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

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59 Data Analysis and Findings Emotional Response All participants expressed that they had an emotional re- sponse to the incidents that the research team chose to focus on during the interviews. Frequently the participants who had experienced other incidents would bring in their first trau- matic exposure as a comparison or contrast to the chosen incident. Participants also freely brought in other traumatic incidents besides these two as part of the interviews. There were variations in the degree of response that the par- ticipants experienced. Participants, less involved at the site of the incident but responsible for peripheral tasks, were able to express feeling “sadness” that the incident had happened and people had died. They were connected to the situation through media coverage and shared stories from co-workers in the work environment. This group did not indicate other symptoms of post-traumatic stress, or post-traumatic stress disorder. There were variations of symptoms experienced among the participant groups of responders and accident investigators. A continuum from post-traumatic stress response (i.e., prob- lems sleeping, experiencing a physical illness) to symptoms of a significant disorder (i.e., change in personality, altered functioning and behaviors, intrusive thoughts, labile emo- tions) was reported and described by participants. Several sought relief through medication and therapy, while others identified support systems of family, friends and co-workers as significant to their coping. The risk factors identified in the following section influenced the reactions and coping strate- gies of participants. Antecedents During the analysis several factors emerged as antecedents that affect the participant’s degree of emotional response to the experience. The following characteristics could be viewed as risk factors: • First time exposure to trauma. Participants that had mul- tiple traumatic experiences reverted back to their first experience and spoke of what it meant to them and how they dealt with it. Then they could communicate how the chosen incident required similar or different responses from them. The succeeding incidents of trauma were reported as having less of a traumatic impact or at least the participant felt more in control of their response and the situation. Participants that experienced the chosen incident as their first trauma spoke at length of its impact and how they attempted to deal with their emotional and physical responses. Some reported becoming physically ill after their first day of working within the role established for the incident response. First time expo- sure to trauma is a risk factor for an adverse reaction since they had no previously established coping strategies, lacked predictability of response in the situation, and had no under- standing of the post-traumatic process. • Perceived magnitude and gravity (gruesomeness) of the incident. Participants spoke of their lack of preparedness for the “real” situation. All their practice and tabletop discus- sions could not get them ready to see the actual event. See- ing the gruesome scene made it real and more difficult to remove the memory of it. Feelings of sadness were positively related to proximity to the site and hearing about the inci- dent from coworkers. Having survivors at the site created questions that were rehashed such as “why couldn’t we save more?” Guilt seemed more prevalent in this latter situation. • Type of exposure and tasks to do at the site and after. The persons completing tasks that they didn’t usually do and those involved in more gruesome activities spoke of their shock/surprise of how they felt unprepared for the realness of the situation. The stress of this combination heightened their overall response to the trauma. • Length of exposure or involvement in the incident (marathon vs. sprint). Longer exposure to the cleanup or details surrounding the incident increased the potential of experiencing post-traumatic stress reaction (PTSR) or A P P E N D I X C Data Analysis

