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Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited. Resource caravans and resource caravan passageways: a new paradigm for trauma responding Stevan Hobfoll We have long outgrown the capacity of the accepted clinical models of trauma, and a paradigm shift in our thinking is long overdue.The data on traumatic stress were posited from a certain cognitive-beha- vioural viewpoint, with particular emotional com- ponents based almost in their entirety on western, mostly white individuals seeking treatment for post- traumatic stress disorder, and focusing on that time frame.Assuch,mechanismssuchasfearandemotional conditioningtheory and the waystraumas are encoded in memory only partially explain trauma response. Conservation of resources theory posits that severe trauma responses occur when personal, social or material resources, which are key to the self, survival and social attachments, are lost severely and rapidly. These resources tend to aggregate or fail to aggregate inwhatconservationofresourcestheoryterms‘resource caravans’; they do not exist in isolation. Because resource caravans are created and sustained within the environmental and social context of resource cara- vanpassageways,environmentalcontextisfundamen- tal to trauma response. It is argued that resource loss and the maintaining of resource caravans are the best predictorsoftraumaresponse,bothintermsofposttrau- matic stress disorder and in terms of the idioms of trauma distress across cultures. Keywords: posttraumatic stress disorder, resilience, resource loss, stress, trauma Introduction It is my thesis in this paper that we have long outgrown the capacity of the accepted models of trauma. A paradigm shift in our thinking is overdue (Hobfoll & de Jong, 2013). The data on traumatic stress were pos- ited from a certain cognitive-behavioural viewpoint, with particular emotional com- ponents based almost in their entirety on individuals seeking treatment for posttrau- matic stress disorder (PTSD), and focusing on that time frame. Further, this viewpoint was accomplished mostly within a western, European and American social context, and mainly by studying middle-class, white patients. It then had a layer added by key work in neuroscience, again almost entirely with the same limitations, which was then force-¢tted to the cognitive-behavioural model. One important area of challenge emerged from those who argued that PTSD could be more complex than was originally presented, meaning that it is more multifa- ceted (Cloitre et al., 2009; van der Kolk, et al., 2005). However, all these viewpoints focus on clinical, western, mostly white populations, which represent a small frac- tion of those with PTSD or other trauma- related disorders (de Jong, 2004; 2005). A key limitation to this model building has been the lack of consideration of ¢ndings from large scale studies that included nonpatient populations over longer periods of time, stu- dies from nonwestern nations and more anthropological evidence. In particular, research has focused naturally on the time around the trauma event for clinical popu- lations, or the time period when individuals seek treatment. This, in turn, meant that researchers did not incorporate the fuller time sequenceincludingeventsbeforeandlongafter trauma, which greatly impact PTSD and causeadi¡erentconceptualisationandtheory to understand trauma response and recovery. Finally, the consideration of resilience, and Hobfoll 21

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Page 1: Resource caravans and resource caravan passageways: a new

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Hobfoll

Resource caravans and resourcecaravan passageways: a newparadigm for trauma responding

Stevan Hobfoll

We have long outgrown the capacity of the accepted

clinical models of trauma, and a paradigm shift in

our thinking is long overdue.The data on traumatic

stress were posited from a certain cognitive-beha-

vioural viewpoint, with particular emotional com-

ponents based almost in their entirety on western,

mostly white individuals seeking treatment for post-

traumatic stress disorder, and focusing on that time

frame.Assuch,mechanismssuchasfearandemotional

conditioningtheoryand thewaystraumasare encoded

in memory only partially explain trauma response.

Conservation of resources theory posits that severe

trauma responses occur when personal, social or

material resources, which are key to the self, survival

and social attachments, are lost severely and rapidly.

These resources tend to aggregate or fail to aggregate

inwhatconservationofresourcestheoryterms ‘resource

caravans’; they do not exist in isolation. Because

resource caravans are created and sustained within

the environmental and social context of resource cara-

vanpassageways,environmentalcontextisfundamen-

tal to trauma response. It is argued that resource loss

and the maintaining of resource caravans are the best

predictorsoftraumaresponse,bothintermsofposttrau-

matic stress disorder and in terms of the idioms of

trauma distress across cultures.

