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

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

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

42 traumatic reactions that can occur in the wake of disasters, an overview of the factors that increase the risk for adverse reac- tions to disaster and trauma, a review of the psychological reactions to disaster and trauma in selected at-risk groups, and a description of the nature and correlates of vicarious or secondary traumatization. The subsequent sections review and summarize relevant literature related to prevention, screening, and intervention and planning. The focus of the review then shifts toward mental health screening and intervention issues and includes an overview of screening tools and procedures for identifying at risk individ- uals in the aftermath of disasters, a review of the current evi- dence base for early intervention in the acute stages following disaster, an overview of the evidence base for early interven- tion with specific at-risk groups (e.g., emergency responders, untrained disaster volunteers), a summary of recommenda- tions for preventing and managing vicarious traumatization, a summary of recommendations for the use of pharmaco- logic interventions in the acute stages of trauma, a review of methods for prevention of adverse reactions by building resilience, a summary and description of interventions aimed at reducing and treating longer-term adverse stress reactions and a overview of emerging treatments for post trauma reactions. In the final section, the focus turns to disaster planning and preparation that includes a review of the educational and preparatory training factors important to disaster plans that ad- dress mental health issues and an overview of the organiza- tional, social, and community factors that are important to con- sider in developing mental health disaster management plans. Overview of Disaster and Trauma Overview and Epidemiology of Post- Traumatic Reactions in the Wake of Disaster Although numbers vary somewhat for each specific trau- matic situation, in general, epidemiological statistics sug- gest that nearly 90–100% of those with exposure to trauma exhibit the same symptoms as those associated with PTSD during the traumatic event itself. This is not surprising because these same symptoms reflect the human survival reaction and are not considered pathologic when they occur during a crisis situation. About 15% of those subjected to traumatic situa- tions will go on to develop PTSD. It is also important to note that the percentage of people exhibiting some but not all the symptoms of PTSD is likely much greater than that for those who exhibit full blown PTSD, although there are currently no reliable estimates of this. These individuals are experiencing post-traumatic stress (PTS), not post-traumatic stress disorder (PTSD). They are often quite impaired or distressed but “fall through the cracks” because they do not have a diagnosable condition and because they continue to “function” (e.g., they go to work), although functioning may be significantly compromised relative to pre- trauma functioning. For example, someone with PTS may be able to maintain a job and/or marriage but continues to experience increased anxiety around reminders of the trauma, problems sleeping, repeated nightmares, impaired concen- tration, and persistent intrusive and disturbing memories and intrusive thoughts associated with the trauma. Previous research has indicated that of the 89% of adults ex- posed to a traumatic incident at least one time in their lives, only 15% develop PTSD (Breslau et al., as cited in Adams & Boscarino, 2006). Of those who develop PTSD, 30–40% are di- rect victims of the event, 10–20% are rescue workers, and 5–10% are in the general population (Galea, Nandi, & Vlahov, 2005). Corneil, Beaton, Murphy, Johnson and Pike (1999) re- ported PTSD in an estimated 22.2% of American Firefighters. Additional research conducted has generally found rates of PTSD ranging from 13–18% of firefighters, 1–4 years after a traumatic event (Fullerton, Ursano & Wang, 2004; McFarlane & Papay, 1992; North, Tivis, McMillen, Pfefferbaum, Pitznagel et al., 2002). Kessler, Sonnega and Bromet et al. (1995) reported that 60.7% of men and 51.2% of women had experienced at least one traumatic event while 19.7% of men and 11.4% of women have encountered at least three traumatic events. Kessler, Berland, Demler, Jin, Merikanga & Walters (2005) reported a lifetime prevalence rate of PTSD at 6.8% of the general population. Katz, Pellegrino, Pandya, Ng, & DeLisi (2002) reviewed the prevalence of psychiatric morbidity and interventions 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- dations of communities—a factor that contributes to the development of adverse mental health outcomes. Mollica, Cardozo, Osofsky, Raphael, Ager & Salama (2004) presented a conceptual framework for understanding the impact of dis- asters on the communities they affect. They point out that, in addition to its direct impact on individuals, a disaster neg- atively impacts a community’s political, economic, socio- cultural, and health care infrastructures. Katz et al. (2002) note that previous reviews have indicated a 17% increase in the prevalence of psychopathology in the wake of mass disasters compared to controls (e.g., Rubonis & Bickman, 1991). They go on to state that, although some studies have found increased rates of psychiatric morbidity following man-made vs. natural disasters, the evidence for this is inconsistent, with some studies showing increased rates in natural disasters or no difference between the two in terms of psychiatric morbidity. These authors identify the follow- ing as the primary psychiatric disorders found in the acute phase (first two months) following disasters: acute stress disorder, PTSD, generalized anxiety disorder (consistently detected following disasters), major depression, and substance abuse disorders (although results are conflicting).

