Helping Airport and Air Carrier Employees Cope with Traumatic Events (2009)

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3Introduction Disaster recovery in the aviation industry can have a dra- matic mental health impact upon the personnel involved in the incident, as well as a wide range of people who assist in the investigation and recovery efforts after the incident. The pur- pose of this research project is to develop a resource manual to assist airport and air carrier organizations in the manage- ment of psychological trauma related to aircraft accidents, terrorist acts, or natural disasters. This effort is also aimed at further understanding and fostering human resiliency— the ability for a person to recover after a psychological set- back and to resume their near normal level of performance. Catastrophic and human-based accidents are infrequent occurrences in the transportation industry, nonetheless it is imperative that organizations and their employees are pre- pared to handle the physical situation of a large-scale disaster, as well as the mental health considerations that may follow. This research project examines an aviation organizations’ ability to promote human resiliency and to provide guidance for those organizations to develop procedures and prepare for the impact of natural and man-made disasters they may one day face. The industry recognizes a variety of people who have experienced traumatic events, and this resource manual aims to educate organizations regarding the issues, findings, and guidance and appropriate assistance within the organiza- tion or region. The goal of this research is to prepare direc- tors of airports and air carriers for the mental health recovery of employees, who have faced a traumatic event, and to pro- mote and improve practices for employees’ ability to success- fully cope with such an event and build resilience. The lack of training can have a significant effect on the health and well- being of an individual, and may have legal implications for an employer, so careful planning and mitigation strategies need to be formulated for the longevity of any organization. The following is a short excerpt from a field interview: I am an analyst for the airline, and when I heard that one of our airplanes had crashed, I called my supervisor at the hub and asked what I could do. . . . In moments he called me back, told me to go get the ‘crash kit’ and head out to the scene. The crash kit was on a pallet in a storage room and I had to bring it to the scene with a front loader, and it turned out to be filled with body bags and toe tags. . . . I was not prepared for what I saw at the scene and still think about it today. . . . The limitation of this paper regards the ability to make specific recommendations that apply to all situations, for individuals and organizations alike. Treatment programs for individuals recovering from mental health trauma are best designed by the professionals providing their care. Likewise, specific mental health recovery plans need to be tailored to each organization, as a function of their size, resources, and type of trauma. There are many types of traumatic events than an aviation employee may encounter; those can be, but are not limited to: disease, workplace violence, an aircraft incident/or accident, an actual aircraft crash, terrorism, or a single ramp event. For the purpose of their guidebook, a traumatic event could mean any of the listed examples. Background According to the FAA’s 2008-2012 Flight Plan, “our skies are safe,” the industry has achieved an incredibly low rate of commercial (airline) fatal accidents. In the past ten years the accident rate has dropped 57 percent. The FAA has imple- mented many new and enhanced safety initiatives in the past years with the hope of achieving the lowest rate practical. Man-Made Disasters In 2007, the National Transportation Safety Board (NTSB) reported a reduced accident rate in commercial airline oper- ations (Part 121). There were 24 non-fatal accidents. One C H A P T E R 1 Introduction and Background

fatality occurred on a non-Part 121 operator. The rate of general aviation accidents rose from 1,518 in 2006 to 1,631 in 2007; however the number of fatalities was down by 30 percent, the lowest in the last 30 years (NTSB, 2008). The NTSB also reported no fatalities among Part 135 com- muter operators, with on-demand Part 135 operations at 43 fatalities, which are up from 16 reported in 2006. The NTSB reports, “The U.S. aviation industry has produced an admirable safety record in recent years, however we must not become complacent, we must continue to take the lessons learned from our investigations and use them to create even safer skies for all operators and passengers” (NTSB, 2008, p. 1). The aviation industry has inherent risk associated with it, which means that accidents will occur, but presently at a very low rate. The nation’s airlines transport nearly two million passengers per day and employ nearly half a million workers (Air Transport Association, 2007). According to the Air Transport Association’s (ATA) tes- timony to Congress, “In 2006, Part 121 carriers transported 750 million passengers more than eight billion miles and logged 19 million flight hours on 11.4 million flights. There were two fatal accidents in 2006 which claimed 50 lives. This is an accident yield rate of 0.18 per 1,000,000 departures which is down by 30 percent from 2005” (2007). This down- ward trend from the early 1990s appears to be continuing and it is hoped that air travel becomes an even safer mode of transportation. Natural Disasters Natural disasters disrupt thousands of lives each year and can do unimaginable damage in mere moments. Whether the disaster is fire, flood, hurricane, earthquake, or tornado, the threat is immediate to human life, but the recovery process is long term. Recently, Hurricanes Katrina and Rita bore down on the southern United States engulfing the states of Louisiana and Mississippi, forest fires have greatly impacted the west- ern United States, and tornadoes and floods have ravaged the Midwest. The National Oceanic and Atmospheric Administration (NOAA) has a process of forecasting such events and has installed warning systems throughout the United States. The NOAA attempts to utilize these systems and technologies to mitigate loss, such as the significant loss of life associated with the Great Hurricane of Galveston, Texas, that killed an esti- mated 8,000 people in 1900; or, the Johnstown flood of 1889, in which an estimated 2,000 people were killed. However, natural disasters still pose a threat to all communities, and the long term recovery associated with a natural disaster can be debilitating. In 1994, the Northridge earthquake in California is esti- mated to have cost over $23 billion, a flood in New Orleans in 1995 cost over $1.36 billion, the 1997 flood of the Red River Valley in North Dakota and Minnesota was estimated at $2 billion, and in 1999, 66 tornadoes ripped through Okla- homa, Kansas, Texas, and Tennessee costing nearly $1.5 bil- lion in recovery. In 2004 and 2005, Hurricane(s) Ivan, Frances, Charley, Katrina, and Rita claimed 2,139 lives, and the cost of recovery for the areas that were adversely affected will not be known for some time. The damage of these Hurricanes was felt from the east coast to Texas. The