed
the importance of practicing community intervention prior to more possible terrorist attacks. She stated that often the first
reaction to terrorism, particularly, if the attack occurred as an "exception to the rule," that, after time, society's
response could culminate into an atmosphere of denial. Given the lack of national action to train the average citizen in the
United States the skills to stay aware of possible terrorist objects, and how to respond to Homeland Security's color-coded
chart of levels of emergency, this may be true. However, training and role playing at least on the side of a formal community
response is essential in order to respond promptly and effectively in minimizing psychological and physical damage.
In Tel Aviv, the first port of call to a terrorist incident is the hospital. Externally, a chain of relationships has
been set up between Community Health Centers, Welfare Offices, Emergency Medical Teams, other Hospitals and Police and Military
authorities. Certain types of wounded (e.g., head wounds) are taken to specified hospitals. Such hospitals have acute and
specialized care facilities that can deal with those types of patients. Children may be taken to a specialized Children's'
Hospital, for example. Hospitals also reorganize their internal systems to be ready in the event of terrorist attacks.
For instance, a few months ago, a bombing took place at the Dolphinarium, a seaside entertainment spot in Tel Aviv. Emergency
police, military, and city ambulance services rushed people to Ichilov Hospital. Admissions at the hospital went on alert
mode. Upon their arrival, patients were immediately numbered and sent to the Emergency Room. All through their stay they would
stay numbered in order to protect confidentiality and to process them as terrorist victims. Depending on the numbers of wounded,
this seems to be the most efficient process. Only later, admissions staff takes care of the paperwork and insurance.
Hospital social workers fulfill many functions during a terrorist alert. Medical social work staffs who are off duty know
to come in to the hospital as soon as they hear of an incident over the radio or television. They are then organized to go
to the Information Center that has been set up close to Admissions, to the Emergency Room and to the Operating Room. Some
social workers go to their regularly assigned wards to wait for hospitalized victims to arrive. A phone and fax system are
set up with outside lines going to the Emergency Medical services at the scene of the attack, to the police and military,
and to the welfare offices. Inside the hospital, a centralized software program lists incoming patients by number, names
if known, and any other critical details.
The Information Center is composed of a public reception area, a waiting area for patients' families, friends, and relatives,
and a crisis line to answer public inquiries regarding loved ones. On the night of the Dolphinarium attack, hospital social
workers did group work with the thirty or more youth that had been visiting the site of attack. A form of debriefing and mutual
support took place that centered on encouraging participants to talk about what had happened to them, where had they been,
how they were feeling, and what was going on. Group work is seen as one of the basic tools to be used with waiting area populations
from an attack.
A multidisciplinary team sits inside the Information Center itself. The team is usually composed of a nurse, doctor, psychologist,
hospital social workers, a police representative, translators, and Department of Social Services social workers from the community.
The DSS people are skilled in going out into the community to find family members of patients who have been brought in from
the attack for purposes of identification, and to aid family members of patients who have been killed at the Forensic facilities.
One of the main responsibilities of the Information Center is to keep people out of the Emergency Room. This allows medical
staff to concentrate freely on treating the physical casualties. They deal with the public when they come in and man the
phone lines. Their purpose is to provide reliable information. As Ms. Posen stated, depending on the size of the incident,
people may come in from anywhere. Often former victims of prior terrorist attacks show up experiencing a "double-effect."
The hospital social worker in the Emergency Room's main function is to meet the concrete immediate needs of disabled victims,
such as contacting a family member. Through talking, a main goal is to give support and a sense of control to the patient.
This social worker also helps families who come inside the Emergency Room to aid in identification of unconscious patients,
sometimes with great difficulty. Patients arrive covered with dust and wounds from the attack. As Ms. Posen stated, often
hair color has become gray and one patient who was identified with a mustache turned out to have a burn instead.
In the Operating Room area, the hospital social worker works mainly to provide resources and support to waiting families.
A telephone and computer line between this area and the Emergency Room, Admissions, and the Information Center are critical
in providing a flow of information from and to the Operating Room area.
Response to a terrorist attack occurs in stages. After the initial reception of patients, the hospital after a few hours
returns to its routines. However, the work of the hospital social workers and those social workers in the community continue
in follow-up and support of victims that have returned home, providing resources to families. In the hospital, the social
work supervisor must make decisions regarding how many social workers to have on at one time, when do they need to rotate
out and go home and rest, and how to keep staff functioning. An automatic debriefing session takes place the day after an
attack with social work staff and emergency room staff that basically cover the group work topics that were covered in the
waiting area with victims and families along with an analysis of the effectiveness of the response network. Sometimes, two
or three days later or three weeks later, a victim at the scene of the terrorist attack appears at the hospital requesting
help, often with PTSD symptoms.
The majority of American communities have some kind of disaster system in place. However, how adjustable and responsive
will they be if terrorist attacks continue to occur? Whatever is done has to be practiced on a regular basis, not after something
has happened. Education of citizens along with coordination between agencies will help to combat that aim of terrorists to
instill fear, vulnerability, and panic. Social workers with skills in crisis intervention and the ability to do effective
group work, who know how to do debriefing, how to work with a multidisciplinary staff, and taught how to take care of their
own needs will be essential to be prepared to take control when needed most.
Telephone Interview: February 23, 2002, Ms. Jenny Posen, LMSW, Supervisor, Social Services Dept., Ichilov Hospital, Tel
Bandura, A. (1998). Mechanisms of moral disengagement. In W. Reich (Ed.), Origins of terrorism: Psychologies, ideologies,
theologies, states of mind (pp. 161-191). Washington, D.C.: Woodrow Wilson Center Press.
Drory, M., Posen, J., Vilner, D., & Ginzburg, K. (1998). Mass casualties: An Organizational model of a hospital information
center in Tel Aviv. Social Work in Health, 27(4), 83-96.
Rackley, F. (1982). Religion and terrorism - a romantic model of secular gnosticism. In D. C. Rapoport & Y. Alexander
(Eds.), The rationalization of terrorism (pp, 91-100). Frederick, MD: Aleithia Books, University Publications of America.
What is post-traumatic stress disorder? National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs.
Retrieved December 16, 2001, from
There is more on terrorism in the next article.