Keywords: posttraumatic stress disorder,resilience, resource loss, stress, trauma

IntroductionIt is my thesis in this paper that we have longoutgrown the capacity of the acceptedmodels of trauma. A paradigm shift in ourthinking is overdue (Hobfoll & de Jong,2013).The data on traumatic stress were pos-ited from a certain cognitive-behavioural

ht © War Trauma Foundation. Unautho

viewpoint, with particular emotional com-ponents based almost in their entirety onindividuals seeking treatment for posttrau-matic stress disorder (PTSD), and focusingon that time frame. Further, this viewpointwas accomplished mostly within a western,European and American social context,and mainly by studying middle-class, whitepatients. It then had a layer added by keywork in neuroscience, again almost entirelywith the same limitations, which was thenforce-¢tted to the cognitive-behaviouralmodel. One important area of challengeemerged from those who argued that PTSDcould be more complex than was originallypresented, meaning that it is more multifa-ceted (Cloitre et al., 2009; van der Kolk,et al., 2005). However, all these viewpointsfocus on clinical, western, mostly whitepopulations, which represent a small frac-tion of those with PTSD or other trauma-related disorders (deJong, 2004; 2005).A key limitation to this model building hasbeenthe lackofconsiderationof ¢ndings fromlarge scale studies that included nonpatientpopulations over longer periods of time, stu-dies from nonwestern nations and moreanthropological evidence. In particular,research has focused naturally on the timearound the trauma event for clinical popu-lations, or the time period when individualsseek treatment. This, in turn, meant thatresearchersdidnot incorporate the fuller timesequenceincludingeventsbeforeandlongaftertrauma, which greatly impact PTSD andcauseadi¡erentconceptualisationandtheoryto understand trauma response and recovery.Finally, the consideration of resilience, and

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Intervention 2014, Volume 12, Supplement 1, Page 21 - 32

the fact that none of the accepted traumamodels account for the extent towhichpeople(even those with PTSD) are resilient, has ledtoafurtherchallengethathasnotbeenincorp-orated into the accepted models of traumaand trauma response.

Resource caravans and their tieto world view, body and brainConservation of resources (COR) theoryposits that individuals strive to obtain,retrain and protect their personal, socialand material resources. COR theory envi-sions this process as a basic evolutionaryprinciple that has many consequences andcorrelates. Foremost, it sees the seeking andpreservation of resources as a primaryhuman motivation, and Hobfoll (1991)theorised that trauma response will occurwhen there is major loss of fundamentalresources and where this loss occurs rapidly.What appears to characterise traumaticresource loss is a rupture of the constellationof ¢ve principal resource groups: safety,calmness, attachment, hope, and e⁄cacy(i.e., the ability to a¡ect positive change)(Hobfoll et al., 2007). As resource conserva-tion is of primary concern, the processesinherent inbuildingandmaintaining‘resourcecaravans’are also the essential buildingblocksof culture and society. As individuals striveto obtain, retrain and protect personal,social and material resources for the self,they create social structures that necessarilysupport this primary motivation.COR theory has held, from its origin, thatpersonal, social and material resources arenot possessedpiecemeal, but that rather theyare developed and associate in aggregate(Hobfoll,1989,1998). More recently, Hobfoll(2010) further developed the long-standingunderpinning of COR that asserts thatresource caravans, the association of linkedresources, are created and sustained withina resource caravan passageway. That is,families, organisations and societies createand maintain circumstances that create

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and maintain resources when at their best,but that often produces the groundwork forresource loss (Hobfoll, 1988; 1998). CORtheory greatly broadens the landscape ofhow we see PTSD. It emphasises, in particu-lar, that trauma responding is deeplya¡ected by life history—long prior, duringand long after events^which this paper willexamine in depth (King, et al, 1999; Vogtet al., 2011). Traumatic circumstances notonly challenge the individual, but compro-mise the ability of this social structure to sup-port and protect people.

