Intervention and Resilience after Mass Trauma

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Intervention and Resilience after Mass Trauma

Intervention and Resilience after Mass Trauma Edited by

Michael Blumenfield Robert J. Ursano

CAMBRIDGE UNIVERSITY PRESS

Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521883740 © Cambridge University Press 2008 This publication is in copyright. Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press. First published in print format 2008

ISBN-13 978-0-511-42341-3

eBook (EBL)

ISBN-13

hardback

978-0-521-88374-0

Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Every effort has been made in preparing this publication to provide accurate and up-todate information which is in accord with accepted standards and practice at the time of publication. Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved. Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation. The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this publication. Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use. All material contained within the DVD is protected by copyright and other intellectual property laws. The customer acquires only the right to use the DVD and does not acquire any other rights, express or implied, unless these are stated explicity in a separate licence. To the extent permitted by applicable law, Cambridge University Press is not liable for direct damages or loss of any kind resulting from the use of this product or from errors or faults contained in it, and in every case Cambridge University Press’s liability shall be limited to

Dedicated to those who have suffered from disasters and terrorism and taught us how better to care for them. Dedicated also to the late Sidney E. Frank, industrialist, creative entrepreneur, and philanthropist. Mr Frank recognized the importance of supporting the study of the impact of disaster and it was his grant to New York Medical College which sponsored the conference upon which this book is based.

Contents

List of contributors Foreword by Joseph T. English Preface 1

Systems, science, and populations Effective early mental health intervention following mass trauma: the roles of government, clinicians, and communities

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1

Beverley Raphael

2

Factors in the development of community resilience to disasters

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Rose L. Pfefferbaum, Dori B. Reissman, Betty Pfefferbaum, Karen Fraser Wyche, Fran H. Norris, and Richard W. Klomp

3

Psychological first aid

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Patricia J. Watson

4

Acute stress disorder and early interventions after trauma

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Richard A. Bryant

5

The role of pharmacotherapy in early interventions

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Matthew J. Friedman

6

Should culture considerations influence early intervention?

127

Carl C. Bell

7

Resilience is the default: how not to miss it

149

Arieh Y. Shalev and Yael L. E. Errera

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Contents

8

Epilog Early intervention for individuals and communities: planning for the future while meeting present needs

173

Robert J. Ursano and Michael Blumenfield

Index

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Contributors

Carl C. Bell, M.D. President/CEO, Community Mental Health Council, Inc. Professor of Psychiatry, School of Medicine Professor of Public Health, School of Public Health University of Illinois at Chicago Chicago, Ill. USA Michael Blumenfield, M.D. Sidney E. Frank Professor Emeritus of Psychiatry and Behavioral Sciences Department of Psychiatry and Behavioral Sciences New York Medical College at Westchester Medical Center Valhalla, N.Y. USA Richard A. Bryant, Ph.D. School of Psychology University of New South Wales Sydney Australia Joseph T. English, M.D. Sidney E. Frank Professor and Chairman Department of Psychiatry and Behavioral Sciences St. Vincent’s Catholic Medical Center of New York New York, N.Y. USA Yael L. E. Errera The Center for Traumatic Stress Studies Department of Psychiatry Hadassah University Hospital Jerusalem Israel

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List of contributors

Matthew J. Friedman, M.D., Ph.D. Executive Director National Center for Posttraumatic Stress Disorder US Department of Veteran’s Affairs White River Junction, Vt. USA Richard W. Klomp, MOB, MS, LPC, BCPC Workforce and Responder Resilience Office of Health and Safety Office of the Chief Operating Officer Centers for Disease Control and Prevention US Department of Health and Human Services Atlanta, Ga. USA Fran H. Norris, Ph.D. Department of Psychiatry, Dartmouth Medical School and National Center for Posttraumatic Stress Disorder US Department of Veterans Affairs White River Junction, Vt. USA Betty Pfefferbaum, M.D., J.D. Department of Psychiatry and Behavioral Sciences College of Medicine University of Oklahoma Health Sciences Center Oklahoma City, Okla. USA Rose L. Pfefferbaum, Ph.D., M.P.H. Liberal Arts Department Phoenix College Phoenix, Ariz. USA Beverley Raphael, M.D. Professor of Population Mental Health and Disasters University of Western Sydney Professor of Psychological Medicine Australian National University Canberra Australia

List of contributors

Dori B. Reissman, M.D., M.P.H. Senior Advisor for Disaster Mental Health and Terrorism CAPT, US Public Health Service Centers for Disease Control and Prevention US Department of Health and Human Services Atlanta, Ga. USA Arieh Y. Shalev, M.D. Professor of Psychiatry Hebrew University School of Medicine Head, Department of Psychiatry Director, Center for Traumatic Stress Hadassah University Hospital Jerusalem Israel Robert J. Ursano, M.D. Director, Center for the Study of Traumatic Stress Chair, Department of Psychiatry Uniformed Services University of the Health Sciences Bethesda, Md. USA Patricia J. Watson, Ph.D. National Center for Posttraumatic Stress Disorder US Department of Veteran’s Affairs White River Junction, Vt. USA Karen Fraser Wyche, MSW, Ph.D. Department of Psychiatry and Behavioral Sciences College of Medicine University of Oklahoma Health Sciences Center Oklahoma City, Okla. USA

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Foreword

American psychiatry has been a leader in addressing the psychological sequelae of trauma no matter what the etiology may be. Erich Lindemann working at Massachusetts General Hospital in 1943, when confronted with survivors of the Boston Grove Fire, was able to recognize and define the psychological symptoms, which became a model for many years. It was only fitting that more recently when the Committee on Dimensions of Disaster of the American Psychiatric Association (APA) chaired by Dr Ursano, co-editor of this book, recognized the need for financial support for local psychiatrists at the time of disaster, they named a proposed grant that would be given to local District Branches in such circumstances: the Lindemann Grant. The co-editor of this book, Dr Blumenfield, introduced this proposed resolution to the Assembly of the APA which enthusiastically endorsed it, making funds available whenever needed. Unfortunately, there have been numerous tragic events, such as Katrina and September 11, 2001, which have required psychiatrists to mobilize and to offer assistance together with other emergency workers. Disasters and mass trauma have certainly not been limited to the United States. Earthquakes, tsunamis, terrorist bombings and war itself can occur anywhere on our globe. The resultant trauma impinges on the human psyche and presents a challenge for all the healing professions. The tradition of modern psychiatry in these circumstances brings compassion, empathy and what we know about how to help in these circumstances. There is a need to continue to learn more about better therapeutic techniques, meaning that clinical services must always be linked with research and evaluation of past experience drawn from our work. It was for this reason that we held the first Sidney E. Frank Conference at New York Medical College in June of 2006, co-chaired by Drs Ursano and Blumenfield, which brought together some of the world’s leading experts in dealing with psychological intervention following mass trauma. This book is a product of the thinking of the outstanding people who made presentations at that meeting and the subsequent day-long discussion. It is very gratifying to appreciate the continued evolution of their thinking.

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Foreword

It is also worth noting that they all agreed that, despite the horrific experiences that victims of disaster often undergo, a remarkable human resilience becomes our ally as we administer our therapeutic interventions. Joseph T. English, M.D.

Preface Meeting the challenge of providing intervention following mass trauma

Traumatic events and disasters are an unexpected but not uncommon aspect of our lives. Disasters of the scale of the Southeast Asian tsunami in 2004 are thankfully rare. But consider that, worldwide, there are over 20 000 earthquakes a year and over 1300 per year are magnitude 5 or greater. The earthquake in Iran in 1990 killed 50 000 people. In the Armenian earthquake of 1988 over 25 000 died and the earthquake in Tangshan China in 1976 resulted in at least 255 000 deaths and perhaps as many as 655 000 (National Earthquake Information Center). Earthquakes are only one of many natural disasters yet they highlight the difficulty of planning and understanding the mental health effects of traumatic events, disasters, and terrorism. Earthquake disasters remind us that the distinction between natural and human-made disasters is only relative. In an earthquake, those buildings built with poor materials or built near the water in the case of a tsunami are at much increased risk. Worldwide, those of lower socioeconomic means have a high likelihood of becoming disaster victims, because their homes are often built in high risk areas (Brewin et al., 2000). The public health perspective on early intervention requires considering the needs of large populations as well as individuals. Disaster mental and behavioral health is directed to fostering resilience and recovery while recognizing that trauma, disaster, and terrorism lead to mental illness, distress, and health-risk behaviors all of which must be planned for and considered in early intervention (Benedek and Ursano, 2005; Fullerton et al., 2003; Ursano et al., 2007). It was in this context that the idea for the first Sidney E. Frank Conference at New York Medical College was conceived. This book is a result of the presentations and interactions that occurred at this meeting. Sidney E. Frank was a marketing genius who was able to understand the needs of the public at large and appreciate the value of utilizing the very best experts to help him read the changing times and apply their knowledge to make his products successful. He gave a generous gift to New York Medical College to support the concept of delivering mental health services in the most creative and effective manner possible. He personally approved the concept that

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Preface

one of the components of the grant that he gave to the Department of Psychiatry would be to have a conference that would examine psychological intervention following mass trauma. The editors of this book co-chaired the first Sidney E. Frank conference, which is on this topic. We followed the approach of Mr Frank by choosing eight of the most outstanding experts in the field. Each person was invited to make a presentation in his or her special area of expertise related to the subject of the meeting. The presentation was held on the campus of the New York Medical College in Valhalla, New York on June 13, 2006. It was also carried live on web cast. In addition to the filled auditorium there were more than 400 people from 20 different countries on line viewing the presentation either live or in archived form, which included questions and answers. A DVD is included with this book so that the readers can also hear the presentation made on that day. On the second day of the conference all the presenters met privately for a full-day meeting co-chaired by the editors of this book. They discussed the subject in a free-flowing manner without restrictions. The role of resiliency became the centerpiece of discussion and finally a strategic plan for action was developed by all the participants. The latter will be presented at the conclusion of this book. At the end of the conference, the eight participants all agreed to re-write their presentation utilizing any colleagues that they wished to join them in writing their chapter. The goal was to make a state-of-the-art book on the subject as it had evolved from this conference. The word resilience was added to the title because it was clear that the vanguard is now to understand the vulnerability of individuals to mass trauma and to attempt to dissect out the complex factors that lead to resiliency. All the authors in their own way moved in this direction during the preparation of their chapter. It was quite notable that despite the original invitation to the experts to speak at the June 13 conference on the subject of early psychological intervention following mass trauma, all the presenters independently stressed the issue of resiliency in response to trauma. They all appear to be saying that if we understand resilience, we understand the psychological response to disaster. Dr Beverley Raphael in her analysis of the systems involved following a mass trauma concludes that some individuals are more vulnerable because of their nature, genes, and history as well as their experience during and after the incident. She also appreciates that people are more resilient in spite of the fact that the various systems are impacted by catastrophes. Dr Raphael looks at the existing research that might explain resiliency in various individuals whether they be related to genetics or other factors related to stress and exposure. Drs Pfefferbaum, Reissman and colleagues look at factors in the development of communities with resiliency to disaster. They state that resiliency is a life-sustaining process that must be continued over time and examine the intersection between personal resiliency and community resiliency.

Preface

Dr Patricia J. Watson puts into perspective the concept of resiliency by noting that the management of acute stress reaction following disaster and mass violence has the aim of fostering resilience and preventing chronic emotional problems, as well as minimizing long-term problems and affecting the quality of life following traumatic exposure. She emphasized that there is no evidence that Critical Incidence Stress Debriefing (CISD) prevents longterm negative outcome (after an incident), a point that was thoroughly examined and agreed upon in the post-conference discussion. In the aftermath of a disaster, Dr Watson calls for a more flexible and multi-model approach due to the chaotic post-incidence environment. A psychological first aid model is advocated and explained in which its various components will ultimately improve the capacity of the individual and the community to be resilient (Center for the Study of Traumatic Stress, 2005). Dr Bryant zeroes in on acute Stress and the importance of understanding prior dissociation including childhood trauma. The role of cognitivebehavioral therapy (CBT) is discussed by him, including the work of Dr Edna Foa, which is brought up by multiple authors in this book. In his chapter on the role of psychopharmacology, Dr Friedman concludes that even if there were a reliable method by which to differentiate resilient survivors who recover on their own from vulnerable survivors who are at great risk to develop post-traumatic stress disorder (PTSD), there are few data to guide us regarding the choice of medication for early intervention following mass traumatic events. Dr Bell, after a comprehensive review of culture and race, goes on to show how these factors will clearly influence early intervention and perceived resiliency. In the final chapter Dr Shalev concludes that the occurrence of resiliency and the development of mental disorders are independent dimensions of the response to traumatic events. He believes that good adaptation is the most frequent outcome of adversity and is mediated by the normal mental processes. In other words, as is the title of his chapter, ‘‘resiliency is the default.’’ Michael Blumenfield Robert J. Ursano

REFERENCES Benedek, D. M., Ursano, R. J. (2005) Beyond post-traumatic stress disorder [Commentary]. Biosecurity and Bioterrorism, 3(2), 164–165. Brewin, C. R., Andrews, B., Valentine, J. D. (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 746–766.

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Preface Center for the Study of Traumatic Stress (2005) Psychological first aid: helping victims in the immediate aftermath of disaster. Courage to Care. Retrieved 4 January 2008, from http://www.centerforthestudyoftraumaticstress.org/downloads/CTCPsychological FirstAid.pdf. Fullerton, C. S., Ursano, R. J., Norwood, A. E., Holloway, H. H. (2003) Trauma, terrorism and disaster (pp. 1–22). In: Ursano, R. J., Fullerton, C. S., Norwood, A. E. (eds.) Terrorism and Disaster: Individual and Community Mental Health Intervention. Cambridge: Cambridge University Press. National Earthquake Information Center, US Geological Survey, http://neic.usgs.gov/ neis/eqlists/eqstats.html (accessed 30 December 2007). Ursano, R. J., Fullerton, C. S., Weisaeth, L., Raphael, B. (2007) Individual and community responses to disasters (pp. 3–29). In: Ursano, R. J., Fullerton, C. S., Weisaeth, L., Raphael, B. (eds.) Textbook of Disaster Psychiatry. Cambridge: Cambridge University.

BIBLIOGRAPHY Butler, A. S., , Panzer, A. M. and , Goldfrank, L. R. (eds.) (2003) Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy, Committee on Responding to the Psychological Consequences of Terrorism, Institute of Medicine of the National Academies. Washington, DC: The National Academies Press. Watson, P. J. and , Shalev, A. Y. (2005) Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events. CNS Spectrums, 10 (2), 123–131. World Health Organization (2001) Fact Sheet No. 218. Mental Health Problems: the Undefined and Hidden Burden. Revised November 2001. http://www.who.int/ mediacentre/factsheets/fs218/en/print.html. World Health Organization (2003) Mental Health in Emergencies: Mental and Social Aspects of Health of Populations Exposed to Extreme Stressors. Geneva: Department of Mental Health and Substance Dependence, WHO (http://www.who.int/mental_ health/media/en/640.pdf). World Health Organization (2005) Mental Health Atlas 2005. Geneva: WHO.

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Systems, science, and populations Effective early mental health intervention following mass trauma: the roles of government, clinicians, and communities Beverley Raphael

Introduction This paper discusses three main themes that need to be addressed for effective early intervention. The first is the examination, through a systems analysis, of the factors that may impact on mental health through formal and informal organizational activity and behaviors, in the prevention, preparation, response, and recovery to disasters and terrorism. These systems may be vehicles to support positive mental health outcomes, or may contribute to vulnerability; the identification and mobilization of these are critical for early intervention and more specifically for good mental health outcomes. Such factors may far outweigh the efforts of individual clinicians and specialist mental health programs, despite their valuable contributions overall. The second is a more thorough examination of the science of early intervention, its conceptualization and current scientific underpinnings and rationale, and the necessary components of an effective early intervention strategy to inform the mental health response to mass emergencies. Thirdly, it will draw together these elements in a template for the delivery of ‘‘early intervention.’’ This review will highlight the significant further work that is needed to both build the scientific base and to translate it into real world policy and services for affected populations. This requires government and organizational support to lead to the delivery of effective early intervention across the range of potential disaster and terrorism scenarios. Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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Chapter 1. Systems, science, and populations

Systems and early intervention There is a growing interest in systems and complex systems – systems in fields as diverse as molecular biology, information systems, emergency and the military organizations, health care systems, and many others. While the theory of complex systems is outside the scope of this paper, several themes it encompasses are relevant; for instance, the interest in collective patterns of behavior, the different observational processes that may describe a system, and the evolution of systems over time and their responses to challenge or threat (see New England Complex Systems Institute and Commonwealth Scientific and Industrial Research Organisation.) There are interacting systems, and more or less formal complex systems that evolve in response to challenges such as disaster or terrorism. The field of disaster prevention, preparation, response, and recovery needs to be better informed by systems analysis, including from societal, human behavior, and mental health points of view. Consideration of such issues is very relevant to a field where there are any of the following: high levels of demand and uncertainty; rapid change; disruptions of social and institutional functioning; high and unknown levels of ongoing threat; death and destruction; a vast spectrum of potential harms to those who may be vulnerable; and, by definition, there is a potentially overwhelming challenge to the resource base which is called upon to respond. The relevance of systems for early intervention relates to the potential goals for early mental health interventions. These are, as highlighted by many important contributors to this field (Litz, 2004; Ritchie et al., 2006), to lessen morbidity that might otherwise occur as a consequence of exposure to the diverse stressors affecting populations and individuals. Such outcomes have been well summarized by Norris in her critical reviews of disaster research findings (Norris et al., 2002a, 2002b). The potential diversity of health, mental health, and other outcomes following terrorist incidents is also increasingly reported; as revealed for instance in Neria et al.’s (2006) compendium of research into, and program response to, September 11. What is clear from all this work is that some populations and some individuals are more vulnerable than others because of their nature, their genes, their history, and their experience during and after the incident; equally, some are more resilient than others. The critical significance of contexts and related systems, both social and geographical, is highlighted by findings about the variable outcomes of different communities following trauma exposures (Kawachi and Subramanian, 2006). Social capital is one such community-level system variable that contributes to how well a community responds to trauma: it is protective where there are good pre-existing community organizations and social networks, or it may increase vulnerability where there is less functional organization with little


resilience. It is also clear that impacts may appear over a prolonged period or be delayed; that there may be impacts far from the site of disaster; that there may be ‘‘ripple effects’’ across populations; that there may be a ‘‘contagion’’ of distress and indeed strengths, particularly between children and parents, within the complex systems of diverse families, and through communities, organizations, collectives, and crowds. It is also apparent that there are dominating themes of goodwill, of regret, grief, anger, of hope, and compassionate humanity; and all this is likely even in the face of horrendous impact – be it through natural forces such as the Southeast Asian tsunami, or malevolent attack as with September 11. Systems will be impacted by such catastrophe and systems will respond. Understanding and influencing these systems are essential for an effective mental health response to terrorism and disaster, and for early intervention. The systems for disaster and terrorism prevention, preparation response, and recovery strategies ‘‘Developed’’ countries have significant and indeed multiple formal organizational systems of response. In addition there are ‘‘spontaneous,’’ non-formal groups which may evolve into organizations of action and advocacy. Government and non-government systems are involved, as well as private sector businesses and industry. In developing regions there may be fewer formalized disaster-specific organizations, possibly because survival priorities take precedence over resources for sporadic, even if potentially devastating, events. In international settings, as exemplified by the response to the Southeast Asian tsunami, the United Nations, the United Nations Children’s Fund UNICEF, International Red Cross and Red Crescent and the World Health Organization, and many other groups, particularly major aid organizations and other non-govermental orgenizations (NGOs), are prominent response systems and have important roles in partnership with the leadership of affected nations and communities. For instance, over 200 NGOs were registered in Aceh in the aftermath of the tsunami. There is frequently the aim to build capacity in the longer term, as well as to respond optimally to the current episode. Where repeated natural disasters occur, for instance hurricanes in the USA, bushfires in Australia, floods in Europe, earthquakes, and land slides, a ‘‘disaster culture’’ builds, with belief systems about what will happen and what can or cannot be done to deal with these threats. Such a belief system may influence the capacity of systems to respond, or lead to beliefs that the problem has been fixed. Impacts may be increased by a failure of preparation, greater ‘‘shock,’’ anger, attributions, and poor resources for response, as systems are not ready, leading to delayed reaction times. Mental health outcomes may be worse in such circumstances. Or there simply may not be recognition of the potential for such overwhelming catastrophe, as with the tsunami, the Pakistan earthquake and Hurricane Katrina. A greater focus on prevention and preparedness

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systems has been developed with respect to terrorist attacks, especially in countries where these had not been to the fore previously, e.g., USA, Australia. If there is not adequate and formalized preparation activity through systems developed for such purposes, then each group involved may act in a silo, untouched by its requirements for complex interfaces with other responder systems. Without preparation and collaboration, it will be difficult to implement early intervention. There are the issues that surround disasters in any setting – the convergence of response systems. These range from traditional emergency sector providers such as police, fire, ambulance and health sectors, as well as defense/military, to the broader community, and many other organizations who believe they can contribute. While formal emergency response systems may be practiced in collaborative focussed effort, others may not. There is enormous diversity among individuals and groups wanting to help, to be there, and to make things better. Affected populations are most likely themselves to be in the first line of response, and actively involved in the matters of their own recovery. Informal responders may spontaneously organize themselves into an ‘‘emergency organization.’’ Some may make up longer term groups focussed on ‘‘recovery organization.’’ These diverse formal and informal systems may add to the chaos, with potential for further disruptions that can unintentionally interfere with effective response. Critical for these multiple systems of acute and longer term response are the issues of governance, decision-making processes, roles and responsibilities, and the degree to which they are prepared for the range of catastrophes that may arise. Key systems variables identified more broadly by theorists in this field include system domains or elements; flexible repertoires of response; interfaces/interactive capacities with other systems; and thresholds of challenge/threat which, when approached or exceeded, may ‘‘tip’’ organizational systems into more negative functional repertoires from which recovery may be difficult. In response to specific challenges, systems may mobilize a repertoire of appropriate actions that lead to a new ‘‘regime’’ of stability and functioning. The system survives, evolves and develops for positive future identity: when negative thresholds are tipped, the system may be neither efficient nor effective, and its survival may not be of value. Planning systems for terrorism and disaster Governance and co-ordination will be key elements, particularly for pluralistic societies. In the emergency, it is likely that government agencies will be responsible for control, containment, and acute response, but this overarching management becomes more diffuse as time elapses. The degree to which co-ordination occurs, engaging affected communities, may be central to recovery trajectories. This is a challenge for mental health, particularly if there is


a wish to implement early intervention. There will be a need to define what it will involve, its potential benefits, who can provide it and who should receive it as a priority, and to negotiate how it will be encompassed by these systems and their processes, from the earliest stages. The World Health Organization (WHO) in its guidelines for the disaster planning for mental health has provided a template linked to mental health systems more broadly, identified as the WHO AIMS-E, E for Emergency (Assessment Instrument for Mental Health Services, see WHO Kobe Centre, 2005). It emphasizes the importance of two levels of planning and their necessary co-ordinating processes and governance. These two levels are a preparation plan for readiness, and a response plan geared to shape the response to a particular incident or incidents. For mental health, there are many key stakeholders within health and welfare systems who may be engaged in such planning. The World Health Organization acknowledges that both psychosocial and mental health interventions may contribute to positive mental health outcomes. Multiple other systems may impact positively or adversely. The degree to which an emergency response saves lives and lessens injury rates is likely, as a consequence, to lessen the impact on mental health of tragedies such as deaths, losses, and injuries. Defense, police, and fire services are also complex systems of response that interface with mental health. The media, political systems, and information systems may be powerfully influential. Furthermore ‘‘trauma,’’ and ‘‘psychological trauma’’ are popular causes and many agencies that are not specialized mental health providers may believe that they have something to offer. This is aside from the more complex motivations to respond felt by individuals (e.g., facing one’s own fear of death, triumph of survival) or organizations (e.g., profile, rationale for existence, ‘‘doing good’’). Additionally, there are the mental health needs of these formal and informal responders and systems, in terms of the impact of the catastrophe on them and their preparation for, and response to, it. Even looking at the international response, many formal organizations, including WHO, hold a brief for response in emergency (van Ommeren et al., 2005); for example, the International Red Cross and Red Crescent Societies; the United Nations, UNICEF, International refugee and humanitarian groups, Me´dicins Sans Frontie`res, diverse NGOs, and among others more recently the World Psychiatric Association. Then affected countries have their own organizations. Each of these organizations will have specific and more general contributions to make, but unless there are opportunities for collective understanding and knowledge within and across these complex political and social systems, there may be little potential for effective early intervention. Furthermore, the challenge is to ensure coherent and scientifically informed responses, that are culturally appropriate and adaptable to local systems for intervention (including primary care and indigenous healing), and that are effective and do no harm.

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In the USA there are organizations such as FEMA (Federal Emergency Management Agency), the American Red Cross (Weaver et al., 2000), US Department of Defense, and Centers for Disease Control, to name a few. Specialized mental health groups include the American Psychiatric Association Disaster Response Committee, the Disaster Response Network of the American Psychological Association, and the All Hazards Disaster Planning Group of the National Association of State Mental Health Program Directors; there are also professional groups such as the National Association of Social Workers and no doubt many others, including for instance crime victims groups and veterans associations. There are also many NGOs, and many faith-based groups with strong pastoral care as well as disaster response commitments. How these and other key groups are governed, tasked, and co-ordinated for a mental health response either broadly or specifically for early intervention is not clear, at least to someone who is not a US citizen. Nor is it clear who has which role, what sanctions exist for their organization to provide mental health care, and of course the whole issue of financing in public and private sector managed health care systems. The USA, as Australia, has very complex state and federal systems; jurisdictions of ‘‘ownership’’; legislative responsibilities; accountabilities; as well as the interaction of such systems. While a whole-of-government response is often the ideal, it is very difficult to achieve. These complex systems, with diverse motivations, governance and decision-making, have many components, are dynamically interacting, and give rise to a number of levels at which they may variably operate. The most likely time of co-operative action is in the acute emergency, for such is a ‘‘life/death’’ time. This time and the immediate aftermath have collectively been called the ‘‘honeymoon phase,’’ in terms of affiliation and altruistic behaviors, goodwill, collaboration, and intense reparative responses (e.g., political promises). Next the ongoing realities beyond survival come to the fore, such as the loss, destruction, the financial costs of the disaster and who will foot the bill. At this point, bitterness, anger, grief and bureaucratic requirements may overwhelm co-ordination and collaboration, adding stressor components related to both the aftermath and the systems’ response to it, i.e., the phase of ‘‘disillusionment.’’ Such a chronic phase may move to recovery, and regeneration systems, or tip actions over a negative threshold into a ‘‘second’’ disaster. The US Department of Health and Human Services through Substance Abuse and Mental Health Services Administration (SAMHSA) and its Center for Mental Health Services (CMS) has provided Mental Health All Hazards Disaster Planning Guidelines (US Department of Health and Human Services, 2003) for state and local planners. It emphasizes the importance of preparation and planning beforehand, and integrating this with other response agencies. It also describes systems involved and the importance of engaging with these, ‘‘Ideal plans identify a clear decision making structure and articulate the


authority of each plan participant’’ (p. 13). Those who should be involved are delineated within their systems, as is the need for response logistics, such as mobilization capacity and deployment strategies. Basic elements are outlined, including the organization and assignment of responsibilities in times of emergencies (e.g., relation to FEMA, State Emergency Management Agency (SEMA), SAMHSA/CMS and so forth). As well there is delineation of necessary administration, record keeping, logistics, and the management of volunteers. The content deals with formalizing needs assessment – for instance, the numbers of dead and injured, homes destroyed, priorities for service, and monitoring changing needs overtime, and the administrative and legal instruments that support the plan’s implementation. Specific issues also addressed in context include communication, public information, identification of roles and responsibilities, mobilization in relation to mental health system priorities, mass casualties, evacuation, health and medical systems, and resource management. Quite specific issues are also identified in this all hazards approach, including terrorism, continuity for the ongoing functioning of mental health systems, and links to other organizations, public, private, academic, business, and so forth. There is also the need for additional components of guidance such as standard operating procedures. This useful volume also carries the template for a plan (pp. A1–A9). Nevertheless, as in most systems, disaster plans for mental health may not be adequately exercised with other emergency and recovery systems, may not inform response in the real world, or may not even be known to, and owned by, those required to implement them. It is frequently the case that mental health may not have the same level of priority for all those involved in planning and response. Nor is it always clear whether a national plan for mental health response exists. Early intervention is not a specific priority in this plan, and neither are the education, training, and accreditation of potential providers for such an early intervention response capacity, or indeed clear sanctions for implementation. Response systems for terrorism and disaster The ‘‘readiness’’ for response, delineated above, may be variably tuned to the extent and nature of particular catastrophes. Since September 11, 2001 the repertoire of potential scenarios has been greatly increased, with preparations to prevent, or counter, a wide range of terrorist events – from bombing of transport, such as in Madrid or London, to potential hostage and siege situations such as Beslan, and the possibility of ‘‘dirty bombs,’’ and bioterrorism. Enormous investments have been made to develop health protection systems, to increase security, and to exercise counter-terrorism strategies. Each emergency and counter-terrorism system has delineated responsibilities both for those it would protect, and for its personnel. While it might be recognized that natural

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disasters may also have catastrophic impacts, there tends to be a belief that these can more readily be managed by existing disaster response systems even though this has recently been challenged by events such as Katrina and the Southeast Asian tsunami. Mental-health-related issues have been identified as priorities by many response systems, because of both demonstrated long-term consequences and the high levels of anxiety generated by some scenarios, with the potential to block resource systems, for instance triage, health and emergency systems, communication, and other critical infrastructures. Sustaining the effectiveness of response personnel in the shorter and longer term and protecting their health and mental health are system requirements. Challenges exist with such dynamically interacting multicomponent systems operating at a number of levels, so that while mental health is a recognized need, as is dealing with such issues ‘‘early,’’ the demands for effective operations take precedence. Strategies required are those that would enhance positive mental health as opposed to increasing morbidity-oriented trajectories. Mental health systems have long existed in relative isolation. Despite the emerging demands of the broader medical interfaces, generic knowledge and skills to protect mental health have not been systematically built into responding emergency systems. The longer term recovery systems have close interfaces with social domains, health care systems, welfare, and familiarity with mental health systems and services. Strategies to promote early intervention may be more readily adopted in these latter contexts when there are knowledge and skills in other responding systems. ‘‘Institutional’’ systems may have complex, multiple components and levels of functioning that may be affected by any catastrophe. The degree to which these infrastructures are damaged, how they respond to the incident and throughout this period, and the services they put in place for their populations can be vital for mental health protection, and for early intervention. Their institutionalized systems need to adapt in the face of threat or disaster in such a way as to achieve their goals and responsibilities with respect to the communities they serve. For example, strong leadership, support, and the valuing and engaging of staff and user populations can all be deployed in active steps to return to effective functioning and achieve business continuity. Organizational systems may provide their members and stakeholders with prevention or early intervention programs to deal with the impacts of a catastrophe, mobilizing an effective mental health strategy as part of the emergency and recovery process for its members or in some instances its client populations. This can be seen in some common systems likely to be affected by major community catastrophe; for example business, schools, emergency response systems, health care systems, media, information and communication.


Systems supporting protection of mental health Core themes of systems that are likely to be more positive or protective for the mental health of members and those with whom they engage include: compassionate and effective leadership; forward preparation and planning for emergency response and exercising of such plans; engagement with, valuing of, and responsiveness to members and external stakeholders; the capacity to respond to challenge and emergency in systematic, effective ways that are nevertheless flexible and responsive to unanticipated threats and changing demand; the capacity for appropriate, knowledgeable, and flexible interaction with other relevant ‘‘external’’ systems with which they interface in the emergency and aftermath; effective mental health capacity-building systems for ‘‘looking after’’ the wellbeing including the mental health of their members, from leaders and high level managers to workers at the coal face, informed by the best available scientific expertise; systems of communication and information sharing that support response and provide for the needs of members and stakeholders; systems of acknowledging achievement and need; learning cycles and cultures of evaluation and building for the future. Potentially traumatogenic systems Potentially traumatogenic systems include: Systems that lack effective and compassionate leadership Systems that do not have clear lines of responsibility and accountability Systems that lack clear command, decision-making and appropriately

consultative governance Systems that have not prepared, planned and exercised for potential

catastrophes Systems which do not interact well with other relevant systems Systems which favor bullying, negative management strategies Systems which do not educate their members, and do not adequately

inform and communicate with them about what is happening and what they will need to do Systems which have cultures of blame, and scapegoating rather than evaluation, learning, accountability, and improving future response Systems which are inflexible, resistant to challenge and change and cannot adapt to emerging needs Systems which do not value either their workers and members, or their clients, except in commercial or output terms

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Chapter 1. Systems, science, and populations Systems that do not provide for their mental health and wellbeing and

cannot balance these requirements with growth, system recognition of members’ achievements and of the contributions of all. Systems may respond in ways which further traumatize workers and clients, by additional stressors related to system dysfunction or failure, abandonment or blame. Systems that demonstrate greater levels of deficits are more likely to be ‘‘traumatogenic’’ in the broad sense and contribute to greater vulnerability of members and possibly clients. This will challenge the resilience of those with whom there are interactions, and possibly lessen opportunity for effective early intervention. System engagement Many systems can contribute positively to the field of early intervention and some of these things are exemplified but not limited to the systems identified below. Business Well prepared business systems have leadership, plans for prevention and response, and strategies for business continuity and recovery. There are Employee Assistance Programs (EAP) or the like to meet the needs of workers, ranging from personal and family support, psychological first aid through to early intervention, treatment, and rehabilitation. As well businesses may provide support programs to their communities. School systems Schools have a primary commitment to the needs of children and their families, and their own staff. Effective plans, strong leadership, and rapid return to functioning for the benefit of students will all contribute to wellbeing. In addition early intervention system programs may be provided to staff to assist recovery from adverse impacts. Schools provide a valuable framework for specific early intervention programs for children and families from the communities they serve. It is estimated that schools are likely to reach up to 70%–80% of people in a given community; they may serve as a community focus and have authority with respect to their mission with children and families. Emergency response systems Emergency response systems such as police, fire and ambulance, as well as defense, have goals for management, response, and sustaining functioning and operational goals. Building the mental health aspects of occupational health and safety systems has been a major goal of many such systems, commencing with programs such as the Critical Incident Stress Debriefing (CISD) movement and with roles for chaplains, counselors and peer support


programs. These systems have moved to more systematic early intervention programs with a strong trauma focus and strategies beyond the earliest period. There is an indication that they are effective in sustaining their workforce’s functioning, giving the workers the sense that their experience is acknowledged, including stressors associated with their work roles, and that they are valued for their contributions and achievements. However, these programs have yet to be shown through empirical research to prevent or even mitigate trauma-related mental health outcomes such as PTSD, although the value for a work unit’s morale is generally supported (Adler, 2005). The incorporation of key evidence-based mental health program components assists where these are built into such occupational health programs (e.g., Alexander, 2000). Additionally, the impacts on families are increasingly acknowledged and provided for. Nevertheless, available data suggest that: (1) considerable psychiatric morbidity still occurs, and that more effective early intervention programs need to be built in; (2) particular exposures, such as those of multiple gruesome deaths, are associated with higher risk; and (3) early rehabilitive interventions need to be strengthened.

Health systems Disaster and terrorism plans, their governance, the capacity for surge response and sustainability, and health business continuity strategies exist for most public sector systems and large private providers. Focus is usually strongly oriented toward injury and disease. Early intervention strategies may be provided for staff, for instance through Employer Assistance Plan providers, but in general there are inherent beliefs that doctors and nurses are ‘‘used to’’ dealing with catastrophe and can cope. As the studies following the severe acute respiratory syndrome (SARS) outbreak showed, there may be significant psychiatric casualty rates (Maunder et al., 2003). Furthermore, general health staff may not see the provision of early intervention for mental health as a priority to be integrated with their functions, for either themselves or their client populations. Health systems strategies for members and clients in general need further development. The mental health system may be seen as a component of the overall health system, but has long operated as a somewhat separate entity. Its own system characteristics have at times demonstrated: a lack of flexibility and responsiveness; leadership and governance uncertainties; limited response repertoires to deal with threat/challenge; system interaction difficulties in terms of interfaces with other systems; and limited growth and evolution. At other times mental health systems have led to change. Shaping the mental health system for effective response in relation to health systems more broadly may be a key requirement.

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Health system efficiency is also a key issue more broadly. The capacity to encompass population, health, and clinical approaches as effective and efficient strategies together has recently been highlighted for health systems generally (Bar-Yam, 2006), and is very relevant for disaster and terrorism response, including mental health disaster response. Communication, information, and media systems Such systems have major impact in supporting response, informing the public, and providing a voice for leaders. When infrastructure is damaged communication failures may add to the stressors experienced by affected populations through more prolonged uncertainty, lack of capacity to contact loved ones (as occurred with the London bombing; Wessely, 2005), greater opportunities for misinformation and catastrophic themes to build momentum. If media systems do not provide accurate up-to-date information, or focus only on negatives as news, their contribution may be more stressful than positive, although this balancing may be problematic. The culture of media response may be influential, and is now better informed in terms of trauma paradigms, disasters, and mental health through programs such as those inspired by the DART Foundation for Journalists (2008). Media coverage has potential to support adaptive coping, or at times to further traumatize. It is a powerful influence when information is critical in the immediate post-disaster period, and is increasingly aware of the psychological trauma issues. Systems to communicate, to provide information about what is happening, what to do and the whereabouts of loved ones will be helpful, particularly if those providing such information are trusted sources and do so clearly, without jargon and with compassion. Information centers are systems that can contribute to early mental health intervention (Weisaeth, 2004). Information systems such as the internet and web can also be helpful by providing advice and self-help strategies for early intervention, and as communication channels for workers as well as the broader community, e.g., with deployed teams and responders, and assisting their family contact. Community systems At a community level there are further formal and informal systems including non-governmental and community organizations, sporting, recreational and social bodies, cultural and ethnic groups as well as faith and religious communities. These have variable structures, and may or may not have been involved in disaster preparedness planning. However, when a disaster or terrorist incident occurs in a community the first responders are most frequently members of the affected community. Their responses are usually an effective and positive component of response. Informal ‘‘emergency organizations’’ may develop, with natural leaders who can contribute to the


community’s effective response, even in tragic circumstances. Similarly spontaneous ‘‘recovery organizations’’ may develop to support the longer term recovery processes. Engagement, broad education and information through planning and response phases can build mental health understanding about trauma and its impacts. Psychological first aid skills, and knowledge of effective caring, support and self-help strategies are also important. There is much to support the view that a community’s active engagement in its own response and recovery is associated with better outcomes, perhaps through the sense of empowerment, mastery, and efficacy such actions engender. Political systems The governance of a nation is in the hands of its politicians, where, depending on the democratic process, power for action may vary. Political leaders are usually well informed in terms of planning and potential threats, as well as their state’s or country’s response capacities. Nevertheless observation, comment, and research have highlighted the further powers that even democratic societies may hand to their leaders in the face of threats such as terrorism, or indeed the response to a major emergency, particularly if associated with attack, violence, mass casualties or uncertain futures. Political systems may be drawn into the altruistic, honeymoon phase with leaders promising to ‘‘make things right’’; promises that they may not be able to fulfil, as the wishes of those affected may be linked to the longing for it not to have happened at all, and for life to go back to the way it was. ‘‘Compassionate leadership’’ is seen as a positive model, as is ‘‘grief leadership,’’ and the spontaneity of leadership in understanding the needs of those affected and ‘‘being there’’ at the site have all been identified as important. Leaders may need informed support and advice and it is important that these are available through expert, high-level, and confidential consultative processes, before, during the emergency, and in the aftermath (Raphael, 1983). Systems variables: conclusion Understanding the nature of systems is vital to both those primarily involved in mental health and the mental health themes that will flow through the activities of other systems. Both mental health systems (which have often been slow to change) and other systems will face major demand, change, and evolution as they become engaged in the critical emergency response to terrorism and disasters. Such system’s evolution can in and of itself contribute positively to mental health, and to early intervention. Any delineation of early intervention strategies needs to build a recognition of systems, to identify roles and strengths that can contribute positively, to implement a mental health consultative role and promote activity that protects mental health and mitigates any traumatogenic system response.

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The science of early intervention The concept of ‘‘early intervention’’ for mental health has developed as a ‘‘virtuous’’ entity, a ‘‘good thing to do,’’ yet it is poorly defined, diversely conceptualized and variably deployed as a mental health strategy. The term is used to describe approaches in the early stages of the life cycle, including preand post-natal periods, infancy, and early childhood. It is also taken up at other stages of the life cycle. Its further meaning lies with ‘‘early’’ in the disease process, the disorder trajectory. From a public health point of view, it sits in the spectrum of interventions from prevention through to treatment and rehabilitation, with implications for both prevention and effective treatment (Commonwealth Department of Health and Aged Care, 2000). Public or population health and prevention proponents would focus on early childhood strategies, such as enrichment programs like HEADSTART (Silverstein et al., 2004) or the systematic home visiting programs (Olds et al., 2000), which have, like many other studies in the prevention field, demonstrated significant shorter and long-term benefits (Commonwealth Department of Health and Aged Care, 2000). Clinicians have chiefly focused on the vulnerabilities to disease, for example programs for early intervention with schizophrenia, focusing on the prodromal state in the onset period of the late adolescent years (McGorry et al., 2002). Even in the later stages of life there are evolving programs for early intervention with dementia. Such programs generally demonstrate benefits, for instance a decrease in burden and cost savings (human and economic) with better outcomes for schizophrenia (McGorry and Yung, 2003), perhaps altering the disease trajectory.

Scientific themes for early intervention Complex scientific methodologies are required when examining early intervention because of the multiple influencing variables, including factors such as gene–environment interactions, interactions between environments, interventions with exposures and background factors, and the potential for resilience, delayed impacts, attributions, and even the impact of research itself. Of particular significance however is the matter of time. The science informing early intervention relies on population and clinical assessments. The nature of trajectories is an inherent challenge, as are prediction capacities and the potential power of any intervention. King et al., (2004) have highlighted the need to take such factors into account, including the effect size of potential interventions, the accuracy of their application and timing, and the stringency of methodological considerations for research to back


early intervention. More recently they have highlighted how this may influence measurement times, and the need to use statistical techniques such as structural equation modeling (SEM) to account for time factors (King et al., 2006). Positive prediction indicators, odds ratios, and numbers needed to treat to demonstrate benefit are all significant to trajectories, which may change so much over time (including both pathology and resilience changes). The context too is very important. For instance, while it has long been recognized that some communities and the individuals in them may recover better than others after a disaster, and the role of social capital has been hypothesized, it is now a domain to be taken into account in potentially influencing outcomes. This has been evidenced by studies by Kawachi and Subramanian (2006), measuring and monitoring the social and geographical contexts of trauma and the systems in which it occurs. These issues sit in the context of the enormous complexity of translating research from randomized controlled trials into effective programs in realworld, diverse disaster contexts and through diverse responding systems (Neria et al., 2006). Current science of early intervention: knowledge and gaps Prevailing focus of intervention research In the field of disaster and terrorism, the focus of early intervention has been chiefly in the field of traumatic stress and post-traumatic stress disorder, as this has been the lens through which such events have been viewed, and for the most part their impacts measured. Clinicians working to respond in this field have looked at the prodroma of PTSD and one-to-one or group interventions for those who appear vulnerable to the development of this disorder; for instance, with identified predictors such as acute stress disorder, peri-event dissociation, rapid heart rate (Shalev et al., 1998), heightened and prolonged arousal, re-experiencing and numbing phenomena (Watson and Shalev, 2005). In this context there have also been population-focused strategies aimed at the reaction to potentially traumatic exposures, and attempting to diminish their impacts, for example as with the debriefing movements. There is also increasingly a focus on information as a potential intervention. As well there is the transfer of scientifically based self-help programs for mass population access and use on the internet. The science supporting such strategies will be discussed below. As is now increasingly recognized, there are other exposures beyond those that most typically lead to PTSD. These stressor exposures may be acute and/or chronic and may co-occur with those that are more likely to lead to PTSD outcomes. Particularly significant is the loss of a loved one leading to bereavement. The deaths in disaster and as a result of terrorism are frequently acute, traumatic, unexpected, and often untimely, and as such are more

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likely to be associated with pathological bereavement outcomes including depression, PTSD, complicated grief or traumatic grief (Norris, 2005). Early intervention strategies have been developed in non-disaster contexts, and recently applied in circumstances post September 11, 2001, and other disasters (Cohen et al., 2006). The outcomes are yet to be evaluated, and it is not clear to what degree their focus was ‘‘early’’ intervention. Population oriented programs for bereaved individuals and communities do not appear to have been systematically applied, although the spontaneous systems of support and memorization that occur are likely to be helpful. Dislocation from home and community is another stressful exposure with recognized impacts on mental health and wellbeing (Bankoff, 2003; Parker, 1977). These may be amongst many chronic stressors that contribute to prolonged health impacts, particularly demoralization and depression; adverse impacts on family functioning; and an increase in risky behaviors, including those relevant to health. Early intervention is not generally discussed in these contexts. Nevertheless, practical strategies to re-establish ‘‘home’’ or ‘‘place,’’ social support networks, and functioning community institutions may all produce significant benefits, or lessen adverse outcomes in terms of mental health. The types of incidents may presage particular risks to mental health; for example, the impacts of slow floods with pre-warning will be different from the impact of similar forces occurring suddenly. Variables such as suddenness of onset, anticipation or otherwise, extent of life threat, death, destruction, violence, loss, and dislocation factors may all be relevant, yet few may provide a clear basis for early intervention in relation to dislocation. This is chiefly the case because there is evidence that exposure, even to the most horrifying circumstances, and loss (even when totally devastating) may still be dealt with, and that resilience is generally the norm. Resilience does not mean that there was not suffering but rather the person’s adaptations were ultimately effective. Thus any early intervention strategy requires a rationale that recognizes this force of resilience in individuals and groups, and does not negate it. It also recognizes the diverse trajectories to adverse outcomes that may need to be taken into account if they are to be mitigated. Critical in this context is the consideration of timelines, trajectories of change, and the potential effect sizes, positive and negative of any proposed interventions as discussed above (King et al., 2006). Finally, it is essential that any such early intervention strategy ‘‘does no harm.’’ Specific and complex mental health impacts are likely to arise with ongoing, or invisible or uncertain threat – for instance with terrorism or bioterrorism (Shalev, 2006). Anxiety may be high in the early stages, but demoralization, depression and somatization may subsequently predominate. Early intervention could be important in mitigating impacts, particularly any chronic


disorder trajectories such as might occur with somatic presentations leading into somatization disorders. As yet there is no established scientific base to inform, except for some CBT strategies that have been shown to be effective for some people with somatization disorders. In the early prodromal period before the disorder is apparent, such strategies could potentially lessen the risk of chronic disability. The injured may receive early intervention for their physical trauma, but there may be less focus on their psychological trauma, except for more integrated models such as those of Zatzick and Wagner (2004) and on work such as that following motor vehicle accidents (Mayou et al., 1997). Screening and evaluation of those injured in such circumstances are recommended. How mental health early intervention and other strategies are integrated with physical health care is relevant both for circumstances of injury and circumstances such as bioterrorism. Collaborative care can be offered in a stepped care approach including an embedded CBT module, which is seen as clinically beneficial for injured patients. Other brief interventions have shown early benefits (e.g. Blanchard et al., 2004). Even late intervention may be difficult in such circumstances. Vulnerable populations Vulnerable populations may have greater risk, and potentially greater need for early intervention than less vulnerable populations, but research to inform a basis for action is limited. One group of particular interest is those who have previously been profoundly traumatized; for instance, refugee populations who may have either greater vulnerability to subsequent exposures, or greater ‘‘hardiness’’ and resilience. Those currently exposed to ongoing conflict are another group for whom superimposed disasters may lead to profound complex emergencies. People with pre-existing mental illnesses may also be vulnerable, yet there are no data identifying them and few specific programs to meet their needs (SAMHSA, 2000). Indigenous populations may be vulnerable through higher levels of current and past traumatic exposures and losses and ongoing disadvantage (Raphael et al., 2007). Disadvantaged populations may be both more subject to disasters and more affected by their impacts. Yet early intervention strategies may not be well taken up by them. Where survival predominates as a demand it is unlikely that there will be time, space or resources for the ‘‘luxury’’ of early intervention in any formal sense. Vulnerable individuals Individuals may be vulnerable through pre-existing variables, levels and severity of event exposures, and post-exposure factors. Pre-existing variables may include genetic make-up, particularly in terms of gene–environment interactions; for instance, the short form of the 5HTT gene may increase vulnerability to poor mental health outcomes when there are multiple adverse

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stressor exposures, but not otherwise (Wilhelm et al., 2006). Temperament, coping styles, previous history of trauma, particularly child abuse and child sexual abuse, may increase vulnerability, as may experiences of loss, illness, dislocation, the personal impacts of disadvantage, and past or current psychiatric disorder or traits such as ‘‘neuroticism’’ (Watson and Shalev, 2005). Event-related factors that may increase vulnerability include the severity and extent of exposure to the major stressors of: death/personal life threat and the multiple deaths of others; loss, including the loss of loved ones and multiple other significant losses; severe injury; dislocation; and exposure to human malevolence. Reactions at the time may include vulnerability, for instance panic and dissociation. Post-event variables are multiple and occur over time. They include the ongoing impact of a catastrophe in terms of loss and destruction, changed resource base; perceptions and realities of social support; and further ongoing stressor exposures from other sources including everyday life, community disintegration and cultures of blame. Multiple protective influences including personal hopefulness and other positive expectancies may mitigate any of these above influences (Watson et al., 2006). Cultural variables Cultural variables may be a very significant influence in many aspects of mental health disaster response, as highlighted at this meeting by Bell (2006). Cultural variables may operate at both population and individual levels. Language, race, ethnicity, migration transitions, status of the cultural group – its norms, beliefs and practices, including religious practice – would all need to be taken into account in any early intervention strategy. But more particularly early intervention as a mental health system response may not be understood or accepted. Silove’s (1999) model highlights how inappropriate as a concept PTSD may be seen to be in many cultures, as may early intervention for this, with its aims of improving mental health and recovery from disaster impacts. ‘‘Alien’’ status in the dominant culture, paucity of language-based services to inform, and history of past persecution could all contribute to vulnerability and indicate the need for early intervention. Yet, culturally based views of mental health, its disorders and treatment may make it unlikely that those in need will access services, or that services will be available to provide ‘‘early intervention’’ in culturally appropriate and acceptable ways. Intervention early in the life cycle Further to the question of ‘‘early’’ intervention is that of ‘‘early’’ in the lifespan; particularly with children and families, although there is limited evidence for benefit apart from programs in other settings (Lieberman and Van Horn, 2004). Programs may focus on trauma and grief (e.g., Cohen, 2004) or on giving parents the skills to help their children with any reaction or symptoms that may arise, such as separation anxiety phenomena.


