five essential elements of immediate and mid–term mass trauma

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

284 Essential Elements of Mass Trauma Intervention

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


“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


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-


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


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, &


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


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


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


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


TA

BL

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port

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gent

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lyti

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rven

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s w

ith

a co

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bre

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into

sm

all,

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agea

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s. T

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f co

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prov

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itie

s fo

r sm

all w

ins

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crea

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ems

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gº

“Nor

mal

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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

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razy

,” “

The

re’s

som

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wro

ng w

ith

me,

” “I

mus

t be

wea

k.”)

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volv

emen

t w

ith

uplif

ting

act

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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


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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five essential elements of immediate and mid–term mass trauma

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