Currentmodels of trauma: theirstrengths and limitationsAt the outset, I will outline which key ¢nd-ings must be incorporated in any traumamodel from current clinical models. First,there is clearly something about exposureto events that threaten life orbodily integritythat produces a powerful cognitive,emotional and physiological response. Thisis well captured in emotional processingtheory (Foa & Kozak, 1986; Rauch & Foa,2006). Speci¢cally, trauma events create afear structure that is comprised of associatedstimuli, responses and meaning elementsthat become linked. Further, for some indi-viduals, these fear structures become exces-sive and resistant to modi¢cation. It followsthat treatment that could extinguish theinterweaving of this fear structure withresponding would aid recovery, and thereis ample evidence that this is the case(McLean & Foa, 2011).Second, there are neurological rami¢cationsof trauma that are accompanied by bio-logical perturbations, some of which canbecome chronic (Brewin, et al., 2010).Whilethese sequences are interesting and import-ant to note, they do not add greatly toemotional processing theory nor to the ear-lier dual representation theorising of Brewin(Brewin & Holmes, 2003). Tying neurologi-cal ¢ndings to theory helps support theory,but these neurological ¢ndings have not led

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to changes in what is predicted by fear pro-cessing theory or dual representation theory.Of greater importance for my thesis here,the neurological research has continued thefocus on memories and images embeddedat the time of the trauma event, and therather unfounded supposition that personswith PTSDhave‘repeated visual intrusions corre-sponding to a small number of real or imaginary

events’ (Brewin et al., 2010, p. 210). Thisassumption is likely because so muchresearch has been on clinical samples wherethere was a speci¢c target event. I do notbelieve that this key assumption, on whichso much of current trauma theory rests, hasever been empirically tested.This point is already cogently covered in thediscussion of complex PTSD (van der Kolket al., 2005). Those who have experiencedtrauma at times have a principal or worstset of memories, but many report that theyhave multiple images and memories thatare often disorganised and unsequenced,and are an amalgam. As proponents of com-plex PTSD have argued, traditional PTSDdiagnosis o¡ers a rather limited, if partiallycorrect, set of responses to trauma. Suchlimitations are critical, as they con¢neunderstanding, research and intervention,which in turn have to be narrowly con-strained in order to ¢t into more limitedmodels. Giving just one concrete example:if shame orhonour are not included in PTSDmeasures, then the many factor analyses ofwhat is PTSD appear to indicate that shameand honour are not central. However, formany collectivist cultures, honour is centralto the trauma experience, not ancillary.

Resource caravans andpassagewaysTrauma responding, including PTSD, is notonly a product of the occurrences aroundthe time of the event, but is strongly a¡ectedby the cascade of personal, social andmaterial losses that may occur weeks ormonths or years before or after the event,

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and possibly much later in life. Indeed,resource loss is one of the best predictors ofwhether someone will develop PTSD orother trauma responses, a fact that is notincorporated in the emotional processingor dual representation theory. Theseresource losses need not occur at the timeof trauma.They may occur in earlier child-hood or earlier life or well after the event(Kaniasty, 2012; King et al., 1999; Vogtet al., 2011). Hence, studies ¢nd that exposureto childhood trauma and possessing fewersocial resources combine to predict an adulttrajectory of posttraumatic disorder (Loweet al., 2014). Referring to a later lifetimesequence, individuals who escaped theKatrina disaster appeared to develop PTSDafter they returned home and witnessedtheir destroyed homes (Adeola, 2009; DeSalvo et al., 2007). This moment was notlife-threatening, but it had elements thatmay both be critical and o¡er us insight asto a broader theory of PTSD. Speci¢cally,when people lose a sense of safety or have achronic sense of lack of safety, and this ispaired with a sequence of events in whichthey can imagine or actually experienceevents that are life threatening or threaten-ing to their sense of bodily integrity, theycan develop PTSD and other posttraumasequelae.This point is especially germane to thosewho live in chronically unsafe circum-stances, such as zones of con£ict or manyurban inner-city environments that arecharacterised by pervasive violence. Suchenvironments result in an ongoing loss ofsafety, fear of loss of loved ones and thoserelationships, and a sense of future hopeless-ness and the inability to a¡ect positivechange. This hopelessness may be betterunderstoodwhenwe appreciate that it is rea-lity based and the darkened sense of futureis an accurate representation of likely futureevents. Once this is understood, eachmoment of life a¡ords ample opportunityto tie visual, environmental and physiologi-cal sequelae in ways that may have more of

