Mental Health and Mass Violence Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence A Workshop to Reach Consensus on Best Practices (cid:1) Recommended Citation: National Institute of Mental Health (2002). Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence. A Workshop to Reach Consensus on Best Practices. NIH Publication No. 02-5138, Washington, D.C.: U.S. Government Printing Office. Single copies of this report are available through: The National Institute of Mental Health Office of Communications and Public Liaison 6001 Executive Boulevard, Room 8184 Bethesda, MD 20892-9663 Telephone: 301-443-4513 and are available on line at: http://www.nimh.nih.gov/research/massviolence.pdf Mental Health and Mass Violence Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence A Workshop to Reach Consensus on Best Practices U.S. Department of Health and Human Services U.S. Department of Defense U.S. Department of Veterans Affairs U.S. Department of Justice American Red Cross Airlie Conference Center Warrenton, Virginia October 29-November 1, 2001 Table of Contents Acknowledgements ...................................................................................................... i Executive Summary .................................................................................................... 1 Introduction ................................................................................................................ 5 Implications ................................................................................................................. 5 Core Questions ............................................................................................................. 6 Areas of Consensus ..................................................................................................... 6 Key Operating Principles of Early Intervention ...................................................... 6 Guidance on Best Practices Based on Current Research Evidence .......................... 7 Key Considerations for Timing of Early Interventions ............................................ 8 Screening for Survivors ......................................................................................... 8 Follow-Up (For Whom and Over What Period of Time?) ........................................ 9 Expertise, Skills and Training for Providers of Early Intervention Services ............ 9 Research and Evaluation ..................................................................................... 10 Ethical Issues ...................................................................................................... 11 Key Questions to Address Within the Field of Early Intervention ......................... 11 Appendix A: Key Components of Early Intervention ................................................... 13 Appendix B: Guidance for Timing of Early Interventions ........................................... 15 Appendix C: Resource Organizations ......................................................................... 17 Appendix D: Glossary of Terms ................................................................................. 22 Appendix E: Training of the Early Intervention Workforce ........................................ 28 Appendix F: Additions and Dissenting Opinions ....................................................... 34 Appendix G: Intervention Literature Review Tables ................................................... 37 Appendix H: Measures .............................................................................................. 98 Appendix I: References ............................................................................................ 100 Acknowledgments We wish to thank the following individuals and organizations for sharing their time and expertise. Planning Committee Elspeth Cameron Ritchie, M.D., LTC, USA, Planning Committee Chair and Program Director, Mental Health Policy, Office of the Assistant Secretary of Defense Clete DiGiovanni, M.D., Psychiatrist, National Naval Medical Center Joye Whatley, MHSM, Department of Justice Matthew J. Friedman, M.