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

44 hood of the development of PTSD. In this study, no relation- ship was shown between previous trauma, family history of mental illness, personal history of mental illness, and the exis- tence of bodily injury and subsequent development of PTSD. Those who developed PTSD and those who did not develop PTSD reportedly experienced similar amounts of stress and anxiety during the traumatic event. However, those individ- uals who directly experienced a traumatic event were more likely to acquire PTSD than those who witnessed a traumatic incident. These results have important implications when detecting those at risk for the development of PTSD (females and those who perceived their life to be threatened) and plan- ning treatment interventions. Adams and Boscarino (2006) examined the factors asso- ciated with PTSD at one and two years following the WTC disaster in a community sample. A great deal of interest has focused on demographic characteristic (age, gender, race, and socioeconomic status) that are associated with differ- ent rates of PTSD. The results indicate that younger individ- uals (ages 18–29), females, those who experienced more WTC disaster-related events, those who reported low levels of social support, and those with low self-esteem had a greater risk of developing PTSD symptoms one year following the disaster. At two years following the disaster; however, those who were Latino, aged 30–64, and who had low self-esteem were more likely to develop PTSD symptoms. Those who experienced symptoms at two years following the disaster but not at one year (delayed-onset PTSD) reported more suffering, more negative life events, and a reduction in self-esteem post-disaster. Latinos were also shown to be at an increased risk for the development of PTSD. Those who re- ported experiencing symptoms at one year post disaster, but not two years (remitted PTSD), reported an improvement in self esteem and less negative events. The work of Acierno et al. (2002) indicates that older adults are typically more resilient to the psychological effects of traumatic events and natural disasters yet have an increased risk of negative post disaster physical health effects. Indeed, increased age is connected with lower rates of post disaster psychopathology, although it may reflect the fact that older adults tend to express psychological symptoms somatically. Acierno, Ruggiero, Kilpatrick, Resnick and Galea (2006) ex- amined older and younger adults who experienced the 2004 Florida hurricanes. Symptoms of PTSD, major depressive dis- order, generalized anxiety disorder, previous exposure to trau- matic events, social support, and hurricane-related impact, pos- itive outcomes, and current health status were assessed through the implementation of the National Women’s Study Event History-PTSD module, the Medical Outcomes Study module, and the SCID-IV structured interview. The results indicated that older adults were indeed more resistant than younger adults to the