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40 APPENDIX A Comprehensive Literature Review Introduction and Overview reference and safety, can contribute to the development of psy- chological problems of those involved in traumatic situations What is Psychological Trauma involving mass disasters (Noy, 2004). and What Causes It? As noted above, traumatic stress occurs when an event is The physical and psychological response to any demand-- perceived as life threatening to an individual or others and positive or negative--is stress. Positive stress includes responses which severely challenges or compromises one's coping capac- to events such as getting a promotion, getting married, or grad- ity (Noy, 2004). In these situations, one early reaction typi- uating from college. However, the term stress usually describes cally involves an activation of the human survival response-- responses to negative demands such as taking a test, getting a physiological and psychological response that prepares the divorced, or performing under pressure. In order to cope body and mind to fight, flee, or even freeze in attempts to effectively when faced with a source of negative stress people cope with or "survive" the situation. In order to fight or flee, must evaluate the situation, determine the realistic level of risk this response causes a part of the body's nervous system, called (i.e., differentiate real from imagined or irrational perceptions the autonomic nervous system (ANS), to prepare for these of risk) and decide how they are going to cope with the situ- activities (e.g., fighting off an assailant or running away from ation based on their own personal resources (e.g., physical a wild animal) by increasing heart and respiration rates, dilat- strength, the ability to think clearly in a crisis, basic problem- ing pupils, narrowing attention, increasing vigilance, and solving abilities, premorbid psychopathology or physical dis- increasing blood flow to muscles. ability) and the potential for support from others (e.g., emo- During an actual traumatic event, this response is consid- tional support, access to necessary tangible resources; Lazarus, ered a normal, adaptive survival response to a situation that 1966; Lazarus, 1984). is perceived as life threatening. If one is able to establish safety The most extreme form of negative stress is traumatic stress-- by fighting or fleeing, it will often decrease, although not elim- stress resulting from a traumatic event or situation. People ex- inate, the risk for long-term negative effects of the stressful perience traumatic stress in response to events such as natural event. However, traumatic events may not accommodate these disasters, motor vehicle accidents, physical or sexual assault/ survival responses such that one must attempt to cope with a abuse, combat, industrial accidents, terrorist attacks, torture, or situation that is perceived as, and frequently is, life-threatening, as in the present discussion, airline disasters. A commonality uncontrollable, and/or inescapable--a situation that carries among these traumatic situations is that they involve a threat to a higher risk for longer-term problems. one's life or the lives of others. When people are not successful Life-threatening, inescapable situations can also result in a in coping with such situations (or perceive themselves to be un- different physical and psychological response--freezing or successful) feelings of helplessness, rage, resentment, and in- becoming immobilized (e.g., people going limp and psycho- creased anxiety may result (Kardiner & Spiegel, 1947). logically numb when being mauled by a bear). Although this The devastation of large-scale disasters like the terrorist response is less well understood from a physiological stand- attacks of the World Trade Center on September 11, 2001, point, it appears that the stress response may activate a differ- may threaten or destroy the existing social structure and order ent part of the ANS that immobilizes the body and decreases such that the "normal" frames of reference and expectations the experience of pain or fear. Along those lines, people can are gone. This loss, particularly in combination with a lack of experience psychological "numbness" or what is more gener- leadership and guidance in restoring a normal social frame of ally called dissociation--separating oneself psychologically from

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41 anunbearablesituation. Dissociation describes a fragmentation, paired relationships, employment problems) in addition to or splitting-off, from the psychologically (or physically) painful the criteria just described. reality of a situation in an attempt to minimize that pain. Individuals for whom these same symptoms persist for In some ways, and over the short term, this can be consid- less than one month would be classified as having Acute Stress ered an adaptive reaction, but over extended periods this Disorder (ASD; American Psychiatric Association, 2000). reaction can interfere with recovery to the extent that a per- As noted previously, dissociation is one possible response to son is then unable to integrate the complete experience of the traumatic stress. There is evidence that if dissociation is pres- trauma (Noy, 2004). Dissociation can occur at many different ent in the early or acute stages of the traumatic stress reaction, levels of severity with the most severe involving a complete the risk is increased for developing subsequent PTSD (Birmes, "splitting off" from oneself--what was previously referred to Brunet, Carreras, Ducasse, Charlet, Lauque, Sztulman & as a multiple personality and currently referred to diagnosti- Schmitt, 2003) although conflicting results have been reported cally as Dissociative Identity Disorder (American Psychiatric (Wittman, Moergeli, & Schnyder, 2006). Association, 2000). Symptoms of PTSD usually appear within the first three months following exposure to a traumatic event. However, a significant number of individuals may also experience delayed- Post-traumatic Stress and Human Reactions onset PTSD (Buckley, Blanchard, & Hickling, 1996) in which to Trauma symptoms may not appear for months or years (American When one continues to experience a persistent traumatic Psychiatric Association, 2000). The duration of PTSD also stress reaction after the traumatic event has past, or post- varies. For trauma victims with early onset PTSD, PTSD has trauma, it is called post-traumatic stress (American Psychiatric been shown to persist from months to years following the Association, 2000). A stress response that was adaptive and disaster (Galea, Nandi, & Vlahov, 2005). Even with appropriate normal during a time of crisis can become maladaptive when treatment, PTSD can persist as a chronic condition with peri- it persists after the traumatic event has passed. Post-traumatic ods of exacerbation and remission of symptoms (Noy, 2004). stress is a human survival reaction or elements of this reaction that occur when there is no actual threat present--a survival Other Psychological Reactions reaction that occurs at the wrong time. When post-traumatic to Traumatic Events stress is severe and persistent it is called Post-Traumatic Stress Disorder (PTSD) as described in the Diagnostic and Statistical Although a range of post-traumatic stress reactions can occur Manual of Mental Disorders: Text Revision (DSM-TR)--the for individuals who experience trauma, other psychological standard reference used for classifying and diagnosing psy- problems have been noted. Depression is often observed in the chiatric disorders (American Psychiatric Association, 2000). aftermath of trauma (Norris, Friedman, Watson, Byrne, Diaz & According to DSM-TR (American Psychiatric Association, Kaniasty, 2002; Noy, 2004; Rubonis & Bickman, 1991) along 2000) diagnostic criteria, to qualify for a diagnosis of PTSD, with a spectrum of grief reactions (Bonanno & Kaltman, 2001). one must have (1) experienced an event that is life threaten- Further,posttraumatic stress reactions and depression co-occur ing or perceived as life threatening, (2) witnessed an event quite often following disaster. Another human reaction to trau- that is perceived as life threatening to others, or (3) heard ma is the use of alcohol or drugs in attempts to cope with the about violence to or the unexpected or violent death of others. traumatic memories and intrusive thoughts associated with the The latter can involve such things as watching a traumatic trauma (Ford, Hawke, Alessi, Ledgerwood & Petry, 2007). event unfold on television (e.g., Hurricane Katrina, the events One of the most enduring effects of traumatic stress involves of 9/11) or hearing about the unexpected death of a loved increases in physical complaints that are not usually limited to one--referred to as vicarious or secondary traumatization any specific organ system and are often medically unexplained (Palm, Polusny & Follette, 2004). (Morren et al., 2007). Further studies suggest that a substantial Further one must exhibit persistent evidence (i.e., lasting number of trauma survivors experience an overall decreased more than one month) of the following symptoms: (1) per- quality of life, more absenteeism from work, and impaired sistent re-experiencing of the traumatic event (e.g., intrusive social relationships. memories or thoughts, flashbacks, nightmares), (2) avoidance of reminders or the trauma that can involve physical avoid- Organization and Content of ance or psychological "avoidance" or numbness in the form the Present Literature Review of dissociation, and (3) chronic hyperarousal of the autonomic on Disaster Mental Health nervous system (e.g., difficulties sleeping, problems concen- trating, hyper-vigilance, increased anxiety, exaggerated startle The following presents a review of the literature on disas- response; American Psychiatric Association, 2000). One must ter and trauma. The first section is an overview of disaster and also exhibit severe impairments in daily functioning (e.g., im- trauma that includes an overview and epidemiology of post

