Fluent Essays

Acts of terrorism are intended to have an impact far beyond the death and destruction of the immediate attack. Mass fear and interruptions to normal daily functioning occur in the aftermath of terrorist attacks, like concentric surges that erupt when dropping a boulder in a mill pond. When terrorism and violence are systemically directed toward ethnic cleansing or intentional destruction of a national, ethnic, racial, tribal, or religious group, it is considered genocide. Terrorism and genocide can also disrupt the social and economic functioning of neighboring countries that must contend with refugees. National and international bodies that choose to counteract terrorism and genocide with economic sanctions, military actions, or humanitarian interventions can also face repercussions. Bronfenbrenners Ecosystemic Model for Crisis (James, 2013, p. 657) illustrates the following: that which impacts the international macrosystem (e.g., world culture, United Nations, international media) affects the mesosystems (e.g., neighborhoods, churches, police) and microsystems (e.g., individuals, families), as well.To prepare for this Discussion:Think about how various acts of terrorism and genocide might affect behavioral patterns, traditions, and beliefs of impacted populations.With these thoughts in mind:By Day 4Post an explanation of the global (macrosystem) impact of terrorism or genocide. Be sure to provide at least one specific example of terrorism or genocide that supports your explanation.Be sure to support your postings and responses with specific references to the Learning Resources. mental__and_physical_health_effects_of_acute_exposure.pdf assessment_a_developmenta_eco_perspective.pdf anticipated_attitudes_for_providing_psychological_services.pdf Unformatted Attachment Preview 460406 research-article2013 PSSXXX10.1177/0956797612460406Silver et al.Media Exposure to Collective Trauma Research Article Mental- and Physical-Health Effects of Acute Exposure to Media Images of the September 11, 2001, Attacks and the Iraq War Psychological Science 24(9) 1623­–1634 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0956797612460406 pss.sagepub.com Roxane Cohen Silver1, E. Alison Holman2, Judith Pizarro Andersen3, Michael Poulin4, Daniel N. McIntosh5, and Virginia Gil-Rivas6 1 Department of Psychology and Social Behavior, University of California, Irvine; 2Program in Nursing Science, University of California, Irvine; 3Department of Psychology, University of Toronto-Mississauga; 4Department of Psychology, University at Buffalo; 5Department of Psychology, University of Denver; and 6Department of Psychology, University of North Carolina, Charlotte Abstract Millions of people witnessed early, repeated television coverage of the September 11 (9/11), 2001, terrorist attacks and were subsequently exposed to graphic media images of the Iraq War. In the present study, we examined psychologicaland physical-health impacts of exposure to these collective traumas. A U.S. national sample (N = 2,189) completed Web-based surveys 1 to 3 weeks after 9/11; a subsample (n = 1,322) also completed surveys at the initiation of the Iraq War. These surveys measured media exposure and acute stress responses. Posttraumatic stress symptoms related to 9/11 and physician-diagnosed health ailments were assessed annually for 3 years. Early 9/11- and Iraq War–related television exposure and frequency of exposure to war images predicted increased posttraumatic stress symptoms 2 to 3 years after 9/11. Exposure to 4 or more hr daily of early 9/11-related television and cumulative acute stress predicted increased incidence of health ailments 2 to 3 years later. These findings suggest that exposure to graphic media images may result in physical and psychological effects previously assumed to require direct trauma exposure. Keywords September 11, Iraq War, terrorism, media, television, acute stress symptoms, posttraumatic stress symptoms, physical health Received 1/26/12; Revision accepted 8/14/12 Mass media turn local disasters into national and global events. This widespread exposure generates an outpouring of philanthropy (Chochinov, 2005). But the media also transmits the negative impact of disasters to people far beyond those directly exposed (Vasterman, Yzermans, & Dirkzwager, 2005; Wright, Ursano, Bartone, & Ingraham, 1990). In such cases, vicariously experienced events can become collective traumas. For example, although tens of thousands of individuals directly witnessed the September 11 (9/11), 2001, terrorist attacks, millions more viewed the attacks and their aftermath via the media. Indeed, a survey conducted in 2012 found 9/11 to be the most impactful event experienced by television viewers over the past 50 years, almost twice as impactful as the second-ranked event (Bauder, 2012). When war was initiated in Iraq 18 months after 9/11, international media provided unprecedented graphic images of hostilities. The potentially detrimental mental-health impact of media exposure to violence or disasters has concerned many commentators. Research conducted among children after the Oklahoma City bombing (Pfefferbaum et al., 2001) and the 1990 Gulf War (Cantor, Mares, & Corresponding Author: Roxane Cohen Silver, Department of Psychology and Social Behavior, 4201 Social & Behavioral Sciences Gateway, University of California, Irvine, CA 