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14 process, most feel that the application of debriefing methods The International Critical Incident Stress Foundation should not be the "default" mode for early interventions-- (ICISF) supports a model developed by Dr. Jeffrey Mitchell especially in light of findings that it caused harm for some in which a multiphase interaction with small groups and indi- individuals (Blythe & Slawinski, 2004; Rose et al., 2003; Rose viduals would proceed through a stepwise progression, with et al., 2005; van Emmerik et al., 2002). the support of trained psychologist and professional peers. While the authors of CISM claim its effectiveness, prospec- CISM in Aviation has been utilized by major groups in the tive clinical trials are lacking. Without evidence to show its aviation industry, including airport personnel, air traffic con- effectiveness over that of the natural course of the disorder, trollers, airlines, and pilot groups. which includes spontaneous recovery for some individuals, its effectiveness, while inherent, is not scientifically verified. Research involves self reporting and the assessment of return Individual and Community to work data. While program satisfaction is noted, it has not Resilience and Exposure been correlated with improved performance or decreased to Traumatic Circumstances incidence of mental health complications, such as PTSD. It is interesting that so much of the research on disaster Statements regarding prevention of stress complications were recovery has focused on risk or vulnerability factors related not supported with data in their publication. The process may to the development of psychopathology because the majority indeed be very promising, but clinical trials are needed to show of those exposed to traumatic circumstances do not go on to statistical significance in operator performance as a result of develop long-term problems. There has been less focus in the this program. literature on PTSD, trauma, and disaster recovery that relates Due to the fact that it may be impossible in the short term to the notion of "resilience." to conduct controlled studies on these early interventions, Bonnano, Galea, Bucciarelli and Vlahov (2006) investigated experts have come together to determine what we do know resilience following the September 11th World Trade Center about what helps people cope with trauma and how that can attacks. These authors defined resilience as the absence of be applied in disasters (Blythe & Slawinski, 2004; Hobfoll, 2007; psychopathology (i.e., 0 or 1 PTSD symptoms). The sampling International Society of Traumatic Stress Studies Resources, was taken from all adults residing in New York City and the 2008; WHO, 2006). surrounding areas, and occurred six months following the September 11th attacks. Overall 65% of the sample showed Treatment Strategies no evidence of PTSD. They found that the percentage of in- dividuals showing resilience decreased as the level of exposure Much of the literature that addresses workplace critical to the trauma increased, but that it never dropped below incidents refers to manuals that provide procedures, support 33%--even in the most severely exposed groups with the personnel, and guidance to manage the emergency (Federal highest rates of PTSD. Aviation Administration, 2008). These publications greatly Interestingly, as in previous work (Bonnano, Rennicke & assist individuals who may not recall proper procedures or Dekel, 2005), Bonnano et al. (2006) found that a "compound may make an incorrect decision in the chaos of an emer- exposure" or exposure to the event under two different cir- gency. With regard to personnel, publications and strategies cumstances (e.g., saw the attacks occur on September 11th and are also available to provide guidance on critical incident were involved in rescue efforts) resulted in decreased resilience. stress management programs with the goal of improving This has some important implications regarding the selection resiliency and decreasing psychological trauma and its asso- of who will be involved in rescue efforts or in terms of train- ciated complications. ing that focuses on increasing the stress resistance of those While reaching out to assist passengers, their families, who may have repeated exposure to traumatic events. and co-workers is a natural response in disasters, a wide Bonanno, Galea, Bucciarelli, and Vlahov (2007) investi- variety of techniques have been used. Single session debrief- gated variables that might predict psychological resilience ing (CISD) programs were used, and while they enjoyed a following mass disaster using a sample of adults with vary- high rate of satisfaction among the participants, the single ing levels of exposure to the attacks of September 11th. This session did not "prevent the development of negative psycho- study defined resilience in the same manner as earlier studies logical sequelae." These sessions may be useful in reduction with resilient individuals showing only 0 or 1 symptoms of of immediate distress and/or identification of individuals PTSD. They also included measures of depression and sub- needing further mental health support (van Emmerick, stance abuse in examining resilient outcomes. The variables et. al, 2002). of interest included the following: demographic variables

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15 (gender, ethnicity, education, age), measures of social and which may only show themselves when one is placed in a stress- material resources (material, interpersonal, energy, and work ful situation (Rutter, 1987). resources), and levels of life stress prior to and after the Hoge et al. (2007) suggest that it may be advantageous to traumatic event. Previous studies have shown many of these define resilience as modifiable factors that are inherent within variables to be correlates of increased risk for PTSD. the individual--noting that this could include environmen- First, Bonanno et al. (2007) found that resilient individu- tal factors in the sense that the focus is on how an individual als had lower levels of depression and substance abuse than interacts with the environment--utilizing or not utilizing those with mild to moderate trauma or PTSD. Female gender resources. These authors also suggest that resilience is almost was a robust predictor of decreased resilience, consistent with exclusively in retrospective experimental designs--measuring findings that female gender is a risk factor for PTSD. Older the characteristics of individuals who do not develop PTSD. age predicted resilience