Five Essential Elements of Immediate and Mid–Term Mass Trauma Intervention: Empirical Evidence - KAMHA.ORG

8/9/2019 Five Essential Elements of Immediate and MidTerm Mass Trauma Intervention: Empirical Evidence - KAMHA.ORG

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mendations for intervention during the immediate and the midterm post masstrauma phases. Because it is unlikely that there will be evidence in the near ormidterm future from clinical trials that cover the diversity of disaster and massviolence circumstances, we assembled a worldwide panel of experts on the study

and 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 midtermstages. 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 fewdecades. No evidencebased con-sensus has beenreached to date with regard toeffective interventions for use in the immedi-ate and the midterm 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 longterm 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-dencebased framework for postdisasterpsychosocial intervention. This gap in thefield has led to a search for an evidencein-formed framework for postdisasterpsychosocial intervention.Onesolution to thelack of direct research evidence for such inter-ventions hasbeen to both extrapolate from re-lated fields of research to create evidencein-formed practices and to attempt to gainconsensus from researchers and practitionersin the fields of trauma and disaster recovery.Ofgreatest interest is the identification of coreinterventionrelated foci that are best sup-ported by the literature as promotingstressresistant 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 increasesworldwidein 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 caninforminterventionpolicy. Notall 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 summarizeourview of the distilled version of best interven-tion practices following major disaster andterrorist attacks for the shortterm andmidterm 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 traumaticeventsandtheir 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, ranging

from prevention, to support, to therapeuticintervention that are supported by the empiri-cal literature and canbe termedevidencein-formed. It ishighlyunlikely that wewill havean adequate representation of randomizedcontrolled trials of interventions for major di-saster events or terrorist attack in the near tomidterm future, if ever. Therefore a major

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step in promoting the development of effec-tive, efficient, and sustainable interventions isto ensure that, to the extent possible, they areinformed by empirical evidence and meet

standards 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 overwhelmingeither 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, bodiesfloatingina NewOrleans street) orby their symbolic implications (beheading ofprisoners) or personal relevance (e.g., assum-ing that an act of terror could reach ones ownneighborhood) (Reissman, Klomp, Kent, &Pfefferbaum, 2004). Second, the devastationof resourcescanimpoverish thecapacity of in-dividuals and communities to cope with atraumatic situation and recover from its con-sequences, especially where individuals orcommunit ies a l ready 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 initsintensity andeffect to theprevious elementsof witnessing horrors and direct personalthreat. Many traumatic events involve power-ful reactivationof attachment systems anden-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 territoryeither via relocationorindirectly,aspeoplespreviously securebase 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 posttrauma. Finally, the potentiallydamaging effects of traumatic events on peo-ples senseofmeaning, justice,andorderoften

have extremely stressful effects. Many traumasurvivors struggle with challenges to sense ofmeaning andjustice in the face of shatteredas-sumptions about prevailing justice in theworld due tothe way inwhich theywereeitherexposed to traumatic events (e.g., being senttoa war theyperceiveassenseless,being an in-nocent vict im) or treated during theposttraumatic af termath (e .g. , v iadiscriminatory distribution of resources). It ison the basis of these principles thatwecametoseek, identify,anddescribe thebasic,practicalrecommendations that follow.

It is important to recognize from theoutset that peoples 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(Galeaet 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 wideranging 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 andpro-grams following disaster and mass violence.We recommend that these practices and tech-niques, or their elements, should be containedwithin intervention and prevention efforts attheearly to midterm stages. These guidelineswill be particularly important to those respon-sible for broader publichealth and emergencymanagement. These principles are:

1. Promote sense of safety.

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right now, even if safety is restored. Thismodel holds that corrective information isneeded in the aftermath of trauma to ensurethat individuals canappraise future threat in a

realistic 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 strategies

that 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 posttrau-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 realworld, invivoexposure in ways that relink those images,people, and events with safety (The bridgethat collapsedwas threatening, butall bridgesarenot Thatnightwasunsafe, butallnightsare not unsafe.). Interventions have also uti-lized reality reminders, teaching contextualdiscrimination in the face of trauma and losstriggers,assistingin developingmoreadaptivecognitions and coping skills, and groundingtechniques to enhance peoples 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 of

trauma 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 safetycannotbeachieved, theextentthatsafety is enhanced will aid peoples 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 automat ic i ty of thethreatsurvival physiology and associatedcognitions (Solomon et al., 2005).