There are programs addressing many of the stressor exposures as above and their impacts on these groups. Interventions may be early in the course of pathology, in prodromal domains of the trajectory into disorder or dealing with broad behavioral and emotional problem domains rather than specific disorders (Wooding and Raphael, 2004). Programs through school systems have generally followed a public or population health model; for instance, involving classes, or whole schools in an intervention for children based on models such as ‘‘books’’ of their experience of fires and other disasters. These have followed variable time periods after such incidents and have demonstrated effectiveness (McDermott et al., 2005), focusing early on in the illness ‘‘course’’ as well as early in the life cycle. Late use of early intervention modalities such as debriefing has shown some benefit, as population-focused intervention (Chemtob, 2000). Information for those affected and their parents may also be seen as population-based ‘‘early’’ or potentially protective intervention, however such information has not yet been tested for its effectiveness in mitigating potential mental health morbidity. The National Child Traumatic Stress Network (http://www.nctsnet.org/) has provided such information resources through its web-based services. Many organizations dealing with children provide similar guidelines. Trauma and early intervention Much of the science that supports early clinically based intervention in response to disaster and terrorism comes from studies carried out in other settings, for instance after smaller acute incidents that could traumatize psychologically (Bryant et al., 2003), such as motor vehicle accidents, assaults, rape and so forth. These randomized controlled trials (RCTs) have had some translation to real-world settings, such as with disaster- and terrorist-affected populations (e.g., Goenjian et al., 1997; Neria et al., 2006; Pynoos et al., 1995, 2006). Science supporting early interventions in military settings has been strongest with work such as that of Solomon with the Israeli army (Solomon et al., 2005). The model of early interventions for combat stress rests on the PIE (Proximity, Immediacy, Expectancy) model of frontline response, which, while focused on individuals, is supported within a military population health framework. The most recent reports of long-term benefits of such early prevention provide strong support for the value of such an approach (Solomon et al., 2005) although it is clear that some of those affected may not be helped and may go on to develop severe and chronic PTSD – perhaps through repeated exposures (Solomon and Mikulincer, 2006). Castro et al., (2004) have identified the challenges of early intervention in military settings, noting however contributions of Shalev, Adler, Litz and others to this field. This type of work highlights the twofold purpose of early intervention in this and other settings. One purpose is, of course, to help the soldier by preventing psychological traumatization as far as is possible, and to look after his or her mental health

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and wellbeing. The other purpose is to keep the soldier functioning in his or her role as fighter, to sustain the military or other imperative. Both need to be recognized. Similarly twofold purposes may exist with emergency responders as will be discussed below. The support of ongoing functioning in professional or work roles is worthy in its own right, but may of course need to be balanced against risks of further acute or cumulative traumatization. There are many ‘‘early intervention’’ or related programs for responding workers, particularly emergency services such as police, fire, ambulance and defense, as will be discussed below (Eriksson et al., 2004). These are chiefly based on traumatic stress paradigms, such as those relating to ‘‘debriefing’’ and trauma counseling, and delivered through chaplains, counseling, and employee-assistance-type programs. Health care workers are poorly addressed with little research on which to base programs of early intervention for them. Debriefing models, such as the Critical Incident Stress Debriefing (CISD; Mitchell and Everley, 1993, 2000) and other debriefing models for emergency responders (e.g., Alexander, 2000; Weiseath, 2000) build on the model of frontline response for military populations, and transfer it to civilian but ‘‘militaristic’’ type operations. This work was enormously important in leading to a recognition of the potentially traumatizing nature of such work, in providing an acceptable framework that men could utilize. It overcame many gender stereotypes about their possible vulnerabilities and needs, and provided organizationally sanctioned structural approaches to address them. These generic benefits (i.e., organizational support and system recognition of stressor aspects of work roles) continue, although there is now a significant evidence base that debriefing does not prevent PTSD. Furthermore, when broadly applied to disaster- or terrorism affected populations who do not come together in organizationally based ways, it may be associated with poorer mental health outcomes, i.e., it may be a damaging early intervention. Even with military populations, as Shalev (2000) suggested, it may bring people closer to some median response. Weisaeth (2000) considered that it may be most useful or least likely to cause harm when it is an integrated part of the review process, carried out by the skilled and informed team leader following an incident, for groups who regularly function together for specified roles, rather than ad hoc groups, and for those who have been briefed beforehand. There is great ongoing debate about debriefing as an early intervention, applied through organizational systems, to populations, or more broadly (Litz, 2004; Raphael and Wilson, 2000). The originators of the CISD framework have seen it widely taken up, perceived as helpful and valued by many, but challenged by others. They have adapted it to a more comprehensive CISM, or Critical Incident Stress Management framework, recognizing that it may be one part of a process to protect and provide for the mental health and wellbeing of workers in emergency and other service response systems.


Nevertheless there is clear evidence from high-quality RCTs (Adler, 2005) that it does not prevent PTSD, although it is viewed as helpful, and may support wellbeing in units or groups who routinely function together in response (Everly and Mitchell, 1999). The critical issue in such work is that it clearly demonstrates this as a public or population health approach using an organizational system framework – tailored for the norm and to the requirements of the system, to its goals. Early interventions for the bereaved There are fewer systematic, scientifically based early interventions for those bereaved in disaster or terrorism settings. Those currently provided in general build on research from other settings of bereavement (e.g., Shear et al., 2005; Raphael and Wooding, 2004; Raphael, et al., 2006). While early bereavement interventions for disaster response were evaluated some time ago (Singh and Raphael, 1981), such interventions more recently have tended to focus on the traumatic nature of the bereavement, sometimes dealing with it through a PTSD-related strategy. The segue of complicated grief into traumatic grief and back to complicated grief and the merging of these concepts in the language have somewhat confused this field (see Prigerson and Jacobs, 2001). Nonetheless, the principal early intervention framework rests on clinical, grief counseling-type interventions, delivered to individuals deemed to be at high risk in these circumstances. Risk relates usually to the nature of the death (traumatic circumstances), the relationship to the deceased or the nature of the relationship with the deceased, or to measures of heightened bereavement phenomenology, and to pathology that is evolving as indicated in Prigerson’s work regarding complicated grief (Prigerson and Maciejewski, 2005). The work of Pynoos et al., (1995), Cohen (2004) and others has extended such interventions to children affected by trauma and loss, with demonstrated benefits. There have also been very valuable studies highlighting resilient trajectories in such settings (e.g., Bonnano, 2004). The translation of these findings to the bereaved who are vulnerable has yet to occur on a systematic and effective basis for disaster-affected populations. At the population level, interventions by leaders demonstrating ‘‘grief leadership’’ may have positive benefits, as may the memorialization responses. There are no studies to the writer’s knowledge examining such issues. However, another vital facet relates to the earliest stages of loss of loved ones in such circumstances – the time of uncertainty, searching, and formal processes of disaster victim identification. The bereaved interfaces with a number of complex systems in such processes, and may be exposed to profound additional stressors that will further complicate their adjustment subsequently. For instance, the need for DNA, the state of bodies, or body parts, or no body being found may all complicate the bereavement, as may the inability to fulfil religious, cultural, and personal requirements for the

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deceased, as has occurred after terrorist incidents such as September 11, 2001 or Bali (Raphael et al., 2004) or other mass casualty circumstances (e.g., Southeast Asian tsunami, see Miller, 2005). Early intervention support through such circumstances may play a vital role, but is not yet scientifically tested, although studies are in process addressing such issues (Mowll, 2005). Additional traumatic exposures may come from system responses that are insensitive, as well as exposure to the multiple, gruesome and mutilating deaths of others, the search through temporary morgues for loved ones amongst other disfigured remains, or the return of limited body parts, and the dread of the suffering that the loved ones experienced in dying in this way (Gagin et al., 2005). There is the need for the systems of response to the bereaved, as with those who are traumatized, to operate in ways that protect mental health, support positive early intervention, and do no further harm. Population health and system frameworks need to address the vulnerability and needs of those affected by disaster and terrorism, and also to provide appropriate clinical interventions. Population-focused early intervention The recognition of the need for a broadly based, population-focused approach or, from the earliest stages, approaches that support need but do no harm has led to a refocussing on the concept of psychological first aid, or PFA for short (Raphael, 1977; Young, 2006). This approach has been endorsed by the consensus conference on Early Intervention after Mass Violence (NIMH, 2001). Elements identified in an integrated approach with other emergency response systems focus on basic survival needs for safety, shelter, protection, comforting, and practical and emotional support. More recently, and prioritized in response to Hurricane Katrina, detailed guidelines have been developed into a Field Operations Guide by the National Child Traumatic Stress Network and National Center for PTSD (NCTSN and NCPTSD, 2005). These cover domains of preparation; contact and engagement; comfort; safety; information gathering regarding current needs and concerns; practical assistance; connection with social supports; information on coping; linkages with collaborative services; and dealing with adults’ as well as children’s needs. They will be evaluated, but have been made widely available to assist with large-scale natural catastrophes of recent times. Other contributors to this field such as Young (2006) have also provided specific guidance for such approaches. The Australian model (New South Wales Health Department, 2000) has linked the PFA approach to Disaster Victim Identification (DVI) systems, and to a potential triage model, using the ABC rubric as with physical first aid (airway, breathing, and circulation). The ABC of PFA refers to arousal, behaviors, cognitions, where these are such as to place the person at heightened risk through the intensity of arousal, behaviors that impair


function, or cognition processes reflecting organic or dissociative states. The utility of PFA is that it is a universal approach and can be applied, if skills are developed, by all responders not just specialized mental health workers, and potentially sets in place core, initiating components of early intervention to protect and support positive mental health. Nevertheless to date, this is based on experience and assumptions. Randomized controlled trials, as well as translational and evaluative research, could provide a sound evidence base to validate the consensus of experts. Clinical intervention guidelines for trauma Guidelines to support intervention for PTSD have been developed through work such as those of the National Center for PTSD in the USA (Veterans Health Administration, 2004) and the American Psychiatric Association (APA, 2004) and more recently (ACPMH, 2007). These are useful frameworks but can represent only one facet of disaster response. Apart from models dealing with acute stress disorder, these frameworks do not systematically address other early intervention strategies, in terms of either setting a basis for assessment or decision-making about how to apply them, to whom, and with what processes to translate them into effective provision for those affected by terrorism or disaster. Nor do such guidelines move far beyond clinical intervention to population health approaches, or systems of application. Another facet requiring further development is that related to support for return to functioning, the rehabilitation strategies. While those physically injured are likely to be provided with rehabilitation of interventions focused on returning them to as full functioning as possible from the earliest stages, this is less clearly so for those psychologically injured, and the more so as avoidant reactions may strongly interfere. Early rehabilitation interventions dealing with the impacts of psychological and traumatic stressors on functions require development, consensus, and research testing if positive post incident trajectories, rather than increasing pathology and disability, are to be achieved. Systems such as those of compensation, or those with a focus on victim-hood may complicate effective early rehabilitation intervention strategies even further. Human malevolence and early intervention Human malevolence is another stressor when the catastrophe is the result of terrorism or related intentional human acts. The forms of trauma and grief, the loss of the sense of personal or even national invulnerability, the rage and need to attack, the search for justice and meaning, or even vengeance all have the capacity to complicate resolution of the experience, and to lock those exposed into the event, so that the usual psychological interventions are less effective in the face of such complexity.

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While inquiries, the pursuit and punishment of perpetrators, and justice models, including those such as the Truth and Reconciliation Commission, all address such themes, it is important that they are dealt with separately from, but in parallel with, strategies specifically addressing mental health needs. This allows mental-health-focused early interventions to help those affected deal with their trauma, grief, rage, and their loss of sense of personal and even national invulnerability. While ‘‘justice,’’ if achieved to victims’ satisfaction may help, it cannot undo what has happened. A sense of ‘‘closure,’’ if this occurs, is just one component in the trajectory forward. Population/public health platforms for early intervention Preparation and planning There is evidence that vulnerabilities may be decreased in experienced, prepared populations, or in those who have practised, exercised or planned for, or in other ways prepared themselves to respond to mass catastrophe. Strengthening social capital also has potential benefits. Early intervention could build well on such background preparation and its associated burgeoning knowledge and skills in the population. Information as intervention Publicly available information provided in response to the catastrophe, information that provides support for effective coping strategies, expectations of resilience, advice as to appropriate actions, and where to find help, have all been suggested as positive strategies, such as the Courage to Care set of strategies. All such strategies would benefit from systematic outcome evaluation in terms of mental health impacts. The role of the media in the provision of information from trusted sources, leaders, and clear direct, incident-based appraisal and advice as to action are potentially helpful as compared to information without integrity or which focuses only on the horror (e.g., Taylor, 2006). Dissemination, community languages and multiple channels, both local and national systems of information delivery, and the use of consistent messages all reflect potentially beneficial approaches, but the science to support these guidelines is not well developed. Limiting the exposure to very graphic images, particularly for children, may be important as part of information in early intervention. Psychological first aid Psychological first aid (PFA) is intended as a universally available intervention in the immediate post impact period. As such it is a further component of a population health approach. While the strategies this involves are generally agreed (National Institute of Mental Health, 2001) their operational testing is still progressing. The research base to build on consensus needs further


development both to ensure effectiveness, and to support this into skills development for real-world actions by the multitude of potential responders. Just as physical first aid training is provided to the broad community, there is the need to extend knowledge and capacity for PFA to community members, such as including informal first responders as well as formal ones. Strengthening positive aspects of system response It is important to strengthen positive aspects of system response to populations who are traumatized and bereaved, and to those affected in other ways. This involves a coherent, systematic approach recognizing the specific needs of those who have been severely impacted. It may involve the provision of support persons through the earliest stages: to protect from further harm; to assist with family reunion; to provide general emotional support; to assist with information and practical needs or support through DVI processes. Strengthening systems for wellbeing and mental health Consultancy models can assist with this process using the themes identified as associated with adaptive systems in terms of their functional adaptations to potential disaster and terrorism impacts, and caring for their members and others (McCaroll and Ursano, 2006). Occupational mental health systems These are necessary components of early intervention to prepare for to, prevent adverse exposures where possible, and to respond rapidly to exposures that may affect the mental health and wellbeing of responder populations, particularly emergency responders. Building positive systems will include strategies of organizational commitment to positive mental health outcomes; the provision of information; response to support workers with acknowledgment of their experience and exposure; counseling; rehabilitation; and positive expectations as well as provisions for those most adversely affected or disabled. These responses build upon what is known, including preparation and training, stress inoculation training and other aspects of mental health protection. Spontaneous community responses and systems Many processes arise directly from communities’ own actions. These include actions to address impacts and recovery; ‘‘natural’’ gatherings; discussion; review; or informal debriefing; self-help strategies; organization of spontaneous networks of affiliation; and outreach and support to those most affected. These are poorly researched, yet appear to constitute active, effective, early intervention for many of those involved, perhaps building on existing social capital systems, and contributing to their evolution. Positive interfaces with the mental health response system can facilitate referral, avoid splitting and scapegoating, or provide tools for such movements’ recovery goals.

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Building population mental health capacity Mental-health-based approaches using a population health framework can contribute to using capacity for mental health more broadly in the population/ public health system and indeed models for service delivery (Raphael, 2000). Clinical platforms for early intervention Clinicians involved in mental health care, and with trauma and PTSD in particular, are most familiar with early intervention prescribed in one-to-one or group formats. These may merge with public health approaches when implemented in institutionalized systems, for instance programs for children and young people in schools. The core elements are now discussed. Interventions for trauma exposures The strongest evidence for benefit is in the provision of cognitive behavioral interventions, plus exposure paradigms (Bryant, 2004; Bryant and Litz, 2006). Guidelines and manuals (Foa et al., 2000) have been developed to inform care provision. Nevertheless, the translation of such strategies to disaster- or terrorism-affected populations has yet to be adequately tested. As McNally et al. (2003) suggest, the convergence of trauma counselors to New York after September 11, 2001 was not useful; nor did intervention programs meet the level of need as it emerged subsequently, even though many were resilient. This type of intervention may be applied for those with heightened traumatic stress reactions or acute stress disorder. Further clinical themes involve the testing of these strategies for children, young people and families, and identification of what additional components may be required, such as skills for parents to deal with children’s fears, separation anxiety, and regressions in the response to trauma exposures, or so that they can recognize children’s needs if these are reflected in changed behaviors (Wooding and Raphael, 2004). This is particularly important given findings that children’s early mental health impacts and coping may be strongly influenced by those of their parents (McFarlane, 1987). Pynoos and Nader (1993) also emphasized that there is not only the clinical work required to deal with the original exposure, but also the need to teach those affected how to deal with triggers that may reopen the trauma-related distress, and other consequences of the impact in the aftermath. Particularly significant in this context are impacts or behaviors such as increased antisocial or acting out responses, substance use problems (e.g., increased binge drinking, marijuana use), health-risk behaviors, and health impacts on sleep, fatigue and general health, as well as work, functioning, and personal relationships. Thus ‘‘early intervention’’ for trauma exposures may need a series of modules, to deal not only with the psychological impacts, as


occurs with exposure-based CBT interventions, but also with other possible consequences. Recent reports have suggested interventions for alcohol use problems, and advice regarding sleep, exercise, nutrition, and health checks including holistic approaches. Interventions for loss Although trauma is the accepted overarching paradigm dominating response, components of grief and bereavement also need to be specifically addressed. The phenomena are different from those of traumatic stress although both may overlap in disaster and terrorism or other sudden violent death contexts. Bereavement-focused early intervention, like that of trauma, builds on work in non-disaster settings. Grief counseling requires support for review of the lost relationship, the changes in the bereaved person’s life and roles that are the consequence of the loss, and dealing with the yearning, sadness, anger, and perhaps guilt. The nature of the pre-existing relationship with the person who has died may increase vulnerability, highlighting relationships with dependants as being more likely to be associated with complicated grief (Prigerson et al., 2002). The traumatic circumstances of the death may also make grieving more difficult, as there may be traumatic stress phenomena complicating resolution which may need to be dealt with first or alongside grief counseling processes (Raphael and Wooding, 2004; Raphael et al., 2006). The indications for early intervention for bereavement, as for trauma, lie with the highly intense reactive process that may be prolonged and a readiness for early (or any) intervention will need to be taken into account. Specific programs for children, young people, and families need to build on consensus of what is effective, on work such as that of Pynoos and Nader (1993), Cohen et al. (2004, 2006) and others and wherever possible involve a family focus. Testing core elements in real-world post-disaster settings is a research challenge. Interventions for other stressor exposures Clinicians may identify risk, potential pathology trajectories and define clinical interventions for many of the possible stressors noted earlier, including: ongoing threat, dislocation, uncertain and invisible threat of disease, poisoning or radiation and the myriad disruptions to community functioning that may occur in the aftermath. Interventions for the injured have been more systematically developed (Wain et al., 2006; Zatzick and Wagner, 2004). There is a limited scientific basis on which to provide clear guidance for clinical interventions and an urgent need for research to progress them – the clinicians’ informed assessment is at present the best process. It should be informed, by the requirements not to harm, not to interfere with natural processes of resilience and to assess strengths as well as vulnerabilities as a basis for determining any intervention strategies.

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Early clinical interventions for those with evolving disorders A range of evolving disorders may be associated with specific exposures, the broader disruption of systems or the specific decompensation of those with pre-existing psychiatric disorders, particularly anxiety and depressive syndromes. In response, it is likely that clinicians will mobilize appropriate strategies. The broad challenge clinically is to address both exposures and their meaning, as well as their interface with the underlying vulnerabilities. In doing so clinicians need to avoid unbalanced attributions – too great a focus on either the event or the underlying condition. Pharmacological intervention possibilities Pharmacological intervention possibilities for the acute post-disaster setting have recently been reviewed by Simon and Gorman (2004). Examining possible agents that could reduce psychobiological distress, and facilitate effective coping, they conclude that the available evidence is limited and that the focus should be on psychotherapeutic modalities unless medication is specifically indicated. Interventions for children, young people, and families While these specific issues have been discussed briefly above, it is vital that there are skilled providers cognizant of the specific needs of children in terms of development, family dynamics, and the potential impacts on families over time (Cohen et al., 2006; Wooding and Raphael, 2004). Early intervention requires better development and research for these constellations as a priority in mitigating impact and potential burden. Rehabilitation interventions This implies functional impairments, yet prevention and early intervention to mitigate possible functional impacts, to return social, interpersonal, work, and other functional strengths, is a critical requirement and needs to be an active component of clinical frameworks for early intervention. This will require effective systems to be in place to assist such processes. Self-care and information Critical to all aspects of early intervention is the provision of information about what can be provided and why, what the client’s role will be and what he or she can do to progress these goals themselves. This is particularly important in post-emergency contexts as it helps the person to move from helplessness or victim status, to a position of personal agency. Again, benefits need further research and evaluation, although clear evidence exists of some effective programs for trauma-related pathologies. Other platforms for early intervention will evolve over time and their benefits or otherwise will be established. Substantive ‘‘templates’’ for the


implementation of early intervention, reflecting both barriers and facilitation processes, may then be identified, along with the necessary sanctions for such programs of response. It is clear however that the scientific bases must be further strengthened and increased priorities given to both population and clinical intervention research studies, and their translation to and evaluation within mass emergency contexts. Capacity building The skills of mental health systems and providers can be further developed so that cultures supporting effective early intervention strategies are more broadly incorporated into the work of mental health professionals and systems. The science of early intervention: conclusion The trauma paradigm, psychological injury, and the trauma archetype (Wilson, 2005) are all terms for the predominant framework through which the mental health aspects of disaster and terrorism are viewed. Yet there are many other profoundly affecting experiences, particularly those of loss, which impact on individuals and populations. Such impacts occur across the life cycle, and may affect vast numbers of people, from the most vulnerable groups to the most resilient. Social and cultural themes will set the stage, influence the interpretation and response, and provide prescriptions and sanctions for what can be done to heal, to recover, to renew. Early intervention is a sanctioned response in Western Mental Health care paradigms, valued and seen as potentially changing negative trajectories that reflect heightened risk of pathology and morbidity. Assessment, screening, and other possible strategies to identify risk, as a rationale for early intervention, will be discussed in the following Section, ‘‘Delivering early intervention.’’ At this stage, however, it is possible to draw together the current scientific platforms for early intervention, which are built from the available evidence base and expert consensus, and clearly indicate the need to build the research base to inform such practice. Early intervention is an initiative focused on mitigating the trajectories and levels of pathology, functional impairment, and adverse mental health and behavioral outcomes. It is based on the hypothesis that it will be possible to prevent the full development of disorder, or lessen its severity, extent, associated impairments, and disabilities. Early intervention sits as a strategy on the spectrum of interventions for prevention and treatment, outlined in the Institute of Medicine Report (Mrazek and Haggerty, 1994) and links both universal and selective prevention components to indicated interventions, early case funding, and rehabilitative and treatment endeavors. Early intervention applies across the life span and may be particularly significant where the earliest origins of vulnerability begin in the earliest years of life, leading in to illness trajectories. It also applies to early intervention in

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the disease process through intervention that may alter risk influences, may build protective influences or may change the course of disease. In the field of disaster and terrorism, it builds chiefly on the trauma paradigm, but is also relevant to the full range of experiences, vulnerabilities and resiliences that affected populations may demonstrate, including those related to loss and those related to multiple other stressor exposures of the impact, ongoing threat and aftermath. It thus requires multiple levels of potentially beneficial intervention ranging from those addressing the population, to those clinical processes addressing the most vulnerable individuals, and it means ‘‘early’’ in terms of various times, trajectories, and timelines.

Delivering early intervention To deliver effective early interventions to populations and individuals who would benefit from these it is necessary to set systems in place that can provide the necessary frameworks and personnel (Norris et al., 2006; Ursano and Friedman, 2006). Such frameworks will need sanctions, expertise and a resource base, and the support of government, and disaster and emergency response and recovery systems. The systematic translation of the evidence supporting early intervention to effective programs of delivery for populations and individuals affected by disaster or terrorism has yet to be broadly enacted, although there have been major efforts in this direction, as exemplified after September 11, 2001 (Neria et al., 2006). The consensus of experts and social sanctions favor ‘‘early intervention’’ as a potentially ‘‘good’’ approach. Necessary components to support delivery are discussed below. Policy, planning, preparation, and programs As is well established, a systematic plan for disaster response is a basic requirement as is the mental health component of such a plan, or indeed an aligned and integrated mental health plan. The World Health Organization in its proposed planning framework WHO-AIMS-E, supports such preplanning and sets some guidelines for it (WHO Kobe Centre, 2005). At a national or jurisdictional level there will be government requirements for planning which articulate, for instance, the mental health components such as early intervention, or require a specific mental health plan. The policy will identify the aims and goals of any interventions, the rationale, and will set directions for government programs and for other providers. This will need the engagement of key stakeholders including managers, agencies, providers and the community, and in pluralistic systems is likely to require private sector as well as government commitment. Governance needs to be established and clearly delineated, including roles, reporting and responsibilities, decision making processes and resourcing.


Dedicated funding of programs for early intervention is an essential commitment. Planning, negotiation, and preparation before any incident occurs, as well as a potent rationale, are essential for achieving commitment to such a strategy. Systems for early intervention and their engagement As is indicated above, early intervention will interface with and involve a number of systems as well as those encompassing specialist mental health providers. Developing a systematic mental health framework requires negotiating these interfaces, including those which cover population-based and clinical initiatives, child and adolescent programs, as well as those for adults. Roles, support processes, and governance all need to be clearly established. Systems need to establish realistic goals, to exercise their response with other agencies in order to test the framework, and to establish processes of review and evaluation. Such systems will also need to be flexible, perhaps with modules that can be brought on line to deal with diverse incidents, from hurricanes to bombing, from earthquakes to bioterrorism. Guidelines to inform intervention at different levels also need to be identified, as do the education and training strategies to support this system and program providers (e.g., Eisenman et al., 2006; Young, 2006). Such systems also require clear mobilization strategies, communication cascades, and standard operational procedures. It is an obvious but vital point that resourcing and accountability processes need to be identified. Engagement with other terrorism and disaster emergency response systems to build each group’s mental health capacity, as well as their ability to work in collaboration with early intervention providers and programs needs to be negotiated and developed in preparation for disasters. Then roles, and the operation of potential intervention programs can be worked out. System engagement for early intervention as exemplified above will be most acceptable where the system itself is ‘‘looked after’’ with its own early intervention strategies. The greater the impact on such systems, their destruction or destabilization, the less likely it is that they will be able to contribute generically to positive mental health and the more important it is that mental health is engaged with them. Some key systems can usefully exemplify these issues. Schools A rapid return to school and support of school functioning are considered vital targets for disaster response, for instance by UNICEF and WHO. This has a normalizing effect of reintroducing known rituals, expectations of positive activity, as well as support. Furthermore schools can be a focus for community activities to recover. Early intervention programs can be delivered through the classroom, or can be provided directly to students through books, projects or counseling (McDermott et al., 2005). Supporting and strengthening the school system will benefit early intervention.

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Health systems The mental health response is integrated with other health responses, yet it may not regularly function in close engagement. When the health system is disrupted, overwhelmed or impacted in other ways, its functioning may not be such as to support the wellbeing of clients – for instance through fears they will not be treated, problems of access, pain, injury or, with bioterrorism, with fear of contagion or contamination. Mental health early intervention can enhance the mental health understanding, the capacity of the broader health system to provide PFA, and to function effectively with recognition of mental health elements of care. Mental health early intervention can be delivered through hospital-based services such as through the emergency department and trauma/injury units, with models of dealing with psychological injury as above, or the community health system may be similarly engaged or private sector providers, both generalist such as family doctors and private mental health clinicians. Mental health care systems are a primary vehicle but are often challenged by the high levels of ongoing demand, by their usual tasking to ‘‘the seriously mentally ill,’’ and by a lack of capacity, skills, and knowledge relevant to an early intervention disaster response to terrorism and disaster. Developing effective complementary system components and interface for prevention, preparation, response, and recovery for disaster and terrorism is a core goal if effective early intervention is to occur. Such a mental health disaster response system, including its early intervention component, will only be sustained if it is a valued element, improving the capacity of the broader mental health program/service to respond to the personal disasters that are such a critical component of their patient’s experience. Population and public health strategies Population and public health strategies for early intervention require sanctions from all those systems and individuals involved in response. Sanctions can be developed through participation in joint response, recognition of the role delineations of others, and respect for their expertise. The ways in which the roles of others can contribute to early intervention, and how their PFA capacities can be developed are key elements. While clinical services are the defined responsibilities of mental health clinicians, population health response involving early intervention as a component requires specific commitment of a range of organizational systems including community general responders, emergency workers, government, and leaders. Negotiated inter-relationships to achieve public health interventions need to be established occur with relevant agencies well before any event, often needing the rationale for this to include benefits for the organization and capacity building. Education and training will be key elements for all responder groups.


Of particular importance is the consultative framework, which provides guidance for media, information providers, and leaders. Interaction with these systems needs to encompass two way processes so that the mental health contribution they develop is tailored and synchronous with their primary role functions and broader responsibilities; for instance, skills for the interaction with affected populations, information requirements for mental health, PFA for all, and strategies to support their own mental health. Clinically focused early intervention Primary care is one such level. People are likely to present for example to general practice, to community nurses, physicians or other primary care providers, or to be contacted by them as part of outreach initiatives. At this level, the provision of early intervention is likely to involve domains of PFA, basic clinical assessment of symptoms or signs related to exposures, or to evolving disorders and generic interventions of counseling, or medication. If the trajectory of pathology is non-responsive at this first level of intervention, referral process may be needed. Specialized mental health providers such as psychologists, social workers, nurses, and psychiatrists may provide early intervention through general clinical services or disaster-specific programs, and privately funded or publicly funded initiatives. For the most complex circumstances tertiary levels of early intervention might need to be available through specialist teams focused on trauma complexities. Specialized providers skilled in dealing with children or other groups are also required. Non-government agencies frequently offer services in such settings, which may or may not extend beyond PFA, to trauma counseling, or even mental health professional roles. Trauma and grief counseling are offered by many organizations. Delivery systems will need to identify the appropriate levels of provision and appropriate providers, as these ubiquitous terms can lead everyone to believe that they are skilled, whereas techniques may vary from generic support and listening, to practical advice, to high level skills and manualized evidence-based approaches. While it is possible for different skills and interventions to be effective, it is also possible to have, by excessive action, unskilled strategies and too much too soon, leading to harm. Convergence of ‘‘counselors’’ is the norm. It is clear that any providers will require skills, knowledge, and competencies to address early intervention in effective ways, and in the post-disaster context. Specific clinical early interventions may require a system for clinical service delivery. This context is quite different, particularly for early intervention, from the ‘‘office’’ of traditional clinical care provision. It is likely to have less clear delineation of the client’s disease status, and of the clinician’s professional status, and perhaps presents further challenges in identifying those who have been affected; indeed, perhaps those required to deliver the intervention will

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have had personal experience of, and exposure to, the disaster or incident and in general there may be fewer reassuring structural boundaries than is the ideal. Such clinical systems need to be engaged, developed, and prepared for their roles in the clinical response systems for emergency and recovery periods. Education, training, and accreditation of education programs Education, training and accreditation of education programs are challenges for both broad population system interventions and clinical initiatives. International standards have been developed to guide educational strategies (Weine et al., 2002). Public health/population health education for response to disaster and terrorism will need to include relevant mental health knowledge and skills. Clinicians may require further disaster specific education and training although many may believe they know, on the basis of their professional disciplines, how to intervene early. As evidenced after September 11, 2001, building the skills to levels of competence and ensuring manualized implementation of interventions known to be effective are very difficult to accomplish. Engagement is a core skill that may not be well identified in a manualized response; neither may the genuineness, empathy, warmth, or natural reaching out to others that are likely to involve those affected. Whether further education and training will translate to effective intervention and whether outcomes will be better as a consequence involve a complex chain of causality. As well, further education and training require systems that can draw required expertise to the areas of need, can mobilize and task them to early intervention response, and can provide review and clinical supervision, all tuned to the circumstances of chaos, system disruption, evolving resilience and morbidity, and varying demand characteristics. Education and training, identifying necessary providers at all levels, need to be part of the preparation and planning as identified by WHO guidelines (WHO Kobe Centre, 2005). Accredited providers for public health and clinical platforms of early intervention The ideal is to have providers who are trained to levels of competency, who are experienced in disaster or emergency response relevant to early intervention, and who are cognizant of their roles in relation to other systems responders, including emergency, health, welfare, legal systems and so forth. When potential providers are tasked to meet mental health needs, they also require knowledge and skills in interfacing with the practical resourceprovision systems that are essential to those affected, and the provision of which resources may in their own right benefit mental health and wellbeing, just by dealing with these other sources of stress. Practical provision may also be a vehicle to assist access to mental health interventions, by providing these at the same time. These issues highlight the complex skills required for response in real-world post-disaster settings.


Briefing, tasking, and mobilization Similarly the briefing, or tasking, of responders to meet the needs of early intervention associated with particular incidents and how they will access clients or how clients will access them are further challenges. Then, if this can be achieved, it tests in the real world the validity, utility, and effectiveness of the strategy. Systems of preparation, mobilization, and stand down, as well as the identification of appropriate providers at appropriate levels all require quite specific endeavors. These are likely to work best when they link to capacity building of the basic mental health systems, and have frameworks that are adequately structured but flexible to different needs, and that also look after the providers. Assessing needs for early intervention Assessment occurs both at population and individual levels. Immediate needs assessed cover a range of domains relevant to the incident (Speier, 2006) and response architecture needs to link to such needs assessment. It also needs to consider social, geographic, cultural and incident contexts and the systems of preparation and response, as well as other risk and protective variables. Population assessments This involves estimating: the numbers exposed to potential stressors; the numbers and nature of deaths; the numbers and nature of exposures, such as the destruction to homes, of communities, businesses, workplaces, institutions, and infrastructure; ongoing threat; human malevolence and violence associated with the event; stressors associated with the response; the aftermath; and populations likely to be affected including the formal and informal responders. Any major incident must be assessed at the population level in the first instance. Although there have been some formulae developed that are suggested to assist in this process, it is likely to require knowledge of communities, their background vulnerabilities and strengths, their resource base and their capacity to deal with what their exposures will mean. How much they have been able to mobilize to be involved in their own response and recovery will also be important. Assessment at population levels serves two purposes. Firstly it provides a basis for population-based interventions in the public health frameworks described above; for instance, the provision of PFA, system response to the needs of the bereaved, the use of shelters to begin support and self-help processes, and dissemination of information. It also allows baselines to be set for evaluation and estimates based on knowledge about the likely levels of resilience, the potential levels of evolving pathology, and the factors that may contribute to each. In this population-level assessment it will be important to identify post incident additional trauma and loss experience; for instance, with any delayed response to an incident such as Hurricane Katrina, or the

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facilities providing information about what is happening and what to do, or the need to provide shelter in the face of an ongoing cyclone such as Larry in far North Queensland, or the implications of power failures on top of other stressors, or the loss of communication. The presence or absence of strong compassionate leadership is another potentially significant variable. The second purpose of such population assessments is that they provide the basis on which potential clinical service requirements can be estimated. How many people are likely to require early intervention to deal with trauma exposures and acute stress disorder? How many are likely to need specialized counseling through DVI for their bereavement? How many children have been separated from parents and exposed to traumatizing experiences? What level of specialized counseling will be needed for children and families? What specialized additional care will be needed to assist populations with high levels of vulnerability? What culturally and language-focused programs may be required? What levels of clinical intervention can be provided through primary care settings and how can these be supported and linked to referral systems to specialized care? What private and public sector clinical systems as well as individual clinicians can meet these needs, and where and how? Clinical assessments There need to be established standards for assessment to determine the individual need for early intervention, how it should be shaped, and which other clinically relevant domains will need to be addressed. Examples include: acute stress disorder phenomena, which may be clear indicators of the potential for emerging PTSD, but there may also be depressive symptomology; phobic states; substance use problems; adverse health and risk behaviors; relationship difficulties; even risk of violence to self or others. Assessment also involves assessing the nature of experiences, risk, and protective factors, and how those affected are adapting to their impacts, plus ongoing or additional exposures resulting from the incident. The question of prevention, early intervention or psychopharmacologic interventions may need to be considered. Specific assessment of strengths and resilience is also required. Assessment of children, adolescents, and families will require understanding of family dynamics and coping strategies, as well as the developmental processes and likely impacts of traumatic experiences with respect to these. Assessing trauma through checklists of possible exposures, or for young children with play strategies, may provide baseline data for early intervention or for monitoring over time. Such data can also be collected in specific settings – ranging from the family to the school, and through tools such as ‘‘books’’ or story telling, or artwork demonstrating understanding and reaction. Again there is the need for consensus on the best systematic assessment processes. Focusing on the trauma per se, scales of exposure, a history of stressor exposures, reactions to them and subsequent distress and coping strategies may


be achieved through systematic questioning with or without the use of standardized questionnaires. Then the questions also arise as to findings from such assessments and their implications – do they indicate the need for ‘‘early intervention’’ or ‘‘watch and wait’’; is there evidence of resilience and recovery? The Impact of Event Scale (Horowitz et al., 1979) has been widely used, however the measure developed by Bryant et al. (2000) for acute stress disorder links directly to research demonstrating beneficial outcomes from such early intervention following trauma, and is important as a valid approach in this context. Systematic assessment measures, and formats for history taking, and for assessing function and coping are all invaluable, but there is little consensus regarding these, making findings difficult to translate beyond the specific studies. Clinical responsibilities require systematic assessment as a basis for intervention so this is recommended, but it must be noted that it will have core as well as additional requirements. Screening is one of the strategies that is open to debate on ethical grounds in that screening may not provide accurate enough identification of those in need of early intervention in its sensitivity and specificity, and neither may there be availability of treatments for all those so identified. Screening may provide a useful baseline, however for populations as well as individuals a measure such as the K10 (Kessler 10-items screen, which reflects distress and ‘‘caseness’’; Kessler et al., 2002) can be used to assess this and monitor trends for both populations and individuals. This screening, if carried out, needs to provide data for population level monitoring over time to identify emerging or diminishing need; and in the clinical setting the patterns of change of distress can be potentially related to intervention or spontaneous recovery effects. It would be critical to ensure that any screening identifies not only vulnerabilities and potential pathology trajectories, but also strengths and potential resilience trajectories, and does no harm. Integrated with all of the above is the requirement to assess strengths and other protective and positive factors including resilience. Cultural assessment In this diverse and global world assessment needs to take into account cultural factors that will influence need, intervention, and outcome. Provisions for language-based assessment and intervention may be difficult to ensure, but should be a goal, especially when it is known that significant numbers of those affected do not speak the language of the dominant culture, for instance English. Cultural parameters of assessment include numbers at population levels of the different cultural, ethnic, and religious groups, languages for delivery of assessment, information and possible interventions, and particular cultural issues relevant to the disaster or terrorism incident.

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Assessment of underlying vulnerabilities This should include recognition at the population level of factors such as social disadvantage, previous traumatization, or current stressors; for instance, conflict and high unemployment. For individuals, underlying vulnerabilities may include the above as well as chronic illness or disability, and a past history or current experience of profound trauma and loss. This could be exemplified at both the population and individual levels by vulnerabilities such as those of indigenous peoples, where disadvantage, past traumatization, high rates of premature morbidity and mortality, and family violence could all complicate any capacity to deal with an acute catastrophe (Ober et al., 2000). Tracking, information, and documentation Systematic national and even international agreement about core documentation requirements could greatly progress this field. While those affected directly are usually ‘‘registered,’’ the lists of ‘‘victims’’ will not cover all those who have been exposed and impacted. Furthermore, privacy arguments may mean that such lists are not available to those who would mobilize early intervention. Assessment and intervention also require systematic documentation as formal health records. Tracking those affected and establishing databases where confidentiality is protected, or where information is generic in de-identified or population-level formats are challenges in the chaos of any aftermath. Special issues also arise with outreach programs, such as Project Liberty, hot-lines and drop-in centers (Naturale, 2006). These require systematic pre- and postintervention documentation to be collected, especially as it can provide data on levels of need and submission for resources to address these. Collaboration between agencies to address this requirement, at least at state and national levels, would set a very important baseline against which the effectiveness of a program could be judged. High-level agreement on minimum data sets is an important strategy. Communities, collectives, and others Communities may determine their own early intervention agenda through neighborhoods, support networks, spontaneous groupings, and social movements in the aftermath. The heightened affiliation, the shared experience, the special understanding of those who have ‘‘been through it together,’’ the social support and networks can all facilitate recovery. Volunteers are a special group of helpers who converge at the time of disaster, and may be disappointed that they have not been engaged to help, yet their considerable energies can be usefully turned to other needs. Community organizations from local government, to non-government organizations (NGOs) may all make contributions. NGOs may perceive themselves as able to provide early intervention but may or may not be skilled to do so. Standards for response such as the Sphere Standard of WHO


recognizes such important generic contributions with potential benefit. It is also acknowledged that some will develop special mental health programs. While all of these agencies and community groups may contribute spontaneously, there is the potential to shape their interests with broad education and development programs, which can enhance their capacity and contribute positively for early intervention. Highly specialized groups such as NGOs working in disaster contexts may also seek to further their mental health expertise alongside other roles. Mental-health-related skills and knowledge can be developed, and the positive contribution that engagement in the community’s recovery makes should be supported. Looking after those involved These strategies relate to the consultation component (McCarroll and Ursano, 2006; Raphael, 1983) of specialized mental health intervention pre- and postdisaster and terrorism. Amongst the many issues it can address to promote effective early (and late) interventions the following are significant. 1. Structured systems of mental health response. Clear goals, review and supervision, limited tours of duty and monitoring the needs of those providing specialized mental health care are key issues that can be addressed in caring for mental health care providers. 2. Looking after those providing response who are also personally impacted – through trauma exposure, loss of loved ones, and so forth. Workers in all spheres from emergency to recovery, from health to welfare, from police to fire, require both direct support and support with role functioning in ways that will help improve their mental health trajectories. 3. Looking after the media. Although journalists are now more actively engaged in their own strategic frameworks to address trauma and disaster through the DART Foundation, the specialist mental health expertise can bring an additional dimension and thus can lead to positive media responses which can contribute to early intervention. 4. Looking after leaders. Advice, consultation on mental health, being there, information in response, positive communication strategies, and a response to needs can all have benefits. 5. Self-care. Building expertise in self-care, recognition of counter-disaster syndromes, or advice on trauma, and beneficial but realistic expectations can all support early intervention. Governance: implementation and evaluation of the mental health response plan All of the above – the science, the systems, and the delivery of early and other mental health interventions – need to be drawn together in a Mental Health Response Plan for the specific incident. As discussed, WHO strongly

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recommends that there is a Mental Health Disaster Plan, which informs preparation. Then, when an incident occurs, there should be a Mental Health Disaster Response Plan, targeted to the particular incident. It requires clear goals, strategies to achieve these in terms of identified need, documentation, and research and evaluation. This system is one for the particular disaster, the specific terrorist incident, with specific aims for the affected populations. Strong governance processes and accountability again need to be clearly identified. How outcomes of ‘‘making a difference,’’ in this case altering negative trajectories through effective early intervention, will be achieved should be clearly spelled out in terms of real-world and achievable goals. The information documented, the assessments, and monitoring can form the bases for determining benefits or otherwise. Surveillance of progress, of emerging need, and emerging resilience are also helpful. Evaluation is ideally informed by documenting achievements of measurable goals: numbers provided with intervention, populations reached, and what the results were. Evaluation is also informed by formal review processes (Rosen et al., 2006). In an ideal setting, there is research supporting evaluation so that judgments of benefit or otherwise can be scientifically sound and inform not only this response, but also provide a cycle of learning for the future. Conclusion: badging and selling early intervention If we believe ‘‘early intervention’’ to be an important strategy for mental health in the context of response to disaster and terrorism we must convince others. We must strengthen its scientific foundations, and engage and build systems through which it can be delivered to populations to their benefit. There is the need to ‘‘badge’’ and sell it to governments, organizations, all stakeholders, and indeed to those who may need and benefit from it in the wider community. Commitment of governments, organizational systems, and communities needs to be such that early intervention is defined in policies, expected and provided in funded programs, and is a valued effective resource, that is available, accessible, and utilized. It must be demonstrated that it contributes to better outcomes and lessened costs, and to the positive development of individuals and communities.

Acknowledgments With acknowledgment to Garry Stevens, Senior Research Fellow, and my office staff Catriona Thomson and Anne Cantle with the support of NSW Health and ACT Health Department.


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Chapter 1. Systems, science, and populations van Ommeren, M., Saxena, S., Saraceno, B. (2005) Aid after disasters: needs a long term public mental health perspective. British Medical Journal, 330, 1160–1161. Veterans Health Administration (2004) VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress. Washington DC: Veterans Health Administration, Department of Veterans Affairs and Health Affairs, Department of Defense. Office of Quality and Performance publication 10Q-CPG/PTSD-04. Wain, H., Grammer, G., Statinos, J., DeBoer, C. (2006) Psychiatric intervention for medical-surgical patients following traumatic injuries (pp. 278–299). In: Ritchie, C., Watson, P., Friedman, M. (eds.) Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. New York: Guilford Press. Watson, P. J., Shalev, A. Y. (2005) Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events. CNS Spectrums, 10, 125–127. Watson, P. J., Ritchie, E. C., Demer, J., Bartone, P., Pfefferbaum, B. J. (2006) Improving resilience trajectories following mass violence and disaster (pp. 37–53). In: Ritchie, C., Watson, P., Friedman, M. (eds.) Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. New York: Guilford Press. Weaver, J. D., Dingman, R. L., Morgan, J., Hong, B. A., North, C. S. (2000) The American Red Cross Disaster Mental Health Services: development of a cooperative, single function. Multidisciplinary Service Model, 27 (3), 314–320. Weine, S., Danieli, Y., Silove, D., Van Ommeren, M., Fairbank, J. A., Saul, J. (2002) Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry, 65 (2), 156–164. Weisaeth, L. (2000) Briefing and debriefing: group psychological interventions in acute stressor situations (pp. 43–57). In: Raphael, B., Wilson, J. (eds.) Psychological Debriefing: Theory, Practice and Evidence. Cambridge: Cambridge University Press. Weisaeth, L. (2004) Preventing after-effects of disaster trauma: the information and support centre. Pre-Hospital and Disaster Medicine, 19 (1), 86–89. Wessely, S. (2005) The London attacks-aftermath: victimhood and resilience. New England Journal of Medicine, 353, 548–550. WHO Kobe Centre: World Health Organization Centre for Health Development (2005) Consultative meeting on the development of a WHO assessment instrument for mental health systems – emergencies (WHO-AIMS-E), October 4-5, 2005, Kobe, Japan. Retrieved January 3, 2008 from http://www.who.or.jp/2005/mentalhealth.html. Wilhelm, K., Mitchell, P., Niven, H., et al. (2006) Life events, first depression onset and the serotonin transporter gene. British Journal of Psychiatry, 188, 210–215. Wilson, J. (2005) The Posttraumatic Self: Restoring Meaning and Wholeness to Personality. New York: Routledge. Wooding, S., Raphael, B. (2004) Psychological impact of disasters and terrorism on children and adolescents: experiences from Australia. Pre-Hospital and Disaster Medicine, 19(1), 10–20. Young, B. (2006) The immediate response to disaster: guidelines for adult psychological first aid, considerations and recommendations. In: Ritchie, C. (ed.) Interventions Following Mass Violence and Disasters. New York: Guilford Press. Zatzick, D., Wagner, A. (2004) Evaluating and treating injured trauma survivors in trauma care systems (13, pp. 263–283). In: Litz, B. T. (ed). Early Intervention for Trauma and Traumatic Loss. New York: Guilford Press.

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Factors in the development of community resilience to disasters Rose L. Pfefferbaum, Dori B. Reissman, Betty Pfefferbaum, Karen Fraser Wyche, Fran H. Norris, and Richard W. Klomp

Introduction Terrorist incidents and severe natural disasters have focused concern on preparedness and response activities to enhance psychological and social adjustment in the aftermath of extreme events and to minimize maladaptation over time. Borrowing from a growing body of work describing the characteristics that promote resilience in individuals, the concept of community resilience has emerged as a community-level construct to foster individual, family, and community adaptation. The likelihood of unanticipated terrorist events and the possibility of massive infrastructure destruction associated with major disasters increase the importance of community resilience strategies. Relatively little is known about what constitutes a resilient community or about the factors, conditions, and processes that promote it. In this paper, we (1) describe the construct of community resilience in the context of disasters, (2) propose a set of contributing factors, (3) identify potential barriers, and (4) make recommendations for enhancing community resilience. The paper does not constitute a formal review of the literature on community resilience.