60 many of its symptoms. If the person had not resolved pre- vious trauma, the new incident increased their need to seek therapeutic resources. • Focus person maintains about the task being done. Persons that did their job without time for idle thinking (thought dwelling) and maintained an objectified perception about their work (“did the job you were expected to do”) coped better with the situation. Participants stated that this re- sponse was similar to a firefighter’s mentality. Those who personalized the situation (present when family members were present or saw personal artifacts of the victims) had more difficulty moving beyond the memories of the inci- dent. Subjectivity was accompanied with internalization and more emotional responses. • Amount of external stressors present during incident. The number of other agencies and organizations (inves- tigative and regulator people) involved that are outside of the planned protocols add stress to the setting. Not know- ing what their protocols and needs are adds another layer of stress to a traumatic event for the local people. The media adds chaos and strains the local resources profoundly. In summary, the following table lists key factors that help or hinder a person’s ability to cope with a traumatic event. The number of risk factors the person experiences is positively related to development of post-traumatic stress response or disorder. Environmental Influences The factors discussed above exist within an environment of multiple variables that influence the stress response experi- enced by the workers. Supervisors and employees have vary- ing degrees of control over planning a proactively responsive environment. The following environmental variables relate to the tasks to be done that influence outcome and can sup- port or interfere with coping processes of individuals: • Preexisting collaboration agreements that reduce confusion and support a smooth transition from emergency response to recovery. • Preexisting process/protocols with all people having knowl- edge of and involvement in traumatic accidents/disasters (awareness of and practice with what a real situation could be like with explicit details). • Degree of support/trust present in relationships among and between workers, departments and agencies. • Flexibility in being able to show up for the emergency job or transfer off the job without repercussions. • Inference of no guilt for work done or inability to do all the work (e.g., person becomes ill in response to first day of over working). • Defined outcomes with an end in sight, including the intent to move into normalizing work as soon as possible. • Pre-knowledge of the role, length of time, and degree of involvement in the task to be completed by all workers (“marathon” vs. a “sprint”). • Resources available (or have quick access to them) that support having control of the situation (tools, experts, money etc.). • Number of hours a person has to put in without a break; level of exhaustion experienced in disaster work. • An understood meaning and purpose to the work being done (personally or corporately which is recognized/verbalized). • Presence of familiar support systems, including formal (counseling services) and informal (family, spouse/ significant other, peers/coworkers) that meet the needs of the person throughout crisis to recovery. • Number of “insiders” that are familiar with their situation and post traumatic stress response (a lot of explaining not necessary) to provide support. • Acknowledgment that this work is difficult and an expres- sion of gratitude by significant leaders towards workers. Summary of Significant Findings From the themes (points and factors) that emerged during the semi-structured interviews, a composite description has been created that explicates the ideal responsive environment that would assist airline and airport workers in coping with natural and man-made disasters. Hinders coping (heightens risk of PTSR) • First traumatic event with limited knowledge of post traumatic response • Perceived magnitude/gruesomeness of the event • Personalization of the work and feelings of guilt (more could have been done) • Long term involvement in the incident • Required task is new with unknown/hidden aspects • Multiple unexpected demands from outside agencies/sources (additional stress) Helps coping • Has experienced multiple traumatic events with some resolution • Perceived magnitude/gruesomeness of the event • Objectifies the tasks to be done or gives meaning to the work • Short term focused task within the incident • Comfortable with task and no surprises • Limited outside intrusion and knowledge of their expectations

