Remarks as prepared; not a transcript

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
United States Surgeon General
U.S. Department of Health and Human Services

American Psychological Association Plenary Session

Saturday, August 9, 2003
Toronto, Canada

"Building Resilience: Psychologyís Role in Emergency Preparedness"

Thank you, Dr. Zimbardo, for that kind introduction. [Dr. Phil Zimbardo]

Thank you for your leadership of the American Psychological Association, and for all that you and your colleagues are doing to help Americans in these challenging times.

Iím pleased to be here in Toronto with you. Itís an opportunity to celebrate a public health success and to meet with experts on one of the topics that continues to drive me forward as Surgeon General.

The public health success is all over the news: Toronto has a clean bill of health.

The Centers for Disease Control and Prevention, as well as the World Health Organization, have removed Toronto from their travel alerts and their lists of SARS-affected areas.

This is a beautiful, safe city.

Just ask Mike Myers, who at some point is going to have to wash that "I Love Toronto" t-shirt heís been wearing on every talk show in America.

The Rolling Stones also gave Toronto some satisfaction last week. Today, it gives me great satisfaction to tell you that Iíve survived my first year as United States Surgeon General.

Last March President Bush announced that I was his nominee for this post, and one year ago this week, Congress unanimously confirmed that nomination. President Bush, Secretary Thompson, and many other elected leaders at the state and national levels have asked me to regularly address the importance of mental health issues, based on the best available science.

I have worked over the past year to reach out to others in federal and state government, as well as to colleagues in every health care profession.

Iíve also met with concerned educators, parents, large and small employers, and local community leaders.

I tell them that today, thereís no greater mental health issue facing us as a nation than emergency preparedness. Itís about building capacitance and resilience to handle emergencies and disasters.

Natural and man-made disasters, including wars and acts of terrorism, impact our entire nation, at every level:

  • The public as a whole, who are inundated with a 24-hour stream of front-line newsfeeds when disaster strikes. And the coverage isnít limited to local disasters in your hometown or state. This spring, tens of millions of Americans from all walks of life tuned in for hours on end to their favorite embedded reporter in Iraq.
  • Rescue and recovery workers and our servicemen and women, many who are today still in harmís way, may tomorrow have psychological effects.
  • And the families of our servicemen and women continue to endure long separations. This time is excruciating for moms, dads, husbands, wives, and children of servicemen and women, especially as they await any news of their loved ones.
  • And the most seriously affected ó the people who are seriously injured or who lose loved ones when disasters strike.
  • The reality is that the heightened awareness of terrorism concerns us all.

    What more Americans have come to understand is that terror isnít always at the hands of something called al-Qaeda ó but is also brought on by events with names like Hurricane Claudette, tragic incidents like The Station Nightclub fire in Rhode Island, and the shootings that continue to plague our nationís schools.

    Itís also the anticipation of disasters that never actually happen, but that are predicted, that can cause large-scale emotional and mental trauma.

    Thatís true whether the disaster is anticipated in our hometowns or in faraway places that we only experience through TV.

  • Itís the hurricane that never hits, but that we prepare for by boarding up the windows, closing down business, and leaving town.
  • Itís the tornado thatís predicted to hit our hometown, but somehow passes by.
  • Itís the fear of the next terrorist attack after September 11.
  • All these anticipated disasters take their toll, hanging over us like the Sword of Damocles.

    Like Ciceroís Damocles, itís easy for people to feel like thereís a threat hanging over their heads.

    For Damocles, that threat was a sword hanging by a single hair.

    For Americans today, even the very reasonable preparations that the government and others are making to minimize the possibility and effects of terrorism and natural disasters can cause some people to experience a heightened sense of anxiety, fear, and even impending doom.

    This is our new reality ó the new Sword of Damocles.

    We all know that our fighting forces are the greatest in the world, and that our nation is better prepared than ever before to prevent a terrorist attack.

    We also know that organizations like The Red Cross and FEMA are prepared to respond to any disaster. But the stress of terrorism, war, and natural disasters can lead to psychological challenges. All traumatic events bring intense reactions. Many bring personal upheaval.

