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Acknowledgements. CBRN Psychosocial Guidelines Project Partners:

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Acknowledgements Chemical, Biological, Radiological & Nuclear Terrorism: Psychosocial Aspects & Strategies is an emergency services collaboration supported by the National Security, Science and Technology
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Acknowledgements Chemical, Biological, Radiological & Nuclear Terrorism: Psychosocial Aspects & Strategies is an emergency services collaboration supported by the National Security, Science and Technology Unit of the Office of Prime Minister & Cabinet (NSST Project ). CBRN Psychosocial Guidelines Project Partners: Australian Red Cross Australian Defence Force Australian Federal Police Emergency Management Australia Victoria Police Victorian Metropolitan Fire Brigade Rural Ambulance Victoria Metropolitan Ambulance Service, Vic. NT Police, Fire & Emergency Services ACT Fire Brigade S.A. Metropolitan Fire Service NSW Fire Brigade NSW Police (CT & Public Order Unit) NSW Health Counter-Disaster Unit W.A. Department of Health Queensland Department of Health Centrelink (Social Work Services) South Eastern Sydney & Illawarra Area Health Service The project team would like to acknowledge the specific advice and support of Prof Andy Robertson (W.A. Health), Dr. Jane Canestra (Victorian Department of Human Services), Peter Channells (Emergency Management Australia), Jim Hamilton (NSW Fire), GPCAPT. Leonard Lambeth (Australian Department of Defence), Dr Eric Wenger (Australian CBRN Data Centre), Andrew Coghlan (Australian Red Cross), Prof. Louise Lemyre (University of Ottawa), Prof. Robert Ursano (Uniformed Services University School of Medicone), Prof. Simon Wessely (King s College School of Medicine, London), Prof. Dori Reissman (CDC Coordination Centre for Environmental Health Injury Prevention) & Prof. Alison Jones (University of Newcastle). The following SCHIMA staff assisted with the development of this document: Garry Stevens, Dr Melanie Taylor, Catriona Thompson, Anne Cantle & Vicki Kennett Chemical, Biological, Radiological & Nuclear Terrorism: Psychosocial Aspects & Strategies, Prof. Beverley Raphael SCIMHA Unit, Medical School, University of Western Sydney, 2008. Table of Contents TABLE OF CONTENTS PSYCHOLOGICAL CHALLENGES OF TERRORISM AND CBRN TERRORISM... 1 THE PSYCHOLOGICAL CHALLENGE OF TERRORISM... 1 THE NATURE OF CHEMICAL, BIOLOGICAL, RADIOLOGICAL & NUCLEAR TERRORISM... 3 PERCEPTIONS OF CBRN TERRORISM... 8 CBRN TERRORISM: POTENTIAL EFFECTS ON MENTAL STATE... 9 RISK REALITIES, RISK PERCEPTIONS & RISK CONSEQUENCES RISK COMMUNICATION: INFORMATION AND RISK MANAGEMENT KEY ELEMENTS OF PSYCHOSOCIAL SIGNIFICANCE The Unknown Dread The Uncontrollable FIRST RESPONDERS: CBRN PSYCHOSOCIAL EFFECTS TERRORISM IMPACTS AND FIRST RESPONDERS TERRORISM INVOLVING CHEMICAL AGENTS AND FIRST RESPONDERS TERRORISM INVOLVING BIOLOGICAL AGENTS AND FIRST RESPONDERS TERRORISM RELATED TO RADIOLOGICAL / NUCLEAR AGENTS AND FIRST RESPONDERS GENERAL CONCLUSIONS ABOUT PSYCHOSOCIAL EFFECTS OF CBRN TERRORISM FOR FIRST RESPONDERS CBRN AGENTS AND MATERIAL: CHEMICAL, BIOLOGICAL, RADIOLOGICAL/NUCLEAR AND THEIR SPECIFIC PSYCHOSOCIAL EFFECTS.. 34 CHEMICAL TERRORISM Specific Characteristics of Agents Chemical Threat: Psychosocial Aspects BIOLOGICAL TERRORISM Specific Characteristics of Agents Biological Threat: Psychosocial Aspects RADIOLOGICAL AND NUCLEAR TERRORISM Specific characteristics of materials Radiological/Nuclear Threat: Psychosocial Aspects CBRN TERRORISM: GENERAL PRINCIPLES FOR THE MANAGEMENT OF THE PSYCHOSOCIAL ASPECTS KEY THEMES Preparation and Planning Response Restoration and Recovery Mental Health Strategy Building New Futures FIRST RESPONDERS: PSYCHOSOCIAL RESOURCES FOR THE MANAGEMENT OF CBRN CHALLENGES I SAFE STRATEGIES FOR EMERGENCY RESPONSE II PREPARATION: BUILDING RESILIENCE AND PSYCHOSOCIAL STRENGTHS FOR RESPONSE III STRATEGIES FOR FIRST RESPONDERS TO DEAL WITH AFFECTED PERSONS IV ACTION AND EFFICACY i Table of Contents V PROTECTING THE HEALTH AND WELLBEING OF THE FIRST RESPONDERS POST INCIDENT VI HEALTH CARE WORKERS: FIRST RESPONDERS/RECEIVERS IN CBRN TERRORISM APPENDIX A AN EXAMPLE OF POPULATION INFORMATION APPENDIX B THE BIO-EVENT FEAR & RESILIENCE (FR) CHECKLIST APPENDIX C THE CBRN S.A.F.E. INCIDENT POCKET GUIDE REFERENCES ADDITIONAL REFERENCES ii Psychosocial Challenges of Terrorism and CBRN Terrorism Psychological Challenges of Terrorism and CBRN Terrorism This review deals with psychosocial reactions to terrorism, to its threat, and to incidents. Its primary focus is CBRN (Chemical, Biological, Radiological and Nuclear) terrorism. It builds on knowledge about the threat of terrorism generally including conventional terrorism. It addresses the nature and impact of such threat; how risk is perceived; psychosocial impacts; strategies to prevent and manage these; specific issues for first responders; and how to assist others affected in terms of individual distress and behaviours, as well as group/crowd management. The