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the elements that have been tied to complexPTSD (van der Kolk et al., 2005) and fewerof the elements that havebeen tiedclassicallyto PTSD with a particular well-framedmemory of a speci¢c event. This also availsintervention to a broad array of alternativefoci for intervention and types of interven-tion. Traditional theories focus on the mindand perception; however, the alternativepresented here further encourages socialand environmental intervention, so as toshape environments to enable healing.Several studies of veteransmake these pointscogently. In the ¢rst study, King et al.(1999) found that PTSD was the outgrowthof multiple cumulative e¡ects of stressors,beginning in family and personal life eventsdecades earlier. Most important, this studyfound that the cascade of resource loss wasthe key element in the endpoint of PTSD.Indeed, events around the time of deploy-ment were only partially related to PTSD,and the fuller context of postdeploymentexperience was as fundamental. Morerecently,Vogt et al. (2011) found that PTSDis best explained by multiple chains of risk,with many of these originating in predeploy-ment experiences. These pathways led tomajor psychosocial andmaterial resource lo-ss andan inability to access critical resourceswhen needed. Central to the discussion ofresource caravans andpassageways, not onlywas the availability of postdeployment socialsupport a larger predictor of posttraumaticresponse than was exposure to warfare, butthat social support was largely in£uencedby childhood family resources, relationshipdisruptions, perceived threat of warfareexposure andpostdeployment stressors.Thiswas examined more closely by Interianet al. (2014), who foundthat home-front stres-sors predicted PTSD whether they occurredbefore or after deployment. Moreover, thesefactors were stronger predictors of PTSDthan combat exposure or unit cohesion.These studies further clearly illustrate thatemotional processing theory (Foa & Kozak,1986) and dual representation theory

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(Brewin, 2001) fail to explain more than asmall portion of how PTSD comes about orhow it is sustained. These theories areimportant, but they are partial andrepresent a small element of the whole interms of predictive capacity. Rather, asCOR theory predicts, PTSD is predictedby the rupture of personal, social andmaterial resource losses that combatantsexperience, and the web of safety and con-nections at the home front have as much todo with PTSD as fear conditioning or thelayingdownof traumaticmemories. Further,these results challenge neurological ¢ndings,which are important, but clearly are beinginterpreted without consideration of thefull context.

Cultural adaptation modelsCrosscultural ¢ndings also illustrate theneed for a paradigm shift and indicate thepartiality, and even inaccuracy, of currenttrauma models. PTSD is one manifestationof trauma responding. It appears to be uni-versal, but is not necessarily the principalaspect of trauma response in non westerncultures (Akello, Richters, & Reis, 2009; deJong & Reis, 2010; Hagengimana & Hinton,2009; Hinton & Lewis-Ferna¤ ndez, 2011;Hobfoll & de Jong, 2013; Igreja, 2008; vanDuijl et al. 2010; van Ommeren et al., 2001).This should appear obvious, but it is not awell accepted supposition. The reason itshould be obvious is that it follows ina straightforward manner from bothemotional processing theory (Foa & Kozak,1986) and dual processing theory (Brewin& Holmes, 2003), if they are not so strictlytied to western cognitive models and if wedonot prematurely tie neurological evidenceas meaning that mind^brain connectionsare universal.What needs tobe understood is that, inmanycultures, the borders between real andunreal, this world and the dream world,and the very acceptance of the linear natureof events are looser, or even rejected. Further,

