by Steven Crimando
Author’s notes: The following material is intended as a primer on the unique psychosocial reactions to CBRN events. Part II of this series will focus on the anticipated emotional and behavioral reactions to a possible pandemic influenza. The reactions to such public health emergencies are complex and atypical in comparison to other disaster mental health reactions. Furthermore, how individuals, families and communities behave in such emergencies will either greatly facilitate or obstruct public health and emergency management efforts (ex: polio quarantine revolt of 1916, Oyster Bay, NY).
Readers of these materials often quickly point out that the common terminology for this group of hazards is “CBRNE.” For the sake of discussing the psychological considerations of such emergencies, it is important to recognize that accidental or purposeful detonations of explosives generally results in a psychological response similar to those following natural disasters. Of course in the instance of terrorism, there is the added dynamic that someone has deliberately set out to hurt or kill others, but stress reactions following explosions are usually more acute, while those following chemical, biological, radiological or nuclear exposures tend to be more chronic.
A good way to conceptualize this is with the idea of “bookends.” In a violent explosion, much like a natural disaster, victims and survivors clearly know when the event started, when it ended, and can more or less see the area of impact. They know if they were in or out. In the instance of CBRN exposure, the hazard may be colorless, odorless, tasteless and silent; therefore it is more difficult to determine exactly when it began, when it ended and if one was truly in or out of the affected area. Beyond the blurriness of clear boundaries marking the disaster, CBRN hazards often leave those exposed with fears of illness or death in the future. For example, someone exposed to radiation or certain chemical agents may be just as concerned about a serious disease, such as cancer, arising five years later, as any illness or injury today. This “future orientation” represents an ongoing stressor for the victim that often leads to chronic, long- term stress reactions, rather than the shorter, acute psychological reactions that accompany most natural and technological disasters
Therefore, the use of the abbreviation CBRN is purposeful, and not an oversight, at least for this limited discussion.
Introduction
The ultimate tool of the terrorist is not chemical, biological, nuclear or radiological…it is psychological. Terror is fear. Terrorism generates fear so intense that it can immobilize an individual, a community, a business or a nation. Terrorist attacks are intended to cause psychological, social and economic disruption, not simply to hurt or kill those in close proximity to the attack.
By definition, anti-terrorism involves efforts to prevent terrorist acts, such as hardening high-value targets, enhancing intelligence capabilities and developing detection technologies. Counterterrorism, on the other hand, is a form of consequence management. Since the intended consequence of terrorism is the creation and manipulation of fear, managing the psychological consequences of terrorism is a form of counterterrorism.
Community and business leaders need to know about the psychological impact of terrorism, as well as the key concepts of psychological counterterrorism, if they are to prepare and protect their properties and their people.
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FACT: Following the 1995 sarin nerve gas attack in the Tokyo subway system, the ratio of psychiatric casualties to medical casualties was 4:1.
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The emotional aftermath of a CBRN attack may be far greater than the physical response and even more disruptive to individual lives and business operations. A critical factor in operational assurance is a working knowledge of the psychological consequences of these unique hazards.
Unconventional terrorism involves the use of exotic substances, such as chemical, biological and radiological agents to inflict harm, generate extreme fear and create anxiety. There are several unique psychological reactions associated with this type of terrorism that differ greatly from the emotional response to natural disasters, conventional terrorism and other forms of mass violence. Within the business organization, it is critically important for senior managers to recognize and be able to respond to the emotional consequences of bioterrorism. A failure to predict and prepare for the psychological response of employees and the community can greatly reduce an organization’s ability to effectively respond to, and rebound from a bioterror attack.
Once the initial emergency medical and HAZMAT response is complete, it becomes obvious that bioterror incidents are simultaneously public health and mental health emergencies. Anticipating a surge in healthcare-seeking behavior following a bioterror attack, emergency rooms should anticipate the numbers of the “worried well” to greatly exceed those of true medical emergencies. From the perspective of a community or business leader, it is unrealistic to expect that the local mental health system or a company’s Employee Assistance Program (EAP) will be able to handle the surge in demand for crisis counseling services if their business or surrounding community has been the target of CBRN terrorism. Preparedness and Response Plans must incorporate the psychological aspects of this form of terrorism into all four phases: mitigation, planning, response and recovery. In most instances, the company’s general disaster recovery plan will not sufficiently address this unique risk.
The Impact of CBRN Terrorism
Both the lay person and mental health professional often assume that the psychological byproduct of CBNR terrorism will be posttraumatic stress disorder (PTSD). Based upon this idea, leaders concerned with the psychological wellness of individuals and their families are over-prepared to recognize and intervene when traumatic stress reactions are present, but under-prepared to deal with the acute fear and anxiety created by CBRN terrorism, never mind the possibility of Mass Sociogenic Illness, misattribution of normal arousal symptoms, and acute distrust of authorities, possibly including executive managers. While these reactions seem complex and perhaps improbable, first hand experience at Anthrax Screening Centers, smallpox vaccination clinics and following accidental releases of CBRN agents has demonstrated that these are more likely than traumatic stress reactions. Caregivers and decision-makers should have a working understanding of these unique reactions if they are to prepare for these risks.
Mass Sociogenic Illness (MSI)
Mass Sociogenic Illness is best described as psychological contagion or epidemic hysteria. It is a social phenomenon of two or more people experiencing a cluster of physical symptoms for which there is no apparent medical cause. This type of reaction can be caused by all types of contaminants when individuals attribute their symptoms to a perceived toxic exposure. Despite evidence to the contrary, individuals who believe that they may have been exposed to a CBRN agent or are unsure if they were exposed, begin to experience physical symptoms triggered by their psychological response. For individuals having this type of reaction, their symptoms are very “real”, and in most cases they will seek medical attention or at least behave as if they are truly injured or ill due to the perceived exposure. The term, “worried well”, refers to individuals and groups experiencing this phenomena, as well as misattribution of normal arousal.