aviation industry is not immune to the effects of a natural disaster as the organizations involved may become instantly crippled, with effects felt throughout their local areas. However, airports and air transportation become a vital link to receiving needed supplies and restoring order by allow- ing disaster relief workers to begin their work. In the case of Hurricane Katrina, the New Orleans-Louis Armstrong International Airport was the staging point for all egress and ingress of the afflicted areas. The airport became the virtual lifeline to the people of southern Louisiana (Blanchard, 2008). Disaster Readiness Incident Command System The Incident Command System (ICS) is a nationally con- trolled set of procedures, constructs and operating practices which dictate synergistic principles between responding emer- gency agencies. The system was first established in the 1970s in various formats and has since become the de facto standard amongst all federal agencies. At the core of the system is the principle of command and control, wherein the first respond- ing agency maintains oversight and enacts other stabilizing pro- tocol until resolutions or transference to a more appropriate entity (National Response Team, n.d.) The key concepts included in the ICS are: Unity of Com- mand, Clear Text (common terminology), and Manage- ment by Objective, Flexible/Modular Organization, and Span-of-Control. In the United States, ICS has been used for more than 30 years in both emergency and non-emergency situations. Presently, all levels of government and some private sector agencies are required to maintain differing levels of ICS training. ICS is used widely in law enforcement activities as it is perceived to elicit clear communication, accountability, and an efficient use of community resources. As part of the Fed- eral Emergency Management Agency’s (FEMA’s) National Response Plan (NRP), ICS has been expanded and integrated into the National Incident Management System (NIMS). National Incident Management Systems In 2004, the Department of Homeland Security (DHS) Sec- retary, Tom Ridge, as directed by President George W. Bush, required all Federal departments and agencies to adopt NIMS and use it in their individual domestic event and incident man- 4

agement and emergency prevention, preparedness, response, recovery and mitigation programs and activities. In addition, the DHS also directed that those agencies support and assist state, local and tribal entities if they request Federal assistance (DHS, 2004, p. iii). According to the DHS, “NIMS represents a core set of doctrine, concepts, principles, terminology and organiza- tional processes to enable effective, efficient and collabora- tive event and incident management at all levels. It is not an operations incident management or resource allocation plan” (DHS, 2004, p. ix). NIMS is described as a framework for “interoperability and compatibility based on appropriate balance of flexibility and standardization” (nimsonline.com). This framework integrates what many regard as the best prac- tices into a nationwide approach to event and incident manage- ment that is broken down into six major areas (1) command and management, (2) preparedness, (3) resource management, (4) communications and information management, (5) sup- porting technologies, and (6) ongoing management and main- tenance (nimsonline.com). The DHS reports that NIMS has undergone extensive vetting and coordination with the Federal government which has also included outreach to state and local officials, and the private sector. As a result, the NIMS program incorporates best practices at all levels of emergency management systems (DHS, 2004). Aside from this assertion, it should be noted that there is presently little empirical evidence identified in- dicating the efficacy of NIMS or the ICS. While many incidents are handled by a single local juris- diction, there are certain types of events and incidents and disasters that will require Federal aid. In order to meet these needs, and because of the diverse and expansive structure amongst governmental agencies and divisions, the DHS hopes NIMS will create successful coordination across all levels of government. It is hoped that NIMS will provide the effective coordination across the varied groups that may be involved in a major disaster, which will enable all groups to come to- gether and offer a well-integrated, effective incident manage- ment system. Aviation Requirements— Disaster/Emergency Planning Air Carriers (Part 121, 125, and 135) The FAA currently requires all air carriers operating under 14 CFR 121, 125, or 135 to have established accident report- ing procedures. These procedures must be published in the carrier’s operations manual stipulated in 14 CFR 121.135, 125.73, and 135.23. Aside from this requirement, the FAA does not mandate any type of structured program dealing with issues of employee or operator resiliency after an acci- dent; rather, the emphasis is keenly placed on an operator’s ability to manage an acute emergency. 14 CFR 121.417 outlines the specific requirements needed by an air carrier in order to mitigate an actual emergency situation such as in-flight aircraft fires or hijackings, but does not list any post-event psycholog- ical or “trauma handling” regulations. The Air Line Pilots Association (ALPA) currently maintains a Critical Incident Response Program (CIRP) for its pilot members (Steenblik, 2001). As part of this program, every member airline has a trained CIRP team which utilizes several trauma-related mitigation techniques. Their preferred meth- ods of stress interventions include debriefings and “defusings” which typically involve interaction between those experienc- ing traumatic events and the peer-based CIRP-trained team (Steenblik, 2001). Airports In a review of the Airport Emergency Plan (AEP) advisory circular (AC/150/5200-31B) currently in draft format, it appears the Federal Aviation Administration has initiated a number of changes for airports. This draft, if approved, will replace an advisory circular from 1999. The substantial changes suggested in the new advisory circular primarily relate to the addition of National Fire Protection Association stan- dards for equipment and training related to airport firefighters and the application of the National Incident Management System (NIMS) and Incident Command System (ICS). The FAA cites that the recent terrorist attacks and natural disasters highlight a need to refine the airport emergency plan- ning efforts and have all jurisdictions act together across all functional disciples. Under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, Public Law 03-288, as amended, the elected offi- cials and the communities that own and operate airports are legally responsible for ensuring that necessary and appropriate actions are taken to protect people and property from the conse- quences of emergencies and disasters. These communities must also develop emergency preparedness programs to assist the local and state emergency management officials in complying with emergency preparedness responsibilities. The Federal Emergency Management Agency (FEMA) has published the National Inci- dent Management System (NIMS) and the State and Local Guide (SLG 101), Guide for All-Hazard Emergency Operations Planning. NIMS and SLG 101 provide emergency managers and other emergency services providers with information regarding the FEMA concept for developing risk-based, all hazards Emergency Operations Plans (EOPs) (FAA, 2008b, p. 3). Section 8 of the advisory circular, AEP, outlines health and medical planning. It is evident that the advisory circular is oriented toward treatment, transport, and evacuation of injured persons, or the response actions; but, the plan does not address the actual airport workers’ mental health issues that may arise from working during traumatic events. However, 5