    The message I am working to get out to all Americans is that we must be as vigilant about our mental and emotional health as we are about our physical health.

    Americans need to understand that they and their children may experience some psychological challenges ó and that beyond talking through these fears and concerns with their usual support groups of family; friends; and their church, synagogue, or mosque family, additional help is available.

    Help is Available

    There is help in the form of reliable information about how to cope with mental health concerns. Groups such as the APA, as well as academic institutions and other organizations have excellent resources so people can quickly get useful advice for coping.

    The Department of Health and Human Services recently launched a new section on the HHS web site. Itís focused on Mental Health and Traumatic Events.  The site offers a wealth of materials and tips on ways to deal with exposure to traumatic events, including violence, terrorism, and war. 

    It includes citizen-centered information for a variety of audiences, including first responders, children, parents, and teachers. The information can be found at

    You may also be familiar with HHSí efforts to strengthen state and local efforts in all-hazards preparedness and response. Last month, the Substance Abuse and Mental Health Services Administration, or SAMHSA, announced cooperative agreements with 35 states to enhance capacity for responding to the mental health needs that states may have in the aftermath of large-scale emergencies. These grants, which SAMHSA hopes to extend to all states and territories next year, are for mental health preparedness effortsóranging from planning to training and technical assistance.

    And APAís Disaster Response Network, or DRN, is a national network of psychologists with training in disaster response. The DRN is a partnership with the American Red Cross. With one phone call to the APA, the Red Cross can be sure that specially trained psychologists in the local area are mobilized to respond to any disaster.


    In addition, research in the area of mental health preparedness is strong and encouraging.

    Mental health researchers, including many with HHSís National Institute of Mental Health, are studying the reactions that occur in a time of crisis or terror.  Weíve studied the reactions of people following the Oklahoma City bombing; wars; and natural disasters such as tornadoes, floods, and fires.

    Most people have intense feelings after a traumatic event.  Many will completely recover from the trauma. Others are more vulnerable, especially those who have had previous traumatic experiences, and will need additional help.

    Findings of mental health studies in this country and other countries that have had extensive wars or crises indicate that people are amazingly resilient.

    We are currently working with our colleagues in Israel and Ireland to better understand how their populations have built and maintained mental health resilience in the face of tremendous traumas.

    Today I will address your professionís role in helping Americans build and maintain resiliency.

    There have been new challenges for all of us since September 11, 2001.  We are living in a world of elevated risk.

    But this isnít the first time in our history that your profession has been called to special duty.

    Roots of professional psychological practice

    After World War II, the Veteranís Administration became a major employer of psychologists. Clinical skills were urgently needed for treating the thousands of post-war traumas of returning servicemen and women.

    From that experience came recognition that psychologists had the skills to help with a broad range of life problems ó not just those of severely disturbed. Psychologists started private practices to meet the needs of a broader range of patients. States, cities, and counties established community mental health centers. Thatís when we began moving toward an era of new understanding of the role of psychological well-being in individual and public health.

    Weíre at a time again in our history when your expertise is paramount to our nationís health.  We need you to help build the resilience of our nation.

    Challenge of building the resilience of a nation

    APA is already communicating the new three Rs: readiness, recovery, and resiliency, and has developed a list of "10 Steps for Resilience in a Time of War."

    The steps ranging from "Give yourself a news break" to "Help yourself by helping others," which reminds us that assisting others in a time of need can be beneficial.

    Iím glad that APA suggests volunteering at a community organization or helping families of military personnel. Thatís the kind of pulling together that we all need to stay healthy.

    And just in time for back-to-school, APA will launch the youngest member of the "Road to Resilience" campaign next monthó"Resilience for Kids & Teens." The campaignís message is that resilience can be learned. It is couched in kid-friendly terms and will reach millions of schoolchildren and their teachers.

    Developing mental and emotional resilience helps kids and parents by building the skills to better handle stress, uncertainty, and trauma.


    Through initiatives like this, APA, HHS, The Red Cross, and many other professional organizations, corporations, and academic institutions are making great strides in building Americansí capacitance and resilience.

    These are important collaborations. Keep working together to examine and enhance capacity to provide psychological treatment before, during, or after disasters.