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Farris Tuma, Sc.D., Chief, Traumatic Stress Program, National Institute of Mental Health Robert J. Ursano, M.D., Chairman, Department of Psychiatry, Uniformed Services University of the Health Sciences Patricia Watson, Ph.D., Deputy for Education and Clinical Networking, National Center for Post- Traumatic Stress Disorder, Department of Veterans Affairs Gregory Belenky, M.D., COL, USA, Director, Division of Neuropsychiatry, Walter Reed Army Institute of Research Connie L. Best, Ph.D., Professor, National Crime Victims Center, Medical University of South Carolina Robert DeMartino, M.D., CDR, USPHS, Associate Director, Program in Trauma and Terrorism, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration Thomas A. Grieger, M.D., CAPT, USN, Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences Susan E. Hamilton, Ph.D., Disaster Mental Health Services Associate, American Red Cross Kenneth Hoffman(cid:0)(cid:1)M.D.,(cid:1)COL,(cid:1)USA, Medical Director, Military and Veterans Health Coordinating Board Ann E. Norwood(cid:0)(cid:1)M.D., COL, USA, Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences Beverley Raphael, M.D., Centre for Mental Health, New South Wales, Australia James R. Rundell(cid:0)(cid:1)M.D., COL, USAF, Deputy Commander for Clinical Services, Landstuhl Regional Medical Center Josef Ian Ruzek, Ph.D., Associate Director for Education, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs James W. Stokes(cid:0)(cid:1)M.D., COL, USA, Combat/Operational Stress Control Program Officer, U.S. Army Medical Command Simon Wessely, M.D., Department of Psychological Medicine, King’s College London, and Institute of Psychiatry, London, U.K. Richard Jed Wyatt, M.D. (Deceased), Chief, Neuropsychiatry Branch, National Institute of Mental Health i Literature Review Tables and Coding System for Levels of Evidence Matthew J. Friedman(cid:0)(cid:1)M.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Laura Gibson(cid:0)(cid:1)Ph.D., National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Beverley Raphael(cid:0)(cid:1)M.D.,(cid:1)Centre for Mental Health, New South Wales, Australia Josef Ian Ruzek(cid:0)(cid:1)Ph.D., Associate Director for Education, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Paula P. Schnurr(cid:0)(cid:1)Ph.D., Deputy to the Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Patricia Watson(cid:0)(cid:1)Ph.D., Deputy for Education and Clinical Networking, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Simon Wessely(cid:0)(cid:1)M.D., Department of Psychological Medicine, King’s College London, and Institute of Psychiatry, London, U.K. Participants Gregory Belenky(cid:0)(cid:1)M.D.,(cid:1)COL, USA, Director, Division of Neuropsychiatry, Walter Reed Army Institute of Research Connie L. Best, Ph.D., Professor, National Crime Victims Center, Medical University of South Carolina Randy Boddam(cid:0)(cid:1)M.D.,(cid:1)COL, Director, Mental Health Services, Canadian Forces, Base Hospital, CFB Borden Richard Bryant, Ph.D., Associate Professor, School of Psychology, University of New South Wales, Australia Carl Andrew Castro(cid:0)(cid:1)M.D.,(cid:1)LTC, USA, Division of Neuropsychiatry, Walter Reed Army Institute of Research Joseph P. Chozinski(cid:0)(cid:1)M.D., LTC, USAF, Psychiatry Consultant to the U.S. Air Force Surgeon General Robert DeMartino(cid:0)(cid:1)M.D., CDR, USPHS, Associate Director, Program in Trauma and Terrorism, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration Clete DiGiovanni, M.D., Psychiatrist, National Naval Medical Center Charles C. Engel(cid:0)(cid:1)M.D., M.P.H., LTC, USA, Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences George S. Everly, Jr., Ph.D., Chairman Emeritus, International Critical Incident Stress Foundation Chip J. Felton, M.S.W., Associate Commissioner and Director, Center for Performance Evaluations and Outcomes Management, New York State Office of Mental Health Brian W. Flynn(cid:0)(cid:1)Ed.D., RADM, USN, Director, Division of Program Development, Special Populations and Projects, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration Matthew J. Friedman, M.D., M.P.H., Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Carol S. Fullerton, Ph.D., Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences Thomas A. Grieger(cid:0)(cid:1)M.D., CAPT, USN, Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences Fred D. Gusman, M.S.W., Director, National Center for Post-Traumatic Stress Disorder, VA Palo Alto Healthcare System ii Susan E. Hamilton, Ph.D., Disaster Mental Health Services Associate, American Red Cross Seth Daniel Hassett, M.S.W., Public Health Analyst, Emergency Services and Disaster Relief Branch, Center for Mental Health Services Kenneth Hoffman(cid:0)(cid:1)M.D., COL, USA, Medical Director, Military and Veterans Health Coordinating Board Harry Charles Holloway, M.D., Professor of Psychiatry and Neuroscience, Uniformed Services University of the Health Sciences Terence M. Keane, Ph. D., Director, Behavioral Science Division, National Center for Post-Traumatic Stress Disorder, VA Boston Healthcare System John S. Kennedy(cid:0)(cid:1)M.D., LCDR, USN, Staff Psychiatrist, Behavioral Healthcare Service Line, National Naval Medical Center Rayford Kytle, Writer/Editor, National