Pre-trauma Environment and Activities Assumptions exist that there would be a presence of key environmental factors/behaviors that positively support the work of the employees. These relate to dynamics in the envi- ronment including open communication, trust between and among workers and departments, and a demonstration of respect for each other. The system would also have preexisting collaboration agreements and protocols in place to follow dur- ing a disaster. Team members would be cross-trained within their areas of comfort. The system would integrate mental health support into the response and recovery planning team. The mental health sup- port person(s) would have familiarity with the workers in all the settings, spend time in the work environments, and would assess/observe the current and ongoing levels of function among and between workers. These observations would in- clude, but not be limited to, identification of daily stressors in the environment and coping strategies used by workers. The mental health support personnel would promote personal re- siliency, provide information about symptoms of stress re- sponse, and explain healthy coping strategies via brochures, presentations and/or published materials for workers and their families. Mental health support personnel would also assess the cul- tural response to counseling and health seeking behaviors; they would work to reduce or eliminate the myths that inter- fere with health seeking behaviors. Therefore, they would build therapy into the culture of the work environment. This method recognizes mental health support as growth produc- ing rather than a need for individuals who “are out of con- trol,” “not doing [their] job” and “need to get back in shape.” Also, the therapy process and what can be expected from therapy would be discussed. The mental health support personnel or other contracted services would also train peers to act as mentors. These peers would be volunteers that have had some exposure to the types of trauma that could be expected in the setting. If it is not pos- sible to recruit from the setting, a pre-identified “sister” or- ganization with trained mentors would assist in the time of a disaster. The mentors would provide support needed, obser- vation of changes and recognition of depletion of coping strategies of individuals in the work environment during dis- aster response and recovery. During Disasters Established protocols are followed to minimize exposure to trauma since extensive exposure puts individuals at greater risk for exhaustion and potential of physical illness. Workers should be aware of their roles, know all associated aspects (nothing hidden or unknown) and have practiced these roles. They are informed about what the real situation could entail before entering the site. At the end of each day during the crit- ical period, they participate in a group meeting (more than a debriefing) that supports their ability to recall the work of the day, how it was accomplished and what needs to be com- pleted. The environment would encourage members to speak freely of their feelings, graphically describe what they are dealing with (senses overload), and discuss how they are cop- ing with the whole incident. Normalization of the experiences and reinforcement of previous learning related to PTSR would be part of the group members’ response. Mental health support personnel (or mentors or trained peers) would do family outreach. They would connect with family members that observe the worker at home to assess how that environment is being affected by the trauma/disaster. Workers that use spouses as significant support resources may also shield (“protect”) them from many of the “grue- some” details especially if the spouse had no real understand- ing of what could be happening. The degree of sharing or protection employed affects the degree of internalization used. Internalization also affects the development of PTSR symp- toms. Moreover, the degree of sharing with a spouse could also create a secondary traumatic response in their spouse or family members. Therefore, outreach would include assess- ing the worker and other family members. As workers complete their roles and others continue, this supportive process is continually available to all who wish to participate. Workers are referred to other resources (by peers, mentors, and professionals) as observation identifies those in need of more intense assistance. Costs are managed by the agency and do not burden the employees for the duration of their need. Recovery The mental health support personnel would be present throughout the trauma, helping workers to see their strengths in moving through the incident and recommending other ways of coping and reframing of the incident (re-capping re- siliency information). Administration within the environ- ment would recognize the need of workers to talk more with one another to process their current feelings and experiences; thus, a reduction in productivity may be necessary to deal with these stress let downs. “Let downs” may also require em- ployees to have unscheduled days off to recuperate from the experience. Normal work hours and responsibilities would return as quickly as possible to support predictability and feelings of being in control of work expectations. Acknowledgment of worker’s contributions and expressions of gratitude would be issued to all involved. 61