Definitions A discussion of community resilience requires consensus in our understanding of several key terms including ‘‘community,’’ ‘‘disaster,’’ and ‘‘resilience.’’ Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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Chapter 2. Developing community resilience to disaster

Community The notion of community has been widely discussed in both the social science and health literatures (Cohen, 2003; Institute of Medicine, 2003; Jewkes and Murcott, 1996). Depending on context, a variety of conceptualizations and components have been described. Traditionally, a community refers to people, organizations, structures, and systems in close geographic proximity and with physical boundaries and borders (e.g., a town). Community has been used in reference to people who share history, culture, and language; common characteristics, norms, interests, and values; laws; and a sense of membership or belonging (Institute of Medicine, 2003; Jewkes and Murcott, 1996; Kulig, 2000). A cluster of people with like culture within a city (e.g., ‘‘Chinatown’’ in any major US city) exemplifies these characteristics of community. More recently, community has been used in reference to individuals with shared access to and proficiency with technology, as in an online community. Cohen (2003) focused on relational aspects of communities, specifically on simultaneous similarities that include those characteristics held in common among members of a community and differences in characteristics that significantly distinguish members of one community from members of other communities (Cohen, 2003; Jewkes and Murcott, 1996). The existence of simultaneous similarities and differences emphasizes boundaries (Cohen, 2003; Jewkes and Murcott, 1996), the internal and external (English and Hicks, 1992), and the position of one community in relation to another. Boundaries take many forms (e.g., geographic, racial, socioeconomic, electronic) (Cohen, 2003; Jewkes and Murcott, 1996) that may change depending on circumstances or stresses (English and Hicks, 1992). Communities also function in relation to the larger society within which they are nested. For example, communication links of varying complexity and formality occur across communities as well as within a community. Thus a community influences, and is influenced by, the larger society (English and Hicks, 1992). Members of a community may share the experience of living and working in the same environment. They are influenced by similar social, economic, and physical factors in that environment (Institute of Medicine, 2003). While there are differences among members of a community, the community exists and functions despite, or perhaps because of, these differences. Communities include relatedness, relationships, and interactions among individuals and groups. Communities presume some type of social system that provides services and addresses problems (Cottrell, 1976; Institute of Medicine, 2003; Jewkes and Murcott, 1996; Kulig, 2000). Communities comprise multiple systems linked for common functioning and support (English and Hicks, 1992). These systems can include production and distribution of goods and services; social control that reinforces and implements standards for social interaction; social participation in areas of


common interest; socialization that encourages and perpetuates the community’s laws, customs, beliefs, attitudes, art, and history; and mutual support that extends beyond family and friends (English and Hicks, 1992). Disasters Disasters result from internal or external forces over which a community or system has no effective control. Disasters may be of natural or human origin or a combination of the two. Those of human origin may be volitional or accidental. Disasters are characterized by sudden onset, overwhelming severity, and mass destruction leading to property damage and resource loss. They cause injury and death, and they trigger emotional reactions in individuals. Disasters disrupt social networks and routines, and may affect the structure and functioning of the community itself (Era¨nen and Liebkind, 1993). Social support may be mobilized or deteriorate after a disaster depending, in part, on characteristics of the community, its members, and the disaster (see, eg., Kaniasty and Norris, 2004). Because the primary impact of disasters is on communities rather than society at large, the larger society may be relatively unaffected and remain available to assist the disaster-affected community by providing external aid for response and reconstruction. Disasters tax psychological, social, and economic resources (Jerusalem et al., 1995). Jerusalem and colleagues (1995) contend that stress at any level always begins with the individual. When individual and community resources are exhausted, the negative effects for the individual and/or for the community are increased while the capacity for coping generally decreases. Secondary adversities such as job loss or interruption of educational opportunity may also affect individuals and consequently reduce community capacity for coping. Community effects and the resultant impact on community capacity may extend to those who were not directly victimized. Resource loss at the community level exacerbates negative effects at the individual level as illustrated by the delayed and often averted return to New Orleans of residents displaced following Hurricane Katrina in 2005. Community vulnerability to stress is a function of ‘‘resource reserves’’ reflected in the relationship between depleted resources and remaining resources post-disaster (Jerusalem et al., 1995). The future of New Orleans post-Katrina has been threatened, in part, by the dramatic decline in resource reserves. Resilience Resilience in individuals is the ability to adjust to stress and to restore equilibrium when confronted with trauma, tragedy, and threat (Steinberg and Ritzmann, 1990). Requiring flexibility as well as strength, resilience involves the ability to adjust to both expected and unexpected stress (Bruneau et al., 2003).

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Rather than an endpoint, resilience is a life-sustaining process that must be continued over time and that facilitates growth (Steinberg and Ritzmann, 1990). It involves attitudes, behaviors, and skills that can be cultivated, taught, and practiced (American Psychological Association Task Force, n.d.; Reissman et al., 2004). Community resilience has been described as the capacity for social units to mitigate the effects of hazards and to implement recovery activities in ways that limit social disruption and the effects of future events (Bruneau et al., 2003). Dealing specifically with community resilience to earthquakes, Bruneau and colleagues (2003) described four interrelated dimensions of community resilience: technical, organizational, social, and economic. The technical dimension refers to the capacity of physical systems to meet acceptable performance standards when subjected to a disaster. The organizational dimension refers to the ability of organizations responsible for managing critical facilities and performing critical disaster-related functions to make decisions and act in ways that reduce the probability and absorb the consequences of disasters and promote recovery. The social dimension consists of steps designed to reduce adverse consequences due to the loss of critical services in the aftermath of a disaster. The economic dimension refers to the ability to limit direct and indirect economic losses associated with a disaster. Similar to personal resilience, community resilience is a process evident in adaptation to threat or attack, stress, disruption, and security concerns. More than individual action and coping, community resilience involves interactions as a collective unit. Members of resilient communities address problems through deliberate, meaningful collective action involving analysis, intervention, and resolution. Resilience of a part or parts does not necessarily assure resilience of the whole (Brown and Kulig, 1996/97; Kulig, 2000; Pfefferbaum et al., 2007). Personal resilience is fostered through, among other things, supportive relationships and connectedness (American Psychological Association Task Force, n.d.; Reissman et al., 2004), which also enhance community resilience. Hence, one might expect increased individual resilience to result in external benefits for others in a community as well as for the community as a whole (Pfefferbaum et al., 2007). However, during a disaster and its aftermath, exposed individuals may be focused primarily on self and family, potentially leading to a disconnection, and possible oppositional pull, between personal survival and service to community. Such appears to have been the case, for example, in New Orleans following Hurricane Katrina when some police officers failed to report for duty to focus on the needs of their own families (Anderson, 2006; US Congress, 2006). Then again, disasters – including Katrina – share many stories of altruism in which individuals (including police officers) risk their own safety for the benefit of others and for the community. Community resilience may enhance individual resilience to emotional, behavioral, and functional problems. Consisting of both reactive and


proactive elements, community resilience couples recovery from adversity with efforts by individuals and groups to transform their environments to mitigate future problems or events. Community resilience, then, is not the simple return to homeostasis; it entails the potential to grow from a crisis (Brown and Kulig, 1996/7; Kulig, 2000; Pfefferbaum et al., 2007). Resilience may be related to maintaining and/or regaining stability when stability is desirable. When stability is not possible or not desirable, such as in evolutionary terms (Adger, 2000) or when adverse conditions persist in an unhealthy environment, resilience requires the ability to change and adapt (Longstaff, 2005).

Factors associated with community resilience Multiple disciplines (e.g., engineering, geography, health, psychology, and sociology) are beginning to recognize that enhancing community resilience can be a preparedness strategy for mass casualty events and a mechanism to prevent or reduce adverse consequences associated with disasters (Friedman, 2005b; Reissman et al., 2005). Still relatively new to the lexicon, community resilience is related to community health and associated concepts such as community capacity, competence, mobilization, and empowerment. Pfefferbaum and colleagues (2007) drew on the community capacity and competence literature (Cottrell, 1976; Gibbon et al., 2002; Goeppinger and Baglioni, 1985; Goodman et al., 1998; Labonte and Laverack, 2001a) to describe seven factors associated with community resilience. These factors were endorsed by a panel of experts at the Community Resilience Mini-Summit: Developing Community Resilience for Children and Families (Community Resilience Summit), convened in 2004 by the Centers for Disease Control and Prevention and the Terrorism and Disaster Branch of the National Center for Child Traumatic Stress. The seven interrelated factors are: connectedness, commitment, and shared values; participation; structure, roles, and responsibilities; resources; support and nurturance; critical reflection and skill building; and communication (Pfefferbaum et al., 2004, 2007). When community resilience is considered in the context of disasters, we recommend adding an eighth factor: disaster prevention and mitigation, preparedness, and response. The factors, which await empirical examination and validation with respect to disasters, are described below. Connectedness, commitment, and shared values Community membership suggests connection to a place or a group of people with shared history, laws, interests, and social mores. The sense of belonging may be strengthened if members perceive their personal well-being as derived from, and their needs fulfilled through, affiliation with the community.

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A strong commitment to the community, coupled with relationships found therein that are characterized by mutual concern and benefit, should contribute to consensus building and collaboration. Communities that embrace diversity among members may be better able to address the needs of members in the face of adversity. Participation Participation may strengthen the sense of belonging, personal contribution, and ownership. Communities that foster and facilitate member involvement in activities and organizations may be better able to identify and address issues through co-operation and civic engagement at the local level. Opportunities for involvement should be sensitive to the interests, ability, and diversity of members. When participation is deemed important, members are likely to take pride in their contributions and derive increased benefit from involvement, thus helping the community address needs and problems that arise in conjunction with disasters as well as those that occur more commonly. Structure, roles, and responsibilities Communities include individuals, groups, and organizations with reciprocal links that form overlapping networks. In resilient communities, interactions are frequent, supportive, and collaborative, with individuals and groups identifying and addressing common concerns. Structure, roles, and responsibilities create the capacity for mitigation of, as well as decisive and timely response to, crises thereby diminishing adverse secondary consequences. Solutions may emerge from new associations that occur either formally or informally to establish priorities and resolve issues. Communities with strong and responsive leadership, able teamwork, clear organizational structures, and well-defined roles, responsibilities, and lines of authority can support adaptation and recovery. In the current, highly uncertain, all-hazards environment, structural elements must also permit sufficient flexibility to address unforeseen threats and vulnerabilities. Community resilience is enhanced when community standards, rules, and procedures facilitate social interaction and governance. Communities must manage relations with the larger society, accepting, working with, and supporting other communities. Resources A community’s resources include those belonging to its members as well as those attached to the community itself. In addition to land and raw materials, resources include physical capital which creates an infrastructure and tools for the community. Human resources include a workforce, expertise, and


leadership for personal and community development, and member qualities such as hope and the will to improve community well-being. The relationships and support systems within a community, as well as characteristics such as cohesion, constitute social resources. Resilient communities acquire, mobilize, allocate, and use resources effectively to meet community goals. Infrastructure and systems must be able to respond suitably to, and endure, a wide variety of potential disasters and secondary adversities. Further, sufficient resources must substitute for and complement each other so that essential community operations can be maintained even in the event of major disasters. Resilience is likely to necessitate ongoing investment in physical, human, and social capital which may include, for example, improvements in schools and health facilities, job training, and neighborhood development. Support and nurturance Support and nurturance are important in enhancing resilience at the community as well as the individual level. Supportive and nurturing communities attend to the needs of their members regardless of background or socioeconomic status. Such communities help members achieve goals and overcome problems. They promote member well-being, instill hope, and empower individuals and groups. Communities should become more resilient through the process of providing support and nurturance and through attention to basic human needs and the environment in which their members live and work. Support and nurturance may be enhanced when communities become more adept at identifying, acquiring, and equitably distributing resources within community boundaries and with the larger society. In resilient communities, support mechanisms provide early and ongoing assessment of, and assistance to, vulnerable sub-groups before, during, and in the aftermath of disasters. Support is sustained through crises and buffers the personal, social, and economic losses that accompany tragedy. Critical reflection and skill building Resilient communities identify and address issues, needs, and problems; they establish structures to identify, collect, analyze, and use information; and they plan, manage, and evaluate activities and programs. Critical reflection about values, their own history, and the experiences of others should permit formal and informal community leaders to reason, set goals, make decisions, and develop and implement strategies for the betterment of members. Resilient communities assess their performance, study their successes and failures, and learn from adversity. They support introspection and skill building at individual and systemic levels. Learning, accommodation, and growth may lead to enhanced capacity.

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Communication Community resilience is reinforced by effective, clear, timely, and accurate communication among members and across boundaries. Effective communication requires common meanings and understandings and the perception of openness and honesty. Members and groups should have opportunities to identify and articulate their needs, views, and attitudes, especially if diversity is to be addressed and supported. Open and productive communication can foster trust in leadership and increase the likelihood of participation and compliance with directives in the face of community disasters. It can also focus attention on and promote resolution of pre-existing and emerging unmet needs as well as those that accompany disaster. There must be sufficient redundancy in communication channels to ensure timely resource mobilization in response to threats. Disaster prevention and mitigation, preparedness, and response Resilient communities take deliberate steps to prevent and mitigate, prepare for, and respond to disasters. Prevention and mitigation include activities to avoid or control an incident, to reduce risks to people and property, and to lessen actual or potential adverse effects of an incident. Implemented prior to, during, or after an incident, mitigation measures focus on decreasing the likelihood of hazardous incidents and reducing exposure to, or potential loss from, such events. Preparedness is a continuous process that assesses threats, identifies vulnerabilities, and determines resource requirements. It involves efforts to prevent adverse consequences and to assemble resources to respond. Disaster response addresses the direct, short-term effects of an incident. Along with emergency assistance, disaster response includes efforts to limit further damage during or immediately after a disaster, efforts to support basic human needs, and efforts to maintain the social, economic, and political structure of the affected community. The relatively short-term response phase transitions to a longer period of recovery and reconstruction during which survivors begin to rebuild their lives and their community. Robustness, redundancy, resourcefulness, and rapidity For a community to be resilient, the eight factors must embody, to varying degrees, four properties of resilience identified by Bruneau and colleagues (2003): robustness, redundancy, resourcefulness, and rapidity. Redundancy and resourcefulness are means to improve resilience while robustness and rapidity are ends or outcomes of resilience enhancement (Bruneau et al., 2003). Robustness – strength, the ability to withstand stress without degradation or loss of function (Bruneau et al., 2003) – must characterize all eight factors.


Robustness may be evident in the intensity of connectedness and the extent of participation in activities and organizations. It should be apparent in the clarity of structure, roles, and responsibilities; in the caliber of resources; and in the support and nurturance available to community members through formal and informal services. Ideally, application of critical reflection to skill building and the quality, effectiveness, and frequency of communication demonstrate robustness. Finally, community resilience to disasters requires robustness in all phases of disaster management (prevention and mitigation, preparedness, response, and recovery). Redundancy – substitutability of elements, systems, and resources in terms of functional requirements (Bruneau et al., 2003) – is particularly important with respect to structure, roles, and responsibilities; resources; support and nurturance; critical reflection and skill building; communication; and disaster prevention, preparedness, and response. Overlap in roles and responsibilities within a structure that facilitates appropriate assumption of responsibility can help sustain a community during and after a disaster if clarity of tasking can be maintained and accountability and performance are not compromised. Substitutability is a necessity with respect to critical resources and systems that provide support and nurturance. Multiple organizations within the community must engage in analysis and skill building and must participate in these activities with other organizations to ensure that community issues are addressed and that lessons learned are incorporated into planning. Communication channels must permit effective interaction within the affected community as well as with external communities and state and federal governments. Redundancy in resources associated with disaster prevention, preparedness, and response can help ensure the survival and recovery of a community and its members when resources are depleted, damaged, or destroyed by a disaster. The advantages of redundancy may be offset by the opportunity cost associated with diverting resources from alternative uses (Longstaff, 2005). Careful consideration is needed to determine the optimal use of any resource in developing and implementing resilience strategies. Community resilience strategies that are characterized by benefits that accrue to the community at large (such as improved communication channels and more effective social interaction and governance) and that protect against varied assaults may result in lower opportunity costs than strategies that do not share these effects. Resourcefulness – the ability to identify problems, formulate priorities, and creatively apply resources to achieve goals (Bruneau et al., 2003) – is particularly important with respect to structure, roles, and responsibilities; resources; critical reflection and skill building; and disaster prevention, preparedness, and response. Resourcefulness is limited without appropriate resources and without the structures, roles, and responsibilities needed to support problem identification, analysis, and response. Communication is a

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vital component in the process that makes resourcefulness in disaster management possible. Rapidity – the ability to address priorities and accomplish goals in a timely manner so as to contain losses and prevent future disruption (Bruneau et al., 2003) – applies especially to structure, roles, and responsibilities; resources; support and nurturance; critical reflection and skill building; communication; and disaster prevention, preparedness, and response. Responsible parties will be aided in disaster response by clearly defined goals, roles, and responsibilities within a known structure that permits expeditious application of resources throughout disaster management. Expediency in providing support and nurturance may be lifesaving for some community members and should help sustain connectedness and commitment to community goals. Critical reflection and skill building based on analysis and evaluation of programs and operations should be used to enhance the timeliness and efficiency of disaster management activities. Assumptions and implications The operating assumption is that communities with higher levels of the eight factors may be more effective at mitigating adverse outcomes associated with disasters. While the eighth factor anchors the others in community disasters, community resilience-building activities need not focus directly on disaster-related issues to reduce adverse consequences of mass trauma. Jerusalem and colleagues (1995) maintain that the more communal resources communities have, the better able they are to interrupt loss cycles experienced by their members. An accessible support system and redundancy in emergency and human services are likely to improve disaster response and recovery even if those resources were not established specifically to address community disasters. Critical reflection and skill building at the community level can help identify and rectify resource limitations. A clearly defined and recognized community structure and effective communication facilitate problem solving. A tight-knit community in which members know each other personally through frequent participation in organizations and activities may rally better in response to a disaster than a community in which individual members have limited interaction and share little in the way of values. We illustrate these concepts and relationships in Figure 2.1. The seven resilience factors derived from the community capacity and competence literature are shown as spokes contributing directly to community resilience. The eighth factor – disaster prevention and mitigation, preparedness, and response – is separated from the other seven because disasters are our primary concern. Disaster prevention and mitigation, preparedness, and response contribute directly to and are affected by community resilience; they also, of

Chapter 2. Developing community resilience to disaster Pa

rti cip ati o Su pp n ort Res ourc es Connectednes s g Skill Buildin oles e, R r u t c on ati Stru nic u mm Co

Response

Community Resilience

Recovery

Prevention & Mitigation Preparedness Figure 2.1. The relationship of resilience factors to disaster management

course, affect the recovery environment independent of their relationship to community resilience. Our primary point is that community resilience can improve prevention and mitigation, preparedness, response, and recovery – especially with respect to psychosocial issues – and reduce adverse consequences associated with disasters even when community resilience efforts are not related directly to disaster management. This is particularly important in an environment in which unexpected and unknown events and problems are likely. Community resilience strategies can complement and enhance other disaster management efforts. Community resilience fortifies a community against a host of social concerns, such as crime and poverty, as well as disasters. The initial seven factors pertain to community resilience across a broad spectrum of concerns. Because factors associated with risk or resilience in one context may not be relevant in other contexts, the eighth factor may be altered to reflect the specific problem being addressed.

Barriers to community resilience In addition to endorsing the original seven community resilience factors, participants at the 2004 Community Resilience Summit identified barriers to community resilience (Pfefferbaum et al., 2004). While the Summit focused primarily on disaster mental health for children and families, barriers identified

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by Summit participants are applicable to community concerns at large. Among the identified barriers to community resilience was the overarching concern that communities differ with respect to multiple parameters, making it difficult to identify and develop strategies with general application across communities. The Summit expressed concern that a lack of integration across elements of a community could result in insular thinking, limited communication, and disenfranchised groups which we consider particularly problematic insofar as access to services and care may be negatively affected. Identified mental health issues that may create barriers to community resilience include limited familiarity with mental health issues among non-mental health care professionals, a chasm between community health and mental health, stigma associated with mental illness and treatment, and limited evidence base for disaster mental health services and for distinguishing universally appropriate and culture-specific approaches. Resource considerations – including a focus on physical rather than social capital, a paucity of resources for disaster preparedness and response, and leadership limitations – also create barriers to community resilience. We would note further that poor communities lacking individual and communal resources as well as a solid economic base and capable transitional leadership will likely be less resilient no matter how committed and engaged their members may be. Finally, the Summit identified failure to utilize research in support of policy development, public decisionmaking, and advocacy as barriers to community resilience. Apathy is also a potential barrier to the development of community resilience. Public apathy toward disaster preparedness has been attributed to lack of awareness and underestimation of disaster risks, a false sense of security provided by technology and manmade protective devices, denial, fatalism, and social pressures to appear brave. Public apathy and budget constraints are reflected in limited political support for disaster preparedness. Competing priorities, overestimation of capability, ambiguity of responsibility, difficulty substantiating the benefits of preparedness, defeatism, opposing special interest groups, and the lack of an organized constituency advocating disaster preparedness are factors in governmental apathy toward disaster preparedness (Auf der Heide, 1989). Community resilience strategies may be met with less apathy than disaster preparedness to the extent that they are grounded in community values and priorities, address current social issues, and result in obvious benefits for individuals and the community. Once undertaken, community resilience strategies potentially reduce apathy, giving rise to additional resilience building.

Building community resilience to disasters We propose four general recommendations for building community resilience to disasters: (1) create consciousness about community resilience;


(2) foster community development based on community input and engagement; (3) adopt a holistic wellness focus; and (4) develop and practice emergency plans. Barriers to community resilience should be addressed as part of implementing these recommendations. Create consciousness regarding community resilience As we have defined it, community resilience involves deliberate, collective action to transform the environment to mitigate future problems. Proactive, as well as reactive, involvement can be enhanced by consciousness of community resilience. Such a consciousness may encourage community members to identify shared values, provide a focus for critical reflection and skill development, and reinforce the concept of resilience as a process rather than an endpoint. Further, since communities have their own unique characteristics, resilience-building strategies must be developed around community specifics including, for example, values, goals, demographic make-up, and resources. An appreciation of community resilience can draw attention to community characteristics that advance or detract from problem identification and resolution as well as crisis management. In considering community capacity building, Labonte and Laverack (2001b) recommend that program planners ask a series of questions regarding program planning, implementation, and evaluation. We have added to, and organized, their questions to fit our framework involving eight resilience factors. A consciousness of community resilience should increase the likelihood that these questions, presented in Table 2.1, will be addressed. Foster community development based on input and engagement Community resilience can be fostered by community development based on community input and engagement. Kretzmann and McKnight (1993) maintain that a community is strengthened and becomes more self-reliant when residents link with others to solve problems and when organizations connect to take collective action. A belief in their effectiveness as problem solvers creates a greater capacity for self-direction among community members. Kretzmann and McKnight (1993) are particularly interested in engaging community members who are marginalized as a result of age or label. These individuals may ask new questions, perceive roles and responsibilities differently, and bring fresh energy and insight to the development process. Glass and Schoch-Spana (2002) emphasize the role of the general public in bioterrorism preparedness and response. Recognizing that actions taken by non-professionals and groups could have a pronounced effect on the outcome of a bioterrorism event, they recommend guidelines for integrating the public into planning for bioterrorism response. Their recommendations,

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Chapter 2. Developing community resilience to disaster Table 2.1. Program review based on community resilience factorsa Consider if and how a program or an activity – from planning to implementation through evaluation and revision – can address the following issues related to the eight community resilience factors Connectedness, commitment, and shared values Connect individuals to the community Enhance commitment of community members to the community Demonstrate commitment of the community to its members Reinforce community values Participation Foster individual involvement in community activities and organizations Provide opportunities for people of different backgrounds to be engaged Involve children and families in community life Increase benefits associated with community participation Improve community participation Structure, roles, and responsibilities Elucidate community processes Strengthen community links among organizations and people Develop community leadership Create equitable relationships Increase community control over program management Build empowering organizational structures Support meaningful interaction with other communities Enhance community response to crises Resources Improve community resource mobilization and utilization Build social capital Provide opportunities for training and employment Develop expertise for personal and community development Enhance the resource base of the community Support community development Contribute to the long-term productive capacity of the community Instill hope among community members Support and nurturance Enrich existing support systems Create new support networks Address basic human needs Empower community members Build caring relationships among community members

Chapter 2. Developing community resilience to disaster Table 2.1. (cont.) Critical reflection and skill building Contribute to the establishment of community goals and priorities Increase community problem-assessment capacities Contribute to a community database Support the identification, analysis, and use of data for community evaluation and improvement Encourage community members to be inquisitive Promote skill building among community members Foster community improvement Communication Enhance communication among community members Improve community member communication with service providers Encourage community leaders to listen to community members Strengthen community information channels Promote the timely delivery of information Increase the accuracy and effectiveness of community information systems Provide opportunities for people to problem solve Disaster prevention and mitigation, preparedness, and response Contribute to disaster prevention and mitigation Enhance disaster preparedness among individuals and organizations Improve the disaster response capacity of organizations and the community Foster recovery from disasters a

Adapted and expanded from Labonte and Laverack (2001b).

all of which relate to community development and resilience, include enlisting the public as a capable ally, involving civic organizations in implementing public health measures, investing in outreach and communication, and ensuring that planning and intervention reflect the values and priorities of affected populations. In addition to community engagement, we recommend adoption of some specific goals to address multiple identified barriers to community resilience and help define community development activities. To the extent possible, interventions should instill hope and engender trust while building social capital that creates and reinforces connections among individuals and organizations and with other communities. These connections should be based on and enhance cross-cultural awareness and appreciation. Roles and responsibilities of various community agencies and personnel should be identified and clarified, and leadership should be developed at all levels within the community.

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Adopt a holistic wellness approach Our third recommendation for developing community resilience is the adoption of a holistic wellness (rather than an illness) perspective for communities as well as individuals. Friedman (2005a) recognizes that this requires societal endorsement of and support for specific, prioritized aims that focus on restoration of function, effective coping and health-seeking behaviors, better understanding of traumatic stress, and promotion of mental as well as physical health. He acknowledges that outcomes must be operationalized to permit unambiguous, quantitative, scientific assessment of success or failure. This would help establish evidence-based guidelines to support advocacy, service delivery, program and policy development, and public decision-making. Increased communication among health and human service providers and greater integration of mental, physical, and public health services are potential mechanisms for addressing barriers associated with mental health care services and the stigma attached to them. Ideally, such measures would be designed to improve access to and quality of care. Integrating mental health care into health care, public health care, and emergency management systems requires a clear understanding of these systems including separate and overlapping structure, roles and responsibilities, and a knowledge of available resources. These service systems provide essential support and nurturance for community members, which may be augmented by informal resources that exist outside traditional market structures and that are known to some community members if not to care providers. Communication and investment in skill building will be needed to integrate mental health care into complementary systems. Noting that no one approach will work well for everyone, Friedman (2005a) would build multiple intervention strategies, ‘‘on the scaffold of existing community infrastructure’’ and institutions (p. 98). Legislation, education, public safety, self-help networks, and the media are avenues through which complementary strategies could be developed and implemented. Strategies should be designed to make desired outcomes relatively inexpensive and available to the general population, be proactive, involve credible outreach to subgroups of the population, and empower families and communities. Develop and practice disaster plans While we believe that community resilience can contribute to improved disaster management even when it is not developed specifically for that purpose, we would be remiss if we did not address the importance of developing and practicing community emergency plans. Plans should reflect a flexible, all-hazards approach that recognizes the potential for unforeseen and


unknown events and that advances universal preparedness. Community preparedness activities, training, and drills require knowledge of existing structure, roles, and responsibilities as well as critical reflection and skill building. Resources must be developed and dedicated to these efforts. Effective risk assessment and communication are essential components of emergency management in their own right. Ideally they also reduce apathy and provide direction for active coping and successful adaptation.

Conclusions Community resilience contributes to and is enhanced by resilience at the individual level. But community resilience differs from personal resilience in that it requires deliberate, meaningful, collective action involving purposeful analysis, intervention, and resolution. Community resilience consists of proactive as well as reactive elements that couple recovery from adversity with collective efforts to transform the environment to mitigate future events or problems. Community resilience protects a community against a wide range of social concerns. Community resilience also promises to be an important mechanism for promoting disaster prevention and mitigation, preparedness, response, and recovery within communities especially with respect to psychosocial considerations. The likelihood of unexpected events and the devastation accompanying major disasters, brought home dramatically by September 11 and Hurricane Katrina, underscore the need to complement and enhance traditional disaster management activities with resilience-building strategies. Building community resilience promotes a multi-faceted, multi-disciplinary approach to disaster management with benefits that extend well beyond disasters to the social fabric of communities. The eight proposed factors – connectedness, commitment, and shared values; participation; structure, roles, and responsibilities; resources; support and nurturance; critical reflection and skill building; communication; and disaster prevention and mitigation, preparedness, and response – represent a preliminary set of determinants of community resilience. They warrant further examination and clarification especially in their potential to improve disaster response and recovery even when developed primarily for purposes other than disaster prevention, mitigation, and preparedness. Community resilience requires private sector engagement and public support. Barriers to and recommendations for community resilience building address a lack of integration and limited communication within and across community sectors; the need for social capital, civic engagement, and crosscultural sensitivity; and the importance of critical reflection and resource development.

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Acknowledgments This paper was supported in part by grants from the Centers for Disease Control and Prevention (CDC); the Substance Abuse and Mental Health Services Administration (SAMHSA), United States Department of Health and Human Services (HHS); and the United States Department of Homeland Security (HS) through the National Consortium for the Study of Terrorism and Responses to Terrorism (START). The opinions, views, findings, recommendations, and conclusions expressed are those of the authors and do not necessarily reflect those of the CDC, SAMHSA, HHS, HS, or START.

REFERENCES Adger, W. N. (2000) Social and ecological resilience: are they related? Progress in Human Geography, 24 (3), 347–364. American Psychological Association Task Force (n.d.) Fostering Resilience in Response to Terrorism: A Fact Sheet for Psychologists Working with Adults. Retrieved January 7, 2008, from http://www.apa.org/psychologists/pdfs/adults.pdf. Anderson, W. (2006) This isn’t representative of our department: lessons from Hurricane Katrina for police disaster response planning. Paper submitted to Disasters and the law: Katrina and beyond. Boalt Hall School of Law, University of California – Berkeley (Law 224.9). Retrieved January 7, 2008, from http://www.law. berkeley.edu/library/disasters/Anderson.pdf. Auf der Heide, E. (1989) Disaster Response: Principles of Preparation and Coordination. Retrieved January 7, 2008, from http://orgmail2.coe-dmha.org/dr/flash.htm. Brown, D. D., Kulig, J. C. (1996/97) The concept of resiliency: theoretical lessons from community research. Health and Canadian Society, 4 (1), 29–50. Bruneau, M., Chang, S. E., Eguchi, R. T., et al. (2003) A framework to quantitatively assess and enhance the seismic resilience of communities. Earthquake Spectra, 19 (4), 733–752. Cohen, A. P. (2003) The Symbolic Construction of Community. London: Routledge. Cottrell, L. S., Jr. (1976) The competent community (pp. 195–209). In: Kaplan, B. H., Wilson, R. N., Leighton, A. H. (eds.) Further Explorations in Social Psychiatry. New York: Basic Books, Inc. English, J. C. B., Hicks, B. C. (1992) A systems-in-transition paradigm for healthy communities. Canadian Journal of Public Health, 83 (1), 61–65. Era¨nen, L., Liebkind, K. (1993) Coping with disaster: the helping behavior of communities and individuals (pp. 957–964). In Wilson, J. P., Raphael, B. (eds.) International Handbook of Traumatic Stress Syndromes. New York: Plenum Press. Friedman, M. J. (2005a) Every crisis is an opportunity. CNS Spectrums, 10 (2), 96–98. Friedman, M. J. (2005b) Toward a public mental health approach for survivors of terrorism. Journal of Aggression, Maltreatment and Trauma, 10 (1/2), 527–539. Gibbon, M., Labonte, R., Laverack, G. (2002) Evaluating community capacity. Health and Social Care in the Community, 10 (6), 485–491.

Chapter 2. Developing community resilience to disaster Glass, T. A., Schoch-Spana, M. (2002) Bioterrorism and the people: how to vaccinate a city against panic. Clinical Infectious Diseases, 34 (15), 217–223. Goeppinger, J., Baglioni, A. J., Jr. (1985) Community competence: a positive approach to needs assessment. American Journal of Community Psychology, 13 (5), 507–523. Goodman, R. M., Speers, M. A., McLeroy, K., et al. (1998) Identifying and defining the dimensions of community capacity to provide a basis for measurement. Health Education and Behavior, 25 (3), 258–278. Institute of Medicine. (2003) The Future of the Public’s Health in the 21st Century. Washington, DC: National Academy of Sciences. Jerusalem, M., Kaniasty, K., Lehman, D. R., Ritter, C., Turnbull, G. J. (1995) Individual and community stress: integration of approaches at different levels (pp. 105–129). In: Hobfoll, S. E., de Vries, M. W. (eds.) Extreme Stress and Communities: Impact and Intervention. Netherlands: Kluwer Academic Publishers. Jewkes, R., Murcott, A. (1996) Meanings of community. Social Science and Medicine, 43 (4), 555–563. Kaniasty, K., Norris, F. H. (2004) Social support in the aftermath of disasters, catastrophes, and acts of terrorism: altruistic, overwhelmed, uncertain, antagonistic, and patriotic communities (pp. 200–228). In: Ursano, R. J., Norwood, A. E., Fullerton, C. S. (eds.) Bioterrorism: Psychological and Public Health Interventions. Cambridge: Cambridge University Press. Kretzmann, J. P., McKnight, J. L. (1993) Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets. Chicago: ACTA. Kulig, J. C. (2000) Community resiliency: the potential for community health nursing theory development. Public Health Nursing, 17(5), 374–385. Labonte, R., Laverack, G. (2001a) Capacity building in health promotion, Part 1: for whom? And for what purpose? Critical Public Health, 11(2), 111–127. Labonte, R., Laverack, G. (2001b) Capacity building in health promotion, Part 2: whose use? And with what measurement? Critical Public Health, 11(2), 129–138. Longstaff, P. H. (2005) Security, Resilience, and Communication in Unpredictable Environments such as Terrorism, Natural Disasters, and Complex Technology. Cambridge, MA: Program on Information Resources Policy, Harvard University. Pfefferbaum, B., Reissman, D., Gurwitch, R., Steinberg, A., Montgomery, J. (2004) Executive summary: Community Resilience Mini-Summit: Developing Community Resilience for Children and Families. 24–25 March, 2004. Los Angeles: National Child Traumatic Stress Network. Pfefferbaum, B., Reissman, D. R., Pfefferbaum, R. L., Klomp, R. W. Gurwitch, R. H. (2007) Building resilience to mass trauma events (pp. 347–358). In: Doll, L. S., Bonzo, S. E., Mercy, J. A., Sleet, D. A., Haas, E. N. (eds.) Handbook of Injury and Violence Prevention. New York: Springer. Reissman, D. B., Klomp, R. W., Kent, A. T., Pfefferbaum, B. (2004) Exploring psychological resilience in the face of terrorism. Psychiatric Annals, 33 (8), 626–632. Reissman, D. B., Spencer, S., Tanielian, T., Stein, B. D. (2005) Integrating behavioral aspects into community preparedness and response systems (pp. 707–720). In: Danieli, Y., Brom, D., Sills, J. (eds.) The Trauma of Terrorism: Sharing Knowledge and Shared Care; An International Handbook. New York: The Haworth Maltreatment and Trauma Press.

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Chapter 2. Developing community resilience to disaster Steinberg, A., Ritzmann, R. F. (1990) A living systems approach to understanding the concept of stress. Behavioral Science, 35, 138–146. US Congress (2006) A Failure of Initiative: Final Report of the Select Bipartisan Committee to Investigate the Preparation for and Response to Hurricane Katrina. Retrieved 7 January, 2008 from 109th Congressional Report (109–377) online via: http://www.gpoaccess.gov/congress/index.html.

3

Psychological first aid Patricia J. Watson

Introduction The management of acute stress reactions following disasters and mass violence generally aims to foster resiliency, prevent chronic emotional problems, and minimize long-term deterioration in quality of life following the trauma exposure. Although it is widely believed by traumatic stress specialists that early intervention can help prevent longer-term problems, evidence addressing this belief is limited at present. This chapter will review the current empirical literature on early interventions following mass violence, and describe the principles of a consensusrecommended intervention called ‘‘psychological first aid.’’

Background research: effects of disasters Researchers wishing to conduct studies on acute interventions following disaster face many methodological challenges. Early interventions typically take place in chaotic and uncontrolled settings, with little pre-planning, funding or co-ordination between researchers and interventionists, a focus on action and assistance rather than research, and cross-community barriers between local responders and external researchers. Therefore, in the absence of wellcontrolled intervention studies, an initial examination of the effects of disasters, as well as risk and protective factors, has often been the basis for developing interventions that foster identified protective factors and ameliorate vulnerability factors. Rates of traumatic stress disorders and functional impairment in the general population following disaster or mass violence may be somewhat low over time, as evidenced by recent epidemiological studies following the September 11 Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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Chapter 3. Psychological first aid

terrorism attack in New York (Galea et al., 2002). Galea found a sharp decline in post-traumatic stress disorder (PTSD) symptoms in New York over the course of 6 months, from 7.5% to 0.6%. However, in a recent review of the literature (Norris, 2005), while the majority (50%) of disaster studies reviewed showed moderate effects, indicative of increased or prolonged stress but little enduring psychopathology, a significant proportion of studies showed severe (24%) or very severe (17%) effects, indicative of a high (25%–49%) or very high (50% þ) prevalence of clinically significant distress or psychological disorder. Symptoms and effects were most likely exhibited in the first year post-disaster, with 70% of the samples showing improvement as time passed. Of those with strong exposure to the incident, such as those in the building or the injured, rates were 37% and 30%, respectively. Therefore, not everyone will require early interventions, particularly in the immediate aftermath of disaster, and some level of screening for predictors of continued distress is recommended, although other than symptom severity at 1–2 weeks post-trauma, no algorithm for predictive factors has been created as yet (McNally et al., 2003). Of the factors commonly influencing the likelihood of serious or lasting psychological problems following disasters (Norris, 2005), severity of exposure has been one of the strongest, defined differentially as number of stressors, bereavement, injury to self or family member, life threat, panic during the disaster, property damage or financial loss and relocation. Other factors include: female gender, middle-age range, specific minority ethnic group membership, lower socioeconomic status, spouse’s symptom severity, parenthood, parental distress (predicts child distress), predisaster psychological symptoms (one of the best predictors of post-disaster symptoms), avoidance coping, and assignment of blame. Of those individuals exhibiting a negative recovery trajectory following disasters, the effects most commonly observed in research samples were: PTSD (with intrusion and arousal more often prevalent and avoidance less so), dissociative responses, acute stress disorder, depression, anxiety, demoralization, perceived stress, negative affect, physical health problems and/or somatic concerns, high physiological indicators of stress, poor sleep quality, and increases in the use of alcohol or, drugs (which generally are more persistent in nature than mental health effects (Schlenger et al., 2002)). Declines in psychosocial resources (particularly declines in social embeddedness and perceived social support) as well as chronic problems in living (interpersonal, familial, financial, and ecological changes and stress), have sometimes been defined as mediating factors that intervene between acute exposure and chronic psychological effects (Norris, 2005). The breadth of the outcomes observed indicated that researchers should not focus too narrowly on any one aspect of mental health, and that interventions aimed at those suffering from lasting negative impacts should seek to both address the multitude of possible effects of disasters and foster the protective mediating factors and reduce vulnerability factors.


In summary, the current literature on the effects of disasters on mental health functioning suggests that: (1) people’s reactions should not necessarily be regarded as pathological responses or even as precursors of subsequent disorder, (2) many people will have transient stress reactions in the aftermath of mass violence, and such reactions may occur, occasionally, even years later, (3) rather than traditional diagnosis and clinical treatment, most people are likely to need support and provision of resources to ease the transition to normalcy, and (4) some survivors may experience great distress and require community and at times clinical intervention (Galea et al., 2003).

Background research: early post-trauma intervention To date, there are few published RCT of interventions initiated in the first 14 days following disaster, mass violence, or other trauma, and difficulties in obtaining empirical support as well as lack of a conceptual framework have impeded the development of definitive recommendations. Critical Incident Stress Debriefing (CISD), a structured group model designed to explore facts, thoughts, reactions, and coping strategies following trauma, was originally developed as a protocol to mitigate stress response among emergency personnel (Mitchell, 1983). It began to be increasingly applied to victims of community-wide disasters in the late 1980s. However, a number of reviews of the post-trauma intervention literature have concluded that there is no evidence that CISD prevents long-term negative outcomes. Two RCTs of CISD reported a higher incidence of negative outcomes in those who received CISD compared with those who did not receive an intervention (for recent reviews, see Bisson, 2003; Litz et al., 2002; McNally et al., 2003; Watson et al., 2003). A recent large-scale RCT of a group debriefing intervention with active duty personnel found no differences among the CISD, stress education, and survey-only conditions on any behavioral health outcome, including subjective distress, PTSD, depression, general well-being, aggressive behavior, marital satisfaction, perceived organizational support, or morale, even though soldiers rated their satisfaction with CISD as high (Litz et al., 2004). While the CISD studies indicating negative outcomes have unintended sampling effects that draw their findings into question, a number of experts have suggested that the use of CISD in the immediate aftermath of disasters may have inadvertent negative effects (Watson, 2004). For instance, CISD interventions with primary civilian survivors of disaster may interfere with the practical steps that need to be taken to increase self-efficacy and reduce postevent stress, may be too brief to allow for adequate emotional processing, may increase arousal and anxiety levels, or may inadvertently decrease the likelihood that individuals will pursue more intensive interventions. It is possible that future research will demonstrate that CISD may be useful for some

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populations, or has more subtle positive effects (e.g., increasing perceived social support). In the meantime, numerous reviews of the best-controlled studies have concluded that it cannot be endorsed as an intervention which prevents long-term distress or psychopathology, given the current state of the research (Gray and Litz, 2005; McNally et al., 2003; Rose et al., 2003). Given preliminary evidence that increased arousal in the immediate phases post-trauma is linked to long-term pathology, there is concern that any intervention that focuses on emotional processing during this period may be contraindicated. It has therefore been recommended that any early interventions requiring emotional processing, which has the potential to increase arousal, should be more fully researched prior to recommending their routine practice post-disaster (Watson, 2004). Particularly in postdisaster settings involving mass trauma, a more flexible and multi-modal model is called for, due to the chaotic post-incident environment, the need for attention to be paid to pragmatic material needs, possible cultural and bereavement issues, and multiple recovery needs based on complex variables. A brief cognitive-behavioral treatment (CBT) model may have elements that can be applied to immediate intervention. Its elements include education, anxiety management training, imaginal exposure therapy, in vivo exposure, and cognitive restructuring. Research suggests that it results in prevention of PTSD and in decreased depressive symptoms when compared to repeated assessment, self-help, and education and support. In addition, benefits in psychological functioning are maintained 9 months to 4 years later (Bryant et al., 2003; Ehlers et al., 2003). A number of RCTs have been conducted with individuals diagnosed with acute stress disorder who are survivors of non-sexual assault, industrial accidents, and motor vehicle accidents (including those with acute injuries) (Bryant et al., 1998, 1999; Bisson et al., 2004; Ehlers et al., 2003; Zatzick et al., 2004). While the most empirical support for prevention of psychopathology and distress comes from short-term (four to five sessions) cognitivebehavioral interventions delivered within a month of trauma, CBT has not been empirically examined in the immediate aftermath (0–14 days) of trauma, particularly mass trauma. Offering multiple sessions of a structured intervention such as this is highly unlikely in the chaotic aftermath of mass trauma. Victims of accidents, assault, or injuries do not typically experience the disruption in the physical and social environment that is common following mass trauma. Members of recent consensus efforts (Watson, 2004) agreed that the chaotic and stressful post-event environment may reduce the energy and effort needed to participate in CBT treatments (i.e., homework, emotional, and time investment). They suggest that structured cognitivebehavioral interventions should not be implemented until secondary stressors in the environment are under sufficient control to allow the individual to focus on the intervention (usually not sooner than 3 weeks post-incident) (Watson, 2004).


Modifications of the cognitive-behavioral model that take into account the need for reduction of treatment intensity following mass violence have been applied in several efforts. For instance, brief telephone interventions using adapted cognitive-behavioral techniques (e.g., relaxation breathing and challenging maladaptive thoughts) have indicated decreased anxiety and PTSD symptoms post-intervention and at 3–4 months follow-up (Gega et al., 2004; Gidron et al., 2001; Greist et al., 2000; Mohr et al., 2000; Somer et al., 2005). The post-traumatic stress management (PTSM) program, implemented following community stressors (i.e., suicide cluster, bus accident), is put into place within 24 hours. The model includes both individual and group interventions which help people orient, stabilize, and improve coping skills (i.e., identification of access to support and resources, education regarding the neurophysiology of traumatic stress, its impact on psychosocial functioning, planning, problem-solving, and self-care, and processing of the trauma narrative). Survey information indicates that the most helpful parts of the program were providing direction to help communities heal and assisting the communities to handle the crisis together. Program creators recommend that this program is overlaid on existing human services programs until a trained resource network is in place and stable (Macy et al., 2004). Clearly, further research is needed to determine whether the early provision of CBT-influenced interventions following mass violence or disaster is likely to produce significant reduction in long-term problems enough to warrant its use earlier than 2 weeks post-trauma.

Expert consensus recommendations Experts from several consensus conferences (National Institute of Mental Health, 2002; Watson, 2004; Watson et al., in preparation) have attempted to incorporate empirical findings into more co-ordinated guidance regarding overall systems of post-disaster care. Consensus findings indicate that the foundation for an effective public mental health disaster response is an integrated local, state, and federal emergency preparedness response community (Emergency Management Associations, Public Health Offices, hospitals, faith-based community, law enforcement, etc.), with recognition among community leaders and planners that each aspect of disaster response has the potential to impact on community mental health. Central tenets include: (1) prior training of relevant responders (i.e., mental health professionals, media, government, public agencies, and educational institutions), (2) limitation of inappropriate interventions, (3) initiation of psychological first aid to those who need it, (4) identification of the needs of at-risk individuals who may require additional surveillance and evidence-based intervention over time, (5) provision of pragmatic and culturally competent programs that enhance

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natural resilience in as many individuals and communities as possible, (6) periodic monitoring of at-risk individuals, and (7) evaluation of services. Primary goals are to increase the evidence-informed principles of safety, efficacy, hope, connectedness, and calming. Key components of disaster behavioral interventions as identified by expert consensus are: 1. Provide for basic needs 2. Triage 3. Psychological first aid 4. Outreach and information dissemination 5. Technical assistance, consultation, and training 6. Treatment Provision for basic needs Essential for mental health are the meeting of basic needs for safety, security, and survival, such as food and shelter, orientation to the disaster and recovery efforts, facilitating communication with family, friends and community, and reducing ongoing environmental threat. Triage Mental health personnel assess survivors, identify vulnerable, high-risk individuals and groups, and provide referral and/or emergency hospitalization when indicated. Psychological first aid Basic strategies to reduce psychological distress include orientation to disaster and recovery efforts, reduction of physiological arousal, mobilization of support for those who are most distressed, facilitation of reunion with loved ones and keeping families together, providing education about available resources and coping strategies, and using effective risk communication techniques. Outreach and information dissemination Following disasters and incidents of mass violence, services are provided in the many environments where survivors can be found (sometimes referred to as ‘‘therapy by walking around’’). Established community structures are utilized to provide information and support. Information is disseminated via distribution of fliers and referral to websites, which can also provide online support. The media are provided with materials (e.g., interviews, releases, and programs) to help increase knowledge about trauma and recovery.


Technical assistance, consultation and training Organizations, leaders, responders, and caregivers are supported via the dissemination of knowledge, consultation, and training, so that they can improve their capacity to provide what is needed to re-establish community structure, foster family recovery/resilience, and safeguard the community. Treatment Mental health personnel seek to reduce symptoms and improve functioning via education, individual, family, and group psychotherapy, pharmacotherapy, spiritual/existential support, and short-term or long-term hospitalization. These components are provided by a range of individuals, organizations, and professionals, and create an overall framework within which recovery from mass violence can be maximized. Experts have recommended a stepped care approach with these components, such that some early deliveries may help most people in early adaptation but, as time progresses, more individualized and time-consuming interventions are reserved for a minority of people who require it (Zatzick et al., 2004). In the immediate phase, the components of meeting basic needs, triage, psychological first aid, and outreach/information dissemination are most salient. The difficulty in applying the current literature base to interventions following disasters and mass trauma, led a recent expert consensus conference to identify the following five empirically supported intervention principles to guide a wide variety of intervention practices following disaster and mass violence at the early to mid-term stages. These principles are: (1) promoting sense of safety, (2) promoting calming, (3) promoting sense of self- and community-efficacy, (4) promoting connectedness, and (5) instilling hope (Hobfoll et al., 2007). Promotion of psychological sense of safety can reduce biological aspects of post-traumatic stress reactions (Antonovsky, 1979; Bryant, 2006; Charney, 2004; Friedman and McEwen 2004; McEwen, 1998), and can positively affect cognitive processes that inhibit recovery, including a belief that ‘‘the world is completely dangerous’’ and exaggeration of future risk (Ehlers et al., 1998; Foa and Rothbaum, 1998; Smith and Bryant, 2000; Warda and Bryant, 1998). Promotion of calming can reduce the trauma-related anxiety that can generalize to many situations (Harvey and Bryant, 2002; McNally et al., 2003), as well as reduce high arousal, numbing, or emotionality, which can interfere with sleep, eating, hydration, decision-making, and performance of life tasks and lead to panic attacks, dissociation, PTSD, depression, anxiety, and somatic problems, if prolonged (Harvey et al., 2003; Shalev and Freedman, 2005).