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42 traumatic reactions that can occur in the wake of disasters, an functioning may be significantly compromised relative to pre- overview of the factors that increase the risk for adverse reac- trauma functioning. For example, someone with PTS may tions to disaster and trauma, a review of the psychological be able to maintain a job and/or marriage but continues to reactions to disaster and trauma in selected at-risk groups, experience increased anxiety around reminders of the trauma, and a description of the nature and correlates of vicarious or problems sleeping, repeated nightmares, impaired concen- secondary traumatization. The subsequent sections review and tration, and persistent intrusive and disturbing memories and summarize relevant literature related to prevention, screening, intrusive thoughts associated with the trauma. and intervention and planning. Previous research has indicated that of the 89% of adults ex- The focus of the review then shifts toward mental health posed to a traumatic incident at least one time in their lives, screening and intervention issues and includes an overview of only 15% develop PTSD (Breslau et al., as cited in Adams & screening tools and procedures for identifying at risk individ- Boscarino, 2006). Of those who develop PTSD, 3040% are di- uals in the aftermath of disasters, a review of the current evi- rect victims of the event, 1020% are rescue workers, and dence base for early intervention in the acute stages following 510% are in the general population (Galea, Nandi, & Vlahov, disaster, an overview of the evidence base for early interven- 2005). Corneil, Beaton, Murphy, Johnson and Pike (1999) re- tion with specific at-risk groups (e.g., emergency responders, ported PTSD in an estimated 22.2% of American Firefighters. untrained disaster volunteers), a summary of recommenda- Additional research conducted has generally found rates of tions for preventing and managing vicarious traumatization, PTSD ranging from 1318% of firefighters, 14 years after a a summary of recommendations for the use of pharmaco- traumatic event (Fullerton, Ursano & Wang, 2004; McFarlane logic interventions in the acute stages of trauma, a review & Papay, 1992; North, Tivis, McMillen, Pfefferbaum, Pitznagel of methods for prevention of adverse reactions by building et al., 2002). Kessler, Sonnega and Bromet et al. (1995) reported resilience, a summary and description of interventions aimed at that 60.7% of men and 51.2% of women had experienced reducing and treating longer-term adverse stress reactions and at least one traumatic event while 19.7% of men and 11.4% a overview of emerging treatments for post trauma reactions. of women have encountered at least three traumatic events. In the final section, the focus turns to disaster planning and Kessler, Berland, Demler, Jin, Merikanga & Walters (2005) preparation that includes a review of the educational and reported a lifetime prevalence rate of PTSD at 6.8% of the preparatory training factors important to disaster plans that ad- general population. dress mental health issues and an overview of the organiza- Katz, Pellegrino, Pandya, Ng, & DeLisi (2002) reviewed tional, social, and community factors that are important to con- the prevalence of psychiatric morbidity and interventions sider in developing mental health disaster management plans. following mass disasters. They note that disasters are unique in the sense that they involve trauma to many individuals at the same time and they overtax the social and political foun- Overview of Disaster and Trauma dations of communities--a factor that contributes to the Overview and Epidemiology of Post- development of adverse mental health outcomes. Mollica, Traumatic Reactions in the Wake of Disaster Cardozo, Osofsky, Raphael, Ager & Salama (2004) presented a conceptual framework for understanding the impact of dis- Although numbers vary somewhat for each specific trau- asters on the communities they affect. They point out that, matic situation, in general, epidemiological statistics sug- in addition to its direct impact on individuals, a disaster neg- gest that nearly 90100% of those with exposure to trauma atively impacts a community's political, economic, socio- exhibit the same symptoms as those associated with PTSD cultural, and health care infrastructures. during the traumatic event itself. This is not surprising because Katz et al. (2002) note that previous reviews have indicated these same symptoms reflect the human survival reaction and a 17% increase in the prevalence of psychopathology in the are not considered pathologic when they occur during a crisis wake of mass disasters compared to controls (e.g., Rubonis situation. About 15% of those subjected to traumatic situa- & Bickman, 1991). They go on to state that, although some tions will go on to develop PTSD. studies have found increased rates of psychiatric morbidity It is also important to note that the percentage of people following man-made vs. natural disasters, the evidence for exhibiting some but not all the symptoms of PTSD is likely this is inconsistent, with some studies showing increased rates much greater than that for those who exhibit full blown in natural disasters or no difference between the two in terms PTSD, although there are currently no reliable estimates of of psychiatric morbidity. These authors identify the follow- this. These individuals are experiencing post-traumatic stress ing as the primary psychiatric disorders found in the acute (PTS), not post-traumatic stress disorder (PTSD). They are phase (first two months) following disasters: acute stress often quite impaired or distressed but "fall through the cracks" disorder, PTSD, generalized anxiety disorder (consistently because they do not have a diagnosable condition and because detected following disasters), major depression, and substance they continue to "function" (e.g., they go to work), although abuse disorders (although results are conflicting).

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43 Norris et al., (2002) reviewed literature on the impact of traumatic circumstances where life as they knew it had turned disaster on the mental health of the people exposed. They into chaos and horror with no reference point telling them that identified six sets of outcomes that resulted from the effects the rest of the world was still intact. Also, with respect to of trauma. These include specific psychological problems, Katrina, research suggests that it was the slowed response and nonspecific distress, health problems and concerns, chronic the subsequent prolonged exposure to unimaginable and problems in living, psychosocial resource loss, and problems horrific conditions--in many cases, the human-made events specific to youth. rather than those events directly caused by the hurricane itself-- The specific psychological problems identified by the liter- that contributed most significantly to the post-traumatic ature include the symptoms of PTSD, anxiety, depression and problems (Mills, Edmondson, & Park, 2007). other psychiatric conditions along with the incidence of full Other research also suggests that human-made disasters clinical presentation of PTSD, major depressive disorder, or traumatic events (particularly intentional human acts like generalized anxiety disorder and panic disorder. violent crime or terrorist acts) are often experienced as more The outcomes of nonspecific distress include those studies traumatic than those resulting from natural disasters, although in which there were elevations of a variety of stress-related psy- the literature is conflicting on this with some studies showing chological and psychosomatic symptoms rather than the pres- no real differences between natural and man-made disasters in ence of a specific syndrome. producing trauma (Noy, 2004). Finally, as mentioned earlier, The third set of outcomes, health problems and concerns, one response to traumatic stress is dissociation or removing include higher scores on self-report inventories of somatic oneself mentally from an inescapable situation (e.g., torture, complaints and medical conditions or elevated physiological rape, being mauled by a wild animal, prolonged exposure indicators of stress. Also, in this area are elevated reports of to horrific circumstances such as serving as a body handler/ alcohol, tobacco or drug use after a disaster. identifier following a disaster involving mass casualties). A fourth set of outcomes refers to chronic problems of There is evidence suggesting that if dissociation is present living. These refer to findings that victims of disaster are more as part of the traumatic stress reaction, the risk for developing likely than nonvictims to experience hassles or life events that subsequent PTSD may increase, although these results have serve as stressors in their own right. Specific examples could been inconsistent across studies. The relationship between include troubled interpersonal relationships, new family strains dissociation and more dramatic reactions may be due to the and conflicts as well as occupational and financial stress. dissociation itself or because the situation may have been pro- A fifth outcome, psychosocial resource loss, refers to losses longed or perceived as inescapable. Further, dissociation may in perceived social support, losses in the feeling of social embed- interfere with recovery because of the fragmentation among dedness, losses in self-efficacy, optimism and perceived control. thoughts, emotions and behavior--factors that help one to gain a full understanding of what happened and enable them to gain better control over anxiety reactions that can appear Factors that Increase the Risk for Adverse "out of nowhere" because a person is cut off from awareness Reactions to Trauma of the association between their reaction and its connection Numerous studies examined the factors that contribute to the traumatic event (Noy, 2004). to the development of PTSD in some individuals but not in Voges and Romney (2003) tested fifty-two individuals who others. Some factors associated with a higher risk for devel- were exposed to traumatic events that included physical or oping PTSD include: close proximity to the traumatic situa- sexual assault, an accident, combat, the sudden death of a fam- tion, prolonged exposure to the traumatic situation, situa- ily member, suicide of a family member, and a life threaten- tions involving extreme horror or gruesomeness, a personal ing illness. Forty-eight percent of the sample met criteria for history of stressful life circumstances or previous trauma, a PTSD. The Posttraumatic Stress Diagnostic Scale (Foa, 1995), lack of preparation for the possibility of a traumatic event, the Coping Inventory for Stressful Situations (Endler & Parker, increased pre-trauma anxiety about death, feelings of extreme 1999), the State-Trait Anxiety Inventory (Spielberger, 1983), helplessness during the event, feeling culpable for causing some and an ad hoc questionnaire designed to gauge vulnerability aspect of a traumatic event, and a lack of reference or ability and resiliency factors were administered to individuals exposed to return to "normal life" following the traumatic event (Galea, to a traumatic event who developed PTSD and those indi- Nandi, & Vlahov, 2005) viduals exposed to a traumatic event who did not experience The latter increases risk because psychological trauma PTSD. The results indicate that being female significantly often results in extreme disorientation and a lack of feeling increased the risk for developing PTSD following exposure to grounded. Hurricane Katrina would be a good example of this a traumatic event. due to the long waiting period before someone from the "out- Additionally, the degree to which one perceived their life to side" responded. Katrina survivors were cocooned within the be in danger or threatened significantly increased the likeli-