Quantitative Analysis A number of self-report measures were administered to each participant. These measures were meant to assess psy- chological and physical reactions to trauma exposure. These measures had been used in previous work. A detailed descrip- tion of each measure is presented below. Trauma Symptom Inventory The Trauma Symptom Inventory (TSI) is a 100-item self- report measure used in the evaluation of acute and chronic posttraumatic symptomatology, including the effects of rape, spousal abuse, physical assault, combat experiences, major accidents, natural disasters, and the lasting sequelae of child- hood abuse and other early traumatic events. Each symptom item is rated according to its frequency of occurrence over the prior six months using a four point scale ranging from 0 (“never”) to 3 (“often”). This measure has three validity scales and ten clinical scales, all of which yield sex- and age- normal T scores. The various scales of the TSI assess a wide range of psychological impacts. These include intra- and interpersonal difficulties often associated with chronic psycho- logical trauma in addition to symptoms typically associated with PTSD and ASD. The following is a list of TSI validity scales: • Response Level (RL) measures a tendency toward defen- siveness, a general under-endorsement response set, or a need to appear unusually symptom-free. • Atypical Response (ATR) measures psychosis or extreme distress, a general over-endorsement response set, or an attempt to appear especially disturbed or dysfunctional. • Inconsistent Response (INC) measures inconsistent responses to TSI items, potentially due to random item endorsement, attention or concentration problems, or reading/language difficulties. The following is a list of the clinical scales: • Anxious Arousal (AA) measures symptoms of anxiety, including those associated with posttraumatic hyperarousal. • Depression (D) measures depressive symptomatology, both in terms of mood state and depressive cognitive distortions. • Anger/Irritability (AI) measures angry or irritable affect, as well as associated angry cognitions and behavior. • Intrusive Experiences (IE) measures intrusive symptoms associated with posttraumatic stress, such as flashbacks, nightmares, and intrusive thoughts. • Defensive Avoidance (DA) measures posttraumatic avoid- ance, both cognitive and behavioral. • Dissociation (DIS) measures dissociative symptomatology, such as depersonalization, out-of-body experiences, and psychic numbing. • Sexual Concerns (SC) measures sexual distress, such as sexual dissatisfaction, sexual dysfunction, and unwanted sexual thoughts or feelings. • Dysfunctional Sexual Behavior (DSB) measures sexual behavior that is in some way dysfunctional, either because of its indiscriminate quality, its potential for self-harm, or its inappropriate use to accomplish non-sexual goals. • Impaired Self-reference (ISR) measures problems in the “self” domain, such as identity confusion, self-other distur- bance, and a relative lack of self-support. • Tension Reduction Behavior (TRB) measures the respon- dent’s tendency to turn to external methods of reducing internal tension or distress, such as self-mutilation, angry outbursts, and suicide threats. The Symptom Checklist-90-Revised (SCL-90-R) This is a 90 item self-report symptom inventory test. It has been developed to reflect the psychological symptom patterns of psychiatric or medical patients. Each of the 90 items is a problem or complaint that patients sometimes have. The respondent is to rate each item according to “how much dis- comfort that problem has caused during the past week, includ- ing today” on a 5-point scale of distress, ranging from “not at all” to “extremely.” The SCL-90-R is scored and interpreted in terms of 9 primary symptom dimensions and 3 Global Indices of Distress. These symptom dimensions and indices of distress are listed below with a brief description of each dimension. The scores for each dimension are T-Scores that have a mean of 50 and a standard deviation of 10. The scores were compared to a non-patient gender appropriate sample. The definition of each scale is listed: • Somatization Scale reflects distress arising from perception of bodily dysfunction. • Obsessive-Compulsive Scale reflects symptoms that are highly identified with the standard clinical syndrome with this name. • Interpersonal Sensitivity Scale focuses on feelings of per- sonal inadequacy and inferiority, particularly in comparison with others. • Depression Scale reflects endorsement of a broad range of symptoms compatible with depression, such as dysphonic mood, feelings of hopelessness, and somatic complaints compatible with depression. • Anxiety Scale includes symptoms of nervousness, ten- sion, apprehension, and somatic complaints associated with anxiety. 62