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Promotion of self-efficacy increases people’s beliefs about their capabilities to manage the distressing events, principally through self-regulation of thought, emotions, and behavior (Benight and Harper, 2002; Benight et al., 1999, 2000). Promotion of connectedness is based on research indicating that social support is related to better emotional well-being and recovery following mass trauma (Bleich et al., 2003; Litz et al., 2002; Rubin et al., 2005; Stein et al., 2004). Promoting social connectedness increases opportunities for knowledge essential to disaster response, and provides opportunities for a range of social support activities, including practical problem-solving, emotional understanding and acceptance, sharing of traumatic experiences, normalization of reactions and experiences, and mutual instruction about coping (Norris et al., 2002; Vaux, 1988). Instilling hope has been identified as a crucial component of post-disaster intervention because those who are likely to have more favorable outcomes after experiencing mass trauma are those who maintain optimism (because they can retain hope for their future), have a positive expectancy, a feeling of confidence that life and self are predictable, or other hopeful beliefs (e.g., in God, that there is a high probability that things will work out as well as can reasonably be expected) (Antonovsky, 1979; Carver and Scheier, 1998; Crowson et al., 2001; Ironson et al., 1997; Salmon, 1929; Smith et al., 2000; Solomon, 2003). The National Child Traumatic Stress Network and the National Center for PTSD have applied both research literature and expert consensus in developing a ‘‘psychological first aid’’ (PFA) model, in consultation with a diverse group of disaster response professionals. The resulting PFA field guide has been designed, as far as possible, to be consistent with research evidence, applicable in field settings, tailored to the full developmental spectrum, and culturally informed (NCTSN and NCPTSD, 2006). It has been designed to be flexible and targeted at practical assistance and skill-building related to the current concerns and needs identified by survivors themselves.

An evidence-informed psychological first aid model Psychological first aid has been defined as the use of pragmatic psychosocial interventions delivered during the immediate impact phase (first 4 weeks) to individuals experiencing acute stress reactions or problems in functioning, with the intent of aiding adaptive coping and problem-solving (Young, 2006). It was developed on the foundations of crisis intervention (Lindemann, 1944; Schneiderman et al., 1970) and was first coined in the early disaster work of Raphael (1977) and Farberow (1978) with adults, and Pynoos and Nader (1988) with children.


The NCTSN/NCPTSD PFA model includes the following eight core actions: 1. Contact and engagement Goal: respond to contacts initiated by affected persons, or initiate contacts in a non-intrusive, compassionate, and helpful manner. 2. Safety and comfort Goal: enhance immediate and ongoing safety, and provide physical and emotional comfort. 3. Stabilization (if necessary) Goal: to calm and orient emotionally overwhelmed/distraught survivors. 4. Information gathering: current needs and concerns Goal: identify immediate needs and concerns, gather additional information, and tailor PFA interventions. 5. Practical assistance Goal: to offer practical help to the survivor in addressing immediate needs and concerns. 6. Connection with social supports Goal: to reduce distress by helping structure opportunities for brief or ongoing contacts with primary support persons or other sources of support, including family members, friends, and community helping resources. 7. Information on coping support Goal: to provide the individual with information (including education about stress reactions and coping) that may help them deal with the event and its aftermath. 8. Linkage with collaborative services Goal: to link survivors with needed services, and inform them about available services that may be needed in the future. Psychological first aid should be tailored depending on the context. The choice of actions and the amount of time spent on each will depend on the needs of the survivor and on the context of delivery. Group application of PFA can be made primarily in connecting others with social supports and in providing information on coping support. A key tenet of PFA is respect for individual variation in recovery from trauma. In group interventions, this is particulary salient, in that the fluctuating course of trauma response (from avoidance to processing) may render an individual incapable of, or unwilling to, discuss their experiences or responses, and may indeed be an adaptive response (Raphael et al., 1996; Watson and Shalev, 2005). Brewin (2005) cautions against interfering with natural recovery processes within the acute phases post-trauma, and in group application it is important to provide opportunities to tailor coping information to specific needs, while not in any way making participants feel that they need to share their experiences.

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As a relatively brief, non-stigmatizing, low-cost form of care, providing information on coping support is generally designed to be tailored to cover any number of the following points: (1) help survivors better understand a range of post-trauma responses; (2) view their post-trauma reactions as expectable and understandable (not as reactions to be feared, signs of personal failure or weakness, or signs of mental illness); (3) recognize the circumstances under which they should consider seeking further counseling; (4) know how and where to access additional help, including mental health counseling; (5) increase use of social supports and other adaptive ways of coping with the trauma and its effects; (6) decrease use of problematic forms of coping (e.g., excessive alcohol consumption, extreme social isolation); and (7) increase ability to help family members cope (e.g., information about how to talk to children about what happened). Accurate and timely information regarding the nature of the unfolding disaster situation is also an important part of education. Care should be taken when providing self-help coping information, as its use is still being tested; indeed, one study (Ehlers et al., 2003) indicated that those who received a self-help manual as compared to repeated assessments or a more formal cognitive-behavioral intervention following traumatic stress did not fare as well at follow-up as either of the other groups. The researchers recommend that self-help advice be modified to take into account the conditions under which self-exposure to traumatic material is helpful, and to give more concrete advice regarding how to go through traumatic memories, how to address problematic appraisals, and how to change them (Ehlers et al., 2003, p. 8). Clearly this application following disasters is in need of study, as other cognitive-behavioral self-help interventions have been found to be effective for treatment of non-trauma-related anxiety problems in a number of controlled treatment outcome studies (e.g., Gould and Clum, 1995; Lidren et al., 1994). While PFA has not yet been systematically studied, experience in the field suggests that it will be acceptable to and well-received by consumers, due to its flexible, tailored approach to helping to solve practical needs, as well as its voluntary nature. It is, however, important to remain cautious in our estimation of what early interventions can accomplish in terms of prevention of long-term functional and symptomatic impact. It is unknown whether most early intervention activities are associated with significant improvements in functioning. The relative contribution of early and short interventions may be necessarily small because past history, differing exposure, and ongoing stress levels make it difficult to identify which persons are at risk for continued problems. It may additionally be extremely difficult to conduct effective interventions in the early aftermath of disastrous events. Finally, ethnic, cultural, political, and economic factors may create differing outcome goals for individuals, groups, and communities.


Therefore, there is a great need for both program evaluation and RCTs that will evaluate the effectiveness of PFA principles in a number of contexts. In addition, PFA is meant to be embedded in a consensus-recommended systemic response involving mental health, public health, medical, and emergency response systems, and federal, state, local, and non-profit agencies (including non-mental health agencies such as law enforcement, fire and rescue, school systems, social services, etc.). Finally, PFA takes place in the context of community intervention (e.g., publicly disseminated information related to risk, resources, and care of self and family; memorials, VIP visits, etc.) and community-level surveillance/assessment related to community service needs.

Conclusions While PFA is a set of interventions that are founded on both empirical and expert consensus findings, it is apparent that there is a great need for both program evaluation and RCTs that will evaluate the effectiveness of PFA principles in a number of contexts, and eventually rigorously evaluate the effectiveness of each separate component, especially with respect to the optimal post-traumatic timing of such interventions. This research should include a range of outcomes, including not only PTSD, but also substance abuse, depression, anger and violence, interpersonal and role functioning, and physical health. In addition to such individual outcomes, research is needed that focuses on group, organizational, and community outcomes, such as behavioral, emotional, and functional consequences most likely to be expressed in the school or workplace (staff turnover, organizational cohesion, morale, absenteeism, performance deficits, or medical symptoms). In addition to continued efforts to conduct evaluation and research, it is important to remain cautious in our overstatement of what PFA can accomplish towards prevention of long-term functional and symptomatic impact. For instance, the provision of PFA principles may be more feasible than structured clinical interventions, but it is unknown whether such interventions are associated with significant improvements in functioning. As can be seen with the debriefing literature, overstating the proposed effects of an intervention prior to evidence of its impact can result in programs being implemented at the expense of careful consideration of more viable alternatives. Additionally, care should be taken to include the preferences of recipients as a disaster response is planned. Research on service utilization indicates that the majority of individuals exposed to a traumatic event will not choose to seek mental health services, and, therefore, a careful study of what interventions are acceptable and supportive of natural recovery trajectories may be called for prior to strong recommendations for any

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mental health intervention. For instance, in keeping with social support research (Kaniasty and Norris, 2004), a more acceptable intervention than individual crisis response might be to provide family and friends with the tools necessary for helping loved ones more effectively process traumatic stress, as distinct from severe stress. Finally, international planning and co-ordination is needed when planning for the implementation of psychological interventions in different countries. Recent ethnocultural guidelines caution against applying western standards to different ethnocultural formulations of healing and recovery (Watson et al., in preparation). As McNally and colleagues point out after an excellent review of the early intervention literature (2003), ‘‘the bottom line is that in the immediate aftermath of trauma, professionals should take their lead from the survivors and provide the help they want, rather than tell survivors how they will get better (p. 68).’’ While the field of disaster behavioral health intervention is still in its infancy, it is hoped that continued examination of many of these factors and creative collaboration across disciplines will contribute to a realistic and informed approach to assisting in recovery from incidents of mass violence. REFERENCES Antonovsky, A. (1979) Health, Stress, and Coping. San Francisco: Jossey-Bass. Benight, C. C., Harper. M. L. (2002) Coping self-efficacy perceptions as a mediator between acute stress response and long-term distress following natural disasters. Journal of Traumatic Stress, 15(3), 177–186. Benight, C. C., Swift, E., Sanger, J., Smith, A., Zeppelin, D. (1999) Coping self-efficacy as a mediator of distress following a natural disaster. Journal of Applied Social Psychology, 29, 2443–2464. Benight, C. C., Freyaldenhoven, R. W., Hughes, J., Ruiz, J. M., Zoschke, T. A., Lovallo, W. R. (2000) Coping self-efficacy and psychological distress following the Oklahoma City bombing. Journal of Applied Social Psychology, 30, 1331–1344. Bisson, J. I. (2003) Single-session early psychological interventions following traumatic events. Clinical Psychology Review, 23, 481–499. Bisson, J. I., Shepherd, J. P., Joy, D., Probert, R., Newcombe, R. G. (2004) Early cognitive-behavioural therapy for post-traumatic stress symptoms after physical injury: randomised controlled trial. British Journal of Psychiatry, 184, 63–69. Bleich, A., Gelkopf, M., Solomon, Z. (2003) Exposure to terrorism, stress-related mental health symptoms, and coping behaviors among a nationally representative sample in Israel. Journal of the American Medical Association, 290(5), 612–620. Brewin, C. R. (2005) Risk factor effect sizes in PTSD: what this means for intervention. Journal of Trauma and Dissociation, 6 (2), 123–130. Bryant, R. A. (2006) Cognitive behavior therapy: implications from advances in neuroscience (pp. 255–270). In: Kato, N., Kawata, M., Pitman, R. K. (eds.) PTSD: Brain Mechanisms and Clinical Implications. Tokyo: Springer-Verlag.

Chapter 3. Psychological first aid Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., Basten, C. (1998) Treatment of acute stress disorder: a comparison of cognitive-behavioral therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66(5), 862–866. Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., Guthrie, R. (1999) Treating acute stress disorder: an evaluation of cognitive behavior therapy and supportive counseling. American Journal of Psychiatry, 156, 1780–1786. Bryant, R. A., Moulds, M. L., Nixon, R. V. (2003) Cognitive behaviour therapy of acute stress disorder: a four-year follow-up. Behavioral Research and Therapy, 41(4), 489–494. Carver, C. S., Scheier, M. R. (1998) On the Self-Regulation of Behavior. New York: Cambridge University Press. Charney, D. S. (2004) Psychobiological mechanisms of resilience and vulnerability: implications for successful adaptation to extreme stress. American Journal of Psychiatry, 161(2), 195–216. Crowson, J. J., Frueh, B. C., Snyder, C. R. (2001) Hostility and hope in combat-related posttraumatic stress disorder: a look back at combat as compared to today. Cognitive Therapy and Research, 25, 149–165. Ehlers, A., Mayou, R. A., Bryant, B. (1998) Psychological predictors of chronic PTSD after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508–519. Ehlers, A., Clark, D. M., Hackmann, A. et al. (2003) A randomized controlled trial of cognitive therapy, a self-help booklet, and repeated assessments as early interventions for posttraumatic stress disorder. Archives of General Psychiatry, 60 (10), 1024–1032. Farberow, N. L. (1978) Field Manual for Human Service Workers in Major Disasters: Adult Psychological First Aid. DHHS Publication No. ADM 78–537. Rockville, MD: National Institute of Mental Health. Foa, E. B., Rothbaum, B. O. (1998) Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York: Guilford. Friedman, M. J., McEwen, B. S. (2004) Posttraumatic stress disorder, allostatic load, and medical illness (pp. 157–188). In: Schnurr, P. P., Green, B. L. (eds.) Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress . Washington DC: American Psychological Association. Galea, S., Ahern, J., Resnick, H. et al. (2002) Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, 346, 982–987. Galea, S., Vlahov, D., Resnick, H. et al. (2003) Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology, 158(6), 514–524. Gega, L., Marks, I. M., Mataix-Cols, D. (2004) Computer-aided CBT self-help for anxiety and depressive disorders: experience of a London clinic and future directions. Journal of Clinical Psychology / In Session, 60, 147–157. Gidron, Y., Gal, R., Freedman, S. A. et al. (2001) Translating research findings to PTSD prevention: results of a randomized-controlled pilot study. Journal of Traumatic Stress, 14, 773–780. Gould, R. A., Clum, G. A. (1995) Self-help plus minimal therapist contact in the treatment of panic disorder: a replication and extension: mechanisms, populations, and treatment innovations in anxiety disorders. Behavior Therapy, 26 (3), 533–546.

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Chapter 3. Psychological first aid Gray, M. J., Litz, B. T. (2005) Behavioral interventions for recent trauma: empirically informed practice guidelines. Behavior Modification, 29 (1), 189–215. Greist, J. H., Osgood-Hynes, D. J., Baer, L., Marks, I. M. (2000) Technology-based advances in the management of depression. Focus on the COPE program. Disease Management and Health Outcomes, 7(4), 193–200. Grieger, T. A., Fullerton, C. S., Ursano, R. J. (2003) Posttraumatic stress disorder, alcohol use, and perceived safety after the terrorist attack on the Pentagon. Psychiatric Services, 54(10), 1380–1382. Harvey, A. G., Bryant, R. A. (2002) Acute stress disorder: a synthesis and critique. Psychological Bulletin, 128(6), 886–902. Harvey, A. G., Bryant. R. A., Tarrier, N. (2003) Cognitive behaviour therapy for posttraumatic stress disorder. Clinical Psychology Review, 23(3), 501–522. Hobfoll, S. E., Watson, P., Bell, C. C. et al. (2007) Five essential elements of immediate and mid-term trauma intervention: empirical evidence. Psychiatry, 70(4), 283–315. Ironson, G., Wynings, C., Schneiderman, N. et al. (1997) Post-traumatic stress symptoms, intrusive thoughts, loss, and immune function after Hurricane Andrew. Psychosomatic Medicine, 59, 128–141. Kaniasty, K., Norris, F. H. (2004) Social support in the aftermath of disasters, catastrophes, and acts of terrorism: altruistic, overwhelmed, uncertain, antagonistic, and patriotic communities (pp. 200–229). In: Ursano, R., Norwood, A., Fullerton, C. (eds.) Bioterrorism: Psychological and Public Health Interventions. Cambridge: Cambridge University Press. Lidren, D. M., Watkins, P., Gould, R. A., Clum, G. A., Asterino, M., Tulloch, H. L. (1994) A comparison of bibliotherapy and group therapy in the treatment of panic disorder. Journal of Consulting and Clinical Psychology, 62, 865–869. Lindemann, E. (1944) Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141–148. Litz, B. T., Gray, M. J. (2002) Early intervention for mass violence: what is the evidence? What should be done? Cognitive and Behavioral Practice, 9(4), 266–272. Litz, B. T., Gray, M. J., Bryant, R. A., Adler, A. B. (2002) Early intervention for trauma: current status and future directions. Clinical Psychology: Science and Practice, 9, 112–134. Litz, B. T., Williams, L., Wang, J., Bryant, R., Engel, C. C. (2004) A therapist-assisted internet self-help program for traumatic stress. Professional Psychology: Research and Practice, 35(6), 628–634. Macy, R. D., Behar, L., Paulson, R., Delman, J., Schmid, L., Smith, S. F. (2004) Community-based, acute posttraumatic stress management: a description and evaluation of a psychosocial-intervention continuum. Harvard Review of Psychiatry, 12(4), 217–228. McEwen, B. (1998) Development of the cerebral cortex: XIII. Stress and brain development: II. Journal of the American Academy of Child and Adolescent Psychiatry, 38(1), 101–103. McNally, R. J., Bryant, R. A., Ehlers, A. (2003) Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4(2), 45–79.

Chapter 3. Psychological first aid Mitchell, J. T. (1983) When disaster strikes . . . The critical incident stress debriefing. Journal of Emergency Medical Services, 13 (11), 49–52. Mohr, W. K., Lutz, M. J. N., Fantuzzo, J. W., Perry, M. A. (2000) Children exposed to family violence: a review of empirical research from a developmental-ecological perspective. Trauma, Violence, and Abuse: A Review Journal, 1(3), 264–283. National Child Traumatic Stress Network and the National Center for PTSD (2006) The Psychological First Aid Field Operations Guide, second edition. Retrieved from: http://www.ncptsd.va.gov/pfa/PFA.html on January 30, 2007. National Institute of Mental Health (2002) Mental health and mass violence – evidence based early psychological intervention for victims / survivors of mass violence: a workshop to reach consensus on best practices. US Department of Defense; U.S. Department of Health and Human Services, the National Institute of Mental Health, the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services; US Department of Justice, Office for Victims of Crime; US Department of Veterans Affairs, National Center for PTSD; and the American Red Cross. NIMH Report. Norris, F. (2005) Range, magnitude, and duration of effects of disasters on mental health: Review update 2005. Retrieved from: http://www.redmh.org/research/ general/REDMH_effects.pdf on January 30, 2007. Norris, F. H., Friedman, M. J., Watson, P. J. (2002) 60,000 disaster victims speak, part II: summary and implications of the disaster mental health research. PsychiatryInterpersonal and Biological Processes, 65(3), 240–260. Pynoos, R. S., Nader, K. (1988) Psychological First Aid and treatment approach to children exposed to community violence: research implications. Journal of Traumatic Stress, 1, 445–473. Raphael, B. (1977) The Granville train disaster: psychological needs and their management. Medical Journal of Australia, 1, 303–305. Raphael, B. (1986) When Disaster Strikes: A Handbook for the Caring Professional. Boston: Unwin Hyman. Raphael, B., Meldrum, L., McFarlane, A. C. (1996) Does debriefing after psychological trauma work? Time for randomised controlled trials. Accident and Emergency Medicine, 4(2), 65–67. Rose, S., Bisson, J., Wessely, S. (2003) A systematic review of single-session psychological interventions (‘‘debriefing’’) following trauma. Psychotherapy and Psychosomatics, 72, 176–184. Rubin, G. J., Brewin, C. R., Greenberg, N., Simpson, J., Wessely, S. (2005) Psychological and behavioural reactions to the bombings in London on 7 July 2005: a cross sectional survey of a representative sample of Londoners. British Medical Journal, 331, (7517), 606. Salmon, T. W. (1929) The care and treatment of mental diseases and war neuroses (‘shell shock’) in the British Army (pp. 497–523). In: Bailey, P., Williams, F. E., Komora, P. O., Salmon, T. W., Fenton, N. (eds.) Neuropsychiatry: in the United States [and] in the American Expeditionary Forces. Washington, DC: Government Printing Office. Schlenger, W., Cadell, J., Ebert, L., et al. (2002) Psychological reactions to terrorist attacks: findings from the National Study of Americans’ Reactions to September 11. Journal of the American Medical Association, 288, 581–588.

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Chapter 3. Psychological first aid Schneiderman, E. S., Farberow, N. L., Litman, R. E. (eds.) (1970) The Psychology of Suicide. New York: Science House. Shalev, A. Y., Freedman, S. (2005) PTSD following terrorist attacks: a prospective evaluation. American Journal of Psychiatry, 162(6), 1188–1191. Smith, B. W., Pargament, K. I., Brant, C., Oliver, J. M. (2000) Noah revisited: religious coping by church members and the impact of the 1993 Midwest flood. Journal of Community Psychology, 28(2), 169–186. Smith, K., Bryant, R. A. (2000) The generality of cognitive bias in acute stress disorder. Behavior Research and Therapy, 38, 709–715. Solomon, Z. (2003) Coping with War-Induced Stress: The Gulf War and the Israeli Response. New York: Plenum. Somer, E., Tamir, E., Maguen, S., Litz, B. T. (2005) Brief cognitive-behavioral phonebased intervention targeting anxiety about the threat of attack: a pilot study. Behavior Research and Therapy, 43(5), 669–679. Stein, B. D., Elliott, M. N., Jaycox, L. H. et al. (2004) A national longitudinal study of the psychological consequences of the September 11, 2001 terrorist attacks: reactions, impairment, and help-seeking. Psychiatry, 67(2), 105–117. Vaux, A. (1988) Social Support: Theory, Research and Intervention. New York: Praeger. Veronen, I. J., Kilpatrick, D. G. (1983) Stress management for rape victims (pp. 341–374). In: Meichenbaum, D., Jaremko, M. E. (eds.) Stress Reduction and Prevention. New York: Plenum. Warda, G., Bryant, R. A. (1998) Cognitive bias in acute stress disorder. Behavior Research and Therapy, 36, 1177–1183. Watson, P. (2004) Mental health interventions following mass violence. Stresspoints, 12(2), 4–5. Watson, P. J., Shalev, A. Y. (2005) Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events. CNS Spectrums, 10 (2), 123–131. Watson, P. J., Friedman, M. J., Gibson, L. E., Ruzek, J. I., Norris, F. H., Ritchie, E. C. (2003) Early intervention for trauma-related problems. Review of Psychiatry, 22, 97–124. Young, B. (2006) Psychological first aid. In: Ritchie, E. C., Friedman, M. J., Watson, P. J. (eds.) Mental Health Intervention Following Disasters or Mass Violence. New York: Guilford Press. Zatzick, D. F., Roy-Byrne, P. P., Russo, J. E. et al. (2004) A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors. Archives of General Psychiatry, 61(5), 498–506.

4

Acute stress disorder and early interventions after trauma Richard A. Bryant

Who should we treat with early intervention? The possibility of early intervention after trauma exposure presumes that people exposed to trauma are high risk for developing a psychiatric disorder. There are reports of high rates of emotional numbing (Feinstein, 1989; Noyes et al., 1977), reduced awareness of one’s environment (Berah et al., 1984; Hillman, 1981), derealization (Cardenã and Spiegel, 1993; Freinkel et al., 1994; Noyes and Kletti, 1977; Sloan, 1988), depersonalization (Cardenã and Spiegel, 1993; Freinkel et al., 1994; Noyes et al., 1977; Sloan, 1988) dissociative amnesia (Cardenã and Spiegel, 1993; Feinstein, 1989; Madakasira and O’Brien, 1987), intrusive thoughts (Cardenã and Spiegel, 1993; Feinstein, 1989; Sloan, 1988), avoidance behaviors (Bryant and Harvey, 1996; Cardenã and Spiegel, 1993; North et al., 1989), insomnia (Cardenã and Spiegel, 1993; Feinstein, 1989; Sloan, 1988), concentration deficits (Cardenã and Spiegel, 1993; North et al., 1989), irritability (Sloan, 1988), and autonomic arousal (Feinstein, 1989; Sloan, 1988) in the weeks after trauma exposure. It is apparent that psychological distress is very commonplace in the weeks after a traumatic experience. Although acute stress reactions are very common, there is also strong evidence that the majority of these stress responses are transient. That is, the majority of people who initially display distress naturally adapt to their experience in the following months. For example, whereas 94% of rape victims displayed post-traumatic stress disorder (PTSD) symptoms 2 weeks post-trauma, this rate dropped to 47% 11 weeks later (Rothbaum et al., 1992). In another study 70% of women and 50% of men were diagnosed with PTSD at an average of 19 days after an assault; the rate of PTSD at the 4-month follow-up had dropped to 21% for women and zero for men (Riggs et al., 1995). Similarly, half of a sample meeting criteria for PTSD shortly after a motor vehicle accident had remitted by 6 months and two-thirds had Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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Chapter 4. ASD and early interventions after trauma

remitted by 1 year post-trauma (Blanchard et al., 1996). There is also evidence that most stress responses after the terrorist attacks of September 11 may have been temporary reactions. Galea et al. (2002) surveyed residents of New York City to gauge their response to the terrorist attacks. At 5–8 weeks after the attacks, 7.5% of a random sample of adults living south of 110th Street in Manhattan had developed PTSD, and of those living south of Canal Street, 20% had PTSD. In February 2002, Galea’s group did a follow-up study on another group of adults living south of 110th Street, and found that only 1.7% of the sample had PTSD related to the attacks (Galea et al., 2003). The available evidence suggests that the normative response to trauma is to initially experience a range of PTSD symptoms but that the majority of these reactions will remit in the following months. That is, it is unnecessary to treat the vast majority of trauma survivors because they are not suffering a mental disorder. A key question facing the field is how to identify the minority of people shortly after trauma exposure who will subsequently develop PTSD.

The history of acute stress disorder In 1994 the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) introduced the acute stress disorder (ASD) diagnosis to describe stress reactions in the initial month after a trauma. There were two primary goals of this diagnosis. Firstly, the diagnosis was intended to describe initial traumatic stress reactions that occur in the month immediately after trauma exposure. There was a perception that initial reactions needed to be described in diagnostic terms because DSMIV stipulated that PTSD could only be recognized at least 1 month after a trauma. Secondly, the diagnosis was meant to identify people who, shortly after trauma exposure, would subsequently develop PTSD (Koopman et al., 1995). It is worth noting that the goal of the ASD diagnosis to predict PTSD contrasted significantly with the conceptualization of acute stress reactions described in the tenth edition of the International Classification of Diseases (ICD-10; World Health Organization, 1992). ICD-10 describes acute stress reaction as a transient reaction that occurs in the initial 48 hours after a trauma, and encompasses a broad range of anxiety and depressive reactions. Some commentators have noted that the ICD-10 approach is more clinically friendly and flexible in describing acute trauma reactions (Solomon et al., 1996).

Definition of ASD DSM-IV stipulates that ASD can occur after a fearful response to experiencing or witnessing a threatening event (Cluster A). The requisite symptoms to


meet criteria for ASD include three dissociative symptoms (Cluster B), one re-experiencing symptom (Cluster C), marked avoidance (Cluster D), marked anxiety or increased arousal (Cluster E), and evidence of significant distress or impairment (Cluster F). The disturbance must last for a minimum of 2 days and a maximum of 4 weeks (Cluster G) after which time a diagnosis of PTSD should be considered. The primary difference between the criteria for ASD and PTSD is the time frame and the former’s emphasis on dissociative reactions to the trauma. Acute stress disorder refers to symptoms manifested during the period from 2 days to 4 weeks post-trauma, whereas PTSD can only be diagnosed from 4 weeks. The diagnosis of ASD requires that the individual has at least three of the following: (1) a subjective sense of numbing or detachment, (2) reduced awareness of one’s surroundings, (3) derealization, (4) depersonalization, or (5) dissociative amnesia.

The role of dissociation The ASD diagnosis was strongly influenced by the notion that dissociative reactions are a crucial mechanism in post-traumatic adjustment. This perspective originated in work conducted at the Salpeˆtrie`re in Paris over 100 hundred years ago. Charcot (1887) proposed that traumatic shock could evoke responses that were phenomenologically similar to hypnotic states, and in this sense Charcot believed that traumatic experiences resulted in dissociative states that are evident in hysteria and could also be elicited during hypnosis. Extending this argument, Janet (1907) proposed that traumatic experiences that were incongruent with existing cognitive schema led to dissociated awareness. He argued that although this splitting of traumatic memories from awareness led to a reduction in distress, there was a loss of mental functioning because mental resources were not available for other processes. Janet proposed that adaptation following trauma required integrating the fragmented memories of the trauma into awareness. These views have enjoyed renewed attention in the last 20 years, and represent the basis for the current notion that trauma-induced dissociation is a pivotal trauma response (Nemiah, 1989; van der Kolk and van der Hart, 1989).

Criticisms of the acute stress disorder diagnosis There have been many criticisms of the ASD diagnosis (see Bryant and Harvey, 2000; Butler, 2000; Keane et al., 2001; Koopman, 2000; Marshall et al., 2000; Simeon and Guralnik, 2000; Spiegel et al., 2000). Firstly, the new ASD diagnosis was introduced with very little evidence to support its inclusion. At the time of its introduction, even the proponents of the

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diagnosis admitted that the alleged relationship between ASD and PTSD was, ‘‘based more on logical arguments than on empirical research’’ (Koopman et al., 1995, p. 38). While inclusion of other diagnoses into DSM-IV required satisfaction of a number of standards (including literature reviews, statistical analyses of established datasets, and field trials), the ASD diagnosis did not undergo this rigorous scrutiny (Bryant and Harvey, 2000). Secondly, the emphasis on dissociation as a necessary response to trauma was criticized on the grounds that there was insufficient evidence to warrant this construct’s playing such a pivotal role in acute trauma response (Bryant and Harvey, 1997; Keane et al., 2001; Marshall et al., 2000). Thirdly, some objected to the notion that the primary role of the ASD diagnosis was to predict another diagnosis (McNally, 2003). Fourthly, there was concern that the diagnosis may pathologize transient reactions (Marshall et al., 1999). Fifthly, it was argued that distinguishing between two diagnoses (ASD and PTSD) that have comparable symptoms on the basis of the duration of these symptoms is not justified (Marshall et al., 1999).

Incidence of acute stress disorder Numerous studies have now reported the incidence of ASD following a range of traumatic events. Acute stress disorder has been reported at between 13% and 21% following motor vehicle accidents (Harvey and Bryant, 1998a; Holeva et al., 2001), 14% following mild brain injury (Harvey and Bryant, 1998b), between 16% and 19% following assault (Brewin et al., 1999; Harvey and Bryant, 1999a), 16% following traumatic loss (Green et al., 2001), 10% following burns (Harvey and Bryant, 1999a), between 6% and 12% following industrial accident (Creamer and Manning, 1998; Harvey and Bryant, 1999a), 33% following a mass shooting (Classen et al., 1998), and 7% following a typhoon (Staab et al., 1996).

Does acute stress disorder predict post-traumatic stress disorder? A series of prospective studies have prospectively assessed the relationship between ASD in the initial month after trauma and development of subsequent PTSD (Brewin et al., 1999; Bryant and Harvey, 1998; Creamer et al., 2004; Difede et al., 2002; Harvey and Bryant, 1998a, 1999a, 1999b, 2000; Holeva et al., 2001; Kangas et al., 2005; Murray et al., 2002; Schnyder et al., 2001; Staab et al., 1996). Table 4.1 presents a summary of the 12 studies in terms of (1) the proportion of people who initially had ASD and who subsequently developed PTSD, and (2) the proportion of people who

Chapter 4. ASD and early interventions after trauma Table 4.1. Summary of prospective studies of acute stress disorder Trauma type MVA Brain injury Assault MVA MVA MVA Typhoon Cancer MVA Brain injury MVA Burns

Study Harvey and Bryant (1998a) Bryant and Harvey (1998b) Brewin et al. (1999) Holeva et al. (2001) Creamer et al. (2004) Schnyder et al. (2001) Staab et al. (1996) Kangas et al. (2005) Harvey and Bryant (1999) Harvey and Bryant (2000) Murray et al. (2002) Difede et al. (2002)

Percentage of those with ASD who develop PTSD (%)

Percentage of those with PTSD who had ASD (%)

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39

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40

83 72 30 34 30 53 82

57 59 34 10 37 61 29

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77 87

34 78

eventually developed PTSD who initially met criteria for ASD. In terms of people who meet criteria for ASD, a number of studies have found that approximately three-quarters of trauma survivors who display ASD subsequently develop PTSD (Brewin et al., 1999; Bryant and Harvey, 1998; Difede et al., 2002; Harvey and Bryant, 1998a, 1999a, 1999b, 2000; Holeva et al., 2001; Kangas et al., 2005; Murray et al., 2002). Compared to the expected remission of most people who display initial post-traumatic stress reactions, these studies indicate that the ASD diagnosis is performing reasonably well in predicting people who will develop PTSD. The utility of the ASD diagnosis is less encouraging when one considers the proportion of people who eventually developed PTSD and who initially displayed ASD. In most studies, the minority of people who eventually developed PTSD initially met criteria for ASD. That is, whereas the majority of people who develop ASD are at high risk for developing subsequent PTSD, there are many other people who will develop PTSD who do not initially meet ASD criteria. It appears that a major reason for people who are at high risk for PTSD not meeting ASD criteria is the requirement that three dissociative symptoms be displayed. In one study, 60% of people who met all ASD criteria except for the dissociation cluster met PTSD criteria 6 months later (Harvey and Bryant, 1998a), and 75% of these people still had PTSD 2 years later (Harvey and Bryant, 1999b). This pattern suggests that emphasizing

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dissociation as a critical factor in predicting subsequent PTSD leads to a neglect of other acute stress reactions that also represent a risk for development of chronic PTSD. The two published studies of the predictive ability of ASD in children and adolescents suggest that ASD is similarly limited because the emphasis on dissociative symptoms excludes many children who are high risk for PTSD development (Kassam-Adams and Winston, 2004; Meiser-Studman et al., 2005).

Does acute dissociation predict post-traumatic stress disorder? The apparent limited utility of the ASD diagnosis questions the role of acute dissociation as a predictor of subsequent psychopathology. Many of the earlier reports of peritraumatic dissociation involved retrospective accounts of acute dissociation that were obtained months after trauma exposure (e.g., Blanchard et al., 1996; Holen, 1993; Marmar et al., 1994; McFarlane, 1986; Solomon et al., 1989). This practice was very flawed because of increasing evidence that recollections of acute reactions to trauma are often inaccurate and are influenced by the psychological state of the individual at the time of the recollection (Harvey and Bryant, 2000; Marshall and Schell, 2002; Southwick et al., 1997). There are a number of prospective studies indicating that peritraumatic dissociation is a strong predictor of PTSD (Ehlers et al., 1998; Koopman et al., 1994; Murray et al., 2002; Shalev et al., 1998; for a review, see a meta-analysis by Ozer et al., 2003). In contrast, however, there is also evidence suggesting that there is not a linear relationship between acute dissociation and longerterm PTSD. A number of prospective studies have found that peritraumatic dissociation did not predict PTSD (Dancu et al., 1996; Marshall and Schell, 2002). It appears that the presence of dissociative responses in the initial period after trauma plays a role in subsequent PTSD development, but the specific nature of this role has yet to be clarified. There are several possible mechanisms that may account for the mixed findings about peritraumatic dissociation and subsequent PTSD. One possibility is that dissociation plays a role in PTSD development in some individuals but not others. Diathesis-stress models of dissociative disorders suggest that only people who possess dissociative tendencies respond to trauma with dissociative reactions (Butler et al., 1996; Kihlstrom et al., 1994). Consistent with this view, Davidson and Foa (1991) suggest that dissociative responses are coping mechanisms that are used by individuals who can utilize these skills. Accordingly, only people who possess dissociative tendencies prior to the traumatic experience will display acute dissociation in response to a trauma (Atchison and McFarlane, 1994). This notion is supported by evidence that higher levels of hypnotizability have been reported in people with ASD


compared to those who report a comparable acute stress reaction but lack dissociative symptoms (Bryant et al., 2001). Although both groups may have a high risk for developing PTSD, only the subset of people who possess dissociative tendencies appear to respond with acute dissociative symptoms. Another possibility is that peritraumatic dissociation is associated with subsequent PTSD because it is associated with other known risk factors for PTSD development. For example, there is a documented relationship between a history of childhood trauma and subsequent dissociation tendencies (Spiegel and Cardenã, 1991). Moreover, childhood trauma is a known risk factor for adult PTSD. Accordingly, it is possible that peritraumatic dissociation may be linked to PTSD because of its association with childhood trauma (Keane et al., 2001). This view suggests that our understanding of the role of dissociation in PTSD development will be enhanced by including childhood trauma, prior dissociation, and peritraumatic dissociation in mathematical models that recognize the relative influences of pre-trauma, peritraumatic, and post-trauma factors (Keane et al., 2001). Another potential role of dissociation is its association with hyperarousal in the acute phase after trauma exposure. Peritraumatic dissociation may be a consequence of the elevated arousal that occurs during trauma. Indirect support for this proposal comes from evidence that dissociative phenomena (e.g., flashbacks) occur in PTSD-affected individuals with yohimbine-induced arousal (Southwick et al., 1993). Further, dissociative reactions are commonly reported during panic attacks (Krystal et al., 1991). Panic attacks are very common during trauma, with more than half of trauma survivors experiencing panic attacks during the trauma itself (Bryant and Panasetis, 2001; Resnick et al., 1994). Moreover, dissociative responses can be induced in recently trauma-exposed individuals with hyperventilation (Nixon and Bryant, 2003). There is also evidence that panic during trauma is associated with ongoing panic in trauma survivors (Nixon and Bryant, 2005, 2006). Further, hyperarousal in the acute phase following trauma has been associated with subsequent PTSD (Shalev, 1992). It is possible that peritraumatic dissociation may be associated with later PTSD because it is linked to hyperarousal, which contributes directly to PTSD development. Another possibility is that appraisals of peritraumatic dissociation, rather than peritraumatic dissociation itself, may influence subsequent PTSD. Cognitive theories of PTSD place much emphasis on the role of appraisals of the trauma and resulting symptoms in the development and maintenance of PTSD (Ehlers and Clark, 2000). There is much evidence that psychopathological responses to trauma are characterized by catastrophic interpretations of events. For example, individuals with ASD exaggerate the probability of future negative events occurring (Smith and Bryant, 2000; Warda and Bryant, 1998). Further, catastrophic appraisals in the initial period after trauma exposure predict subsequent PTSD (Dunmore et al., 2001; Ehlers et al., 1998;

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Engelhard et al., 2002), as do catastrophic attributions of responsibility for a trauma in this period (Andrews et al., 2000; Delahanty et al., 1997). Catastrophic appraisals of peritraumatic dissociation may predict subsequent PTSD more than actual dissociative reactions. For example, a woman who interprets her emotional numbing towards her child as a normal response to an assault may be much less distressed than a woman who interprets emotional numbing as an indication of an uncaring mother.

Is dissociation pathological? The available evidence suggests that not all dissociative responses are pathological. Alterations in awareness appear to occur under many circumstances in which there is increased arousal or perceived threat; many of these dissociative responses do not develop into pathological states. For example, weapon focus studies have found that there are marked alterations in attentional focus towards the narrow source of threat in non-clinical populations; that is, there is reduced awareness of peripheral events during mildly stressful experiences (Kramer et al., 1990; Maas and Kohnken, 1989). Further, novice skydivers display elevated levels of dissociative reactions during their skydive, even though they do not develop subsequently (Sterlini and Bryant, 2002). Some commentators have suggested that dissociation during a trauma may actually be adaptive because it may protect the individual, to some degree, from encoding many distressing features of a traumatic experience (Horowitz, 1986; Noyes and Kletti, 1977). In this sense, dissociation may serve a partially similar function to traumatic brain injury, where trauma survivors may be unconscious throughout much of the trauma and may be spared awareness of many potentially distressing experiences (Bryant et al., 2000a). In this context, it is worth noting that DSM-IV confuses dissociation that occurs at the time of a traumatic experience and those experiences that persist after the trauma has finished. This may be erroneous because whereas peritraumatic dissociation may reflect limited encoding of the traumatic experience, persistent dissociation may reflect cognitive avoidance of material already encoded. In this context, it is worth noting that persistent dissociation is more predictive of ASD (Panasetis and Bryant, 2003) and subsequent PTSD (Briere et al., 2005) than dissociation that only occurs at the time of the traumatic experience.

Assessing acute stress disorder Although there are several measures for ASD, they are hampered by a number of factors. The first measure to be developed was the Stanford Acute Stress


Reaction Questionnaire (SASRQ). The current version of the SASRQ (Cardenã et al., 2000) is a self-report inventory that encompasses each of the ASD symptoms. Each item asks respondents to indicate the frequency of each symptom on a 6-point Likert scale (0 ¼ ‘‘not experienced,’’ 5 ¼ ‘‘very often experienced’’) that can occur during and immediately following a trauma. The SASRQ possesses high internal consistency (Cronbachs alpha ¼ 0.90 and 0.91 for dissociative and anxiety symptoms, respectively) and concurrent validity with scores on the Impact of Event Scale (r ¼ 0.52 0.69; Koopman et al., 1994). The Acute Stress Disorder Interview (ASDI; Bryant et al., 1998a) is based on DSM-IV criteria and possesses good internal consistency (r ¼ 0.90), test-retest reliability (r ¼ 0.88), sensitivity (91%) and specificity (93%) relative to independent clinician diagnosis of ASD. The Acute Stress Disorder Scale (ASDS; Bryant et al., 2000b) is a self-report inventory that is based on the same items described in the ASDI. Each item on the ASDS is scored on a 5-point scale that reflects degrees of severity. Using a formula to identify ASD caseness, the ASDS possesses good sensitivity (95%) and specificity (83%) in relation to diagnoses based on the ASDI. Development of reliable measures of ASD has been hampered by the problems associated with the diagnostic criteria (Bryant and Harvey, 1997). Development of psychometric tools require related measures or constructs to establish concurrent validity or construct validity (Haynes et al., 1995). The absence of any established construct independent of the ASD diagnosis has resulted in measures being constructed in reference to the DSM-IV definition of the disorder. Considering the dubious foundation upon which the ASD diagnosis is based, it has been difficult to establish the construct validity of ASD measures. Assessing ASD is also difficult because the rapidly changing nature of acute stress reactions both defies the requirement for stability and challenges the need to establish the reliability of any measure. Test-retest reliability is difficult to determine because one cannot be sure whether one is testing the reliability of the assessment tool or indexing changing stress reactions at different points after a trauma. These issues underscore the proposal that the ASD diagnosis is a difficult construct to justify because its nature has not been objectively verified.

Treating acute stress disorder Psychological treatments for PTSD symptoms in the initial weeks and months after trauma were mainly adapted from cognitive-behavioral therapy (CBT) programs for PTSD (e.g., Foa and Meadows, 1997; Foa and Rothbaum, 1998). Much as in the case of psychological debriefing, early attempts to apply CBT techniques in the first few weeks following rape failed to demonstrate efficacy (Frank et al., 1988; Kilpatrick and Veronen, 1983). Although the patients

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receiving CBT showed substantial improvement in psychological symptoms, the studies did not establish that these changes were greater than those occurring with natural recovery. Furthermore, these studies had methodological problems that made their interpretation difficult. However, more recent studies, including several randomized controlled trials (RCTs), suggest that CBT may be effective in treating PTSD symptoms and thus speeding up recovery in people recently exposed to trauma, and some of the studies have shown that early CBT treatments reduce the risk of long-term PTSD (see reviews by Ehlers and Clark, 2003; Litz et al., 2002). In contrast to the studies of debriefing, the CBT studies have focused on individual treatment. Using a CBT approach, Foa et al. (1995) treated ten female victims of rape or aggravated assault, most within several weeks after the trauma. All met symptomatic, but not duration, criteria for PTSD. The intervention comprised four weekly 2-h sessions that included treatment elements that have figured prominently in subsequent RCTs: education about trauma symptoms, detailed reliving of the traumatic event in memory, real-life exposure to avoided situations associated with the assault, cognitive restructuring designed to modify maladaptive beliefs, and training in relaxation and breathing skills. Ten other assault victims received only repeated assessments. Unfortunately, victims were not randomly assigned to the treatment versus assessment-only conditions. The treatment Foa et al. (1995) provided proceeded as follows. During the first session, the therapist educated the patient about typical acute responses to trauma, and assembled a list of objectively safe situations and activities that the patient had been avoiding since the assault. During the second session, the therapist furnished a rationale for exposure therapy, emphasizing that many symptoms continue to occur because the patient has not adequately processed the trauma. After teaching the patient deep muscle relaxation and controlled breathing skills, the therapist asked the patient to close her eyes and describe the assault in the present tense as if it were happening again (imaginal exposure). As the patient repeatedly relived the traumatic event, the therapist took note if she expressed any cognitive distortions regarding the excessive dangerousness of the world or her own perceived incompetence. Both the relaxation procedure and the imaginal reliving were audiotaped, and the patient was instructed to listen to the tapes as homework practice. The patient was also encouraged to confront avoided situations and activities (exposure in vivo). Finally, the therapist initiated a discussion of the irrational beliefs expressed by the patient during the imaginal reliving. The third session began with 45 min of imaginal exposure followed by further cognitive therapy designed to correct distorted beliefs. Chief targets included the patient’s beliefs about the unpredictability, uncontrollability, and dangerousness of the world, as well as any extremely negative beliefs she expressed about herself. The therapist helped the patient to identify these problematic beliefs, and the


patient’s homework was to address negative thinking in everyday life. The fourth session included imaginal exposure, cognitive restructuring, and a review of skills mastered by the patient in the program. In addition to the pretreatment assessment, Foa et al. (1995) administered assessments at 2 months and 5.5 months post-assault. At 2 months, fewer treated than untreated patients met criteria for PTSD (10% vs. 70%). Relative to untreated patients, treated patients reported significantly fewer re-experiencing and arousal (but not avoidance) symptoms of PTSD. However, both groups continued to improve, and at the 5.5-month assessment, the untreated and treated patients did not differ significantly on measures of PTSD. This pilot study suggests that CBT may accelerate natural recovery from trauma. Encouraged by these findings, Foa et al. (2006) conducted an RCT involving survivors of physical or sexual assault who met symptomatic criteria for PTSD in the initial weeks after the event (range: 2–46 days; mean: 21 days). Patients were randomly assigned to receive four weekly 2-h sessions of CBT (n ¼ 31), repeated assessment (n ¼ 30), or supportive counseling (n ¼ 29). The third group was added 1 year into the study. Unlike in the previous study, patients in the repeated-assessment condition improved just as much as did those in the CBT condition (Foa et al., 2006). Among those patients who completed the study, at post-treatment (i.e., when treatment ended) the proportion of CBT-treated patients who had PTSD was 45%, whereas the proportion of repeated-assessment patients who had the disorder was 55% – a non-significant difference. The supportive-counseling group had similar PTSD rates at post-treatment (52%), but reported greater PTSD severity and greater general anxiety than the CBT group. Thus, there was some evidence that CBT led to greater improvements in the severity of symptoms than did supportive counseling. Follow-up assessments, conducted about 9.5 months later, did not alter the picture (Foa et al., 2006). There were no differences among the groups in the proportion of patients who still had PTSD (CBT, 32%; repeated assessment, 30%; supportive counseling, 29%). The positive outcome of the assessment group is noteworthy, although it is not clear why this study and the previous one (Foa et al., 1995) had different patterns of results for the assessment-only groups. The assessment conditions in the studies differed somewhat in that patients in the Foa et al. (2006) study received longer clinical assessments (whose durations matched those of the other treatment conditions) than patients in the assessment condition in the Foa et al. (1995) study. The pattern of results from these studies raises several possibilities: (1) it is conceivable that detailed assessments with an empathic clinician have a positive impact on recovery; (2) for unknown reasons, the sample of the Foa et al. (2006) study may have been less responsive to CBT than the sample of the early study; (3) early supportive counseling may impede rather than promote recovery from trauma.