On a public health level, how to estab-lish safety may appear obvious, in that weshouldbring people toa safeplace and make itclear that it is safe. The promotion of a senseof safety is very similar to Bells and Pynoossprinciple of reestablishing the protectiveshield, which is a key principle of their respec-tive work in community and disaster psychia-tryon healthbehavior 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 toenhance safetymust in-clude a social systems perspective. Althoughsocial support has a major positive impact, aswe will detail, in the aftermath of largescalecommunity trauma it may have the oppositeimpact. When complete information aboutmass trauma is lacking (a commonoccurrencefollowingdisastersand massviolence),peopletend to share rumors and horror storiesabout the event. Hobfoll and London (1986)termed this the pressurecooker effect.

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While this is probably intended to gain sup-port, it hasbeen found that increasing dosesofthis 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 thisadditionaloverexposure. Interventionshould, therefore, recommend limiting theamount of this type of talking about thetrauma ifdoing somakes one moreanxious 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 disasters

and terrorist acts (see, for example, Bleich etal., 2003).Because fears concerning the safetyof relatives may be greater than those con-cerning theself, interventionmust aid identifi-cation of loved ones and their condition as anutmost priority. Thus, even prior to peoplesneed 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 Bushs 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 governmentissued

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 messages

may 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. Bushs election in 2004 was themedia attention, and the attention focused onterrorism by those seeking electiongiven toimminent terrorist threats (Cohen, Ogilvie,Solomon, Greenberg, & Pyszczynski, 2005).This evidence highlights that communitiesmay have difficulty maintaining a sense ofsafety in the aftermath ofmassviolence ifgov-

ernmentagenciesand electedofficialsstrategi-cally elevate the communitys 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 significantsocietallevel obstacle to establishing a senseof safety. Media may report events in waysthat inadvertently decrease a sense of safetyorthat are intentionally unclear as to the degreeof safety because marketing research suggeststhat uncertainty and fear promote increasedviewing of the news. Additionally, it is com-monformedia to repeatedly display imagesofthreat that can serve to reduce the commu-nitys perception of safety. Thus, mediare-lated factors may impede recovery since adoseresponse effect has been found in multi-ple studies linking exposure to televised im-ages of the traumatic event to greater psycho-logical distress (Ahern et al., 2002; Nader &Pynoos, 1993; Neria et al., 2006; Pfefferbaum



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et al., 2002; Schlengeret al., 2002; Silveret al.,2002; Torabi & Seo, 2004). Although it is dif-ficult to determine the causal relationship be-tween media viewing and fear, these findings

are consistent with the proposal that mediaexposure influences fear in the community.Additionally, young childrenarelikelyto havedifficulty understanding that an event hasended,believingthat replays on the local newsrepresent new incidents or continued threat(Fremont, 2004; Lengua, Long, Smith, &Meltzoff, 2005; Pfefferbaum et al., 2002). Forthis reason, media shouldbe educated that en-hancing safety perceptions in a communitycanbe achieved by mediacoverage that strate-gically conveys safety and resilience ratherthan imminent threat. Additionally, effective

mental 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 results

in 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 performance

of life tasks. Such disruptions of necessarytasks and normal life rhythms are not only im-pairing, but potentialprecipitants 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 maybe adaptive,prolongedstatesof

heightened emotional responding may lead toagitation, depression, and somatic problems(Harvey & Bryant, 1998; Shalev & Freed-man, 2005). In addition, in some studiesheightened heart rate in theearlyposttraumaphase has been demonstrated to be associatedwith longtermPTSD 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 severeemotionality isa 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 interferewith 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 individualsand familiescapacities to ef-fectivelyengage 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 infunct ioning precisely when opt imalfunctioning 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 requiringpeopleto ventilate in the immediate aftermathof traumacanincreasearousal at thevery 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 peoples stress reactions after trauma(Bisson, Jenkins, Alexander, & Bannister,1997; Hobbs, Mayou, Harrison, & Worlock,1996).