section 6-8-2 (6) does address potential utilization of mental health agencies; the circular indicates that an airport should ensure that the appropriate mental health services are avail- able for disaster victims, survivors, bystanders, responders and their families, and other airport caregivers during response and recovery (FAA, 2008b, p. 82). Services may include crisis counseling, critical incident stress debriefings, information and referral to other resources, and edu- cation about normal, predictable reactions to disaster experience and how to cope with them. There should be predictable reactions to disaster experience and how to cope with them. There should be specialized family crisis assistance available for those affected by a traumatic event or who become traumatized by cumulative stress related to the disaster experience (FAA, 2008b, p. 82). The FAA introduces the idea of CISM, but clearly leaves the concept and its implementation up to each individual airport. It is not evident whether the FAA will direct an air- port to implement any sort of mental health programs for airport workers. It should be noted that the FAA’s advisory circular on emergency planning pertains only to FAR Part 139 airports, which are those airports that serve regularly sched- uled air carrier (FAR Part 121) operations with aircraft oper- ating with more than nine seats on board. Under Federal Aviation Regulation 14 CFR 139 (FAR 139), those airports serving air carrier aircraft with more than nine seats on board, must have Aircraft Rescue and Firefighting (ARFF) capabilities on the airfield when the air carrier is con- ducting operations. The ARFF personnel must be trained to FAR specifications and must be able to respond to the mid- point of the farthest runway from the fire station within 3 min of the alarm. Airports falling under FAR 139 must have an Airport Emer- gency Plan (AEP). This plan must specify how it would han- dle a myriad of emergency situations, including aircraft and natural disasters. Each airport must have their AEP approved by the FAA. In addition, each airport must comply with train- ing standards that predicate a full scale mock emergency exer- cise every 3 years, and with those years in between, training must be satisfied with a “table top,” or a classroom-type emer- gency exercise. Those airports that receive general aviation traffic and non- scheduled air carrier operations have no emergency planning requirement under the FAA. A critical factor is to understand that under present rules, no airport is required to have a Men- tal Health Recovery Plan (MHRP) for employees post-disaster. Aviation Entities Not Covered by Federal Regulations Airports that do not serve FAR Part 121 air carriers are not required to have an emergency plan and are not governed by FAR 139. Therefore, if an airport is open to the public and receives general aviation traffic, there is no requirement for emergency planning and training. Many airports across the country have emergency plans, but there is no reporting or training requirement set forth by the FAA. It is recommended that organizations that do not have a regulatory requirement look within their region to locate the appropriate resources. A small general aviation airport would be directed to look within their city, county, region, and state to determine which resources would be appropriate and necessitate the proper mutual aid agreements. National Transportation Safety Board The National Transportation Safety Board (NTSB) is a gov- ernment agency tasked with the investigation of transporta- tion accidents and incidents with the overall goal of making safety recommendations. In the process of investigation, they can request expertise from a variety of sources, including, but not limited to, the FAA, airlines, equipment manufacturers, maintenance organizations, air traffic control, meteorology information sources, and advocate groups. Their purpose is to identify the probable cause of the accident, issues related to safety, and to make recommendations to the appropriate agencies for actions which mitigate safety hazards in all forms of transportation. While jurisdiction of the scene can vary by location (military installations) or activity (potential crime scenes), the NTSB is often the lead organization present during aircraft incident recovery and investigation. In that position, NTSB investi- gators provide guidance to the victims, families, and support personnel from the airlines, airport, and surrounding commu- nity agencies. While their original job tasking was primarily the investigation of the incident, their duties were expanded by the Aviation Disaster Family Assistance Act of 1996. The mission of the Federal Family Assistance Plan for Avi- ation Disasters (2000) is to “provide psychological assistance and logistical support and services to victims and their fam- ily members.” In the details of the plan, mental health sup- port is also intended for individuals who are supporting the incident investigation as well. The responsibilities are divided into seven victim support tasks with primary organizations holding responsibility. The area of family care and mental health is delegated to the American Red Cross in the case of commercial air carrier disasters. The American Red Cross activates trained personnel who staff operations centers with primary goals of providing assis- tance to those in need and coordinating and managing vol- unteers and organizations who offer counseling, religious, and other support services. The Red Cross is tasked with activat- ing personnel to “provide crises and grief counseling to fam- ily members and support personnel.” Additional direction in their plan directs the Red Cross to “ . . . assess the needs and available resources of other agencies and coordinate with 6

