Essential Elements of Mass Trauma InterventionHobfoll et al.
Five Essential Elements of Immediateand Mid–Term Mass Trauma Intervention:
Empirical Evidence
Stevan E. Hobfoll, Patricia Watson, Carl C. Bell, Richard A. Bryant, Melissa J.Brymer, Matthew J. Friedman, Merle Friedman, Berthold P.R. Gersons, JoopT.V.M de Jong, Christopher M. Layne, Shira Maguen, Yuval Neria, Ann E.
Norwood, Robert S. Pynoos, Dori Reissman, Josef I. Ruzek, Arieh Y. Shalev,Zahava Solomon, Alan M. Steinberg, and Robert J. Ursano
Given the devastation caused by disasters and mass violence, it is critical that inter-vention policy be based on the most updated research findings. However, to date,no evidence–based consensus has been reached supporting a clear set of recom-
Psychiatry 70(4) Winter 2007 283
Stevan E. Hobfoll, PhD, is affiliated with Kent State University and Summa Health System. PatriciaWatson, PhD, is with the National Center for PTSD. Carl C. Bell, MD, is affiliated with the CommunityMental Health Council and the Department of Psychiatry—School of Medicine and School of PublicHealth at the University of Illinois at Chicago. Richard A. Bryant, PhD, is Scientia Professor, School ofPsychology, at the University of New South Wales in Sydney, Australia. Melissa J. Brymer, PsyD, is affili-ated with the UCLA/Duke University National Center for Child Traumatic Stress, Department of Psychia-try and Biobehavioral Sciences, at the University of California, Los Angeles. Matthew J. Friedman MD,PhD, is with the National Center for PTSD, U.S. Department of Veterans Affairs, and is Professor of Psy-chiatry and Pharmacology at Dartmouth Medical School. Merle Friedman, PhD, is at the South AfricanInstitute of Traumatic Stress in Johannesburg, South Africa. Berthold P.R. Gersons, MD, PhD, Depart-ment of Psychiatry, Academic Medical Center, University of Amsterdam. Joop T.V.M. de Jong, MD, PhD,Professor of Mental Health and Culture at Vrije Universiteit Amsterdam. Christopher M. Layne, PhD, isaffiliated with Brigham Young University and the UCLA National Center for Child Traumatic Stress.Shira Maguen, PhD, is affiliated with the San Francisco VA Medical Center and University of California atSan Francisco. Yuval Neria, PhD, is with the Department of Psychiatry, College of Physicians and Sur-geons, Columbia University. Ann E. Norwood, MD, is with the Office of Public Health Emergency Pre-paredness Department of Health and Human Services in Washington, DC. Robert S. Pynoos, MD, MPH,is affiliated with the UCLA/Duke University National Center for Child Traumatic Stress, Department ofPsychiatry and Biobehavioral Sciences, at the University of California, Los Angeles. Dori Reissman,MD,MPH (CDR, U.S. Public Health Service) is with the Division of Violence Prevention, National Centerfor Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Department of Healthand Human Services. Josef I. Ruzek, PhD, is affiliated with the National Center for PTSD. Arieh Y Shalev,MD, is with the Department of Psychiatry, Hadassah University Hospital, Jerusalem, Israel. Zahava Solo-mon, PhD, is affiliated with the School of Social Work, Tel Aviv University, Ramat Aviv, Israel. Alan M.Steinberg, PhD, is with the UCLA/Duke University National Center for Child Traumatic Stress, Depart-ment of Psychiatry and Biobehavioral Sciences, at the University of California, Los Angeles. Robert J.Ursano, MD, Department of Psychiatry at the Uniform Services University School of Medicine.
Address correspondence to Stevan E. Hobfoll Ph.D., Director, Summa-Kent State University, Cen-ter for the Treatment and Study of Traumatic Stress, 444 North Main Street, Akron, OH 44310; e-mail:[email protected].
This work was made possible in part by the support of the NIMH Traumatic Stress Research Pro-gram and by SAMSHA/HHS who supported a meeting wherein the central ideas of this paper were gener-ated and discussed.
mendations for intervention during the immediate and the mid–term post masstrauma phases. Because it is unlikely that there will be evidence in the near ormid–term future from clinical trials that cover the diversity of disaster and massviolence circumstances, we assembled a worldwide panel of experts on the studyand treatment of those exposed to disaster and mass violence to extrapolate fromrelated fields of research, and to gain consensus on intervention principles. Weidentified five empirically supported intervention principles that should be usedto guide and inform intervention and prevention efforts at the early to mid–termstages. These are promoting: 1) a sense of safety, 2) calming, 3) a sense of self– andcommunity efficacy, 4) connectedness, and 5) hope.
Restoring social and behavioral func-tioning after disasters and situations of masscasualty has been extensively explored overthe last few decades. No evidence–based con-sensus has been reached to date with regard toeffective interventions for use in the immedi-ate and the mid–term post mass traumaphases (Gersons & Olff, 2005). Recent find-ings indicating that commonly utilized inter-ventions, such as psychological debriefing, donot prevent PTSD may not be effective in pre-venting long–term distress and dysfunction,and they may even be harmful to direct survi-vors of disasters (for recent reviews, seeCarlier, Lamberts, van Uchelen, & Gersons,1998; Litz & Gray, 2002; McNally, Bryant,& Ehlers, 2003; Rose, Bisson, & Wessely,2003). This has left the field without an evi-dence–based framework for post–disasterpsychosocial intervention. This gap in thefield has led to a search for an evidence–in-formed framework for post–disasterpsychosocial intervention. One solution to thelack of direct research evidence for such inter-ventions has been to both extrapolate from re-lated fields of research to create evidence–in-formed practices and to attempt to gainconsensus from researchers and practitionersin the fields of trauma and disaster recovery.Of greatest interest is the identification of coreintervention–related foci that are best sup-ported by the literature as promotingstress–resistant and resilient outcomesfollowing exposure to extreme stress (Layne,Warren, Shalev, & Watson, in press).
Given the devastation caused both bydisasters and mass violence, it is critical thatintervention policy be based on the most up-dated research findings (Foa et al., 2005;
Pynoos, Schreiber, Steinberg, & Pfefferbaum,2005). Recent increases worldwide in terroristattacks and disasters make this all the morenecessary. It is always a difficult task to ex-tract findings from the empirical literature onresearch and intervention in a format that caninform intervention policy. Not all areas of re-search receive the same attention, and contro-versies and questions will always remainopen, with new questions to be investigated.Nevertheless, in this paper, we summarize ourview of the distilled version of best interven-tion practices following major disaster andterrorist attacks for the short–term andmid–term period, a period that we define asranging from the immediate hours to severalmonths after disaster or attack.
This is not to say that we intend to rec-ommend specific intervention models, as theliterature does not currently support this. Theheterogeneity of traumatic events and their af-termath defies any specific guidelines, andthere is a need for flexibility of interventionsand adaptations to specific circumstances.We, therefore, address this issue by assertingseveral general principles for successful inter-vention or policies, attempting to formulatethese principles in a way that will allow theirsmooth translation to specific circumstances.Thus, we believe that there are central ele-ments or principles of interventions, rangingfrom prevention, to support, to therapeuticintervention that are supported by the empiri-cal literature and can be termed “evidence–in-formed.” It is highly unlikely that we will havean adequate representation of randomizedcontrolled trials of interventions for major di-saster events or terrorist attack in the near tomid–term future, if ever. Therefore a major
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step in promoting the development of effec-tive, efficient, and sustainable interventions isto ensure that, to the extent possible, they areinformed by empirical evidence and meetstandards of reasonable support frompublished studies of relevance to disasterenvironments.
There are several ways in which stress-ful events may reach traumatic proportionsfor individuals and communities. First, thesheer physical, social, and psychological de-mands of situations involving mass casualtymay be overwhelming—either directly (by theextent of pain, injury, destruction or devasta-tion) or because of their grotesque and incon-gruous elements (e.g., bodily disfigurement,school children being starved or massacred,people jumping from the burning Twin Tow-ers, bodies floating in a New Orleans street) orby their symbolic implications (beheading ofprisoners) or personal relevance (e.g., assum-ing that an act of terror could reach one’s ownneighborhood) (Reissman, Klomp, Kent, &Pfefferbaum, 2004). Second, the devastationof resources can impoverish the capacity of in-dividuals and communities’ to cope with atraumatic situation and recover from its con-sequences, especially where individuals orcommunit ies already have depletedpsychosocial and economic resources due toprior trauma, a history of psychiatric disor-der, or socioeconomic disenfranchisement(Hobfoll, 1998). The loss, or threatened loss,of attachment bonds that occurs in disastersand instances of mass casualty comes close inits intensity and effect to the previous elementsof witnessing horrors and direct personalthreat. Many traumatic events involve power-ful reactivation of attachment systems and en-suing agony and distress (such as looking forrelatives in the rubble of an earthquake orsearching casualty lists). Third, and linked tothe former, is the loss of territory, or safetywithin a territory—either via relocation—orindirectly, as people’s previously secure base isinfiltrated by threat and horror. In many in-stances of disaster and mass casualty, the on-going violence, aftershocks, massive failure toprovide aid, and the secondary losses that fol-low the initial phase mean that there may be
no clearly demarcated period that can betermed post–trauma. Finally, the potentiallydamaging effects of traumatic events on peo-ple’s sense of meaning, justice, and order oftenhave extremely stressful effects. Many traumasurvivors struggle with challenges to sense ofmeaning and justice in the face of shattered as-sumptions about prevailing justice in theworld due to the way in which they were eitherexposed to traumatic events (e.g., being sentto a war they perceive as senseless, being an in-nocent victim) or treated during thepost–traumatic aftermath (e.g. , v iadiscriminatory distribution of resources). It ison the basis of these principles that we came toseek, identify, and describe the basic, practicalrecommendations that follow.
It is important to recognize from theoutset that people’s reactions should not nec-essarily be regarded as pathological responsesor even as precursors of subsequent disorder.Nevertheless, some may be experienced withgreat distress and require community or attimes clinical intervention (Galea et al., 2003).This pattern underscores the conclusion thatmany people will have transient stress reac-tions in the aftermath of mass violence andthat such reactions may occur, occasionally,even years later. As such, most people aremore likely to need support and provision ofresources to ease the transition to normalcy,rather than traditional diagnosis and clinicaltreatment. Thus, in this paper, we consider in-tervention in its broad sense, ranging fromprovision of wide–ranging community sup-port and public health messaging to clinicalassessment and intensive intervention.
We have identified five interventionprinciples that have empirical support toguide evolving intervention practices and pro-grams following disaster and mass violence.We recommend that these practices and tech-niques, or their elements, should be containedwithin intervention and prevention efforts atthe early to mid–term stages. These guidelineswill be particularly important to those respon-sible for broader public health and emergencymanagement. These principles are:
1. Promote sense of safety.
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2. Promote calming.3. Promote sense of self– and collec-
tive efficacy.4. Promote connectedness.5. Promote hope.
PROMOTION OF SENSE OF SAFETY
The principle of promotion of sense ofsafety comes from several avenues of investi-gation relating to both objective reality andperceived reality. It is the nature of disastersand mass violence that people are forced to re-spond to events that threaten their lives, theirloved ones, or the things they most deeplyvalue (Basoglu, Salcioglu, Livanou, Kalender,& Acar, 2005; Briere & Elliot, 2000; de Jong,2002a, 2002b; Hobfoll et al. 1991; Ursano,McCaughey, & Fullerton, 1994; van der Kolk& McFarlane, 1996). Young children, par-ents, and caretakers are especially challengedby a mutual sense of disruption of a “protec-tive shield” that underlies much of early childdevelopment and family life (Pynoos,Steinberg & Wraith, 1995). As such, it is notsurprising that negative post–trauma reac-tions are common in large percentages of pop-ulations, across the full spectrum of ageranges that are exposed to disasters or massviolence. Hence, it is not unexpected that di-saster-affected populations have been foundto have high prevalence rates of mental healthproblems, including acute stress disorder,posttraumatic stress disorder (PTSD), depres-sion, anxiety, separation anxiety, inci-dent–specific fears, phobias, somatization,traumatic grief, and sleep disturbances(Balaban et al., 2005). These negativepost–trauma reactions tend to persist underconditions of ongoing threat or danger, asstudies in a variety of cultures have shown (deJong et al., 2001; de Jong, Mulhern, Ford, vander Kam, & Kleber, 2000; Neria, Solomon, &Dekel, 2000; Porter & Haslam, 2005;Yzermans & Gersons, 2002). To the extent,however, that safety is introduced, these reac-tions show a gradual reduction over time(Ozer, Best, Lipsey, & Weiss, 2003; Silver,Holman, McIntosh, Poulin, & Gil–Rivas,
2002). Moreover, even where threat contin-ues, those that can maintain or re–establish arelative sense of safety have considerablylower risk of developing PTSD in the monthsfollowing exposure than those who do not(Bleich, Gelkopf, & Solomon, 2003; Grieger,Fullerton, & Ursano, 2003).