TheExpert ConsensusGuidelineSeries:Treatment of Posttraumatic Stress Disordernotes that anxiety management can be a keypsychotherapeutic treatment for patients (Foaet al., 1999; National Institute forClinical Ex-cellence, 2005). Most successful traumare-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 increasedemotionalityduring earlyphasesof 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 approachesaregenerallyrec-

ommended for thosewith severeagitationandracing emotions or extreme numbing reac-tions. Therapeutic grounding is used to re-mind individuals that they are no longer in the

threattrauma condition and that theirthoughts and feelings arenotdangerous in thewaythedisasteror terroristattack was. This isimportant because those developing PTSD arelikely to be reexperiencing 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, aphonebased intervention successfully em-

ployed diaphragmatic breathing and a modi-fied cognitiverestructuring 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 forteachingrelaxation andis included instress inoculation training (Bernstein &Borkovec, 1973; Foa & Rothbaum, 1998;Veronen & Kilpatrick, 1983). Yoga alsocalms individuals and lowers their anxietywhen facing traumatic circumstances, whilemuscle relaxationand 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, & ChaoulReich, 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 antiadrenergic agents, antide-pressants, and conventional anxiolytics(Friedman & Davidson, in press; Pitman et al,2002). At the same time, these must be usedcautiously, for although benzodiazepinesmayhave an initial calming effect, they may in-



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crease likelihood of later PTSD (Gelpin,Bonne, Peri, Brandes, & Shalev, 1996).

Stress inoculation training (SIT) is atype of cognitive behavioral therapy (CBT)

that can be thought of as a toolbox, or set ofskills, for managing anxiety and stress(Hembree & Foa, 2000; Meichenbaum,1974). SIT typically consists of education andtraining of coping skills, including deep mus-cle relaxation, breathing control, assertive-ness, role playing, covert modeling, thoughtstopping, positive thinking, and selftalk. 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, HearstIkeda & Perry, 1995).

For both those who develop more se-vere stress reactions and the general popula-tion of exposed individuals, normalizationof stress reactions is a key intervention princi-ple to enhance calming. When individuals in-terpret their experience in distressing ways(e.g., Im going crazy, Theres 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 challenge

negative thinking.Several recent studies examinedtherole

of 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 afunc ti ona l capaci ty t o b roaden athoughtactionrepertoireand leadto effec-tive coping. For this reason, it may help to en-courage people to increase activities that fos-

terpositive emotions (Biglan & Craker, 1982;Zeiss,Lewinsohn,& Munoz,1979),as well asreduceor eliminatewatching, listeningto,andreading information that produces negativeemotionalstates(i.e.,news). This maybediffi-cult for people because they feel a need to bevigilant and remain updated. For those withminor to midlevelproblems of anxiety, limit-ing media exposure toonce inthe morning,af-ternoon, and early evening (but not near bed-time) may be sufficient. Those with moresevere emotionalitymayagree 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 problemfo-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). Problemsolving 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 selfconcept, less depression

and anxiety, and vocational adjustment.Because problemsolving appraisal can

be learned and such training is effective(DZurilla & 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 theface of a challenge(Bandura,

1986).Later inthis paper,we address theissueof selfefficacy directly, but it is important tonote that the calming effect of increased senseof control and predictability is an importantaspect of such interventions.

It shouldbenoted further that somefre-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.B ecause o f t he ir c a lm ing e ff ec ts ,benzodiazepines continue to be widely usedclinically in the treatment of anxiety disor-ders, andattentionmust be given to maintain-ing calmness in populations for whom suchmedications are part of their pre-masscasu-alty treatment. This is especially relevant be-cause those with pre-masscasualty anxietydisordersareat particular risk for further neg-ative psychological impact if exposed tomasscasualty trauma. Having similarlysoothing activity, alcohol can be used toselfmedicate and lead to potential misuseand other alcoholrelated behaviors. Finally,the use of lies, or spinning information inorder to calm a population or a group ofrescued individuals, ultimately underminescredibility and is counterproductive.

