psychosocial resilience and its influence on managing mass emergencies and disasters

EpidEmiology, thEorEtical basis and managEmEnt

Psychosocial resilience and its influence on managing mass emergencies and disastersrichard Williams

John drury

Abstractthis article argues that, while emergencies and disasters are distressing

for most people and may result in mental disorders for a substantial

minority of affected persons at some time in the following months and

years, there are personal and collective sources of psychosocial resil-

ience. the concepts, bases, and practical potential of resilience have

been explored for more than 40 years. however, studies of pathology,

which emphasizes people’s vulnerability over their adaptive capacities,

have predominated. the nature and basis of personal psychosocial

resilience are outlined, and a new approach to collective resilience that

has been developed through recent research on crowd psychology is

described. the article concludes with some implications for managing

disasters and practice, including the suggestion that crowds be treat-

ed as part of the solution rather than part of the problem in mass

emergencies and disasters.

Keywords collective resilience; crowds; disasters; disorders; distress;

emergencies; personal resilience; psychological first aid; psychosocial

resilience

Introduction: disasters and emergencies

On average, a disaster occurs somewhere in the world every day. Although some are anticipated, it is difficult to predict accu-rately when disasters may occur or the nature of the next major incident.

Emergencies and disasters have the potential to disadvantage many persons. Stressors include: • threat to life and physical integrity • exposure to injured and dying people, and corpses • exposure to gruesome sights and noxious smells • social and material loss and bereavement

Richard Williams TD FRCPsych DMCC is Professor of Mental Health Strategy

at the Welsh Institute for Health and Social Care, University of

Glamorgan, Honorary Professor of Child and Adolescent Mental Health,

University of Central Lancashire, and Consultant Child and Adolescent

Psychiatrist, Gwent Healthcare NHS Trust, UK. Conflicts of interest:

none declared.

John Drury BA MSc PhD is Senior Lecturer in Social Psychology,

Department of Psychology, University of Sussex, Brighton, UK. Conflicts

of interest: none declared.

psychiatry 8:8 29

• social, employment, school, and community disruption • consequential continuing hardship.The psychosocial, behavioural, and health consequences of disasters result from interactions of the: • direct impacts on the people involved • consequences of the response (e.g. economic loss, disruption) • health and social effects on people who are involved directly

or indirectly, or who carry the burden of worry and care for survivors

• impact of subsequent preparedness (e.g. counter-terrorism strategies) and the social ramifications of new security procedures.

Therefore, it is not surprising that so many of the people who are directly or indirectly affected develop social, relationship, and/or psychological problems, physical health care problems, or psy-chiatric disorders. The literature contains numerous papers that describe the enormity of these effects. Yet, that is an incomplete picture. In its recent guidance, NATO adopts “… an evidence-informed and values-based approach to psychosocial intervention after disasters … that takes the psychosocial resilience of persons and the collective psychosocial resilience of families, groups of people and communities as the anticipated responses, but not as inevitable”.1

Protecting people and communities against the psychosocial effects of disasters and promoting their resilience is, therefore, a critical component of disaster preparedness and of responses to major incidents. This paper explores the nature and bases of resilience, and its implications for managing disasters.

Disorder, distress, and resilience

A high percentage of people who are involved in emergencies experience health complaints after their exposure to traumatic events. NATO1 has estimated that up to 80% of affected people may experience at least short-term mild distress; 15–40% medium-term, moderate, or more severe distress; 20–40% a mental disorder or other psychological morbidity associated with dysfunction in the medium term, and 0.5–5% may have a long-term disorder. These figures are broad guidelines only, because it is difficult to provide precise prevalence rates.

The figures reported in the literature vary considerably with factors that include the differing effects and durations of differ-ent emergencies, variations in the profile of vulnerabilities of the people who are affected, differences in how the affected popula-tions are defined, variations in the methods used to ascertain the impacts, and differences in the sensitivity of their application. However, it seems clear that more people suffer from distress rather than psychiatric disorder.

Distress refers to the experiences and feelings of people after external events that challenge their tolerance and adaptation. It is initiated and maintained directly by primary and secondary stressors, and subsides when the stressors disappear or as people adapt to the changed circumstances. Distress is an anticipated human experience that has emotional, cognitive, social, and physical aspects. It is not a disorder when it emerges and persists in proportion to external stressful situations.1

The distinction between distress and disorder is evaluative because it is subject to cultural considerations and differing personal perceptions and values. However, the distinction is

3 © 2009 Elsevier ltd. all rights reserved.


important prognostically, and, we argue, in respect of planning for humanitarian aid, and psychosocial and mental health care responses to disasters.

Psychosocial resilience describes people’s ability to cope with stress. In technology, resilience refers to the capacity of a material to return to its original shape after an applied force is removed. Thus, the concept of psychosocial resilience does not imply any lack of impact of events on people’s feelings, actions, or performance, but the reverse. It embraces distress that is fol-lowed by recovery if the circumstances are supportive.