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While Foa’s group in Philadelphia was testing methods for treating post-trauma symptoms soon after the event, Bryant and his colleagues were doing likewise in Sydney, Australia. The chief difference between the two research programs is that Foa targeted trauma survivors meeting symptomatic criteria for PTSD, whereas Bryant targeted those who met criteria for ASD. Thus, in the Australian studies, only patients who showed significant dissociative symptoms in addition to their PTSD symptoms were included. In their first study, Bryant’s group randomly assigned survivors of industrial or motor vehicle accidents to either CBT (n ¼ 12) or supportive counseling (n ¼ 12; Bryant et al., 1998b). All patients met criteria for ASD, and treatment commenced within 2 weeks of the accident. Both interventions consisted of five weekly 1.5-h sessions of individual therapy. Cognitivebehavioral therapy included education about common post-traumatic reactions, progressive muscle relaxation training, imaginal exposure to the traumatic memory, cognitive restructuring of distorted trauma-related beliefs, and graduated in vivo exposure to avoided situations. Supportive counseling included education about post-traumatic reactions plus training in general problem-solving skills within the context of an unconditionally supportive therapeutic relationship. Post-treatment assessment occurred approximately 42 days after the pre-treatment assessment, and the follow-up assessment occurred approximately 6 months post-trauma. At posttreatment, significantly fewer CBT-treated patients (8%) than counseled patients (83%) met criteria for PTSD. This difference remained at follow-up (17% vs. 67%). At both time points, patients in the CBT group also reported significantly fewer intrusive, avoidance, and depressive symptoms relative to patients in the counseling group. In their second study, Bryant et al. (1999) randomly assigned survivors of motor vehicle accidents or non-sexual assault to five weekly 1.5-h sessions of (1) combined exposure therapy, cognitive therapy, and anxiety management (n ¼ 15); (2) combined exposure therapy, cognitive therapy, and supportive counseling (n ¼ 14); or (3) supportive counseling (n ¼ 16). All patients met (or nearly met) criteria for ASD, and treatment began within 2 weeks of the trauma. At the end of treatment, fewer patients who had received CBT (exposure, cognitive therapy, and anxiety-management group, 20%; exposure, cognitive therapy, and supportive-counseling group, 14%) than who had received supportive counseling only (56%) met criteria for PTSD. Likewise, at 6 months post-trauma, the percentages meeting criteria for PTSD were 23%, 15%, and 67% in the three groups, respectively. The two groups receiving exposure therapy plus cognitive therapy were indistinguishable on various outcome measures. These results indicate that a combination of prolonged imaginal and in vivo exposure with cognitive therapy is more effective in preventing PTSD than is supportive counseling. Anxiety management does not enhance these preventive effects. Because as many as 80% of persons with ASD later


develop PTSD (Harvey and Bryant, 1998b; Murray et al., 2002), the results suggest that supportive counseling may have some preventive power. However, some prospective studies have indicated that the percentage of ASD patients who later develop PTSD may be as low as 30% (Creamer et al., 2004), so it is also possible that supportive counseling impeded natural recovery. The lack of an assessment-only control condition makes it impossible to conclude what effect supportive counseling had, if any. Another limitation of this study is that several patients (not included among those whose results we have reported) dropped out of each of the treatments. The dropouts had significantly more severe ASD than those who completed the trial. A 4-year follow-up study of ASD patients who had received either CBT or supportive counseling (Bryant et al., 1998, 1999) revealed that CBT patients maintained most of their gains and that they were still doing better than patients who had received supportive counseling (Bryant et al., 2003a). Additional studies from Bryant’s group demonstrated encouraging results for five to six sessions of CBT with ASD patients. In one study, civilian trauma survivors (n ¼ 89) were randomly assigned to receive CBT, CBT plus hypnosis, or supportive counseling (Bryant et al., 2005). Hypnosis was added to CBT in one group because some scholars believe that hypnosis may be especially helpful for trauma survivors with dissociative symptoms (Spiegel, 1996) and because ASD patients are excellent hypnotic subjects (Bryant et al., 2001). Hypnosis occurred prior to imaginal exposure therapy in an effort to foster emotional processing. Among those completing the RCT, fewer patients in either the CBT (13%) or CBT-plus-hypnosis (9%) condition than in the counseling condition (56%) met criteria for PTSD at post-treatment. At the 6-month follow-up, the numbers were 21%, 22%, and 59%, respectively. At post-treatment, patients in the CBT-plus-hypnosis group reported significantly fewer re-experiencing symptoms than did those in the CBT-alone group. There may be value in adding hypnosis to imaginal exposure. A 3-year follow-up of this study indicated that these treatment gains were maintained (Bryant et al., 2006). Finally, 24 ASD patients who had sustained a mild traumatic brain injury during a motor vehicle accident were randomly assigned to receive five sessions of either CBT or supportive counseling (Bryant et al., 2003b). Acute stress disorder patients who have sustained a mild brain injury are at risk for PTSD despite having lost consciousness during the accident (Bryant and Harvey, 1998). The proportions of patients meeting criteria for PTSD at the 6-month follow-up were 8% in the CBT group and 58% in the counseling group. Thus, loss of consciousness during part of the traumatic event does not impede an ASD patient’s ability to benefit from CBT. Another center used this approach with 152 patients attending emergency rooms and who indicated elevated anxiety, depression, or post-traumatic

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stress within 3 weeks of injury (Bisson et al., 2004). Patients were administered either four 1-h sessions of CBT between 5 and 10 weeks after trauma, or a no-intervention control condition. Independent assessments conducted 13 months later indicated that those in the CBT condition had less post-traumatic stress than those in the no-intervention condition. Another team provided a two-session CBT intervention that was intended to promote memory reconstruction in 17 survivors of accidents (Gidron et al., 2001). This approach was based on the premise that facilitating people’s organization of trauma memories would assist processing of these memories, thereby assisting recovery. Using an entry criterion of a heart rate higher than 94 beats per minute at admission to the emergency room, this study provided a telephone-administered protocol 1–3 days after the accident. Patients who received this intervention had greater reductions in severity of PTSD symptoms 3–4 months after the trauma than did those who received two sessions of supportive listening over the telephone.

Future challenges Although early provision of CBT shows promise for reducing subsequent PTSD, the gains are limited. Across studies, approximately 20% drop out of treatment and 20% do not respond. Intent-to-treat analyses indicate that half of people who require early intervention will use and benefit from it. This raises serious challenges for developing new treatment delivery and content so that more highrisk people can benefit from evidence-based treatments in the acute phase after trauma. In the context of mass violence and large-scale disasters, there is also a need for treatments that can be distributed to many people. This is a difficult challenge when resources are limited (e.g., New York after September 11 attacks or New Orleans after Hurricane Katrina). In these situations, early intervention may not be indicated and there may be a need to allocate limited resources at a later stage during the post-traumatic period. Alternately, using novel approaches to disseminate strategies to those in need may need to be developed. Recent attempts that have used the web to assist implementation of CBT strategies have been suggested, and there is initial evidence to suggest that this approach is helpful in enhancing adaptation when resources are limited (Litz et al., 2004).

REFERENCES Atchison, M., McFarlane, A. C. (1994) A review of dissociation and dissociative disorders. Australian and New Zealand Journal of Psychiatry, 28(4), 591–599. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Publishing.

Chapter 4. ASD and early interventions after trauma Andrews, B., Brewin, C. R., Rose, S., Kirk, M. (2000) Predicting PTSD in victims of violent crime: the role of shame, anger and blame. Journal of Abnormal Psychology, 109, 69–73. Berah, E. F., Jones, H. J., Valent, P. (1984) The experience of a mental health team involved in the early phase of a disaster. Australian and New Zealand Journal of Psychiatry, 18(4), 354–358. Bisson, J. I., Shephard, J. P., Joy, D., Probert, R., Newcombe, R. G. (2004) Early cognitive-behavioural therapy for post-traumatic stress symptoms after physical injury. British Journal of Psychiatry, 184, 63–69. Blanchard, E. B., Hickling, E. J., Barton, K. A., Taylor, A. E., Loos, W. R., JonesAlexander, J. (1996) One-year prospective follow-up of motor vehicle accident victims. Behaviour Research and Therapy, 34, 775–786. Brewin, C. R., Andrews, B., Rose, S., Kirk, M. (1999) Acute stress disorder and posttraumatic stress disorder in victims of violent crime. American Journal of Psychiatry, 156, 360–366. Briere, J., Scolt, C., Weathers, F. (2005) Peritraumatic and persistent dissociation in the presumed etiology of PTSD. American Journal of Psychiatry, 162(12), 2295–2301. Bryant, R. A., Harvey, A. G. (1996) Initial post-traumatic stress responses following motor vehicle accidents. Journal of Traumatic Stress, 9, 223–234. Bryant, R. A., Harvey, A. G. (1997) Acute stress disorder: a critical review of diagnostic issues. Clinical Psychology Review, 17, 757–773. Bryant, R. A., Harvey, A. G. (1998) Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 155, 625–629. Bryant, R. A., Harvey, A. G. (2000) New DSM-IV diagnosis of acute stress disorder. Letter to the Editor. American Journal of Psychiatry, 157, 1889–1890. Bryant, R. A., Panasetis, P. (2001) Panic symptoms during trauma and acute stress disorder. Behaviour Research and Therapy, 39, 961–966. Bryant, R. A., Harvey, A. G., Dang, S., Sackville, T. (1998a) Assessing acute stress disorder: psychometric properties of a structured clinical interview. Psychological Assessment, 10, 215–220. Bryant, R. A., Harvey, A. G., Dang, S. T., Sackville, T., Basten, C. (1998b) Treatment of acute stress disorder: a comparison of cognitive behavior therapy and supportive counseling. Journal of Consulting and Clinical Psychology, 66, 862–866. Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., Guthrie, R. (1999) Treating acute stress disorder: an evaluation of cognitive behavior therapy and counselling techniques. American Journal of Psychiatry, 156, 1780–1786. Bryant, R. A., Harvey, A. G., Guthrie, R., Moulds, M. (2000a) A prospective study of acute psychophysiological arousal, acute stress disorder, and posttraumatic stress disorder. Journal of Abnormal Psychology, 109, 341–344. Bryant, R. A., Moulds, M., Guthrie, R. (2000b) Acute stress disorder scale: a self-report measure of acute stress disorder. Psychological Assessment, 12, 61–68. Bryant, R. A., Guthrie, R. M., Moulds, M. L. (2001) Hypnotizability in acute stress disorder. American Journal of Psychiatry, 158(4), 600–604. Bryant, R. A., Moulds, M. A., Nixon, R. (2003a) Cognitive behaviour therapy of acute stress disorder: a four-year follow-up. Behaviour Research and Therapy, 41, 489–494.

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Chapter 4. ASD and early interventions after trauma Bryant, R. A., Moulds, M. L., Guthrie, R., Nixon, R. D. V. (2003b) Treating acute stress disorder after mild traumatic brain injury. American Journal of Psychiatry, 160(3), 585–587. Bryant, R. A., Moulds, M. L., Guthrie, R. M., Nixon, R. V. (2005) The additive benefit of hypnosis and cognitive behavior therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73, 334–340. Bryant, R. A., Moulds, M. L., Nixon, R. V., Mastrodomenico, J., Felmingham, K., Hopwood, S. (2006) Hypnotherapy and cognitive behaviour therapy of acute stress disorder: a 3-year follow-up. Behaviour Research and Therapy, 44(9), 1331–1335. Butler, L. D. (2000) New DSM-IV diagnosis of acute stress disorder. Letter to the Editor. American Journal of Psychiatry, 157, 1889. Butler, L. D., Duran, R. E., Jasiukaitis, P., Koopman, C., Spiegel, D. (1996) Hypnotizability and traumatic experience: a diathesis-stress model of dissociative symptomatology. American Journal of Psychiatry, 153[7 Suppl], 42–63. Cardenã, E., Spiegel, D. (1993) Dissociative reactions to the San Francisco Bay Area earthquake of 1989. American Journal of Psychiatry, 150, 474–478. Cardenã, E., Classen, C., Spiegel, D. (1991) Stanford Acute Stress Reaction Questionnaire. Stanford, CA: Stanford University Medical School. Cardenã, E., Koopman, C., Classen, C., Waelde, L. C., Spiegel, D. (2000) Psychometric properties of the Stanford Acute Stress Reaction Questionnaire (SASRQ): a valid and reliable measure of acute stress. Journal of Traumatic Stress, 13, 719–734. Classen, C., Koopman, C., Hales, R., Spiegel, D. (1998) Acute stress disorder as a predictor of posttraumatic stress symptoms. American Journal of Psychiatry, 155, 620–624. Creamer, M., Manning, C. (1998) Acute stress disorder following an industrial accident. Australian Psychologist, 33, 125–129. Creamer, M., O’Donnell, M. L., Pattison, P. (2004) The relationship between acute stress disorder and posttraumatic stress disorder in severely injured trauma survivors. Behaviour Research and Therapy, 42(3), 315–328. Dancu, C. V., Riggs, D. S., Hearst-Ikeda, D., Shoyer, B. G., Foa, E. B. (1996) Dissociative experiences and posttraumatic stress disorder among female victims of criminal assault and rape. Journal of Trauma and Stress, 9(2), 253–267. Davidson, J. R., Foa, E. B. (1991) Refining criteria for posttraumatic stress disorder. Hospital and Community Psychiatry, 42(3), 259–261. Delahanty, D. L., Herberman, H. B., Craig, K. J., et al. (1997) Acute and chronic distress and posttraumatic stress disorder as a function of responsibility for serious motor vehicle accidents. Journal of Consulting and Clinical Psychology, 65, 560–567. Difede, J., Ptacek, J. T., Roberts, J. et al. (2002) Acute stress disorder after burn injury: a predictor of posttraumatic stress disorder? Psychosomatic Medicine, 64(5), 826–834. Dunmore, E., Clark, D. M., Ehlers, A. (2001) A prospective investigation of the role of cognitive factors in persistent posttraumatic stress disorder (PTSD) after physical or sexual assault. Behavioral Research and Therapy, 39(9), 1063–1084. Ehlers, A., Clark, D. (2000) A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–345.

Chapter 4. ASD and early interventions after trauma Ehlers, A., Clark, D. M. (2003) Early psychological interventions for adult survivors of trauma: a review. Biological Psychiatry, 53, 817–826. Ehlers, A., Mayou, R. A., Bryant, B. (1998) Psychological predictors of chronic PTSD after motor vehicle accidents. Journal of Abnormal Psychology, 107, 508–519. Engelhard, I. M., van den Hout, M. A., Arntz, A., McNally, R. J. (2002). A longitudinal study of ‘‘intrusion-based reasoning’’ and posttraumatic stress disorder after exposure to a train disaster. Behaviour Research and Therapy, 40 (12), 1415–1424. Feinstein, A. (1989) Posttraumatic stress disorder: a descriptive study supporting DSM III-R criteria. American Journal of Psychiatry, 146, 665–666. Foa, E. B., Meadows, E. A. (1997) Psychosocial treatments for posttraumatic stress disorder: a critical review. Annual Review of Psychology, 48, 449–480. Foa, E. B., Rothbaum, B. O. (1998) Treating the Trauma of Rape: Cognitive-Behavioral Therapy for PTSD. New York: Guilford Press. Foa, E. B., Hearst-Ikeda, D., Perry, K. J. (1995) Evaluation of a brief cognitivebehavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63(6), 948–955. Foa, E. B., Zoellner, L. A., Feeny, N. C. (2006) An evaluation of three brief programs for facilitating recovery after assault. Journal of Traumatic Stress, 19(1), 29–43. Frank, E., Anderson, B., Stewart, B. D., Dancu, C., Hughes, C., West, D. (1988) Immediate and delayed treatment of rape victims. Annals of the New York Academy of Sciences, 528, 269–309. Freinkel, A., Koopman, C., Spiegel, D. (1994) Dissociative symptoms in media witnesses of an execution. American Journal of Psychiatry, 151, 1335–1339. Galea, S., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., Vlahov, D. (2002) Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, 346, 982–987. Galea, S., Vlahov, D., Resnick, H. et al. (2003) Trends of probable post-traumatic stress disorder in New York City after the September 11th terrorist attacks. American Journal of Epidemiology, 158, 514–524. Gidron, Y., Gal, R., Freedman, S. et al. (2001) Translating research findings to PTSD prevention: results of a randomized-controlled pilot study. Journal of Traumatic Stress, 14, 773–780. Green, B. L., Krupnick, J. L., Stockton, P., Goodman, L. (2001) Psychological outcomes associated with traumatic loss in a sample of young women. American Behavioral Scientist, 44, 817–837. Harvey, A. G., Bryant, R. A. (1998a) Relationship of acute stress disorder and posttraumatic stress disorder following motor vehicle accidents. Journal of Consulting and Clinical Psychology, 66, 507–512. Harvey, A. G., Bryant, R. A. (1998b) Acute stress disorder following mild traumatic brain injury. Journal of Nervous and Mental Disease, 186, 333–337. Harvey, A. G., Bryant, R. A. (1999a) Acute stress disorder across trauma populations. Journal of Nervous and Mental Disease, 187, 443–446. Harvey, A. G., Bryant, R. A. (1999b) A two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 985–988.

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Chapter 4. ASD and early interventions after trauma Litz, B. T., Williams, L., Wang, J., Bryant, R. A., Engel, C. C. (2004) The development of an Internet-based program to deliver therapist-assisted self-help behavioral treatment for traumatic stress. Professional Psychology: Science and Practice, 35, 628–634. Maas, A., Kohnken, G. (1989) Eyewitness identification. Law and Human Behavior, 11, 397–408. Madakasira, S., O’Brien, K. F. (1987) Acute posttraumatic stress disorder in victims of a natural disaster. Journal of Nervous and Mental Disease, 175, 286–290. Marmar, C. R., Weiss, D. S., Schlenger, W. E. et al. (1994) Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. American Journal of Psychiatry, 151, 902–907. Marshall, G. N., Schell, T. L. (2002) Reappraising the link between peritraumatic dissociation and PTSD symptoms severity: evidence from a longitudinal study of community violence survivors. Journal of Abnormal Psychiatry, 111(4), 626–636. Marshall, R. D., Spitzer, R., Liebowitz, M. R. (1999) Review and critique of the new DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 156, 1677–1685. Marshall, R. D., Spitzer, R., Liebowitz, M. R. (2000) New DSM-IV diagnosis of acute stress disorder. American Journal of Psychiatry, 157, 1890–1891. McFarlane, A. C. (1986) Posttraumatic morbidity of a disaster. Journal of Nervous and Mental Disease, 174, 4–14. McNally, R. J. (2003) Psychological mechanisms in acute response to trauma. Biological Psychiatry, 53(9), 779–788. Meiser-Studman, R., Yule, W., Smith, P., Glucksman, E., Dalgleish, T. (2005) Acute stress disorder and posttraumatic stress disorder in children and adolescents involved in assaults or motor vehicle accidents. American Journal of Psychiatry, 162, 1381–1383. Murray, J. Ehlers, A., Mayou, R. A. (2002) Dissociation and post-traumatic stress disorder: two prospective studies of road traffic accident survivors. British Journal of Psychiatry, 180, 363–368. Nemiah, J. C. (1989) Janet redivivus: the centenary of l’automatisme psychologique. American Journal of Psychiatry, 146(12), 1527–1529. Nixon, R., Bryant, R. A. (2003) Peritraumatic and persistent panic attacks in acute stress disorder. Behaviour Research and Therapy, 41, 1237–1242. Nixon, R., Bryant, R. A. (2005) Induced arousal and reexperiencing in acute stress disorder. Journal of Anxiety Disorders, 19, 587–594. Nixon, R., Bryant, R. A. (2006) Dissociation in acute stress disorder after a hyperventilation provocation test. Behavioural and Cognitive Psychotherapy, 34, 343–349. North, C. S., Smith, E. M., McCool, R. E., Lightcap, P. E. (1989) Acute postdisaster coping and adjustment. Journal of Traumatic Stress, 2, 353–360. Noyes, R., Kletti, R. (1977) Depersonalizaton in response to life-threatening danger. Comprehensive Psychiatry, 18, 375–384. Noyes, R., Hoenk, P. R., Kuperman, S., Slymen, D. J. (1977) Depersonalization in accident victims and psychiatric patients. Journal of Nervous and Mental Disease, 164, 401–407. Ozer, E. J., Best, S. R., Lipsey, T. L., Weiss, D. S. (2003) Predictors of posttraumatic stress disorder and symptoms in adults: a meta-analysis. Psychological Bulletin, 129(1), 52–73.

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Chapter 4. ASD and early interventions after trauma Panasetis, P., Bryant, R. A. (2003) Peritraumatic versus persistent dissociation in acute stress disorder. Journal of Traumatic Stress, 16 (6), 563–566. Resnick, H. S., Falsetti, S. A., Kilpatrick, D. G. et al. (1994) Association between panic attacks during rape assaults and follow-up PTSD or panic outcomes. Paper presented at the 10th annual meeting of the International Society for Traumatic Stress Studies. Chicago, I11, October 1994. Riggs, D. S., Rothbaum, B. O., Foa, E. B. (1995) A prospective examination of symptoms of posttraumatic stress disorder in victims of non-sexual assault. Journal of Interpersonal Violence, 10, 201–214. Rothbaum, B. O., Foa, E. B., Riggs, D. S., Murdock, T., Walsh, W. (1992) A prospective examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5, 455–475. Schnyder, U., Moergeli, H., Klaghofer, R., Buddeberg, C. (2001) Incidence and prediction of posttraumatic stress disorder symptoms in severely injured accident victims. American Journal of Psychiatry, 158, 594–599. Shalev, A. Y. (1992) Posttraumatic stress disorder among injured survivors of a terrorist attack. Predictive value of early intrusion and avoidance symptoms. Journal of Nervous and Mental Diseases, 180(8), 505–509. Shalev, A. Y., Freedman, S., Peri, T. et al. (1998) Prospective study of posttraumatic stress disorder and depression following trauma. Americal Journal of Psychiatry, 155(5), 630–637. Simeon, D., Guralnik, O. (2000) New DSM-IV diagnosis of acute stress disorder. Letter to the Editor. American Journal of Psychiatry, 157, 1888–1889. Sloan, P. (1988) Post-traumatic stress in survivors of an airplane crash-landing: a clinical and exploratory research intervention. Journal of Traumatic Stress, 1, 211–229. Smith, K., Bryant, R. A. (2000) The generality of cognitive bias in acute stress disorder. Behaviour Research and Therapy, 38, 709–715. Solomon, Z., Kotler, M., Shalev, A., Lin, R. (1989) Delayed onset PTSD among Israeli veterans of the 1982 Lebanon War. Psychiatry, 52(4), 428–436. Solomon, Z., Laor, N., McFarlane, A. C. (1996) Acute posttraumatic reactions in soldiers and civilians (pp. 102–114). In: van der Kolk, B. A., McFarlane, A. C., Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford Press. Southwick, S. M., Krystal, J. H., Morgan, C. A. 3rd et al. (1993) Abnormal noradrenergic function in post-traumatic stress disorder. Archives of General Psychiatry, 50, 266–274. Southwick, S. M., Morgon, C. A. 3rd., Nicolaon, A. L., Charney, D. S. (1997) Consistency of memory for combat-related traumatic events in veterans of Operation Desert Storm American. Journal of Psychiatry, 154(2), 173–177. Spiegel, D. (1996) Dissociative disorders (pp. 583–604). In: Hales, R. E., Yudofsky, S. C. (eds.) Synopsis of Psychiatry. Washington DC: American Psychiatric Press. Spiegel, D., Cardenã, E. (1991) New uses of hypnosis in the treatment of posttraumatic stress disorder. Journal of Clinical Psychiatry, 51 [Suppl], 39–43; discussion 44–46. Spiegel, D., Classen, C., Cardenã, E. (2000) New DSM-IV diagnosis of acute stress disorder. Letter to the Editor. American Journal of Psychiatry, 157, 1890–1891.

Chapter 4. ASD and early interventions after trauma Staab, J. P., Grieger, T. A., Fullerton, C. S., Ursano, R. J. (1996) Acute stress disorder, subsequent posttraumatic stress disorder and depression after a series of typhoons. Anxiety, 2, 219–225. Sterlini, G., Bryant, R. A. (2002) Hyperarousal and dissociation: a study of novice skydivers. Behaviour Research and Therapy, 40, 431–437. van der Kolk, B. A., van der Hart, O. (1989) Pierre Janet and the breakdown of adaptation in psychological data. American Journal of Psychiatry, 146, 1530–1540. Warda, G., Bryant, R. A. (1998) Cognitive bias in acute stress disorder. Behaviour Research and Therapy, 36, 1177–1183. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorder: Diagnostic Criteria for Research, 10th revision. Geneva: World Health Organization.

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The role of pharmacotherapy in early interventions Matthew J. Friedman

There is understandable reluctance to utilize pharmacotherapy during the immediate aftermath of exposure to a traumatic event. Although most people will be distressed during the acute post-impact phase, the great majority will recover during the following weeks. As a result, clinicians are hesitant to ‘‘pathologize’’ such normal reactions to traumatic stress by utilizing medications. It is recognized that a substantial minority of survivors will not recover on their own but will go on to develop a psychiatric disorder such as posttraumatic stress disorder (PTSD), depression, another anxiety disorder, or alcohol/substance misuse. Since PTSD is the most common post-disaster adverse psychiatric consequence, and because what little empirical research that has been published on acute post-traumatic pharmacotherapy has focused on that disorder, I will only discuss early interventions for PTSD. It should be kept in mind, however, that some survivors who never develop PTSD may become symptomatic with a different psychiatric problem. Ideally, there would be a reliable way to identify the minority of survivors who are at greatest risk of developing PTSD following disasters. Such a reliable method for psychiatric triage would support the argument for early pharmacotherapy as prophylaxis, despite the reluctance to prescribe medications, discussed previously. Several prodromal signs and symptoms have been proposed as predictors of post-disaster PTSD such as acute stress disorder (ASD), elevated heart rate, peritraumatic dissociation, or manifestation of PTSD’s A2 criteria (e.g., expression of ‘‘fear, helplessness, or horror’’) (Friedman et al., 2004; Friedman and Karam, in press). At this time, however, the positive predictive value has not been established for any of these suggested indicators so there is currently no accepted screening approach suitable for field work. Even if there were a reliable method by which to differentiate resilient survivors who will recover on their own from vulnerable Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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survivors who are at great risk of developing PTSD (or some other psychiatric disorder), there are few data to guide us with regard to choice of medication for early intervention following exposure to trauma. My approach to this topic is to begin by reviewing the psychobiology of the human stress response in order to delineate the theoretical context within which to consider different pharmacological agents that might prove useful either to prevent the later development of PTSD and/or to ameliorate acute post-traumatic distress. Then I will review the sparse empirical literature that has been published to date. Finally, I’ll suggest a future agenda for research in this area. A truism in disaster mental health is that the best intervention is best preparation. In other words, the more resilience that can be enhanced before disaster strikes, the greater the likelihood that people will recover without psychiatric sequelae. This principle, which has received attention within a military pre-deployment context, should also apply to civilian mental health. Psychobiological strategies that might be expected to enhance resilience have been considered elsewhere (Charney, 2004; Friedman, 2002). They are beyond the scope of the present discussion, which focuses on early interventions with medication to ameliorate post-traumatic reactions and to prevent the later development of PTSD.

Review of the literature: the human stress response Neurocircuitry The presumed circuitry underlying the human stress response focuses on excessive activation of the amygdala by stimuli, perceived to be threatening. Such activation produces outputs to a number of brain areas that mediate memory consolidation of emotional events and spatial learning (hippocampus), memory of emotional events and choice behaviors (orbital frontal cortex), autonomic and fear reactions (locus ceruleus, thalamus, and hypothalamus), and instrumental approach or avoidance behavior (dorsal and ventral striatum) (Davis and Whalen, 2001; Southwick et al., 2007). For resilient individuals, normal allostatic balance will be restored by termination of the acute stress response when the danger has passed. Failure to recover occurs when the restraining influence on the amygdala of the medial prefrontal cortex (PFC), especially the anterior cingulate gyrus and orbitofrontal cortex, is severely disrupted (Charney, 2004; Vermetten and Bremner, 2002). Disinhibition of the amygdala produces a vicious spiral of recurrent fear conditioning in which ambiguous stimuli are more likely to be appraised as threatening; mechanisms for extinguishing such responses are nullified; and key limbic nuclei are sensitized thereby lowering the threshold for fearful


reactivity (Charney, 2004; Charney et al., 1993; Friedman, 1994; Southwick et al., 2007). The pharmacological challenge, therefore, is to identify where and how to intervene in order to rein in the amygdala and the cortical and subcortical effects it has set in motion. We will consider the adrenergic, hypothalamic– pituitary–adrenocortical (HPA), glutamatergic, GABAergic, serotonergic, and dopaminergic systems. Adrenergic mechanisms Animal research indicates that central noradrenergic neurons play an important role in mobilizing the human stress response. All three principle adrenergic receptor systems are involved in the fear conditioning circuitry and consolidation of traumatic memories described previously. (A more thorough review is provided by Southwick et al., 2007.) Beta and alpha-1 post-synaptic adrenergic activity may be related to the intrusive recollections, dissociative flashbacks, and psychological/physiological reactivity provoked by exposure to traumatic stimuli that are usually seen among individuals with PTSD. This post-synaptic noradrenergic input promotes activation of the amygdala. In addition the amygdala’s projections to the locus ceruleus generate extra adrenergic input, thereby resulting in a vicious cycle of adrenergic stimulation. Alpha-2 adrenergic receptors, which provide presynaptic inhibition of amygdala catecholamine release, suppress fear conditioning and reduce consolidation of emotional memories (Davies et al., 2004). They may also play a role in dissociation since the alpha-2 antagonist yohimbine (which disinhibits adrenergic activity) provoked dissociative flashbacks among Vietnam veterans with PTSD (Southwick et al., 1997, 1999). Thus, from the perspective of the amygdala alone, agents that antagonize alpha-1 and beta adrenergic receptors or enhance alpha-2 adrenergic (presynaptic inhibitory) activity might be expected to reduce PTSD symptoms. High levels of catecholamines that enhance amygdala activation impair PFC function, thereby reducing its capacity to inhibit amygdala hyperactivity (Arnsten, 2000). Both alpha-1 and beta receptor activation appear responsible for nullifying PFC activity during uncontrollable stress and these effects can be prevented with alpha-1 adrenergic antagonists such as prazosin (Arnsten and Jenstsch, 1997) as well as with the beta adrenergic antagonist propranolol (Li and Mei, 1994). Therefore, the therapeutic goal of targeting the adrenergic system is to inhibit excessive alpha-1 and beta receptor activation and to augment the inhibitory influence of alpha-2 adrenergic receptors. The result of such treatment would be expected to reduce amygdala activation, enhance PFC function and inhibit stimulation of the locus ceruleus and its secondary activation of other cortical and subcortical structures.

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Neuropeptide Y Neuropeptide Y (NPY) is an amino acid neurotransmitter, co-localized in noradrenergic neurons, which inhibits the release of both noradrenaline and corticotropin-releasing factor (CRF, see below). By virtue of its endogenous antiadrenergic actions, NPY would be expected to produce the antistress/ anxiolytic benefits postulated above for antiadrenergic agents and, thereby, improve cognitive function. Indirect evidence for this assertion has been obtained in studies of military personnel exposed to extreme stress in which there was an inverse relationship between NPY release and stress-induced performance decrements due to dissociation (Morgan et al., 2000, 2001). Clinically, it has been shown that, in comparison with healthy controls, PTSD patients exhibit both reduced baseline NPY levels as well as a blunted release of NPY in response to yohimbine stimulation (Rasmusson et al., 2000). Based on such findings, it has been suggested previously that medications that enhance NPY function might ameliorate acute stress reactions, PTSD, and other stress-induced problems (Friedman, 2002). No pharmacological agents of this nature are currently available. Corticotropin-releasing factor: the neurobiological effects of stress-induced amygdala activation are mediated by CRF As a neurotransmitter it promotes release of noradrenaline from the locus ceruleus, thereby enhancing amygdala and reducing PFC activity as described previously. As a hormone, it activates the HPA system by releasing corticotropin (ACTH) from the pituitary gland, which then promotes the release of cortisol and other glucocorticoids from the adrenal cortex. Vietnam veterans with PTSD have been shown to have elevated resting levels of cerebrospinal fluid CRF (Baker et al., 1999; Bremner et al., 1997b) and enhanced hypothalamic release of CRF (Yehuda, 2002). Given its key role in mobilizing the human stress response as well as its increased expression among PTSD patients, there is good reason to predict that CRF antagonists might have beneficial clinical effects on PTSD-related symptoms. Although CRF antagonists are currently utilized in animal research and are under development by pharmaceutical companies, none is available for clinical use. In animal studies, the CRF receptor antagonist antalarmin has been shown to produce reductions in cerebrospinal fluid CRF, to reduce stress-induced fearful behavior and to suppress both adrenergic and HPA responses to stress (Habib et al., 2000). Glucocorticoids Glucocorticoids, such as cortisol, appear to impair PFC function by enhancing catecholamine levels during activation of the stress response (Arnsten, 2000;


Roozendaal et al., 2004). Although excessive HPA system activity does appear to be associated with trauma exposure and PTSD, there is controversy over how this may be manifested. On the one hand, it may be expressed by elevated cortisol levels, as has been found in some PTSD patients and in children exposed to sexual trauma. On the other hand, it may be expressed by reduced cortisol levels associated with supersensitivity of glucocorticoid receptors (DeBellis et al., 1994; Heim et al., 2001; Lemieux and Coe, 1995; Rasmusson and Friedman, 2002; Rasmusson et al., 2001; Yehuda, 2002; Yehuda et al., 1994). An important reason for considering acute interventions to reduce excessive stress-induced HPA activation is the possibility that abnormal HPA activity may have neurotoxic effects. The proposed mechanism is HPAinduced release of excitatory amino acids which promote calcium influx into susceptible neurons (McEwen et al., 1992; Sapolsky, 2000). From a PTSD perspective, the theory that acute (or chronic) cortisol elevation and/or glucocorticoid receptor supersensitivity is neurotoxic has been invoked to explain the reduced corpus callosum and intracranial volumes observed among traumatized children (DeBellis et al., 2002) and reduced hippocampal and anterior cingulategyrus volumes among adults with PTSD (Bremner et al., 1997a, 2003; Woodward et al., 2006; Yehuda, 1999). Prevention of neurotoxicity might be achieved by rectifying HPA abnormalities with CRF antagonists or glucocorticoids. It might also be achieved with glutamate antagonists, such as certain anticonvulsants which, through blockade of excitatory amino acid actions, protect neurons by preventing toxic calcium influx. Finally, reversal of neurotoxicity might be achieved with treatments that promote neurogenesis. For example the selective serotonin reuptake inhibitor (SSRI) paroxetine has been shown to increase hippocampal volume in PTSD patients (Vermetten et al., 2003). Glutamate Glutamate is the major excitatory neurotransmitter in the brain. It plays a crucial role in the human stress response and probably in the pathophysiology of PTSD. Anticonvulsant agents, also known as mood stabilizers, exert their primary actions on glutamate and/or gamma-aminobutyric acid (GABA) activity (see below). Such actions also have potential importance in ameliorating PTSD symptoms. There are several different types of glutamate receptor. The present focus will be on inotropic receptors, which exert their actions through neuronal receptor ion channels. There are three types of inotropic glutamate receptors named after the agonists to which they are differentially sensitive: N-methyld -aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA), and kainate. During the fear response NMDA receptors in the amygdala activate the fear circuit described previously. N-methyl-d -aspartate antagonists such as certain

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anticonvulsants inhibit such actions (Berlant, 2003; Davis and Whalen, 2001; Paul et al., 1994). In addition to enhancing the startle response and anxious behavior, AMPA receptors mediate long-term potentiation, sensitization, and kindling of brain neurons, which is an important neurobiological model of PTSD (Post et al., 1995, 1999; Walker and Davis, 2002). Kainate receptors appear to promote fear and anxiety through actions in the periaqueductal gray and frontal cortex, where they promote reduction of benzodiazepine (e.g., GABAergic) sites. N-methyl-d-aspartate receptors are crucial for all forms of learning, including fear conditioning (Bardgett et al., 2003; Liang et al., 1994; Nakazawa et al., 2002) and extinction (Davis, 2002; Falls et al., 1992; van der Meulen et al., 2003). They also play a major role in neurogenesis, the production of new neurons (Gould et al., 1997; Nacher et al., 2003; Okuyama et al., 2004). The AMPA receptors may also promote neurogenesis through activation of brain-derived neurotropic factor (BDNF; Mackowiak et al., 2002). An important model of dissociation involves the interplay of NMDA and AMPA receptors. It is based on the observation that NMDA receptor antagonists such as ketamine or phencyclidine can produce dissociative symptoms such as slowed time perception, alterations in body perceptions, and derealization. The model proposes that NMDA blockade intensifies glutamate stimulation of AMPA receptors (Chambers et al., 1999; Krystal et al., 1995). It is noteworthy that the dissociative effects of ketamine are blocked by lamotrigine, an anticonvulsant that inhibits glutamate release (Anand et al., 2000). Thus, the centrality of glutamatergic actions in amygdala activation has strong empirical support from laboratory research. It suggests that anticonvulsants/mood stabilizers that antagonize glutamate activity might be useful for acute post-traumatic pharmacotherapy. Gamma-aminobutyric acid Gamma-aminobutyric acid is the brain’s major inhibitory neurotransmitter. It suppresses stress-induced actions of the amygdala. The GABA receptors within the basolateral amygdala inhibit glutamatergic excitation. Furthermore, serotonin enhances this GABAergic suppression of the amygdala (Berlant, 2003; Stutzmann and LeDoux, 1999), which is a major mechanism through which serotoninergic agents ameliorate both the acute stress response and PTSD symptomatology. Post-traumatic stress disorder patients exhibit both reduced GABA plasma levels (Vaiva et al., 2000) and reduced benzodiazepine receptor activity in the amygdala, PFC, and other brain areas (Bremner et al., 2000). Since benzodiazepine receptors are part of the GABA–receptor complex, these findings suggest that deficiencies in GABAergic mechanisms in the amygdala, PFC, and elsewhere result in insufficient protection against the activating effects of


noradrenaline and glutamate. It is possible that intrusive recollections, hyperarousal symptoms, and disinhibited social and emotional behavior observed among PTSD patients may be due to such deficient GABAergic function (Morgan et al., 2003). It should be noted in this regard that pre-treating animals later exposed to inescapable shock with benzodiazepines blocks stressinduced increases in noradrenaline in the amygdala, cortex, locus ceruleus, hypothalamus, and hippocampus (Drugan et al., 1984; Grant et al., 1980). This suggests that benzodiazepines or anticonvulsants/mood stabilizers that potentiate GABAergic mechanisms might be useful agents for acute posttraumatic pharmacotherapy. The serotonin system The serotonergic system has important interactions with the adrenergic, HPA, glutamate, GABA, and dopamine systems. There also appear to be synergistic interactions between 5-hydroxytryptamine (5HT) and GABA receptors with regard to acute stress and PTSD. It is thought that stimulation of 5HT-1 receptors in the amygdala potentiates GABAergic neurons, which, in turn, antagonize the excitatory glutamate neurotransmission that mediates stress-related amygdala activation (Charney, 2004; Vermetten and Bremner, 2002). This model suggests three potential amygdala-based target sites for pharmacological intervention: antagonism of glutamate, potentiation of GABA, and enhancement of serotonin neurotransmission. As with NMDA receptors, serotonin 5HT-1 receptors also promote neurogenesis in the hippocampus. It has been shown that SSRIs, as well as all clinically effective antidepressants, promote neurogenesis through activation of BDNF and cyclic adenosine monophosphate (cAMP) (Duman et al., 2001). This obviously has important implications for prevention of neurogenesis and reversal of neurotoxicity, as discussed previously. Clinical studies have long indicated that many symptoms observed among PTSD patients are associated with serotonin deficiency, such as impulsivity, suicidal behavior, rage, aggression, depression, panic, obsessional thoughts, and chemical dependency (Friedman, 1990). Furthermore, since the serotoninergic 5HT-2 agonist m-chlorophenylpiperazine (mCPP) can provoke panic reactions and dissociative flashbacks in PTSD but not control subjects (Southwick et al., 1997), there is reason to presume that serotonin 5HT-2 antagonists might be clinically useful in this regard. Given the many different types of serotonin receptors, a review of the basic science literature suggests that effective early pharmacotherapeutic intervention might be achieved with agents that activate 5HT-1-A receptors such as SSRIs, venlafaxine, tricyclic antidepressants or monoamine oxidase inhibitors. In addition, it suggests that medications that also block 5HT-2 receptors, such as nefazodone or trazodone, might also be useful.

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The dopaminergic system During uncontrollable stress, amygdala activation produces PFC dopamine release (Charney, 2004). There is evidence that dopamine (D-1) receptor agonists can produce stress-induced PFC impairments in working memory (Zahrt et al., 1997) and that both D-1 and D-2 receptor antagonists can prevent such cognitive deficits (Arnsten, 2000; Druzin et al., 2000). Excessive dopamine release may have a role in PTSD hyperarousal, hypervigilence and possibly in provoking the brief hypervigilent/paranoid/ psychotic states sometimes observed among PTSD patients. It is surprising how little PTSD research has focused on dopamine in comparison with neurotransmitters discussed previously. Elevated urinary and plasma dopamine concentrations have been found among PTSD subjects (Hamner and Diamond, 1993; Lemieux and Coe, 1995; Yehuda et al., 1994). These findings suggest that administration of dopamine antagonists, such as atypical or conventional antipsychotic agents, might ameliorate acute posttraumatic reactions and prevent the later development of PTSD.

Evidence from clinical trials Considering all that has been learned about the psychobiology of the human stress response, one might expect that such knowledge has been translated into clinical trials of pharmacological agents known to act at key receptor sites identified previously. Unfortunately, this has occurred quite rarely. Only a few medications have been tested rigorously, mostly in small clinical trials. Positive or promising results have rarely been replicated. Given the challenges inherent in any randomized clinical trial, recognizing that such challenges are magnified in the acute post-disaster setting, and acknowledging that biases against utilizing medications under such circumstances constitute additional obstacles against conducting such research, it is unfortunate that we know so little about the potential of pharmacotherapy as an acute post-traumatic intervention. In 1993, within the military context of the Persian Gulf War, we reported that there were no published articles testing acute pharmacotherapy for survivors of traumatic events (Friedman et al., 1993). Based on what was known from animal and human research at that time, we recommended that antiadrenergic agents and benzodiazepines be used for hyperarousal, anxiety, and panic; that benzodiazepines be used for insomnia; and that haloperidol be prescribed for severe agitation. (Atypical antipsychotic agents were not available at that time.) We also speculated that SSRIs might be useful for individuals in whom avoidant/numbing symptoms were prominent. Since that time, there have been a total of ten reports: three on acute administration


of the beta-adrenergic antagonist propranolol, one on the tricyclic antidepressant imipramine, two on acute treatment with benzodiazepines, one on the atypical antipsychotic risperidone, and three on the glucocorticoid hydrocortisone. Propranolol Pitman and Delahanty (2005) have argued that the beta-adrenergic antagonist propranolol was ‘‘the most promising candidate drug for intervening in the aftermath of a traumatic event to block potentiation of the consolidation of its memory trace by stress hormones’’ through blockade of beta receptors in the basolateral nucleus of the amygdala (Pitman and Delahanty, 2005, p. 102). Antiadrenergic agents are also an attractive choice because of evidence from prospective studies that acute post-traumatic heart rate elevation (as an indicator of heightened systemic arousal) predicts the later development of PTSD (Shalev et al., 1998). In a randomized clinical trial, he and coworkers (Pitman et al., 2002) administered oral propranolol (40 mg) or placebo four times daily to 41 patients who had come to the emergency room immediately after a traumatic event. Eligible patients had to meet PTSD diagnostic criteria and have a pulse rate 80 beats per minute (BPM). Patients received 10 days of treatment followed by a 9-day taper. They were evaluated 1 and 3 months after the initial emergency room visit. Although propranolol pharmacotherapy did not prevent the later development of PTSD, it did significantly reduce physiological reactivity to script-driven imagery among patients who had received the adrenergic antagonist. Considering the low statistical power to detect differences between groups in this small study, these results are promising. A larger replication study is currently in progress. Another report also suggests that acute propranolol treatment may have prophylactic benefits. Vaiva and associates conducted an open label trial in which French motor vehicle accident survivors who had visited the emergency room within 20 hours of the accident and whose heart rate was 90 BPM were offered propranolol (30 mg) three times a day for 7 days followed by an 8- to 12-day taper period. Eleven patients agreed to the propranolol trial while eight did not. There were no baseline differences between the two groups. Two months after the initial visit, patients who had been treated with propranolol had significantly fewer PTSD symptoms than those who had refused treatment (Vaiva et al., 2003). Finally, there is a single case report with a middle-aged woman who had previously experienced PTSD after each of her prior motor vehicle accidents. Propranolol, administered within 48 hours of her most recent accident, reduced the emergence of PTSD symptoms (Taylor and Cahill, 2002). Obviously more research is needed with propranolol and other antiadrenergic agents such as clonidine, guanfacine, and prazosin. It is encouraging,

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however, that the results in these three reports are consistent with what would have been predicted theoretically. Hydrocortisone As stated previously, cortisol levels among chronic PTSD patients have been found to be elevated, unchanged, and reduced. Among acutely traumatized individuals in whom cortisol was assessed shortly after their motor vehicle accidents, lower cortisol levels predicted later PTSD (Delahanty et al., 2000; McFarlane et al., 1997). Pitman and Delahanty (2005) suggest that since cortisol reduces recall of traumatic memories and suppresses sympathetic nervous system arousal, reduced cortisol may have potentiated the development of traumatic memories and permitted excessive release of adrenergic neurotransmitters during the acute post-accident phase. It follows that glucocorticoid administration might protect against the later development of PTSD. One report and two randomized clinical trials are consistent with this prediction. First, Schelling et al. (1999) published a retrospective case–control report indicating that hydrocortisone treatment (100-mg intravenous bolus followed by 0.18 mg/kg per hour administration) protected intensive care unit (ICU) patients exhibiting septic shock from the later development of PTSD. Based on this finding, these investigators (Schelling et al., 2004) next conducted a randomized clinical trial in which 9 ICU patients with septic shock received the same hydrocortisone dosage regimen while 11 patients received placebo. Subsequent assessment 31 months after discharge from the ICU showed that only 1 of the hydrocortisone patients developed PTSD whereas 7 of the 11 placebo patients met diagnostic criteria for the disorder. Interpretation of these results is confounded, however, because placebo patients were more likely to receive higher doses of noradrenaline to sustain their blood pressure (Pitman and Delahanty, 2005). Finally, Schelling et al. (2004) conducted a similar prospective study with patients recovering from cardiac surgery: 26 patients were randomized to receive hydrocortisone while 22 received treatment as usual. The glucocorticoid dose was a 100-mg bolus and the hydrocortisone dose was tapered from continuous infusion at 10 mg/hour on post-operative day 4. Again the hydrocortisone recipients exhibited significantly fewer PTSD symptoms when evaluated 6 months after cardiac surgery. As with the propranolol studies, the hydrocortisone findings are promising. Understanding the site of action for acute glucocorticoid administration, however, is less clear than with propranolol. Pitman and Delahanty (2005) suggest that this effect might be due to reduced recall of traumatic memories or suppression of noradrenaline release. A third possibility is inhibition of CRF release, and a fourth is that acute


hydrocortisone treatment prevents the development of glucocorticoid receptor supersensitivity. None of these four proposed mechanisms is mutually exclusive and all involve key target sites that mediate the human stress response. Imipramine Imipramine is a tricyclic antidepressant that blocks presynaptic reuptake of both serotonin and noradrenaline. Serotonin enhancement appears to correct a functional deficiency of 5HT mechanisms associated with affective and most anxiety disorders. Blockade of adrenergic reuptake (which is also effective for panic disorder) probably exerts its therapeutic action through enhancement of (presynaptic inhibitory) alpha-2 receptors and/or through downregulation of post-synaptic beta receptors. In either case, the end result is a reduction in adrenergic activity in the amygdala, PFC, and locus ceruleus. The only prospective randomized controlled trial with tricyclics compared imipramine (100 mg at bedtime) with the hypnotic chloral hydrate (500 mg at bedtime), among hospitalized pediatric burn patients with ASD. Results showed that imipramine treatment was significantly superior in reducing ASD symptoms among hospitalized child and adolescent burn victims (Robert et al., 1999). Unfortunately, these investigators did not carry out a long-term follow-up to assess how effectively this treatment prevented the later development of PTSD. These findings certainly indicate the need for additional studies with tricyclic antidepressants designed with longer-term follow-up assessment intervals. Atypical antipsychotic medications There is one small retrospective report about administration of the atypical antipsychotic agent risperidone to ten men and women hospitalized on a burn unit. Their average length of stay was 19.5 days, the average total body surface burned was 14%, and the average number of days from admission to treatment was 5.8 days. Atypical antipsychotics have two actions, D-2 receptor blockade (which they share with conventional antipsychotics) as well as a unique 5HT-2 receptor antagonism. The ten patients received a bedtime dose of 0.5–2 mg risperidone. After 2 days of treatment, all patients reported improved sleep, diminished intensity of traumatic recollections, reduced severity/complete relief of nightmares and flashbacks, and reduced hyperarousal symptoms. This improvement was maintained through the hospitalization. Six patients stopped the medication by the time of discharge without recurrence of PTSD symptoms. Two others stopped risperidone 2 weeks after discharge (Stanovic et al., 2001). As the authors state, these promising results suggest the need for a prospective randomized clinical trial with a larger sample size to test the

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effectiveness of risperidone administration during the acute post-traumatic aftermath. Benzodiazepines One might expect that acute treatment with benzodiazepines, which act at GABA-A receptors, might ameliorate PTSD symptoms. This has not been the case. Treatment of recently traumatized emergency room patients with clonazepam (Gelpin et al., 1996) or the hypnotic benzodiazepine temazepam (Mellman et al., 2002) did not prevent the later development of PTSD. These results suggest that acute benzodiazepine-mediated activation of GABA receptors is not sufficient to prevent the later development of PTSD. This is somewhat surprising in view of GABA’s capacity to suppress glutamatergic excitation in the basolateral amygdala (see above). One potential explanation for this finding is that benzodiazepines may blunt cortical function and, thereby, also interfere with the cognitive processing of traumatic material that is considered essential for normal recovery during the acute post-traumatic period (Ehlers and Clark, 2003). Perhaps anticonvulsant agents that potentiate GABA function will prove more effective than benzodiazepines.

Treatment of acute stress responses: general principles I have argued previously (Friedman, 2002) that individuals most likely to develop PTSD are: (1) those who produce excessive HPA and/or adrenergic activation; (2) those who are unable to achieve normal recovery because of blunted glucocorticoid, NPY and/or opioid mobilization; or (3) a combination of both factors. I have already described how CRF mediates activation of HPA, adrenergic, and other systems during acute reactions to traumatic exposure. Evidence for inadequate countermeasures to shut off the stress response is less robust but includes reduced glucocorticoid levels (Yehuda, 1999), blunted NPY levels (Morgan et al., 2000; Rasmusson et al., 2000), and reduced opioid levels (Baker et al., 1997) among individuals with PTSD. Therefore, future pharmacological treatment for acutely traumatized individuals will seek to reduce the magnitude of the stress response and to promote rapid recovery of normal function. This might be accomplished in the following ways: (1) by reducing CRF activity with CRF antagonists, NPY agonists or opioid agents; (2) by reducing HPA activation with glucocorticoids (such as cortisol or hydrocortisone) with an adrenal steroid such as dehydroepiandosterone (DHEA); or (3) by reducing adrenergic activation with NPY agonists and/or a variety of antiadrenergic agents (such as clonidine/guanfacine, propranolol or prazosin).