    Today, Iím here to ask all of you as professional psychologists, as well as your colleagues throughout the mental health professions, to continue researching, planning, and implementing mental health preparedness programs and campaigns, and to specifically consider the mental health effects of disasters on three groups:

  • First, the public. This includes two particularly vulnerable groups ó the previously traumatized and the homeless.
  • Second, emergency first responders and servicemen and women, and
  • Finally, the people who are seriously injured or who lose loved ones when disasters strike.
  • In addressing these three groups of people, one of the first things we all recognize is that images of disasters and emergencies are everywhere through the ubiquitous media.

    When people are constantly exposed to these images and thereís no respite, fear builds up until it becomes an individualís primary emotion.

    We know that fear is critical to survival because it readies the body for danger. Physiologic responses include the activation of the sympathetic nervous system, which increases heart rate, blood pressure, and blood flow to muscles, and the release of stress hormones such as cortisol, which make energy available.

    While this physiologic response is highly adaptive in response to a short-term emergency, it has harmful effects on the body if it becomes chronic.

    Automatic behaviors are best known in "prey animals," such as deer or rabbits, which freeze.

    This is an adaptive response because the vision of most predators is tuned to detect motion. (Of course, freezing is not so adaptive in a world of automobiles.)

    Psychologic responses are also powerful in facilitating memory formation. Trauma is effective at promoting "one-time learning."

    The survival benefits of this are clear. One will not put oneself in harmís way again.

    But this powerful memory system is also what makes the human brain vulnerable to post-traumatic stress disorder in which an excessive trauma usurps this powerful memory system to produce chronic psychiatric symptoms.

    The value of fear is to permit rapid adaptive responses to transient threats. Terrorism acts to create a sense that the world is not safe and to make people chronically afraid. It aims at undercutting coping abilities.

    A question that Iím often asked is "Why does terrorism work? The numbers of individuals killed by terrorism have been relatively small. Terrorism works because terrorists exploit two aspects of human nature:

  • First, because novel, unpredictable and uncontrollable dangers are extremely stressful.
  • Second, we as human beings empathize with others. Indeed part of the survival value of emotions comes from the fact that they are "contagious."
  • Thus when we see or read personalized descriptions of those who are being victimized, the normal human response is to identify with their situation, and not to do a dispassionate risk analysis.

    Fear is contagious person to person even if anthrax is not! Terrorists exploit our negative response to uncontrolled situations.

    What we need to do in the wake of terrorist incidents is to develop coping strategies that will allow us as a nation to reassert control over circumstances.

    Coping strategies include:

  • Achieving progress in shoring up the professions, like psychology, and all other aspects of the public health infrastructure so that our nation can respond to further attacks effectively, and
  • Communicating with the public to make sure that people are aware of this progress.
  • PTSD

    Psychologists also need to be prepared to help first responders and direct victims of terrorist attacks.

    Post traumatic stress disorder is a risk faced by first responders and people who are the victims of trauma. Itís also a threat to servicemen and women:

  • An estimated 5.2 million American adults ages 18 to 54 have PTSD.
  • About 30% of Vietnam veterans developed PTSD at some point after the war. The disorder also has been detected among veterans of the first Persian Gulf War, with some estimates running as high as 8%.
  • More than twice as many women as men experience PTSD following exposure to trauma.
  • Depression, alcohol or other substance abuse, or other anxiety disorders frequently co-occur with PTSD. The likelihood of treatment success is increased when these other conditions are appropriately diagnosed and treated as well.
  • We know from our experiences in wars and disasters that while immersed in the traumatic situations, most soldiers, sailors, and first responders do very well. Their training takes over.

    After I returned home to New York from Vietnam, I didnít experience PTSD. But it did take me a while to re-integrate.

    The military does a good job of watching out for people who are exhibiting problems, but a lot of servicemen and women donít exhibit problems. That doesnít mean that they arenít hurting, or that they donít need help. It means that they need someone to reach out to them.

    Friends and family and the soldier or sailorís other support networks need to understand that they are coming back a different person than who they were when they left.

    Many of our fighting men and women are returning from hell on earth. There may be scenes going through their minds that ó although theyíre trying to them shut off ó just keep replaying.