with those over age 65 years showing For example, they note that "avoidant coping style" is iden- significantly better resilience than young adults. Interestingly, tified as a factor that decreases resilience. Yet, avoidance is a this study found that higher education levels were associated primary sign of PTSD and thus retrospective studies cannot with decreased resilience. Decreases in income, decreases in tease out this factor as an inherent characteristic of an indi- perceived social support, and the presence of chronic disease vidual from the effect of traumatic stress itself. also predicted decreased resilience. Finally, people who had not A recent critical review of the research literature on resilience experienced traumatic events prior to September 11th, who identifies several methodological problems with some of the had no recent life stressors, and who had no additional trauma previous work in this area--much of which relates to what is following September 11th were more likely to exhibit resilience. meant by resilience, how it has been studied from a concep- Hoge, Austin and Pollack (2007) reviewed the literature tual standpoint, and what conclusions have been drawn from on resilience and how it is associated with the development and the implications of this previous work (Layne, Warren, of PTSD. Hoge et al. (2007) reviewed the focus of earlier Watson & Shalev, 2007). studies of resilience in children--identifying easy tempera- This research differentiates the terms "protective factor" ment, a warm relationship with an adult, social support, inter- (a measurable attribute that decreases the susceptibility for nal locus of control (self-efficacy), and positive self-esteem being negatively affected by adverse circumstances or stress- as important to longer-term resilience. The review of early ful events), "stress resistance" (the capacity to maintain adap- research on resilience in adults identifies a focus on the notion tive functioning during and after adverse circumstances), and of "hardiness"--considered a constant and stable personal "resilience" (the capacity to apply adaptive strategies early on resource (Kobasa, 1979). following an adverse event, such that one is able to bounce Many aspects of the notion of hardiness are consistent with back following a period of temporary decrease in adaptive other factors that had been identified earlier such as self-efficacy functioning). These authors specifically focus on differen- and an internal locus of control as well as a willingness to take tiating stress resistance from resilience. Secondly, and perhaps some risks or take on challenging activities. In their review, more importantly, they assert that both are "domain specific." these authors note that, in addition to those factors noted Specifically, in response to significant stress or trauma, a per- above, positive distancing (accepting the next best thing to son may be resilient and competent in one domain of func- what one wants), hope, optimism, religious behavior, a sense tioning (e.g., work) and at the same time show a deterioration of control, social support and active involvement in and main- of functioning in another domain (e.g., close interpersonal tenance of relationships, and psychological preparedness have relationships). They further emphasize that resilience is not been shown to be related to a greater sense of purpose as well simply the absence of overt psychopathology, but rather that a as structured training experiences. Finally, successful past person's adaptive functioning following a trauma or stressful experiences with previous stressors has also been identified as event is similar to their previous level of adaptive functioning. potentially protective, possibly increasing self-efficacy. These authors also indicate that although resilience refers Other researchers have also identified procedural problems to the notion of bouncing back after exposure to trauma, they in studying resilience. For example, Hoge et al. (2007) identify stress that people can expect to be changed in some ways by the difficulties of defining and characterizing the concept of exposure to traumatic circumstances and that the notion of resilience. Is it the "converse" of a risk factor? These authors returning to previous functioning is "unrealistic"--suggesting suggest that certain factors seem to be more likely to be related other ways of thinking about resilience such as "acceptance of to both risk and resilience (e.g., social support) while others loss" or a "positive adaptation to enduring or ongoing change" would not (e.g., the presence or absence of developmental (p. 515). delays, male vs. female gender). Others suggest that resilience What does previous work in the area of resilience report involves the notion of factors that "confer protection" and regarding application to real-world disaster recovery and

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16 interventions that emphasize resilience? In their extensive reinforce and build stress resistance. Such measures may be review, Layne et al. (2007) suggest that resilience-focused related to attempts to prevent the stressor from occurring interventions can "compliment" trauma-focused (i.e., reduc- (e.g., safety planning and disaster mitigation), building up tion of psychopathology/problem-focused) interventions. a reserve of tangible resources to be used in the event of a These authors indicate that resilience-focused interven- disaster, or building resistance to stress in those most likely tions could include identification of those at a higher risk for to have exposure to trauma (e.g., table-top training exercises; developing particular adverse outcomes due to particular learning how to analyze problems to determine an appro- combinations of risk, vulnerability, and protective variables. priate course of action). During or shortly after the trauma Interventions could target reduction in risk and vulnerability (the peri-trauma period) systematic measures could be taken factors as well as enhancement of protective factors. to enhance resilience (e.g., building self-efficacy, improving Another recommendation by these authors includes divid- ability to solve problems, improving the ability to evaluate risks ing events according to a timeline: pre-, peri- and post event in particular situations). Finally, during the post-trauma period, time periods. In this way, one could incorporate systematic interventions could target aspects of longer-term recovery in preventive measures during the pre-event period in order to those who do not "bounce back."