Rapid antagonism of CRF would seem to be the most direct approach since it would reduce enhanced HPA, adrenergic, immunological, and secondary stress responses. Such clinical trials will have to wait for the development of safe CRF antagonists or NPY agonists that can be tested in humans. Rapid reduction of post-traumatic HPA activation with cortisol (hydrocortisone, or other glucocorticoids) might prevent the subsequent development of PTSD by reducing noradrenaline release, reducing recall of traumatic memories, reducing CRF activation or inhibiting the sensitization of glucocorticoid receptors as discussed previously. Rapid antagonism of adrenergic excitation with NPY agonists or antiadrenergic agents might not only prevent elevations in heart rate shown to predict PTSD (Bryant et al., 2000; Shalev et al., 1998) but would also be expected to prevent adrenergically mediated encoding of traumatic memories (Cahill, 1999). Enhanced serotoninergic activity (with SSRIs or other agents) and reduced dopaminergic excitation might also prove beneficial in the future.

Final thoughts As more psychobiological research is carried out with acutely traumatized individuals, other pharmacological strategies will undoubtedly become apparent. Among those of greatest theoretical interest are anticonvulsant/ antikindling agents that exert their effects through inhibition of glutamatergic agents, potentiation of GABAergic agents, or both. We understand a great deal about the psychobiology of the human stress response. Many safe agents with known actions are waiting to be tested. Other new medications such as CRF antagonists and NPY agonists need to be made available. There is a great opportunity to identify effective medications for acute post-traumatic interventions. This should be a high priority for future research.

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Chapter 5. Pharmacotherapy in early interventions Baker, D. G., West, S. A., Orth, D. N., et al. (1997) Cerebrospinal fluid and plasma b-endorphin in combat veterans with posttraumatic stress disorder. Psychoneuroendocrinology, 22, 517–529. Baker, D. G., West, S. A., Nicholson, W. E. et al. (1999) Serial CSF corticotropinreleasing hormone levels and adrenocortical activity in combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 156, 585–588. Bardgett, M. E., Boeckman, R., Krochmal, D., Fernando, H., Ahrens, R., Csernansky, J. G. (2003) NMDA receptor blockade and hippocampal neuronal loss impair fear conditioning and position habit reversal in C 57BI/6 mice. Brain Research Bulletin, 60, 131–142. Berlant, J. L. (2003) Antiepileptic treatment of posttraumatic stress disorder. Primary Psychiatry, 10, 41–49. Bremner, J. D., Randall, P. K., Vermetten, E., et al. (1997a) Magnetic resonance imaging-based measurement of hippocampal volume in posttraumatic stress disorder related to childhood physical and sexual abuse: a preliminary report. Biological Psychiatry, 41, 23–32. Bremner, J. D., Licinio, J., Darnell, A. et al. (1997b) Elevated CSF corticotropinreleasing factor concentrations in posttraumatic stress disorder. American Journal of Psychiatry, 154, 624–629. Bremner, J. D., Innis, R. B., Southwick, S. M., Staib, L., Zoghbi, S., Charney, D. S. (2000) Decreased benzodiazepine receptor binding in prefrontal cortex in combat related posttraumatic stress disorder. American Journal of Psychiatry, 157, 1120–1126. Bremner, J. D., Vythilingam, M.,Vermetten, E. et al. (2003) MRI and PET study of deficits in hippocampal structure and function in women with childhood sexual abuse and posttraumatic stress disorder. American Journal of Psychiatry, 160, 924–932. Bryant, R. A., Harvey, A. G., Guthrie, R. M., Moulds, M. L. (2000) A prospective study of psychophysiological arousal, acute stress disorder and posttraumatic stress disorder. Journal of Abnormal Psychology, 109, 341–344. Cahill, L. (1999) A neurobiological perspective on emotionally influenced, long-term memory. Seminars in Clinical Neuropsychiatry, 4, 266–273. Chambers, R. A., Bremner, J. D., Moghaddam, B., Southwick, S., Charney, D. S., Krystal, J. H. (1999) Glutamate and PTSD: toward a psychobiology of dissociation. Seminars in Clinical Neuropsychiatry, 4, 274–281. Charney, D. S. (2004) Psychobiological mechanisms of resilience and vulnerability: implications for the successful adaptation to extreme stress. American Journal of Psychiatry, 161, 195–216. Charney, D. S., Deutch, A. Y., Krystal, J. H., Southwick, S. M., Davis, M. (1993) Psychobiologic mechanisms of posttraumatic stress disorder. Archives of General Psychiatry, 50, 295–305. Davis, M. (2002) Role of NMDA receptors and MAP kinase in the amygdala in extinction of fear: clinical implications for exposure therapy. European Journal of Neuroscience, 16, 395–398. Davis, M., Whalen, P. J. (2001) The amygdala: vigilance and emotion. Molecular Psychiatry, 1, 13–34.

Chapter 5. Pharmacotherapy in early interventions Davies, M. F., Tsui, J., Flannery, J. A., Li, X. C., DeLorey, T. M., Hoffman, B. B. (2004) Activation of alpha2 adrenergic receptors suppresses fear conditioning: expression of c-Fos and phosphorylated CREB in mouse amygdala. Neuropsychopharmacology, 29, 229–239. DeBellis, M. D., Chrousos, G. P., Dorn, L. D. et al. (1994) Hypothalamic–pituitary– adrenal axis dysregulation in sexually abused girls. Journal of Clinical Endocrinology and Metabolism, 78, 249–255. DeBellis, M. D., Keshaven, M. S., Shiflett, H. et al. (2002) Brain structure in pediatric maltreatment-related posttraumatic stress disorder: a sociodemographically matched study. Biological Psychiatry, 52, 1066–1078. Delahanty, D. L., Raimonde, A. J., Spoonster, E. (2000) Initial posttraumatic urinary cortisol levels predict subsequent PTSD symptoms in motor vehicle accident victims. Biological Psychiatry, 48, 940–947. Drugan, R. C., Ryan, S. M., Minor, T. R., Maier, S. F. (1984) Librium prevents the analgesia and shuttlebox escape deficit typically observed following inescapable shock. Pharmacology, Biochemistry, and Behavior, 21, 749–754. Druzin, M. Y., Kurzina, N. P., Malinina, E. P., Kozlov, A. P. (2000) The effects of local application of D2 selective dopaminergic drugs into the medial prefrontal cortex of rats in a delayed spatial choice task. Behavioral Brain Research, 109(1), 99–111. Duman, R. S., Nakagawa, S., Malberg, J. (2001) Regulation of adult neurogenesis by antidepressant treatment. Neuropsychopharmacology, 25, 836–844. Ehlers, A., Clark, D. M. (2003) Early psychological interventions for adult survivors of trauma: a review. Biological Psychiatry, 53, 817–826. Falls, W. A., Miserendino, M. J., Davis, M. (1992) Extinction of fear-potentiated startle: blockage by infusion of an NMDA antagonist into the amygdala. Journal of Neuroscience, 12, 854–863. Friedman, M. J., (1990) Interrelationships between biological mechanisms and pharmacotherapy of posttraumatic stress disorder (pp. 204–225). In: Wolfe, M. E., Mosnaim, A. D. (eds.) Posttraumatic Stress Disorder: Etiology, Phenomenology, and Treatment, first edition. Washington, DC: American Psychiatry Press. Friedman, M. J. (1994) Neurobiological sensitization models of post-traumatic stress disorder: their possible relevance to multiple chemical sensitivity syndrome. Toxicology and Industrial Health, 10, 449–462. Friedman, M. J. (2002) Future pharmacotherapy for PTSD: prevention and treatment. Psychiatry Clinics of North America, 25, 1–15. Friedman, M. J., Karam, E. G. (in press) PTSD: looking toward DSM-V and ICD-11. In: Andrews, G., Charney, D., Sirovatka, P., Regier, D. (eds.) Stress-Related Fear Circuitry Disorders: Refining the Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association. Friedman, M. J., Charney, D. S., Southwick, S. M. (1993) Pharmacotherapy for recently evacuated military casualties. Military Medicine, 158, 492–497. Friedman, M. J., Hamblen, J. L., Foa, E. B., Charney, D. S. (2004) Fighting the psychological war on terrorism. Psychiatry, 67, 123–136. Gelpin, E., Bonne, O., Peri, T., Brandes, D., Shalev, A. Y. (1996) Treatment of recent trauma survivors with benzodiazepines: a prospective study. Journal of Clinical Psychiatry, 57, 390–394.

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Chapter 5. Pharmacotherapy in early interventions Gould, E., McEwen, B. S., Tanapat, P., Galea, L. A. M., Fuchs, E. (1997) Neurogenesis in the dentate gyrus of the adult tree shrew is regulated by psychosocial stress and NMDA receptor activation. Journal of Neuroscience, 17, 2492–2498. Grant, S. J., Huang, Y. H., Redmond, D. E. (1980) Benzodiazepines attenuate single unit activity in the locus coeruleus. Life Science, 27, 2231. Habib, K. E., Weld, K. P., Rice, K. C. et al. (2000) Oral administration of a corticotropin-releasing hormone receptor antagonist significantly attenuates behavioral, neuroendocrine, and autonomic responses to stress in primates. Proceedings of the National Academy of Sciences of the USA, 97, 6079–6084. Hamner, M. B., Diamond, B. I. (1993) Elevated plasma dopamine in posttraumatic stress disorders: a preliminary report. Biological Psychiatry, 33, 304–306. Heim, C., Newport, J. D., Bonsall, R., Miller, A. H., Nemeroff, C. B. (2001) Altered pituitary-adrenal axis responses to provocative challenge tests in adult survivors of childhood abuse. American Journal of Psychiatry, 158, 575–581. Krystal, J., Bennett, A. L., Bremner, J. D., Southwick, S. M., Charney, D. S. (1995) Toward a cognitive neuroscience of dissociation and altered memory functions in post-traumatic stress disorder (pp. 239–269). In: Friedman, M. J., Charney, D. S., Deutch, A. Y. (eds.) Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to Post-Traumatic Stress Disorder. Philadelphia, PA, LippincottRaven. Lemieux, A. M., Coe, C. L. (1995) Abuse-related posttraumatic stress disorder: evidence for chronic neuroendocrine activation in women. Psychosomatic Medicine, 57, 105–115. Li, B.-M., Mei, Z.-T. (1994) Delayed response deficit induced by local injection of the alpha-2 adrenergic antagonist yohimbine into the dorsolateral prefrontal cortex in young adult monkeys. Behavioral and Neural Biology, 62, 134–139. Liang, K. C., Hon, W., Davis, M. (1994) Pre- and posttraining infusion of N-methyld -aspartate receptor antagonists into the amygdala impair memory in an inhibitory avoidance task. Behavioral Neuroscience, 108, 241–253. Mackowiak, M., O’Neill, M. J., Hicks, C. A., Bleakman, D., Skolnick, P. (2002) An AMPA receptor potentiator modulates hippocampal expression of BDNF: an in vivo study. Neuropharmacology, 43, 1–10. McEwen, B. S., Angulo, J., Cameron, H. et al. (1992) Paradoxical effects of adrenal steroids on the brain: protection versus degeneration. Biological Psychiatry, 31, 177–199. McFarlane, A. C., Atchison, M., Yehuda, R. (1997) The acute stress response following motor vehicle accidents and its relation to PTSD. In: Yehuda, R., McFarlane, A. C. (eds.) Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821, 437–441. Mellman, T. A., Bustamante, V., David, D., Fins, A. I. (2002) Hypnotic medication in the aftermath of trauma [letter]. Journal of Clinical Psychiatry, 63, 1183–1184. Morgan, C. A., Wang, S., Mason, J. et al. (2000) Hormone profiles in humans experiencing military survival training. Biological Psychiatry, 47, 891–901. Morgan, C. A. III, Wang, S., Rasmusson, A., Hazlett, G., Anderson, G., Charney, D. S. (2001) Relationship among cortisol, catecholamines, neuropeptide-Y and human performance during exposure to uncontrollable stress. Psychosomatic Medicine, 63, 412–422.

Chapter 5. Pharmacotherapy in early interventions Morgan, C. A. III, Krystal, J. H., Southwick, S. M. (2003) Toward early pharmacological posttraumatic stress intervention. Biological Psychiatry, 53(9), 834–843. Nacher, J., Alonso-Llosa, G., Rosell, D. R., McEwen, B. S. (2003) NMDA receptor antagonist treatment increases the production of new neurons in the aged rat hippocampus. Neurobiology of Aging, 24, 273–284. Nakazawa, K., Quirk, M. C., Chitwood, R. A. et al. (2002) Requirement for hippocampal CA3 NMDA receptors in associative memory recall. Science, 297, 211–218. Okuyama, N., Takagi, N., Kawai, T., Miyake-Takagi, K., Takeo, S. (2004) Phosphorylation of extracellular-regulating kinase in NMDA receptor antagonistinduced newly generated neurons in the adult rat dentate gyrus. Journal of Neurochemistry, 88, 717–724. Paul, I. A., Nowak, G., Layer, R. T., Popik, P., Skolnick P. (1994) Adaptation of the N-methyl-d -aspartate receptor complex following chronic antidepressant treatments. Journal of Pharmacological and Experimental Therapeutics, 1, 95–102. Pitman, R. K., Delahanty, D. L. (2005) Conceptually driven pharmacologic approaches to acute trauma. CNS Spectrums, 10, 99–106. Pitman, R. K., Sanders, K. M., Zusman, R. M. et al. (2002) Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biological Psychiatry, 51, 189–192. Post, R. M., Weiss, S. R. B., Smith, M. A. (1995) Sensitization and kindling: implications for the evolving neural substrate of PTSD (pp. 135–147). In: Friedman, M. J., Charney, D. S. Deutch, A. Y. (eds.) Neurobiological and Clinical Consequences of Stress: From Normal Adaptation to Post-Traumatic Stress Disorder. Philadelphia, PA: Lippincott-Raven. Post, R. M., Weiss, S. R. B., Li, H. et al. (1999) Sensitization components of posttraumatic stress disorder; implications for therapeutics. Seminars in Clinical Neuropsychiatry, 4, 282–294. Rasmusson, A. M., Friedman, M. J. (2002) The neurobiology of PTSD in women (pp. 43–75). In: Kimerling, R., Ouimette, P. C., Wolfe, J. (eds.) Gender and PTSD. New York: Guilford Press. Rasmusson, A. M., Hauger, R. L., Morgan, C. A. III., Bremner, J. D., Southwick, S. M., Charney, D. S. (2000) Low baseline and yohimbine stimulated plasma neuropeptide Y (NPY) levels in combat-related PTSD. Biological Psychiatry, 47, 526–539. Rasmusson, A. M., Lipschitz, D. S., Wang, S., et al. (2001) Increased pituitary and adrenal reactivity in premenopausal women with PTSD. Biological Psychiatry, 50, 965–977. Robert, R., Blakeney, P. E., Villarreal, C., Rosenberg, L., Meyer, W. J. 3rd (1999) Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 873–882. Roozendaal, B., McReynolds, J. R., McGaugh, J. L. (2004) The basolateral amygdala interacts with the medial prefrontal cortex in regulating glucocorticoid effects on working memory impairment. Journal of Neuroscience, 24(6), 1385–1392. Sapolsky, R. M. (2000) Glucocorticoids and hippocampal atrophy in neuropsychiatric disorders. Archives of General Psychiatry, 57, 925–935.

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Chapter 5. Pharmacotherapy in early interventions Schelling, G., Stoll, C., Kapfhammer, H. P. et al. (1999) The effect of stress doses of hydrocortisone during septic shock on posttraumatic stress disorder and healthrelated quality of life in survivors. Critical Care Medicine, 27, 2678–2683. Schelling, G., Kilger, E., Roozendaal, B. et al. (2004) Stress doses of hydrocortisone, traumatic memories, and symptoms of posttraumatic stress disorder in patients after cardiac surgery: a randomized study. Journal of Biological Psychiatry, 55, 627–633. Shalev, A. Y., Sahart, T., Freedman, S. et al. (1998) A prospective study of heart rate response following trauma and the subsequent development of posttraumatic stress disorder. Archives of General Psychiatry, 55, 553–559. Southwick, S. M., Krystal, J. H., Bremner, J. D. et al. (1997) Noradrenergic and serotonergic function in posttraumatic stress disorder. Archives of General Psychiatry, 54, 749–758. Southwick, S. M., Paige, S. R., Morgan, C. A., Bremner, J. D., Krystal, J. H., Charney, D. S. (1999) Adrenergic and serotonergic abnormalities in PTSD: catecholamines and serotonin. Seminars in Clinical Neuropsychiatry, 4, 242–248. Southwick, S. M., Davis, L. L., Aikins, D. E. et al. (2007) Neurobiological alterations associated with PTSD (pp. 166–189). In Friedman, M. J., Keane, T. M., Resick, P. A. (eds.) Handbook of PTSD: Science and Practice. New York, Guilford Press. Stanovic, J. K., James, K. A., VanDevere, C. A. (2001) The effectiveness of risperidone on acute stress symptoms in adult burn patients: a preliminary retrospective pilot study. Journal of Burn Care and Rehabilitation, 22, 210–213. Stutzmann, G. E., LeDoux, J. E. (1999) GABAergic antagonists block the inhibitory effects of serotonin in the lateral amygdala: a mechanism for modulation of sensory inputs related to fear conditioning. Journal of Neuroscience, 11, RC8. Taylor, F. B., Cahill, L. (2002) Propranolol for reemergent posttraumatic stress disorder following an event of retraumatization: a case study. Journal of Traumatic Stress, 15, 433–437. Vaiva, G., Boss, V., Addesa, G., et al. (2000) Low GABA levels and posttraumatic stress disorder. International Society for Traumatic Stress Studies, San Antonio, TX, November 17, 2000. Vaiva, G., Ducrocq, F., Jezequel, K., et al. (2003) Immediate treatment with propranolol decreases posttraumatic stress disorder two months after trauma. Biological Psychiatry, 54, 947–949. van der Meulen, J. A., Bilbija, L., Joosten, R. N., de Bruin, J. P., Feenstra, M. G. (2003) The NMDA-receptor antagonist MK-801 selectively disrupts reversal learning in rats. Neuroreport, 14, 2225–2228. Vermetten, E., Bremner, J. D. (2002) Circuits and systems in stress. II. Applications to neurobiology and treatment in posttraumatic stress disorder. Depression and Anxiety, 16, 14–38. Vermetten, E., Vythilingam, M., Southwick, S. M., Charney, D. S., Bremner, J. D. (2003) Long-term treatment with paroxetine increases verbal declarative memory and hippocampal volume in posttraumatic stress disorder. Biological Psychiatry, 54, 693–702. Walker, D. L., Davis, M. (2002) The role of amygdala glutamate receptors in fear learning, fear-potentiated startle, and extinction. Pharmacology, Biochemistry, and Behavior, 3, 379–392.

Chapter 5. Pharmacotherapy in early interventions Woodward, S. H., Kaloupek, D. G., Streeter, C. C., Martinez, C., Schaer, M., Eliez, S. (2006) Decreased anterior cingulate volume in combat-related PTSD. Biological Psychiatry, 59, 582–587. Yehuda, R. (1999) Linking the neuroendocrinology of post-traumatic stress disorder with recent neuroanatomic findings. Seminars in Clinical Neuropsychiatry, 4, 256–265. Yehuda, R. (2002) Current status of cortisol findings in post-traumatic stress disorder. Psychiatric Clinics of North America, 2, 341–368. Yehuda, R., Giller, E. L., Southwick, S. M. et al. (1994) Relationship between catecholamine excretion and PTSD symptoms in Vietnam combat veterans and holocaust survivors (pp. 203–220). In: Murburg, M. M. (ed.) Catecholamine Function in Post-Traumatic Stress Disorder: Emerging Concepts. Washington, DC: American Psychiatric Press. Zahrt, J., Taylor, J. R., Mathew, R. G., Arnsten, A. F. (1997) Supranormal stimulation of D1 dopamine receptors in the rodent prefrontal cortex impairs spatial working memory performance. Journal of Neuroscience, 17(21), 8528–8535.

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Should culture considerations influence early intervention? Carl C. Bell

Introduction The question ‘‘Should culture considerations influence early intervention?’’ is not easy to answer because behavior is multidetermined and complex. Thus, this question has multiple different answers. One answer is ‘‘Of course culture considerations should influence early intervention.’’ Clearly, a therapist who only speaks English attempting to effect an early intervention with individuals or a population that only speaks Spanish is not going to have an efficacious and effective outcome. A different answer is ‘‘What difference should culture make if a therapist is doing generic early intervention activities?’’ If a population is starving to death, what difference does it make if the food they get is not culturally familiar to them as long as they eat? Accordingly, sometimes the answer to the question ‘‘Should culture considerations influence early intervention?’’ is ‘‘yes’’ and sometimes it is ‘‘no.’’ This chapter seeks to clarify that the answer is neither ‘‘yes’’ nor ‘‘no’’ but ‘‘both/and.’’ Unfortunately, there is a real dearth of research on cultural, racial and ethnic issues (US Department of Health and Human Services, 2001), and even less research on generic and culturally specific early intervention strategies. Further, political polarities cloud the issue of cultural relevance, thus there is very little honest direction to guide the field in this regard.

Diversity within America – it is not a melting pot To begin this conversation we raise the question of the importance or unimportance of culture. Raising the issue of culture immediately causes race Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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and ethnicity to come to mind, and these topics frequently cause audiences to become anxious, defensive, and very rigid in their perspectives. ‘Race constitutes a stubbornly resistant malady in the United States because of ‘‘the color line’’ – a visible (and invisible) barrier that separates whites from nonwhites’ Pulera (2002, p. 3). Pulera (2002) also credits the fact that the relations between groups within the United States are ‘‘remarkably amicable’’ within the context of being the planet’s most racially and ethnically heterogeneous society. Multiculturalism has replaced the Black/White biracial paradigm that dominated American life from 1789 to 1954. We now live in a society where buzz words such as ‘‘cultural sensitivity,’’ ‘‘multiculturalism,’’ and ‘‘cultural diversity’’ abound. The reality is only a few of us live in the new multicultural America, as most of us segregate in houses of worship, neighborhoods, dating habits, schools, restaurants, and entertainment venues. Sadly Americans from other cultures do not always feel welcomed, considered, hopeful, valued, and respected in the United States due to the phenomenon of ‘‘monocultural ethnocentrism’’ (Sue and Sue, 1999).

Monocultural ethnocentrism and generic versus cultural specifics The ‘‘monocultural ethnocentrism’’ of white culture makes it difficult to appreciate cultural differences between the cultural, racial, and ethnic groups. This aspect of white culture also makes it difficult to appreciate diversity within racial groups. To quote George Clinton of the Funkadelics, ‘‘You don’t drink what I drink; You don’t smoke what I smoke; You don’t think like I think; You don’t joke like I joke. I got a thing, you got a thing, everybody’s got a thing’’ (Clinton, 1971; Westbound Records, Southfield, Michigan). Everybody has a ‘‘thing,’’ and a culturally sensitive intervention would respect that ‘‘thing’’ and honor, instead of denigrate, it (Bell, 2005). To be culturally sensitive, an intervention must have content that is welcoming to the target culture. It must contain issues of relevance to the culture and not be offensive. And it must be familiar and endorsed by the target culture. However, if a given intervention has generic principles of health behavior change, i.e., if aspects of the intervention has elements that create social fabric, generate connectedness, help develop social skills, build self-esteem, facilitate some social monitoring, and help to minimize trauma (Bell et al., 2002), that intervention can usually be retro-fitted for cultural sensitivity with a little work (Bhana et al., 2004; Paruk et al., 2005; Petersen et al., 2006). Using the generic principles of health behavior change as a theoretical guide, a culture can be examined for manifestations of these principles and they can be expressed in culturally sensitive ways appropriate to the target culture. For example, if going on a spirit quest builds self-esteem


in Native American culture, the strategy for building self-esteem in Native Americans might be best served by a spirit quest exercise – rather than by building a soccer team (Bell, 2005). Cultural specifics might need to be supplemented to make the intervention culturally specific so that the generic principles of health behavior change are fully embraced. In the USA, research is done ‘‘on’’ specific cultures, but a lack of interventions exists based on research ‘‘for’’ those cultures. This is because the principles of what makes something culturally sensitive are not being followed. To move from the ‘‘on’’ to the ‘‘for’’ scenario, content and processes are needed that include stakeholders from the target cultures as full partners (Bell, 2005). Such a scenario tends to be threatening to research and service providers, as most are from white bastions of power. Until the balance of power shifts, the available interventions are unlikely to support everybody’s ‘‘thing.’’ After all, many say ‘‘This is America, join in, fit in, and love it or leave it.’’ Judith Herman (1992) noted the generic principles for recovery of trauma and loss involved the reconstruction of meaning, the rebuilding of hope, and the sense of empowerment needed to regain control over one being and life. However, ‘‘the imposition of Western, decontextualized views marginalizes local voices and cultural traditions, disempowers communities, and limits healing’’ (Nader et al., 1999).

Issues of culture, race and ethnicity The literature on the issue of how culture, race, and ethnicity should be considered when attempting early psychological intervention following mass trauma is scant. Early on Kleinman (1977) noted that culture influences the vulnerability and resistance to mental illness along with the expression of symptoms. Further, ‘‘factors associated with ethnicity and culture strongly influence individuals’ vulnerability and resilience; determine their coping styles, cognitive response to stress, and the nature of social support; shape their psychopathology, their experiencing of distress, and their clustering of symptoms; and influence the course and outcome of psychiatric conditions’’ (Charney et al., 2002). Culture, race and ethnicity also influence the before, during, and after response to disasters and to clinical encounters that occur as a result of disasters. Shalev (2006) noted that there are two pathogenic mechanisms in disaster survivors – the first being the psychobiological changes and the second being the learning and adaptation that can lead to resolution or prolonged stress; if the method of intervention or the interventionist is hostile toward a disaster victim’s culture, the outcome may be less than optimal. ‘‘Cultural factors may also impose barriers to developing a therapeutic relationship, since many non-Western cultures do not value traditional western psychiatric interventions (American Psychiatric Association, 2004, p. 10).

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Various authors have provided frameworks for how to consider culture in the equation of responding to psychiatric issues. For example, Bernal et al. (1995) provide a framework for culturally sensitive interventions that consists of eight dimensions of treatment including: language, persons, metaphors, content, concepts, goals, methods, and context. Thus, they provide a culturally sensitive perspective to treatment outcome research as a resource to augment the ecological validity of treatment research. These authors also explore the relationships between external validity, ecological validity, and culturally sensitive research. Dr David Satcher (16th US Surgeon General) has a model for cultural competence (CRASH): C – Consider culture R – Respect for culture A – Assess the culture of the patient; affirm the patient’s culture S – Self-awareness of your own culture; sensitivity to the other’s culture H – Humility, as you will never be an expert in a culture different from your own. Many clinicians understand that social and cultural dynamics are an important consideration in treating patients with acute stress distress (ASD) and post-traumatic stress disorder (PTSD) (American Psychiatric Association, 2004). Accordingly, it makes sense that understanding should be a consideration for the early psychological intervention following mass trauma as well. Such considerations would suggest that approaches for early intervention should not alienate mass trauma victims from their families and communities. Early intervention should be knowledgeable and respectful of the cultural context, the cultural meaning of symptoms or illness, and the cultural values of the victims and their family. Intervention should recognize that the development of illness, resistance, or resiliency may depend on the ‘‘cultural context.’’ The perception that non-white Katrina victims were left ‘‘low and wet’’ instead of ‘‘high and dry’’ may help explain different aspects of how these populations will respond to early intervention. Clinicians must be sensitive to the idea that such societal views may also shape treatment response.

Specific factors to consider when considering early psychological interventions for different cultural, racial and ethnic groups following mass trauma Lack of appropriate recognition and assessment of race-based traumatic stress Carter (2007) has advocated giving thoughtful consideration to how racism can generate psychological and emotional injury. Further he has advocated


for developing better concepts and tools for recognizing and assessing racebased traumatic stress. He asserts that one of the major assessment problems affecting people of color is the lack of understanding of racism’s impact on their mental health and the emotional, psychological, and, potentially, physical effects of racism on the victims. This systemic lack of consideration for race-based traumatic stress by the mental health community is a major source of cultural insensitivity toward various non-white cultural, racial, and ethnic groups. Non-white cultural, racial, and ethnic groups may have a higher than average likelihood of being exposed to traumatic events Studies showing the association between race/ethnicity and psychological health status following exposure to stressful events are mixed, but most show that non-white cultural, racial, and ethnic groups show higher rates of PTSD than white groups. One exception is Adams and Boscarino (2005), who found no post-disaster racial/ethnic difference for the development of PTSD a year after the September 11 attack in New York between Latinos, Blacks, and Whites. However, this same research group found that Blacks were less likely to use post-disaster medications than Whites (Boscarino et al., 2005). In contrast, Perilla et al. (2002) found that Whites had the lowest rates (15%), Blacks had rates of 23% and Latinos had the highest rates (38%) of PTSD in response to the impact of hurricane Andrew in Florida. These authors noted the difference was not explained by ‘‘dose exposure’’ or different vulnerabilities to trauma, but suggest that different protective factors may be at work in different populations and such protective factors are based on political, social, economic, and historical contexts of different cultural, racial, and ethnic groups. Clearly, protective factors are found in black women, who have the lowest rates of suicide in the United States (Barnes and Bell, 2003). Galea et al. (2005) interviewed 988 residents of New York City following the September 11 terrorist attacks and discovered that approximately 14% of Latinos (Dominican and Puerto Rican Latinos) met criteria for current PTSD as compared with 9.3% of non-latino Black respondents and 6.5% of nonlatino White respondents. Their hypothesis was that this discrepancy was driven by socioeconomic position, event exposures, social support, and exposure to trauma prior to the attack. Marshall and Orlando (2002) looked at the relationship between acculturation and traumatic stress reactions in Latinos victimized by community violence and found that more acculturated Latinos had lower levels of traumatic symptoms. Yet, Vega et al. (1998) note that Mexican immigrants have lower prevalence rates of affective, anxiety or substance abuse disorders than American-born Mexican-Americans, suggesting that Mexican-American immigrants to the United States, although quite impoverished, enjoy excellent mental health. In this study, immigrants’

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culture was interpreted as protecting them against the impact of poverty. Pole et al. (2005) found elevated PTSD symptoms among Latinos and proposed that this was due to greater peritraumatic dissociation, greater wishful thinking and self-blame coping, lower social support, and greater perceived racism. Higher rates of previous exposure to violence In the literature we find the likelihood of being exposed to traumatic events, as well as the likelihood of receiving a lifetime diagnosis of PTSD, differs by cultural, racial, and ethnic group (Kessler et al., 1995). There are reported high rates of exposure to violence among Blacks, Native Americans, and Alaska Natives, compared to members of more economically advantaged groups (Jenkins and Bell, 1997; US Department of Health and Human Services, 2001). For example, in one study, Jenkins and Bell (1994) learned that nearly two-thirds of Chicago inner-city, high-school black youth reported seeing a shooting, and 45% reported they had seen someone killed. Two similar sister studies of grammar school children in Washington DC (Martinez and Richters, 1993; Richters and Martinez, 1993) and New Orleans (Osofsky et al., 1993) found that 31% reported seeing a shooting and 17% had seen a stabbing and one-third reported seeing a shooting, stabbing or rape, respectively. In another study, 82% of native Americans and Alaska natives had been exposed to one traumatic event, and the prevalence of PTSD was 22% (Kessler et al., 1995). Native Americans have also been reported to have a rate of violent victimization that is more than twice the national average and rates of PTSD among native Americans and Alaska natives are threefold that of the general population (Greenfeld and Smith, 1999). An investigation of Northern Plains Indian youths in grades 8 through 11 found that 61% had been exposed to some kind of traumatic event (Jones et al., 1997). A study of a Southwestern American Indian community found even higher rates of experience of one or more traumatic events but also noted a higher prevalence of lifetime PTSD in this community (Robin et al., 1997). This heightened risk for some members of some racial and ethnic groups to have a greater likelihood of being exposed to traumatic events is partly due to their lower socioeconomic status and inner-city residence. Such conditions are associated with an increased likelihood of experiencing undesirable life events (McLeod and Kessler, 1990). Higher rates of PTSD in veterans The literature also notes racial differences in rates of PTSD among US veterans. The National Vietnam Veterans Readjustment Study found that while 85% of US soldiers were White and only 10% were Black, more black


(21%) than white (14%) veterans experienced PTSD (Kulka et al., 1990). In the Native American Vietnam Veterans Project random samples of Vietnam combat veterans found approximately one-third of the Northern Plains (31%) and Southwestern (27%) Native American Veterans had PTSD (Beals et al., 2002) and that this rate was far greater than in the black or white veterans in the National Vietnam Veterans Readjustment Study (Kulka et al., 1990). Latinos also have been found to be at higher risk for war-related PTSD than white counterparts (Kulka et al., 1990). Because the risk for Latinos was higher than that for black veterans, non-white status must not be the only risk factor (Ruef et al., 2000). Puerto Rican veterans have been found to have a higher probability of experiencing PTSD than Latino subgroups with similar levels of war zone stressor exposure (Ortega and Rosenheck, 2000). As these prevalence differences were not explained by exposure to stressors or acculturation, and because veterans retained levels of functioning, expressive style rather than different levels of illness is hypothesized as causing the difference (Ruef et al., 2000). It appears that the increased rates of PTSD seen in Blacks, Latinos, and Native American/Alaska Natives is driven by both an increased likelihood of traumatic early experiences (Bremner et al., 1993; Greenfeld and Smith, 1999; Jenkins and Bell, 1997; US Department of Health and Human Services, 2001) and greater war zone exposure, as members of some cultural, racial, and ethnic groups were more likely to be US combat veterans (Beals et al., 2002; Fairbank et al., 2001; Matsunaga Vietnam Veterans Project, 1996; Ruef et al., 2000). Immigrants and refugees Non-white cultural, racial, and ethnic groups may also be refugees who have higher rates of exposure to trauma. For example, de Jong et al. (2001) found a prevalence rate of PTSD of 37.4% in Algeria, 28.4% in Cambodia, 15.8% in Ethiopia, and 17.8% in Gaza. Up to 70% of refugees from Vietnam, Cambodia, and Laos met the diagnostic criteria for PTSD, in contrast to prevalence rates of about 4% for the US population as a whole (Kinzie et al., 1989). Hispanic immigrants and refugees A study of adult Latino primary care patients in Los Angeles found that 54% experienced political violence before migration, and, of these, 18% had symptoms of PTSD (Eisenman et al., 2003). Although they are not recognized as political refugees, Central American immigrants to the United States may be at risk for PTSD as a result of their pre-immigration exposure to warrelated trauma (Farias, 1994; US Department of Health and Human Services, 2001). One-half of the Central American participants in a study of Los Angeles adults reported symptoms that were consistent with a diagnosis of PTSD (Cervantes et al., 1989). In another study, 60% of adult Central

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American refugee patients received a diagnosis of PTSD (Michultka et al., 1998). Central American immigrant children have also been found to have high rates of PTSD (33%) (Arroyo and Eth, 1984). Southeast Asian refugees Patient studies of Southeast Asian refugees find high rates of PTSD. Kinzie et al. (1990) found that 70% of the subjects had PTSD, with the Mien from Laos and Cambodians having the highest rates. Kinzie et al. (1989) also found that nearly one-half of a sample of Cambodian adolescents who survived Pol Pot’s concentration camps as children had PTSD. Kroll et al. (1989) found that 73% of Southeast Asian refugees (Cambodian, Hmong, Laotian, and Vietnamese) had major depression, 14% had PTSD, and 6% had anxiety or somatoform disorders. A non-patient, random community sample of Cambodian adults studied for risk factors PTSD found that 45% had PTSD, and a total of 81% had five or more symptoms of PTSD (Blair, 2000). In a similar study on risk factors in parents, samples from Cambodian refugees in Massachusetts found that 43% reported the death of one to six of their children (Caspi et al., 1998). Finally, a large community sample of Southeast Asian refugees found that pre-immigration and refugee camp experiences were significant risk factors predictive of psychological distress (Chung and Kagawa-Singer, 1993) and significant subgroup differences were found. Thus, many Southeast Asian refugees are at risk for PTSD associated with the events they experienced before they immigrated to the United States (US Department of Health and Human Services, 2001). Blacks As most Blacks in the United States are the ancestors of slaves and are not immigrants or refugees, Blacks have experienced significantly high levels of racism which is an abuse of human rights that is identical to, supplementary to, and complimentary to torture and terrorism. Torture is the deliberate, systematic infliction of physical and mental suffering for the purpose of forcing people to conform. Terrorism is actual or threatened violence to gain attention causing people to exaggerate the strength of the terrorists and the importance of their cause. Racism, torture, and terrorism all require the victim to be dehumanized and degraded (Pierce, 1995). In examining oppressed/oppressor relationships one finds that it is critical for the oppressor to monopolize the perception of the victim. One is victimized in proportion to the quality of space, time, energy, and mobility that one must yield or has yielded to the oppressor. Conversely, the more one regains or commands control of these elements the less one is victimized. Blacks are subjected to daily minute insults and aggressions. Known as microinsults and microaggressions, these offensive mechanisms are designed to operationally keep Blacks in the inferior, dependent, helpless role. These mechanisms are


non-verbal and kinetic, and they are well suited to control space, time, energy, and mobility of a black person while at the same time producing feelings of degradation (Bell, 1996; Pierce, 1988). Living in a system of oppressed/ oppressor relationships it should not be any surprise to anyone that Blacks have very different perspectives of traumatic events compared to Whites. Thus, the National Trauma Survey (NTS) (National Organization for Research at the University of Chicago, 2001) found that Blacks have lower general and domain-specific national pride than Whites. For example, the NTS found 68% of Blacks and 81% of Whites were very proud of the military, 44% of Whites and 27% of Blacks had a great deal of confidence in Congress, and 78% of Whites and 69% of Blacks had a great deal of confidence in the military. This study also pointed out that following the terrorist attack 46% of Whites and only 15% of Blacks felt that people are trustworthy and 67% of Whites and 46% of Blacks felt that people are fair. Before the terrorist attacks, Blacks viewed the world and human nature more negatively than whites, and afterwards the racial difference in terms of human nature remained. Further, while Blacks were less likely than Whites to see the world as showing God’s goodness in 2000 (53% and 60%, respectively), this reversed in the 2001 NTS, with 62% of Whites and 67% of Blacks seeing God’s goodness in the world. A brief catalog of Black experiences with terrorism is given in Table 6.1. Thus Vernon E. Jordan, Jr. was quoted at Howard University (2002) as saying ‘‘ . . . the difference between September 11 and the terror visited upon black people is that on September 11, the terrorists were foreigners. But when we were terrorized, it was by our neighbors. The terrorists were American citizens.’’ For a pictorial on lynching see Without Sanctuary: Lynching Photography in America (Allen et al., 2004). Native Americans Similarly, Native Americans are not immigrants or refugees, but have fought terrorism, genocide, and the invasion of their land since 1492, and thus have a legacy of historical trauma in their own country (US Health and Human Services, 2001). The intense terror of being native in an American society that condemns and attacks anyone who is different contrasts sharply with the circle-based native cultures that achieved a sense of healthiness and wholeness (Derrick, 2005). Bury My Heart at Wounded Knee (Brown, 2001) and Trail of Tears (Jahoda, 1995) are excellent histories of Native American genocide and struggle. Culture may be protective Culture may be protective and may contain supportive systems of beliefs, values, mores, rituals, roles, lifestyles, and knowledge that may buffer some of the effects of traumatic events (Bell, 2001; de Vries, 1996). The appropriate

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Chapter 6. Early intervention – culture considerations Table 6.1. Black experiences with terrorism within the US Date

Event

1863

Opposition to Civil War conscription in New York results in 1000 casualties, including lynching Blacks White workers in East St. Louis riot fears of black economic and social advances leading to 48 deaths and hundreds injured White Chicagoan fears of the expansion of black neighborhoods into white areas cause more than 20 deaths, 365 injuries, and 1,000 homeless The ‘‘Little Africa’’ section of Tulsa, Oklahoma was bombed and burned killing 150–200 black men, women and children Rosewood, Fla massacre killed eight Blacks and destroyed the town Murder of Baxter Bell in White Bluff, Tennessee Detroit white supremacists concerned about rapid growth in black populations leads to 25 deaths and 700 injuries Murder of George and Mae Dorsey and Roger and Dorothy Malcom in Walton Country, Ga. Murder of Robert Mallard in Lyons, Ga. Murder of Emmett Till in Money, Miss. Murder of Mack Charles Parker in Poplarvillle, Miss. Murder of Roman Ducksworth, Jr. in Taylorville, Miss. Medgar W. Evers assassinated Church bombing of four little girls in Sunday School in Birmingham, Ala. Murder of Charles Moore and Henry Dee in Meadville, Miss. Assassination of Martin Lurther King, Jr. James Byrd, Jr. dragged to death behind a pick-up truck in Jasper, Tex.

1917 1919

1921 1923 1935 1943 1946 1948 1955 1959 1962 1963 1963 1964 1968 2000

social support expectations, mores, folkways, traditions, rituals, and cosmology of the culture provide a familiar and welcoming perspective that protects against the noxious influences of trauma and its interpretation. The social and cultural context can foster provide self-esteem (a sense of power, a sense of models, a sense of uniqueness, and a sense of being connected to something of value; Bean, 1992), as well as provide social support, both of which buffer the negative effects of stressful events (Lazarus and Folkman, 1984). Bell (2001) suggests that certain cultures have resiliency-cultivating practices that may be protective as well; for example, developing a sense of ‘‘Atman’’ (true self); developing ‘‘kokoro’’ (heart), also known as ‘‘indomitable fighting spirit’’; finding your totem – an animal spirit that lives inside; and learning to cultivate ‘‘chi’’ (the Chinese word for internal energy).


Unfortunately, cultural norms may have the opposite effect by adding to the perception of an experience as traumatic (e.g., a rape victim may be shunned or murdered by family members for having ‘‘shamed’’ them). As cultural cosmologies give expectations and meaning of life, an erosion of culture by traumatic situations or acculturation can strip these protective factors making a population’s individuals more vulnerable to trauma and mental illness (Vega et al., 1998). Consequently, therapy must be conducted in a manner that does not estrange the individual from his or her family and community (Kluft et al., 2000). Thus, while psychosocial treatments that attempt to identify and process traumatic experiences may be effective for individuals from western cultures, they may be contraindicated for some Southeast Asian populations and persons from other non-western cultures (Kluft et al., 2000). Seeking care ‘‘No controlled studies have explored the extent to which specific religious groups or subgroups within the United States may be more or less likely to seek care for psychiatric symptoms related to trauma exposure’’ (American Psychiatric Association, 2004). However, black veterans may be less likely than white veterans to use psychosocial care outside Department of Veterans Affairs (VA) clinical programs, even though both ethnic groups appear to respond similarly to treatment for PTSD (Rosenheck and Fontana, 1994). Further, Neighbors et al. (1983) have found that Blacks use informal help only, or they use informal and professional (hospital emergency rooms, private physicians and ministers were used most frequently) help together. Such considerations must be taken into account when designing early intervention strategies for varying cultural, racial, and ethnic groups following mass trauma. Medication In addition, to the experience that cultural values may affect a particular patient’s decision to take medication or adhere to medication regimens, another important consideration in developing early interventions for different cultural, racial, and ethnic groups is the finding that these groups vary in their levels of tolerance for psychotropic medications (American Psychiatric Association, 2004). For example, it has been hypothesized that, due to genetic polymorphisms in hepatic cytochrome P450 (CYP) enzymes occurring at varying frequencies in Asians and Blacks, these groups have different levels of tolerance for psychiatric medications (Lin and Elwyn, 2004). Further, because only 3%–7% of Whites are poor metabolizers of CYP 2D6 substrates and 1%–3% of middle Europeans and 29% of Ethiopians are ultrarapid metabolizers of CYP 2D6 substrates, we would expect these groups to have different blood levels of medications that are metabolized via these

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pathways (Bertilsson et al., 1997; Cascorbi, 2003; Lin et al., 2001; Poolsup et al., 2000). Additionally, because ethnic groups also differ in genetic polymorphisms affecting sites of psychotropic drug action (e.g., serotonin transporters), a drug’s pharmacodynamic properties may also vary with ethnicity (Gelernter et al., 1997; Williams et al., 2003). Accordingly, the possibility of whether to prescribe medications to attenuate ASD in an effort to prevent the development of PTSD is even more uncertain with regard to different cultural, racial, and ethnic groups. ‘‘Pharmacokinetic or pharmacodynamic properties of medications within subclasses have yet to be studied with regard to their effect on efficacy in treatment of PTSD, nor have the effects of ethnic or cultural considerations on treatment response been clearly delineated.’’ (American Psychiatric Association, 2004, p. 43). Involvement of the target culture’s population to assist with research and services to answer how culture should influence early psychological intervention following mass trauma These findings emphasize the need to take ethnic and cultural factors into consideration in developing a plan of early psychological intervention following mass trauma. While not directly related to the issue of early psychological intervention following mass disaster, we have worked cross culturally on the issue of human immunodeficiency virus (HIV) prevention (Bhana et al., 2004; Paruk et al., 2005; Petersen et al., 2006) and, thanks to the Adverse Childhood Experiences studies, we are acutely aware that trauma is a variable that increases risky behaviors (Felitti et al., 1998). In addition, we have also worked in the area of children being exposed to traumatic stressors (Bell and Jenkins, 1991) and resiliency (Bell, 1997, 2001; Bell and Suggs, 1998). From these experiences, we have learned that the only way to answer the question of whether culture considerations should influence early intervention, one must consult the culture being targeted. Furthermore, we must use scientific methodology to differentiate fact from fiction, intuition, and belief about what is evidence for efficacy and effectiveness. We have found that there are both generic principles of intervention and culturally specific principles of intervention and both must be considered to adequately disseminate or translate the science into service. One solution to the problem is to involve the target culture’s population to assist with early psychological interventions for their culture’s victims of disaster. Without this involvement the knowledge of culturally welcoming, culturally familiar, culturally comforting approaches, music, or comfort foods will not be respected, and there will be more opportunity for stereotypes and microinsults and microaggressions (Bell et al., 2006). Thus, strategies that: (1) increase the target population’s participation (in an effort to turn traumatic helplessness into learned helpfulness and increase a sense of self-efficacy a critical


ingredient in preventing PTSD; Bell, 2006), (2) increase the relevance of the intervention to the target culture, (3) increase the synergy between interveners and recipients of the target culture, (4) increase culturally appropriate interventions based on theoretically sound principles of health behavior change (see above; Bell et al., 2002), and (5) monitor outcomes for an opportunity to improve the intervention should make early disaster interventions more suitable for use by various cultural, racial, and ethnic groups. In addition, we need more diversity of researchers studying the process and content of early psychological intervention following mass trauma.