We recognize two forms of psychosocial resilience. The first, which we term personal resilience, describes how particular people respond to the challenges they face. The second application describes how collectives of people respond to, cope with, and recover from emergencies. We consider the nature, aetiology, and implications of each below.

Personal resilience

Personal resilience describes ‘a person’s capacity for adapting psychologically, emotionally and physically reasonably well and without lasting detriment to self, relationships or personal devel-opment in the face of adversity, threat or challenge’.1

Genetic and acquired personal characteristics determine the extent to which people are more or less resilient or vulnerable. They include people’s developmental experiences and per-sonal characteristics, repertoires of knowledge, and capabilities acquired from our earliest years. Resilience also has dynamic, interactional, and systemic qualities, in which personal factors interact with experience and changing circumstances. Thus, the nature of our family, peer, school, and employment relationships, the life events we experience, and the nature of our attachments are important formative elements. Box 1 summarizes the core features of personal resilience that have emerged from research and practical experience. Table 1 summarizes models and further aspects of personal resilience.

Facets of resilience that are particularly important include capacities and capabilities for forming effective attachments to other people, being able to sustain good relationships with others, and also being able to accept social and emotional sup-port from them. In summary, personal resilience describes more than people being subject to protective factors or lacking risk factors that affect their lives. It includes how well people are able to grasp the realities of their circumstances, how they perceive themselves in relation to the challenges they face, and their abili-ties to innovate. Importantly, it is also a dynamic process of inter-action between people and others and the environment around them.

Collective resilience

Collective resilience refers to the way people in crowds express and expect solidarity and cohesion, and thereby coordinate and draw upon collective sources of practical and emotional support adaptively to deal with an emergency or disaster.4 The ability of established communities and organizations to recover and func-tion successfully without top-down direction is well documented in disaster research. The emergency services, for example, successfully improvised forms of coordination after the World

psychiatry 8:8 29

Trade Center terrorist attack in 2001, despite the loss of their command and control centre. We go further and argue that these qualities do not apply solely to social systems that have clear role structures, but also, importantly, to unstructured groups of survivors thrown together by events. This is a novel argument, which offers a new perspective on the relation between crowds and personal well-being.

In early research on emergencies and disasters, crowds were understood as a problem. Conventional views were that, with limited means of escape, people see others in the crowd as obstacles to their own survival.5 Emergencies are stressful and frightening. It was assumed that these emotions would spread uncritically through a crowd, resulting in people reverting to a basic, instinctual individualism, with disastrous results for all. An increasing body of review evidence from a variety of mass emergencies and disasters has undermined this picture of patho-logical mass panic. The behaviour of crowds in emergencies and disasters is typically orderly, and mutual help among survivors is common. Panic, when it occurs, is displayed by a few people and not the crowd as a whole. Collective reactions to emergen-cies and disasters are more typically resilient.6

Previously, the major explanations for the resilient behaviours of crowds in emergencies have been in terms of the persistence of pre-existing interpersonal relationships, norms, and roles. However, perhaps the most striking and novel social behaviour observed in emergency crowds is mutual aid among strangers.

Resilience factors

Personal skills

• the capacity to receive social support

• good cognitive skills

• good communication skills

• active problem-solving skills

• Flexibility – the ability to adapt to change

• ability to cope with stress (seeing stress as a challenge)

Personal beliefs and attitudes

• self-efficacy (general expectation of competence)

• self-esteem

• hope

• a sense of purpose

• religion or the feeling of belonging somewhere

• positive emotion and humour

• the belief that stress can have a strengthening effect

• acceptance of negative feelings

Interaction skills, relationships, and achievements

• good relationships with other people

• contributions to community life

• talents or accomplishments that one values oneself or that

are appreciated by others

• access to and use of protective processes

• adaptive ways of coping that suit the situation and the person

• growth through negative experiences

(reproduced with permission from Williams 2008).2

Box 1



The nature of resilience

Model of resilience Description

Dynamic resilience changes over time and may be of differing strength in differing situations

Developmental resilience is affected profoundly by a person’s experience in childhood and beyond

Interactivepassive – increasing a person’s ability to

withstand trauma

resilience may be thought of as related to each person’s ability to withstand trauma. thus,

one approach is to help people develop their ability to cope well when faced with trauma

active – shaping the environment to

minimize trauma

a second approach to developing resilience is based on the observation that more resilient

people express agency in doing what they can to organize the world around them in order

to minimize the risk of being exposed to trauma. at the same time, most people also wish

to experience some risks and each one of us has their own setting on a ‘risk thermostat’.

coping well may, therefore, be related to knowing one’s own comfort with risk

Gender related generally, women are more resilient than men, although they are also more likely to develop

longer-term psychiatric disorders

Related to personal characteristics intelligence and temperament and, particularly, a combination of the two