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there is good evidence that somatic responseto psychological distress and illness has quitevaried somatic correlations that are cultu-rally evidenced. Recent research on neuralplasticity (Chiao, 2009; Dom|¤ nguez,Turner,Lewis, & Egan, 2010) would even mean thatthe brain itself would develop to accommo-date these views of the world. This wouldhelp to explain why the principal reactionsto traumatic events in many cultures havebeen reported to be so culturally speci¢c(Hinton & Kirmayer, 2013) and producedi¡erent idioms of distress and di¡erentpathways to wellness.Hinton & Otto (2006), in their carefulresearch onCambodian refugees of a certainera, are illuminating on this point. Considertheir description of many of the Cambodianrefugees that they have studied and treated.Profound and rapid loss of personal, socialand often material resources are commonelements of their reactions, as would ¢t whatis found inwestern European and Americantrauma (Hobfoll, 1991). However, the symp-tom expressions on cognitive, social,emotional and physical levels are quitedi¡erent in remarkable ways. The refugeesexperience frequent palpitations, startledresponses and poor appetite and sleep, feelphysically weak (khsaoy) and report a weakheart (khsaoy beh doung). They often reportkhyal attacks, which in some ways resemblepanic attacks, but which are also accom-panied by catastrophic cognitions aboutimminent bodily dysfunction and loss ofuse of their arms and legs. Sleep paralysis,which is rather uncommonly reported inthe PTSD literature, was found to be evi-denced by 67% of Cambodians with PTSD(Hinton et al., 2005).Hinton et al. (2012) found that both naturalhealing and e¡ective treatment pathwaysbetween cultures likewise di¡er markedly.This is a key point, as if trauma producedspeci¢c emotional and memory sequences,then recovery and treatment pathwayswould ¢t well across cultures. Hinton prac-tices a somatic-psychological treatment

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regimen for Cambodians that does not relateto the memory and cognition based treat-ments e¡ective inwestern populations. Con-sider also that, whereas in American andwestern European patients, panic disordertypically leads to further panic disorder,Puerto Ricans who experience ataque de ner-vios, which close resembles panic disorder,widely report relief after the attack (Lewis-Ferna¤ ndez et al., 2002). Such a paradoxicalreactionmeans either that emotional proces-sing theory (Foa & Kozak, 1986) and thedual processing^neural systemsmodel (Bre-win et al., 2010) are specious (which I donot think is the case) or that they are partialand have been over-generalised, especiallyregarding to the argument that neurologicalevidence supports these models.Miller & Rasmussen (2010) similarly chal-lenge cognitive-emotional theories of PTSD.Based on their work with adults in Afghani-stan, they found that PTSD was not themajor pathway of expression of traumaticexperience. They found, like Hinton, thatindigenous idioms of distress were morecommon and primary than PTSD, even ifPTSD certainly did occur. For example, jigarkhun was a long-term kind of melancholy,which adults reported as more salient thanintrusive images. Asabi was described as asynthesis of nervousness and anger that oftenled to verbal and physical violence and self-beating. What is also key here was thatMiller & Rasmussen found these culturallyspeci¢c symptoms to be more predictive offunctional impairment than was PTSD.Bracken, Giller & Summer¢eld (1995) madea similar argument based on their studiesin Uganda. For example, among Ugandans,dissociation in the form of spirit possessionis a common pathway of expression for thoseexposed to trauma (van Duijl et al., 2010).A sense of spirit possession is consistent withcultural norms and social learning. Hence,it is not surprising that, among northernUgandan former child soldiers, beinghaunted by spirits called Cen is commonposttrauma (Akello et al., 2009). Add to this that

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mass dissociative trance behaviour has beenreported among Bhutanese refugees inNepal (van Ommeren et al., 2001), in post-war Guinea Bissau (de Jong & Reis, 2010),in Mozambique (Igreja, 2008) and inRwanda (Hagengimana & Hinton, 2009).Trauma response follows cultural patternsthat have some common bases, but there ismuch elasticity because the environmentalconditions that create, sustain or impederesource acquisition and maintenance areculturally embedded. Resource caravanswill ¢t cultural and environmental impera-tives through social development and life-long social processing, and interventionmust occur along the paths of these caravansor the structures that support caravan path-ways. Hence, we will see responding thatresembles PTSD worldwide, but as webecome more distanced from western cul-ture, the major expressions of trauma willlook increasingly less like PTSD, or PTSDwill become a more secondary ortertiary response.

