Risk and Resilience

Although school and workplace shootings are relatively rare, almost two thirds of the population may experience a traumatic event during their lives.Reference Norris3–Reference Galea, Nandi and Vlahov8 The psychological consequences are often more devastating then the physical sequelae. Posttraumatic stress disorder (PTSD) is the most common psychological disorder studied after a traumatic event.Reference Norris, Friedman and Watson9, Reference North, Nixon and Shariat10 The prevalence of lifetime trauma in men is 60.2%, and 8.1% of them develop PTSD. In women there is a 51.2% lifetime exposure to trauma with a PTSD rate of 20.4%.Reference Kessler, Sonnega and Bromet6

There is awareness that despite exposure to a disaster most people recover quickly or experience no disruption in their functioning and demonstrate resilience to the negative effects of a disaster. Resilience refers to the ability of an individual, a group, an organization, or even an entire population to rapidly and effectively rebound from psychological perturbations associated with critical incidents, terrorism, and even mass disasters.

Initial studies on resilience focused on the premature death of a spouse at midlife.Reference Bonanno, Keltner, Holen and Horowitz11 Most people experienced moderate symptoms and difficulty in functioning but managed to struggle through for a period of 1 to 2 years and gradually returned to their baseline functioning level; however, there was a group of people that could be clearly distinguished from the other group by having a stable low pattern of distress. They were able to go on with their lives with little disruption—in other words, they were resilient.Reference Bonanno, Keltner, Holen and Horowitz11 Bonanno et al showed that resilient individuals were rated by their friends as better adjusted before the loss than the more symptomatic bereaved individuals.Reference Bonanno, Moskowitz, Papa and Folkman12 They were also able to identify patterns of resilience in the people exposed to the September 11, 2001 World Trade Center disaster.Reference Bonanno, Rennicke and Dekel13

It also appears that resilient people are better able to take comfort from talking or thinking about their spouse, have fewer regrets about the things they should or should not have done while that person was alive, and were less likely to try to understand or make sense out of why the spouse died.Reference Bonanno, Wortman and Nesse14 Being resilient does not mean that a person does not experience emotional distress; he or she is simply able to rebound quickly with little effect on ability to function.

There are also data to suggest that people prone to anxiety disorders score higher on the neuroticism (or instability) dimension on valid personality tests. Neuroticism is defined as a propensity to experience negative emotional states or to be emotionally unstable. These are often people who are prone to psychological distress, unrealistic ideas, excessive cravings or urges, and maladaptive coping responses. One study showed that high neuroticism at age 19 predicted onset of anxiety by age 36.Reference Angst and Vollrath15 Another study in New Zealand showed through diagnostic interview that people at age 18 that had high negative emotionality, or neuroticism, were more likely to have an anxiety disorders at age 21.16 A study looked at 572 United Nations peacekeepers in the former Yugoslavia. Personality characteristics were obtained before deployment with the Dutch version of the Minnesota Multiphasic Personality Inventory and a post–self-rating inventory for PTSD was given after deployment. Personality traits related to neuroticism such as negativism was second only to traumatic event exposure in predicting PTSD symptoms.Reference Bramsen, Dirkzwager and van der Ploeg17 In a study of severe burn victims who were administered the NEO-Personality Inventory Structured Clinical Interview for DSM-III-R (SCID) at hospital discharge and readministered the SCID at 4 and 12 months later, showed that higher baseline neuroticism predicted onset of PTSD in the following year.Reference Fauerbach, Lawrence, Schmidt, Munster and Costa18 These studies suggest that individuals who rate high on neuroticism may be more vulnerable to the consequences of trauma and therefore less resilient.

Several other risk factors for PTSD have been identified. People who have had prior exposure to traumatic events are at higher risk for PTSD.Reference Koopman, Classen and Spiegel19 Individuals with preexisting psychiatric disorders, particularly anxiety disorders,Reference Koopman, Classen and Spiegel19 and people with a lack of social support have also been shown to have higher rates of PTSD. Reference Koopman, Classen and Spiegel19–Reference La Greca, Silverman and Vernberg21

Resistance

The term resilience refers to “bouncing back” from traumatic experiences, but it is also useful to consider the term resistance. Resistance refers to the ability of an individual, a group, an organization, or even an entire population to withstand manifestations of clinical distress, impairment, or dysfunction associated with critical incidents, terrorism, and even mass disasters. Resistance may be thought of as a form of psychological immunity to distress and dysfunction, analogous to vaccination. The notion of creating resistance represents a proactive step in emergency mental health and is a preincident intervention. One study looked at 35 police officers who were followed up 3 years after they were first assessed following their involvement in the retrieval and identification of human remains after a major disaster. Most of these officers were free of signs of psychiatric morbidity. Organizational and managerial practices appear to be powerful antidotes to adverse posttraumatic reactions.Reference Alexander22 The officers were able to resist manifestations of the trauma. Resistance can also be achieved by having in place policies that outline steps and methods to deal with critical events before they occur.