92697-7085 E-mail: rsilver@uci.edu Silver et al. 1624 Oliver, 1993) found relations between television exposure and trauma-related symptoms. Television exposure to 9/11 and psychological symptomatology were associated in cross-sectional studies among New York residents (Ahern et al., 2002; Bernstein et al., 2007) and in U.S. national samples (Butler et al., 2009; Schlenger et al., 2002; Schuster et al., 2001). The impact of 9/11 even crossed the Atlantic: London schoolchildren who witnessed the attacks on television reported posttraumatic stress symptoms and functional impairment during the 6 months following 9/11 (Holmes, Creswell, & O’Connor, 2007), and authors speculated that the observed decline in subjective well-being in the United Kingdom after 9/11 resulted from extensive worldwide media coverage of the attacks (Metcalfe, Powdthavee, & Dolan, 2011). Exposure to traumatic events may affect physical as well as mental health (Schnurr & Green, 2004), even among individuals indirectly exposed to collective stressors (Holman et al., 2008; Shedd et al., 2004). Among women who were pregnant during 9/11, population studies documented deleterious birth outcomes across the United States (Bruckner, Catalano, & Ahern, 2010) and The Netherlands (Smits, Krabbendam, de Bie, Essed, & van Os, 2006), and Iraq War media coverage predicted harmful physical- (and mental-) health outcomes among a sample of Iraqi refugees in the United States (Kira et al., 2008). Researchers have emphasized the need for longitudinal examination of the media’s role—and of graphic images specifically—in mental-health outcomes following traumatic events (Cantor, 2002; Putnam, 2002; Vasterman et al., 2005). Although experimental research has demonstrated that exposure to traumatic film images can induce intrusive emotional memories (Holmes & Bourne, 2008), the extant body of cross-sectional data collected outside the laboratory cannot clarify whether distress increases exposure or vice versa. Only prospective longitudinal studies can begin teasing apart the direction of this relationship. We speculate that repeated exposure to vivid traumatic images in the media may result in a stress response (Bovin & Marx, 2011) sufficient to trigger physiological processes that increase the risk of developing health ailments over time (McEwen, 1998; Schnurr & Green, 2004)—physiological processes distinct from the known associations between media exposure and health-risk factors, such as a sedentary lifestyle and poor dietary choices (Hancox, Milne, & Poulton, 2004). We conducted a 3-year longitudinal study of mentaland physical-health outcomes among a national probability sample of Americans primarily exposed to the 9/11 attacks through the media. Our study included assessments of respondents’ mental- and physical-health history collected before the attacks, media exposure, and acute stress responses collected immediately after 9/11 and at the initiation of the Iraq War, and three annual follow-up assessments. We hypothesized that repeated exposure to graphic media content would be associated with increased acute stress symptoms, subsequent posttraumatic stress, and physical-health ailments over time, controlling for potential confounds (demographics, pre9/11 mental and physical health, and lifetime adversity). We also examined whether repeated media exposure to collective traumas has a cumulative effect on health. Method Sample and procedures Data were collected via Internet-based surveys using a sample drawn from a national probability panel of the U.S. population recruited using stratified random-digitdial telephone sampling and maintained by Knowledge Networks (Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002; Silver et al., 2006). To ensure representation of all population segments, Knowledge Networks provides Internet access, or other compensation (e.g., points for merchandise) if the household is already Web enabled, in return for the completion of 3 to 4 monthly surveys. The panel follows the distribution of U.S. Census population counts on demographic variables. Survey responses are confidential, with identifying information never revealed by Knowledge Networks. Panel members receive notice in their password-protected e-mail account that a survey is available for completion. Surveys are self-administered, accessible for a designated period, and can be completed only once. Media exposure and acute stress symptoms were assessed 9 to 14 days after 9/11 for the majority of the sample and 8 to 18 days after the Iraq War began for the entire sample. Self-reports of physician-diagnosed mental and physical ailments were assessed before 9/11 and 1, 2, and 3 years after 9/11. Posttraumatic stress symptoms related to 9/11 were also assessed 1, 2, and 3 years after 9/11. The study design and dates of survey administrations are described in Table 1. The survey administered in the weeks following the 9/11 attacks was fielded to 3,496 individuals; 78\% completed it (n = 2,729), with more than 75\% doing so within 9 to 14 days after the attacks. For each annual follow-up, responses were obtained only from available respondents from the original sample of 2,729 (some respondents had died or left the Knowledge Networks panel and declined further participation). For the Year 1 follow-up survey, responses were received from 2,033 individuals out of 