psychological effects after natural disasters, such as the 2004 Florida hurricanes. Low amounts of social support, previous exposure to traumatic events, and deficient health status were variables predictive of psychological symptoms for both young and old adults. Income and other financial difficulties (i.e., number of days dislocated from one’s home and the number of post-insurance dollars lost) were predictive of psychopathology for older adults, but not younger adults. Indeed, risk factors that in- cluded financial factors were more significant for older adults which may reflect that economic difficulties following natu- ral disasters are associated with older individuals’ psycholog- ical health. Wittman, Moergeli and Schnyder (2006) examined whether symptoms of peritraumatic dissociation in acute stress dis- order (ASD) are predictive of the development of PTSD or psychopathology later on. The Peritraumatic Dissociative Experiences Questionnaire, Clinician-Administered PTSD Scale, Primary Care Evaluation of Mental Disorders, and Hos- pital Anxiety and Depression Scale, as well as an assessment for the symptom criteria for ASD, were administered to patients in a Zurich hospital following recent accidents or assaults. The results indicate that no strong relationship between peritrau- matic dissociation and posttraumatic stress symptoms or gen- eral psychopathology existed. Additionally, there was a weak relationship between pre-existing psychopathology and peri- traumatic dissociation. Birmes et al. (2003) examined the power of peritraumatic dissociation and acute stress disorder in predicting PTSD symp- toms and diagnosis three months after a traumatic event. Per- itraumatic dissociation involves alterations in the experience of time, place and person during and immediately after trauma exposure. Those reporting more peritraumatic dissociation are at greater risk for the development of PTSD. Acute stress disorder is also a predictor of PTSD. Acute Stress disorder includes a set of symptoms experienced within the first month following trauma exposure that include symp- toms of dissociation, intrusion, avoidance and hyperarousal. The Peritraumatic Dissociative Experiences Questionnaire— Self-Report, Stanford Acute Stress Reaction Questionnaire, Impact of Event Scale, and the Clinical-Administered PTSD Scale were used to assess for peritraumatic dissociation, acute stress disorder, and PTSD, respectively, in victims of violent assaults. The results indicate that peritraumatic dissocia- tion and acute stress disorder were significantly correlated with the presence of PTSD symptoms. These results may assist in the early detection of traumatized individuals at high risk for the acquisition of PTSD. Breslau, Lucia, and Alvarad (2006) examined the extent to which intelligence, anxiety disorders, and conduct issues during childhood affected one’s susceptibility for being exposed to traumatic events and whether, once exposed to traumatic events, these factors influenced the development and expres-