them to ensure ongoing emotional support for workers dur- ing the operation . . .” While the primary focus in the Federal Family Assistance Plan for Aviation Disasters is to support the disaster victims and their families, supporting the emotional needs of support workers is also mentioned in the document. The Office for Victims Assistance (OVA) is contained within the Federal Bureau of Investigation (FBI). According to the FBI’s website, this office is “responsible for ensuring that vic- tims of crimes investigated by the FBI are afforded the oppor- tunity to receive the services and notification as required by federal law and the Attorney General Guidelines on Victim and Witness Assistance” (2005). Additionally, the OVA is re- sponsible for the Terrorism Victim Assistance Unit. This unit “provides emergency assistance to injured victims and fami- lies of victims murdered in terrorist attacks within the U.S. and outside the borders of the U.S. and serves as a permanent point-of-contact for terrorism victims within the FBI” (2005). The FBI website also includes additional resources for service providers and victims of crime. One particularly noteworthy resource link provided is to the Office for Victims of Crime (OVC), an office within the Department of Justice (DOJ). This office publishes the Online Directory of Crime Victim Services which is located at http://ovc.ncjrs.gov/findvictimservices/. This directory “is an OVC resource designed to help service providers and individuals locate nonemergency crime victim service agencies in the United States and abroad. The direc- tory gives individuals the ability to search by location, type of victimization, service needed and agency type.” Critical Incident Stress Management—Aviation The impact of stress on human performance is well docu- mented; therefore, it is expected that aviation managers would be concerned with potential performance impairments among personnel during and immediately following a critical inci- dent (Leonhardt & Vogt, 2006). Aviation personnel involved in critical incidents may have ongoing involvement with rescue, recovery, operational support of ongoing emergency activities, or normal company operations. Distraction, lack of confidence, and feelings of vulnerability are several of many symptoms that can have a significant effect on the safety of ongoing operations following a disaster. A comparison of the industry sectors that actively use CISM shows that the aviation industry responds to critical incidents in similar ways. Emergency medical services, fire/rescue depart- ments, and law enforcement agencies are probably the largest groups who routinely face critical incidents of natural and manmade disasters. The technical nature of aviation-related, safety-sensitive positions may not be well understood by “outsiders.” The psychological response mechanisms are well understood, however, and are common in all groups. The aviation industry has unique aspects as well. While the nature of CISM services is to address these types of issues, individuals are expected to face events that are associated with physical trauma. While Post Traumatic Stress Disorder (PTSD) is a well-known diagnosis, training and experience will offer some familiarity (not immunity) with these types of reac- tions. The aviation industry, outside the fire/rescue and secu- rity forces, may have personnel who may have not dealt with the stress of a disaster at any level in the course of their careers. This is not to say they are incapable of managing the incident, but as a group, they may have individual training or recovery needs that differ as a result of their work experience. These in- clude the relative infrequency of aviation disasters compared to fire/rescue/police operations; the potential for a large scale event; the potential of responsibility or blame for the accident on those who are now asked to be involved in the disaster sup- port process; the large number of people (passengers, family members, rescuers, press, investigators, etc.) needing support services; and the intense press presence. The aviation industry’s focus on safety leads to careful scrutiny of its personnel. Pilots and air traffic controllers must be medically screened on a routine basis to be in compliance with Federal Aviation Regulations. Conditions that would restrict their performance include many of those listed as symptom complexes for acute stress reactions, PTSD, or the variety of other psychological or medical complications that may arise. Self-evaluation of the impact of stress on an indi- vidual’s ability to function in demanding environments is difficult. Pilots and air traffic controllers may also face the dilemma of reporting psychological symptoms because reveal- ing a mental health condition could later compromise their medical certification, and therefore their livelihood. In a safety culture where individuals are carefully monitored to mini- mize risks of performance problems, it may be difficult to identify impaired individuals in a proactive way. As discussed by Bonanno (2005), a large percentage of individuals involved in critical incidents are able to continue to perform at adequate levels in spite of the symptoms they are experiencing as a result of their exposure to a critical incident; that is, these individuals exhibit resilience. While this finding is a very positive aspect of human behavior, individuals with resilience may be difficult to differentiate from those in whom distraction or other impairments may affect operational safety. Resilience is identified as an outcome rather than a finding based on the result of predictors prior to the event (Bonanno, 2005). Factors that predict resilience have been identified. These factors may be considered for selection in high performance teams (e.g., military or exploration teams), but may not be seen as a viable screening tool for hiring in the aviation industry. While some individuals may exhibit resilience consistent with predictive factors, it is not operationally significant; the need for high reliability of human operators in these safety positions 7

(pilots, air traffic controllers, aircraft maintenance, security personnel, fire/rescue, or EMT departments, etc.) necessitates verification of their readiness-to-perform. The high degree of impairment that individuals can suffer due to acute stress reaction and post-traumatic stress syn- drome is quite evident (Leonhardt & Vogt, 2006). The need for individuals to continue to operate in the post-disaster environ- ment, or to return to duty following a critical incident, neces- sitates a review of current evaluation and treatment programs. Procedures Following an Aircraft Disaster Initially, after an aircraft disaster has occurred, the efforts focus on life-saving and rescue operations. Most incident response protocols call for first-responders such as fire- fighters and law enforcement personnel to attempt to miti- gate the loss of life. After these efforts are exhausted, the scene turns toward site preservation, so that an intensive incident investigation can proceed. It is important to note that during the entire process, from the onset of the incident through the completion of the incident investigation, there may be a vast number of people who are exposed to trauma-inducing stimuli. The people who may be exposed to traumatic events after a disaster are partly determined by the location in which the disaster occurred. For instance, if the aircraft disaster occurred outside an airport boundary, airport personnel may not be involved with the scene. Typically, local law enforcement and other local governmental rescue workers will preside over the site. If the incident occurs on the airport proper, then the airport’s emergency response as per its emergency plan will be enacted. This generally prescribes a procedure where ARFF will respond, and other airport employees will provide assistance as needed. It is quite possible that these employees will come in contact with and/or witness traumatic events which could lead to deeper psychological impact. Figure 1 provides the typical flow of responsible person- nel in an aircraft disaster. The chart divides aircraft disasters into two distinct categories, air carrier and non air carrier. Fur- 8 Figure 1. Flow chart outlining ICS-style procedures after an aircraft disaster.