Many of the interventions discussed inthis section are of a more individual interven-

tion nature. However, many can be translatedto group and communitybased interven-tions.For example, psychoeducationhasbeenat theheartof a numberof postdisaster inter-

ventions that have been shown to be effectivein reducing PTSD (Goenjian et al., 1997,2005). Largescale community outreach andpsychoeducation about postdisaster reac-tions should be included among public healthintervent ions to promote ca lming.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 avoidpathologizingtheir 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 specificpostdisaster reactions (i.e., sleep problems,reactivity to reminders, startle reactions, inci-dentspecific new fears). For instance, sleephygiene, guidelines for media exposure, andrelaxation training techniques canallbe pack-aged through media presentation. This maybe particularly important as peopleoften mayfear going out or be advised not to go out inthe immediate to midterm postdisaster ormasstrauma 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 peoplealso do notunderpathologize theirsymptoms and know where to turn forprofessional assessment and treatment.

In any such psychological intervention,it should not be underestimated that peoplesagitationandanxiety aredueto real concerns,and actions that help them directly solve these



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concerns are the best antidote for the vast ma-jority. This follows because real initial re-source lossesand the secondary losses that oc-cur downstream of the original event are the

best predictors of psychological distress(Freedy, Shaw, Jarrell, & Masters, 1992; Ga-lea et al., 2002; Hobfoll, CanettiNisim, &

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 neededforrecovery andrestoration oflosses incurred.

PROMOTION OF SENSE OF

SELFEFFICACY AND

COLLECTIVE EFFICACY

The importance of having a sense ofcontrol over positive outcomes is one of themost well-investigated constructs in psychol-ogy (Skinner, 1996). Selfefficacy is the sensethat individuals belief that his actions arelikely to lead to generally positive outcomes(Bandura, 1997), principally throughselfregulation 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 likely

to experiencepositiveoutcomes (Antonovsky,1979; Benight, 2004).

In their trauma models, Foa and Mead-ows (1997) and Resick and Schnicke (1992)underscore that following trauma exposurepeopleare at risk for losing their sense of com-petency to handle events they must face. Thisbegins with events related to the originaltrauma, butquickly generalizes to a more fun-damental sense of cant 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 selfefficacy, but the spe-cific sense that one can cope with traumare-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).Traumarelated selfefficacy 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 othertraumarelated 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 lendthemselves to

postdisaster and massviolenceenvironmentsand can be applied to the individual, group,organization, and community levels. Individ-ual and groupadministered 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 selfefficacy. 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 translatingCBTto lowand middleincome countries andhave found success when they have carefullytranslated intervention within the sociocul-tural ecologiesof the targetcountries (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 livingnormal livesprior to thedisasterormass 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 selfefficacy, efficacy ofothers(e.g.,protective figures),andefficacyofsocial agencies in response to danger. Ad-dressing such developmental interruptions

and 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 problemsolving skills in re-gard to postdisaster adversities are especiallyimportant components of postdisaster inter-ventions that have been shown to be effective(Goenjian et al., 1997, 2005).

Selfefficacy cannot occur in a vacuum;it requires successful partners with whom to

collaborate, join, and solve the oftenlargescale problems that are beyond thereach of any individual (e.g., when larger sys-tems fail or createbureaucraticobstaclesto re-covery). Tied to perceived selfefficacy is theconstructof 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 selfsufficiency and selfgovernment (de

Jong& Clarke, 1996).In this regard, activitiesthat are conceptualized and implemented bythecommunityitselfmay contribute to a senseof community efficacy. These may include re-ligious activities, meetings, rallies, collabora-tion with local healers, or the use of collectivehealing andmourning rituals (deJong,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 theschoolcommunityis recognized by WHOandthe United Nat ions Chi ldrens Fund(UNICEF) as an essential step in reestablish-ing a sense of selfefficacy through renewedlearning opportunities, engagement inageappropriate, adult-guided memorial ritu-

als, and school-initiated prosocial activity,where children can see grief appropriatelymodeled and fully participate in planning andimplementation of activities (Saltzman et al.,