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44 hood of the development of PTSD. In this study, no relation- natural disasters, such as the 2004 Florida hurricanes. Low ship was shown between previous trauma, family history of amounts of social support, previous exposure to traumatic mental illness, personal history of mental illness, and the exis- events, and deficient health status were variables predictive tence of bodily injury and subsequent development of PTSD. of psychological symptoms for both young and old adults. Those who developed PTSD and those who did not develop Income and other financial difficulties (i.e., number of days PTSD reportedly experienced similar amounts of stress and dislocated from one's home and the number of post-insurance anxiety during the traumatic event. However, those individ- dollars lost) were predictive of psychopathology for older uals who directly experienced a traumatic event were more adults, but not younger adults. Indeed, risk factors that in- likely to acquire PTSD than those who witnessed a traumatic cluded financial factors were more significant for older adults incident. These results have important implications when which may reflect that economic difficulties following natu- detecting those at risk for the development of PTSD (females ral disasters are associated with older individuals' psycholog- and those who perceived their life to be threatened) and plan- ical health. ning treatment interventions. Wittman, Moergeli and Schnyder (2006) examined whether Adams and Boscarino (2006) examined the factors asso- symptoms of peritraumatic dissociation in acute stress dis- ciated with PTSD at one and two years following the WTC order (ASD) are predictive of the development of PTSD or disaster in a community sample. A great deal of interest has psychopathology later on. The Peritraumatic Dissociative focused on demographic characteristic (age, gender, race, Experiences Questionnaire, Clinician-Administered PTSD and socioeconomic status) that are associated with differ- Scale, Primary Care Evaluation of Mental Disorders, and Hos- ent rates of PTSD. The results indicate that younger individ- pital Anxiety and Depression Scale, as well as an assessment for uals (ages 1829), females, those who experienced more WTC the symptom criteria for ASD, were administered to patients disaster-related events, those who reported low levels of social in a Zurich hospital following recent accidents or assaults. The support, and those with low self-esteem had a greater risk of results indicate that no strong relationship between peritrau- developing PTSD symptoms one year following the disaster. matic dissociation and posttraumatic stress symptoms or gen- At two years following the disaster; however, those who were eral psychopathology existed. Additionally, there was a weak Latino, aged 3064, and who had low self-esteem were more relationship between pre-existing psychopathology and peri- likely to develop PTSD symptoms. traumatic dissociation. Those who experienced symptoms at two years following Birmes et al. (2003) examined the power of peritraumatic the disaster but not at one year (delayed-onset PTSD) reported dissociation and acute stress disorder in predicting PTSD symp- more suffering, more negative life events, and a reduction in toms and diagnosis three months after a traumatic event. Per- self-esteem post-disaster. Latinos were also shown to be at an itraumatic dissociation involves alterations in the experience increased risk for the development of PTSD. Those who re- of time, place and person during and immediately after trauma ported experiencing symptoms at one year post disaster, but exposure. Those reporting more peritraumatic dissociation not two years (remitted PTSD), reported an improvement in are at greater risk for the development of PTSD. self esteem and less negative events. Acute stress disorder is also a predictor of PTSD. Acute The work of Acierno et al. (2002) indicates that older Stress disorder includes a set of symptoms experienced within adults are typically more resilient to the psychological effects the first month following trauma exposure that include symp- of traumatic events and natural disasters yet have an increased toms of dissociation, intrusion, avoidance and hyperarousal. risk of negative post disaster physical health effects. Indeed, The Peritraumatic Dissociative Experiences Questionnaire-- increased age is connected with lower rates of post disaster Self-Report, Stanford Acute Stress Reaction Questionnaire, psychopathology, although it may reflect the fact that older Impact of Event Scale, and the Clinical-Administered PTSD adults tend to express psychological symptoms somatically. Scale were used to assess for peritraumatic dissociation, acute Acierno, Ruggiero, Kilpatrick, Resnick and Galea (2006) ex- stress disorder, and PTSD, respectively, in victims of violent amined older and younger adults who experienced the 2004 assaults. The results indicate that peritraumatic dissocia- Florida hurricanes. Symptoms of PTSD, major depressive dis- tion and acute stress disorder were significantly correlated with order, generalized anxiety disorder, previous exposure to trau- the presence of PTSD symptoms. These results may assist in the matic events, social support, and hurricane-related impact, pos- early detection of traumatized individuals at high risk for the itive outcomes, and current health status were assessed through acquisition of PTSD. the implementation of the National Women's Study Event Breslau, Lucia, and Alvarad (2006) examined the extent History-PTSD module, the Medical Outcomes Study module, to which intelligence, anxiety disorders, and conduct issues and the SCID-IV structured interview. during childhood affected one's susceptibility for being exposed The results indicated that older adults were indeed more to traumatic events and whether, once exposed to traumatic resistant than younger adults to the psychological effects after events, these factors influenced the development and expres-

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45 sion of PTSD symptoms. Indeed, previous research utiliz- and Hunt (2005) compared canine search and rescue team ing retrospective approaches have indicated that preexist- handlers deployed to the 9/11 disaster sites to canine han- ing anxiety, depression, and conduct issues during childhood dlers not deployed on measures of PTSD, depression, anx- increase the possibility that an individual will be exposed to iety, acute stress, peritraumatic dissociation, and clinical a traumatic event. diagnoses six months after 9/11. Self-report measures, such as This study, utilizing a prospective approach, employed the the Posttraumatic Stress Disorder Symptoms Scale Self-Report WISC-R, Teacher Report Form, and the NIMH Diagnostic (Foa et al., 1993), the Beck Anxiety Inventory (Beck et al., 1988), Interview Schedule for Children--Parent version 2.1 to assess the Brief Symptom Inventory (Derogatis & Coons, 1993), for intelligence, conduct problems, and anxiety in children at the Peritraumatic Dissociative Experiences Questionnaire age 6. At age 17, these children were interviewed to ascertain (Marmar et al., 1997), and the Interpersonal Support Eval- the number of traumatic events experienced and whether a uation List (Cohen et al., 1985), as well as interview mea- diagnosis of PTSD resulted. The results indicate that children sures, such as the Canine Handler Interview, the Structured who had been rated by teachers to be above the normal range Clinical Interview (First et al., 1995), the Posttraumatic Stress for externalizing problems (conduct issues) at 6 years of age Symptom Scale Interview (Foa et al., 1993), the Stanford were at an increased risk for being exposed to assaultive vio- Acute Stress Reaction Questionnaire (Cardena et al., 2000), lence but not other types of trauma. Children with a higher and the Relationship Assessment Scale (Hendrick, 1988) were IQ (above 115) were at a lower risk for exposure to all types utilized. of traumatic events. Additionally, males were shown to be ex- Results indicated that deployed canine handlers acknowl- posed to traumatic events more often than women. edged more psychological distress overall and reportedly Early identification of individuals with PTSD would aid in experienced more symptoms of PTSD than canine handlers the early utilization of mental health services to assuage many who were not deployed. Although deployed handlers' scores of the harmful effects of PTSD. Previous research has indi- on general distress measures were significantly higher than cated that the experience of peritraumatic dissociation during handlers not deployed, these individuals' scores were lower or immediately following the traumatic experience is a strong than expected and few individuals met diagnostic criteria for predictor of the development of PTSD later on (Fullerton et al., a psychological disorder. These results indicate the possi- (2000). One limitation of the existing research that documents bility of a more resilient population, as well as buffering fac- the influence of peritraumatic dissociation on PTSD is that it tors unique to this population (i.e., the use of companion has been retrospective in nature. animals that provides the impression of safety and protection). Birmes et al. (2003) used a prospective design to determine Important factors contributing to the resiliency of these res- if petritraumatic dissociation is independently predictive of cue workers include training (specifically, those handlers who intrusions, avoidance, and PTSD symptoms at 18 months and were certified members of FEMA were shown to be less likely 4 years following a fireworks disaster. The Peritraumatic Dis- to develop symptoms of PTSD), perceived marital satisfac- sociative Experiences Questionnaire, Dutch version of the tion, and alleged social support. SCL-90, Impact of Event Scale, and the Posttraumatic Stress Reactions during the stressful event have implications Disorder Self-Rating Scale were utilized. The results indicate for later development of PTSD symptoms. For instance, those that peritraumatic dissociation was not a significant indepen- individuals who experience dissociation and detachment dent predictor of intrusions, avoidance, or PTSD symptoms during the traumatic event were more susceptible to the devel- at 18 months or four years following the disaster. opment of PTSD symptoms and other disturbances later on. The results also indicate that initial intrusions and avoid- These results have useful implications for designing effective ance were independently predictive of intrusions, avoidance interventions and training programs. reactions, and PTSD symptoms at 18 months. Psychologi- Police officers are another group of first responders that cal distress was independently significant in the prediction of have received a great deal of study regarding reactions to trau- PTSD symptoms at both 18 months and 4 years. Being dis- matic events. Police officers frequently encounter potentially located following severe home damage put people at signifi- traumatic events. The most frequently reported traumatic cant risk for the development of intrusions, avoidance, and events experienced by police officers are violent death, injury PTSD symptom severity 4 years following the disaster. or the non-accidental death of a child, the threat of physical injury or unpredictable situations. The subculture of police of- ficers involves the denial of feelings and emotions and exhibit- Disaster and Trauma in Selected ing little concern for others' feelings. Indeed, many studies At-Risk Populations have indicated that police officers may disguise or hide their Research has indicated that emergency workers are at higher feelings or perceived personal flaws in order to fit in with the risk for the development of PTSD (Corneil et al., 1999). Alvarez prevailing "macho" police culture. This tendency interferes