When people are confronted with on-going threats of this magnitude they will natu-rally respond with deeply embeddedpsychophysiological and neurobiological re-actions that underscore the brain’s corticaland subcortical responses as well as peripheralfight, flight, or freeze reactions (Ursano et al.,1994; van der Kolk & McFarlane, 1996). Bio-logical adaptation to extreme stress is neces-sary for survival in a Darwinian sense(Hobfoll, 1998; van der Kolk & McFarlane,1996), and hence, it is not surprising thatthese reactions are deeply embedded in thebrain (Charney, Friedman, & Deutch, 1995;Panksepp, 1998; Yehuda, 1998; Yehuda,McFarlane, & Shalev, 1998). There is also adevelopmental neurobiology to theirontogenesis (Pynoos, Steinberg, Ornitz, &Goenjian, 1997). Translational research high-lights that promoting a sense of safety is essen-tial in both animals and humans to reducethese biological responses that accompanyongoing fear and anxiety (Bryant, 2006). Theimplication of this pattern is that promotingsafety can reduce biological aspects ofposttraumatic stress reactions (Bryant, 2006).
Parallel to these physiological reac-tions, cognitive processes that inhibit recoveryalso occur and are exacerbated by ongoingthreat. Foa (1997) has suggested that sponta-neous or natural recovery following exposureto a trauma is associated with maintenance ofa balanced view about the dangerousness ofthe world. A belief that “the world is com-pletely dangerous” is held to be a primary dys-functional cognition that mediates develop-ment of PTSD (Foa & Rothbaum, 1998).Because trauma memories are often encodedin the context of overwhelming emotion andconfusion, Ehlers and Clark (2000) posit thatsuch memories are easily and involuntarilytriggered by a wide range of reminders and of-ten subjectively feel as if they are happening
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“right now,” even if safety is restored. Thismodel holds that corrective information isneeded in the aftermath of trauma to ensurethat individuals can appraise future threat in arealistic manner. Consistent with this view,convergent evidence indicates that peoplewho are likely to develop subsequent disor-ders are more likely to exaggerate future risk(Ehlers, Mayou, & Bryant, 1998; Smith &Bryant, 2000; Warda & Bryant, 1998). If ac-tual safety is not restored, reminders will beomnipresent and contribute to an ongoingsense of exaggerated threat, preventing areturn to a psychological sense of safety(Ehlers & Clark, 2000; Nortje, Roberts, &Moller, 2004).
There are several intervention strategiesthat will promote a psychological sense ofsafety. These can be instituted on individual,group, organization, and community levels.
On an individual level, studies of expo-sure therapy have found that a key to thera-peutic success is to interrupt the post–trau-matic stimulus generalization that linksharmless images, people, and things to dan-gerous stimuli associated with the originaltraumatic threat (Bryant, Harvey, Dang,Sackville, & Basten, 1998; Foa & Rothbaum,1998; Gersons, Carlier, Lamberts, & van derKolk, 2000; Resick, Nishith, Weaver, Astin,& Feuer, 2002). This is done through bothimagined exposure and real–world, in–vivoexposure in ways that re–link those images,people, and events with safety (“The bridgethat collapsed was threatening, but all bridgesare not” “That night was unsafe, but all nightsare not unsafe.”). Interventions have also uti-lized reality reminders, teaching contextualdiscrimination in the face of trauma and losstriggers, assisting in developing more adaptivecognitions and coping skills, and groundingtechniques to enhance people’s sense of safety(Hien, Cohen, Miele, Litt, & Capstick, 2004;Najavits, 2002; Najavits, Weiss, Shaw, &Muenz, 1998; Resick & Schnicke, 1992).Such interventions have been used for individ-uals and small groups and can be applied afterscreening in post-disaster and mass violencesituations. When working with children, inaddition to utilizing these components, the re-
versal of regression in their ability to discrimi-nate among indications of danger is anothercore therapeutic objective (Goenjian et al.,1997; Goenjian et al., 2005; Layne et al.,2001; Pynoos et al., 1995).
Evidence from frontline treatment oftrauma in combat situations also supports thecentrality of promoting safety and has impli-cations for individual and more organiza-tional and large group intervention. Hence,safety must be approached as a relative state,and even in disaster or combat zones wheretotal safety cannot be achieved, the extent thatsafety is enhanced will aid people’s coping. Instudies of combatants in Israel, one of the keyprinciples of immediate treatment of combat-ants who were experiencing acute stress reac-tions was bringing them to relative safety, outof the line of fire (Solomon & Benbenishty,1986; Solomon, Shklar, & Mikulincer, 2005).This breaks the automaticity of thethreat–survival physiology and associatedcognitions (Solomon et al., 2005).
On a public health level, how to estab-lish safety may appear obvious, in that weshould bring people to a safe place and make itclear that it is safe. The promotion of a senseof safety is very similar to Bell’s and Pynoos’sprinciple of reestablishing the protectiveshield, which is a key principle of their respec-tive work in community and disaster psychia-try on health behavior change in large popula-tions and communities (Bell, Flay, & Paikoff,2002; Pynoos, Goenjian, & Steinberg, 1998).In reality, the restoration of confidence in aprotective shield in both adults and childrenrequires repeated attention and can be a slowprocess (Lieberman, Compton, Van Horn, &Ippen, 2003; Pynoos et al., 2005).
Interventions to enhance safety must in-clude a social systems perspective. Althoughsocial support has a major positive impact, aswe will detail, in the aftermath of large–scalecommunity trauma it may have the oppositeimpact. When complete information aboutmass trauma is lacking (a common occurrencefollowing disasters and mass violence), peopletend to share rumors and “horror stories”about the event. Hobfoll and London (1986)termed this the “pressure–cooker” effect.
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While this is probably intended to gain sup-port, it has been found that increasing doses ofthis type of “support” are positively corre-lated with psychological distress (Hobfoll &London, 1986; Pennebaker & Harber, 1993).In fact, those individuals who are sought outas support providers may be most vulnerableto this additional over–exposure. Interventionshould, therefore, recommend limiting theamount of this type of talking about thetrauma if doing so makes one more anxious ordepressed.
Related to the factor of social supportare worries concerning attachment networks.Information about the survival and safety offriends and relatives is the first to be soughtduring the immediate aftermath of disastersand terrorist acts (see, for example, Bleich etal., 2003). Because fears concerning the safetyof relatives may be greater than those con-cerning the self, intervention must aid identifi-cation of loved ones and their condition as anutmost priority. Thus, even prior to people’sneed to be connected to others for social sup-port as we discuss later, their concern for thesafety of their family may be even moreprimary.
Safety, by extension, involves safetyfrom bad news, rumors, and other interper-sonal factors that may increase threat percep-tion. In that sense, providing continuous andunbalanced information about hypotheticalsources of additional stress (e.g., enumeratingall the possible scenarios of terrorism, such aspoisoning wells, destroying crops) under-mines survivors’ sense of safety. Leadershipmust provide an accurate, organized voice tohelp circumscribe threat, and thereby increasethe perception of safety where there is noserious extant threat (Shalev & Freedman,2005).
Finally, media and the use of media bypublic officials are important foci of interven-tion. President Bush’s speech and actions fol-lowing the events of September 11th werelargely seen as increasing Americans’ belief inhis leadership (Bligh, Kohles, & Meindl,2004). However, a societal source of fear re-garding safety in the aftermath of mass vio-lence can also include government–issued
messages. Although the intent of such mes-sages is to keep the public informed and toincrease their knowledge as to how to act, ifnot carefully orchestrated, those messagesmay increase anxiety and make people lessclear about what is expected of them. Unfor-tunately, such messaging is also often used toserve political ends. For instance, it has beensuggested that one factor contributing toGeorge W. Bush’s election in 2004 was themedia attention, and the attention focused onterrorism by those seeking election—given toimminent terrorist threats (Cohen, Ogilvie,Solomon, Greenberg, & Pyszczynski, 2005).This evidence highlights that communitiesmay have difficulty maintaining a sense ofsafety in the aftermath of mass violence if gov-ernment agencies and elected officials strategi-cally elevate the community’s sense of dangerbecause this provides a political advantage.One might think that the media and politi-cians are beyond our influence, but organiza-tions such as the American Psychological andAmerican Psychiatric Associations, and theircounterparts in other countries, are oftenlooked to in times of mass trauma and shouldbe ready to address these questions and take astand on use of the media to produce fear orsensationalize. Likewise, broadcasting is con-trolled by laws and governing boards (e.g.,Federal Communications Commission) thatshould be prepared prior to disaster orterrorism occurrence on such issues.
The media may be another significantsocietal–level obstacle to establishing a senseof safety. Media may report events in waysthat inadvertently decrease a sense of safety orthat are intentionally unclear as to the degreeof safety because marketing research suggeststhat uncertainty and fear promote increasedviewing of the news. Additionally, it is com-mon for media to repeatedly display images ofthreat that can serve to reduce the commu-nity’s perception of safety. Thus, media–re-lated factors may impede recovery since adose–response effect has been found in multi-ple studies linking exposure to televised im-ages of the traumatic event to greater psycho-logical distress (Ahern et al., 2002; Nader &Pynoos, 1993; Neria et al., 2006; Pfefferbaum
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et al., 2002; Schlenger et al., 2002; Silver et al.,2002; Torabi & Seo, 2004). Although it is dif-ficult to determine the causal relationship be-tween media viewing and fear, these findingsare consistent with the proposal that mediaexposure influences fear in the community.Additionally, young children are likely to havedifficulty understanding that an event hasended, believing that replays on the local newsrepresent new incidents or continued threat(Fremont, 2004; Lengua, Long, Smith, &Meltzoff, 2005; Pfefferbaum et al., 2002). Forthis reason, media should be educated that en-hancing safety perceptions in a communitycan be achieved by media coverage that strate-gically conveys safety and resilience ratherthan imminent threat. Additionally, effectivemental health response following disastersshould include encouraging individuals tolimit exposure to news media overall and toavoid media that contain graphic film or pho-tos if they are experiencing increased distressfollowing viewing. This includes education ofparents regarding limiting and monitoringnews exposure to children.
PROMOTION OF CALMING
Exposure to mass trauma often resultsin marked increases in emotionality at the ini-tial stages. Some anxiety is a normal andhealthy response required for vigilance.Hence, there is no reason to be alarmed atsomewhat heightened levels of arousal or,paradoxically, numbing responses that pro-vide some needed psychological insulationduring the initial period of responding(Breznitz, 1983; Bryant, Harvey, Guthrie, &Moulds, 2003). The question is whether sucharousal or numbing increases and remains atsuch a level as to interfere with sleep, eating,hydration, decision making, and performanceof life tasks. Such disruptions of necessarytasks and normal life rhythms are not only im-pairing, but potential precipitants of incapaci-tating anxiety that may lead to anxiety disor-ders. Moreover, extremely high levels ofemotionality, even during immediatepost-trauma periods, may lead to panic at-
tacks, dissociation, and may portend laterPTSD (Bryant et al., 2003; Shalev et al.,1998). Further, although initial arousal andnumbing may be adaptive, prolonged states ofheightened emotional responding may lead toagitation, depression, and somatic problems(Harvey & Bryant, 1998; Shalev & Freed-man, 2005). In addition, in some studiesheightened heart rate in the early post–traumaphase has been demonstrated to be associatedwith long–term PTSD symptoms (Bryant et al.2003; Shalev, 1999). Given such problems, itis important that intervention include theessential ingredient of calming.