63 Mean SD Validity Scales 1. Atypical Response (ATR) 47.68 4.23 2. Response Level (RL) 45.26 5.27 3. Inconsistent Response (INC) 45.47 5.00 Clinical Scales 4. Anxious Arousal (AA) 51.11 10.25 5. Depression (D) 47.16 5.00 6. Anger/Irritability (AI) 48.32 6.80 7. Intrusive Experiences (IE) 48.32 6.68 8. Defensive Avoidance (DA) 49.00 7.02 9. Dissociation (DIS) 52.89 7.99 10. Sexual Concerns (SC) 49.21 7.42 11. Dysfunctional Sexual Behavior (DSB) 49.58 8.88 12. Impaired Self-reference (ISR) 48.16 6.99 13. Tension Reduction Behavior (TRB) 48.00 7.23 Participant 107 DSB, ISR, TRB Participant 102 AA, AI, DA, DIS, DSB, ISR Participant 501 AA, IE, DA, DIS Participant 101 AA, DIS Participant 306 DIS Participant 201 SC Participant 101 DSB • Hostility Scale includes thoughts, feelings, or actions that are characteristic of the negative affect state of anger. • Phobic Anxiety Scale measures a persistent fear response to a specific person, place or object or situation which is characterized as being irrational and disproportionate to the actual stimulus which leads to avoidance or escape behavior. • Paranoid Ideation Scale measures paranoid behavior as a disordered mode of thinking. • Psychoticism Scale measures the extent to which the indi- vidual is isolated, withdrawn, and experiences difficulties in clear thinking. • Global Severity Index (GSI) is designed to measure over- all psychological distress. • Positive Symptom Distress Index (PSDI) is designed to measure the intensity of symptoms. • Positive Symptom Total (PST) reports number of self- reported symptoms The Impact of Events Scale-Revised This is a 22-item self-report scale. Respondents are to report the distress caused by a variety of symptoms of PTSD. The symptoms cover the range of traumatic stress reactions and include intrusion, avoidance and persistent hyperarousal. The respondents were asked to rate the distress caused by each symptom during the past week on a scale ranging from not at all (0) to extremely (4). In light of the unique nature of our data collection in which participants were responding to their experience of a disaster which may have occurred several years ago, two versions of the scale were created. One version asked the participant to indicate how currently distressing each item was (IES-R Current). The second version asked them to recall how distressing each situation was for them in the first few months following the disaster (IES-R Past). The Connor-Davidson Resilience Scale (CD-RISC) This is a 25-item scale that measures the ability to cope with adversity. Participants rated items on a scale from 0 (not at all true) to 4 (true nearly all the time). The scale is rated as to how the subject has felt over the past month. The total score ranges from 0–100 with the higher scores reflecting greater resilience. The SF-36v.2 Health Survey The SF-36v.2 is a 36-item health survey that yields scores on eight scales of functional health and well-being. A mental health and physical health summary index is also included in this survey. This measure assesses general health status, rather than one that targets a specific age, disease or treatment group. The eight domains of health-related quality of life include Physical Functioning, Role-Physical (role limitations due to physical health), Bodily Pain, General Health, Vitality, Social Functioning, Role-Emotional (role limitations due to mental/ emotional health) and Mental Health. The scores on these eight health domains are collapsed into a Physical Component Summary (PCS) measure and a Mental Component Summary (MCS) measure. Results The Trauma Symptom Inventory was scored for each par- ticipant according to the standardized instructions. T-scores were generated for all three validity scales and all 10 clinical scales. The means and standard deviations for all of the scales are presented in Table 1. An examination of the means indi- cates that group performance was near the average in the gen- eral population for each scale. However, in order to identify individuals who may have been scoring in the extreme range, we identified participants who scored more than one T-score standard deviation (60 or greater) above the mean. The par- ticipants with scores in this range are listed below along with the scales on which those elevated scores occurred. The most frequent elevations were observed on the Anxious Arousal (AA), the Dissociation (DIS), the Dysfunctional Table 1. Trauma Symptom Inventory (TSI).