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

with the self-disclosure, which is necessary when receiving mental health support after traumatic events. Recent research has started to recognize the healthy and adaptive ways people cope with potentially traumatic and stressful events. Higher levels of social support have been recognized as being significantly associated with a lower prevalence of PTSD. Alternatively, lower levels of social sup- port have been shown to be related with more PTSD symp- toms, anxiety, depression, and alcohol abuse in Vietnam veterans. Indeed, research has shown that one of the most important therapeutic tools for preventing and reducing PTSD symptoms is talking about the trauma. Disclosing trau- matic experiences has also been shown to result in positive health outcomes. Research has indicated that perceived emo- tional support has shown the most consistent positive find- ings (Marmar et al., 1997) Bryant and Guthrie (2005; Bryant & Harvey, 1996) studied volunteer firefighters and found that proximity to death, severity of trauma and perceived threat were associated with the development of posttraumatic symptoms and PTSD. In a longitudinal study of firefighters, McFarlane and Papay (1992) found that 77% of participants who developed PTSD had a comorbid psychiatric diagnosis such as depression, panic disorder or phobic disorders. Additional work with firefighters has generally found rates of PTSD ranging from 13–18% one to four years after the trau- matic event (Fullerton, Ursano & Wang, 2004; McFarlane & Papay, 1992; North et al., 2002). Heinrichs, Wagner, Schoch, Soravia, Hellhammer and Ehler (2005) noted that predictors of the development of PTSD de- termined from retrospective studies have poor predictive power when evaluated in prospective studies. Therefore, Heinrichs et al. (2005) used a prospective methodology in an attempt to identify salient risk factors for firefighters in the develop- ment of PTSD. This study assessed firefighters immediately after basic training and at 6, 9, 12, and 24 months after job entry. The assessments included several self-report question- naires to measure demographic items, personality characteris- tics, depression, anxiety and other measures of psychopathol- ogy and self-efficacy. In addition, salivary cortisol and urinary catecholamines were measured at each testing point. Higher levels of cortisol predict the development of PTSD (Ehlert et al., 2001), and higher urinary catecholamines have been observed in PTSD patients (Kosten et al., 1987). The results indicated that both cortisol and catecholamine levels before trauma exposure did not predict the development of posttraumatic stress symptoms over the course of two years. Results indicate that the amalgamation of preexisting high levels of hostility and low levels of self-efficacy predisposed individuals to the development of PTSD symptoms, depression, anxiety, general psychological distress, and alexithymia over a 2-year period following job entry. Individuals who exhibited either low levels of hostility or high levels of self-efficacy or both sustained no increase in psychological symptoms, indicating that these personality traits may provide a protective factor against the development of stress-related symptoms. Social support has been shown to mediate the harmful effects of traumatic experiences and decrease the likelihood of the development of PTSD. Thus, individuals who score highly on hostility ratings may not have the resources to handle the stress resulting from stressful expe- riences like those with low hostility ratings. These results have important implications in the identifica- tion of individuals who are at high risk for the development of psychopathological symptoms. Also, these results can assist in the development of training and prevention programs and the creation of screening processes for certain professions. Johnson, Langlieb, Teret, Gross, Schwab et al. (2005) exam- ined the physical and mental health effects of the recovery efforts on workers at the World Trade Center disaster site. During the recovery process, workers (i.e. truck drivers, labor- ers, mechanics, heavy equipment operators) were frequently neglected and ignored in disaster planning and response pro- grams and trainings. A 62-item survey was developed to assess exposures at the site and somatic and mental health symptoms of recovery workers after exposure. In addition, an open-ended ques- tion was included to have participants share other concerns. Johnson et al. (2005) reported the results of analysis of the open-ended question. They found that 24% reported a cur- rent somatic complaint or an injury related to their recovery work. Many respondents wrote about their fears of future health consequences. Ten percent of the respondents volun- teered that they had or were currently experiencing mental health symptoms that included sleeping problems, depres- sion, anxiety, PTSD, and suicidal thoughts. Many reported using alcohol or drugs to cope and reliv- ing their experiences in nightmares or during their daily activities. A number reported a lack of respiratory protec- tion and training. Several respondents also reported that they were unprepared to work with human remains both logisti- cally and psychologically. Additionally, these workers stated that they devised their own ways of coping and conveyed a great sense of pride for being able to assist in the effort. The authors argued that these responses can assist in the prepara- tion and response efforts for future disasters. For instance, a broader array of individuals (besides firefighters, first respon- ders, etc.) should be included in planning efforts. A disaster response plan should be clearly communicated by employers to the workers, and these workers should be provided with leadership and training. They further argued that disaster men- tal health services should be provided to workers to offset the likely adverse mental health issues that can occur follow- ing recovery. 46