Psychological Challenge of Terrorism Terrorism has a long history (Carr, 2002). It has been perpetrated in many forms, ranging from traditional weapons to bioterrorism and related threats. Terrorism aims to change attitudes and behaviours by creating fear, frequently an epidemic of fear, and as such it is a form of psychological warfare. There has been much written about the motivations and behaviours of terrorists, particularly suicide bombers (Hoffman, 2006). It is beyond the scope of this paper to discuss these issues in detail. There is extensive literature on the nature of terrorist organisations and the profiles of terrorist perpetrators (Morice, 2007). Nevertheless characteristics of such groups, for instance Al-Qaeda or Jemaah Islamiya, add to the sense of threat through what is known: their goals; their suggested targets; their hidden networks and cells of operation; the impact of their terrorist acts to date; and their potential for future activity (Hoffman, 2006). In a valuable paper before 9/11, the terrorist attack that has greatly increased alarm, Robertson (2000) highlighted the long history of one form of terrorism, bioterrorism. Terrorism has been equated to total war in that civilians are targeted rather than military combatants (Carr, 2002). Terrorism in general, regardless of form, poses threat to the future. Inherent in this is: 1 Psychosocial Challenges of Terrorism and CBRN Terrorism Threat of Terrorism Uncertainty of timing, target and type Uncertainty for the individual or group as to whether or not he or she will be directly affected, or loved ones, or community Potential for death, injury, destruction, disfigurement, disability Potential for loss: of loved ones, of home, work, resources, country Potential for social and economic disruption Prolonged nature of threat or possibility of repetition Malevolent intent Terrorism has been categorised as conventional with attacks such as those with IED s (Improvised Explosive Devices), suicide bombers, shooting, bombing, and unconventional such as chemical, biological, radiological and nuclear terrorism (CBRN). It is sometimes referred to as CBRNE, E referring to explosives. There are multiple other potential forms of terrorism such as those attacking the internet, called cyberterrorism, or those that focus on agricultural systems and the food supply, called agriterrorism and so forth. While there have been some common patterns in recent attacks such as the multiple bombings of Madrid and London transport systems, the ingenuity and sophistication of planning, the use of fuel loaded domestic airliners as weapons in 9/11, has demonstrated the creativity that can be mobilised. These attacks involved not only the death and loss impacts, but the symbolic targeting of national icons with the World Trade Centre and Pentagon, and the subsequent social, financial and economic disruption. Hostage taking, as with the Moscow theatre and Beslan school incidents, also extends the threats that can be used to create fear. The threat and fear inducing elements of the terrorist s strategy are further amplified through extensive and repetitive media coverage. This extends the potential psychological impacts of fear, traumatisation and behavioural changes, which will have ripple effects through communities and beyond. In the past, Australia has seen itself as relatively immune in terms of terrorist attacks, although, as Robertson (2000) and Edwards et al. (2006) highlight, there have been acts of terrorism and 2 Psychosocial Challenges of Terrorism and CBRN Terrorism politically motivated violence, including the Hilton bombing in 1978, and other incidents in Australia. Australians were a target in the 2002 and subsequent Bali bombings, and also the bombing of the Australian embassy in Djakarta in Extensive planning and preparation in Australia deals with the possibility of such attacks on Australian soil, as for instance for the Sydney 2000 Olympics (Evangeli, 2000; Raphael & Hills, 2004) and subsequently. Strong intelligence activity and multiple other strategies aiming at prevention have been outlined (Protecting Australia Against Terrorism 2006). There has been a number of valuable and informative reports dealing with weapons of mass destruction (WMD) and the potential significance of such attacks for Australia, (Smallwood et al., 2002) and the challenges for emergency health response (Robertson, 2000; Caldicott and Edwards, 2002; Edwards et al., 2006). There has also been discussion of the degree of readiness and response following a major exercise, Exercise Supreme Truth, and the need to test plans (Edwards et al., 2006). Questions have arisen about the extent of hospital preparedness for any attack leading to large numbers of injured (Rosenfeld et al., 2005). These reports provide a thorough overview of the risk matrices, for such threat, while recognising the greater likelihood of conventional terrorism. None of these reports details the psychosocial issues of CBRN terrorism. There are ongoing planning strategies to deal with surge in health care settings (Robertson and