More homogeneous studies of personaltrauma, such as rape, demonstrate that themajority of individuals initially show symp-toms that, if persistent, would be indicators ofPTSD. This initial severe emotionality is a nor-mal way of responding. However, most indi-viduals return to more manageable levels ofemotions within days or weeks. Those that donot return to these lower manageable levels ofresponding are at considerable risk for even-tual development of PTSD (McNally et al.,2003; Shalev & Freedman, 2005). Further,even if their hyperarousal, increased emo-tional lability, and distress symptoms do di-minish, such heightened emotional states arelikely to interfere with sleep (DeViva, Zayfert,Pigeon, & Mellman, 2005; Ironson et al.,1997; Meewisse et al., 2005) and daily func-tioning, such as concentration and social in-teraction. This hyperarousal can have a majoreffect on risk perception, such that the exter-nal environment is perceived as potentiallyharmful beyond any proportion to the avail-able objective information. As describedabove, once a context or a situation has beenperceived as threatening, neutral or ambigu-ous stimuli are more likely to be interpreted asdangerous. In response to elevated levels offear, a process of avoidance may begin thatinitially may be adaptive. However, as theavoided stimuli increase in number and type,the ensuing avoidance may strongly interferewith individuals’ and families’ capacities to ef-fectively engage in salutogenic human interac-tions in the aftermath of disasters. Finally,physiological demands may compete with
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other mental resources on priorities inattention and action, causing decrements infunctioning precisely when optimalfunctioning is so critical.
A major reason why psychological de-briefing (such as Critical Incident Stress De-briefing) has been criticized in recent years isthat it serves to enhance arousal in the imme-diate aftermath of trauma exposure. There isconvincing evidence that these early interven-tions are not effective in preventing subse-quent psychological disorder (McNally et al.,2003). It has been suggested that requiringpeople to ventilate in the immediate aftermathof trauma can increase arousal at the very timethat they are required to calm down and re-store equilibrium after the traumatic experi-ence. It is possible that this increase in arousalmay be the cause of debriefing exacerbatingsome people’s stress reactions after trauma(Bisson, Jenkins, Alexander, & Bannister,1997; Hobbs, Mayou, Harrison, & Worlock,1996).
The Expert Consensus Guideline Series:Treatment of Posttraumatic Stress Disordernotes that anxiety management can be a keypsychotherapeutic treatment for patients (Foaet al., 1999; National Institute for Clinical Ex-cellence, 2005). Most successful trauma–re-lated psychosocial andpsychopharmacological treatments targetcalming of extreme emotions associated withtrauma as an essential therapeutic element(Davidson, Landerman, Farfel, & Clary,2002; Foa, Keane, & Friedman, 2000; Fried-man, Davidson, Mellman, & Southwick,2000), as does frontline treatment of combat-ants with acute stress reactions (Solomon,2003). Even treatments that focus on expo-sure do not conclude until the individual hasattained a state of mastery or calming over theaversive memory (Foa & Rothbaum, 1998;Jaycox, Zoellner & Foa, 2002). They allowfor increased emotionality during early phasesof treatment, but provide individuals with theskills to achieve a relaxed state as a criticaltreatment goal.
Treatments for calming range from di-rect, targeted treatments to more indirect ap-proaches. Direct approaches are generally rec-
ommended for those with severe agitation and“racing” emotions or extreme numbing reac-tions. Therapeutic grounding is used to re-mind individuals that they are no longer in thethreat–trauma condition and that theirthoughts and feelings are not dangerous in theway the disaster or terrorist attack was. This isimportant because those developing PTSD arelikely to be re–experiencing the trauma intheir imaginations and dreams. Breathing re-training is a simple technique that is used toget individuals to breathe deeply and avoidhyperventilating or dissociating (Foa &Rothbaum, 1998). Deep breathing countersanxious emotionality. In one novel interven-tion, following the threat of attack, aphone–based intervention successfully em-ployed diaphragmatic breathing and a modi-fied cognitive–restructuring technique to re-duce anxiety in Israeli citizens (Somer, Tamir,Maguen, & Litz, 2005). Deep muscle relax-ation is a more involved, but still simple, treat-ment for teaching relaxation and is included instress inoculation training (Bernstein &Borkovec, 1973; Foa & Rothbaum, 1998;Veronen & Kilpatrick, 1983). Yoga alsocalms individuals and lowers their anxietywhen facing traumatic circumstances, whilemuscle relaxation and mindfulness treatmentsthat help people gain control over their anxi-ety are being applied that draw from Asianculture and meditation (Carlson, Speca, Patel& Goodey, 2003; Cohen Warneke, Fouladi,Rodriguez, & Chaoul–Reich, 2004;Somasundaram & Jamunantha, 2002; van dePut & Eisenbruch, 2002). Similarly, imageryand music paired with relaxed states has beenfound to be successful in calming and aidingsleep among those threatened by cancer(Roffe, Schmidt, & Ernst, 2005).
Although there has been little system-atic research on pharmacological approachesto induce calming, there are also a number ofmedications that hold promise for this pur-pose, such as anti–adrenergic agents, antide-pressants, and conventional anxiolytics(Friedman & Davidson, in press; Pitman et al,2002). At the same time, these must be usedcautiously, for although benzodiazepines mayhave an initial calming effect, they may in-
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crease likelihood of later PTSD (Gelpin,Bonne, Peri, Brandes, & Shalev, 1996).
Stress inoculation training (SIT) is atype of cognitive behavioral therapy (CBT)that can be thought of as a toolbox, or set ofskills, for managing anxiety and stress(Hembree & Foa, 2000; Meichenbaum,1974). SIT typically consists of education andtraining of coping skills, including deep mus-cle relaxation, breathing control, assertive-ness, role playing, covert modeling, thoughtstopping, positive thinking, and self–talk. Therationale for this treatment is that trauma-re-lated anxiety can generalize to many situa-tions (Rothbaum, Meadows, Resick, & Foy,2000). A number of studies have found SIT tobe effective both with women who have sur-vived sexual assault and accident survivors(Foa, Rothbaum, Riggs, & Murdock, 1991;Hickling & Blanchard, 1997; Kilpatrick,Veronen, & Resick, 1982; Rothbaum et al.,2000). Important to this discussion, SIT hasalso been found to be effective with soldiersexperiencing combat stress reactions in muchgreater numbers, suggesting its effectivenessas a public health tool in disasters and situa-tions of mass casualty (Solomon, 2003). Like-wise, a brief version of exposure therapy hasbeen adapted to secondary prevention ofPTSD with accident and assault survivors andfound to be effective (Bryant et al., 1998;Bryant, Harvey, Guthrie, & Moulds, 2003;Bryant, Sackville, Dang, Moulds, & Guthrie,1999; Foa, Hearst–Ikeda & Perry, 1995).
For both those who develop more se-vere stress reactions and the general popula-tion of exposed individuals, “normalization”of stress reactions is a key intervention princi-ple to enhance calming. When individuals in-terpret their experience in distressing ways(e.g., “I’m going crazy,” “There’s somethingwrong with me,” “I must be weak”), suchpathologizing of their own common re-sponses is likely to increase anxiety associatedwith these reactions. For instance, effectivetreatment of soldiers with acute stress reac-tions involves communicating the messagethat “You are neither sick nor crazy. You aregoing through a crisis, and you are reacting ina normal way to an abnormal situation” (Sol-
omon, 2003). Provision of accurate informa-tion, survivor education about reactions, andapplication of cognitive therapy approachesmay help calm survivors by helping challengenegative thinking.
Several recent studies examined the roleof positive emotions in coping with stress,trauma, and adverse life circumstances andhave implications for intervention. More spe-cifically, Fredrickson (2001) and Fredrickson,Tugade, Waugh, & Larkin (2003) suggestthat positive emotions which include joy, hu-mor, interest, contentment, and love have afunctional capacity to broaden a“thought–action” repertoire and lead to effec-tive coping. For this reason, it may help to en-courage people to increase activities that fos-ter positive emotions (Biglan & Craker, 1982;Zeiss, Lewinsohn, & Munoz, 1979), as well asreduce or eliminate watching, listening to, andreading information that produces negativeemotional states (i.e., news). This may be diffi-cult for people because they feel a need to bevigilant and remain updated. For those withminor to mid–level problems of anxiety, limit-ing media exposure to once in the morning, af-ternoon, and early evening (but not near bed-time) may be sufficient. Those with moresevere emotionality may agree to getting newsreports from a friend or family member thatgive the facts without the images andhyperbole used in much media reporting.
Another important intervention forcalming that can be broadly applied is to pro-vide training and structure for problem–fo-cused coping. At the same time, these tech-niques will build a sense of efficacy andsupport hope. Hobfoll and colleagues (1991)underscored that following mass trauma peo-ple are likely to interpret the challenges of di-saster and mass violence circumstances as oneenormous unsolvable problem. Here, it is crit-ical to assist and guide individuals to breakdown the problem into small, manageableunits. This will increase sense of control, pro-vide opportunities for small wins, and, practi-cally speaking, decrease the real problemspeople are facing (Baum, Cohen & Hall,1993). Problem–solving appraisal is consis-tently associated with reports of approaching
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and attempting to resolve problems as well asthe awareness, utilization, and satisfactionwith helping resources. It is also associatedwith a positive self–concept, less depressionand anxiety, and vocational adjustment.
Because problem–solving appraisal canbe learned and such training is effective(D’Zurilla & Goldfried, 1971), it is a poten-tially fruitful area for intervention develop-ment (Silver et al., 2002). Once new skills arelearned, encouraging individuals to applyskills can increase and sustain the effortsneeded for recovery. By intervening and pro-viding a structured approach to building effi-cacy, individuals can come to focus their at-tention on the task and may even increasetheir effort in the face of a challenge (Bandura,1986). Later in this paper, we address the issueof self–efficacy directly, but it is important tonote that the calming effect of increased senseof control and predictability is an importantaspect of such interventions.
It should be noted further that some fre-quent ways of calming might be counter– pro-ductive and eventually increase distress anddecrease the sense of mastery and control.Hence, benzodiazepines have shown to in-crease the likelihood of PTSD among symp-tomatic trauma survivors (Gelpin et al.,1996), despite an immediate calming effect.Because of their calming effects ,benzodiazepines continue to be widely usedclinically in the treatment of anxiety disor-ders, and attention must be given to maintain-ing calmness in populations for whom suchmedications are part of their pre-mass–casu-alty treatment. This is especially relevant be-cause those with pre-mass–casualty anxietydisorders are at particular risk for further neg-ative psychological impact if exposed tomass–casualty trauma. Having similarlysoothing activity, alcohol can be used to“self–medicate” and lead to potential misuseand other alcohol–related behaviors. Finally,the use of lies, or “spinning” information inorder to calm a population or a group ofrescued individuals, ultimately underminescredibility and is counter–productive.
Many of the interventions discussed inthis section are of a more individual interven-
tion nature. However, many can be translatedto group and community–based interven-tions. For example, psychoeducation has beenat the heart of a number of post–disaster inter-ventions that have been shown to be effectivein reducing PTSD (Goenjian et al., 1997,2005). Large–scale community outreach andpsychoeducation about post–disaster reac-tions should be included among public healthinterventions to promote calming.Psychoeducation serves to normalize reac-tions and to help individuals see their reac-tions as understandable and expected. Nor-malizing and validating expectable andintense emotional states and promoting survi-vors’ capacities to tolerate and regulate themare important intervention goals at all levels.Disaster survivors should avoid pathologizingtheir inability to remain calm and free of theexpectable intense emotions that are the natu-ral consequences of such threatening andtragic events. These goals can be accom-plished to a great extent through media andcommunity (e.g., church, schools, andbusinesses) processes.