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

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

The incidence of worksite shootings, employee violence, and accidental injuries also increased. This study interviewed in- dividuals 1 year following the attacks and again at a two year follow-up. The number of workdays lost, the number of lower quality workdays, and the number of doctor visits within a 12-month period was assessed. Additionally, the survey assessed the presence of PTSD (assessed by a scale that utilized DSM-IV criteria), the exis- tence of depression (assessed by a scale that utilized a version of the SCID), the presence of three stressors (i.e., exposure to the World Trade Center disaster, negative life events, and traumatic life events), one’s history of chronic diseases, mental health service utilization, social support, and self-esteem. The results indicated that there was a strong correlation between exposure to the World Trade Center disaster and lower worker productivity; this effect was seen primarily in the year follow- ing the incident. The existence of PTSD and depression was also shown to be correlated with lower worker productivity in the first year after the disaster. Although the relationship between exposure to the attack and lower productivity existed at the 2 year follow-up, this con- nection was less significant and less reliable. PTSD was shown to be related to lower work quality at the two year follow-up; however, depression was not related to work quality at the two year follow-up. These results indicate that interventions and programs should be designed to negate some of the harm- ful effects that result from exposure to disasters and trau- matic events. Schlenger, Caddell, Evert, Jordan, Rourke, Wilson, Thalji, Dennis, Fairbank and Kulka (2002) also studied the impact of the September 11 attacks on the general population. Following the World Trade Center disaster, those individuals who lived closest to the disaster site were more at risk for the development of PTSD than those who lived farther away from the site. Through the employment of the PTSD Checklist (PCL), the SCL-90, and the Brief Symptom Inventory, this study assessed PTSD symptoms and other clinically significant mental health symptoms in adults in New York, NY, Washington, D.C., and other metropolitan areas in the United States. The results indi- cate that those who lived in New York City were significantly more likely to develop PTSD than individuals who resided in other metropolitan areas, including Washington, D.C. The Nature and Correlates of Vicarious or Secondary Trauma Exposure Lating, Sherman, Lowry, Everly and Peraquine (2004) ex- amined vicarious traumatization by examining American Air- line flight attendants who worked on the East Coast (n = 513) and the West Coast (n = 353) on measures of general well- being, psychological symptoms, life-functioning and probable PTSD. There were no significant differences between the crews regarding probable PTSD (19.1% east coast, 18.3% west coast) despite the fact that the East Coast flight attendants were twice as likely to know someone who perished as a result of the September 11 attacks than West Coast flight attendants. The authors argued that their results were evidence of a psycholog- ical contagion—a spreading of the negative impact of trauma to those who do not have direct contact with the source of the threat. Lating, Sherman and Peraquine (2006) further examined this issue by including a third group of flight attendants who were not employed by American Airlines at the time of the September 11 attacks but were employed by American Air- lines at the time of this study. Further, this third group of flight attendants was not operating out of the East Coast or West Coast at the time of this study. The results indicated that there were no significant differences among the three groups regarding the reported incidence of probable PTSD. The rates of probable PTSD for East Coast (19.1%), West Coast based (18.3%) and the attendants hired after Septem- ber 11, 2001 (15.1%) were not significantly different. The results were similar to the 13% prevalence rates of male rescue workers after the bombings in Oklahoma City (North et al., 2002), the 20% prevalence rates of residents living near the World Trade Center (Galea et al., 2005), and the 23% probable PTSD preva- lence rate for Pentagon staff members (Grieger, Fullerton, & Ursano, 2004). The above prevalence rates should be viewed in the context of a 4% national prevalence rate of probable PTSD (Sclenger et al., 2002) The deleterious impact of exposure to trauma has been identified in the children of first responders. Hoeven (2005) reported that one factor that likely contributed to children with emotional disturbance 6 months after the September 11 terrorist attack was having a family member exposed to the attack. Duarte et al. (2006) reported that children had a higher rate of probable PTSD 6 months following the attack on the World Trade Center when a family member was an emergency medical technician (18.9%) or there were two first responders in the family (17%) compared to those that had no first respon- ders in the family (10.1%). Propper, Stickgold, Keeley and Christman (2007) utilized 11 undergraduate students taking a class on dreaming in a 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 students lived in the Boston area (where one of the planes involved had taken off) so they may have experienced more stress than the general population. Results indicated that students had more event-related dreams following the attacks and the frequency of the dreams and distressing content was directly associated with the number of hours they observed these events on television—a 5–6% increase in the propor- tion of post-attack dreams containing features related to the 49