    When I came back from Vietnam, I really only wanted to associate with people who had the same experience of going to war. Over time, and through good talks with friends and family, I bounced back to wanting to be with all kinds of people. Iím thankful that my upbringing had instilled me with a certain resilience, so that I could get on with my education, get married, and live life.

    Psychologists, especially any who through private or community practice have the opportunity to work with first responders and returning servicemen and women, need to be mindful of the symptoms of PTSD and be prepared to treat it.

    I often speak to groups of disabled Veterans and law enforcement officers who were injured on the job. They are incredibly brave men and women, true inspirations to me. One of the things we talk about was that the toughest battles arenít always on the battlefield or on the street. Sometimes the toughest battles are right here. <<< POINT TO HEAD. >>>

    Some of the men and women who are coming home from Iraq and Afghanistan will need a lot of physical rehabilitation, and some emotional and mental rehab as well. Some will need to see and feel hope again. As psychologists, you can help them.

    Issues for Children
    It can be a dilemma for parents: How do you shield a child from the horrors of war when its images are everywhere ó TV, newspapers, and the Internet?

    We all need keep talking about the importance of mental health. We cannot allow this to become the forgotten wound. For anyone, including our children.

    My advice to parents, grandparents, teachers, and everyone who takes care of children is to:

  • Limit childrenís exposure to televised images of violence on the news;
  • Talk with children to find out their level of understanding;
  • Reassure children that they are safe;
  • Increase family time; and
  • Take care of yourself. Keep as much as possible to your normal routine. Try to eat and exercise and sleep in your usual way. If you are okay, those who depend on you will do better. Like the emergency oxygen masks in the airplane ó put yours on first.
  • Depression

    Finally, I want to ensure that we talk about depression. When people suffer losses, or when they see the images on television of disasters at home and throughout the world, itís possible to become overwhelmed by anxiety and sadness.

    The Surgeon Generalís Report on Mental Health suggested that depression is one of the leading disabilities worldwide. (1999 report)

    Health threats from depression include increased rate of stroke, diabetes, heart disease, and osteoporosis. Women are twice as likely as men to be depressed, although men suicide four times as often as women.

    In 2002, there were 30,000 suicides in the United States. Thatís twice the number of homicides. The majority of those suicides were men. Those are preventable deaths, and you can help prevent them.

    Like women, men suffer emotional trauma from divorce, death, and work or family challenges. We are not so willing as women to say, "Iím hurting. I need help."

    As someone who is ex-Army Special Forces, an ex-cop, ex-paramedic, and a trauma surgeon, I can tell you that for generations, men like me have been told that we have to "act tough."

    Through the National Institute of Mental Health launched a public education campaign called "Real Men, Real Depression." It says to men, "Itís okay to talk to someone about what youíre thinking, or how youíre feeling, or if youíre hurting."

    The campaign includes video spots featuring real men who tell their stories. The basic messages are that any man can have depression, that depression is treatable, and that recovery is possible.

    Three of the men featured in the campaign were first responders. One, a firefighter, was among those who ran into the World Trade Center.

    The "Real Men, Real Depression" campaign was released in April 2003. A special website, e-mail address, and phone lines have received thousands of calls from men and their families asking for information and help for depression.

    The good news is that 80% of people with depression respond to treatment. Depression is an illness that we can treat, but unfortunately, we donít treat. You can change that. With help, many people will eventually feel better.

    We need to keep communicating that if someone continues to feel depressed, upset, worried, or fearful over time it is important to seek help, just as you would if you had another chronic health condition.

    There is help available from psychologists, and other mental health professionals, as well as through primary care professionals and religious leaders.

    Charge and Closing

    I consider psychology an equal partner with all the other health professions at the table as we approach these challenges before us.

    In the future, I will call on you for assistance, guidance, and expertise. Let us know how you can best serve your country.

    This is a time of great tests for Americans, including mental and emotional tests.

    Together we will make sure that not only every broken bone has a chance to heal, but that every broken spirit has a chance to soar.

    This wonít be done in a day, it wonít be done in a year, but the hurt will heal, and hope will see us through.


    Last revised: January 9, 2007