Resources Until we are able recognize the value of diversity and devote more time, energy, and resources into the research and infrastructure necessary to meet the needs of a growing and diverse American population, we will have to be satisfied with clinical wisdom and the few research studies that address how best to provide early psychological interventions for varying cultural, racial, and ethnic groups in America. That being the case, we can only offer a few materials, which, while not directly related to early psychological interventions for diverse populations, may inform this work. Honoring differences: cultural issues in the treatment of trauma and loss Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss (Nader et al., 1999) is a wonderful resource that informs work with different cultural, racial, and ethnic groups that have already been impacted by trauma and loss, and accordingly offers some guidance that may be useful in approaching early psychological interventions for diverse populations. Of course, the generalizations contained in this resource may not fit individuals within the cultural, racial, and ethnic groups described due to varying levels of acculturation to American culture. Blacks Tully (1999) discusses Black American cultural responses to trauma and loss. She makes the point that slavery, segregation, poverty, and isolation are historical facts of Black American history, and accordingly will influence how some Blacks experience current day trauma and loss, as these common traumas continue to plague this subpopulation of Americans. She underscores black people’s experience with captivity, which, ‘‘creates a relationship of coercive control where the captor seeks to achieve not only

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power over the victim but also to extract affirmation, gratitude and even love’’ [which] ‘‘crush the individual’s sense of identity and strike at the heart of the community.’’ (p. 26). She asserts that ‘‘traditions of deep spirituality, dedication to family, and the communication of thoughts, feelings, and social commentary through music and story telling’’ protect and heal this black population. She observes that religious faith defines a powerful identity and an aspect of this practice is testifying or being a witness, which consists of retelling the trauma story by way of songs, stories, and humor. She also observes that Blacks stress commonality and community as they recognize that family and friends guard against the effects of trauma as families teach children how to cope. The art of toughening themselves and their children is also practiced by Blacks and they teach these skills to their children (Grier and Cobbs, 1968). She also explains that Blacks also seek to build strong communities and develop political unity to create a sense of oneness that is protective. She gives sound advice for practitioners serving black people and suggests they consider greetings, etiquette about feelings, negotiating cultural territory, professionalism, confidentiality, medicine, and healing, along with the mistrust of doctors, death also know as ‘‘homegoing,’’ codes of morality, important rituals such as prayer on Sunday and Wednesdays, hospitality, and funerals. Native North Americans Stamm and Stamm (1999) discuss issues of trauma and loss in Native North Americans. They note how family dynamics, politics, and tribal life influence the reception to western models of addressing trauma as these models usually focus on the individual, but native communities may require family or tribal interventions (Mason et al., 1996). She highlights how folktales, legends, and stories offer a powerful entrance into the native world and how elders, power politics, family structure, important beliefs, and native ceremonies and celebrations all influence efforts to ameliorate trauma. But, she also indicates how the problems in native life, e.g., mistrust of the government, can erode efforts to assist these populations when they get into trouble. Latinos Velez-Ibanez and Parra (1999) suggest that many Mexicans struggle with limited income, occupational precariousness, and cultural, linguistic and gender conflict, which impacts on their mental health and wellness. They observe that there are certain ‘‘culturally stereotypic stress behaviors’’ among Latinos that are associated with trauma and stress such as ‘‘Susto (fright),’’ and ‘‘Males (hexes).’’ They further suggest that the intentional social forms of ‘‘Calpulli’’ (religious oriented co-operatives), ‘‘Calmecac’’ (special training for reciprocal relations and community interests which cultivate common


experiences, ideologies and world views through friendship), ‘‘confianza’’ (mutual trust), and ‘‘Santeria’’ (religious practice of ‘‘Saint’s Belief’’) are very important aspects of Latino culture. Finally, these authors point out the other mitigating cultural resources within the Latino culture such as the Curandero and Catholic priests, along with reading of Gospels, Spiritualism, and Evangelicalism, all of which may assist with trauma interventions. Southeast Asians Gerber et al. (1999) address the issues of working with Southeast Asian people, specifically refugees from Cambodia, Laos, and Vietnam. They note, for example, that the majority of the population in Cambodia practice Theravada Buddhism, but also incorporate Hinduism brought from India; accordingly, Buddhist beliefs and practices are important in helping Cambodians deal with experiences of trauma. Laotians also practice Theravada Buddhism and have various rituals and celebrations characteristic of that population, such as a ceremony of prayers and good wishes called ‘‘Baci.’’ It turns out that Laotians do not believe in expressing their emotions verbally and have other than western ideas about death and dying. Complicating issues further is the reality that the roles of men, women, and children are quite different, e.g., it is a Laotian custom for 10-year-old children to still sleep with their parents. Vietnamese people were infused with Confucianism, Buddhism, and Taoism and later Roman Catholicism and when you add their war experiences (from 1940 to 1975) you have a complex mixture of values, beliefs, mores, and folkways to consider. Thus, they bring different issues to the table. Psychological First Aid: Field Operations Guide More specific to the issue of whether culture should matter in the early intervention of trauma, the Psychological First Aid: Field Operations Guide (National Child Traumatic Stress Network and National Center for PTSD, 2005) addresses the issue of culture in its section on ‘‘Professional Behavior,’’ in which it is specifically proscribed ‘‘Be knowledgeable and sensitive to issues of culture and diversity.’’ (p. 6). The section of ‘‘Preparing to Deliver Psychological First Aid’’ suggests: ‘‘Sensitivity to culture and ethnic, religious, racial, and language diversity is central to providing Psychological First Aid. It is critical to both outreach efforts and service provision. Providers should be aware of their own values and prejudices, and how these may coincide or differ with those of the community being served. Helping to maintain or reestablish customs, traditions, rituals, family structure, gender roles, and social bonds is important to helping survivors cope with the impact of a disaster. Information about the community being served, including how emotions and other psychological reactions are expressed, attitudes towards

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governmental agencies, and receptivity to counseling, should be gathered with the assistance of community cultural leaders who represent and best understand local cultural groups.’’ (p. 9) In their section on ‘‘Contact and Engagement’’ there is a Culture Alert: ‘The type of physical or personal contact that is appropriate may vary from person to person and across cultures and social groups, for example, how close to stand to someone, how much eye contact to make or how acceptable it is to touch someone. You should look for clues to a survivor’s need for ‘‘personal space,’’ and be informed about cultural norms through community cultural leaders who best understand local customs.’ (p. 11). Finally, in their section on ‘‘Give Special Consideration for Acutely Bereaved Individuals’’ there is one more useful Culture Alert: ‘‘The nature and course of grief is strongly influenced by family, cultural and religious beliefs and rituals related to mourning. You should inform yourself about cultural norms with the assistance of community cultural leaders who best understand local customs. Remember that it is important for families to decide from their own tradition of practices and rituals how to honor the death.’’ (p. 17). This valuable in-depth report on psychological first aid can be downloaded from the internet at http://www.ncptsd.va.gov. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-Traumatic Stress Disorder The American Psychiatric Association’s Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder (American Psychiatric Association, 2004) has many references on issues of culture as they pertain to the treatment of patients with ASD and PTSD, many of which are cited in this paper. Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General Finally, a good source of general information about various cultural, racial, and ethnic groups within the United States can be found in the Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General (US Department of Health and Human Services, 2001), as this report can be downloaded from the internet at http:// www.surgeongeneral.gov. Diagnostic and Statistical Manual – IV TR’s – cultural formulation A sadly underused but readily available resource is the Diagnostic and Statistical Manual, 4th edition’s cultural formulation (American Psychiatric


Association, 2000). These guidelines provide exemplary guidance for the consideration of culture, but are rarely used due to the one size-fits-all attitude of American Psychiatry.

REFERENCES Adams, R. E., Boscarino, J. A. (2005) Difference in mental health outcomes among Whites, African Americans, and Hispanics following a community disaster. Psychiatry, 68 (3), 250–265. Allen, J., Als, H., Lewis, J., Litwack, L. F. (2004) Without Sanctuary – Lynching Photography in America. Santa Fe, NM: Twin Palms. American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Text revision. Washington, DC: American Psychiatric Association. American Psychiatric Association (2004) Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Posttraumatic Stress Disorder. Washington DC: American Psychiatric Press. Arroyo, W., Eth, S. (1984) Children traumatized by Central American warfare (pp. 103–117). In Eth, S., Pynoos, R. S. (eds.) Posttraumatic Stress Disorder in Children. Washington, DC, American Psychiatric Press. Barnes, D. H., Bell, C. C. (2003) Paradoxes of Black suicide. Preventing Suicide The National Journal, 2 (1), 2–4. Beals, J., Manson, S. M., Shore, J. H. et al. (2002) The prevalence of posttraumatic stress disorder among American Indian Vietnam veterans: disparities and context. Journal of Trauma Stress, 15, 89–97. Bean, R. (1992) The Four Conditions of Self-Esteem: A New Approach for Elementary and Middle Schools, 2nd edn. Santa Cruz, CA: ETR Associates. Bell, C. C. (1996) Treatment issues for African-American men. Psychiatric Annals, 26 (1), 33–36. Bell, C. C. (1997) Promotion of mental health through coaching of competitive sports. Journal of the National Medical Association, 89 (8), 517–520. Bell, C. C. (2001) Cultivating resiliency in youth. Journal of Adolescent Health, 29, 375–381. Bell, C. C. (2005) Cultural sensitivity is essential – perspective. Clinical Psychiatry News, 33 (5), 64. Bell, C. C. (2006) Exposure to a traumatic event does not automatically put a person on a path to develop PTSD: the importance of protective factors to promote resiliency. Retrieved 28 January 2008 from www.giftfromwithin.org/html/promote.html. Bell, C. C., Jenkins, E. J. (1991) Traumatic stress and children. Journal of Health Care for the Poor and Underserved, 2 (1), 175–188. Bell, C. C., Suggs, H. (1998) Using sports to strengthen resiliency in children – training heart: using sports to create resiliency. Child and Adolescent Psychiatric Clinics of North America, 7 (4), 859–865. Bell, C. C., Flay, B., Paikoff, R. (2002) Strategies for health behavioral change (pp. 17–40). In: Chunn, J. (ed.) The Health Behavioral Change Imperative: Theory,

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Chapter 6. Early intervention – culture considerations Education, and Practice in Diverse Populations. New York: Kluwer Academic/ Plenum Publishers. Bell, C. C., Dove, H. W., Williamson, J. L. (2006) Challenges and obstacles in treating mentally ill black patients. Psychiatric Times, 23 (14), 48–49. Bernal, G., Bonilla, J., Bellido, C. (1995) Ecological validity and cultural sensitivity for outcome research: issues for the cultural adaptation and development of psychosocial treatments with Hispanics. Journal of Abnormal Child Psychology, 23 (1), 67–82. Bertilsson, L., Dahl, M. L., Tybring, G. (1997) Pharmacogenetics of antidepressants: clinical aspects. Acta Psychiatrica Scandinavica, 391 (Suppl), 14–21. Bhana, A., Petersen, I., Mason, A., Mahintsho, Z., Bell, C., McKay, M. (2004) Children and youth at risk: adaptation and pilot study of the CHAMP (Amaqhawe) programme in South Africa. African Journal of AIDS Research (AJAR), 3 (1), 33–41. Blair, R. G. (2000) Risk factors associated with PTSD and major depression among Cambodian refugees in Utah. Health and Social Work, 25, 23–30. Boscarino, J. A., Adams, R. E., Stuber, J., Galea, S. (2005) Disparities in mental health treatment following the World Trade Center disaster: implications for mental health care and health services research. Journal of Traumatic Stress, 18 (4), 287–297. Bremner, J. D., Southwick, S. M., Johnson, D. R., Yehuda, R., Charney, D. S. (1993) Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans. American Journal of Psychiatry, 150, 235–239. Brown, D. (2001) Bury My Heart at Wounded Knee: An Indian History of the American West. New York: Henry Holt & Company. Carter, R. T. (2007) Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress. The Counseling Psychologist, 35(1), 13–105. Cascorbi, I. (2003) Pharmacogenetics of cytochrome p4502D6: genetic background and clinical implication. European Journal of Clinical Investigation, 33 (Suppl 2), 17–22. Caspi, Y., Poole, C., Mollica, R. F., Frankel, M. (1998) Relationship of child loss to psychiatric and functional impairment in resettled Cambodian refugees. Journal of Nervous and Mental Diseases, 186, 484–491. Cervantes, R. C., Salgado de Snyder, V. N., Padilla, A. M. (1989) Posttraumatic stress in immigrants from Central America and Mexico. Hospital and Community Psychiatry, 40, 615–619. Charney, D. S., Barlow, D. H., Botteron, K. et al. (2002) Neuroscience research agenda to guide development of a pathophysiologically based classification system. In: Research Agenda for DSM V. Regier, D.A. (eds.) Kupfer, D. J., First, M. B., Regier, D. A. Washington DC: American Psychiatric Press. Chung, R. C., Kagawa-Singer, M. (1993) Predictors of psychological distress among Southeast Asian refugees. Social Science and Medicine, 36, 631–639. de Jong, J. T., Komproe, I. H., Van Ommeren, M. et al. (2001) Lifetime events and posttraumatic stress disorder in 4 postconflict settings. Journal of the American Medical Association, 286, 555–562. de Vries, M. W. (1996) Trauma in cultural perspective (pp. 398–413). In: van der Kolk, B. A., McFarlane, A. C., Weisaeth, L. (eds.) Traumatic Stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York, Guilford Press.

Chapter 6. Early intervention – culture considerations Derrick, J. M. (2005) When turtle met rabbit: native family systems. In: Rastogi, M., Wieling, E. (eds.) Voices of Color: First Person Accounts of Ethnic Minority Therapists (pp. 43–63). Thousand Oaks, CA: Sage Publications. Eisenman, D. P., Gelberg, L., Liu, H., Shapiro, M. F. (2003) Mental health and healthrelated quality of life among adult Latino primary care patients living in the United States with previous exposure to political violence. Journal of the American Medical Association, 290, 627–634. Fairbank, J. A., Friedman, M. J., Southwick, S. M. (2001) Veterans of armed conflicts (pp. 121–131). In: Gerrity, E. T., Keane, T. M., Tuma, F. (eds.) The Mental Health Consequences of Torture. New York, Kluwer Academic/Plenum. Farias, P. (1994) Central and South American refugees: some mental health challenges, in amidst peril and pain (pp. 101–113). In: Marsella, A. J., Bornemann, T., Ekblad, S., Orley, J. (eds.) The Mental Health and Well Being of the World’s Refugees. Washington DC: American Psychological Association. Felitti, V. J., Anda, R. F., Nordenberg, D. et al. (1998) Relationship of child abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14 (4), 245–258. Galea, S., Vlahov, D., Tracy, M., Hoover, D. R., Resnick, H., Kilpatrick, D. (2005) Hispanic ethnicity and post-traumatic stress disordes after a disaster: evidence from a general population survey after September 11, 2001. Annals of Epidemiology, 14 (8), 520–531. Gelernter, J., Kranzler, H., Cubells, J. F. (1997) Serotonin transporter protein (SLC6A4) allele and haplotype frequencies and linkage disequilibria in African- and European-American and Japanese populations and in alcohol-dependent subjects. Human Genetics, 101, 243–246. Gerber, L., Nguyen, Q., Bounkeua, P. K. (1999) Working with Southeast Asian People who have migrated to the United States (pp. 98–118). In: Nader, K., Dubrow, N., Stamm, B. H. (eds.) Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss. Philadelphia, PA: Brunner/Mazel. Greenfeld, L. A., Smith, S. K. (1999) American Indians and Crime. Washington DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Grier, W. H., Cobbs, P. M. (1968) Black Rage. New York: Basic Books. Herman, J. (1992) Trauma and Recovery. New York: Harper Collins. Jahoda, G. L. (1995) Trail of Tears. New York: Random House Value Publishing. Jenkins, E. J., Bell, C. C. (1994) Violence exposure, psychological distress and high risk behaviors among inner-city high school students (pp. 76–88). In: Friedman, S. (ed.) Anxiety Disorders in African-Americans. New York: Springer Publishing. Jenkins, E. J., Bell, C. C. (1997) Exposure and response to community violence among children and adolescents (pp. 9–31). In: Osofsky, J. (ed.) Children in a Violent Society. New York: Guilford Press. Jones, M. C., Dauphinais, P., Sack, W. H., Somervell, P. D. (1997) Trauma-related symptomatology among American Indian adolescents. Journal of Traumatic Stress, 10, 163–173. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B. (1995) Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060.

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Chapter 6. Early intervention – culture considerations Kinzie, J. D., Sack, W., Angell, R., Clarke, G., Ben, R. (1989) A three-year followup of Cambodian young people traumatized as children. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 501–504. Kinzie, J. D., Boehnlein, J. K., Leung, P. K., Moore, L. J., Riley, C., Smith, D. (1990) The prevalence of posttraumatic stress disorder and its clinical significance among Southeast Asian refugees. American Journal of Psychiatry, 147, 913–917. Kleinman, A. (1977) Culture, and illness: a question of models. Culture, Medicine, and Psychiatry, 1 (3), 229–331. Kluft, R. P., Bloom, S. L., Kinzie, J. D. (2000) Treating traumatized patients and victims of violence (pp. 79–102). In: Bell, C. C. (ed.) Psychiatric Aspects on Violence: Understanding Causes and Issues in Prevention and Treatment. San Francisco: Jossey-Bass. Kroll, J., Habenicht, M., Mackenzie, T. et al. (1989) Depression and posttraumatic stress disorder in Southeast Asian refugees. American Journal of Psychiatry, 146, 1592–1597. Kulka, R. A., Schlenger, W. E., Fairbank, J. A. et al. (1990) Trauma and the Vietnam War Generation: Report of Findings From the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel. Lazarus, R. S., Folkman, S. (1984) Stress, Appraisal, and Coping. New York: Springer. Lin, K. M., Elwyn, T. S. (2004) Culture and drug therapy (pp. 163–180). In: Tseng, W. S., Streltzer, J. (eds.) Cultural Competence in Clinical Psychiatry. Washington DC: American Psychiatric Press. Lin, K. M., Smith, M. W., Ortiz, V. (2001) Culture and psychopharmacology. Psychiatric Clinics of North America, 24, 523–538. Marshall, G. N., Orlando, M. (2002) Acculturation and peritraumatic dissociation in youth adult Latino survivors of community violence. Journal of Abnormal Psychology, 111 (1), 166–174. Martinez, P., Richters, J. (1993) The NIMH community violence project: II. Children’s distress symptoms associate with violence exposure. Psychiatry, 56, 22–35. Mason, S., Beals, J., O’Nell, T., et al. (1996) Wounded spirits, ailing hearts: PTSD and related disorders among American Indians (pp. 255–283). In: Marsella, A. J., Friedman, M. J., Gerrity, E. T., Scurfield, R. M. (eds.) Ethnocultural Aspects of Posttraumatic Stress Disorder. Washington DC: American Psychological Association. Matsunaga Vietnam Veterans Project (1996) Matsunaga Vietnam Veterans Project. White River Junction, VT: National Center for Post-Traumatic Stress Disorder and the National Center for American Indian and Alaska Native Mental Health Research. McLeod, J. D., Kessler, R. C. (1990) Socioeconomic status differences in vulnerability to undesirable life events. Journal of Health and Social Behavior, 31, 162–172. Michultka, D., Blanchard, E. B., Kalous, T. (1998) Responses to civilian war experiences: predictors of psychological functioning and coping. Journal of Trauma Stress, 11, 571–577. Nader, K., Dubrow, N., Stamm, B. H. (eds) (1999) Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss. Philadelphia, PA: Brunner/Mazel, pp. xvii. National Child Traumatic Stress Network and National Center for PTSD (2005) Psychological First Aid: Field Operations Guide. Retrieved 28 January from www.ncptsd.va.gov.

Chapter 6. Early intervention – culture considerations National Organization for Research at the University of Chicago (NORC) (2001) America Rebounds: A National Study of Public Response to the September 11th Terrorist Attacks. Washington DC: National Science Foundation, Robert Wood Johnson Foundation, and Russell Sage Foundation. Neighbors, H. W., Jackson, J. S., Bowman, P. J., Gurin, G. (1983) Stress, coping and black mental health: preliminary findings from a national study. Prevention in Human Services, 2 (3), 5–29. Ortega, A. N., Rosenheck, R. (2000) Posttraumatic stress disorder among Hispanic Vietnam veterans. American Journal of Psychiatry, 157, 615–619. Osofsky, J. D., Wewers, S., Hann, D. M., Fick, A. C. (1993) Chronic community violence: what is happening to our children? Psychiatry, 56, 36–45. Paruk, Z., Petersen, I., Bhana, A., Bell, C., McKay, M. (2005) Containment and contagion: how to strengthen families to support youth HIV prevention in South Africa. African Journal of AIDS Research, 4 (1), 57–63. Perilla, J. L., Norris, F. H., Lavizzo, E. A. (2002) Ethnicity, culture, and disaster response: identifying and explaining ethnic differences in PTSD six months after Hurricane Andrew. Journal of Social and Clinical Psychology, 21, 20–45. Petersen, I., Mason, A., Bhana, A., Bell, C., McKay, M. (2006) Mediating social representations using targeted micro media in the form of a cartoon narrative in the context of HIV/AIDS: the AmaQhawe Family Project (CHAMP) in South Africa. Journal of Health Psychology, 11 (2), 197–208. Pierce, C. (1995) Stress analogs of racism and sexism: terrorism, torture, and disaster (pp. 277–293). In: Willie, C. Rieker, P., Kramer, B. Brown, B. (eds.) Mental Health, Racism and Sexism. Pittsburgh: University of Pittsburgh Press. Pierce, C. M. (1988) Stress in the workplace (pp. 27–33). In: Conner-Edwards, A. F., Spurlock, J. (eds.) Black Families in Crisis. New York: Brunner/Mazel. Pole, N., Best, S. R., Metzler, T., Marmar, C. R. (2005) Why are Hispanics at greater risk for PTSD? Cultural Diversity and Ethnic Minority Psychology, 11 (2), 144–161. Poolsup, N., Li Wan Po, A., Knight, T. L. (2000) Pharmacogenetics and psychopharmacotherapy. Journal of Clinical and Pharmaceutical Therapeutics, 25, 197–220. Pulera, D. J. (2002) Visible Differences: Why Race Will Matter to Americans in the Twenty-First Century. New York: Continuum International Publishing Group. Richters, J., Martinez, P. (1993) The NIMH community violence project: I. Children as victims of and witness to violence. Psychiatry, 56, 7–21. Robin, R. W., Chester, B., Rasmussen, J. K., Jaranson, J. M., Goldman, D. (1997) Prevalence and characteristics of trauma and posttraumatic stress disorder in a southwestern American Indian community. American Journal of Psychiatry, 154, 1582–1588. Rosenheck, R., Fontana, A. (1994) Utilization of mental health services by minority veterans of the Vietnam era. Journal of Nervous and Mental Diseases, 82, 685–691. Ruef, A. M., Litz, B. T., Schlenger, W. E. (2000) Hispanic ethnicity and risk for combat-related posttraumatic stress disorder. Cultural Diversity and Ethnic Minority Psychology, 6, 235–251. Shalev, A. Y. (2006) Biological responses to disasters. Retrieved 28 January from www.psych.org/psych_pract/biological_responses_to_disasters3501.cfm.

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Chapter 6. Early intervention – culture considerations Stamm, B. H., Stamm, H. E. (1999) Trauma and loss in native north America: an ethnocultural perspective (pp. 49–75). In: Nader, K., Dubrow, N., Stamm, B. H. (eds.) Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss. Philadelphia, PA: Brunner/Mazel. Sue, D. W., Sue, D. (1999) Counseling the Culturally Different: Theory and Practice, 3rd edn. New York: Wiley. Tully, M. A. (1999) Lifting our voices: African American culture responses to trauma and loss (pp. 23–48). In: Nader, K., Dubrow, N., Stamm, B. H. (eds.) Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss. Philadelphia, PA: Brunner/Mazel. US Department of Health and Human Services (2001) Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: US Department of Mental Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. www.surgeongeneral.gov. Vega, W. A., Kolody, B., Aguilar-Gaxiola, S., Alderate, E., Catalano, R., Carveo-Anduaga, J. (1998) Lifetime prevalence of DSM–III–R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry, 55, 771–778. Velez-Ibanez, C. G., Parra, C. G. (1999) Trauma issues and social modalities concerning mental health concepts and practices among Mexicans of the Southwest United States with reference to other latino groups (pp. 76–97). In: Nader, K., Dubrow, N., Stamm, B. H. (eds.) Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss. Philadelphia, PA: Brunner/Mazel. Williams, R. B., Marchuk, D. A., Gadde, K. M. et al. (2003) Serotonin-related gene polymorphisms and central nervous system serotonin function. Neuropsychopharmacology, 28, 533–541.

7

Resilience is the default: how not to miss it Arieh Y. Shalev and Yael L. E. Errera

Introduction Recent studies of potentially traumatic events show apparently paradoxical findings; for example, during the 2001–2004 wave of terror, Bleich et al. (2003) found simultaneous reporting of optimism and of being depressed in a nationally representative sample of Israeli citizens. Shalev et al. (2006) described normal (that is, peacetime) levels of distress in a substantial majority of civilians who were directly exposed by terrorist acts. Galea et al. (2003) and Silver et al. (2002) found limited prevalence of residual distress following the September 11, 2001 attack on New York. These and similar findings have been construed as reflecting ‘‘resilience.’’ Resilience, in this context, is the absence of an expected bad outcome, such as general distress, depression, or post-traumatic stress disorder (PTSD). Following that logic, after an event of the magnitude of the September 11 attacks on New York, or following exposure to terrorist acts, one is either ‘‘traumatized’’ or ‘‘resilient.’’ Assuming that either traumatic response or resilience is the only option has a cost. Like every reduction of complex realities into dichotomies, using this assumption in research, or even as a manner of speech, entails significant loss of information. It may therefore misclassify or mischaracterize survivors at both ends. Most importantly, construing ‘‘PTSD’’ and ‘‘resilience’’ as the two opposing poles of the same continuum is an assumption that requires further validation. This new use of the term resilience is not without reason. Its roots may be traced to the somewhat exaggerated emphasis placed, during the last decade, on psychopathological consequences of traumatic events, and specifically Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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PTSD (e.g., Summerfield, 2001; Wessely, 2005; Young, 2001). Whilst not the most frequent outcome of major adversities, PTSD is their better characterized, and better-studied consequence. Indeed, PTSD has become the equivalent of being seriously affected by a stressful event. For example, PTSD and PTSD symptoms were the main outcome measure of studies of psychological responses to the September 11 terrorist attacks (e.g., Galea et al., 2003; Silver et al., 2002), most of whose participants weren’t directly exposed to the attacks. Furthermore, the emphasis on PTSD in the aftermath of September 11 has led to costly and rather ineffectual efforts to ‘‘prevent’’ this disorder by large-scale ‘‘early interventions’’ (e.g., Norris et al., 2002; Shalev, 2006a). A possible reaction to this ‘‘rise of PTSD’’ (Jackson, 1991), the more recent interest in resilience to the effect of traumatic events has already generated much research (e.g., Bonanno et al., 2006; Charney, 2004), including brain imaging and neuroendocrine studies (Bonanno et al., 2006; Freeman et al., 2006; Yehuda et al., 2006). This ‘‘rise of resilience,’’ however, is essentially caught in the abovementioned dichotomy between pathological responses and resilience: resilience in many studies is simply the absence of PTSD. This chapter will argue that such use of this term is poorly informed by previous knowledge about resilience and that expanding it is essential for better understanding of the responses to major adversities, and for better managing of those who endure such experiences. Following are two examples of research areas in which ‘‘resilience’’ received much sophisticated elaboration. In child development studies (reviewed in Masten, 2001; Rutter, 1993; and see below) resilience often described the successful survival of major developmental challenges. Here, both ‘‘survival’’ and ‘‘challenges’’ were generic, that is capable of taking many facets, and the specifics of the related risk factors (e.g., early loss, abuse, neglect), outcomes (e.g., life trajectory, schooling, vocational career), and moderators (e.g., education, good mentorship) were defined according to the peculiarities of each case or situation. Childhood development studies of resilience also flexibly accommodated long-lasting, continuous, or ongoing risk-protective and risk-moderating factors, whereas those involving traumatic events often addressed distinct and time-limited events – such as past wars, or previous accidents. The risk factors for PTSD, however, extend from childhood to well after the traumatic event (e.g., Brewin et al., 2000). Bio-ecological studies (e.g., Holling, 1973; Walker et al., 2004) used the term resilience to address complex living systems’ successful survival of evolutionary pressures. These studies offer an interesting taxonomy of resilience, in which there is: (1) ‘‘proper resilience’’ (the system’s capacity to reorganize itself, following adversity, without changing its functioning, structure, and identity), (2) ‘‘adaptability’’ (the capacity of actors within the


system to influence resilience) and transformability (capacity to mutate into a new identity, when required). Understanding the array of consequences of a traumatic event in similar terms might offer new insights. This chapter mainly addresses studies of resilience within childhood development. It evaluates lessons learned in this area and their relevance to studies of traumatic events. Within traumatic events, this chapter mainly concerns the early responses and their management. Specifically, this chapter examines the idea that the occurrence of resilience and the development of mental disorders are independent and orthogonal dimensions of the response to traumatic events. It also considers the relevance to the field of traumatic stress of the consistent finding that good adaptation is the most frequent outcome of adversity; the related view that such good outcome is mainly mediated by normal regulatory processes; and the idea that a bad outcome often occurs when the normal adaptive processes are obstructed. Doing so, we hope to derive recommendations for early interventions from the view that traumatic events are a subset of the generic category of adaptation challenge. This view, for example, strongly emphasizes the perception of trauma ‘‘victims’’ as active participants in surviving adversity. It also leads to recommended interventions that organize adaptation, and provide the necessary resources. We will also explore the boundaries to the application of the construct of resilience, i.e., whether promoting resilience suffices to protect survivors from developing mental disorders. In other words, we will try to depict the interface between the biomedical and the socio-psychological models of trauma and its aftermath (e.g., Shalev 2006a; Watson and Shalev 2005). There is a lot of confusion in this area, and the direction of the observed interaction is unclear: on the one hand, those who develop PTSD may not be able to engage in normal adaptation and on the other hand those who do not engage in these processes will develop a disorder (e.g., Horowitz, 1974; Lindemann, 1944). The chapter starts by justifying the need for a new approach to resilience, in the context of potentially traumatic events. It then examines the construct of resilience, using the literature of childhood development as an anchor. The following section explores the implications of perceiving the response to major adversities as a challenge to adaptation, and illustrates the related ‘‘ordinary magic’’ view of resilience (Masten, 2001) by an example of dealing with the terror threat in Israel. Finally we will offer a template for evaluating the quality of survivors’ adaptation at each stage of the early response to traumatic events and discuss signals that should make helpers shift from the stress-management to the biomedical model. The concluding section will examine ways in which the current disease model has generated messages and practices that interfere with resilience.

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Why do we need a new perspective? The occurrence of PTSD in the aftermath of wars, disasters, and individual traumata has been extensively documented. Estimates of the lifetime prevalence of PTSD in the general population (5%–12%, e.g., Breslau et al., 1998; Kessler et al., 1995) make this disorder one of the most frequent mental health problems. Traumatic events (as per DSM IV; American Psychiatric Association, 1994) occur to almost every adult, even during peacetime (Breslau et al., 1998). The conditional probability of developing PTSD following exposure is about 9%, across studies and continents (e.g., Kessler et al., 1995; Perkonigg et al., 2000). Post-traumatic stress disorder is often chronic and very disabling (e.g., Kessler, 2000). These numbers imply an extreme vulnerability of humans to the effect of rather frequent stressors. Indeed, it is hard to conceive of another living species where being exposed to species-specific stressors (e.g., fighting, being injured, being defeated or exposed to violent death) would so frequently lead to protracted distress and dysfunction. Notwithstanding, the human race has somehow survived the 26 years that followed the delineation of PTSD in DSM III (American Psychiatric Association, 1980). Indeed, studies of the most severe stressors (e.g., the Holocaust, protracted exposure to torture or war) consistently show a limited proportion of severely affected individuals. This, along with the realization that traumatic events are widespread and virtually inevitable, have led to conclusions that: (1) a traumatic event is not a sufficient cause of PTSD (e.g., Yehuda and McFarlane, 1995), and (2) the non-traumatic consequences of exposure are worth studying (e.g., Charney, 2004; Frazier and Kaler, 2006). Studying ‘‘resilience’’ to ‘‘trauma’’ is not without difficulties. Both terms are poorly defined (e.g., Layne et al., 2007). Resilience is often the absence of something rather than something. The likelihood of effectively exploring any construct, however, requires enough homogeneity of the related phenomena. Defining resilience as the very frequent good outcome of adversities (i.e., 91% if the conditional prevalence of PTSD is 9%) implies an extremely complex array of risk factors and outcomes. Predictably, such an array will defy any effective exploration. Therefore, studying resilience in large groups, where the expected prevalence of a disorder is low is a close-to-hopeless endeavor: there are many degrees of exposure, many ways of coping with it, and many forms of successful survival. In order to become a subject of study ‘‘resilience’’ must become a specific outcome. A few recent studies used a positive definition of resilience. For example, a study of mock captivity exercises, in the US armed forces, defined resilience as the capacity to successfully cope with pressure and not break down (e.g., Morgan, et al., 2000a, 2000b). Under these specific circumstances it was


possible to identify association with that specific outcome including biological factors. Arguably, these very specific circumstances differ significantly from those encountered by civilians during trauma and disasters. The heterogeneity of exposure in the latter, the persistence of stressors following exposure (e.g., loss, separation or injury), the heterogeneity of those exposed, and the very diverse forms and degrees of harm (compare losing a loved one with seeing the World Trade Center’s towers collapse) defies any good definition of shared ‘‘good’’ outcome. An alternative to considering resilience as a specific outcome is to perceive it as being the default, i.e., that which happens in the absence of specific pathogenic factors. Not being injured in combat can be used as an analogy: it is what happens in the absence of a physical or chemical intruder. Seeing resilience as the default, and using the previously developed multifactorial model of resilience in children can better accommodate the heterogeneity of exposure, the diversity of those exposed, the array of expected responses, and the numerous legitimate and relevant adaptive outcomes. Seeing resilience as the default also assumes an inherent ability of humans to recover from transient misery (e.g., Shalev, 2006b). Practically, it perceives the facilitation of normal adaptation as being essential, and defines the main goal of early intervention as identifying and addressing barriers to adaptation. This approach also assumes that resilience might mean different things to different people at different times, that there are many ways to be resilient, and that the main generic attribute of resilience is a sufficient level of stability and regularity under adversity.

Defining resilience Borrowed from the material sciences, the term resilience refers to ‘‘the physical property of a material that can return to its original shape or position after deformation that does not exceed its elastic limits.’’ The origin of the term is the Latin resillire (rebound; re¼back þ salire¼ to jump; Steinmetz and Barnhart, 1999). The assumption of an ‘‘elastic limit’’ is an important one and will be addressed in ‘‘The boundary of resilience’’ below. Applied to psychology, the term resilience has received various definitions (Table 7.1). As can be seen, definitions differ, but all of them pertain to an essential link between a risk and an outcome. Layne et al. (2007) suggested that the term resilience should be reserved for conditions in which there is an initial deflection of the relevant outcome measure (Figure 7.1). This view is in line with Selye’s (1946) General Adaptation Response, which also includes an initial deflection (e.g., of blood

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Chapter 7. Resilience is the default: how not to miss it Table 7.1. Definitions of resilience (adapted from Layne et al., 2007) Pathways to competent adaptation despite exposure to conditions of adversity (Cicchetti, 1996) The individual’s capacity for adapting successfully and functioning competently despite experiencing chronic stress or adversity, or following exposure to prolonged or severe trauma (Cicchetti and Rogosch, 1997) The possession and sustaining of key resources that prevent or interrupt loss cycles (Hobfoll et al., 2000) Good outcome in spite of serious threats to adaptation or development (Masten, 2001) The ability of adults . . . who are exposed to potentially disruptive events to maintain relatively stable healthy levels of psychological and physical functioning (Bonanno, 2004)

Pertinent outcome

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Resistance Resilience Recovery

Attrition

Failure Time

Figure 7.1. Resilience is shown as a V-shaped response in which a transient decline in an outcome measure is followed by rapid return to normal functioning (adapted from Layne et al., 2007 with permission)

pressure during hypovolemia). Resilience, therefore, involves an initial loss of functioning and subsequent recovery followed by a quick return to basic functioning (the V-shaped line in Figure 7.1). The absence of an initial decline is defined as ‘‘stress resistance.’’ A delayed return to a previous level of functioning bears the name ‘‘protracted recovery.’’ The failure trajectory leads to an irreversible negative change. Attrition represents good initial adaptation followed by progressive exhaustion and decline. Knowledge about response trajectories has important implications for interventions. Assuming, for example, that stress resistance is rarely followed by decline implies that survivors with little initial impairment are relatively safe (Freedman et al., 1999). Importantly response trajectories remain open to


the effect of response moderators, such as secondary stressors or lack of adequate social support (Brewin et al., 2000). Masten (2001) defines resilience as a relation between a risk factor and an outcome. The relevant outcome, however, may vary between situations and according to personal, group, or cultural expectations. Thus, it is not always explicit. Survivors of abuse are somehow ‘‘expected’’ to have a disturbed emotional life, and would be resilient if they don’t. Inversely, a soldier might be expected to go on fighting despite exposure to death and horror, in which case resilience is the capacity to preserve a military function. The same soldier will be resilient if, upon returning home, he or she does not develop PTSD, or smoothly regains a pre-war level of functioning. Expected outcomes often define what we conceive as ‘‘resilience.’’

Resilience in childhood development studies Historical perspective Early studies of resilience (e.g., Garmezy, 1971, 1974) evaluated life trajectories of children who grew up under significant adversity. A salient occurrence in these studies was that of children who, paradoxically, showed good adaptation. These children were reverently referred to as ‘‘invulnerable’’ (e.g., Anthony and Cohler, 1987). Early research on resilience also consisted of comparing ‘‘resilient’’ with ‘‘non-resilient’’ survivors of childhood adversity. These studies have identified several personal, environmental, and biographical moderators of the relationship between exposure and outcome. The latter included intelligence, education, or good mentorship (Layne et al., 2007; Masten 2001). These protective factors were often stable and immutable (e.g., IQ, level of education) and therefore rarely amenable to change. Furthermore, the related group comparison (resilient versus non-resilient) could not address the specific ways in which these factors operated (e.g., whether higher intelligence ‘‘worked’’ via better planning, better learning, higher capacity for abstraction, or better choice of an alternative). Subsequent studies of resilience in children concerned qualities of adaptation and their underlying mechanisms (e.g., Masten and Coatsworth, 1998; Rolf and Johnson, 1999). The two salient insights from these studies were: (1) the very frequent occurrence of good adaptation, and (2) the role of normal regulatory processes (e.g., rule-driven behavior, self-monitoring) in positive adaptation. These findings are elegantly reflected in the title of Masten’s (2001) review of the field: Ordinary Magic. The ordinary magic view has led to recommending interventions that strengthen basic protective systems, such as effective social networks. These interventions have the distinct advantage of mainly addressing behaviors and

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dispositions that concern everyday life and thereby are concrete and relevant. The following extract illustrates this view. The great surprise of the resilience research is the ordinariness of the phenomena. Resilience appears to be a common phenomenon that results in most cases from the operation of basic human adaptational systems. If those systems are protected and in good working order, development is robust even in the face of severe adversity. If these major systems are impaired antecedents of consequences to adversity then the risk for developmental problems is much greater, particularly if the environment hazards are prolonged. (Masten 2001, p. 227)

Masten’s conclusion requires few transformations in order to apply to post-traumatic adaptation: Resilience does not come from rare and special qualities, but from the everyday magic of ordinary, normative human resources in the minds, brains and bodies of children, in their families and relationships, and in their communities . . . It follows that efforts to promote competence and resilience in children at risk should focus on strategies that protect or restore the efficacy of these basic systems. (Masten 2001, p. 227)

Finally, resilience theory developed from addressing static predictors of outcome to evaluating arrays of protective attributes and multiple outcomes (e.g., Layne et al., 2007). This development provided the construct of resilience with the necessary versatility to include a wide variety of situations and outcomes (for more see below). Resilience, thereby, became generic.

Characteristics of resilience In a seminal overview of resilience, Rutter (1993) outlined several generic characteristics of resilience (Table 7.2). These attributes and their translation to the field of traumatic stress are the subjects of the following section. Resilience follows exposure The first attribute of resilience (Rutter, 1993) is that it could only follow an experience with stressors. Resilience cannot follow avoidance. It may start

Table 7.2. Generic characteristics of resilience (Rutter, 1993) Avoidance does not confer resilience Traumatic events are sources of life transitions Multifactorial view of resilience Resilience is domain-specific Similar regulatory processes confer resilience to normal and extreme conditions The individual is the active agent in shaping his or her life trajectory Resilience is significantly affected by its social context


with developing stressor-specific competency and this experience is subsequently generalized to other situations and stressors. The relevance of this point to studies of traumatic stress can be illustrated by a recent survey of two Israeli communities during a wave of terror (Shalev et al., 2006a). In this survey, residents of a highly exposed community showed lower levels of anxiety and distress than those of a community with lower exposure. Rutter’s view can explain this ‘‘paradoxical’’ finding: the highly exposed residents had daily encounters with stressful situations (e.g., taking the road to work) and consequently developed ways to better appraise the actual threat and had more experience of dealing with it. They also had a chance to develop and implement stress-reducing routines (e.g., mutual help in guarding children, radio emitters in cars) and thereby became more confident and eventually less anxious. Soldiers also gain a level of resilience from stressful exposure. However, they may also become more vulnerable. As illustrated below, the immediate outcome of exposure determines its long-term effect: Solomon et al. (1987) showed that veterans of the 1973 Yom Kippur War reacted to retuning to combat zone in the subsequent 1982 Lebanon war with lower levels of distress – except for those who had combat stress reaction in 1973. The latter had much higher levels of stress. Exposure, therefore, can be either protective or sensitizing. Expanding this lesson to the management of acute stress, almost every survivor of traumatic circumstances has both positive and negative lifetime exposure to stressors. Stress, therefore, is never entirely new. Consequently, it might be good practice to help distressed survivors create a link between current occurrences and previously successful experiences. Connecting with inner sources of competency might put survivors’ current experience into better perspective. Helpers as well might wish to perceive themselves and their clients as inherently competent survivors of adversities. Stressful events and life transitions Extending the discussion of the potential benefit of exposure, Rutter (1993) suggested that potentially traumatic life events (e.g., going to war, losing a relative) are also ‘‘transition generating events.’’ This view has important heuristic implications, since it suggests that the occurrence of such events should be evaluated for both negative and positive effects. Importantly, positive and negative effects may coexist. Keeping that perspective is particularly important in the presence of major losses with, apparently, no gain. This is because even minor gains can, sometimes, launch a process of reconstitution. Often-heard expressions, such as ‘‘I lost a son, but realized how many friends I have’’ can make the point: having friends cannot be measured against losing a son. However, the presence of a small ‘‘but’’ is of essence, because it completely denies the totality of the loss. In evaluating people’s inner resources following trauma one might wish to be tuned to the ‘‘but.’’

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The idea of bi-directional effect of exposure also implies that measuring negative outcomes (e.g., PTSD symptoms) predictably leads to showing negative reactions. It is measuring the half-empty part of the glass. In the field of traumatic stress, however, most research instruments evaluate negative responses (such as PTSD, anxiety and depression symptoms). Moreover, all current research instruments have ‘‘no response’’ as the lowest score of their items. Bi-directional instruments might better capture the essence of resilient responses (e.g., I have more or less friends following combat; I have lost or gained interest in life, etc. . . . ). Multiple risks, multiple outcomes, modulators, and moderators Studies of traumatic stress and PTSD implicitly assume a salient single stressor (a rape, an accident) and a preferential outcome (e.g., PTSD). They thereby tend to simplify the exposure proposition in their design – as well as its hypothesized outcome. In reality, however, many of the presumed exposure items (e.g., ‘‘combat exposure’’ or ‘‘rape exposure’’) are extremely heterogeneous, and parameters related to their heterogeneity (e.g., duration and incongruity of the event, perceived controllability of one’s behavior and emotions, perceived outcome) may strongly influence their outcome. The weaknesses of the related simplified outcome have been discussed before. Indeed, when multiple outcomes have been examined in combat veterans (e.g., Rosenheck et al., 1997), the effects were also diverse (e.g., no effect on PTSD symptoms, positive effect of social adaptation). Studies of resilience often consider an array of exposure and outcome variables. The latter can include multiple indicators of development, growth, social insertion, educational achievement, stable marriage, etc. The former may include neglect, abuse, inadequate parenting, lower education, etc. Two consequences of the multiple-causation/multiple-outcome view of resilience studies are worth considering here. Firstly there is, the abovementioned idea that contributing factors can be expressed in continuous and bi-directional variables – as in the following citation: . . . most risk factors actually index continuous bipolar dimensions that have a positive end associated with positive outcome (e.g., good parenting versus poor parenting, high education versus low education) as well as negative end associated with negative outcome. (Masten, 2001, p. 228)

Secondly there is, the idea that the effect of a risk factor strongly depends on the co-occurrence of other risk or protective factors and on ‘‘contextual’’ factors. For example, authoritative parenting may be protective in a rough neighborhood, and counter-productive in more affluent areas, where much more depends on one’s capacity to choose. Rutter (1993) suggested that the occurrence of resilience is better understood by assuming multi-causality (several contributing factors needed


for an outcome to be reached), equi-finality (an outcome can be reached in many ways) and multi-finality (similar factors can lead to diverse outcomes). This view has direct implications for interventions. It makes the generic tasks of a responder to: (1) maximize resources, and (2) minimize the effect of an array of situation-specific risk factors. The perception of the resilience as an array of positive outcomes that results from a matrix of risk and protective factors places this construct in the domain of open systems. The result of using restricted clusters of contributing factors is often a significant proportion of unexplained variance of the outcome (e.g., Shalev et al., 2006). It may also explain inconsistencies across studies. A previous paper (Shalev 2006b) has argued that whilst restricted models might be tolerable in studies of chronic PTSD, they are extremely counter-productive in studies of early responses to traumatic events, in which symptoms are ‘‘polymorphous and labile’’ and the surrounding reality has major and rapidly changing effects. Domain-, time-, and situation-specific resilience Another important insight from studies of resilience is the above-mentioned domain-specific resilience. Accordingly, there might be functional or emotional domains in which an exposed person reaches good adaptation (e.g., in work performance) and other areas of lesser success (e.g., emotional regulation). This is quite frequently seen in trauma survivors as well (e.g., return to work despite persistent dysphoria), specifically during prolonged adversities, during which a preference has to be given to one domain over another (e.g., one must continue to perform as an effective parent despite personal difficulties). A parsimonious formulation of this idea is that many exposed individuals are both resilient and impaired. Several insights may be derived from this view. Firstly is the need to independently assess various domains of performance. Secondly, one has to carefully choose time-, situation-, and person-specific domain(s) as relevant dimensions of resilience. Thirdly, a limited success in one domain (e.g., return to work) may lead to more optimistic self-appraisal and thereby contribute to a better general outcome. The boundary of resilience As we have suggested in the introduction of this chapter, resilience and mental disorders should be seen as independent and orthogonal dimensions of the response to traumatic events. The two may coexist, in fact; for example, a patient with PTSD can be resilient in that he or she keeps working despite significant difficulties, or successfully masters spells of anger. Conversely, the absence of PTSD symptoms or depression in exposed individuals should not be confounded with resilience: a survivor’s life may be shattered in many other ways. The orthogonal dimension argument is incomplete, however, without better specifying the difference between the two dimensions. The PTSD (or ‘‘disorder’’)

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dimension is characterized by specific symptoms – or lack thereof. Resilience, in contrast, may have different expressions. It is, therefore, a generic outcome. There are several ways to conceive of such a generic outcome. One pertains to remaining within homeostatic control. Another can be borrowed from descriptions of coping efficacy. Considering the first approximation, resilience concerns the general capacity to conserve cardinal parameters of a system despite pressure, or to change without reaching critical conditions. This is expressed by Rutter’s insistence on preserving rule-driven behavior during adversity. Applied to traumatic stress responses, a failure or resilience might be equated with the loss of the capacity to modulate the effect of, and monitor the response to, internal and external stimuli. Poor resilience is therefore an attribute of a system that had lost its buffers. An approximation of the ‘‘coping efficacy’’ view (Benight and Harper, 2002) might be sought in Pearlin and Schooler’s (1978) four dimensions of behavioral expression of a failure to cope. These four include: (1) poor emotional control, (2) negative self-perception, (3) inability to pursue task performance, and (4) loss of the capacity to enjoy rewarding interpersonal contacts (and thereby to benefit from social support). These four dimensions can be seen in some survivors and not in others – including some PTSD patients and not others. A failure to cope can also be observed under other stressful conditions, such as having cancer, or experiencing separation or loss. All these conditions may result in better controllable and less controllable reactions, and better or poorer conservation of the above four parameters of coping. The nature of normal adaptation The ‘‘ordinary magic’’ view suggests that resilience principally involves continuity (i.e., of meaning, of personal identity). A ‘‘trauma’’ in contrast is often perceived as discontinuity (e.g., with previous life, with one’s earlier identity; e.g., Omer and Alon, 1994). These contrasting views have several practical implications. The resilience perspective emphasizes that which, within a stressful situation, is still stable and reliable, whereas the ‘‘trauma’’ perspective enhances novel and often incongruous experiences. Accordingly, rescue workers can be trained to expect entirely novel experiences when disaster strikes (i.e., have a ‘‘discontinuous’’ experience) or be taught to trust their life experiences in dealing with the new occurrence (the ‘‘continuity’’ view). Because both approaches create expectations and may color rescuers’ perception of realities, both can be self-fulfilling. Arguably, the emphasis on continuity within changing circumstances offers the better solution. The individual as active agent Beyond continuity of meaning and action, successful adaptation requires deliberate effort and decisions (Rutter, 1993). Ultimately, resilient individuals


are also those who had made proper choices (e.g., not to use drugs). Survivors of prolonged adversities might be demoralized, helpless, and defeated, and therefore at risk of drifting (e.g., gangs or drug habits) and not trusting their capacity to choose. Restoring survivors’ capacity to actively direct their lives often may start by helping them make small choices and experience small amounts of ‘‘pleasurable success.’’ A previously published descriptive study of survivors of a terrorist attack could help in ‘‘translating’’ this view to the management of acute traumatic circumstances (Shalev et al., 1993). In that study I described how severely injured survivors were still attempting to cope – often with secondary dimensions of the stress (e.g., having to break the news to relatives). We also described how partial success in these efforts helped survivors to regain a sense of mastery and lowered their anxieties. It seems important, therefore, to provide trauma survivors with opportunities for active participation and pleasurable success. It might also be important to validate their limited achievements, as they occur. Successful adaptation and rule-driven behavior Another insight from studies of resilience concerns the adaptive role of maintaining rule-driven behavior despite pressure (as opposed to chaotic or disorganized responses). Individuals whose behavior is guided by internal rules, norms or beliefs may better survive harsh living conditions. This is old truth, in fact: armed forces produce combat-resilient service personnel via harsh training, in which they learn to maintain rule-driven behavior under pressure (e.g., follow orders despite fatigue or anger, use ammunition sparingly and purposefully). Because rule-driven behavior is such an important mediator of resilience, the occurrence of unruly or erratic behavior during disaster should be a prime candidate for early interventions. Intervention at the aftermath of traumatic events should similarly attempt to help the survivor recover from poorly modulated states of mind, such as dissociation, paralyzing anxiety or overwhelming fear. These uncontrollable states of mind, and the subsequent sense of disarray and defeat, have been linked with maintaining PTSD symptoms over time (Ehlers, 2006; Fullerton et al., 2000; Marmar et al., 1994; Shalev et al., 1996).

Trauma as challenge to adaptation Implications of the ‘‘ordinary magic’’ view Conceiving the responses to extreme stressors as essentially engaging basic processes of human adaptation has several implications. It may help shift the focus of observation from tracking potentially ‘‘pathogenic’’ processes to monitoring the extent to which normal reparative processes can operate. This view can be illustrated by the following text (Box 7.1), which describes various ways in which Israelis coped with continuous terrorism during the years 2001–2004 (Shalev, 2005).