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

Several measures approached the performance of the SCID or the CAPS. This was often accomplished by raising the cut- off score. The Impact of Events Scale (IES; Horowitz, Wilner, & Alvarez, 1979) and the Trauma Screening Questionnaire (TSQ; Foa, Riggs, Dancu, & Rothbaum, 1993) were found to be the best screening measures overall; they had been tested in the first year following a traumatic event—another aspect of these measures that was examined in this review—making them especially useful for monitoring victims during the early months following a trauma to identify the individuals who may need further intervention. On a different but related note, Horowitz (2007) exam- ined the difference between distress and disorder and the im- portance of distinguishing the two. He describes disorder as existing within the individual which may be independent of environmental stress and which may or may not be a result of environmental stress. In this case, as environmental stress decreases, symptoms will likely persist, and if a mental dis- order does exist, treatment is warranted. Distress is defined as a normal human response to stressful environmental circumstances—a situation that does not require a diagno- sis of a mental disorder. In this case, as environmental stress decreases, symptoms of distress are likely to also decrease. Distress is most likely to be a consequence rather than a cause of stress. Measures of environmental stress exist that could help determine what responses are expected and nor- mal and which responses are signs of disorder. The importance of distinguishing the two relates to how each are treated. If distress is treated as a disorder, then ap- propriate environmental changes to reduce stress may not be addressed (e.g., treating symptoms pharmacologically rather than looking at and modifying the source of the stress). Over- all, recognizing distress will help in emphasizing the impor- tance of making adjustments to the environment to reduce stress. This would be especially true in the event of a disaster as many are distressed, relatively few develop disorders, and restoring the environment and support systems to normal functioning as soon as possible is likely to reduce or eliminate symptoms and distress. Focusing on the “individual with a mental disorder” as the sole source of the problems may delay addressing these larger social issues. Conversely, Dyregrov (2004) proposes that “demedicaliza- tion” has gone too far in some cases. He argues that demed- icalization had led to individuals not receiving essential professional intervention. As Horowitz (2007) suggests, deme- dicalization refers to labeling a condition of distress as disorder, which may diminish an individual’s natural coping resources and decrease the focus on environmental issues that would re- duce or eliminate distress. Dyregrov (2004) argues that this movement to demedicalize the effects of trauma produces bar- riers to getting necessary and often desired professional mental health services. It would appear that careful disaster planning and organi- zation, appropriate and timely screening, appropriate train- ing for those involved in identification and triage of at risk in- dividuals, and access to services independent of whether or not a person is in distress or is experiencing more entrenched mental health issues would help to find some common ground from these two important perspectives on the best way to con- ceptualize and subsequently manage at risk individuals in the aftermath of disaster. Early Intervention Issues and Strategies in the Acute Stages Following a Traumatic Event Prior to the 1980s, there were no mental health interven- tions following disasters. As more was learned about trauma from the Vietnam veterans in the early 1980s, Psychological Debriefing, a model developed in response to the needs of the Vietnam veterans and later more fully described by Dyregrov (1997) began to be routinely applied in circum- stances involving traumatized victims of adverse events. Psy- chological debriefing is a group intervention method that is applied within 48–72 hours following a trauma. Sessions encourage group participants to describe factual components and process emotional components of the trauma experience. Its use rests on the belief that this immediate processing of the event allows the individual to reorganize the memory of the event so that it is recalled in a less traumatic way (Van der Kolk, 1997). Critical Incident Stress Debriefing (CISD), developed by Mitchell in 1988, expanded and further articulated a process for psychological debriefing (Everly & Mitchell, 2000; Mitchell, 2004; Mitchell, 1988; Riddell & Clouse, 2004) that was later termed Critical Incident Stress Management (CISM). Katz et al. (2002) review the literature from 1966 to 2002 re- lated to what interventions have been used for prevention and intervention during the first two months after an event. Their review of acute psychiatric interventions indicates that the primary focus has been on attempts to minimize the long-term effects of disaster trauma on its survivors. They note that sev- eral organizations have come up with intervention teams (e.g., US Navy Special Psychiatric Intervention Teams (SPRINT), the US Army Stress Management Team (SMT)). Also noted is the fact that these interventions have been generously ap- plied in the absence of any scientific evidence that they reduce psychiatric morbidity and further note that the same has been true for most acute interventions that “are often performed post-trauma on the basis of good intentions and theorized benefits” (Katz et al., 2002, p. 208). Until more recently, these models have been routinely utilized in emergency and disaster situations despite a lack of evidence-based outcome studies demonstrating their safety, usefulness in the acute phase following disaster, and whether they decrease the risk 51

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

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

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

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

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