2,729 who were contacted (74.5\%). For the Year 2 follow-up survey, responses were received from 1,571 individuals out of 2,123 who were contacted (74\%, or 57.6\% of the original sample of 2,729). For the Year 3 follow-up survey, Media Exposure to Collective Trauma 1625 Table 1. Study Design: Measures Collected at Each Time Point of the Study Measure Acute stress Media exposure Physician-diagnosed mental health Physician-diagnosed physical health Posttraumatic stress symptoms Pre-9/11 survey (N = 2,592) September 2001 Post-9/11 survey (N = 2,729) September– October 2002 Annual Survey: Year 1 (N = 2,033) March 2003 Iraq War Survey (N = 1,349) September– October 2003 Annual Survey: Year 2 (N = 1,571) September– October 2004 Annual Survey: Year 3 (N = 1,771) — — X X X — — X X X X — — — X — — X X — X — X X — — X — X X Note: Prior to September 11 (9/11), 2001, Knowledge Networks administered a health survey. Responses to the post-9/11 survey were obtained between September 20 and October 4, 2001. Data for the Year 1 post-9/11 follow-up survey were collected between September 20 and October 24, 2002. Data for the Year 2 post-9/11 follow-up survey were collected between September 12 and October 31, 2003. Data for the Year 3 post9/11 follow-up survey were collected between September 12 and November 2, 2004. The Iraq War survey was fielded between March 27 and April 6, 2003. responses were received from 1,771 individuals out of the 2,242 who were contacted (79\%, or 64.9\% of the original 2,729). Data for the Iraq War survey were collected over 10 days from a random subset (n = 1,800) of the respondents from the Year 1 follow-up survey. All procedures for this study were approved by the institutional review boards of the University of California, Irvine, and the University of Denver. Measures Demographics. Age, sex, marital status, ethnicity, education, and annual household income were provided by Knowledge Networks. Missing income values were imputed using a mean income score for the respondent’s census block. Direct exposure to the 9/11 attacks. On recruitment into our study, participants were asked about their degree of exposure to and loss from the 9/11 attacks. Individuals were grouped into three mutually exclusive categories (with priority placed on the highest level of exposure reported). The first category was direct exposure—being in the World Trade Center or Pentagon during the attacks, seeing or hearing the attacks in person, or having a close relationship with someone in the targeted buildings or airplanes. The second category was live media exposure—watching the attacks live on television. The third category was no live exposure—seeing or learning of the attacks only after they occurred. Media exposure to the 9/11 attacks. Media exposure to the 9/11 attacks was assessed at the first wave of data collection with the following question: “Since the terrorist attack, about how much time each day have you spent watching news footage about this on TV? Please give your best estimate for the first seven days after the attack.” A categorical variable was used (less than 1 hr per day, 1 to 3 hr per day, and 4 or more hr per day). Media exposure to the Iraq War. Media exposure to the Iraq War was assessed starting a week after the Iraq War began by asking respondents to indicate on a 5-point scale how frequently they had seen 16 progressively aversive war images (e.g., military equipment, bombs exploding, injured/dead soldiers). These items were modeled after items on the Escobar Combat Intensity Scale (Escobar et al., 1983). The mean of these items served as an index of war-related media exposure. Scale items were also analyzed individually to identify the specific images associated with outcomes. In addition, respondents provided the average number of hours per day they spent watching war-related television coverage. These items were coded similarly to the items related to 9/11-related television watching (less than 1 hr per day, 1 to 3 hr per day, and 4 or more hr per day). Acute stress responses to the 9/11 attacks and the Iraq War. Acute stress symptoms were assessed after 9/11 using a modified version of the Stanford Acute Stress Reaction Questionnaire (SASRQ), which measures symptoms of acute stress disorder (ASD; see Cardena, Koopman, Classen, Waelde, & Spiegel, 2000, for reliability and validity information). Respondents reported whether they experienced or did not experience stress symptoms related to 9/11. Following criteria from the fourth edition Silver et al. 1626 of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association, 1994), we created two scores—mean acute stress symptoms and high versus low acute stress—using ASD Criteria B (three or more dissociative symptoms), C (one or more reexperiencing/intrusive symptoms), D (one or more avoidance symptoms), and E (one or more arousal/anxiety symptoms); respondents meeting all four criteria were coded as having high acute stress. Because most respondents did not meet DSM–IV Criterion A (direct exposure) and symptom duration was not assessed, respondents were not assumed to have ASD. Acute stress responses to the Iraq War were assessed using the original SASRQ focused specifically on reactions to the war. Items were classified so that symptoms experienced at least “sometimes” on the 6-point scale were considered positive. Continuous and