64 Sexual Behavior (DSB), and the Impaired Self-Reference (ISR) scales. Each of these scales yielded elevated scores with three participants, except the DSB which yielded elevated scores with two participants. The AA scale indicates a high number of symptoms of anxiety, including those associated with posttraumatic hyperarousal. The DIS scale indicates dis- sociative symptomology, such as depersonalization and psy- chic numbing. The DSB scale reflects sexual behavior that is in some way dysfunctional, either because of its indiscrimi- nate quality, potential for self-harm or inappropriate use to accomplish non-sexual goals. The ISR indicates a lack of cop- ing resources. The Symptom Checklist 90 revised (SC-90-R) was scored for each participant according to the standardized instruc- tions. T-scores were generated for all nine clinical scales and the three composite scales. The raw scores were compared to a non-patient gender appropriate normative sample when computing T-scores. The means and standard deviations for all of the scales are presented in Table 2. An examination of the means indicates that group performance was near the average in the general population for most of the scales and all three of the composite measures. The exceptions to this observation are the Somatization scale, the Obsessive Com- pulsive scale and the Depression scale. All three were at least 5 T-Score points higher than the mean of 50. In order to iden- tify individuals who may have been scoring in the extreme range on the remaining scales, we identified participants who scored more than one T-score standard deviation (60 or greater) above the mean. The participants with scores in this range and the scales on which those elevated scores occurred are listed. An examination of the scores indicated that several participants were reporting a high degree of psychological distress on many of the scales. The analysis of the Symptom Checklist 90 revised revealed that 12 of the 24 participants had an elevation on at least one of the subscales with two individuals having nine elevations and one having six. The most frequent number of elevations observed was on the Somatization scale (six participants), the Obsessive-Compulsive scale (five participants), the Depres- sion scale (four participants) and the Interpersonal Sensitiv- ity Scale (three participants). Elevations on the Somatization scale indicate the individual is reporting a high degree of dis- tress from the perception of physical symptoms. Elevations on the Obsessive-Compulsive scale indicate difficulties with impaired concentration, distractibility and inattention. Ele- vations on the Interpersonal Sensitivity scale reflect a high de- gree of feelings of personal inadequacy and inferiority, par- ticularly in comparison with others. Finally, elevations on the Depression scale indicate endorsement of a broad range of symptoms compatible with depression, such as dysphoric mood, feelings of hopelessness, and somatic complaints com- patible with depression. Clearly our participants were report- ing a high degree of psychological distress. Therefore, the scores for each scale are the sum of the items endorsed for each scale. The means and standard deviations for all of the scales are presented in Table 3. An examination of the means indicates that overall the participants reported that the traumatic event was less stressful currently than when it immediately happened. In order to identify individuals who may have been scoring in the extreme range on the re- maining scales, we identified participants who scored more than one standard deviation above the mean. The participants with scores in this range are listed below. An examination of the scores indicated that several participants were report- ing a high degree of current stress and past stress over the traumatic event. Mean STD Extreme Scores 1. Somatization: 56.2 6.53 60,64,65,68 2. Obsessive-Compulsive: 57.05 8.47 61,62,63,69,74 3. Interpersonal Sensitivity: 52.15 8.41 61,62,66,68 4. Depression: 55.1 7.66 60,63,70,74 5. Anxiety: 47.2 10.38 67,73 6. Hostility: 48.45 8.64 60,61,73 7. Phobic Anxiety: 48.5 5.63 66 8. Paranoid Ideation: 50.55 8.78 62,67 9. Psychoticism: 52.6 7.65 60,63 10. Global Severity Index (GSI): 53.1 9.57 64,67,74 11. Positive Symptom Distress Index (PSDI): 51.6 7.17 60,61,64,65 12. Positive Symptom Total (PST): 53.7 7.76 60,64,68,70 Participant 100 Som Participant 101 Som, Psy, PSDI Participant 102 Som, Psy, IS, OC, HOS, PST Table 2. Symptom Checklist (SC-90-R).