Institute of Mental Health Laurent S. Lehmann, M.D., Chief Consultant, Mental Health and Behavioral Sciences, Department of Veterans Affairs Brett T. Litz, Ph.D., Associate Director, National Center for Post-Traumatic Stress Disorder, Behavioral Science Division, VA Boston Health Care System and Boston University School of Medicine David H. Marlowe, Ph.D., Senior Lecturer, Uniformed Services University of the Health Sciences Randall D. Marshall, M.D., Director of Trauma Studies and Services, New York State Psychiatric Institute, and Associate Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons Yuval Neria, Ph.D., Tel Aviv University, Columbia University Fran H. Norris, Ph.D., Professor, Department of Psychology, Georgia State University Ann E. Norwood(cid:0)(cid:1)M.D., COL, USN, Associate Professor, Department of Psychiatry, Uniformed Services University of the Health Sciences John M. Oldham, M.D., Director, New York State Psychiatric Institute Roderick J. Orner, Ph.D., Baverstock House, Lincoln, U.K. Virgil J. Patterson(cid:0)(cid:1)Ph.D., COL, USA, Social Work Consultant to the Army Surgeon General, U.S. Army Medical Department Center and School Kyle L. Pehrson(cid:0)(cid:1)D.S.W., COL, USAR, Reserve Social Work Consultant to the Army Surgeon General, U.S. Army Medical Command Betty Pfefferbaum, M.D., J.D., Chairman of Psychiatry, University of Oklahoma Health Sciences Center Jack Pierce(cid:0)(cid:1)M.D., CDR, MC, USNR, Clinical Program Officer, Headquarters, U.S. Marine Corps Robert S. Pynoos, M.D., M.P.H., Co-Director, National Center for Child Traumatic Stress, and Professor of Psychiatry, UCLA Department of Psychiatry Beverley Raphael, M.D., Centre for Mental Health, New South Wales, Australia Elspeth Cameron Ritchie(cid:0)(cid:1)M.D., LTC, USA, Program Director, Mental Health Policy, Office of the Assistant Secretary of Defense James R. Rundell(cid:0)(cid:1)M.D., COL, USAF, Deputy Commander for Clinical Services, Landstuhl Regional Medical Center Josef Ian Ruzek, Ph.D., Associate Director for Education, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Paula P. Schnurr, Ph.D., Deputy to the Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Gregory Smith, Vice President/Deputy Director, Disaster Services, American National Red Cross iii Arieh Y. Shalev, M.D., Professor and Head, Department of Psychiatry, Hadassah University Hospital, Israel Zahava Solomon, Ph.D., Professor and Director, The Adler Research Center, Tel Aviv University, Israel Anthony Speier, Ph.D.,(cid:1)Director, Division of Community Services, Louisiana Office of Mental Health James W. Stokes(cid:0)(cid:1)M.D., COL, USA, Combat/Operational Stress Control Program Officer, U.S. Army Medical Command Eric S. Swanson(cid:0)(cid:1)GYSGT, USMC, Operational Stress Control and Restoration Team, Staff Non- Commissioned Officer in Charge, Division Psychiatry, 2D Marine Division John R. Tassey, Ph.D., Clinical Psychologist, American Red Cross/VA Medical Center Farris Tuma, Sc.D., Chief, Traumatic Stress Program, National Institute of Mental Health Kathryn M. Turman, Deputy Director, Office for Victims of Crime, U.S. Department of Justice Robert J. Ursano, M.D., Professor and Chairman, Department of Psychiatry, Uniformed Services University of the Health Sciences Patricia Watson, Ph.D., Deputy for Education and Clinical Networking, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs Lars Weisaeth, M.D., Ph.D., Professor and Director, Defense Headquarters, Norway, Medical Staff Simon Wessely, Ph.D., Professor, Department of Psychological Medicine, King’s College London and Institute of Psychiatry, London, U.K. Joye Whatley, MHSM, Program Specialist, Office for Victims of Crime, U.S. Department of Justice Richard J. Wyatt, M.D. (Deceased), Chief, Neuropsychiatry Branch, National Institute of Mental Health Douglas Zatzick, M.D., Assistant Professor, Harborview Injury Prevention and Research Center, University of Washington TRW Systems Todd Trafford, Program Manager Bob Johnson, Operations Manager Jose Salazar, Logistics Support Bonnie Stephens, On-Site & Video Support Scott Henderson, Technical Editor Anne Saphara, Graphic Artist And many others from the Systems Analysis Directorate of Information & Technical Services Division. National Institute of Mental Health Editorial and Publications Staff(cid:1) Rayford Kytle, Writer/Editor Principal Authors and Editors Elspeth Cameron Ritchie(cid:0)(cid:1)M.D., LTC, USA, Program Director, Mental Health Policy, Office of the Assistant Secretary of Defense, Department of Defense Matthew J. Friedman(cid:0)(cid:1)M.D., Ph.D., Executive Director, National Center for Post-Traumatic Stress Disorder, Department of Veterans Affairs iv