dichotomous acute-stress indices were computed as described above. A cumulative index of collective acute stress was created from the dichotomous 9/11-related and Iraq War–related acutestress scores (0 = never had high acute stress, 1 = had high acute stress after either 9/11 or the beginning of the Iraq War, 2 = had high acute stress after both events). (e.g., asthma, hypertension) or mental-health ailments (i.e., anxiety disorder, depression) and provided smoking status, height, and weight (to calculate body mass index, or BMI). The number of pre-9/11 physician-diagnosed physical-health ailments (0–33) and mental-health ailments (0–2) were computed as baseline assessments. Three follow-up health surveys, patterned after the pre9/11 assessment, were administered to all available respondents annually (Holman et al., 2008). Missing-atrandom tests for physician-diagnosed ailments were nonsignificant (ps > .10), so missing data were imputed within age groups using expectation-maximization methods (Little & Rubin, 1987). Respondents’ tendency to somatize was also assessed annually using the Brief Symptom Inventory 18 somatization subscale (Derogatis, 2001). Posttraumatic stress symptoms related to 9/11. The PTSD Checklist Civilian (PCL-C), a reliable 17-item screening tool for posttraumatic stress disorder (PTSD), was administered annually to assess prior-week 9/11-related symptoms of posttraumatic stress (see Weathers, Litz, Herman, Huska, & Keane, 1993, for reliability and validity information). A standardized mean score and dichotomous index of high versus low posttraumatic stress using DSM–IV PTSD Criteria B (one or more reexperiencing symptoms), C (three or more avoidance symptoms), and D (two or more arousal symptoms) were created. For dichotomous scores, only symptoms that were reported as being at least moderately distressing were considered positive (i.e., 2 on a scale from 0 to 4); respondents meeting all three criteria were coded as having high posttraumatic stress. Because we did not assess all DSM–IV criteria (e.g., duration of symptoms) and most respondents were not directly exposed, they were not assumed to have PTSD. The base sample for this report included respondents with 9/11-related exposure and acute stress data (N = 2,189). The analysis predicting 9/11-related acute stress used this full sample. As all subsequent analyses included data from the Iraq War survey, only Iraq War–survey respondents with 9/11-related exposure and acute-stress data (n = 1,322) were used. Stata data analysis and statistical software (Version 10.0; StataCorp, College Station, TX), which handles weighted complex longitudinal survey data and provides necessary standard-error adjustments, was used for analyses. Data were weighted to adjust for differences in probabilities of selection and nonresponse. Poststratification weights were calculated using demographic combinations to make the weighted sample cells match the data from the U.S. census (U.S. Census Bureau, 2001) and Knowledge Networks panel. Predictors of low versus high acute stress following 9/11 and the initiation of the Iraq War were examined with survey logistic regression. We used separate survey linear and Poisson regressions to examine media variables as predictors of posttraumatic stress and physicalhealth ailments at 2 and 3 years after 9/11, controlling for pre-9/11 health. Generalized estimating equations (GEEs) were then used to test predictors of posttraumatic-stress scores and physician-diagnosed physical ailments in multivariate models over time (2–3 years after 9/11). GEE explicitly models the contribution of time to longitudinal outcomes and minimizes the number of tests conducted, thereby strengthening our confidence in estimating the Pre- and post-9/11 physical- and mental-health status. Prior to 9/11, Knowledge Networks administered a health survey assessing physician-diagnosed mental- and physical-health ailments. This survey was modeled after and validated against the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics annual National Health Interview Survey (NHIS; U.S. Department of Health and Human Services, 2000). Respondents reported whether a physician had ever diagnosed them with any of 35 physical-health ailments Adverse life events. At the time of recruitment and annually, participants reported whether they had experienced any of 37 stressful events (other than 9/11; e.g., physical assault). The number of lifetime and post-9/11 adverse events was computed. Overview of analyses Media Exposure to Collective Trauma unique contribution of media viewing. Temporally separate assessments of predictors (before 9/11, 2–3 weeks after 9/11, 12 and 18 months after 9/11) and outcomes (2–3 years after 9/11) prevented confounding from simultaneous measurement. This allowed prospective evaluation of 9/11- and Iraq War–related media exposure and cumulative event-related acute stress in relation to the onset of posttraumatic stress symptoms and health ailments. Analyses were repeated using continuous mean acute stress symptoms reported after 9/11 and the Iraq War; findings were consistent with those reported here. Individual regression and GEE analyses produced similar findings unless indicated. Because the rates of meeting DSM–IV PTSD-related Criteria B, C, and D were minimal (< 5\% of the sampl ... Purchase answer to see full attachment