Cooper, 2007), burns patient needs across Australia (AusburnPlan), and the range of other necessary strategic response components in the health care system. Pre-hospital, hospital, healthcare work force professionals, and numerous other systems that would contribute to response require support, including education and training, to build this role capacity on the already strong basic demand, and thereby answer the concerns about readiness (Bergin and Khosa, 2007). A special report on counterterrorism in Australia (Metcalfe et al., 2005), deals with many specific challenges for planning themes, equipment, and exercises, and for responding to CBRN terrorism (Patterson, 2005). The special issues of Radiological terrorism (Colella et al., 2005) and Incident Response Management to support emergency response have also been considered. The Nature of Chemical, Biological, Radiological & Nuclear Terrorism These emergencies contaminate in ways that never seem to end. An all clear is never sounded. The book of accounts is never closed (Erikson, 1994) The purpose of terrorism is to induce fear, uncertainty and disruption; in essence, to create an epidemic of fear. Terrorism is psychological warfare; the manifestations of which need to be 3 Psychosocial Challenges of Terrorism and CBRN Terrorism understood as a background to its effective management. Importantly, most people demonstrate courage and resilience when faced with such an event and the recognition of this also needs to be an intrinsic part of response frameworks. It has been argued that the power of terrorism to threaten and undermine pertains to three main factors 1) the unknown parameters of its threat, 2) dread associated with the potentially deadly nature of its impacts and the intent behind these and 3) a perceived lack of ability to control this threat and its effects and consequences. Effective CBRN counter-terrorism will rely on the capacity to mitigate or potentially control these factors at each phase of the event response. These specific threat elements of conventional forms of terrorism (i.e. explosives related) and potential counter-measures are outlined in Figure 1. Figure 1. Terrorism: Core Threat Elements & Potential Counter-Measures UNKNOWN: Timing: When it may occur Target: Who will be affected, self, loved ones, others Type: The attack agent guns, explosives, hijacking Impact: Personal & family, community, society. Effects of conventional terrorism more delineated event trauma Counter-Measures: Development of knowledge base & strategic skill sets DREAD: Life Threat: Self & loved ones - injury, illness, death Loss: Loved ones, home, community, safe world view Intent: Malevolent intent. Who and why. Counter-Measures: Strategies to mitigate and manage fear / distress UNCONTROLLABLE Safety: Actions to ensure safety may not be available or effective Mitigation: Actions to prevent or mitigate may be untested & uncertain Capability: Spectrum of capacities needed to address impacts may be limited Counter-Measures: Capacity-building Progressive actions to control, and increase safety. Mass casualty events that are the result of violent actions are found to produce consistently higher levels of distress and psychological impairment (North et al., 1999). Large-scale comparisons of disaster studies have shown that those exposed to mass violence and terrorism experience severe mental health problems (e.g. Post Traumatic Stress Disorder, Major Depression and Generalised Anxiety Disorder) at almost twice the rate of those involved in natural or technological disasters (Norris, 2005). Disasters that are the direct result of human malevolence, such as terrorism, may be particularly difficult for survivors to comprehend and come to terms with in their daily lives. There may be persistent intrusive thoughts, 4 Psychosocial Challenges of Terrorism and CBRN Terrorism physiological reactivity and changed personal and social behaviours and relationships (Pfefferbaum et al., 2007). A useful review of mental health following terrorist attacks highlighted some of the recent findings after 9/11 and other incidents (Whalley and Brewin, 2007). After both the September 11 attacks and the Madrid rail bombings there were high levels of substantial stress over the first few months, but much of this settled, although a significant number continued to have symptoms and disorders, such as PTSD affecting 3% of the population more broadly, particularly those closer to the incident and most directly involved. High rates of 20% or more occurred with those closest to the 9/11 impacts. Also vulnerable were minority groups, those with previous experiences of adversity, or who had pre-existing disorders related to similar experiences. These authors also reported on the wide range of disorders, although PTSD was often the focus. They noted as well the studies of children with 28.8% affected 6 months after 9/11 (Hoven et al., 2006), with agoraphobia, separation anxiety disorder and PTSD. Whalley and Brewin also describe the wide variability of findings for emergency workers but again effects were associated