Misattribution of Normal Arousal
Most people are familiar with the basic “fight or flight” response to life-threatening situations. In the face of a real or perceived threat to life or limb, we all typically experience an elevation in vital signs: increased heart rate, increased blood pressure, faster, shorter breathing, and so on. In the immediate aftermath of a CBRN event, many of those exposed or who believe they were exposed to toxic substances, will experience this normal elevation in cardiac and respiratory functioning, but will be convinced that their pounding heart or shortness of breath is due to the biological or chemical agent, therefore proving that they are injured or ill as a result of the attack.
In a true CBRN event it can be extremely difficult for medical personnel to sort out which are true and which are pseudo-medical emergencies driven by psychological reactions. As a general rule, medical emergencies always triage higher than psychological emergencies, but when in doubt it is safer to treat medical complaints as medical emergencies until they are otherwise ruled out. This, of course, means treating the individual as if they were truly exposed to the CBRN agent, therefore possibly reinforcing their belief that they are injured or ill, and straining the emergency medical system.
The psychological response contributes to the overall number of individuals who may require immediate care, and in terms of business continuity, may significantly decrease the number of employees who are willing or able to return to work quickly in the wake of a bioterror attack. In extreme cases, employees may hold onto the idea that the workplace has become a “sick building”, and cannot be decontaminated to their satisfaction. The anthrax attacks on both the Brentwood (DC) and Hamilton (NJ) postal facilities left those facilities unusable for years after the events.
Mistrust of Authorities
Even the most sincere government or business leader can be accused of spinning the facts following a tragic event in order to calm fears and get people back to work. In communities and organizations that have had a history of distrust between management and labor, or senior management and line staff, this dynamic is often exacerbated in times of stress or fear. In the instance of a CBRN attack, levels of fear or panic may be so high that there is little can do to assure employees that they are getting accurate information. Business leaders also may struggle with the question of how much information is too much information, and worry that they might further traumatize employees or contribute to greater emotional distress.
Just the Facts
Following most disasters, but especially in the wake of CBRN incidents, few individuals seek out crisis counseling services in the first hours and days. Instead, there is an immediate hunger for information. It is not unlikely that employees will gather information, opinions and rumors from many sources, including TV news, the Internet and word of mouth. At a time when fear may be running high, perception truly becomes reality, and it becomes clear how quickly media reports and rumors shape our perception.
A useful strategy for addressing this intense need for information is to offer “fact sheets” and other publications from credible sources. These may include the Center for Disease Control and Prevention (CDC), the World Health Organization and other well-known or trusted experts. Information must be timely and accurate. Because the news cycle accelerates during crises, business leaders must stay in touch with the most recent developments. Distributing dated or inaccurate information can be seen as management being “out of touch” with the crisis at hand.
A Neighbor Helping Neighbor Approach
In the wake of an actual CBRN attack against a company or community, basic Psychological First Aid may be more useful than formal “debriefing” and structured mental health interventions. Communities and businesses with Community or Corporate Emergency Response Teams (CERTs) can train responders in the fundamentals of Psychological First Aid, active listening skills and the recognition of psychiatric emergencies, so that they can deliver emotional support in conjunction with other emergency services.
Helping first responders within your community or organization to anticipate the emotional consequences of CBRN terrorism will reduce the likelihood of being blindsided by the powerful psychological reactions of those exposed. This, of course, applies to first responder’s reactions, as well as the reactions of civilian victims of such an attack. The emotional power of CBRN terrorism creates universal vulnerability.
No one is immune from the acute fear and anxiety that follow such incidents and everyone who may be part of the response and recovery effort should be well briefed on the psychological aspects of CBRN terrorism.
Likewise, everyone can be part of the solution, by managing the emotional response as best possible and reaching out to their co-workers and neighbors in their home, at work and in the community with support and a willingness to allow others to share their thoughts and feelings about the situation.
Conclusion
Prior technological disasters, terrorist attacks and the use of unconventional weapons in warfare lead experts to believe that the psychological reaction to these events may be much greater, and more difficult to contain, than the physical or medical reaction. Conservative estimates predict a 4:1 ratio of psychiatric to medical emergencies following CBRN terrorism, but based on the experience at the Goiania, Brazil radiological accident; this ratio may be much higher in a “dirty bomb” scenario.
In the chaos that will likely follow a CBRN attack; the learning curve related to the psycho-social impact of the event will be very steep indeed. The time to learn about and plan for the emotional consequences of unconventional terrorism is now, when community and business leaders can thoughtfully predict and prepare for the aftershock of bioterrorism and other emerging risks.
Part II of this series will focus exclusively on the anticipated emotional and behavioral responses to pandemic influenza.
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Steven M. Crimando, MA, BCETS, is a noted author, consultant and trainer to governmental agencies, NGOs and multinational corporations. He is the Managing Director of Extreme Behavioral Risk Management (“XBRM”), a consultancy focused on the human factor in disaster recovery, business continuity and homeland security. XBRM is a division of ALLSector Technology Group, Inc., a New York based full service technology consulting company offering systems integration, managed services and applications development and implementation. ALLSector Technology Group, Inc. is a subsidiary of the F∙E∙G∙S Health and Human Services System, one of the nation’s largest and most diversified not for profit organizations.