65 Three participants had elevations on the Impact of Events Scale-Revised (past) and the Impact of Events Scale-Revised (current), with two of the three participants having elevations on both versions of the scale. The scales addressed how cur- rently distressing each item was for each participant (IES-R Current) and how distressing each situation was for them in the first few months following the airline/natural disaster (IES-R Past). For three of our participants, the perception of their subjective distress was high at the time of the trauma and remained high several years after their exposure to the trauma. The means and standard deviations for all of the scales are presented in Table 4. An examination of the means indicate that overall our participants rated themselves as very resilient. Results from the Connor-Davidson Resilience Scale (CD- RISC) indicate a relatively high degree of self-reported resilience among our participants. Interestingly, the two participants with relatively low scores on the Connor-Davidson Resilience Scale (CD-RISC) reported the least amount of psychologi- cal distress. A series of Pearson Correlations were computed between each participant’s Connor-Davidson Resilience Scale (CD- RISC) and all of the subscales of the various self-report mea- sures used. Surprisingly, all correlations were positive and above 70. The SF-36v2 Health Survey (SF-36v2) was scored accord- ing to the standardized instructions and Physical Component Summary (PCS) measure, and a Mental Component Summary (MCS) measure was produced for each participant. These scores are T-scores with a mean of 50 and a standard deviation of 10. The higher number on either scale indicates better functioning. The means and standard deviations for all of the scales are presented in Table 5. Results from the SF-36v2 Health Survey indicated there were four participants who reported a high number of physical symptoms and two participants who reported a high number of mental health problems. Integration of Qualitative and Quantitative Methodologies One important theme that emerged from the quantitative and qualitative analysis is that some of the participants con- tinue to report an above average number of symptoms of psy- Table 3. The Impact of Events Scale (current and past). Mean SD 1. Impact of Events Scale-Revised Current 10.16 9.38 Participants who scored > 1sd above mean (19.54) Participant 306 34 Participant 307 22 Participant 400 25 2. Impact of Events Scale-Revised Past 19.74 14.36 Participants who scored > 1sd above mean (34.09) Participant 205 51 Participant 306 46 Participant 400 35 Table 4. Connor-Davidson Resilience Scale. Mean SD Connor-Davidson Resilience Scale (CD-RISC) 78.74 8.01 Participants who scored < 1sd below mean (70.73) Note (66.68 is 1.5 SD below mean) Participant 100 66 Participant 204 68

66 chological distress, several years after their exposure to trauma. On the SCL-90, five participants produced scores in the above average range on three or more of the 12 indices examined. Six of the participants produced elevations on the Somatiza- tion scale, reporting a high number of physical symptoms. Five of the participants produced elevations on the obsessive- compulsive scale which reflects a high degree of inattention, distractibility and repeated thoughts. Four of the participants produced elevations on the depression scale. Clearly, five of the participants were reporting an above average number of symp- toms of psychological problems some time after the trauma exposure had occurred. It was clear that a subset of our par- ticipants continued to report difficulties with psychological functioning some time after experiencing the trauma. The Impact of Events Scale-Revised also revealed that two of the participants reported a high degree of distress caused by a variety of symptoms of PTSD in the first few months fol- lowing the trauma and currently. The symptoms covered the range of traumatic stress reactions including intrusion, avoid- ance and persistent hyperarousal. Despite having a number of participants report a high degree of continuing psychological distress, participants reported a high degree of resilience with a mean score of 78.74. Further, the resilience scores were positively correlated with the self- report measures of psychological trauma. It appears that several of our participants continued to view themselves as resilient while reporting a high degree of psychological trauma. Online Airport Survey In order to determine the extent of post-disaster mental health crisis programs existing at airports in the United States, a survey was conducted among airport management personnel. A membership roster of the American Association of Airport Executives (AAAE) was utilized to generate contact informa- tion. In general, representatives on the roster list were the highest ranking management officials associated with a par- ticular airport. Each member on the AAAE roster was sent an email which contained an Internet link to an online survey in- strument. This survey used the software on www.surveymon key.com. To ensure anonymity, the survey did not require any participant to identify themselves or their airports. The survey was administered to 175 airports nationwide. Some demographic information was collected for the pur- poses of measuring