Along with psychoeducation about re-actions, anxiety management techniques canbe taught that are directly linked with specificpost–disaster reactions (i.e., sleep problems,reactivity to reminders, startle reactions, inci-dent–specific new fears). For instance, sleephygiene, guidelines for media exposure, andrelaxation training techniques can all be pack-aged through media presentation. This maybe particularly important as people often mayfear going out or be advised not to go out inthe immediate to mid–term post–disaster ormass–trauma phase and so will be linked totelevision and radio for news and advice. In-teractive websites and computer programscan also be used. It will be critical in this re-gard to communicate at the same time whatthe signs of more severe dysfunction are sothat people also do not underpathologize theirsymptoms and know where to turn forprofessional assessment and treatment.
In any such psychological intervention,it should not be underestimated that people’sagitation and anxiety are due to real concerns,and actions that help them directly solve these
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concerns are the best antidote for the vast ma-jority. This follows because real initial re-source losses and the secondary losses that oc-cur downstream of the original event are thebest predictors of psychological distress(Freedy, Shaw, Jarrell, & Masters, 1992; Ga-lea et al., 2002; Hobfoll, Canetti–Nisim, &Johnson, 2006; Ironson et al., 1997). Hence,psychological intervention should not be seenas a substitute for interventions that directlyrelieve threat or that furnish the material re-sources needed for recovery and restoration oflosses incurred.
PROMOTION OF SENSE OFSELF–EFFICACY ANDCOLLECTIVE EFFICACY
The importance of having a sense ofcontrol over positive outcomes is one of themost well-investigated constructs in psychol-ogy (Skinner, 1996). Self–efficacy is the sensethat individual’s belief that his actions arelikely to lead to generally positive outcomes(Bandura, 1997), principally throughself–regulation of thought, emotions, and be-havior (Carver & Scheier, 1998). This can beextended to collective efficacy, which is thesense that one belongs to a group that is likelyto experience positive outcomes (Antonovsky,1979; Benight, 2004).
In their trauma models, Foa and Mead-ows (1997) and Resick and Schnicke (1992)underscore that following trauma exposurepeople are at risk for losing their sense of com-petency to handle events they must face. Thisbegins with events related to the originaltrauma, but quickly generalizes to a more fun-damental sense of “can’t do.” It is a centralgoal of all successful treatments to reverse thisnegative view regarding the ability of the self,the family, and the social group to overcomeadversity. The best evidence suggests that it isnot so much general self–efficacy, but the spe-cific sense that one can cope with trauma–re-lated events that has been found to be benefi-cial (Benight & Harper, 2002). For example,in a national Israeli sample, despite feeling inconstant danger, 75% of participants stated
that they would function efficaciously follow-ing a terror attack (Bleich et al., 2003).Trauma–related self–efficacy pertains to theperceived ability to regulate troubling emo-tions and to solve problems that follow in thedomains of relationships, restoration of prop-erty, relocating, job retraining, and othertrauma–related tasks (Benight et al., 2000;Benight, Swift, Sanger, Smith, & Zeppelin,1999). In line with this thinking, interventionsspanning from prevention of burnout (Freedy& Hobfoll, 1994) to work with victims oftrauma (Resick et al., 2002) are founded inpart on the proposition that people must feelthat they have the skills to overcome threatand solve their problems.
Several interventions lend themselves topost–disaster and mass violence environmentsand can be applied to the individual, group,organization, and community levels. Individ-ual and group–administered CBT have beendesigned to promote the individual as expert,focusing on imparting skills to the individual,rather than invoking an expert therapist whoretains all the relevant expert knowledge(Follette & Ruzek, 2006). CBT encourages ac-tive coping and good judgment about whenand how to cope, elements that are critical inraising or regaining self–efficacy. In theirwork with Turkish earthquake survivors,Basoglu and colleagues (2005) developed anefficacious single session CBT treatment thataimed at enhancing sense of control over trau-matic stressors. A number of programs havemade the difficult transition of translatingCBT to low and middle–income countries andhave found success when they have carefullytranslated intervention within the socio–cul-tural ecologies of the target countries (Hinton,Hsia, Um, & Otto, 2003; Hinton, Um, & Ba,2001a, 2001b; Otto et al. 2003; Saltzman,Layne, Steinberg, Arslanagic, & Pynoos,2003). If we keep in mind that most victimswere living normal lives prior to the disaster ormass trauma, we can see that the task may bemore one of reminding them of their efficacythan of building efficacy where there wasnone.
When working with children and ado-lescents, there is a developmental course in the
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schematization of self–efficacy, efficacy ofothers (e.g., protective figures), and efficacy ofsocial agencies in response to danger. Ad-dressing such developmental interruptionsand promoting normal and adaptive progres-sion is an important component of post-disas-ter and mass casualty childhood interventions(Saltzman, Layne, Steinberg & Pynoos,2006). Teaching children emotional regula-tion skills when faced by trauma remindersand enhancing problem–solving skills in re-gard to post–disaster adversities are especiallyimportant components of post–disaster inter-ventions that have been shown to be effective(Goenjian et al., 1997, 2005).
Self–efficacy cannot occur in a vacuum;it requires successful partners with whom tocollaborate, join, and solve the oftenlarge–scale problems that are beyond thereach of any individual (e.g., when larger sys-tems fail or create bureaucratic obstacles to re-covery). Tied to perceived self–efficacy is theconstruct of collective efficacy (Benight, 2004;Sampson, Raudenbush, & Earls, 1997). Peo-ple in mass casualty situations are aware thatthey will often sink or swim together. This facthas underscored work by the World HealthOrganization (WHO) in dealing with refugeesfleeing traumatic circumstances, where a keyprinciple of service delivery is the promotionof self–sufficiency and self–government (deJong & Clarke, 1996). In this regard, activitiesthat are conceptualized and implemented bythe community itself may contribute to a senseof community efficacy. These may include re-ligious activities, meetings, rallies, collabora-tion with local healers, or the use of collectivehealing and mourning rituals (de Jong, 2002b,p. 73). Hence, one of the major mental healthinterventions following the tsunami in Asiawere community efforts to support rebuildingfishing boats that allowed fishermen to re-sume their daily activities. Similarly, for chil-dren and adolescents, restoration of theschool community is recognized by WHO andthe United Nations Children’s Fund(UNICEF) as an essential step in reestablish-ing a sense of self–efficacy through renewedlearning opportunities, engagement inage–appropriate, adult-guided memorial ritu-
als, and school-initiated pro–social activity,where children can see grief appropriatelymodeled and fully participate in planning andimplementation of activities (Saltzman et al.,2006).
A competent community providessafety, makes material resources available forrebuilding and restoring order, and shareshope for the future (Iscoe, 1974; McKnight,1997). Collective efficacy may be most poi-gnant on the family level, where psychologi-cal, material, or social losses are most likely tobe felt deeply by loved ones. Families are alsooften the main source of social capital withinany community, and the main provider ofmental health care after disasters, especiallyamong rural populations (de Jong, 2002b).Murthy (1998) argues that the family must of-ten substitute for professional care and soshould be considered a primary axis for inter-vention. Thus, competent communities pro-mote perceptions of self–efficacy among theirmembers, foster the perception that others areavailable to provide support, and supportfamilies who, in turn, provide sustenance totheir members. Holding the perception thatothers can be called upon for support miti-gates the perception of vulnerability and em-boldens individuals to engage in adaptiveactivities they might otherwise see as risky(Layne et al., in press).
Two aspects of self–efficacy and collec-tive efficacy are critical, but are often omittedfrom intervention and planning. The first ofthese is that self– and collective efficacy re-quire behavioral repertoires and skills that arethe basis of the efficacy beliefs (Bandura,1997). Saltzman and colleagues (2006) foundthat people must feel they have the skills toovercome threat and solve their problems. In-deed, self–efficacy beliefs that are not rein-forced by ongoing successful action are likelyto be quickly compromised (Bandura, 1997;Ozer & Bandura, 1990). For instance, sol-diers, emergency service workers, and first re-sponders must learn self– and collective effi-cacy as well as belief in their leaders,themselves, and their group as a unit (Chen &Bliese, 2002; Ginzburg, Solomon, Dekel, &Neria, 2003; Keinan, Friedland, &
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Sarig-Naor, 1990; Solomon, 2003; Solomon,Margalit, Waysman, & Bleich, 1991). Notsurprisingly, research indicates that this is bestdeveloped by practice involving increasinglydifficult situations in which increments of suc-cess build to a reality–based appraisal ofefficacy (Keinan et al., 1990; Meichenbaum,1974).
The second aspect of self– and collec-tive efficacy, one that is often ignored, is thatempowerment without resources is counter-productive and demoralizing (Rappaport,1981). Research on disasters and trauma hasrepeatedly found that those who lose the mostpersonal, social, and economic resources arethe most devastated by mass trauma (Galea etal., 2002; Ironson et al., 1997; Neria et al.,2006). However, research also suggests thatthose who are able to sustain their resourceshave the best ability to recover (Benight,2004; Galea et al., 2003; Norris & Kaniasty,1996). As outlined in Conservation of Re-sources (COR) theory (Hobfoll, 1988, 1998,2001), self– and collective efficacy are them-selves personal resources that are likely to bediminished by mass trauma (Benight et al.1999; Benight, Swift, Sanger, Smith, & Zep-pelin, 1999), and they are made effective bytheir being central management resources that“manage” or orchestrate other personal andenvironmental resources that people possess(Hobfoll, 2002).
Lack of understanding of the link be-tween efficacy beliefs, behavioral skills, andpracticed repertoires as well as access to re-sources leads to serious attribution and inter-vention errors. Hence, people will wrongly as-sume that they, and not circumstances, are thefailure, and intervention will over– or un-der–estimate people’s capabilities. People notonly need the belief that they can effectivelyevacuate, gain access to temporary housing,and find a job on their return, they requirelinkage to resources to act on these beliefs andthe skills required to meet their goals. Thus, itis not surprising that attempts to send traumavictims home with self–help pamphlets islikely to backfire (Turpin, Downs, & Mason,2005), as it assumes that they possess the skillsand resources necessary to enact what is sug-
gested to them in the form of “self–help.”These outcomes will, therefore, be greatly in-fluenced by population vulnerability factors,such as poverty, ethnic minority status, andalready depleted resource reservoirs (e.g., dueto prior exposure and psychiatric history)(Hobfoll, 1998). These related beliefs, skills,and resources, in fact, mutually influence oneanother. Because mass trauma is, typically, anunpracticed experience for all but trained per-sonnel, and because of the unequal distribu-tion of resources in society, there will almostalways be holes in the fabric of thisbelief–behavior–resource linkage thatintervention must attend to, whether on theindividual, family, or group level.
Finally, it must be underscored that be-cause disasters and situations of mass violencemay undermine already fragile economies, ef-forts to return things to “normal” may bedoomed to failure. Because of this, de Jong(2002b) suggests that public mental healthprograms need to collaborate with develop-ment initiatives (i.e., processes of change lead-ing to better living conditions and more securelivelihood) to help local populations enhancetheir survival capacities and increase their re-siliency and quality of life. For example, fol-lowing an earthquake in Iran, interventionistsworked with communities, providing re-sources and guidance to help restore sanita-tion services that lead to empowerment andrestored dignity among citizens (Pinera, Reed,& Njiru, 2005). Benight and colleagues(Benight, 2004; Benight et al., 2000) havenoted that the more that victims of masstrauma are truly empowered, the morequickly they will move to survivor status. Thismay be especially true of children. While par-ents and society quite naturally try to protectchildren, even for children the rule should beto encourage as much self– and collective effi-cacy as possible and for intervention to becognizant of the dangers of over–protective-ness. Adolescents, in particular, can play akey role in community recovery. Admittedly,although the evidence supporting promotionof community development and empower-ment is mainly qualitative (de Jong, 1995;Paardekooper, 2001), the principle
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underpinning this approach has strongempirical support, and its translation tointervention deserves fuller investigation.