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46 with the self-disclosure, which is necessary when receiving Individuals who exhibited either low levels of hostility or mental health support after traumatic events. high levels of self-efficacy or both sustained no increase in Recent research has started to recognize the healthy and psychological symptoms, indicating that these personality adaptive ways people cope with potentially traumatic and traits may provide a protective factor against the development stressful events. Higher levels of social support have been of stress-related symptoms. Social support has been shown recognized as being significantly associated with a lower to mediate the harmful effects of traumatic experiences and prevalence of PTSD. Alternatively, lower levels of social sup- decrease the likelihood of the development of PTSD. Thus, port have been shown to be related with more PTSD symp- individuals who score highly on hostility ratings may not have toms, anxiety, depression, and alcohol abuse in Vietnam the resources to handle the stress resulting from stressful expe- veterans. Indeed, research has shown that one of the most riences like those with low hostility ratings. important therapeutic tools for preventing and reducing These results have important implications in the identifica- PTSD symptoms is talking about the trauma. Disclosing trau- tion of individuals who are at high risk for the development of matic experiences has also been shown to result in positive psychopathological symptoms. Also, these results can assist in health outcomes. Research has indicated that perceived emo- the development of training and prevention programs and the tional support has shown the most consistent positive find- creation of screening processes for certain professions. ings (Marmar et al., 1997) Johnson, Langlieb, Teret, Gross, Schwab et al. (2005) exam- Bryant and Guthrie (2005; Bryant & Harvey, 1996) studied ined the physical and mental health effects of the recovery volunteer firefighters and found that proximity to death, efforts on workers at the World Trade Center disaster site. severity of trauma and perceived threat were associated with During the recovery process, workers (i.e. truck drivers, labor- the development of posttraumatic symptoms and PTSD. In ers, mechanics, heavy equipment operators) were frequently a longitudinal study of firefighters, McFarlane and Papay neglected and ignored in disaster planning and response pro- (1992) found that 77% of participants who developed PTSD grams and trainings. had a comorbid psychiatric diagnosis such as depression, panic A 62-item survey was developed to assess exposures at the disorder or phobic disorders. site and somatic and mental health symptoms of recovery Additional work with firefighters has generally found rates workers after exposure. In addition, an open-ended ques- of PTSD ranging from 1318% one to four years after the trau- tion was included to have participants share other concerns. matic event (Fullerton, Ursano & Wang, 2004; McFarlane & Johnson et al. (2005) reported the results of analysis of the Papay, 1992; North et al., 2002). open-ended question. They found that 24% reported a cur- Heinrichs, Wagner, Schoch, Soravia, Hellhammer and Ehler rent somatic complaint or an injury related to their recovery (2005) noted that predictors of the development of PTSD de- work. Many respondents wrote about their fears of future termined from retrospective studies have poor predictive power health consequences. Ten percent of the respondents volun- when evaluated in prospective studies. Therefore, Heinrichs teered that they had or were currently experiencing mental et al. (2005) used a prospective methodology in an attempt health symptoms that included sleeping problems, depres- to identify salient risk factors for firefighters in the develop- sion, anxiety, PTSD, and suicidal thoughts. ment of PTSD. This study assessed firefighters immediately Many reported using alcohol or drugs to cope and reliv- after basic training and at 6, 9, 12, and 24 months after job entry. ing their experiences in nightmares or during their daily The assessments included several self-report question- activities. A number reported a lack of respiratory protec- naires to measure demographic items, personality characteris- tion and training. Several respondents also reported that they tics, depression, anxiety and other measures of psychopathol- were unprepared to work with human remains both logisti- ogy and self-efficacy. In addition, salivary cortisol and urinary cally and psychologically. Additionally, these workers stated catecholamines were measured at each testing point. Higher that they devised their own ways of coping and conveyed a levels of cortisol predict the development of PTSD (Ehlert et al., great sense of pride for being able to assist in the effort. The 2001), and higher urinary catecholamines have been observed authors argued that these responses can assist in the prepara- in PTSD patients (Kosten et al., 1987). The results indicated tion and response efforts for future disasters. For instance, a that both cortisol and catecholamine levels before trauma broader array of individuals (besides firefighters, first respon- exposure did not predict the development of posttraumatic ders, etc.) should be included in planning efforts. A disaster stress symptoms over the course of two years. Results indicate response plan should be clearly communicated by employers that the amalgamation of preexisting high levels of hostility to the workers, and these workers should be provided with and low levels of self-efficacy predisposed individuals to the leadership and training. They further argued that disaster men- development of PTSD symptoms, depression, anxiety, general tal health services should be provided to workers to offset psychological distress, and alexithymia over a 2-year period the likely adverse mental health issues that can occur follow- following job entry. ing recovery.

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47 These workers should also be provided with specialized history of exposure to traumatic experiences may contribute training, such as specific coping strategies, stress reduction, nor- to their ability to cope and the severity of stress experienced mal reactions to stress, and how to obtain physical and mental following exposure to psychological trauma. Research indicates health support services. These specialized trainings should be that repeated exposure to trauma increases an individual's designed to accommodate the educational, literacy, and cul- vulnerability for pathology and is connected with more distress. tural makeup of the workers. Above all, these workers should However, the literature also suggests that individuals frequently be recognized for their efforts; recognition will help ensure that exposed to trauma are more resilient and this exposure is thus appropriate training and planning efforts are designed to in- beneficial. clude them in future disasters and will elevate job satisfaction. Dougall, Herberman, Delahanty, Inslicht and Baum (2000) One of the more debilitating symptoms that may result examined 159 rescue and emergency workers and airport from exposure to trauma is the experience of frequent and and medical personnel who recovered and sorted personal persistent intrusive thoughts. These thoughts or memories belongings, plane wreckage, and located, transported and iden- may be particularly distressing if they occurred independ- tified human remains. The participants were involved in four ently of any environmental cues. These thoughts may persist testing sessions. The testing sessions occurred at four to eight for years, but often their frequency decreases as time passes. weeks, and six, nine and 12 months after the crash. Measures Schooler, Dougall and Baum (1999) examined the type of trauma history, intrusive thoughts, and psychological dis- of intrusive thoughts experienced by rescue workers follow- tress were obtained in each session along with measures of ing the crash of Flight 427. Using the IES, GSI, and Intrusive heart rate, blood pressure and a urine sample to measure cat- Thoughts Questionnaire, participants' frequency of intru- echolamine levels. sive and avoidant thoughts, distress, and environmental cues Dougall et al. (2000) reported that previous exposure to associated with thoughts regarding an event were assessed at traumatic events that were similar to the current one was one to two months, six months, nine months, and 12 months not related to lower levels of stress. However, frequent past following the event. The results indicated individuals tended to exposure to traumatic events that were dissimilar to the crash think less frequently about the crash as time passed. Individu- of Flight 427 was significantly related to more distress. Indeed, als also rated their thoughts to be less disturbing over time. more recurrent exposure to past dissimilar traumatic experi- Additionally, the frequency of disturbing thoughts in the ences was related with more distress and intrusive thoughts; month following the crash was not predictive of distress however, this relationship was not found with physiological later on. However, the long-term impact of intrusive thoughts arousal variables, such as heart rate, blood pressure, and uri- tended to depend upon the degree of stress invoked by those nary catecholamine levels. intrusive thoughts. For example, those individuals who fre- The impact of previous experience with stress on the sub- quently experienced uncued thoughts regarded these thoughts sequent development of PTSD is complicated. Mills et al. to be more disturbing than those individuals who only experi- (2007) examined the effect of Hurricane Katrina on the men- enced thoughts prompted by environmental cues, even though tal health of displaced individuals. Specifically, they examined the frequency of thoughts between the uncued and cued groups how demographic variables and experiences during the dis- did not differ. aster predicted the development of acute stress disorder (ASD), As a result, the individuals who experienced uncued intru- which is a major stress response in the first month after trauma sive thoughts reported more distress than those who expe- exposure. Previous work reported that the presence of ASD rienced cued thoughts. These individuals who experienced predicted the occurrence of PTSD up to 2 years posttrauma uncued thoughts were more prone to display signs of chronic (Harvey & Bryant, 2002). stress and report continuing intrusive thoughts for the year A Katrina-specific questionnaire, the Traumatic Events following the crash. For example, early uncued thoughts and Questionnaire, and the Acute Stress Disorder Scale were uti- the distress resulting from intrusive thoughts in the month lized to assess demographic information, prior exposure to following the crash were correlated with higher incidences of trauma, and acute stress disorder (as acute stress disorder has intrusive thoughts and avoidance at six, nine, and 12 months been shown to predict PTSD up to two years following a trau- following the crash. Although the frequency of intrusive matic event). The results indicate that individuals with prior thoughts has typically been used as a gauge for later distress psychological problems, females, Black racial status, those and adjustment, the work of Schooler, Dougall and Baum who experienced an injury as a result of Katrina, and those (1999) indicates that the magnitude of distress resulting from who perceived a threat to their life were more susceptible for intrusive thoughts is an important measure in determining the development of ASD. who may experience distress later on. These factors were indicative of acute stress symptom One factor that seems to be related to the development of severity. However, prior exposure to trauma was not a pre- PTSD is the individual's prior trauma exposure. An individual's dictor of acute stress in this sample. Yet, Epstein, Fullerton