How current models remove usfrom factors of social contextand social interventionIf we donot study social context, andthe car-avan of resources and resource passagewaysthat are contextually evidenced, we missboth a deeper understanding of PTSD aswell as many avenues for potential socialintervention. Following the 1992 HurricaneAndrew in Florida, Ironson et al. (1997)found that cognitive-emotional or infor-mation-processing variables were hardlyrelated to trauma responding. Rather, theyfound that the extent of material resourceloss and length of time before receipt ofinsurance settlementswere themajor predic-tors. Further, the extent of material loss andwaiting for insurance settlements that wouldallow rebuilding were only modestly relatedto the initial trauma experience. Likewise,the prolonged time period waiting for asy-lum and posttraumatic living conditions

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were key predictors of PTSD and depressionamong Iraqi asylum seekers. These factorsoutweighed the impact of direct war-relatedexposure, which is inconsistent with domi-nant models of PTSD (Laban et al., 2008),but highly consistent with COR theory.This was also noted in the responding ofthose a¡ected by the World Trade Center(WTC) attack on 11 September 2001. Onone hand, peritraumatic reaction was amajor predictor of PTSD outcomes (Galeaet al., 2002). However, loss of job and loss ofpossessions were as predictive of PTSD aswas any aspect of the experience thatoccurredcloser in time to the trauma. Again,these factors are not part of the traumamem-ory and are not even present when fear pro-cessing associated with the event occurs.By focusing on the trauma memory andinitial fear responding, we remove ourselvesfrom context, which appears to be a para-mount factor found for thosewhomore care-fully include context, resource caravansand resource passageways in their designs.So, studying survivors ofHurricaneKatrina,Adeola (2009) found that the most signi¢-cant predictors of distress were: residencyin the poorest parishes of New Orleans, hav-ing dependent children, unemployment,degree of property damage, and ¢nancialimpacts sustained due to the disaster. Like-wise, others noted that, among Katrinaevacuees, not being insured, the degree ofhome destruction and human loss were thestrongest predictors of posttrauma exposuredistress (De Salvo et al., 2007; Lee, Shen, &Tran, 2009). However, even this human losswas seldomwitnessed. Add to this, De Salvoet al. (2007) found that lack of propertyinsurance, longer evacuation and commut-ing distance to work during the rebuildingperiod and obstacles to obtaining qualitynew residences were important predictorsof PTSD symptoms. Again, for most people,they were evacuated before home destruc-tion, and this was witnessed only whenthey were allowed to return weeks ormonths later.

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Incorporating resilience intraumamodelsNowherearethe limitationsofcurrentclinicalmodels of trauma more evident than in theirirrelevance to people’s resilience in the face oftrauma. Accepted trauma models, beingpathology-based and concentrating on thetime of the trauma event, fail to account foraspects of resilience that are present, evenwhen individuals develop PTSD.Thepaucityof attention, and therefore the future need foremphasis on resilience inthe faceof traumaticstress, is cogently presented in a recent keypaper by Southwick & Charney (2012) onresilience and depression. I am referring notonly to resilience in terms of not experiencinga powerful initial response, quick or earlyrecovery fromsevereresponse, oronlyexperi-encing a moderate response. Rather, theaccepted models fail to make or even toattempt to make any predictions about whocontinues to engage and even enjoy life tasks.Even those with severe PTSD have a widerange of levels of engagement in life tasks andin resilience processes.In contrast to leading clinical theories ofPTSD, COR theory makes speci¢c predic-tionsaboutbothlevelsofpsychologicaldistressaswellas resilience.Thesepredictionsarewellsupported, although the literature regardingadult resilience is still nascent and requiresmuchmore exploration. In contrast to amoredeveloped child literature on resilience (seeMasten&Narayan,2012), the adult literaturehas focused only more recently on resilienceandbolsteringandprotecting personal, socialand material resources (Bonanno,Westphal,&Mancini, 2011). Basically, CORtheory pre-dicts that, to the extent that the caravan ofresources that people possess remains intact,themore likely they will be resilient, resistantor quickly recover. That is, their lifetimeresourcetrajectoryandresourcereservoirwillbe more central to their response thanwill bethe type or extent of trauma exposure.InoneofthefewstudiesofPTSDandresilienceina zone of con£ict,Hobfoll et al. (2012) inter-viewed1196PalestinianadultsoftheWestBank