PROMOTION OFCONNECTEDNESS
There is a tremendous body of researchon the central importance of social supportand sustained attachments to loved ones andsocial groups in combating stress and trauma(Norris, Friedman, & Watson, 2002; Vaux,1988). Social connectedness increases oppor-tunities for knowledge essential to disaster re-sponse (e.g., “Where is the nearest grocerystore?” “Is safe water available?”). It also pro-vides opportunities for a range of social sup-port activities, including practical problemsolving, emotional understanding and accep-tance, sharing of traumatic experiences, nor-malization of reactions and experiences, andmutual instruction about coping. This, inturn, can lead to sense of community efficacythat we discuss elsewhere in this paper(Benight, 2004). Nevertheless, there is actu-ally little empirical research on how to trans-late this to intervention. Hence, although thisis perhaps the most empirically validated ofthe five principles, interventionists andpolicymakers will have to be creative intranslating this evidence to intervention.
Solomon, Mikulincer, and Hobfoll(1986) noted that prior to development of se-vere emotional distress, combatants experi-ence loneliness and become emotionally dis-tant from those around them, indicating thatthe lack of social connections is a risk factor inthe very onset of PTSD. Following the attackof September 11th in New York and follow-ing terrorist attacks in Israel, one of the mostcommon coping responses was to identify andlink with loved ones (Bleich et al., 2003; Steinet al., 2004). Delay in making connections toloved ones was a major risk factor followingthe London bombings of 2005 (Rubin,Brewin, Greenberg, Simpson, & Wessely,2005). Research on disasters and terrorist at-tacks in the United States (Galea et al., 2002;Weissman et al., 2005), Israel (Bleich et al.,
2003; Hobfoll et al., 2006), Mexico (Norris,Baker, Murphy, & Kaniasty, 2005), Palestine(Punamäki, Komproe, Quota, El Masri, & deJong, 2005), Turkey (Altindag, Ozen, & Sir,2005), and Bosnia (Layne et al., in press) indi-cates that social support is related to betteremotional well–being and recovery followingmass trauma. This key salutogenic role playedby social support is sustained through thepost–trauma period extending for months(Galea et al., 2003) and years (Green et al.,1990; Solomon et al., 2005). Other evidencefrom the field on this issue comes from severalmental health professionals with a high levelof on–site mass trauma experience. They em-phasize that fostering connections as quicklyas possible following mass trauma and assist-ing people in maintaining that contact is criti-cal to recovery (Litz & Gray, 2002; Shalev,Tuval–Mashiach, & Hadar, 2004; Ursano,Fullerton, & Norwood, 1995).
Connecting with others is clearly offundamental importance to children and ado-lescents as well, and facilitating theirreconnection with parents and parental fig-ures is a primary goal in disaster–related inter-ventions (Hagan, 2005). For instance, re-union with at least one family memberfollowing immigration to the United States af-ter the Pol Pot genocide in Cambodia wasl inked with lower levels of chronicposttraumatic stress, depression, and sub-stance abuse in surviving adolescents com-pared to those not reunited with family mem-bers (Kinzie, Sack, Angell, Manson, & Rath,1986). Of particular note, Cambodian youthsliving with war–exposed family membersfared better than their counterparts livingwith non–war-exposed foster families. In lightof such findings, some trauma–focused inter-ventions directly seek to increase the quantity,quality, and frequency of supportive transac-tions between trauma survivors and their so-cial fields (Gottlieb, 1996). A group interven-tion implemented with war–exposed Bosnianadolescents directly targeted social supportvia psychoeducation and skills–building. In-terventions included (a) enhancing knowledgeof specific types of social support (e.g., emo-tional closeness, social connection, feeling
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needed, reassurance of self–worth, reliable al-liance, advice, physical assistance, and mate-rial support); (b) identifying potential sourcesof such support; and (c) learning how to ap-propriately recruit support (Layne et al.,2001). Notably, consumers identified thissupport–seeking skill as one of the mostvaluable program elements (Cox, Davies,Burlingame, Campbell, & Layne, 2005).
The complexity of the social supportprocess is highlighted in the social support, de-terioration, deterrence model (Kaniasty &Norris, 1993; Norris & Kaniasty, 1996). De-veloped through careful research on severaldisasters in the United States, Poland, andMexico, Kaniasty and Norris (1993) note thatat the same time that social support facilitateswell–being and limits psychological distressfollowing mass trauma, parallel social sup-port loss cycles occur. Hence, although initialperiods are characterized by a high degree ofsupport, support systems quickly deteriorateunder the pressure of overuse and the need ofindividuals to get on with their own lives (Ra-phael, 1986). This makes those who beginwith marginal levels of social supportespecially vulnerable.
Moreover, it is important to rememberthat potential supporters may actually act inan undermining, rather than a supportivefashion, and this can be especially destructive(Andrews, Brewin, & Rose, 2003; Hobfoll &London, 1986; Pennebaker & Harber, 1993).Negative social support (e.g., minimizingproblems or needs, unrealistic expectationsregarding recovery, invalidating messages) isa strong correlate to long–term post–traumadistress.
Relating these findings to interventionpolicy, it is paramount that interventionsidentify those who lack strong social support,who are likely to be more socially isolated, orwhose support system might provide under-mining messages (e.g. , blaming,minimalization). Keeping them connected,training people how to access support, andproviding formalized support where informalsocial support fails will be important. It will bemore difficult to reconnect people to socialsupport in cases of evacuation and destruction
of homes and neighborhoods. This means thatintervention in these cases should be a prior-ity, as natural support networks will havedisintegrated (de Jong, 2002b; Sattler et al.,2002).
Large–scale interventions in the major-ity of countries consistently find that efforts topromote social support networks in tempo-rary refugee camps are effective (de Jong,2002b). Work by de Jong (2002b) suggeststhe concept of treating temporary sites as vil-lages rather than camps. Villages have villagecouncils, welcoming committees, places ofworship, places to go for services, meetingplaces, entertainment, a soccer field, andplaces for teens to congregate under supervi-sion. Further, citizens of the village, ratherthan outsiders, fill the social roles and do sowithin their natural cultural traditions andpractices. If people spending most of theirtime alone in their own tents, they are not aslikely to be as connected to others as if theyhave things to occupy their time, social re-sponsibilities, and people to share their expe-riences. This relates again to the issues of self–and collective efficacy noted earlier. It alsoacts to preserve social structures that helpkeep communities intact and preserve rules,order, and social supervision (i.e., the rule oflaw) (Erikson, 1976).
There are also unhealthy sides of thesupport process that intervention policy mustheed. Giel (1990) noted that following masstrauma, previous in group–out group divi-sions, even those that may have been sociallyresolved, may again become salient as peopleuse power to gain access to much needed re-sources. Racial, religious, ethnic, social, andtribal divisions can become active in the pro-cess of vying for favored application of re-sources to those in each group. Work on ter-ror management theory (Landau, Solomon,Greenberg, Cohen & Pyszczynski, 2004;Pyszczynski, Solomon, & Greenberg, 2003)finds that as mortality salience increases, peo-ple become more distrustful of “others,” morejingoistic, and less tolerant. This means thatjust when added social support is needed, so-cial undermining may transpire instead. Sup-porting this theory, Hobfoll and colleagues
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(2006) noted that during a period of high lev-els of terrorism both Jews and Arabs becamemore xenophobic as PTSD increased. Unfor-tunately, politicians may actually attempt tocapitalize on such divisions to increase sup-port from “their” group, as has also beenshown in Sri Lanka (Somasundaram &Jamunantha, 2002).
Despite the research gap between thenatural positive influence of social supportand the influence of intervention–created so-cial support, there is enough experiential evi-dence post September 11th in New York (Sim-eon, Greenberg, Nelson, Schmeidler, &Hollander, 2005) and from WHO experiencewith refugees (van Ommeren, Saxena, &Saraceno, 2005) to make this a “best prac-tices” suggestion, with a clear call for morecareful research on the issue. As Wandersmanand Nation (1998) noted for communitieswith more slow–brewing trauma (e.g., an ar-eas found to be industrial waste sites or havinga high rate of crime), supporting social con-nections is critical to individual, family, andcommunity well-being (see also, Landau &Saul, 2004).
INSTILLING HOPE
There is strong evidence for the centralimportance of retaining hope following masstrauma. Hence, those who remain optimistic(Carver & Scheier, 1998) are likely to havemore favorable outcomes after experiencingmass trauma because they can retain a reason-able degree of hope for their future. Instillinghope is critical because mass trauma is oftenaccompanied by a “shattered worldview”(Janoff–Bulman, 1992), the vision of a short-ened future (American Psychiatric Associa-tion, 1994), and catastrophizing, all of whichundermine hope and lead to reactions of de-spair, futility, and hopeless resignation—thatfeeling that “all is lost.” Because mass traumais usually an experience people are not trainedfor or experienced with, it outstrips theirlearned coping repertoires. Without knowl-edge about how to cope, it is natural that hopeis one of the first victims.
Hope has recently and most commonlybeen defined in psychology as “positive, ac-tion–oriented expectation that a positive fu-ture goal or outcome is possible” (Haase,Britt, Coward, & Leidy, 1992) and, similarly,a thinking process that taps a sense of agency,or will, and the awareness of the steps neces-sary to achieve one’s goals (Snyder et al.,1991). Hobfoll, Briggs–Phillips, and Stines(2003) challenged these perspectives, how-ever, as overly based on “rugged individual-ism” and ignoring the reality that people whoexperience mass trauma, lifetime poverty, andracism often face. Such an action–orientedview of hope is decidedly Western, even up-per–middle class and white. Hope for mostpeople in the world has a religious connota-tion and is not action–oriented (Antonovsky,1979). That is, although hope is internally ex-perienced, it is naturally an outgrowth of thereal circumstances in which people find them-selves. Nevertheless, what is amazing aboutthe human spirit is that many people, whohave been down so long that everything elselooks like up, often do retain a sense of opti-mism, self–efficacy, and belief in both strongothers and a God who will intervene on theirbehalf (Antonovsky, 1979; Lomranz, 1990;Shmotkin, Blumstein, & Modan, 2003).
Perhaps the best theoretical work onhope in the face of mass trauma remains thepioneering work of Antonovsky (1979) in hisexamination of Holocaust survivors. Thehopeful state that Antonovsky describes istermed “a sense of coherence,” which he de-fined as “a pervasive, enduring though dy-namic feeling of confidence that one’s internaland external environments are predictableand that there is a high probability that thingswill work out as well as can reasonably be ex-pected” (p. 123). A major difference betweenthis viewpoint and the efficacy–based views ofhope is that Antonovsky’s belief is based onpast experience and often is the result of thebelief that outside sources act benevolently onone’s behalf . He did not emphasizeself–agency, which he called an expressly up-per–middle class, Western view. Antonovskyemphasized that people, including those in theWest, often find hope, not through internal
298 Essential Elements of Mass Trauma Intervention
agency or self–regulation, but through beliefin God (Smith, Pargament, Brant, & Oliver,(2000), a responsive government (a belief thatmay be diminishing), and superstition belief(e.g., “I’m always lucky; things usually workout for me”).
The danger of hinging hope on an inter-nal sense of agency alone was made apparentafter Hurricane Katrina, where a natural di-saster coupled with a technological disaster inresponding dealt a dual blow to poor residentsof New Orleans in particular. Many did notevacuate, not because they lacked internalagency, but because they had little reason tohope for a positive outcome of evacuating dueto a lack of external resources. This meansthat it is critical to provide services to individ-uals that help them get their lives back inplace, such as housing, employment, reloca-tion, replacement of household goods, andpayment of insurance reimbursements. In astudy of veterans with combat–related PTSD,employment status was found to be the pri-mary predictor of hope (Crowson, Frueh, &Snyder, 2001). Likewise, one of the strongestpredictors of PTSD for victims of HurricaneAndrew was the inability to secure funds to re-build their homes (Ironson et al., 1997).Moves by the state of Mississippi to force in-surance companies to pay for damages fol-lowing state law is a critical mental health in-tervention. On a smaller scale, mental healthprofessionals can develop advocacy programsto aid victims to work through red tape andthe complex processes involved in the tasksthat emerge following mass disaster. Lack ofsuch efforts after the Exxon–Valdez oil disas-ter led to long–term psychological distress andongoing resource loss cycles (Arata, Picou,Johnson, & McNally, 2000). Again, byjoining with individuals, rather than justdoing for them, self–efficacy can be raised inthe process, as well as a sense of hope.