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48 and Ursano (1998) examined the factors that increased one's parison group not exposed to the disaster was also used. The susceptibility for developing PTSD following the Ramstein air disaster involved a fire in a fireworks depot in the Netherlands. disaster in 1988. In this situation, military health care workers The results indicate that rescue workers who responded to the were subjected to varying amounts of involvement and sub- disaster experienced an increase in psychological, respiratory, sequent distress in the evacuation of victims and recovery of musculoskeletal, and nonspecific symptoms immediately the crash site. following the disaster as compared to their pre-disaster levels By employing scores from military medical care workers and a control group of rescue workers who were not exposed on the SCID-NP, SCL-90-R, the Impact of Event Scale, and to the disaster. These results indicate that even with training, several open-ended questions at 2, 6, 12, and 18 months fol- rescue workers are not immune to the physical and psycho- lowing the disaster, these researchers determined that lower logical effects of exposure to traumatic events and disasters. educational level, exposure to burn victims, a higher incidence Given that trained disaster workers are at risk for the of stressful life events following the initial traumatic event, and development of physical and psychological symptoms fol- feeling numb immediately following exposure to the event all lowing exposure to trauma, it would seem that volunteers with independently predicted the development of PTSD. Provid- minimal training would be especially susceptible to the nega- ing care for burn victims was the best predictor of the acqui- tive effects of exposure to trauma. Hagh-Shenas, Goodarzi, sition of PTSD. Furthermore, exposure to stressful life events Dehbozorg and Farashbandi (2005) compared the psycho- after the disaster exacerbated the severity of PTSD symptoms. logical status of rescue personnel who received formal train- Fullerton, Ursano, and Wang (2004) improved the method- ing prior to disasters to those who did not receive any formal ological rigor in this area by examining exposed disaster work- training before helping with the Bam earthquake disaster in ers who handled the response and recovery of a major airline the Kerman province of Iran. The groups compared were two crash compared to a group of disaster and rescue workers from groups with formal training (Red Crescent: Red Cross workers a similar community not exposed to the disaster. Study par- and firefighters) and a group of university student volunteers ticipation occurred 2, 7, and 13 months post disaster. These with no prior formal training in handling traumatic situations. researchers identified the existence of PTSD by utilizing the The participants completed three self-report scales 75 to DSM PTSD-IV Scale during the thirteen month post disaster 103 days after the earthquake. The following is a list of the mea- interview. Acute stress disorder was assessed in accordance with sures used (1) the General Health Questionnaire that measures the DSM-IV criteria one week following the disaster. Depressed physical health, anxiety, social functioning and depression; and non-depressed participants were identified by using a stan- (2) a measure of symptoms of post-traumatic stress in a civil- dardized cutoff for responses on the Zung Self-Rating Depres- ian population; and (3) the Anxiety Sensitivity Index (ASI) sion Scale, measured at 7 and 13 months following the disaster. which measures negative consequences to the experience of This research indicates that disaster workers were more anxiety. The results indicate that the university student volun- likely to develop ASD and PTSD than the comparison groups. teers experienced more unpleasant psychological effects than Also, the exposed disaster workers had higher rates of depres- the Red Crescent workers and fire fighters. It was shown that sion at both seven months and 13 months after the disaster the university student volunteers scored higher on measures than the comparison group. Those workers who were diag- of PTSD, intrusive thoughts, emotionality, depressive and anx- nosed with ASD were over seven times more likely to meet iety symptoms, and physical health symptoms. These results the diagnostic criteria for PTSD at 13 months post-disaster. highlight the impact of formal training as a barrier against the Those workers exposed to the disaster who exhibited early development of PTSD following traumatic experiences. dissociative symptoms were at an increased risk for display- It is clear that those with a direct exposure to a traumatic ing signs of PTSD and depression at seven months follow- event experience physical and psychological problems after ing the disaster. Additionally, workers with prior experience the exposure. Boscarino, Adams and Figley (2006) examined with traumatic events or disasters were almost seven times the impact of the September 11, 2001 terrorist attacks, the more likely to develop PTSD. The rates at which these workers ongoing threats of further attacks on worker productivity and sought services for emotional problems were nearly four times threats to outpatient service use 1 and 2 years after the attacks. that of a control group. These results highlight the importance The participants were ordinary citizens living in the New York of early identification of dissociative symptoms, depression, area (not rescue workers). and the existence of exposure to prior traumatic events in plan- Boscarino et al. (2006) argued that panic attacks and psy- ning health care services for disaster workers. chological distress were prevalent among New York City Morren, Dirkzwager, Kessels and Yzermans (2007) exam- adult residents following the terrorist attacks. Worker pro- ined the effects of disaster on the health of rescue workers using ductivity was also affected. Research indicates that employ- both pre-disaster and post-disaster health records, noting ees who worked near the World Trade Center disaster site absences from work attributable to health problems. A com- experienced increased physical and psychological distress.

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49 The incidence of worksite shootings, employee violence, and regarding probable PTSD (19.1% east coast, 18.3% west coast) accidental injuries also increased. This study interviewed in- despite the fact that the East Coast flight attendants were twice dividuals 1 year following the attacks and again at a two year as likely to know someone who perished as a result of the follow-up. The number of workdays lost, the number of September 11 attacks than West Coast flight attendants. The lower quality workdays, and the number of doctor visits authors argued that their results were evidence of a psycholog- within a 12-month period was assessed. ical contagion--a spreading of the negative impact of trauma Additionally, the survey assessed the presence of PTSD to those who do not have direct contact with the source of (assessed by a scale that utilized DSM-IV criteria), the exis- the threat. tence of depression (assessed by a scale that utilized a version Lating, Sherman and Peraquine (2006) further examined of the SCID), the presence of three stressors (i.e., exposure this issue by including a third group of flight attendants who to the World Trade Center disaster, negative life events, and were not employed by American Airlines at the time of the traumatic life events), one's history of chronic diseases, mental September 11 attacks but were employed by American Air- health service utilization, social support, and self-esteem. The lines at the time of this study. Further, this third group of results indicated that there was a strong correlation between flight attendants was not operating out of the East Coast or exposure to the World Trade Center disaster and lower worker West Coast at the time of this study. The results indicated that productivity; this effect was seen primarily in the year follow- there were no significant differences among the three groups ing the incident. The existence of PTSD and depression was regarding the reported incidence of probable PTSD. also shown to be correlated with lower worker productivity The rates of probable PTSD for East Coast (19.1%), West in the first year after the disaster. Coast based (18.3%) and the attendants hired after Septem- Although the relationship between exposure to the attack ber 11, 2001 (15.1%) were not significantly different. The results and lower productivity existed at the 2 year follow-up, this con- were similar to the 13% prevalence rates of male rescue workers nection was less significant and less reliable. PTSD was shown after the bombings in Oklahoma City (North et al., 2002), the to be related to lower work quality at the two year follow-up; 20% prevalence rates of residents living near the World Trade however, depression was not related to work quality at the two Center (Galea et al., 2005), and the 23% probable PTSD preva- year follow-up. These results indicate that interventions and lence rate for Pentagon staff members (Grieger, Fullerton, & programs should be designed to negate some of the harm- Ursano, 2004). The above prevalence rates should be viewed ful effects that result from exposure to disasters and trau- in the context of a 4% national prevalence rate of probable matic events. PTSD (Sclenger et al., 2002) Schlenger, Caddell, Evert, Jordan, Rourke, Wilson, Thalji, The deleterious impact of exposure to trauma has been Dennis, Fairbank and Kulka (2002) also studied the impact of identified in the children of first responders. Hoeven (2005) the September 11 attacks on the general population. Following reported that one factor that likely contributed to children the World Trade Center disaster, those individuals who lived with emotional disturbance 6 months after the September 11 closest to the disaster site were more at risk for the development terrorist attack was having a family member exposed to the of PTSD than those who lived farther away from the site. attack. Duarte et al. (2006) reported that children had a higher Through the employment of the PTSD Checklist (PCL), the rate of probable PTSD 6 months following the attack on the SCL-90, and the Brief Symptom Inventory, this study assessed World Trade Center when a family member was an emergency PTSD symptoms and other clinically significant mental health medical technician (18.9%) or there were two first responders symptoms in adults in New York, NY, Washington, D.C., and in the family (17%) compared to those that had no first respon- other metropolitan areas in the United States. The results indi- ders in the family (10.1%). cate that those who lived in New York City were significantly Propper, Stickgold, Keeley and Christman (2007) utilized more likely to develop PTSD than individuals who resided in 11 undergraduate students taking a class on dreaming in a other metropolitan areas, including Washington, D.C. study that examined the effects of media coverage of the Sep- tember 11 terrorist attacks. Students had recorded their dreams prior to and after the terrorist attacks. It is of note that the The Nature and Correlates of Vicarious students lived in the Boston area (where one of the planes or Secondary Trauma Exposure involved had taken off) so they may have experienced more Lating, Sherman, Lowry, Everly and Peraquine (2004) ex- stress than the general population. Results indicated that amined vicarious traumatization by examining American Air- students had more event-related dreams following the attacks line flight attendants who worked on the East Coast (n = 513) and the frequency of the dreams and distressing content was and the West Coast (n = 353) on measures of general well- directly associated with the number of hours they observed being, psychological symptoms, life-functioning and probable these events on television--a 56% increase in the propor- PTSD. There were no significant differences between the crews tion of post-attack dreams containing features related to the