2006).A competent community provides

safety, 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 lossesaremost 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 thefamilymust of-ten substitute for professional care and soshould be considered a primary axis for inter-vention. Thus, competent communities pro-mote perceptions of selfefficacy among theirmembers, foster theperception that othersareavailable 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 selfefficacy 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 andskills 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, selfefficacy 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, &Ner ia , 2003; Ke inan, Fr i ed land, &



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Sarig-Naor, 1990; Solomon, 2003; Solomon,Margalit, Waysman, & Bleich, 1991). Notsurprisingly, research indicatesthat this isbestdeveloped by practice involving increasingly

difficult situations in which increments of suc-cess build to a realitybased 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 beingcentral management resourcesthatmanage 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,peoplewill wrongly as-sume that they, andnotcircumstances, are thefailure, and intervention will over or un-derestimate peoples 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 selfhelp pamphlets islikely to backfire (Turpin, Downs, & Mason,2005),as itassumes that they possess theskillsand resources necessary to enact what is sug-

gested to them in the form of selfhelp.These outcomes will, therefore, be greatly in-fluenced by population vulnerability factors,such as poverty, ethnic minority status, and

already 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 thisbeliefbehaviorresource linkage thatintervention must attend to, whether on theindividual, family, or group level.

Finally, it must be underscored that be-

cause disastersandsituations 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.,processesof change lead-ingto better livingconditions andmore 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 overprotective-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 pr inciple

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underpinning this approach has strongempirical support, and its translation tointervention deserves fuller investigation.

PROMOTION OF

CONNECTEDNESS

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? Issafe wateravailable?). Italso 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 and

policymakers 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 mostcommoncopingresponseswas to identify andlink with loved ones (Bleich et al., 2003; Stein

et 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(Punamki, Komproe, Quota, El Masri, & de

Jong, 2005), Turkey (Altindag, Ozen, & Sir,

2005), and Bosnia (Layne et al., in press) indi-cates that social support is related to betteremotional wellbeing and recovery followingmass trauma. This key salutogenic role playedby social support is sustained through theposttrauma 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 onsite 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,TuvalMashiach, & 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 disasterrelated inter-ventions (Hagan, 2005). For instance, re-union with at least one family memberfollowing immigration to theUnitedStates 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 warexposed family membersfared better than their counterparts livingwithnonwar-exposedfoster families. In lightof such findings, some traumafocused inter-ventions directly seek to increase thequantity,quality, and frequency of supportive transac-tions between trauma survivors and their so-cial fields (Gottlieb, 1996). A group interven-tion implemented with warexposed Bosnianadolescents directly targeted social supportvia psychoeducation and skillsbuilding. In-terventions included (a) enhancingknowledgeof specific types of social support (e.g., emo-tional closeness, social connection, feeling



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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 to

capitalize 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 the

natural positive influence of social supportand the influence of interventioncreated so-cial support, there is enough experiential evi-dencepost September11th in NewYork (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 slowbrewing trauma (e.g., an ar-easfoundto be industrial waste sitesor 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 traumabecause they canretaina reason-able degree of hope for their future. Instillinghope is critical because mass trauma is oftenaccompanied by a shattered worldview(JanoffBulman, 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 resignationthatfeeling that all is lost. Because mass traumais usually an experience peoplearenot trainedfor or experienced with, it outstrips theirlearned coping repertoires. Without knowl-edgeabout how tocope, it is natural that hopeis one of the first victims.

Hope has recently and most commonlybeen defined in psychology as positive, ac-tionoriented 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 ones goals (Snyder et al.,1991). Hobfoll, BriggsPhillips, and Stines(2003) challenged these perspectives, how-ever, as overly based on rugged individual-ism and ignoring the reality that people whoexperiencemass trauma, lifetimepoverty, andracism often face. Such an actionorientedview of hope is decidedly Western, even up-permiddle class and white. Hope for mostpeople in the world has a religious connota-

tion and is not actionoriented (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, selfefficacy, 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 ones internaland external environments are predictableand that there is a high probability that thingswillwork out as well as can reasonably be ex-pected (p. 123). A major difference betweenthis viewpointand theefficacybased viewsofhope is that Antonovskys belief is based onpast experience and often is the result of thebelief that outside sources act benevolentlyonones behal f . He did not emphasizeselfagency, which he called an expressly up-permiddle class, Western view. Antonovskyemphasized that people, includingthose in theWest, often find hope, not through internal