ther classification is made between on airport and off airport incidents, as this will typically dictate responding personnel. After these classifications, the specific responding groups are identified, which culminate in reporting requirements to the NTSB under 14 CFR 830. Any of these groups, whether they are first-responding professionals, or other employees could be exposed to trauma depending on a variety of circumstances. Mental Health Options There are several different types of mental health care options for an individual to receive. An obvious avenue would be the Employees Assistance Program (EAP) which is generally accessed through the human resources department of an orga- nization; another area to find care would be through the com- munity, through private mental health care organizations, and through one’s own personal health care provider. Many people also find that their spiritual affiliation is of guidance during times of difficulty. In the following paragraphs, Palm et al. (2004) suggest ways in which to limit vicarious trauma reactions. They detail rec- ommendations for interventions at the individual and orga- nizational levels. The following is a list of actions which may limit vicarious trauma reaction at the individual level: spending time with other people outside of the work environment/staying con- nected and not isolating oneself; asking for support; engag- ing in activities that provide a sense of purpose; attending to physical health; maintaining balance between professional, physical and emotional aspects of life; attaining social sup- port; accepting that emotional distress in trauma survivors is a “normal” reaction to traumatic events; limiting unnec- essary exposure to the traumatic event by decreasing expo- sure through the media/newspaper; maintaining balance in the work situation; taking vacations; identifying personal limits; and talking to coworkers. Poor communication with coworkers has been shown to increase risk of adverse vicar- ious post-traumatic stress reactions. The following is a list of actions which may limit vicarious trauma reaction at the organizational level: providing appro- priate training for dealing with trauma and disaster; provid- ing information about traumatic stress reactions; effective coping and possible interventions and encouraging use of nat- ural social support systems; normalizing traumatic stress reac- tions, being encouraged to advocate for survivors or change policies to help survivors; ensuring manageable workloads; creating a respectful, supportive work environment; having access to support resources without fear of negative conse- quences; and encouraging vacations. Lack of social support in the work situation, poor communication, and poor support from supervisors has been associated with increased risk for secondary trauma, burnout, and fatigue. Employees Assistance Programs An EAP is an initiative undertaken by a company or or- ganization which seeks to provide mental health assistance to employees who may be experiencing stress or trauma. Employees may utilize the services of an EAP, free of charge, for personal psychological traumas and other reasons such as substance abuse problems. One of the hallmarks of most EAPs involves some sort of anonymity or de-identification of participating employees, wherein employers are kept unaware of which of their employees are participating. In spite of the cost to employers, most research indicates overall employee productivity is maintained or even enhanced, and thus justi- fied (Kirk & Brown, 2003). Some EAPs offer a Critical Incident Response Management (CIRM) program, which can be utilized by individual employ- ees after a disaster or crisis occurs (Freeman, 2007). CIRM could be utilized specifically to respond to an organizational- wide disaster. Paul (2006) found that EAPs can be effective when dealing with large scale traumatic events so long as the focus is split between the organization and the individual worker. Badenhorst (1992) further found that for maximum efficacy, an EAP response following a disaster should be tailored to specific circumstances, which include simplicity, proximity, immediacy and expectancy. Central to EAPs is the fact that most mental health or coun- seling services are provided by trained and licensed mental health professionals. Other mental health recovery programs often involve some sort of peer-based counseling, but that is the exception rather than the norm in EAPs. One such EAP that includes peer-based meetings is the FBI EAP (McNally, 1999). While still utilizing professional personnel in its tradi- tional EAP processes, their program also makes use of peer support. To date, the efficacy of such a “mixed-method” EAP regarding traumatic events has not been extensively evaluated but warrants further attention. Timmons (2004) explains that traditional EAPs do not go far enough to support key personnel and their families in times of a severe or regional crisis. Furthermore, existing programs may not have the depth of resources needed for response. Some key areas of concentration for an enhanced EAP would be to have “an executive level champion, an organizational- wide awareness of program, and all personnel should partic- ipate in the initial training program” (p. 74). The article is careful to point out that there is no silver bullet for organiza- tional survival during crisis events and that programs should be tested where appropriate. The human resources depart- ment of any organization should remain as the focal point of contact for supporting personnel and their families through the crisis, as well as providing ongoing support to the recovery process. 9

Organizational Structure and Communication Systems Airports are unique due to their highly structured regula- tory environment from the federal government to the local level of government involvement. The majority of airports are owned and operated by municipalities, city, and county governments, which would assume a degree of complexity and centralization. However, many airports are in the form of an enterprise system, or managed as a separate department, away from local government. Airports are also commonly owned and operated by quasi-independent authorities, which are also a form of public administration. It is quite difficult to put an exact definition on how an airport is operated and which type of organizational structure it has, as defined above. Airport workers are constantly training and upgrading their professional standards, so in that sense the industry is quite formalized; however, since the employees are highly trained, there is usually a lesser degree of centralized decision making. The independent divisions (maintenance, operations, fire department, and law enforcement) within the airport struc- ture are normally self-governed. An organizations structure, whether a complex set of re- porting lines or not, is an important concept to consider when developing a mental health recovery program; and equally important is the method of disseminating and training the employees. Communication is the transference and under- standing of information. There are several functions of com- munication; it can be used to control employee behavior, motivate employees, share information and