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50 attacks for every hour of television watching. Also of signifi- distress as a function of number of contacts with trauma sur- cant note is the fact the time spent talking to others resulted vivors. Previous experience working with trauma survivors in less dreaming about specific events related to the attacks; for mental health professionals decreased the risk of distress. this supports Pennebaker's finding that talking with other More experienced practitioners experience less distress. Mental people ameliorates stress (Pennebaker, 2001). health worker participation in volunteer activities was asso- Results suggest that time spent talking with other people ciated with less distress and more positive feelings in working about the attacks may have improved processing of the trau- with disaster victims. matic events. This study concurs with previous works which show that as people recover from traumas, their dreams con- Screening and Intervention Methods textualize traumatic events, shifting from dreams with specific features of the events to dreams with only thematic associations Screening and Identification of At-Risk to the trauma. In summary, this research suggests that televi- Individuals in the Early Stages Following sion watching of traumatic events increases traumatic stress Traumatic Events and distressing dreams about the event. Furthermore, talking There are a number of mental health screening tools avail- about the trauma with other people decreases stress, improves able for use with individuals who have had exposure to trau- cognitive and emotional processing of the event, decreases the matic circumstances. These tools may be used to assess the pres- frequency of disaster related dreams, and changes the nature of dreams about the event. These results suggest that talking ence of psychopathology from exposure to traumatic events about the traumatic event enhances the recovery process. over the long term (National Center for PTSD Resources, Palm, Polusny and Follette (2004) review the evidence on 2008). Many of these tools are brief self-report measures that vicarious traumatization in disaster and trauma to emer- can be completed in five to ten minutes and which may be gency workers and journalists. As noted previously, vicari- useful in identifying individuals at risk. Research has shown ous traumatization has been referred to as secondary trauma- that individuals who exhibit severe adverse mental health tization and compassion fatigue. It describes post traumatic reactions in the acute period following exposure to trauma stress reactions experienced by those who are indirectly ex- are at a higher risk for long-term problems in the form of posed to traumatic events. Vicarious trauma reactions include PTSD, depression, health problems, and decreased quality intrusive thoughts/images, avoidance, emotional numbing, of life (Birmes et al., 2003, Bryant, Harvey, Sackville, Dang, hyperarousal, somatization, physical problems, alcohol use & Basten, 1998; Bryant, Sackville, Harvey, Dang, Moulds, problems--all similar to those experienced by direct trauma & Guthrie, 1999). Therefore, early screening is an important survivors. Also noted are changes in self-identity, world-view, component of disaster planning and recovery efforts. and spirituality, and general psychological health, disruption In a comprehensive review, Brewin (2005) identified several in beliefs about safety and personal vulnerability and feel- measures that are reliable and valid for early screening and ings of powerlessness. Perceptions and meanings regarding identification of individuals at risk of PTSD following mass life and the world can change. trauma. He noted that useful screening instruments in this Palm et al. (2004) indicate that family, friends, co-workers, context should contain the minimum number of items neces- professionals who assist direct trauma victims, media person- sary for accurate case identification, be written in understand- nel, general population exposed to repeated media coverage of able language, have a purpose that is transparent and accept- events, physicians and other medical personnel, emergency re- able to the respondent, be applicable to varying populations sponse personnel such as police/firefighters/paramedics, rescue experiencing varying traumatic events, and have simple scor- workers and body handlers are at risk for vicarious traumatiza- ing rules that can be scored by non-specialists. tion. Factors that increase the risk for vicarious traumatization Only screening instruments that had been previously vali- include listening to graphic details and consecutive interactions dated by comparison to a structured clinical interview for with trauma survivors, personal loss related to the event, higher PTSD--the Structured Clinical Interview of DSMIV (SCID) levels of stress in general, and poor coping skills. PTSD Module (First, Spitzer, Gibbon, & Williams, 1995) Palm et al. (2004) indicate that the findings for vicarious or the Clinician Administered PTSD Scale (CAPS; Blake, traumatization in healthcare workers are inconsistent. Some Weathers, Nagy, Kaloupek, Gusman, Charney, et al., 1995)-- research suggests that the stressors related to disaster work were included in the review. Instruments had to apply to increase the vulnerability for distress. Other research indi- adults and be applicable to any trauma population. Screening cates that disaster workers, especially rescue workers are well instruments longer than 30 items were omitted because they trained and more resilient. Some studies indicate no increase may take too much time. Thirteen instruments were identified in traumatization as a result of repeated exposure to trauma as the best screening instruments based on the previously survivors and their stories while other studies show increased noted desired characteristics as well as the inclusion criteria.

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51 Several measures approached the performance of the SCID It would appear that careful disaster planning and organi- or the CAPS. This was often accomplished by raising the cut- zation, appropriate and timely screening, appropriate train- off score. The Impact of Events Scale (IES; Horowitz, Wilner, ing for those involved in identification and triage of at risk in- & Alvarez, 1979) and the Trauma Screening Questionnaire dividuals, and access to services independent of whether or (TSQ; Foa, Riggs, Dancu, & Rothbaum, 1993) were found to not a person is in distress or is experiencing more entrenched be the best screening measures overall; they had been tested mental health issues would help to find some common ground in the first year following a traumatic event--another aspect from these two important perspectives on the best way to con- of these measures that was examined in this review--making ceptualize and subsequently manage at risk individuals in the them especially useful for monitoring victims during the early aftermath of disaster. months following a trauma to identify the individuals who may need further intervention. Early Intervention Issues and Strategies On a different but related note, Horowitz (2007) exam- in the Acute Stages Following ined the difference between distress and disorder and the im- a Traumatic Event portance of distinguishing the two. He describes disorder as existing within the individual which may be independent of Prior to the 1980s, there were no mental health interven- environmental stress and which may or may not be a result tions following disasters. As more was learned about trauma of environmental stress. In this case, as environmental stress from the Vietnam veterans in the early 1980s, Psychological decreases, symptoms will likely persist, and if a mental dis- Debriefing, a model developed in response to the needs order does exist, treatment is warranted. Distress is defined of the Vietnam veterans and later more fully described by as a normal human response to stressful environmental Dyregrov (1997) began to be routinely applied in circum- circumstances--a situation that does not require a diagno- stances involving traumatized victims of adverse events. Psy- sis of a mental disorder. In this case, as environmental stress chological debriefing is a group intervention method that decreases, symptoms of distress are likely to also decrease. is applied within 4872 hours following a trauma. Sessions Distress is most likely to be a consequence rather than a encourage group participants to describe factual components cause of stress. Measures of environmental stress exist that and process emotional components of the trauma experience. could help determine what responses are expected and nor- Its use rests on the belief that this immediate processing of mal and which responses are signs of disorder. the event allows the individual to reorganize the memory of the The importance of distinguishing the two relates to how event so that it is recalled in a less traumatic way (Van der Kolk, each are treated. If distress is treated as a disorder, then ap- 1997). Critical Incident Stress Debriefing (CISD), developed by propriate environmental changes to reduce stress may not be Mitchell in 1988, expanded and further articulated a process addressed (e.g., treating symptoms pharmacologically rather for psychological debriefing (Everly & Mitchell, 2000; Mitchell, than looking at and modifying the source of the stress). Over- 2004; Mitchell, 1988; Riddell & Clouse, 2004) that was later all, recognizing distress will help in emphasizing the impor- termed Critical Incident Stress Management (CISM). tance of making adjustments to the environment to reduce Katz et al. (2002) review the literature from 1966 to 2002 re- stress. This would be especially true in the event of a disaster lated to what interventions have been used for prevention and as many are distressed, relatively few develop disorders, and intervention during the first two months after an event. Their restoring the environment and support systems to normal review of acute psychiatric interventions indicates that the functioning as soon as possible is likely to reduce or eliminate primary focus has been on attempts to minimize the long-term symptoms and distress. Focusing on the "individual with a effects of disaster trauma on its survivors. They note that sev- mental disorder" as the sole source of the problems may delay eral organizations have come up with intervention teams (e.g., addressing these larger social issues. US Navy Special Psychiatric Intervention Teams (SPRINT), Conversely, Dyregrov (2004) proposes that "demedicaliza- the US Army Stress Management Team (SMT)). Also noted tion" has gone too far in some cases. He argues that demed- is the fact that these interventions have been generously ap- icalization had led to individuals not receiving essential plied in the absence of any scientific evidence that they reduce professional intervention. As Horowitz (2007) suggests, deme- psychiatric morbidity and further note that the same has been dicalization refers to labeling a condition of distress as disorder, true for most acute interventions that "are often performed which may diminish an individual's natural coping resources post-trauma on the basis of good intentions and theorized and decrease the focus on environmental issues that would re- benefits" (Katz et al., 2002, p. 208). Until more recently, duce or eliminate distress. Dyregrov (2004) argues that this these models have been routinely utilized in emergency and movement to demedicalize the effects of trauma produces bar- disaster situations despite a lack of evidence-based outcome riers to getting necessary and often desired professional mental studies demonstrating their safety, usefulness in the acute health services. phase following disaster, and whether they decrease the risk