whether any group differences occurred. The demographic information is listed in Table 6. The airport locations were divided among Alaskan, Central, Eastern, Great Lakes, New England, Northwest Mountain, Southern, Southwest, and Western Pacific. Type of Airport (based upon FAA criterion) included general aviation, non hub, small hub, medium hub, and large hub. The yearly enplane- ments included the following choices: no enplanements, less than 100,000 enplanements, 100,001 to 250,000 enplanements, 250,001 to 500,000 enplanements, and over 500,000 enplane- ments. The survey had 64 respondents which covered all re- gions except Alaskan and all types of airports and enplanement categories. In addition, exposure to both natural, airline and general aviation disasters within the preceding ten years was recorded. Table 5. The SF-36v2 Health Survey. Mean SD Physical Component Summary (PCS) measure 48.84 4.97 Participants who scored < 1sd below mean (43.87) Participant 100 38 Participant 101 40 Participant 307 42 Participant 103 43 Mental Component Summary (MCS) measure 43.95 4.98 Participants who scored < 1sd below mean (38.97) Participant 306 33 Participant 204 35 Table 6. Demographic identifiers among sample. Airport Location Type of Airport (based upon FAA Criterion) Yearly Enplanements

67 The first question that respondents answered was the fol- lowing: “In regard to your Airport Emergency Plan (AEP), does your airport currently have any formal or informal pro- gram(s) designed to deal exclusively with the mental health trauma that employees may face after responding to an aircraft accident or natural disaster?” Thirty-six respondents indi- cated they do currently have a program in place to deal with employee mental health traumas post-accident, while 28 indi- cated that they do not have such programs. It should be noted that no definition of a “formal or informal program” was used within the survey, and the interpretation was left up to the respondent. It is possible there are wide variances between the structures and types of programs amongst those answer- ing in the affirmative. The second question asked was the following: “Would you be in favor of a program/template that would help your organ- ization initiate a program to assist employees coping with trau- matic events (deal with what they have witnessed) in the course of responding to a disaster?” Forty respondents indicated they would be in favor, with six not in favor and 18 uncertain. There was no significant difference between those organizations who had post-disaster mental health trauma programs in place and those who did not with regard to being in favor of implement- ing such a program, χ2 (2, N = 64) = .666, p > .05. Within the preceding 10 years, airports who had experi- enced an airline disaster (n = 4), a general aviation disaster (n = 24), or a natural disaster (n = 17) reported no group differences in their preference for wanting post-disaster mental health programs, χ2 (2, N = 64) = 4.693, p = .096; χ2 (2, N = 64) = 1.233, p > .05; and, χ2 (2, N = 64) = .205, p > .05, respectively. Airport location, classification and num- ber of annual enplanements also demonstrated no group dif- ferences with regard to favoring or not favoring the creation of a program, χ2 (14, N = 64) = 16.261, p> .05; χ2 (8, N = 64) = 5.908, p > .05; and, χ2 (8, N = 64) = 4.388, p > .05. Interestingly, 36 of 64 respondents reported they already have a mental health recovery program in place at their airport. This does not seem to be congruent with this study’s findings in the field. The incongruity could possibly be explained with a wide variance of definitions as they pertain to a men- tal health recovery program. For instance, it is possible that an airport may simply have a clause in their emergency plan to have employees contact the Red Cross or the Employee Assis- tance Program (EAP) should they encounter mental health trauma. While this may be a productive measure, it may not be comprehensive enough to completely assist employees with their own resiliency and would not be considered a “classic” mental health recovery program. The majority of respondents feel a mental health recov- ery program is a worthwhile addition to their plan (62.5%). This perception held true irrespective of whether the airport already had a plan in place or not and whether they had expe- rienced an aviation or natural disaster within the past 10 years. Only 9.4% did not favor the idea of such a program, with 28.1% unsure. From the data, it appears most airports would be open to some type of guidance on how to implement a mental health recovery program and integrate it within their emergency plan. Regarding the favorability of implementing a program, exten- sive regulation or cumbersome application could be the reason for the higher number of “unsure” respondents. However, a formal definition of such a plan would have to be thoroughly developed and applied in order to alleviate burdensome obsta- cles in implementation. This definition could also increase the robustness of currently implemented plans, whether they are simplistic or involved. In any event, further study into the issue of mental health recovery programs could generate more focused data given that the more detailed definition of a recov- ery program is operationally defined.