express emotions of management. The following is a list of the many variables which must be considered when communicating (1) sender behavior; (2) receiver behavior; (3) feedback; (4) choice of media; (5) one-way vs. two way; (6) verbal vs. nonverbal; (7) defensive vs. non-defensive; (8) interpersonal communica- tion; (9) formal vs. informal networks (grapevine); (10) small- group networks (chain, wheel, all-channel); (11) directional flow (down, up, horizontal); (12) gender differences; and (13) cultural differences (Greenberg, 2002). These variables should be considered when communica- tion networks of any kind are in use. It is important to recog- nize encoding and decoding issues may arise when sending and receiving information. This can stem from gender, cul- tural, and choice of medium used. There appears to be no “one best way” to ensure correct communications all of the time. It is important to choose a media that will provide the most richness for the individual(s) receiving the message and to determine the level of complexity in the message when making that choice. Another area for consideration is the speed and accuracy needed in the process. The basic assump- tion is that communication is “a continual balancing effort of juggling the conflicting needs for intimacy and independence and matching the medium with the message” (Greenberg, 2002, p. 204). Human Continuity through Crisis It is commonly known that most businesses pay more at- tention to the practical matters of a potential business inter- ruption than planning for the people side of the business, yet it is quite apparent that personnel are the most valuable asset to a company in times of distress. Therefore, “human conti- nuity” is a crucial variable in disaster planning for any orga- nization. Determining what and how to respond to the human or mental health issues that may be present after a traumatic event are extremely important. According to Nowlan (2008) businesses need to be well- trained to recognize the issues that may follow an event to prevent potential absenteeism, low morale, or impaired work performance. Nowlan (2008) identifies that companies can implement simple training exercises to mitigate mental health issues, and human resource teams should initiate table top exercises to provide effective support to managers when a crisis arises. Five specific areas that should be addressed by the company are (1) psychological impacts of trauma; (2) man- agerial responsibility; (3) how to support people recovery; (4) leadership in a crisis; and (5) being ready to support and listen after the crisis (2008, p. 42). Managerial responsibility speaks to the ability of a manager to support their staff, even in times of personal crisis. Man- agers should be trained to spot symptoms of stress and be able to support the well-being of their employees and respond with the appropriate level of assistance (Nowlan, 2008). Business Continuity Management (BCM) is a trend to ensure that companies reemerge and minimize lost produc- tivity after a crisis. Whether it be pandemic bird flu, an e-coli outbreak, natural disaster, or other emergency, business lead- ers have come to an important realization that, “people are the most critical issue, and organizations have not thought through all the different aspects associated with people when a crisis happens” (Donston, 2001, ¶4). This is especially true for highly specialized organizations such as airports and airlines. People that work at airports across the country are highly trained individuals, and organizations cannot afford to lose such valuable employees in the wake of a crisis. Therefore, aviation organizations need to ensure the physical and emo- tional well-being of their human capital, as well as the physical structure of the entities. Organizations need to recognize that there are several vul- nerable stakeholder groups including staff, community, cus- tomers, suppliers and family members when trauma is present. It is advisable for companies to consider the well-being of all groups when attempting to return to normal operations. 10

Both family and community members represent a tremendous source for recovery for employees, which can aid in the recov- ery process and reduce down time (Paton, 1999). According to Paton (1999), local government agencies might pursue this cost effective strategy of establishing goodwill and consider a similar course of action. This course of action should be considered as a comprehensive human resources continu- ity plan, which considers traumatic impacts for its staff. This HR plan could use vulnerability data to screen staff so that the organization identifies the demands of key staff and what effects of trauma they may experience as a result of the event (Paton, 1999). Paton (1999) identifies several factors that may constrain business continuity planning. Those include underestimating the risk of event occurrence and its consequences, over- estimating the organization’s existing capabilities, and ambigu- ity of employee roles and responsibilities. The goal of the plan should be to enable each organization to respond effectively to any type of event. Lastly, Paton (1999) explains that orga- nizational effectiveness is influenced by several organizational characteristics and the degree of flexibility within the system. If an organization is rigid in nature and there are internal conflicts present, these variables will inhibit effective organi- zational response. Companies that display this type of rigidity may experience higher absenteeism, turnover, and perfor- mance decline. If the organization is more organic and flexible, the reconciliation of staff needs tends to occur more rapidly. The most important strategy for key executives is to “accept organizational ownership of the crisis and its implications” (Paton, 1999, ¶11). Paton (1999) indicates that “a key factor in disaster recov- ery and safeguarding staff well-being involves training specif- ically to prepare for disaster work” (¶16). It is also necessary to train for an all-hazard event and that both technical and mental health preparedness is needed and the development of a well-thought response and recovery plan for the organi- zation is essential. Management and managers play key roles in the recovery of any organization. It is vitally important that managers plan, manage, and practice recovery scenarios with their employees; this will identify the roles, tasks, and respon- sibilities for each employee group. A disaster may render certain employees, or employee groups incapable of performing their jobs; it is the role of manager and human resources to understand this issue and find the appropriate support that is needed. Paton (1999) explains that recent thinking about support programs for staff is focusing on developing resilient organizational cultures. This would include “empowering staff and managers, and providing them with the knowledge, and skills to design and implement appropriate intrinsic risk-reducing and recovery strategies” (¶26). Due to the sheer magnitude of some events, this may prove to be a cost-effective strategy. What Is Psychological Trauma and What Causes It? The physical and psychological response to any demand— positive or negative—is stress. Positive stress includes