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Box 7.1 Uncharted and common ways of coping Clearly, humans are more resilient than the current risk-averse culture would lead us to assume. Not that most humans are heroes, or otherwise extremely well trained for missions and fight: resilience is probably an attribute of ordinary people. Resilience of the normal type (as opposed to the often depicted heroic resilience under combat stress or during captivity) might be the best lesson we have learned from the response to terrorism in Israel. Having survived three years of intense terrorism in Israel, several patterns of resilience emerge as follows. A frequent way of adjusting to terrorism has been to progressively shift expectations, in ways that enabled most people to successfully live another day, and another week. When living without terror became an illusion, people would be encouraged if terrorist acts did not happen for a week, or a month. When terror occurred, a small number of casualties was a good sign. When one could not go out without risk, returning home unharmed became a small victory . . . Similarly, people came to appreciate non-conflictual areas of living and reprioritize life accordingly. For many, the family became the focus of attention. Feeling safe was more important than being entirely free. Overcoming difficulties superseded risk aversion, etc. Importantly, for those who managed to cope well, the new priorities were chosen such that they were achievable and within reach such that relative satisfaction could follow. Consequently, most people could develop a routine of living under terror. This was particularly obvious in residents of highly threatened areas who, for example, had to plan their entire day based on roadblocks and other constraints. Within days, people found new ‘‘arrangements’’ for getting their children back from school, leaving work earlier or carefully planning previously spontaneous activities, such as driving to work or shopping. Another prevalent way of coping was to re-structure space and time into threatening and non-threatening components. This was often done by assigning degrees of threat to situations and places and organizing one’s behavior accordingly. Thus, each of us had his or her virtual map of fear, which, for some, forbade the travel to East Jerusalem, for others (e.g., residents of Tel Aviv) excluded visits to Jerusalem at all, and yet for others allowed local groceries but excluded shopping malls. These virtual maps seem to have kept people in an illusionary but functional control pertaining to the risk they were ready to take. As long as they were proven stable and reliable, fear maps worked to reduce distress and apprehension. However, as soon as the reality defied one’s virtual map, there was distress and concern. For example, it was believed, at some point, that Fridays are relatively safe because of their meaning for Islam. When a


terrorist bomb exploded one Friday this particular map was betrayed and distress followed. The same distressing shift happened when a bomb hit the Frank Sinatra cafeteria, at the Hebrew University, a would-be safe place that hosted Jews and Arabs in the presumed sanctuary of Academia. Similarly, when a suicide bomber exploded in the midst of a large Pesach celebration in a hotel, readjustment had to be made and strong emotions emerged. The case of the ‘‘Moment cafe´’’ in Jerusalem is similar: this hub of left-wing liberals and international media crowd was supposedly safe, and many Jerusalemites were utterly shocked by its being targeted by terror. But virtual safety maps took a few days to reconstruct, and within such time, most people regained a sense of orientation and relative mastery over their acts and whereabouts. In that sense, one might say that terror did not succeed in creating prolonged havoc and fear, mainly because of the simple, unintended, day-by-day capacity of ordinary people to adjust. The necessities of daily living were another obvious reason for people’s perseverance and persistence. One had to work. One had to have one’s children go to school. Exams were waiting for students, investments for businessmen, babies were born, and weddings planned in families. None of these could be stopped or critically postponed. No one could seriously afford to stop living. Ultimately, the major resilience factor, in Israel, and probably elsewhere, is life’s immense attraction. For as long as one is not depressed or pathologically anxious, life is fundamentally appealing, pleasure and satisfaction are found – or invented – and terrorism, at least at the dimension in which it was present in Israel, does not stop it.

Dimensional view of early responses to adversity To further illustrate the perspective of normal adaptation, Figure 7.2 depicts a way in which interventions can be tailored to time-dependent needs. The figure offers a schematic three-dimensional space within which the early responses take place. It comprises a stressor severity (‘‘demands’’) dimension, a temporal progression axis, and a resources dimension. It illustrates the idea that the early responses to traumatic events are demand-dependent, resourcedependent and time-dependent. The schema is meant to help guiding early interventions as now described. Interventions, tailored on this schema, should address three core targets: the presence and intensity of ongoing demands (e.g., a missing child in a disaster scenario), the intensity and the adequacy of current responses (e.g., the occurrence of uncontrollable dissociation), and the availability of resources (acceptable and willing supporters). Helpers should assess these three dimensions and address one that is (1) critically problematic and (2) manageable.

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Figure 7.2. Three-dimensional depiction of the interaction between stressor (‘‘Demands’’) resources and time in the early aftermath of a traumatic event. Adapted from Shalev, 2006b.

At another level, this schema communicates what we found to be the case in recent terror attacks: there is always something to do to help distressed survivors. When little can be done to reduce the main stressor (as in the case of traumatic loss), reducing survivors’ loneliness is not a bad idea. When reality is truly terrible (as in the case of repeated terror, torture, siege, or captivity) a sense of belonging becomes a major resource. There is much to do before, and often instead of, formal treatment interventions.

Identifying the boundaries of resilience Clarity concerning the boundary between assuming ‘‘resilience’’ and reacting to the risk of developing a mental disorder is extremely important. Unfortunately, drawing this boundary is not an easy task. Conceptually, the boundary might be traced to differences between stress (a homeostatic approach) and mental trauma (a breakdown of defenses) (Shalev, 2006b). The metaphor of ‘‘elastic boundaries’’ can illustrate this view. From a practical perspective, however, some specific symptoms and behaviors might indicate that such a boundary has been reached. Following are some hints that should make helpers shift from a ‘‘stress-management’’ to view preventing PTSD. Post-traumatic stress disorder symptoms persist in those who develop the disorder (Shalev, 2007). The persistence of early PTSD symptoms in survivors who have been brought to safety is a good indication of risk. Some early symptoms have been identified as robust risk indicators of PTSD. Survivors who express the full syndrome of acute stress disorder (ASD, DSM IV) are at a very high risk of developing chronic PTSD (Harvey and Bryant, 2000). Identifying survivors with full ASD including its dissociation component (Ursano et al., 1999) should lead to early and dedicated treatment. The association of depression and PTSD should also be considered as a robust risk indicator of the disorder (Freedman et al., 1999).


Finally, a pathological course may be inferred when (1) PTSD symptoms, or symptoms of depression dominate the survivor’s inner experiences (2) when such symptoms are pervasive and do not allow other experiences; (3) when the emotional consequences of a trauma forcefully determine behavior or interfere with biological functions (sleep, appetite). Importantly, many people who develop these symptoms are still resilient – at least resilient to the point of not seeking help and pursuing whatever function they have in life despite feeling overwhelmed. These ‘‘resilient’’ ASD patients should not be mistaken for being out of risk. During years of experience we have seen many such survivors seek help too late, or hesitantly, or in the wrong place. An advantage of not confounding PTSD with resilience is that such survivors should be advised to seek professional help in time.

How to miss or weaken resilience A discussion of resilience to traumatic circumstances cannot be complete without critically appraising some current attitudes towards traumatic stressors, and their potential outcome. Spoken harshly, during recent decades every possible effort has been made to emphasize the potentially pathogenic outcome of stress. Pertinent examples include formally defining virtually every sudden and negative occurrence as a putative cause of a mental disorder (DSM IV; American Psychiatric Association, 1994). Handing the prevention of the presumed consequences to medical and psychiatric experts, who know how to ‘‘intervene’’ and ‘‘prevent,’’ is another aspect of this trend. Disregard for normal and adaptive reactions and confounding them with symptoms of a disease followed. Finally, belief in the wisdom of ordinary people was rarely expressed, if ever, in advice given to the public, which often consisted of instructions to follow. Arguably, this has led to disseminating fear and weakening resilience. The following table depicts several ‘‘great’’ ways to miss or weaken resilience (Table 7.3). It requires few commentaries – other than to specify what it alludes to. Dramatize refers to a general preference given to particularity, emotionality, and turbulence, at the expense of factual reporting and referring to generic elements of a situation. Exploring the roots of dramatic reporting (e.g., in the struggle to draw attention) is beyond the scope of this paper, but its negative effect on how people (and particularly children) perceive events and recover from their consequences received ample attention following the September 11 attacks. Pathologize refers to emphasizing the potential health hazards of psychologically stressful events or referring to early reactions as symptoms of mental disorders. Since humans generally overestimate potential losses (e.g., Kahneman

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Chapter 7. Resilience is the default: how not to miss it Table 7.3. Eight ways to miss and weaken resilience Dramatize Pathologize Catastrophize Create negative expectations Blur boundaries (e.g., between mental disorder and responses) Lie, mislead, misinform or otherwise manipulate information ‘‘Intervene’’ (and emphasize the role of experts) Ignore, show distance or indifference, lack of sharing

and Tversky, 1979), the fact of emphasizing a dreadful risk (i.e., of developing a mental disorder) is a powerful modulator of appraisal and behavior. Catastrophize, mainly refers to the use of extreme expressions (e.g., evil) and to other ways of depicting events as totally out of the ordinary, entirely unrelated to one’s daily experience and competences. Creating negative expectations refers to expectations embedded in information given about expected bad reactions (e.g., it is normal to experience nightmares, anxieties, and restlessness) in the absence of eventual good reactions (e.g., you might be poised to act, and eager to share your experience and help). Blur boundaries, for example address, in treatment, the fact that everyone has been exposed to a stressor. Manipulating information, for example when ‘‘informing’’ is too heavily contaminated by a desire (and a skill) to shape the recipient’s behavior. This often comes at the expense of providing information that is timely, accurate, and reliable and may ultimately lead to mistrust, confusion, and anxiety. Information during trauma should be treated as a major resource, the prime qualities of which are its accuracy and reliability. ‘‘Intervene’’ refers both to emphasizing the need for specialized expertise and giving preference to top-down processes – at the expense of individuals’ resourcefulness. Finally, these and other mistakes often lead to allocating too much attention and too many resources to ‘‘therapeutic’’ interventions based on a disease model; within such intervention, to individuals (rather than groups); within individuals, to symptoms (rather than adaptation); and in the context of symptoms, to putative biological processes (rather than to perceived stressors, responses, and resources).

Conclusion This chapter examined the construct of resilience, as applied to traumatic stress disorders, and especially to the acute responses to traumatic events.


Attempting to offer a new perspective, we described resilience not as the absence of a disorder or a bad outcome, but rather as the frequent occurrence of successful survival of adversities. We suggested that one should disassociate the fact of resilience from the occurrence of mental disorders. We discussed the practical implications of this view, such as identifying resilience within illness in trauma survivors, and delineating the boundaries between assuming resilience and observing precursors of mental disorders. Resilience has been defined here as the mediator between risk and outcome. We suggested that among the relevant risk factors for appraising resilience one should count the realities of traumatic exposure, its meaning for the survivor, its place in the survivor’s life trajectory, the survivor’s perceived goals and situational constraints, and communities’ appraisals of an expected behavior. The pertinent outcomes of resilience should similarly concern many levels of emotional, cognitive, social or vocational adaptation. We argued that there are many resilience trajectories and many ways in which survivors can fully or partially recover and ultimately return to an ‘‘ordinary’’ life. We perceive resilient survivors as having scars, and diseased trauma survivors as having open wounds. Because resilience concerns different domains of adaptation, defining it is not a simple goal. We suggested that the capacity for resilience is acquired via repeated exposures with successful resolution. The idea that resilience is the default, and that it is mediated by normal adaptive processes has led us to suggest that it is essential to identify and monitor barriers to normal adaptation in the early aftermath of traumatic events. We further suggested that every trauma survivor has a track record of successfully coping with adversities in the past (as well as a track record of failures) and that evoking the former might lead to better dealing with the present. We proposed that survivors are not only active participants in their recovery, but that they often have to make difficult choices in order to recover and regain their autonomy. Using an example of population under the threat of terror, we addressed the importance of flexibility in coping with continuous adversity and the specific advantages of being able to shift priorities, recalibrate expectations, re-create safe territories and continue with life despite constraints and hazards. Addressing the boundaries of resilience, we suggested that resilience does not end when symptoms begin, but rather when, with or without specific symptoms, survivors fail to cope with novel situations, give up, and lose their ability to modulate the effect of internal and external demands. The specific indicators of a failure to cope (demoralization, loss of emotional control, declining task performance, and interpersonal gap) might be taken as signaling problematic resilience. Specific and unrelenting symptoms should be seen as precursors of PTSD and lead to targeted interventions. The consequences of traumatic events are essentially bi-directional. Some people gain, in that they successfully deal with the opportunities for life

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transitions that such events can create. Other people lose, and in many different ways. Intervention in the acute aftermath of highly stressful events should address their potential for a bi-directional solution, and instruments that evaluate these interventions should also be tailored to the task.

Acknowledgments This work was supported by PHS/NIMH research grant MH071651 to Dr. Arieh Y. Shalev.

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Chapter 7. Resilience is the default: how not to miss it Cicchetti, D., Hinshaw, S. (2003) Conceptual, methodological, and statistical issues in developmental psychopathology: a special issue in honor of Paul E. Meehl. Development and Psychopathology, 15(3), 497–499. Cicchetti, D., Rogosch, F. A. (1997) The role of self-organization in the promotion of resilience in maltreated children. Development and Psychopathology, 9, 797–815. Ehlers, A. (2006) More evidence for the role of persistent dissociation in PTSD. The American Journal of Psychiatry, 163(6), 1112. Frazier, P. A., Kaler, M. E. (2006) Assessing the validity of self-reported stress-related growth. Journal of Consulting and Clinical Psychology, 74(5), 859–869. Freedman, S. A., Brandes D., Peri, T., Shalev, A. Y. (1999) Predictors of chronic posttraumatic stress disorder. A prospective study. The British Journal of Psychiatry, 174, 353–359. Freeman, T., Kimbrell, T., Booe, L. et al. (2006) Evidence of resilience: neuroimaging in former prisoners of war. Psychiatry Research, 146(1), 59–64. Fullerton, C. S., Ursano, R. J., Epstein, R. S. et al. (2000) Peritraumatic dissociation following motor vehicle accidents: relationship to prior trauma and prior major depression. Journal of Nervous and Mental Disease, 188(5), 267–272. Galea, S., Ahern, J., Resnick, H. et al. (2002) Psychological sequelae of the September 11 terrorist attacks in New York City. New England Journal of Medicine, 346, 982–987. Galea, S., Vlahov, D., Resnick, H. et al. (2003) Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology, 158(6), 514–524. Garmezy, N. (1971) Vulnerability research and the issue of primary prevention. American Journal of Orthopsychiatry; 41, 101–116. Garmezy, N. (1974) Children at risk: the search for the antecedents of schizophrenia. Part II: ongoing research programs, issues, and intervention. Schizophrenia Bulletin, (9), 55–125. Garmezy, N. (1985) Stress-resistant children: the search for protective factors (pp. 213–233). In: Stevenson, J. E. (ed.) Recent Research in Developmental Psychopathology. [Book supplement no.4 to Journal of Child Psychology and Psychiatry]. Oxford: Pergamon Press. Garmezy, N. (1993) Children in poverty: resilience despite risk. Psychiatry: Interpersonal and Biological Processes, 56, 127–136. Harvey, A. G., Bryant, R. A. (2000) Two-year prospective evaluation of the relationship between acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 157(4), 626–628. Hobfoll, S. E., Ennis, N., Kay, J. (2000) Loss, resources, and resilience in close intespersonal relationships (pp. 267–285). In: Harvey, J. H., Miller, E. D. (eds.) Loss and Trauma: General and Close Relationship Perspectives. Philadelphia: Brunner-Routledge. Holling, C. S. (1973) Resilience and stability of ecological systems. Annual Review of Ecology and Systematics, 4, 1–23. Horowitz, M. J. (1974) Stress response syndromes: character style and dynamic psychotherapy. Archives of General Psychiatry, 31, 768–781. Jackson, G. (1991) The rise of post-traumatic stress disorders. British Medical Journal, 303(6802), 533–534.

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Chapter 7. Resilience is the default: how not to miss it Kahneman, D., Tversky, A. (1979) Prospect theory: an analysis of decisions under risk. Econometrica, 47, 313–327. Kessler, R. C. (2000) Posttraumatic stress disorder: the burden to the individual and to society. The Journal of Clinical Psychiatry, 61 (Suppl. 5), 4–12; discussion 13–14. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B. (1995) Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060. King, L. A., King, D. W., Fairbank, J. A., Keane, T. M., Adams, G. A. (1998) Resiliencerecovery factors in post-traumatic stress disorder among female and male Vietnam veterans: hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74, 420–434. King, L. A., King, D. W., Salgado, D. M., Shalev, A. Y. (2003) Contemporary longitudinal methods for the study of trauma and posttraumatic stress disorder. CNS Spectrums, 8(9), 686–692. Layne, C. M., Warren, J. S., Watson, P. J., Shalev, A. Y. (2007) Risk, vulnerabilities, resistance and resilience: towards integrated conceptualization of posttraumatic adaptation (pp. 497–520). In: Friedman, M. J., Keane, T. M., Watson, P. A. (eds.) Handbook of PTSD, Science and Practice. New York: Guilford Press. Lindemann, E. (1944) Symptomatology and management of acute grief. The American Journal of Psychiatry, 101, 141–148. Marmar, C. R., Weiss, D. S., Schlenger, W. E. et al. (1994) Peritraumatic dissociation and posttraumatic stress in male Vietnam theater veterans. The American Journal of Psychiatry, 151(6), 902–907. Masten, A. S. (2001) Ordinary magic. Resilience processes in development. American Psychologist, 56(3), 227–238. Masten, A. S., Coatsworth, J. D. (1998) The development of competence in favorable and unfavorable environments. Lessons from research on successful children. American Psychologist, 53(2), 205–220. Masten, A. S., Best, K. M., Garmezy, N. (1990) Resilience and development: contributions from the study of children who overcome adversity. Development and Psychopathology, 2, 425–444. Morgan, C. A., Wang, S., Southwick, S. M. et al. (2000a) Plasma neuropeptide-Y concentrations in humans exposed to military survival training. Biological Psychiatry, 47(10), 902–909. Morgan, C. A., Wang, S., Mason, J. et al. (2000b) Hormone profiles in humans experiencing military survival training. Biological Psychiatry, 47(10), 891–901. Norris, F. H., Friedman M. J., Watson, P. J. (2002) 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry, 65 (3), 240–260. Omer, H., Alon, N. (1994) The continuity principle: a unified approach to disaster and trauma. American Journal of Community Psychology, 22(2), 273–287. Pearlin, L. I., Schooler, C. (1978) The structure of coping. Journal of Health and Social Behavior, 22, 337–356. Perkonigg, A., Kessler, R. C., Storz, S., Wittchen, H. U. (2000) Traumatic events and post-traumatic stress disorder in the community: prevalence, risk factors and comorbidity. Acta Psychiatrica Scandinavica, 101(1), 46–59.

Chapter 7. Resilience is the default: how not to miss it Rolf, J. E., Johnson, J. L. (1999) Opening doors to resilience intervention for prevention research (pp. 229–249). In: Glantz, M. D., Johnson, J. L. (eds.) Resilience and Development: Positive Life Adaptations. Longitudinal Research in the Social and Behavioral Sciences. New York: Kluwer. Rosenheck, R., Fontana, A., Errera, P. (1997) Inpatient treatment of war-related posttraumatic stress disorder: a 20-year perspective. Journal of Traumatic Stress, 10(3), 407–413. Rutter, M. (1987) Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 53, 316–331. Rutter, M. (1993) Resilience: some conceptual considerations. Journal of Adolescent Health, 14(8), 626–631. Selye, H. (1946) The general adaptation syndrome and the diseases of adaptation. Journal of Clinical Endocrinology, 6, 117–230. Shalev, A. Y. (2005) The Israeli experience of continuous terrorism (2000–2004). In: Lopez-Ibor, J. J., Christodoulou, G., Maj, M., Sartorius, N., Okasha, A. (eds.) Disasters and Mental Health. Chichester: John Wiley & Sons. Shalev, A. Y. (2006a). Lessons learned from 9/11: the boundaries of a mental health approach to mass casualty events (pp. 605–616). In: Mental Health in the Wake of a Terrorist Attack. 9/11: Neria, Y., Gross, R., Marshall, R., Susser, E. (eds.) Cambridge: Cambridge University Press. Shalev, A. Y. (2006b). Interventions for traumatic stress: theoretical basis (pp. 103–120). In: Ritchie, E. C., Watson, P. J., Friedman, M. J. (eds.) Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. New York: Guilford Press. Shalev, A. Y. (2007) PTSD – a disorder of recovery? (pp. 207–223). In: Kirmayer, L., Lemelson, R., Barad, M. (eds.) Understanding Trauma: Integrating Biological Clinical and Cultural Perspectives. Cambridge: Cambridge University Press. Shalev, A. Y., Freedman, S. (2005) PTSD following terrorist attacks: a prospective evaluation. The American Journal of Psychiatry, 162(6), 1188–1191. Shalev, A. Y., Galai, T., Eth, S. (1993) Levels of trauma: multidimensional approach to the psychotheraphy of PTSD. Psychiatry, 56, 166–177. Shalev, A. Y., Peri, T., Canetti, L., Schreiber, S. (1996) Predictors of PTSD in injured trauma survivors: a prospective study. The American Journal of Psychiatry, 153(2), 219–225. Shalev, A. Y., Tuval, R., Frenkiel-Fishman, S., Hadar, H., Eth, S. (2006) Psychological responses to continuous terror: a study of two communities in Israel. The American Journal of Psychiatry, 163(4), 667–673. Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., Gil-Rivas, V. (2002) Nationwide longitudinal study of psychological responses to September 11. Journal of the American Medical Association, 288, 1235–1244. Solomon, Z., Garb, R., Bleich, A., Grupper, D. (1987) Reactivation of combat-related posttraumatic stress disorder. The American Journal of Psychiatry, 144(1), 51–55. Steinmetz, S., Barnhart, R. K. (1999) Chambers Dictionary of Etymology. Edinburgh: Chambers. Summerfield, D. (2001) The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 322(7278), 95–98.

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Chapter 7. Resilience is the default: how not to miss it Ursano, R. J., Fullerton, C. S., Epstein, R. S., et al. (1999) Peritraumatic dissociation and posttraumatic stress disorder following motor vehicle accidents. American Journal of Psychiatry, 156(11), 1808–1810. Walker, B., Holling, C. S., Carpenter, S. R., Kinzig, A. (2004) Resilience, adaptability and transformability in social-ecological systems. Ecology and Society, 9(2), 5. Watson, P. J., Shalev, A.Y. (2005) Assessment and treatment of adult acute responses to traumatic stress following mass traumatic events. CNS Spectrums, 10(2), 123–131. Wessely, S. (2005) Risk, psychiatry and the military. The British Journal of Psychiatry, 186, 459–466. Yehuda, R., McFarlane A.C. (1995) Conflict between current knowledge about posttraumatic stress disorder and its original conceptual basis. The American Journal of Psychiatry, 152(12), 1705–1713. Yehuda, R., Golier, J. A., Tischler, L. et al. (2006) Hippocampal volume in aging combat veterans with and without post-traumatic stress disorder: relation to risk and resilience factors. Journal of Psychiatric Research, 41(5), 435–445. Young, A. (2001) Our traumatic neurosis and its brain. Science in Context, 14(4), 661–683.

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Epilog Early intervention for individuals and communities: planning for the future while meeting present needs Robert J. Ursano and Michael Blumenfield

The Sidney E. Frank Conference as heard on the accompanying DVD and the revised ideas as presented in this book are a work in progress. As we conclude this book and the latest ideas of the outstanding authors who have participated in this project, we would like to reflect on where we are and where we may be going. Mass trauma and disasters affect large and diverse populations. Interventions require rapid, effective, and sustained mobilization of resources (Ursano and Friedman, 2006). Intervention must both address individual care needs and sustain the social fabric of the community. Psychiatric illness, distress, and health risk behaviors must be addressed (Institute of Medicine, 2003; Raphael and Wooding, 2004). The medical care system, public health system, and emergency response system must work together to meet the health care needs of a mass disaster and in particular the mental health care needs. Resilience of individuals and communities is the expected response to traumatic events and disaster. However, altered sense of safety, increased fear and arousal, and concern for the future, affects not only those who may develop mental health problems but also those who continue to work and care for their families and loved ones.

Intervention Early intervention both for communities and individuals requires research, planning, and evaluation. A well-supported community mental health system is a necessary component of every public health infrastructure, including primary care sites for delivery of disaster mental health care. Education of Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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primary care providers, patients, and the availability of referral for specialty care are important components of this system. Adherence/compliance to medical recommendations (e.g., medication, quarantine, shelter in place) is not well understood or taught to health care providers. Mental health and behavioral health community assessment should be an integral part of ongoing public health surveillance to facilitate the identification of resource needs post event. This requires substantial rethinking to initiate and establish the utility of both ongoing and potentially real-time health assessment for community mental health, behavioral and distress-related symptoms and behaviors. Inclusion of mental and behavioral experts in the training and exercises can facilitate this process. Because of the central importance of public education, increased knowledge of public education’s limits and possibilities to prepare, educate, motivate, and foster resilient responses is needed. Developing better ways to prepare the workplace – business and industrial communities – to embrace the challenges of human continuity as part of their efforts to ensure business continuity is a major challenge. An integrated approach that includes security, human resources, occupational health, and leadership may be most effective. Assuring continuity of human capital is as important as assuring the continuity of buildings and information systems and requires consideration of integrated leadership, medical, employee, and human resource planning. Overall, the public health challenges of disaster mental health span health services planning, intervention, treatment, training, education, and research on the neurobiological to psychological and sociocultural aspects of disaster behaviors, preparedness behaviors, and response behaviors of individuals and groups.

Critical issues in early intervention Culture is an important determinate of the language of response, recovery, and resilience. Effective messaging and leadership are specific to neighborhoods and communities. Leaders are those who have credibility and voice in a community. They are the organizers of the meaning of, and resources for, the response to a disaster. Their efforts will greatly impact the experience of connectedness, hope, and safety of the community. Through these, culturally sensitive leadership moves communities to recovery and may be able to limit distress if not psychiatric illness. Culture must be considered, respected, assessed, and always requires sensitivity and humility in attempts to understand. Recovery and resilience is the expected response even after large-scale disasters. So attention to what interferes with this expected response directs

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population-level interventions. Creativity, improvization, and flexibility are the hallmarks of resilience and recovery. Cognitive behavioral therapy (CBT) has been shown to be successful in preventing post-traumatic stress disorder (PTSD) in those with acute stress disorder (ASD). However, the cost, lack of available therapists, and possibilities of as many negative effects as positive when used in large-scale disasters may limit its practical utility. Cognitive behavioral therapy principles offer the best evidence-based practices on which to model population-level interventions. As proven effective, they offer a starting point for messaging, leadership, and community resource planning for early disaster response. The principles of psychological first aid (SCCEO) are: (1) safety; (2) calming; (3) connectedness both for instrumental (practical) and emotional support; (4) efficacy – including skills to respond as well as belief in one’s ability to respond; and (5) optimism/hope. These evidence-based principles, for which there is good evidence that they are helpful, can also direct early interventions, until we can develop creative approaches to traditional randomized trials that might be employed in disasters. Community interventions also require consideration of system-level function and the boundaries and co-ordination of organizations. Public and private systems, which often do not work with each other. Must do so after mass disasters to protect the health and capacity of trauma victims, from evacuation to law enforcement, medical care and protective sheltering. Deliberate co-ordinated community action is important to response and recovery. Practically community resilience is critically dependent on communication and disaster response practice. Working with communities post-disaster requires additional special skills. Consultation with leadership by mental and behavioral health specialists can aid the community recovery. Post-traumatic stress disorder will most likely be able to be prevented someday by medication. We are not there yet. Sleep disturbance may be the most pressing distress symptom commonly requiring management across traumatic events. Large-scale disasters, with evacuation, always have unique health needs, as the displaced populations carry with them their health needs, from medication for diabetes, hypertension and heart failure to the need, for kidney dialysis and addiction management. The medications required to respond across the medical needs of a community can be wide and diverse and need community planning.

Planning the future of early intervention Early mental health and behavioral intervention for disaster-exposed populations, including children, adolescents, and senior adults, is critically

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dependent upon the health protection strategies of both the public and private healthcare systems. These plans require going beyond disease to address normal recovery, resilience, and the well-being of a nation’s population. Our knowledge base has advanced in recent years after world disasters such as the Southeast Asian tsunami and Terrorism around the globe. While the nature of any disaster will shape its impact, over time most people will adjust, some will experience transient or ongoing distress, and others will face illnesses or disorders that require specialized care. Although there is substantial variation in disasters and mass casualty incidents, some general principles apply to all, and those can inform an optimal strategic plan for mental health protection (New York Medical College, 2006). In particular, sustaining the performance and well-being of community first responders requires training preparation and early intervention for eventual health and behavioral problems. A significant number of individuals exposed to disaster are at high risk of mental health risk behaviors and require evidence-based medical and psychological intervention. Community mental health infrastructure is a critical part of a health protection strategy and key to the rapid early intervention for disaster-exposed populations. Networking and training are required for our community mental health system. Expertise in the treatment of acute trauma can be gained from systematic treatment of pre-disaster occurrences. Understanding the culture of individuals, families, communities, and organizations is critical to effectively increasing resilience before disaster and providing effective, acceptable, and efficacious interventions after disaster. Primary care – the delivery of healthcare through routine primary care providers – is a fundamental component of early preparation for an intervention for the mental and behavioral healthcare needs after disaster. Evidence-based selective and universal interventions to sustain population and group wellness and operational function are needed. Communities exposed to disasters require: (1) minimizing individual and community postdisaster risk factors, (2) ongoing assessment and monitoring of mental health and behavioral needs, (3) a range of population and individual interventions that foster useful and sustaining actions, reduce social and emotional deterioration, and support key personnel in critical infrastructure. Specific interventions to build resilience, provide individual care and foster recovery for communities and individuals, should be: (1) evidence based; (2) built on proven mechanisms of change and recovery demonstrated in studies of risk factors, protective factors, and interventions; and (3) applied using multiple creative delivery strategies for both populations and individuals. Emergent mental health care needs, not previously evident, also occur after disaster as those with previously untreated or under-treated illness seek care

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after disaster. Responding to this care-needing population is part of disaster response. Triage is a necessary component of mental healthcare delivery following disaster and must include assessment of biological hyperarousal, as well as behavioral, emotional, and cognitive disturbances. Strategies of psychological first aid are recommended as a first-line intervention for a large majority of individuals following disaster, but currently require evaluation. People unlikely to benefit from psychological first aid may require additional clinical assessment of needs in terms of symptoms and conditions, leading to provision of appropriate intervention including pharmacological and psychological treatments. Healthcare followup and continuity of care for persistent symptoms are indicated.

Conclusion Early intervention for mental healthcare after exposure to traumatic events is a recognized part of trauma and disaster response. Research to advance evidence-based interventions for individuals and communities to foster mental health, resilience, return to home and work function, and recovery of community life and capacity is important to moving the field forward. Where in the past early mental health intervention was often driven by the wish to help and was the most current form of help, the field is now based on evidenced, informed principles for individual care. Public health perspectives for populations and public education and educating leaders are components of a comprehensive early intervention plan.

REFERENCES Institute of Medicine (IOM) (2003) Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Washington DC: National Academies of Science, National Academies Press. New York Medical College (2006) Early Psychological Intervention Following Mass Trauma. Conference Summary. New York Medical College, Valhalla New York 2006. Available from www.nymc.edu/trauma/NYMC_Conf_Summary.pdf; accessed January 30, 2008. Raphael, B., Wooding, S. (2004) Early mental health interventions for traumatic loss in adults (pp. 147–178). In: Litz, B. T. (ed.) Early Intervention for Trauma and Traumatic Loss. New York: Guilford Press. Ursano, R. J., Friedman, M. J. (2006) Mental health and behavioral interventions for victims of disasters and mass violence: systems, caring, planning, and needs (pp. 405–414). In: Ritchie, E. C., Watson, P. J., Friedman, M. J. (eds.) Interventions Following Mass Violence and Disasters: Strategies for Mental Health Practice. New York: Guilford Press.

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Note: The following abbreviations are used: ASD: acute stress disorder; CBT: cognitive behavioral therapy; CISD: Critical Incident Stress Debriefing; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders; PTSD: post-traumatic stress disorder accident survivors positive effect of CBT 97–98 see also motor vehicle accident survivors acute stress disorder (ASD) assessment of 92–93 criticism of ASD diagnosis 87–88, 93 definition of 86–87 and dissociation 87 future challenges 98 history of 86 incidence of 88 and subsequent development of PTSD 88–90 treatment of 93–98, 118–119 see also post-traumatic stress disorder (PTSD) Adams, R. E. 131 adaptation nature of normal 160, 163–164 through rule-driven behavior 161 trauma as challenge to 161–163 adrenergic mechanisms, human stress response 109 apathy, potential barrier to community resilience 60 ASD see acute stress disorder assessment of acute stress disorder 92–93 clinical assessments 36–37 cultural factors 37 at population levels 35–36 of underlying vulnerabilities 38 atypical antipsychotic medications 117–118

belief systems of different cultures 139–141 mourning rituals 142 protective nature of 135–136 and natural disasters 3, 7–8 Bell, C. C. xv, 134, 136 benzodiazepines, ineffective for PTSD 118 bereavement 15–16 clinical interventions 27 early interventions 21–22 Bernal, G. 130 bioterrorism response, role of public in 61–63 Blacks cultural responses to trauma and loss 139–140 experiences with terrorism 135 help-seeking tendencies 137 higher rates of previous exposure to violence 132 National Trauma Survey findings 135 victimization of 134–135 Boscarino, J. A. 131 brain function see human stress response, psychobiology of Bryant, R. A. xv, 96–97 business systems 10 calming, promotion of 75 Carter, R. T. 130 CBT see cognitive behavioral therapy children assessment of 36 early life cycle interventions 18–19 resilience studies 155–156 school systems 10 trauma exposure 26

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Index CISD see Critical Incident Stress Debriefing clinical intervention bereavement interventions 27 children and families 28, 36 delivery of early intervention services 33–34 early intervention, assessment for 36–37 evolving disorders 28 guidelines for PTSD 23 other stressor exposures 27 rehabilitation 28 self-care and information 28–29 service providers, accreditation of 34 for trauma exposures 26–27, 36–37 see also pharmacotherapy cognitive-behavioral therapy (CBT) effective in treatment of PTSD 72, 94–98 limitations of 72, 98, 175 modifications of CBT model 73 Cohen, A. P. 50 communication and community resilience 56 systems for 12 communities characteristics of 50–51 early intervention agenda 38–39 effect of disasters on 51 response to disaster 12–13 spontaneous community actions 25 see also community resilience community resilience 49, 52–53, 65 assumptions 58–59 barriers to 59–60 contributing factors 53, 62–63 communication 56 connectedness, commitment and shared values 53–54 critical reflection and skill building 55 disaster prevention, mitigation, preparedness and response 56 participation 54 resources 54–55 structure, roles and responsibilities 54 support and nurturance 55 individual resilience overriding 52 properties of resilience 56 rapidity 58 redundancy 57 resourcefulness 57–58 robustness 56–57 ways of enhancing 60–61 adopt a holistic wellness approach 64

create consciousness about community resilience 61 develop and practice disaster plans 64–65 input and engagement 61–63 see also resilience Community Resilience Summit 59–60 complex systems 2, 6 connectedness, promoting 53–54, 76 ‘‘coping efficacy’’ view 160 corticotropin releasing factor (CRF) 110 CRASH, cultural competence model 130 Critical Incidence Stress Debriefing (CISD) 20–21, 71–72 cultural issues 127 Blacks, trauma experienced by 134–135 care-seeking tendencies of different ethnic groups 137 CRASH, cultural competence model 130 cultural assessments 37 diversity within America 127–128 higher rates of PTSD in veterans 132–133 Hispanic immigrants, rates of PTSD 133–134 immigrants and refugees 133 influencing treatment response 129–130 involvement of target culture in early interventions 138 medication, tolerance for 137–138 mental health disaster response 18 monocultural ethnocentrism 128–129 native Americans 135 protective effect of culture 135–137 race-based traumatic stress 130–132 resources 139–143 Southeast Asian refugees 134 violence, rates of exposure to 132 Davidson, J. R. T. 90 debriefing models 20–21, 71–72 diagnosis of acute stress disorder (ASD) 86–87 criticisms of 87–88, 93 Diagnostic and Statistical Manual of Mental Disorders (APA) 86–87, 92, 142–143 ‘‘disaster culture’’ 3 Disaster Victim Identification (DVI) 21–22 disasters and community resilience 56

Index developing and practicing emergency plans 64–65 effect on communities 51 expert consensus recommendations 73–74 behavioral interventions 74–75 intervention principles 75–76 looking after those involved in 39 psychological effects of 69 commonly observed effects 70–71 epidemiological studies 69–70 factors influencing severe 70 response planning, systems for 7–8 governance and co-ordination 4–5 international 5 organizations, USA 6 tracking those affected by 38 victim identification 21–22 see also natural disasters; terrorism dislocation, effects of 16 dissociation 87 beneficial effects of 92 biochemical model 112 during trauma see peritraumatic dissociation diversity of culture, race and ethnicity within America 127–128 documentation, collecting 38 dopaminergic system, stress response 114 DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) cultural guidelines 142–143 diagnosis of acute stress disorder 86–87 criticisms of 87–88, 93 and peritraumtic dissociation 92 early intervention xiii, 14 assessing needs for 35 clinical assessments 36–37 cultural assessments 37 population assessments 35–36 underlying vulnerabilities 38 badging and selling 40 clinical platforms 26 bereavement 27 children and families 28 evolving disorders 28 other stressor exposures 27 pharmacological 28 rehabilitation 28 trauma exposures 26–27 critical issues in 174–175

delivery of 1, 30 accredited providers, need for 34 briefing and mobilization 35 clinical services 33–34 by communities and NGOs 38–39 education and training 34 government policy and planning 30–31 implementing the mental health response plan 39–40 and looking after those involved 39 population and public health strategies 32–33 systems, engagement with 31–32 tracking and documentation 38 involvement of target culture’s population in 138 meaning of term 14 planning future of 175–177 population/public health platforms capacity for mental health, building 26, 29 consultancy models 25 early childhood prevention programs 14, 18–19 information as intervention 24 occupational mental health systems 25 preparation and planning 24 psychological first aid (PFA) 22–23 spontaneous community actions 25 strengthening positive aspects of system response 25 science of 1, 29–30 clinical programs 14 cultural variables 18 and human malevolence 23–24 intervention for the bereaved 21–22 intervention with children 18–19 population-focused approach 14, 22–23 PTSD, clinical intervention guidelines for 23 research focus 15–17, 71–73 scientific methodologies 14–15 trauma studies 19–21 vulnerable individuals 17–18 vulnerable populations 17 systems for 1, 2–13 earthquakes xiii, 52 education for disaster response 34 schools 10, 31

181

182

Index emergency response systems 5, 149 early intervention programs for workers 20–21 formal and informal 4 in the USA 6–7 ethnicity see cultural issues evolving disorders, early clinical interventions for 28 expert consensus conferences, recommendations from 73–76 families assessment of 36 early intervention 28 school systems 10 trauma exposure 26 Foa, E. B. 90, 94–95 Frank, Sidney E. 13–14 Friedman, M. J. xv, 64 GABA (gamma-aminobutyric acid), effect on stress response 112–113 Galea, S. 70, 86, 131, 149 Glass, T. A. 61–63 glucocorticoids, effect on brain function 110–111 glutamate, role in human stress response 111–112 governments and complex systems 6 disaster responses 4–5, 6–7 mental health response plan, implementation of 39–40 policy, planning, preparation and programs 30–31 political leadership 13 grief complicated grief 21 counseling 27, 33 and mourning, cultural norms 142 health systems 11–12, 32 Herman, J. 129 Hispanic immigrants, risk of PTSD 133–134 holistic wellness approach, community resilience 64 Honoring Differences: Cultural Issues in the Treatment of Trauma and Loss 139–141 hope, instilling 76 human malevolence 23–24 human stress response, psychobiology of

adrenergic mechanisims 109 corticotropin releasing factor (CRF) 110 dopaminergic system 114 evidence from clinical trials 114–115 GABA neurotransmitter 112–113 glucocorticoids 110–111 glutamate 111–112 neurocircuitry 108–109 neuropeptide Y (NPY) 110 serotonergic system 113 treatment of acute stress responses 108–119 hydrocortisone, positive effect on PTSD 116–117 hypnosis with CBT, positive effect on PTSD 97 ICD-10 diagnosis of acute stress reaction 86 imipramine, role in reducing stress 117 immigrants, risk of PTSD 133–134 information communication systems 12 on coping support, providing 78 dissemination of 74 as intervention 24 manipulation of 166 on self-care 28–29 for tracking ‘‘victims’’ 38 institutional systems 8 international response 5 intervention 173–174 critical issues in 174–175 principles identified by expert consensus 75–76 target culture involvement 138 see also clinical intervention early intervention Israeli’s ways of coping with terrorism 162–163 Janet, P. 87 Jenkins, E. J. 134 Jerusalem, M. 58 King, D. W. 14–15 Kinzie, J. D. 134 Kretzmann, J. P. 61 Labonte, R. 61, 62–63 Latinos coping with trauma 140–141 exposure to traumatic events 131–132 Laverack, G. 61, 62–63

Index Lavizzo, E. A. 131 Layne, C. M. 153 leadership, political 13 loss see bereavement Marshall, G. N. 131 Masten, A. S. 155–156 McKnight, J. L. 61 McNally, R. J. 26, 80 media dramatization of reporting 165 early intervention role 24, 39 influence of 12 medication tolerance variability in different ethnic groups 137–138 see also pharmacotherapy mental health cultural guidelines 142–143 disaster response plans implementing and evaluating 39–40 low priority of 7 organizations in the USA 6 US Deptartment of Health guidelines 6–7 World Health Organization guidelines 5 systems for protection of 8, 9, 11 see also early intervention Mental Health All Hazards Disaster Planning Guidelines (US Department of Health and Human Services) 6–7 Mental Health: Culture, Race, and Ethnicity – A Supplement to Mental Health: A Report of the Surgeon General (US Dept of Health and Human Services) 142 military settings early intervention in 19–20 effects of stressful exposure 157 use of CISD 71 see also veterans monocultural ethnocentrism 128–129 motor vehicle accident survivors benefits of CBT 96–97 propanolol treatment protecting against PTSD 115 reduced cortisol levels and later PTSD 116 mourning, cultural norms 142 National Child Traumatic Stress Network (NCTSN) 19 Field Operations Guide 22, 76, 77, 141–142

National Trauma Survey (NTS) 135 native Americans 135, 140 natural disasters xiii community resilience to 52 impact of repeated 3 systems for preparation and recovery 3, 7–8 Neighbors, H. W. 137 neurocircuitry underlying response to stress 108–109 neurogenesis, agents promoting 113 neuropeptide Y (NPY) 110 neurotoxicity, prevention of 111 neurotransmitters corticotropin releasing factor (CRF) 110 GABA (gamma-aminobutyric acid) 112–113 glutamate 111–112 neuropeptide Y (NPY) 110 non-government organizations (NGOs) 3, 38–39 occupational mental health systems 25 ‘‘ordinary magic’’ view of resilience 155–156 implications of 161–163 organizational systems 8 Orlando, M. 131 panic attacks 91 Parra, C. G. 140–141 Perilla, J. L. 131 peritraumatic dissociation 87 adaptive nature of 92 catastrophic appraisals of 91, 92 and subsequent development of PTSD 90–91 differing from persistent dissociation 92 and hyperarousal following trauma 91 and panic attacks 91 personal resilience 52 PFA see psychological first aid pharmacotherapy 107–108 clinical trials evidence 114–115 atypical antipsychotic medications 117–118 benzodiazepines 118 hydrocortisone 116–117 imipramine 117 propranolol 115–116 human stress response adrenergic mechanisims 109

183

184

Index pharmacotherapy (cont.) corticotropin releasing factor (CRF) 110 dopaminergic system 114 GABA (gamma-aminobutyric acid) 112–113 glucocorticoids 110–111 glutamate 111–112 neurocircuitry 108–109 neuropeptide Y (NPY) 110 serotonin system 113 treatment of acute stress responses 118–119 Pole, N. 132 political systems 13 population assessments 35–36 population-focused early intervention 14, 22–23 population health models 14, 19, 26 population health strategies 32–33 post-traumatic stress disorder (PTSD) and September 11, 2001 terrorist attacks 150 and catastrophic appraisals of trauma 91 clinical intervention guidelines 23 and DSM-IV diagnosis 86 early intervention research 15 guidelines for treatment of 142 in immigrants and refugees 133–134 linked to hyperarousal following trauma 91 management program 73 medication for see pharmacotherapy predicted by acute dissociation 90–91 predicted by ASD 88–90 prevalence of 152 and resilience 149–150 transient nature of 85–86 treatment with CBT 72, 93–98 Practice Guideline for the Treatment of Patients with ASD and PTSD (APA) 142 programs for early intervention 14, 19 propranolol pharmacotherapy 115–116 psychological first aid (PFA) 22–23, 24–25, 69 background research early post-trauma intervention 71–73 effects of disasters 69–71 context of 79 coping strategies 78 core actions of 77 cultural sensitivity issues 141–142 definition of 76 disaster response, expert recommendations 73–76

evaluation of effectiveness, need for 79 Field Operations Guide 22, 76, 77, 141–142 group application of 77 long-term impact unknown 78, 79 principles of 75, 175 calming, promotion of 75 connectedness, promoting 76 hope, instilling 76 self-efficacy, promoting 76 sense of safety, promoting 75 self-help advice 78 Psychological First Aid: Field Operations Guide (National Child Traumatic Stress Network and National Center for PTSD) 141–142 PTSD see post-traumatic stress disorder public health perspective xiii education and training 34 information provision 24 need for skilled providers 34 occupational mental health systems 25 preparation and planning 24 psychological first aid (PFA) 24–25 spontaneous community actions 25 strategies for early intervention 14, 32–33 strengthening positive aspects of system response 25 Pynoos, R. S. 21, 26–27 racism experienced by Blacks 134–135 impact on mental health 131 and rates of PTSD 131–132 rape victims, effects of CBT on PTSD 94–95 Raphael, B. xiv rapidity, property of resilience 58 redundancy, property of resilience 57 refugees, higher rates of PTSD in 133–134 rehabilitation 23, 28 Reissman, D. B. xiv research early post-trauma intervention 71–73 prevailing focus of 15–17 psychological effects of disasters 69–71 resilience xiv, 51–52 bio-ecological studies 150–151 in child development studies 150 definitions of 152–153, 153–155 generic characteristics of 156 boundaries and failure to cope 159–160

Index domain-, time- and situation-specific 159 follows stressful exposure 156–157 individual as active agent 160–161 multifactorial view 158–159 normal adaptation to change 160 rule-driven behavior, maintaining 161 stressful events and life transitions 157–158 historical perspective 155–156 identifying boundaries of 164–165 ‘‘ordinary magic’’ view of 155–156, 161–163 perceived as ‘‘the default’’ 153 properties of 56–58 versus PTSD 149–150 ways to miss or weaken 165–166 see also community resilience resourcefulness, property of resilience 57–58 response systems 4 mental health 32 for terrorism and disaster 7–8 see also emergency response systems robustness, property of resilience 56–57 rule-driven behavior, adaptive role of 161 Rutter, M., characteristics of resilience 156–161 safety, promoting sense of 75 Schoch-Spana, M. 61–63 school systems 10, 31 scientific methodologies 14–15 screening 37 self-efficacy, promoting 76 self-help programs 78 September 11 terrorism attacks, New York 69–70, 86, 131, 135, 150 serotonergic system, human stress response 113 sexual assault victims, treatment using CBT 94–95 Shalev, A. Y. xv, 129, 149 Sidney E. Frank conference xiv Silver, R. C. 149 social capital 2, 15 soldiers see military settings; veterans Solomon, Z. 19, 157 somatization disorders 16–17 Southeast Asian refugees 134, 141 Stamm, B. H. 140 Stamm, H. E. 140 stressful exposures 152 bereavement and loss 15–16

bi-directional effect of 157–158 clinical interventions for 27 dislocation from home 16 effect on non-white cultural, racial and ethnic groups 131–132 multiple-causation/multiple-outcome view of 158–159 resilience following 156–157 see also military settings; trauma/traumatic events supportive-counseling, CBT trials 95–97 systems 1, 2 business 10 communication 12 community 12–13 contexts and related systems 2–3 disaster and terrorism prevention 3–4 health 11–12, 32 political 13 relevance for early intervention 2 school 10, 31 traumatogenic 9–10 variables 13 see also belief systems; response systems terrorism bioterrorism response, role of public 61–63 Black people’s experiences with 135 Israeli’s ways of coping with 162–163 planning systems for 4–7 response systems for 7–8 September 11 attacks, New York 69–70, 86, 131, 135, 150 systems for prevention 3–4 training 34, 75 trauma/traumatic events adaptation to 161–163 assessment measures 36–37 behavioral consequences 26–27 dimensional view of early responses 163–164 and early intervention 19–21 grief counseling for 33 interventions for 26–27 paradoxical findings from research 149 and psychiatric disorders, risk of 85 rape victims, CBT treatment 94–95 response of Blacks to 135 survivor preferences, importance of 79–80 ‘‘transition generating events’’ 157–158

185

186

Index trauma/traumatic events (cont.) traumatic brain injury, positive effect of CBT 97 see also post-traumatic stress disorder traumatogenic systems 9–10 Tully, M. A. 139–140 Vega, W. A. 131 Velez-Ibanez, C. G. 140–141 veterans racial differences in rates of PTSD 132–133

resilience following stress exposure 157 see also military settings violence, previous exposure to 132 vulnerability assessment of underlying 38 vulnerable individuals 17–18 vulnerable populations 17 war stress see military settings Watson, P. xv, xvii World Health Organization (WHO), guidelines for disaster planning 5

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