Hope can be facilitated by a broadrange of interventions, from individual togroup to mass media messaging. On an indi-vidual level, several studies have shown thatthose showing early signs of severe distressbenefit from CBT that reduces individual’s ex-aggeration of personal responsibility, some-
thing that severely impedes hope due to thefear that one will continue to do badly becausethe problem is an internal, stable trait (Bryantet al., 1998; Foa et al., 1995). The LearnedOptimism and Positive Psychology Model(Seligman, Steen, Park, & Peterson, 2005)adopts the goals of identifying, amplifying,and concentrating on building strengths inpeople at risk. They distilled therapeutic com-ponents that can be applied to strength–build-ing and prevention in which they concentrateon enhancing hope and disputing the cata-strophic and exaggerated thinking that under-mines hope. Trauma-focused treatment withadolescents has similarly shown the efficacy ofaddressing ongoing trauma-generated expec-tations, beyond symptom response, with for-ward looking exercises that promote develop-mental progression to instill hope andrenewed motivation for learning and futureplanning (Saltzman et al., 2006). Addition-ally, the very act of individual intervention bya mental health professional communicatesthe message that, with treatment, things willget better (i.e., “I’m an expert and I believethat you can succeed”). Interventionists areencouraged to normalize people’s responsesand to indicate that most people recover spon-taneously (Foa & Rothbaum, 1998; Resick etal., 2002), as this in itself instills hope againstdistressing thoughts (e.g., “I’m going crazy,”“I’m inadequate,” “My reaction is a sign that Ican’t take it.”). Early intervention can alsofoster hope by using such techniques as guidedself–dialogue (Foa & Rothbaum, 1998;Meichenbaum, 1974) to underscore andrestructure irrational fears, manage extremeavoidance behavior, control self–defeatingself-statements, and encourage positivecoping behaviors.
Decatastrophizing is another importantintervention component that is critical to pre-serving and restoring hope. Many peoplecatastrophize in order to adaptively preparefor the worst. Early CBT interventions havebeen found useful in counteracting these cog-nitive schemas (Bryant et al., 1998; Foa et al.,1995). Resick’s (Resick et al., 2002) CognitiveProcessing Therapy works to correct errone-ous cognitions related to catastrophizing and
Hobfoll et al. 299
self–labeling with traits that spell ultimatefailure in coping. Paradoxically, envisioning arealistic, yet challenging, even difficult out-come may actually reduce people’s distress,compared to envisioning an exaggerated cata-strophic outcome. For instance, acknowledg-ing that one’s home will take months to re-build may need to be accepted, but theassertion that “I will never have a homeagain” is maladaptive. Hence, intervention atal l levels should communicate thatcatastrophizing is natural, but that it shouldbe identified and countered by morefact–based thinking.
Benefit–finding, often associated withincreased hope, appears to be a common pro-cess among individuals facing a myriad ofthreatening events, and it has been shown topredict mental health adaptation months andeven years later (Antoni et al., 2001; King &Miner, 2000; McMillen, Smith, & Fisher,1997; Stanton, Danoff–Burg, Sworowsky, &Collins, 2001). Still undefined is whether thisphenomenon is best conceived as a selectiveevaluation, a coping strategy, a personalitycharacteristic, a reflection of verifiable changeor growth, a manifestation of an implicit the-ory of change, or a temporal comparison.Caution should be taken in designing inter-ventions that promote seeing benefit intrauma, as even well–intentioned efforts toencourage benefit–finding are frequently in-terpreted as an unwelcome attempt to mini-mize the unique burdens and challenges thatneed to be overcome. Moreover, some re-search has found benefit–finding to be relatedto greater PTSD, greater xenophobia, andgreater support for extreme retaliatory vio-lence (Hobfoll et al., 2006). It is suggested thatinterventions focus more on highlighting al-ready exhibited strengths and benefit–finding,rather than promoting benefit–finding priorto individuals’ readiness.
On a community level, group orlarge–scale interventions may be moreimpactful and efficacious than individual in-terventions. For instance, group interventionsfor mass trauma offer the advantage thatmany of the problems are shared by hundredsor thousands of people, and so coping
worksheets that identify common problemsgain efficiency that might otherwise takemany sessions in individual therapy. On alarger scale, Adger and colleagues (2005)point out that social–ecological resilience is animportant determinant in recovery from di-sasters, particularly the ability of communitiesto mobilize assets, networks, and social capi-tal both to prepare for and respond to disas-ters. This underscores how community pro-cesses interface with individual hope. Themedia, schools and universities, and naturalcommunity leaders (e.g., churches, commu-nity centers) can enhance hope by helpingpeople focus on more accurate risk assess-ment, positive goals, building strengths thatthey have as individuals and communities,and helping them tell their story, followingSeligman and colleagues’ (2005) learned opti-mism and positive psychology model. In thisregard, just as CBT directs individuals not todwell on self–blame and to move into a prob-lem–solving mode, this same set of directivescan be recommended broadly, as so manypeople in such situations share these kinds offeelings and thoughts. The advantage of acommunity model over the individual, in thisregard, is that the group (e.g., mosque, school,business organization, chamber of commerce,Rotary Club) can develop hope–building in-terventions, such as helping others clean upand rebuild, making home visits, organizingblood drives, and involving members of thecommunity who feel they cannot actindividually because of the magnitude of theproblem.
SUMMARY AND CONCLUSIONS
We have outlined five key principles ofearly to mid–level intervention following di-saster and mass violence. These principles areseen as central core elements of interventionand will help in the process of setting policyand designing intervention strategy. They ap-ply to all levels of intervention, from those fo-cusing on the individual to those that arebroadly community based. Clearly, we al-ready have effective clinical interventions for
300 Essential Elements of Mass Trauma Intervention
survivors who develop PTSD (Foa et al.,1999; Resick et al., 2002) and for whom suchtreatment is accessible and acceptable. Whatis needed are more broad–scale interventionsthat inform primary and secondary preven-tion, psychological first–aid, family and com-munity support, and community supportfunctioning (de Jong, 2002a; Eisenbruch, deJong, & van de Put, 2004) (See Table 1).
The scale of recent disasters and inci-dents of mass violence also underscores thatthese interactions must be available to largenumbers of individuals, at levels that quicklyoutstrip the available individual–level thera-pists who are local or may be dispatched to aregion. Clearly, what we have referred to asintervention includes actions that must gowell beyond the bounds of psychotherapy.This means that intervention must be con-ducted not only by medical and mental healthprofessionals, but also by gatekeepers (e.g.,mayors, military commanders, school teach-ers) and lay members of the community. Stop-ping the cycle of resource loss is a key elementof intervention and must become the focus ofboth prevention and treatment of victims ofdisaster and mass trauma, and this includesloss of psychosocial, personal, material, andstructural (e.g. , jobs, inst i tut ions,organizations) resources (Hobfoll, 1998).
We believe that there are many ways tooperationalize these principles, and theyshould be applied in the design of more care-fully detailed interventions that must fit theecology of the culture, place, and type oftrauma. These should be tested to the extentpossible in pilot programs, refined, retested,and finally examined with analyses that ex-amine their components. It will be importantto examine a full spectrum of potential indica-tors of psychological distress and impairedfunctioning in these studies. Depressive disor-der, somatoform disorder, and other anxietydisorders show elevated risk ratios after disas-ters and should be addressed as well as PTSD,in addition to a range of psychosocial prob-lems (de Jong, Komproe, & van Ommeren,2003). Moreover, each of these principles re-flects an important outcome in its own right.Hence, interventions that enhance and pre-
serve sense of safety, calming, self– and com-munal efficacy, connectedness, and hope willhave achieved important successes in thepost–disaster period.
It is also critical that we remain modestin our claims about what interventions can ac-complish towards prevention of long–termfunctional and symptomatic impact. While webelieve that the provision of interventionsbased on these principles will be effective, it isunknown to what extent such interventionswill be associated with significant improve-ments in functioning. As occurred in the caseof the stress debriefing literature (e.g., Ra-phael & Wilson, 2000), overstatement of theproposed effects of an intervention prior toevidence of its impact may lead to implemen-tation of programs of limited effectivenessand block the development of more effica-cious programming. It is also important thatinterventions consider the preferences of re-cipients as a disaster response is planned, aswell as the particular ecology of that disaster.These principles wil l not lead to aone–treatment–fits–all approach.
Post-disaster and mass casualty inter-ventions must also be subjected to economicmodeling and cost–benefit analyses. Such in-terventions, given the numbers of potential re-cipients who may be involved, will demandconsiderable revenues and resources. For thisreason, there will be a need to designmulti–layered interventions, with costly (percase) individual–level interventions for themost seriously impaired and less costly (percase) intervention for larger groups and com-munities. For instance, Basoglu and col-leagues (2005), in an attempt to develop abrief treatment for disaster survivors, foundthat a single session of modified behavioraltreatment in earthquake–related PTSD pro-duced significant treatment effects on all mea-sures at post–treatment. More generally, me-dia–, telephone–, and internet–basedinterventions hold promise as cost–effectiveways of promoting sense of safety, efficacy,connectedness, calming, and hope and arelikely to supplement more traditional forms ofresponse (cf., Ruzek, 2006; Ruzek, Maguen,& Litz, in press).
Hobfoll et al. 301
302 Essential Elements of Mass Trauma Intervention
TA
BL
E 1
.
Publ
ic H
ealt
h M
easu
res
Indi
vidu
al/G
roup
Mea
sure
sPr
inci
ple:
Saf
ety
•A
s m
uch
as p
ossi
ble,
bri
ng p
eopl
e to
a s
afe
plac
e an
d m
ake
it c
lear
tha
t it
issa
fe•
Prov
ide
an a
ccur
ate,
org
aniz
ed v
oice
to
help
cir
cum
scri
be t
hrea
t an
dth
ereb
y in
crea
se t
he p
erce
ptio
n of
saf
ety
whe
re t
here
is n
o se
riou
s ex
tant
thre
at•
Info
rm t
he m
edia
tha
t en
hanc
ing
safe
ty p
erce
ptio
ns in
a c
omm
unit
y ca
n be
achi
eved
by
med
ia c
over
age
that
str
ateg
ical
ly c
onve
ys s
afet
y an
d re
silie
nce
rath
er t
han
imm
inen
t th
reat
•E
ncou
rage
indi
vidu
als
to li
mit
exp
osur
e to
new
s m
edia
ove
rall,
and
to
avoi
dm
edia
tha
t co
ntai
n gr
aphi
c fi
lm o
r ph
otos
if t
hey
are
expe
rien
cing
incr
ease
ddi
stre
ss f
ollo
win
g vi
ewin
g•
Rec
omm
end
limit
ing
the
amou
nt o
f ta
lkin
g ab
out
the
trau
ma
if d
oing
so
mak
es o
ne m
ore
anxi
ous
or d
epre
ssed
•T
each
peo
ple
how
to
disc
rim
inat
e be
twee
n po
litic
al p
ropa
gand
a an
d m
ore
real
isti
c in
form
atio
n re
gard
ing
thre
at in
the
con
text
of
war
and
ter
rori
sm.
•E
duca
te p
aren
ts r
egar
ding
lim
itin
g an
d m
onit
orin
g ne
ws
expo
sure
for
chi
l -dr
en
•E
ngag
e in
imag
inal
exp
osur
e an
d re
al–w
orld
, in–
vivo
exp
osur
e w
hich
:º
Inte
rrup
t th
e po
st–t
raum
atic
sti
mul
us g
ener
aliz
atio
n th
at li
nks
harm
less
imag
es, p
eopl
e, a
nd t
hing
s to
dan
gero
us s
tim
uli
asso
ciat
ed w
ith
the
orig
inal
tra
umat
ic t
hrea
tº
Re–
link
thos
e im
ages
, peo
ple,
and
eve
nts
wit
h sa
fety
(“T
he b
ridg
e th
at c
olla
psed
was
thr
eate
ning
, but
all
brid
ges
are
not.