It is important that proactive steps be taken to prepare ourselves and our communities for the possibility of unfortunate events. Enhancing resistance and promoting resilience of the target populations may achieve this goal. Historically, this element of disaster mental health response has been conspicuous in its absence. More specifically, disaster mental health services have been almost exclusively reactionary in nature.

Potential Interventions

Resistance and resilience may be facilitated by the following 4 empirically supported strategies. The first is providing realistic preparation. Setting appropriate expectations, developing stress management and coping skills, and providing realistic preincident training may serve to foster stress resistance.Reference Lating, Everly, Pergine, Neel, Glick and Sherman23–Reference Seligman, Reivich, Jaycox and Gillham27

The second strategy is fomenting group cohesion and social support. Social support has been shown to be a buffer against stress.Reference Flannery28 The creation of group cohesion, with an underlying infrastructure for social support, may be useful. An essential element of fostering cohesion and support, we believe, will be effective risk communications. Risk communications should be designed to provide these essential elements: information (and rumor deterrence), reassurance, direction, motivation, and a sense of connectedness.

The third strategy is fostering positive cognitions. Cognitive appraisals appear to be key determinants of stressReference Everly and Lating29 and trauma.Reference Ehlers and Clark30 Positive cognitions seem to deter excessive stress and effect resilience.Reference Hobfoll, Spielberger and Breznitz25,Reference Affleck and Tennen31–Reference Tedeschi and Calhoun33 Positive cognitions may include positive memories of those lost in war/terrorism, and/or identification with a noble motive, such as religion or nationalism.

The fourth strategy is building self-efficacy and hardiness. Self-efficacy is the belief in one's ability to organize and execute the courses of action required to achieve necessary and desired goals.Reference Bandura34 Hardiness is characterized by the belief in one's own agency or self-efficacy (ie, the ability to exert control over relevant life events), the tendency to see stressful events as “challenges” to be overcome and opportunities for growth, and a strong commitment and sense of purpose.Reference Kobasa, Maddi and Kahn35

As an example of facilitating resilience, Virginia Tech held a convocation on April 17, 2007 in the college stadium and via simulcast in a nearby stadium. Members of the faculty, religious community, Virginia governor Tim Kaine, and President George W. Bush spoke to the audience. This technique is similar to what was done by the New York Police Department in the wake of the events of September 11, 2001. The Port Authority Police of New York and New Jersey used a much larger and longer (2 days) variation after the terrorist attacks of September 11. These assemblies were held in the hope of helping the community become more resilient in the face of the tragedy.

The technique described above is essentially the 4-phase group crisis intervention termed crisis management briefing (CMB), which is used to create resilience in a community.Reference Everly36 CMB is designed to be used with “groups” of survivors who may have been directly or indirectly affected by an incident. Such groups may range in size from 10 to more than 300 individuals at a time. The CMB may be thought of as a town meeting. The intervention is designed to be highly efficient, taking between 45 and 75 minutes to implement. CMB may be implemented in schools, corporations, and community settings.Reference Newman37, Reference Mitchell and Everly38

The first phase of CMB consists of bringing together a group of individuals who have experienced a common crisis. In response to a school crisis, for example, 1 grade at a time could be addressed by assembling in the auditorium. In response to a workplace crisis, a company meeting room could be used or a room could be rented at a local hotel or commercial meeting facility. This act of assembly is the first step in reestablishing the sense of community that is so imperative to the recovery and rebuilding process.Reference Ayalon39

Once the group has been assembled, the next intervention component is to have the most appropriate and credible authorities explain the facts of the crisis event. In many instances, a highly respected spokesperson lends credibility to the message and the belief that the actions and support will be effective. Objective and credible information should serve to control destructive rumors, reduce anticipatory anxiety, and return a sense of control to victims.

The next step is to have credible health care professionals discuss the most common reactions that are relevant to the particular crisis event. Common signs and symptoms that should be addressed are grief, anger, stress, survivor guilt, and even responsibility guilt among survivors, friends, and others.

The final component of CMB is to address personal coping and self-care strategies that may be of value in mitigating the distressing reactions to the crisis event. Community and organizational resources available to facilitate recovery should also be introduced. Questions should be actively entertained, as appropriate. Each group participant should leave the meeting with a reference sheet that briefly describes common signs and symptoms, common stress management techniques, and local professional resources (with contact names and telephone numbers).

After a massive traumatic event there is an almost inevitable tendency for people to engage in large group processes like the convocation at Virginia Tech. It must be noted, however, that techniques such as CMB have not been tested, nor have most postdisaster interventions. Interventions such as these do not easily lend themselves to control trials.