responses to events such as getting a promotion, getting married, or graduating from college. However, the term stress usually describes responses to negative demands such as taking a test, getting divorced, or performing under pressure. When faced with a source of negative stress, people must evaluate the sit- uation; determine the realistic level of risk (and differentiat- ing that from imagined or irrational perceptions of risk); and then evaluate how they are going to cope with the situation based on their own personal resources (e.g., physical strength, the ability to think clearly in a crisis, basic problem-solving abilities) and the potential for support from others (e.g., emo- tional support, access to necessary tangible resources; Lazarus, 1966; Lazarus and Folkman, 1984). The most extreme form of negative stress is traumatic stress— stress resulting from a traumatic event or situation. People experience traumatic stress in response to events such as nat- ural disasters like earthquakes or hurricanes, motor vehicle collisions, physical or sexual assault/abuse, combat, industrial accidents, diagnosis of a life-threatening illness, life-threatening medical situations like a heart attack, terrorist attacks, torture, or as in the present discussion, airline disasters. A commonality among these traumatic situations is that they all involve a threat to one’s life or the lives of others. When people try to cope with such situations and are not successful in this coping, it can result in feelings of helplessness, rage, and resentment about the loss of control and random nature of these situations (Kardiner & Spiegel, 1947). In large-scale disasters, like the terrorist attacks of the World Trade Cen- ter on September 11, 2001, the devastation may threaten or destroy the existing social structure and order. The loss of social structure and particularly the lack of effective leader- ship and guidance in restoring social order and safety can contribute to the development of mental health problems of those involved in traumatic situations and particularly mass disasters (Noy, 2004). As noted above, traumatic stress occurs when an event is perceived as life threatening to an individual or others and which severely challenges or compromises one’s coping capac- ity (Noy, 2004). It involves activation of the human survival response—a physiological and psychological response that prepares the body and mind to fight, flee, or even freeze. In order to fight or flee, this response causes a part of the body’s nervous system, called the autonomic nervous system (ANS), to prepare for these activities (e.g., fighting off an assailant or running away from a wild animal) by increasing heart and respiration rates, dilating pupils, narrowing attention and increasing vigilance, and increasing blood flow to muscles. 11

During an actual traumatic event, this response is consid- ered a normal, adaptive survival response to a situation that is perceived as life threatening. If an individual is able to estab- lish safety by fighting or fleeing, it will often decrease, although not eliminate, the risk for long-term negative effects of the stressful event. However, traumatic events may not accommo- date these survival responses, and individuals must attempt to cope with a situation that is perceived as life-threatening, uncontrollable, and/or inescapable—a situation that carries a higher risk for longer-term problems. Life-threatening, inescapable situations can result in a different physical and psychological response—freezing or becoming immobilized. Although this response is less well understood from a physiological standpoint, it appears that the stress response activates a different part of the ANS that immobilizes the body and decreases the experience of pain or fear (e.g., people going limp and psychologically numb when being mauled by a bear). Psychological “numbness” is another way of describing what is more generally called dissociation—separating oneself psychologically from an unbearable situation. It fragments the personality in an attempt to minimize pain, and in this way could be considered an adaptive reaction, but can inter- fere with recovery to the extent that a person is then unable to integrate the complete experience of the trauma (Noy, 2004). Dissociation can occur at many different levels of severity with the most severe involving a complete “splitting off” from oneself—what was previously referred to as a multiple person- ality and currently referred to diagnostically as Dissociative Identity Disorder (American Psychiatric Association, 2000). Psychological Reactions to Traumatic Events A range of post-traumatic stress reactions can occur for individuals who experience or are exposed to trauma. For example North, Nixon, Shariat et al. (1999) examined the impact of trauma exposure on the frequency and types of post-disaster psychopathology that developed. Nearly half of the sample of 182 participants met criteria for one or more psychiatric diagnosis after the disaster. The types of psychi- atric diagnoses included Major Depression, Panic Disorder, Generalized Anxiety Disorder, Alcohol Use Disorder, Drug Use Disorder and PTSD. Subsequent investigators have also documented the impact of trauma exposure on the development of psychopathology. Depression and anxiety are often observed in the aftermath of trauma (Norris, Friedman, Watson, Byrne, Diaz & Kaniasty, 2002; Noy, 2004; Rubonis & Bickman, 1991) along with a spec- trum of grief reactions (Bonanno & Kaltman, 2001). Further, post traumatic stress reactions and depression co-occur quite often following disaster. Another human reaction to trauma is the use of alcohol or drugs in attempts to cope with the trau- matic memories and intrusive thoughts associated with the trauma (Ford, Hawke, Alessi, Ledgerwood & Petry, 2007). Other work has documented that one of the most enduring effects of traumatic stress involves increases in physical com- plaints that are not usually limited to any specific organ system and are often medically unexplained (e.g., fatigue, headache). Further outcome studies suggest that a number of trauma survivors experience an overall decreased quality of life, more absenteeism from work, and impaired social relationships. Post-Traumatic Stress and Human Reactions to Trauma Although a wide variety of psychopathology can result from exposure to trauma, when an individual continues to experi- ence a persistent traumatic stress reaction after the traumatic event has past, or post-trauma, it is called post-traumatic stress (American Psychiatric Association, 2000). Thus, a stress re- sponse that was adaptive and normal during a time of crisis becomes maladaptive when it persists after the traumatic event has passed. Post-traumatic stress is a human survival reaction or elements of this reaction that occur when there is no actual threat present—a survival reaction that occurs at the wrong time. When post-traumatic stress is severe and persistent it is called Post-Traumatic Stress Disorder (PTSD) as described in the Diagnostic and Statistical Manual of Mental Disorders: Text Revision (DSM-TR)—the standard reference used for classifying and diagnosing psychiatric disorders (American Psychiatric Association, 2000). According to the DSM-TR (American Psychiatric Asso- ciation, 2000) diagnostic criteria, to qualify for a diagnosis of PTSD, one must have: (1) experienced an event that is life threatening or perceived as life threatening, (2) witnessed an event that is perceived as life threatening to others, or (3) heard about violence to or the unexpected or violent death of others. The latter can involve such things as watching a traumatic event unfold on television (e.g., Hurricane Katrina or the events of 9/11) or hearing about the death of a loved one— referred to as vicarious or secondary traumatization (Palm, Polusny & Follette, 2004). Further, one must exhibit persistent evidence (i.e., lasting more than one month) of (1) persistent re-experiencing of the traumatic event (e.g., intrusive memories or thoughts, flash- backs, nightmares); (2) avoidance of reminders or the trauma that can involve physical avoidance or psychological “avoid- ance” or numbness in the form of dissociation; and (3) chronic hyperarousal of the autonomic nervous system (e.g., difficulties sleeping, problems concentrating, hypervigilance, increased anxiety, exaggerated startle response). One must also exhibit severe impairments in daily func- tioning (e.g., impaired relationships, employment problems) 12

in addition to the criteria just described. Individuals for whom these same symptoms persist for less than one month would be classified as having Acute Stress Disorder (ASD; American Psychiatric Association, 2000). As noted previously, dissocia- tion or removing oneself mentally from an inescapable sit- uation is one possible response to traumatic stress. There is evidence that if dissociation is present in the early or acute stages of the traumatic stress reaction, the risk is increased for developing subsequent PTSD (Birmes, Brunet, Carreras, Ducasse, Charlet, Lauque, Sztulman & Schmitt, 2003) although conflicting results have been reported (Wittman, Moergeli, & Schnyder, 2006). Symptoms of PTSD usually appear within the first 3 months following exposure to the traumatic event. However, a signifi- cant number of individuals may also experience delayed-onset PTSD (Buckley, Blanchard, & Hickling, 1996) in which symp- toms may not appear for months or years (American Psychi- atric Association, 2000). The duration of PTSD also varies. For trauma victims with early onset PTSD, PTSD has been shown to persist from months to years following the disaster (Galea, Nandi, A. & Vlahov, D., 2005). Even with appropriate treat- ment, PTSD can persist as a lifetime chronic condition with pe- riods of exacerbation and remission of symptoms (Noy, 2004). Early Intervention Issues and Strategies in the Acute Stages Following a Traumatic Event Prior to the 1980s, there were no mental health interven- tions following disasters. In response to the needs of the Vietnam veterans in the early 1980s, Psychological Debrief- ing (PD) began to be routinely applied in circumstances in- volving traumatized victims of disaster and other adverse events. PD is a group of intervention methods that is applied within 48–72 hours following a trauma. Sessions encourage group participants to describe factual events and process the emotional components of the trauma experience. Its use rests on the belief that this immediate processing of the event allows the individual to reorganize the memory of the event so that it is recalled in a less traumatic way (Van der Kolk, 1997). Crit- ical Incident Stress Debriefing (CISD), developed by Mitchell in 1988, expanded and further articulated a process for psy- chological debriefing (Everly & Mitchell, 2000; Mitchell, 2004; Mitchell, 1988; Riddell & Clouse, 2004) that was later termed Critical Incident Stress Management (CISM). Katz et al. (2002) review the literature from 1966 to 2002 related to what interventions have been used for prevention and intervention during the first 2 months after an event. Their review of acute psychiatric interventions indicates that the primary focus has been on attempts to minimize the long-term effects of disaster trauma on its survivors. They note that several organizations have come up with intervention teams (e.g., US Navy Special Psychiatric Intervention Teams (SPRINT), the US Army Stress Management Team (SMT)). Also noted is the fact that these interventions have been gen- erously applied in the absence of any scientific evidence that they serve the purpose of reducing psychiatric morbidity, and further note that the same has been true for most acute inter- ventions that “are often performed post-trauma on the basis of good intentions and theorized benefits” (Katz et al., 2002, p. 208). Until more recently, these models have been rou- tinely utilized in emergency and disaster situations despite a lack of evidence-based outcome studies demonstrating their safety, usefulness in the acute phase following disaster, and whether they decrease the risk for longer-term post traumatic reactions. In fact, it has been noted that debriefing is often the “default” in organizations dealing with disaster (cited in Blythe & Slawinski, 2004). However, these methods and models are now questioned by many experts in the field. Due to questions about their effec- tiveness in decreasing distress and preventing negative long- term outcomes in those individuals exposed to traumatic events (Blyth & Slawinski, 2004; Greenberg, 2001; Pennebaker, 2001) and several large-scale meta-analyses that have not yielded positive findings regarding psychological debriefing and CISD/ CISM (Rose, Bisson, Wessely, 2003; Rose, Bisson, Churchill & Wessely, 2005; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002), these methods have come under much scrutiny and criticism. In review of debriefing methods, it is indicated that the application of debriefing is controversial and, although some show benefits in the short term, others report a worsening of symptoms. Some studies that do show benefits are not con- trolled, and when controlled these studies do show short-term but no long-term benefits in decreasing adverse long-term outcomes (Deahl, Gillhan, & Thomas, 1994; Hobbs, Mayou, Harrison, & Worlock, 1996; Kenardy, Webster, Lewin, Carr, Hazell, & Carter, 1996). These analyses suggest that at best psychological debriefing can help people feel better in the short term but that it has a negligible effect on long-term out- comes for prevention of PTSD and stress-related problems. In some cases, those who have received psychological debrief- ings have shown increased acute distress and poorer long- term outcomes than those that received non-CISD or no formal support. This fact suggests that debriefing may actu- ally be harmful. The debate continues, but most experts in the field have made some recommendations regarding how to best proceed. Namely, more well-designed studies concerning the short- and long-term effects of debriefing are needed to clarify the nature of the current controversy. Despite the fact that some studies have found CISM to have a positive effect and that most research on traumatic stress indicates that some form of reprocessing of the events is a necessary part of the recovery 13

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

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

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