”“T
hat
nigh
t w
as u
nsaf
e, b
ut a
ll ni
ghts
are
not
uns
afe.
”)•
Uti
lize
“gro
undi
ng t
echn
ique
s,”
such
as
real
ity
rem
inde
rs, t
o br
ing
indi
vidu
als
to t
he r
elat
ive
safe
ty o
f th
e pr
esen
t ti
me
•T
each
con
text
ual d
iscr
imin
atio
n in
the
fac
e of
tra
uma
and
loss
tri
gger
s•
Ass
ist
in d
evel
opin
g m
ore
adap
tive
cog
niti
ons
and
copi
ng s
kills
•W
ith
child
ren,
incl
ude
met
hods
tha
t ai
d in
the
rev
ersa
l of
regr
essi
on in
the
abi
lity
to d
iscr
imin
ate
amon
g in
dica
tion
s of
dan
-ge
r
Prin
cipl
e: C
alm
ing
•Fi
rst
and
fore
mos
t, e
ngag
e in
act
ions
tha
t he
lp p
eopl
e di
rect
ly s
olve
con
-ce
rns.
(e.
g., b
olst
erin
g in
itia
l res
ourc
es a
nd p
reve
ntin
g re
sour
ce lo
ss)
•G
ive
info
rmat
ion
on w
heth
er f
amily
and
fri
ends
are
saf
e, a
nd if
fur
ther
dan
-ge
r is
impe
ndin
g•
Prov
de la
rge–
scal
e co
mm
unit
y ou
trea
ch a
nd p
sych
oedu
cati
on v
ia m
edia
pres
enta
tion
, int
erac
tive
web
site
s an
d co
mpu
ter
prog
ram
s ab
out
the
follo
w-
ing
topi
cs:
—Po
st–d
isas
ter
reac
tion
s to
hel
p in
divi
dual
s se
e th
eir
reac
tion
s as
und
er-
stan
dabl
e an
d ex
pect
able
—A
nxie
ty m
anag
emen
t te
chni
ques
for
com
mon
pos
t–tr
aum
a pr
oble
ms
(e.g
., sl
eep
prob
lem
s, r
eact
ivit
y to
rem
inde
rs, s
tart
le r
eact
ions
, inc
i-de
nt–s
peci
fic
new
fea
rs)
—Si
gns
of m
ore
seve
re d
ysfu
ncti
on, s
o th
at p
eopl
e al
so d
o no
tun
derp
atho
logi
ze t
heir
sym
ptom
s an
d kn
ow w
here
to
turn
for
pro
fes-
sion
al a
sses
smen
t an
d tr
eatm
ent
—L
imit
ing
med
ia e
xpos
ure
for
thos
e w
ith
min
or t
o m
id–l
evel
pro
blem
sof
anx
iety
—R
ecei
ving
new
s re
port
s fr
om a
fri
end
or f
amily
mem
ber
that
giv
e th
efa
cts
wit
hout
the
imag
es a
nd h
yper
bole
, for
tho
se w
ith
mor
e se
vere
emot
iona
lity
•N
ot R
ecom
men
ded:
—T
he u
se o
f lie
s, o
r “s
pinn
ing”
info
rmat
ion,
in o
rder
to
calm
a p
opul
a-ti
on o
r a
grou
p of
res
cued
indi
vidu
als,
whi
ch u
ltim
atel
y un
derm
ines
cred
ibili
ty a
nd is
cou
nter
–pro
duct
ive
•O
ffer
dir
ect
appr
oach
es in
anx
iety
man
agem
ent
to h
elp
thos
e w
ith
seve
re a
gita
tion
, “ra
cing
” em
otio
ns, o
r ex
trem
e nu
mbi
ngre
acti
ons
atta
in a
sta
te o
f m
aste
ry o
r ca
lmin
g, s
uch
as:
ºT
hera
peut
ic g
roun
ding
(fo
r th
ose
wit
h re
–exp
erie
ncin
g sy
mpt
oms)
ºB
reat
hing
ret
rain
ing
ºD
eep
mus
cle
rela
xati
onº
Stre
ss in
ocul
atio
n tr
aini
ng, i
nclu
ding
:—
copi
ng s
kills
—de
ep m
uscl
e re
laxa
tion
—br
eath
ing
cont
rol
—as
sert
iven
ess
—ro
le p
layi
ng—
cove
rt m
odel
ing
—th
ough
t st
oppi
ng, p
osit
ive
thin
king
and
sel
f–ta
lkº
Yog
aº
Min
dful
ness
tre
atm
ents
ºIm
ager
y an
d m
usic
pai
red
wit
h re
laxe
d st
ates
ºM
edic
atio
ns s
uch
as a
nti–
adre
nerg
ic a
gent
s, a
ntid
epre
ssan
ts, a
nd c
onve
ntio
nal a
nxio
lyti
csº
Inte
rven
tion
s w
ith
a co
mbi
nati
on o
f an
xiet
y m
anag
emen
t sk
ills,
cog
niti
ve r
estr
uctu
ring
, and
exp
osur
eº
Tra
inin
g in
pro
blem
–foc
used
cop
ing,
whi
ch a
ssis
ts in
divi
dual
s in
bre
akin
g do
wn
the
prob
lem
into
sm
all,
man
agea
ble
unit
s. T
his
will
:—
incr
ease
sen
se o
f co
ntro
l—
prov
ide
oppo
rtun
itie
s fo
r sm
all w
ins
—de
crea
se t
he r
eal p
robl
ems
peop
le a
re f
acin
gº
“Nor
mal
izat
ion”
of
stre
ss r
eact
ions
to
redu
ce a
nxie
ty a
ssoc
iate
d w
ith
reac
tion
s (e
.g.,
“I’m
goi
ng c
razy
,” “
The
re’s
som
e-th
ing
wro
ng w
ith
me,
” “I
mus
t be
wea
k.”)
•In
volv
emen
t w
ith
uplif
ting
act
ivit
ies
not
asso
ciat
ed w
ith
the
trau
ma
ºPu
rpos
e:T
o di
stra
ct f
rom
dis
tres
sing
pre
occu
pati
on w
ith
the
trau
ma
and
its
afte
rmat
h. (
for
indi
vidu
als
who
are
not
in e
xtre
me
dist
ress
)T
o pr
omot
e a
sens
e of
pre
dict
abili
ty, n
orm
alcy
, and
con
trol
(in
bot
h th
e ou
ter
wor
ld a
nd in
ner
wor
ld o
f co
gnit
ion
and
emot
ions
)T
o fo
ster
pos
itiv
e em
otio
ns t
hat
incl
ude
joy,
hum
or, i
nter
est,
con
tent
men
t, a
nd lo
ve a
nd h
ave
a fu
ncti
onal
cap
acit
y to
broa
den
a “t
houg
ht–a
ctio
n” r
eper
toir
e th
at le
ads
to e
ffec
tive
cop
ing
Hobfoll et al. 303
•E
xam
ples
:B
eing
wit
h fr
iend
sL
iste
ning
to
calm
ing
mus
icG
oing
to
a m
ovie
Wat
chin
g a
situ
atio
n co
med
yE
xerc
ise
(als
o ha
s a
depr
essi
on–r
educ
ing
and
an a
nxie
ty–r
educ
ing
effe
ct)
Not
Rec
omm
ende
d:•
Ben
zodi
azap
ene
tran
quili
zers
, whi
ch h
ave
been
sho
wn
to in
crea
se t
he li
kelih
ood
of P
TSD
am
ong
sym
ptom
atic
tra
uma
surv
i -vo
rs, d
espi
te a
n im
med
iate
cal
min
g ef
fect
•Ps
ycho
logi
cal d
ebri
efin
g, w
hich
may
enh
ance
aro
usal
in t
he im
med
iate
aft
erm
ath
of t
raum
a ex
posu
re•
Alc
ohol
, whi
ch c
an le
ad t
o po
tent
ial m
isus
e an
d ot
her
alco
hol–
rela
ted
beha
vior
sPr
inci
ple:
Self–
and
Col
lect
ive
Eff
icac
y•
Prov
ide
peop
le w
ith
outs
ide
reso
urce
s th
at c
an b
e us
ed t
o he
lp r
ever
se t
helo
ss c
ycle
, whi
ch le
ads
to e
mpo
wer
men
t an
d re
stor
ed d
igni
ty a
mon
g ci
tize
ns•
Cre
ate
a w
ay t
o m
anag
e an
d or
ches
trat
e pe
ople
’s p
erso
nal a
nd e
nvir
onm
en-
tal r
esou
rces
•A
s m
uch
as p
ossi
ble,
invo
lve
vict
ims
in d
ecis
ion–
mak
ing
polic
y an
d ef
fort
s(e
.g.,
targ
etin
g of
nee
d), t
o re
build
sel
f– a
nd c
olle
ctiv
e–ef
fica
cy.