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52 for longer-term post traumatic reactions. In fact, it has been Due to the fact that it may be impossible in the short term noted that debriefing is often the "default" in organizations to conduct controlled studies on these early interventions, dealing with disaster (cited in Blythe & Slawinski, 2004). experts have come together to determine what we do know However, these methods and models are now questioned by about how people cope with trauma and how that can be many experts in the field and have come under much scrutiny applied in the event of disaster (Blythe & Slawinski, 2004; and criticism due to questions about their effectiveness in Hobfoll, Watson, Bell, Bryant, Brymer, Friedman et al., 2007; decreasing distress and preventing negative longer-term out- International Society of Traumatic Stress Studies Resources, comes in those individuals exposed to traumatic events (Blyth 2008; WHO, 2006). & Slawinski, 2004; Greenberg, 2001; Pennebaker, 2001). Sev- eral large-scale meta-analyses have not yielded positive findings Addressing Grief regarding psychological debriefing and CISD/CISM (Rose, and Bereavement Bisson, Wessely, 2003; Rose, Bisson, Churchill & Wessely, 2005; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp, 2002). Prevention and Management In review of debriefing methods, researchers indicate that of Vicarious Traumatization the application of debriefing is controversial and, although Palm et al. (2004) suggest the following in order to limit some show benefit in the short term, others report a worsen- vicarious trauma reactions. They detail recommendations for ing of symptoms. Some studies that do show benefits are not interventions at the individual and organizational levels. controlled and when controlled, show short term benefits The following is a list of actions which may limit vicarious but no long term benefits in decreasing adverse outcomes trauma reaction at the individual level: spending time with (Deahl, Gillhan, & Thomas, 1994; Hobbs, Mayou, Harrison, other people outside of the work environment/staying con- & Worlock, 1996; Kenardy, Webster, Lewin, Carr, Hazell, & nected and not isolating oneself, asking for support, engaging in Carter, 1996). These analyses suggest that, at best, psycho- activities that provide a sense of purpose, attending to physical logical debriefing can help people feel better in the short health, maintaining balance between professional, physical and term but that it has a negligible effect on long-term outcomes emotional aspects of life, attaining social support, accepting that for prevention of PTSD and stress-related problems. In some emotional distress in trauma survivors is a "normal" reaction to cases, those who have engaged in psychological debriefings traumatic events, limiting unnecessary exposure to traumatic have shown increased acute distress and poorer long-term events by decreasing exposure through the media/newspaper, outcomes than those who received non-CISD or no formal maintaining balance in the work situation, taking vacations, support. This finding suggests that debriefing may actually identifying personal limits, and talking to coworkers. Poor be harmful. communication with coworkers has been shown to increase In response to these criticisms, Mitchell and others empha- risk of adverse vicarious post-traumatic stress reactions. size that debriefing is just one component of CISD/CISM, The following is a list of actions which may limit vicarious and that it was never intended as a stand-alone method that trauma reaction at the organizational level: providing appro- should be applied to all people in the same manner and tim- priate training for dealing with trauma and disaster, provid- ing (Mitchell, 2004). Mitchell and others also note that many ing information about traumatic stress reactions, effective cop- of the studies included in these reviews were poorly designed ing and possible interventions and encouraging use of natural and as such that they do not accurately reflect the efficacy of social support systems, normalizing traumatic stress reactions, CISM (Everly & Mitchell, 2000; Mitchell, 2004; Mitchell, 1988; being encouraged to advocate for survivors or change policy Riddell & Clouse, 2004). to help survivors, ensuring manageable workloads, creating The debate continues, but most experts in the field have a respectful, supportive work environment, having access to made some recommendations regarding how to best proceed. support resources without fear of negative consequences, and Namely, more well-designed studies assessing the short- encouraging vacations. Lack of social support in the work sit- and long-term effects of debriefing are needed to clarify the uation, poor communication, and poor support from super- nature of the current controversy. Despite the fact that some visors has been associated with increased risk for secondary studies have found CISM to have a positive effect and that trauma, burnout, and fatigue. most research on traumatic stress indicates that some form of reprocessing of the events is a necessary part of the recovery The Use of Pharmacologic Interventions process, most feel that the application of debriefing methods in the Acute Stages of Trauma should not be the "default" mode for early interventions at this point in time--especially in light of findings that it Katz et al. note that the use of medication in the treatment caused harm for some individuals (Blythe & Slawinski, 2004; of acute trauma is not well studied although the studies that Rose et al., 2003; Rose et al., 2005; van Emmerik et al., 2002). exist note that anxiety medication may show some minimal

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53 effects in improving long term outcomes; tricyclic anti- programs were used, and while they enjoyed a high rate of depressants and selective serotonin uptake inhibitors show satisfaction among the participants, the single session did not significantly reduced rates of PTSD and ASD; antiadrener- "prevent the development of negative psychological sequelae." gics may have prophylactic effects (although these were These sessions may be useful in reduction of immediate dis- laboratory studies); glucocorticoids may have a positive tress and/or identification of individuals needing referral to effect for PTSD. Overall, just a few studies exist that exam- additional mental health support services (van Emmerick, ine the use of medication in the acute phases after a trau- et. al, 2002). matic event. The International Critical Incident Stress Foundation (ICISF) supports a model developed by Dr. Jeffrey Mitchell in which a multiphase interaction with small groups and Treatment and Intervention Methods individuals would proceed through a stepwise progression of Longer-Term Post-Trauma Reactions with the support of trained psychologist and professional peers The comprehensive review by Bisson and Andrews (2005) (CISM in Aviation). ICISF has been utilized by major groups reflects the state of the current evidence-based treatments for in the aviation industry including airport personnel, air traf- longer-term post-traumatic reactions, namely Post Traumatic fic controllers, airlines, and pilot groups. Stress Disorder. The conclusions from this review of 33 con- While the authors claim CISM effectiveness is proven, trolled studies on treatment of PTSD indicate that individual prospective clinical trials are lacking. Without evidence to trauma-focused cognitive-behavioral therapy, eye movement show its effectiveness over that of the natural course of desensitization and reprocessing (EMDR), stress management, trauma, which includes spontaneous recovery for some indi- and group administered trauma-focused cognitive behavioral viduals, its effectiveness, while inherent, is not scientifically therapy are all effective in treating PTSD. verified. Research involves self-reporting and the assessment There is some evidence that cognitive behavioral therapy of return to work data. While program satisfaction is noted, and EMDR are more effective than stress management. it has not been correlated with improved performance or General psychological treatments that are not specific to decreased incidence of psychological complications, such trauma (e.g., generic cognitive-behavioral therapy) were as PTSD. Statements regarding prevention of stress compli- found to be less effective than trauma specific treatments. cations were not supported with data in their publication. The review did not provide sufficient evidence to determine The process appears to be very promising, but clinical trials are if psychological treatment could be harmful, but there was needed to show statistical significance in operator performance a greater drop-out rate in active treatment groups relative to as a result of this program. control groups. Overall, this review most strongly supports the use of individual or group cognitive-behavioral therapy An Integrative Organizational Approach or EMDR in treating PTSD, although many questions re- main unanswered with regard to treating longer-term post Jones, Roberts, and Greenberg (2003) describe a strategy trauma reactions. that can be used within a variety of organizations that utilizes peer assessment to identify individuals at risk of developing mental illness following a traumatic event. Treatment Strategies The management protocol as described by Jones et al. Peak performance in a safety-sensitive occupation is not (2003) involves an organized strategy for intervention plan- unique to aviation. Much of the literature that addresses ning and a selection of personnel to be trained in risk assess- workplace critical incidents refers to manuals that provide ment. Specific management strategies include effective site procedures, support personnel, and guidance to manage the management (e.g., minimizing exposure to the traumatic emergency (Federal Aviation Administration, 2008). These event, rotating personnel, ensuring adequate rest), a plan- publications greatly assist individuals who may not recall ning meeting to engage organizational management who proper procedures or make an incorrect decision in the chaos know about the event and who was exposed--including the of an emergency. Publications and strategies are also available support of line-managers to ensure successful implemen- to provide guidance to personnel on critical incident stress tation, making a decision at the planning meeting as to management programs with the goal of improving resiliency whether any intervention is required (organizers are trained and decreasing the prevalence of psychological trauma and its on the situations most likely to result in higher risk of post- associated complications. traumatic distress), conducting a risk-assessment interview While reaching out to assist passengers, their families and using a "before, during and after" with either groups or indi- co-workers is a natural response in disasters, a wide variety viduals to identify those at risk, and conducting a one-month of techniques were used. Single session debriefing (CISD) follow-up interview.

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54 The strategy has a structure for large-scale events that uti- disasters can extend far beyond the immediate geographic lizes a "filtering template" (e.g., those directly exposed, those area with geographic proximity to the disaster listed among with family/friends involved in the event, rescuers and emer- the demographic factors of those at higher risk for negative gency personnel, large-scale community traumatization, vul- mental health consequences. nerable individuals who react strongly to minimal stress, those It has also been determined that the current disaster men- who would have been involved but were not) to ensure that all tal health response model is adequate to meet the short-term personnel are considered in the plan. Overall, these authors mental health needs of most victims (Felton, 2004). However, describe some very concrete strategies to implement within an this mental health response model is inadequate to meet the organization to address post-trauma distress and to facilitate needs of those who develop severe and persistent mental referral as needed. health symptoms following a disaster. This strategy can be used for small-scale trauma involv- Felton (2004) acknowledges the widely accepted belief ing one or a few individuals to large scale disasters involving that mass media propagates negative mental health reactions multiple individuals and multiple organizations. It also builds by continual exposure to horrific scenes, but empirical data upon the positive components of psychological debriefing-- to support this belief are rare. However, he asserts that mass using an interview format to detect those experiencing sig- media is a crucial communication link during disasters. Specif- nificant post-traumatic stress--and addresses the criticisms of ically, mass media is a great tool useful for informing the pub- psychological debriefing in that it does not encourage excessive lic about mental health response efforts and where to seek exploration of emotions (Rose, Bisson, & Wessely , 2003; Rose, mental health support. Bisson, Churchill, & Wessely, 2005). Gheytanchi, et al. (2007) provided a critical analysis of This strategy involves personnel management by well- the response efforts which occurred during the Hurricane trained and psychologically informed managers as well as Katrina disaster. This analysis identified the following twelve early referral if mental health support is needed. The strat- major failures which contributed an inadequate response: egy itself involves training managers to identify those at risk (1) lack of efficient communication, (2) poor coordination through the use of a risk-assessment checklist--an assessment plans, (3) ambiguous authority relationships, (4) unclear of risk factors that can be easily observed or assessed through leadership structures, (5) recent federal government focus on an interview. counterterrorism versus all-hazards response, (6) ambigu- As a final note regarding intervention, Disaster Action is a ous training standards and lack of preparation, (7) failure charity whose members consist of survivors and bereaved to evaluate lessons learned, (8) performance assessment was from major disasters. This group of survivors has developed not integrated into the process, (9) failure to evaluate race and a code of ethics in order to protect the rights and interest of socio-economic status as response factors, (10) rumor and those affected by disaster. It is designed to influence the at- chaos, (11) lack of personal and community preparedness, titudes and behaviors of anyone who works with those af- and (12) uncertainty about the effects and roles of disaster fected by disasters that may include local authorities, coro- mental health plans and professionals. ners and all involved in identification processes, members Examination of the disaster mental health response re- of emergency services and investigation teams, and volunteer veals that the best method of intervention in traumatic agencies. events is uncertain and evidence-based interventions are ambiguous. One widely applied intervention, Critical Incident Pre-Disaster Planning Stress Debriefing (CISD), faces much criticism. As a result, and Preparation alternatives to CISD are becoming more plentiful. How- ever, the mental health community seems resistant to ex- Learning Lessons plore and adopt these contemporary intervention methods Tremendous emphasis is placed on the importance of after- (Gheytanchi, 2007). action reports in disaster recovery. Following through with Furthermore, Gheytanchi et al. (2007) asserts that men- these after-action procedures is rare, but the lessons that emerge tal health professionals should engage more directly with lead to the development of a disaster management protocol. disaster planning agencies. This would allow the role of Recently, several articles have identified the importance of the the mental health professional to expand the treatment of integration of mental health planning and response as a lesson trauma and include mental health planning and mitigation. learned from previous disasters. Gheytanchi et al. (2007) also state that more mental health Felton (2004) specifically addresses the lessons learned integration may also improve some of the previously listed in regard to the mental health impact of terrorism in the wake factors which lead to an inadequate response including com- the September 11 terrorist attacks in New York City and munication, coordination, command structures, training, Washington, DC. Felton (2004) states that impact of such assessment, rumor, and preparedness.