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and Gaza during a period of intense con£ict.This is one of the few multiwave studies in azone of con£ict, and the only to examinebothPTSD symptoms and positive adaptation asmeasuredbydegreeofengagementinlifetasks.Engagement is aconceptadopted fromorgan-isationalpsychology. It is comprisedofdedica-tion, absorption and vigour (Schaufeli et al.,2002).Inmanyways,theseelementsofengage-mentcanbeseenasthepolaroppositeofPTSD,whichresults inavoidance, inabilitytoconcen-trate and be positive and drained energy anddepressive e¡ect.The results of path analysis indicated clearlythat trauma exposure is only weakly relatedto engagement (Hobfoll et al., 2012). As pre-dicted by COR theory, and consistent withthemodel of resource caravans, the impact ofresource loss on both trauma symptoms andengagement far outweighs the impact oftrauma exposure. Likewise, positive aspectsof social support were related to greaterengagement, but again, as COR theory pre-dicts, resource gains in the form of sustainedsocial supportareovershadowedbythe largerin£uence of resource loss.In another of the rare prospective studies ofresilience in the face of the kind that is oftenlinked with PTSD, Pietrzak et al. (2014)examined more than 10,000 (World TradeCenter) WTC responders 3, 6, and 8 yearsafter theWTC attacks. They also examinedthe di¡erential responding of police versusnontraditional responders who were gener-ally less well trained, such as constructionworkers security guards and transportationworkers. Here, resilience was de¢ned as thedegree to which PTSD symptoms were notappreciably experienced at any time point.The majority of police and nontraditionalresponderswere resilient, but the policeweresigni¢cantly more likely to be resilient thannontraditional responders. Correspond-ingly, nontraditional responders were morelikely to have chronic PTSD.In this situation, the predictors of traumasensitivity (i.e., lower likelihood of beingresilient) were Hispanic ethnicity, prior

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psychiatric history, WTC exposure severity,number of life stressors in the year prior tothe attack, number of WTC-related medicalconditions that developed after the attackand having less family support. ConsistentwithCOR’sresourcecaravanmodel, prior lifestressors, having a medical condition follow-ing the events and the level of social supportcombined to have a much greater in£uencethanWTCexposure severity.That two aspects of status and role, being apolice o⁄cer and Hispanic ethnicity, were socritical is a re£ection of the di¡erent resourcecaravans and resource caravan passagewaysthatthesegroups’statusre£ects.Hispaniceth-nicity is likely to be explained as a factor bylanguage and cultural gaps that are obstaclesto translationof resources toaction, as indi⁄-culty of getting accurate news from main-stream media, di⁄culty in accessingtreatment and possibly having more precar-ious employment stability. Importantly,police selection and training made a majordi¡erenceinresilienceoutcomes,eventhoughthepolicehadmuchgreater traumaexposurein witnessing dead bodies, threats to theirown lives and witnessing the death of peers.Clearly, their selection for traits of strengthand resilience and training on dealing withtrauma were critical determinants of PTSDversus resilience.Examination of the trauma literature, incor-porating clinical, epidemiological and moreanthropological study, illustrates the import-ance of resource caravan passageways, whenwe compare them to a similar study of resili-ence trajectories examined in a resiliencetrajectory study with the abovementionedcohort of Palestinians. In this regard, thecritical di¡erence in ¢ndings compared tothe WTC study was that the majority ofrespondents were not resilient. Indeed, morethan four times the proportion of partici-pants were in the severe, chronic distressgroup in this study than in theWTC study,and even those in the best trajectories werenevertheless, experiencing considerable dis-tress. This di¡erence was attributed to the