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agency or selfregulation, but through beliefin God (Smith, Pargament, Brant, & Oliver,(2000), a responsive government (a belief thatmay be diminishing), and superstition belief

(e.g., Im 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 topoor 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 combatrelated 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 HurricaneAndrewwas theinabilityto securefunds 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 ExxonValdez oil disas-ter ledto longtermpsychological distress andongoing resource loss cycles (Arata, Picou,

Johnson, & McNally, 2000). Again, byjoining with individuals, rather than justdoing for them, selfefficacy 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 CBTthat reduces individualsex-aggeration of personal responsibility, some-

thing that severely impedes hope due to thefear that onewill continue todo badly becausethe problem is an internal, stable trait (Bryantet al., 1998; Foa et al., 1995). The Learned

Optimism 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 canbe applied to strengthbuild-ing and prevention in which they concentrateon enhancing hope and disputing the cata-strophic andexaggerated thinking that under-mines hope. Trauma-focused treatment withadolescentshassimilarlyshowntheefficacyofaddressing 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., Im an expert and I believethat you can succeed). Interventionists areencouraged to normalize peoples responsesand to indicate that most peoplerecover spon-taneously (Foa & Rothbaum, 1998; Resick etal., 2002), as this in itself instills hope againstdistressing thoughts (e.g., Im going crazy,Im inadequate,My reaction isa sign that Icant take it.). Early intervention can alsofosterhope by using such techniques asguidedselfdialogue (Foa & Rothbaum, 1998;Meichenbaum, 1974) to underscore andrestructure irrational fears, manage extremeavoidance behavior, control selfdefeatingself-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).Resicks (Resick et al., 2002) CognitiveProcessing Therapy works to correct errone-ous cognitions related to catastrophizing and

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survivors who develop PTSD (Foa et al.,1999; Resick et al., 2002) and for whom suchtreatment is accessible and acceptable. Whatis needed are more broadscale interventions

that inform primary and secondary preven-tion, psychological firstaid, family and com-munity support, and community supportfunctioning (de Jong, 2002a; Eisenbruch, de

Jong, & 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 individuallevel thera-pists who are local or may be dispatched to aregion. Clearly, what we have referred to asintervention includes actions that must go

well 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, ands t ruc tura l ( e .g . , jobs, inst i tu t 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 ratiosafter 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 thepostdisaster period.

It is also critical that we remain modestin ourclaimsabout what interventions canac-complish towards prevention of longtermfunctionaland symptomatic impact. While webelieve that the provision of interventionsbased on these principleswill 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 pr inc ip l e s wi l l not l ead to aonetreatmentfitsall approach.

Post-disaster and mass casualty inter-ventions must also be subjected to economicmodeling and costbenefit analyses. Such in-terventions,given thenumbers of potential re-cipients who may be involved, will demandconsiderable revenues and resources. For thisreason, there will be a need to designmultilayered interventions, with costly (percase) individuallevel 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 earthquakerelated PTSD pro-duced significant treatment effects on allmea-sures at posttreatment. More generally, me-dia, telephone, and internetbasedinterventions hold promise as costeffectiveways of promoting sense of safety, efficacy,connectedness, calming, and hope and arelikelyto supplement more traditional formsofresponse (cf., Ruzek, 2006; Ruzek, Maguen,& Litz, in press).

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Hobfoll et al. 305

Clearly, the major weakness of our rec-ommendations is that therearefewclinicaltri-alsor direct examinations of theprinciples 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, warand other mass casu-alty situations, andmake informed judgmentsand recommendations. Currently, govern-ments, public health agencies, and aid organi-zations arewithout anyroadmap for interven-tion. It is our combined judgment that therewillnot bea blueprint that willbebased ondi-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 havinga clear,articulated blueprint based on strong, direct,

empiricalevidence.Hence,webelieve that ourempirically informed review and principlesare the best strategy for the near and mediumrange future. Clearly, it is not the onlyway the

literature 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 foreach of thegeneral 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 to

nonindustrializedworld. In each case, apply-ing the principles of ecological congruencewill be paramount (Hobfoll, 1988).

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