•Pr
omot
e ac
tivi
ties
tha
t ar
e co
ncep
tual
ized
and
impl
emen
ted
by t
he c
omm
u -ni
ty, s
uch
as:
ºre
ligio
us a
ctiv
itie
sº
mee
ting
sº
ralli
esº
colla
bora
tion
wit
h lo
cal h
eale
rsº
colle
ctiv
e he
alin
g an
d m
ourn
ing
ritu
als
•Fo
ster
“co
mpe
tent
com
mun
itie
s” t
hat:
ºen
cour
age
the
wel
l–be
ing
of t
heir
cit
izen
sº
prov
ide
safe
tyº
mak
e m
ater
ial r
esou
rces
ava
ilabl
e fo
r re
build
ing
and
rest
orin
g or
der
ºsh
are
hope
for
the
fut
ure
ºsu
ppor
t fa
mili
es, w
ho a
re o
ften
the
mai
n pr
ovid
er o
f m
enta
l hea
lth
care
afte
r di
sast
ers
ºfo
ster
the
per
cept
ion
that
oth
ers
are
avai
labl
e to
pro
vide
sup
port
, whi
ch:
—m
itig
ates
the
per
cept
ion
of v
ulne
rabi
lity
—em
bold
ens
indi
vidu
als
to e
ngag
e in
ada
ptiv
e ac
tivi
ties
the
y m
ight
oth
-er
wis
e se
e as
ris
ky•
Col
labo
rate
wit
h ru
ral d
evel
opm
ent
and
voca
tion
al s
kills
tra
inin
g in
itia
tive
sto
:º
help
loca
l pop
ulat
ions
to
enha
nce
thei
r su
rviv
al c
apac
itie
sº
incr
ease
res
ilien
ce a
nd q
ualit
y of
life
ºpr
even
t ex
acer
bati
on o
f ps
ycho
logi
cal d
istu
rban
ces
by in
still
ing
hope
and
help
ing
surv
ivor
s to
acq
uire
a s
ense
of
cont
rol a
nd m
aste
ry•
For
child
ren
and
adol
esce
nts:
ºB
e co
gniz
ant
of t
he d
ange
rs o
f ov
er–p
rote
ctiv
enes
sº
Incl
ude
them
in c
omm
unit
y re
cove
ryº
Faci
litat
e re
stor
atio
n of
the
sch
ool c
omm
unit
y, w
hich
fos
ters
:—
rene
wed
lear
ning
opp
ortu
niti
es—
enga
gem
ent
in a
ge–a
ppro
pria
te, a
dult
–gui
ded
mem
oria
l rit
uals
—sc
hool
–ini
tiat
ed p
ro–s
ocia
l act
ivit
y (l
earn
ed h
elpl
essn
ess
into
lear
ned
help
fuln
ess)
•In
divi
dual
and
gro
up–a
dmin
iste
red
cogn
itiv
e be
havi
oral
the
rapy
(C
BT
) sh
ould
:º
Rem
ind
indi
vidu
als
of t
heir
eff
icac
yº
Enc
oura
ge a
ctiv
e co
ping
and
goo
d ju
dgm
ent
abou
t w
hen
and
how
to
cope
ºE
nhan
ce s
ense
of
cont
rol o
ver
trau
mat
ic s
tres
sors
ºH
elp
to “
reca
libra
te”
expe
ctat
ions
and
goa
ls t
hat
wer
e fo
rmed
und
er “
norm
al”
circ
umst
ance
sº
Tra
nsla
te in
terv
enti
on w
ithi
n th
e so
cio–
cult
ural
eco
logi
es o
f th
e ta
rget
cou
ntri
es•
Fost
er b
ehav
iora
l rep
erto
ires
and
ski
lls t
hat
are
the
basi
s of
the
eff
icac
y be
liefs
, wit
h pr
acti
ce in
volv
ing
incr
easi
ngly
dif
ficu
ltsi
tuat
ions
•T
each
indi
vidu
als
to s
et a
chie
vabl
e go
als,
so
they
may
:—
reve
rse
the
dow
nwar
d sp
iral
tow
ard
feel
ings
of
failu
re a
nd in
abili
ty t
o co
pe—
have
rep
eate
d su
cces
s ex
peri
ence
s—
rees
tabl
ish
a se
nse
of e
nvir
onm
enta
l con
trol
nec
essa
ry f
or s
ucce
ssfu
l dis
aste
r re
cove
ry•
Wit
h ch
ildre
n an
d ad
oles
cent
s:º
Add
ress
dev
elop
men
tal i
nter
rupt
ions
ºPr
omot
e no
rmal
and
ada
ptiv
e de
velo
pmen
tal p
rogr
essi
onº
Tea
ch e
mot
iona
l reg
ulat
ion
skill
s w
hen
face
d by
tra
uma
rem
inde
rsº
Enh
ance
pro
blem
–sol
ving
ski
lls in
reg
ard
to p
ost–
disa
ster
adv
ersi
ties
304 Essential Elements of Mass Trauma Intervention
TA
BL
E 1
. (co
ntin
ued)
Publ
ic H
ealt
h M
easu
res
Indi
vidu
al/G
roup
Mea
sure
sPr
inci
ple:
Con
nect
edne
ss•
Hel
p in
divi
dual
s to
iden
tify
and
link
wit
h lo
ved
ones
•Fa
cilit
ate
reco
nnec
tion
of
child
ren
wit
h pa
rent
s an
d pa
rent
al f
igur
es•
Incr
ease
the
qua
ntit
y, q
ualit
y, a
nd f
requ
ency
of
supp
orti
ve t
rans
acti
ons
be-
twee
n tr
aum
a su
rviv
ors
and
thei
r so
cial
sup
port
s•
Tre
at t
empo
rary
hou
sing
and
ass
ista
nce
site
s as
vill
ages
, whi
ch h
ave:
ºvi
llage
cou
ncils
ºw
elco
min
g co
mm
itte
esº
chur
ches
ºpl
aces
to
go f
or s
ervi
ces
ºm
eeti
ng p
lace
sº
ente
rtai
nmen
tº
spor
ts f
ield
sº
recr
eati
onal
act
ivit
ies
ºpl
aces
for
tee
ns t
o co
ngre
gate
und
er s
uper
visi
onº
relig
ion–
scho
ol–c
omm
unit
y pa
rtne
rshi
p ne
twor
ksº
men
tori
ng s
ervi
ces
ºco
mm
unit
y so
lidar
ity
acti
viti
esº
citi
zens
who
fill
soc
ial r
oles
wit
hin
thei
r na
tura
l cul
tura
l tra
diti
ons
and
prac
tice
s•
As
muc
h as
pos
sibl
e, a
ddre
ss p
oten
tial
neg
ativ
e so
cial
infl
uenc
es (
e.g.
, mis
-tr
ust,
in–g
roup
/out
–gro
up d
ynam
ics,
impa
tien
ce w
ith
reco
very
, exh
aust
ion,
etc.
) w
hen
desi
gnin
g in
terv
enti
ons
•Id
enti
fy a
nd a
ssis
t th
ose
who
lack
str
ong
supp
ort,
who
are
like
ly t
o be
mor
e so
cial
ly is
olat
ed, o
r w
hose
sup
port
sys
tem
mig
ht p
rovi
de u
nder
min
ing
mes
sage
s (e
.g.,
blam
ing,
min
imal
izat
ion)
.•
In c
ases
of
evac
uati
on a
nd d
estr
ucti
on o
f ho
mes
and
nei
ghbo
rhoo
ds, o
r w
here
info
rmal
soc
ial s
uppo
rt f
ails
, mak
e it
a p
rior
-it
y to
:º
keep
indi
vidu
als
conn
ecte
dº
trai
n pe
ople
how
to
acce
ss s
uppo
rtº
prov
ide
form
aliz
ed s
uppo
rt•
Tar
get
soci
al s
uppo
rt v
ia p
sych
oedu
cati
on a
nd s
kills
–bui
ldin
g, in
clud
ing:
º(a
) E
nhan
cing
kno
wle
dge
of s
peci
fic
type
s of
soc
ial s
uppo
rt, s
uch
as:
—em
otio
nal c
lose
ness
—so
cial
con
nect
ions
—fe
elin
g ne
eded
—re
assu
ranc
e of
sel
f–w
orth
—re
liabl
e al
lianc
e—
advi
ce—
phys
ical
ass
ista
nce
—m
ater
ial s
uppo
rtº
(b)
Iden
tify
ing
pote
ntia
l sou
rces
of
such
sup
port
º(c
)L
earn
ing
how
to
appr
opri
atel
y re
crui
t su
ppor
t•
Tea
ch in
divi
dual
s to
igno
re a
ttac
hmen
t bo
nds
in e
vacu
atio
n pr
oced
ures
•W
ith
fam
ilies
, inc
lude
spe
cifi
c st
rate
gies
to
addr
ess
disc
orda
nce
amon
g fa
mily
mem
bers
tha
t m
ay s
tem
fro
m:
ºdi
ffer
ence
s in
the
typ
e an
d m
agni
tude
of
expo
sure
to
trau
ma,
loss
, and
sub
sequ
ent
adve
rsit
ies
ºdi
ffer
ence
s be
twee
n fa
mily
mem
bers
’ per
sona
l rea
ctio
ns t
o tr
aum
a an
d lo
ss r
emin
ders
Prin
cipl
e: H
ope
•Pr
ovid
e se
rvic
es t
o in
divi
dual
s th
at h
elp
them
get
the
ir li
ves
back
in p
lace
,su
ch a
s:º
hous
ing
ºem
ploy
men
tº
relo
cati
onº
repl
acem
ent
of h
ouse
hold
goo
dsº
clea
n–up
and
reb
uild
ing
ºpa
ymen
t of
insu
ranc
e re
imbu
rsem
ents
•D
evel
op a
dvoc
acy
prog
ram
s to
hel
p vi
ctim
s w
ork
thro
ugh
red
tape
and
the
com
plex
pro
cess
es in
volv
ed in
the
tas
ks t
hat
emer
ge f
ollo
win
g m
ass
disa
ster
.•
Supp
ort
rebu
ildin
g of
loca
l eco
nom
ies
that
allo
w in
divi
dual
s to
res
ume
thei
rda
ily v
ocat
iona
l act
ivit
y, t
o pr
even
t on
goin
g re
sour
ce lo
ss c
ycle
s•
The
med
ia, s
choo
ls a
nd u
nive
rsit
ies,
and
nat
ural
com
mun
ity
lead
ers
(e.g
.,ch
urch
es, c
omm
unit
y ce
nter
s) s
houl
d he
lp p
eopl
e w
ith:
ºL
inki
ng w
ith
reso
urce
sº
Est
ablis
hing
sys
tem
s th
at e
nabl
e th
ose
in r
ecov
ery
from
sim
ilar
trau
mas
to s
hare
the
ir e
xper
ienc
e an
d ho
pe w
ith
thos
e st
rugg
ling
wit
h re
cove
ryº
Mem
oria
lizin
g an
d m
akin
g m
eani
ngº
Acc
epti
ng t
hat
thei
r liv
es a
nd t
heir
env
iron
men
t m
ay h
ave
chan
ged,
ºM
akin
g m
ore
accu
rate
ris
k as
sess
men
tº
Red
ucin
g se
lf–b
lam
eº
Prob
lem
–sol
ving
ºSe
ttin
g po
siti
ve g
oals
•B
uild
ing
stre
ngth
s th
at t
hey
have
as
indi
vidu
als
and
com
mun
itie
s
•C
ogni
tive
beh
avio
ral t
hera
py (
CB
T)
that
:º
Red
uces
exa
gger
atio
n of
per
sona
l res
pons
ibili
ty a
nd c
ount
erac
ts c
ogni
tive
sch
emas
, suc
h as
cat
astr
ophi
zing
and
the
bel
ief
that
pro
blem
s ar
e du
e to
an
inte
rnal
, sta
ble
trai
tº
Iden
tifi
es, a
mpl
ifie
s, a
nd c
once
ntra
tes
on b
uild
ing
stre
ngth
sº
Nor
mal
izes
res
pons
esº
Indi
cate
s th
at m
ost
peop
le r
ecov
er s
pont
aneo
usly
ºH
ighl
ight
s al
read
y ex
hibi
ted
stre
ngth
s an
d be
nefi
t–fi
ndin
g, r
athe
r th
an p
rom
otin
g be
nefi
t—fi
ndin
g pr
ior
to a
n in
divi
dual
’sre
adin
ess.
ºIn
clud
es g
uide
d se
lf–d
ialo
gue
to:
—en
visi
on a
rea
listi
c, y
et c
halle
ngin
g, e
ven
diff
icul
t ou
tcom
e (e
.g.,
acce
ptin
g th
at o
ne’s
hom
e w
ill t
ake
mon
ths
to r
ebui
ldvs
. the
ass
erti
on t
hat
“I w
ill n
ever
hav
e a
hom
e ag
ain”
)—
unde
rsco
re a
nd r
estr
uctu
re ir
rati
onal
fea
rs—
man
age
extr
eme
avoi
danc
e be
havi
or—
cont
rol s
elf–
defe
atin
g se
lf s
tate
men
ts—
enco
urag
e po
siti
ve c
opin
g be
havi
ors
•W
ith
child
ren
and
adol
esce
nts,
CB
T t
hat:
ºA
ddre
sses
ong
oing
tra
uma–
gene
rate
d ex
pect
atio
ns, b
eyon
d sy
mpt
om r
espo
nse
ºIn
clud
es f
orw
ard–
look
ing
exer
cise
s th
at p
rom
ote
deve
lopm
enta
l pro
gres
sion
to
inst
ill h
ope
and
rene
wed
mot
ivat
ion
for
lear
ning
and
fut
ure
plan
ning
Hobfoll et al. 305
Clearly, the major weakness of our rec-ommendations is that there are few clinical tri-als or direct examinations of the principles wehave recommended in disaster or mass vio-lence contexts. What we have done is to care-fully review the empirical literature frommany fields, compare it to the broad experi-ences we have as experts involved in work ondisasters, terrorism, war and other mass casu-alty situations, and make informed judgmentsand recommendations. Currently, govern-ments, public health agencies, and aid organi-zations are without any roadmap for interven-tion. It is our combined judgment that therewill not be a blueprint that will be based on di-rect evidence (i.e., randomized, controlled tri-als) in this field in the reasonable future. In-deed, many of us feel that the chaotic andvaried nature of disasters and mass casualtysituations will prevent our ever having a clear,articulated blueprint based on strong, direct,
empirical evidence. Hence, we believe that ourempirically informed review and principlesare the best strategy for the near and mediumrange future. Clearly, it is not the only way theliterature can be interpreted, but we believe itis a sound effort that can have major publichealth impact.
Finally, in applying these principles in-ternationally, it will be critical to consider lo-cal culture and custom at all stages of designand implementation (de Jong, 2002a). We be-lieve that there is international, multiculturalevidence for each of the general principles, buthow they are translated into practice and thedegree, for example, of emphasis on individ-ual versus collective process will vary greatlyfrom East to West and from industrialized tonon–industrialized world. In each case, apply-ing the principles of ecological congruencewill be paramount (Hobfoll, 1988).
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