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55 Individual and Community Resilience estingly, this study found that higher education levels were and Exposure to Traumatic Circumstances associated with decreased resilience. Decreases in income, decreases in perceived social support, and the presence of It is interesting that so much of the research on disaster chronic disease predicted decreased resilience. Finally, people recovery has focused on risk or vulnerability factors related who had not experienced traumatic events prior to Septem- to the development of psychopathology such as PTSD because ber 11th, who had no recent life stressors, and who had no the majority of those exposed to traumatic circumstances additional trauma following September 11th were more do not develop long-term problems--those people who are likely to exhibit resilience. resilient. There has been less focus in the literature on PTSD, Hoge, Austin and Pollack (2007) reviewed the literature on trauma, and disaster recovery that relates to the notion of resilience and how it is associated with the development of "resilience." PTSD. Hoge et al. (2007) reviewed the focus of earlier studies Bonnano, Galea, Bucciarelli and Vlahov (2006) investigated of resilience in children and identified easy temperament, resilience following the September 11th World Trade Center a warm relationship with an adult, social support, internal attacks. These authors defined resilience as the absence of psy- locus of control (self-efficacy), and positive self-esteem as pre- chopathology (i.e., 0 or 1 PTSD symptoms). The sampling dictors of longer-term psychological resilience. The review of was taken from all adults residing in New York City and the early research on resilience in adults identifies a focus on the surrounding areas, and occurred 6 months after the Septem- notion of "hardiness"--considered a constant and stable per- ber 11th attacks. Overall 65% of the sample showed no evi- sonal resource (Kobasa, 1979). dence of PTSD. They found that the percentage of individu- Many aspects of the notion of hardiness are consistent als showing resilience decreased as the level of exposure to the with other factors that had been identified earlier such as trauma increased. Individual resilience never dropped below self-efficacy, an internal locus of control and a willingness 33%, even in the most severely exposed groups with the high- to take some risks or take on challenging activities. These est rates of PTSD. authors note that, in addition to those factors noted above, Interestingly, as in previous work (Bonnano, Rennicke & positive distancing (accepting the next best thing to what one Dekel, 2005), Bonnano et al. (2006) found that a "compound wants), hope, optimism, religious behavior, a sense of con- exposure" (e.g., saw the attacks occur on September 11th and trol, social support, active involvement in and maintenance were involved in rescue efforts) resulted in decreased re- of relationships and psychological preparedness and struc- silience. This has some important implications regarding the tured training experiences have been identified as predictors of selection of who will be involved in rescue efforts and in terms resilience. Finally, successful past experiences with stressors has of training that focuses on increasing the stress resistance of also been identified as potentially protective, possibly increas- those who may have repeated exposure to traumatic events. ing self-efficacy. Bonanno, Galea, Bucciarelli, and Vlahov (2007) investigated Other researchers have also identified procedural prob- variables that might predict psychological resilience following lems in studying resilience. For example, Hoge et al. (2007) mass disaster using a sample of adults with varying levels of identify the difficulties defining and characterizing the con- exposure to the attacks of September 11th. This study defined cept of resilience. Is it the "converse" of a risk factor? These resilience in the same manner as earlier studies with resilient authors suggest that certain factors seem to be more likely to be individuals showing only 0 or 1 symptoms of PTSD. They related to both risk and resilience such as social support, while also included measures of depression and substance abuse others would not such as the presence or absence of develop- in examining resilient outcomes. The variables of interest mental delays or gender. Others suggest that resilience involves included the following: demographic characteristics (gender, factors that "confer protection," which may only show them- ethnicity, education, age), measures of social and material selves when one is placed in a stressful situation (Rutter, 1987). resources (material, interpersonal, energy, and work resources), Hoge et al. (2007) suggest that it may be advantageous to and levels of life stress prior to and after the traumatic event. define resilience as modifiable factors that are inherent within Previous studies have shown many of these variables to cor- the individual--noting that this could include environmental relate with an increased risk for PTSD. factors in the sense that the focus is on how an individual inter- First, Bonanno et al. (2007) found that resilient individu- acts with the environment--utilizing or not utilizing resources. als had lower levels of depression and substance abuse than These authors also suggest the fact that resilience is studied those with mild to moderate trauma or PTSD. Female gender almost exclusively in retrospective experimental designs-- was a robust predictor of decreased resilience, which is consis- measuring the characteristics of individuals who do not develop tent with findings that female gender is a risk factor for PTSD. PTSD. For example, they note that "avoidant coping style" is Older age predicted resilience with those over age 65 years identified as a factor that decreases resilience. Yet, avoidance is showing significantly better resilience than young adults. Inter- a primary sign of PTSD and thus retrospective studies cannot

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56 differentiate this factor as an inherent characteristic of an indi- of risk, vulnerability, and protective variables. Interventions vidual from the effect of traumatic stress itself. could target reduction in risk and vulnerability factors and A recent critical review of the research literature on resilience enhance protective factors. identifies several methodological problems with some of the Another recommendation by these authors includes divid- previous work in this area--much of which relates to what is ing events according to a timeline: pre-, peri- and post event meant by resilience, how it has been studied from a conceptual time periods. In this way, one could incorporate systematic standpoint, what conclusions have been made and the im- preventive measures during the pre-event period in order plications of this previous work (Layne, Warren, Watson & to reinforce and build stress resistance--whether that be Shalev, 2007). related to attempts to prevent the stressor from occurring Research differentiates the terms "protective factor" (a mea- (e.g., aviation accident investigation and safety planning), surable attribute that decreases the susceptibility for being building up a reserve of tangible resources to be used in the negatively affected by adverse circumstances or stressful event of a disaster, or building resistance to stress in those events), "stress resistance" (the capacity to maintain adaptive most likely to have exposure to trauma (e.g., table-top train- functioning during and after adverse circumstances), and ing exercises, learning how to analyze problems to determine "resilience" (the capacity to apply adaptive strategies early on an appropriate course of action). During or shortly after the following an adverse event, such that one is able to bounce trauma, the peri-trauma period, systematic measures could be back following a period of temporary decrease in adaptive taken to enhance resilience (e.g., building self-efficacy, improv- functioning). These authors specifically focus on differentiat- ing ability to solve problems, improving the ability to evaluate ing stress resistance from resilience. Secondly, and perhaps risks in particular situations); during the post-trauma period, more importantly, they assert that both are "domain specific." interventions could target aspects of longer-term recovery in Specifically in response to significant stress or trauma, a per- those who do not "bounce back." son may be resilient and competent in one domain of func- tioning (e.g., work) and show a deterioration of functioning State of the Art Model in another domain (e.g., close interpersonal relationships). in Disaster Management They further emphasize that resilience is not simply the absence of overt psychopathology, but rather that a person's adaptive A number of researchers and professionals, national organ- functioning following a trauma or stressful event is similar to izations, and international organizations have articulated some their previous level of adaptive functioning. recommendations and guidelines for managing trauma in the These authors also indicate that although resilience refers to aftermath of disasters (Blythe and Slawinski, 2004; Alexander, the notion of bouncing back after exposure to trauma, they 2005; Bisson, Brayne, Ochberg, & Everly 2007; Bisson & stress that people can expect to be changed in some ways by Cohen 2006; International Society of Traumatic Stress Studies exposure to traumatic circumstances and that the notion of resources, 2006; WHO IASC guidelines on mental health and returning to previous functioning is "unrealistic"--suggesting psychosocial support in emergency settings, 2006). Hobfoll other ways of thinking about resilience such as "acceptance et al. (2007) represent some recent work done by a group of of loss" or a "positive adaptation to enduring or ongoing international experts from a variety of disciplines relevant to change" (p. 515). disaster mental health. This group was formed to address the What does previous work in the area of resilience inform needs of individuals traumatized by disasters in lieu of the lack as far as application to real-world disaster recovery and inter- of controlled studies in this area in order to articulate some ventions that emphasize resilience? In their extensive review, "evidence informed" recommendations. The project resulted in Layne et al. (2007) suggest that resilience-focused interven- the identification of five essential elements that are important tions can "compliment" trauma-focused (i.e., reduction of for mental health interventions performed in the aftermath psychopathology/problem-focused) interventions. These of disasters. The following is a list of these important elements authors indicate that resilience-focused interventions could (1) a sense of safety, (2) calming, (3) a sense of self- and commu- include identification of those at a higher risk for develop- nity efficacy, (4) connectedness, and (5) hope are all important ing particular adverse outcomes due to specific combinations (see Chapter 2, "Five Essential Intervention Principles").