with close direct exposure to the attack, and to grotesque injury and multiple deaths. The degree to which such mental health needs are effectively met is uncertain and these authors suggest that a targeted outreach program with screening and a tiered approach would be a critical component (p96). Terrorism involving Chemical, Biological, Radiological or Nuclear agents is likely to evoke higher levels of perceived threat. A large-scale population survey carried out in Canada demonstrated that the general public had an awareness of CBRN forms of terrorism (Lemrye et al., 2005). While they considered that conventional terrorism was more likely to occur, they viewed CBRN terrorism as more serious in its potential effects. Ranking of the agent categories indicated that chemical, biological, radiological and nuclear agents were considered to represent progressively greater levels of threat. The underlying threats associated with CBRN terrorism are outlined in Figure 2. 5 Psychosocial Challenges of Terrorism and CBRN Terrorism Figure 2. CBRN Terrorism: Core Elements of Threat UNKNOWN Timing: Target : Type: Impacts: DREAD Unfamiliar Threat: Uncertain: Loss: Intent: Onset / progression may be highly uncertain. End point may never be clear. Spread / dispersal more indiscriminate e.g. wind direction (chemical) or disease course (biological) Multiple agents and forms of attack. Insidious forms - difficult to detect. Contamination, contagion. Effects more diffuse, prolonged. Injury, illness, death Unfamiliar forms, gruesome images (e.g. scenes of WMD) Death, damage to self, family, health, resources, delayed effects (e.g. cancer, birth defects) Life, loved ones, home, health, safe world view Malevolence - Unrestricted death, mass social disruption. Fear UNCONTROLLABLE Safety: Nature of agents makes safety less certain: Actions may not protect. Mitigation: Capability: Less experience, information regarding what works to ensure safety. Complex matrix of agent factors in response environment, capabilities less tested, capacity to control and mitigate less clear. CBRN terrorism has the potential for profound psychological impacts in that it combines the deliberate human intent to cause harm (possibly on a large scale) with the fear and dread associated with mysterious agents and potentially extended over time. Terrorism with conventional weapons typically produces immediate health effects in the form of injuries and deaths. For the perpetrators, these effects may simply be an element of their wider aims - creating fear, uncertainty and civil disruption, in order to achieve wider cultural or political change (Ursano et al., 2004) 1. 1 More recent forms of terrorism may be less concerned with strategic change than what they see as the direct conduct of warfare, albeit in indirect ( asymmetric ) forms, which include terrorism. Such groups may see the direct targeting of civilians as legitimate (i.e. a form of total war ), with associated community fear as a useful but secondary outcome (Cronin, 2002) 6 Psychosocial Challenges of Terrorism and CBRN Terrorism In this sense the intended effects of this type of terrorism are, as the term implies, primarily psychological. These aims are to: 1. Foster pervasive fear and insecurity through specific acts of violence 2. Promote behavioural changes which disrupt public infrastructure 3. Create a loss of confidence in public institutions (Ursano, Norwood & Fullerton, 2004) Terrorism involving CBRN agents represents a particularly insidious, ongoing form of assault. Biological and radiological agents, for example, are typically invisible and odourless, may produce delayed illness (and uncertainty) and may be associated with images of grotesque forms of death. Consider, for example, common perceptions and ideas about diseases such as, mustard gas in the First World War, plague (the black death ), smallpox, and the radiation injuries from Hiroshima. Thus, CBRN agents are particularly well-suited to the fundamental aims of most terrorist groups. The difficulties usually associated with weaponising these materials does not mean that they would not be used, nor that their potential is not threatening. CBRN Agent Classes Within the four CBRN agent classes there are several subcategories, which are noted below. In the case of biological and radiological agents these subcategories relate to the nature of the agent itself (e.g. bacteria, virus, radiation type), while chemical agents are typically classified according to the physical system they primarily affect (e.g. nerves, skin, lungs). 7 Psychosocial Challenges of Terrorism and CBRN Terrorism Figure 3. CBRN Agent Sub-Categories & Response Factors AGENT/MATERIAL TYPE RESPONSE FACTORS Chemical Nerve Effects: Typically rapid Blood Detection: Often simple but high variability Blister (skin) Likely First Responders: Pulmonary (choking) Emergency Service Workers (ESW) Biological Bacterial Effects: Typically delayed Viral Detection: Complex, delayed Toxic * Likely First Responders: Health Care Workers (HCW), Publ
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