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chronic nature of the trauma and the low h-ope for future positive political relief (Hob-foll, Mancini, Hall, Canetti, & Bonanno,2011).The context of ongoing trauma, whichis characterised as a resource caravan passa-geway with intense trauma exposure anddaily threat, and little hope for future changeresulted in avirtual reverse of the proportionof individuals who were resilient versusexperienced chronic symptoms of trauma.Indeed, the level of chronic distress versusresilience was so great as to result in a recon-sideration of resilience theory by Bonanno,one of the co-authors. As previouslyBonanno had theorised that resilience wasevidenced by most of those facing trauma,this key aspect of his pioneering theorisingon resilience had tobemodi¢ed for those liv-ing within chronic traumatic circumstances(Bonanno et al., 2011).

ConclusionsResponding is ¢rst and foremost an expres-sion of the extent and chronicity of traumain the environment and people’s ability toseek safety, retain close attachments andrealistically hope for an end to the risk oftrauma.When circumstances limit people’sability to retain or recreate resources andwhere personal, social andmaterial resourceloss is prominent, then high levels of PTSDand depression occurs, and recovery path-ways become blocked.The resource caravanand resource caravan pathways concept arekey predictors of both pathological andresilience outcomes. This is especially truefor vulnerable populations and low resourcesettings, as in such cases there are oftenmultiple traumas occurring over a lifetime,with a continued spiralling of resource loss.Only a partial element to predictive modelsis added by clinically based theories ofemotions or recorded memories. Nor wouldneurological ¢ndings add much at this stageof research.We must incorporate social context as cen-tral to responding. By focusing on the

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caravan of resources and resource passage-ways that are contextually evidenced, wecreate a deeper, more ecologically validunderstanding of PTSD and the array ofidioms of distress that are represented indi¡erent cultures. This, in turn, opensmultiple new avenues for potential clinicaland social intervention. By way of example,the centrality of honour to many collectivistcultures would require intervention to focuson steps to ‘repair tears in the fabric’ of honourand shame through community reinte-gration, acceptance and recognition. Thismeans that intervention would not be only,or perhaps not at all, on the individual level,but instead would be a community process,incorporating such concepts as collectivee⁄cacy (Benight, 2004).As Norris, Sherrieb & Pfe¡erbaum (2011)prescribe, intervention must work to buildcommunities’ economic resources, increaseaccess to services and mitigate risks associ-ated with social injustice in order to buildresilience systems. Social support should betranslated to building stronger social net-works and enhance natural social supports,ensuring robust linkages that can resist thedestructive impact of a disaster or trauma.An important point here is that trauma iscompounded by social injustice and theunfair access to resources that in some con-texts occurs by class, gender, sexual orien-tation, ethnicity or race.By focusing on the trauma memory andinitial fear responding, we remove ourselvesfrom context because we focus on internalcognitive and emotional processes. This, ofcourse, arti¢cially leaves these aspects outof our clinical models. We lose predictivevalue, become circular in explaining new¢ndings that are shoe horned into existingmodels and leave most of those with PTSDand other trauma responses untreated.Finally, as we begin to think more aboutresilience, we are poorly informedbyclinicalmodels. COR theory, with its emphasis onloss and gain of resources, the concept ofresource caravans and the social and

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cultural understanding of resource caravanpassageways, helps to predict and explaintrauma responding and expands insightsfor intervention across cultures and settings.Future research needs to examine traumain the social and cultural context. It will beimportant to examine whether and to whichextent more traditional western concepts ofPTSD ¢t within these other contexts, but atthe same time to be creative in conceptualis-ing distinctions that are more culturallyspeci¢c. By expanding our view of time, bycomparing groups in context and by com-paring groups in di¡erent contexts, we willengendera richer viewof trauma respondingand how treatment can likewise evolve.

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Stevan E. Hobfoll, PhD, is the Judd and

Marjorie Weinberg Presidential Professor and

Chairof theDepartmentofBehaviouralSciences

at Rush University Medical Center, Chicago,

Illinois, USA.

email: [email protected]

rized reproduction of this article is prohibited.