Quality of each person’s family relationships the level of social support that is available to each person from their family and available

support from people outside each person’s family, including that provided by other persons

and institutions such as employers and workplaces

Related to attachment capabilities research has shown strong relationships between people’s capacities for secure attachments

and their resilience

based on condly (2006)3 and reproduced with permission from Williams (2008).2

Table 1

Sometimes, survivors risk their own safety for the collective good. A new model of resilience based on self-categorization theory provides an explanation for such inclusive solidarity.4,7 In this account, people can act as one and provide mutual aid with-out knowing one another personally, or even communicating. Categorizing oneself cognitively with others on some relevant dimension means sharing a definition of social reality, which, in turn, means expecting agreement and support, and, hence, enables coordination. Shared self-categorization has emotional as well as behavioural consequences; if we define others as part of ‘self’, we are also more likely to care about them, and to act in their interests.

In this account, one criterion for the shift from seeing ourselves as separate persons to members of a collective is perception of a common fate. An emergency or disaster, far from dividing people into instinct-driven competitive individuals, can serve to create a sense of psychological ‘we-ness’ or unity. The common-sense cliché of the Blitz spirit expresses this sense of communality. Shared adversity brings strangers together: neighbours who hardly know one another talk for the first time, and share what meagre resources they have in a spirit of camaraderie.

The recent case study of the London bombings of 7 July 2005 illustrates the nature and extent of collective resilience.4 In an analysis of accounts from 90 survivors, reports of widespread helping during the events outweighed accounts of personally selfish behaviours by a ratio of approximately 10:1. As they waited for the emergency services to arrive, survivors shared water, tied tourniquets round others’ bleeding limbs, dressed others’ wounds with make-shift bandages, broke open doors to help others escape, and carried people who could not support themselves. Crucially, they also provided emotional support:

psychiatry 8:8 29

they reassured and hugged one another, and chatted to keep each other’s spirits up.

Yet, most of the survivors were commuters: archive analysis found that at the time of the bombing only eight said they were with people they knew beforehand, whereas 57 stated that they were with strangers. Most of those interviewed emphasized the strong sense of togetherness they saw and felt with other survi-vors in the event. They also described a common fate in relation to the emergency. We suggest that this common fate was the basis of their shared self-categorization and the collective resil-ience exhibited by the crowd.

A study comparing eleven different emergencies provides still stronger evidence for this model.7 Compared with other survi-vors, people expressing and observing higher levels of identifica-tion with the rest of the crowd: (1) were more likely to describe a common fate; (2) observed, gave, and received more help from others; (3) observed less personally selfish behaviours in others; and (4) observed more examples of mundane social cohesiveness (e.g. courtesy, control of emotions, adherence to social norms and roles, and orderliness).

Pre-existing social bonds are not necessary for collective resilience. It is because a sense of collective unity with others arises during emergencies that we are able accept support, act together with a shared understanding of what is practically and morally necessary, see each other’s plight as our own and hence give others support, sometimes at a cost to our own personal safety. Shared self-categorization means that we trust others to be supportive rather than competitive, which, in turn, reduces anxiety and stress. Finally, shared self-categorization allows us to feel collective ownership of the plans and goals we make together.



Implications of distress and resilience for managing emergencies and disasters

Based on our review, we identify the following matters that require consideration when planning society’s responses to emergencies and disasters. • It is important to distinguish experiences that may indicate personal distress, which may be severe, but which is compat-ible with resilience, from those that are symptoms of mental disorders. This may be challenging because distress and certain post-traumatic disorders may be characterized by similar experi-ences. It is also evaluative, requiring consideration of culture, circumstances, and values. The difference between understand-ing people’s experiences as indicating distress or as the symp-toms of a disorder turns on how their experiences, feelings, and behaviour change over time and whether or not their experiences are associated with persisting dysfunction. This observation is in line with, and supports, the commonly accepted clinical policy of allowing for a month of watchful waiting before initiating spe-cialist clinical interventions with the majority of affected people. We emphasize that, during the first month, responses that are based on the concepts of psychological first aid (PFA) should be made available for everyone who requires them.1 However, we recognize that a small minority of people who develop extreme reactions that may be indicative of severe mental disorders, for example, may require earlier or urgent psychiatric assessment and, possibly, intervention. • The model of personal resilience outlined here emphasizes the importance within disaster planning of providing adequate responses to people’s basic needs. A core component of PFA is attending to practical material and social support.8 Arguably, this is effective and the risks of re-traumatization are less than those that may result from single-event debriefing that focuses on re-visiting emotional experiences in the immediate aftermath of a disaster.8

• If our notion of collective resilience is right, then crowds are not a problem but a resource to be harnessed: we should think of survivors as the fourth emergency service. This means that we should accommodate the inevitable public need to help. • If communities, and crowds, are a source of resilience, a key implication of our argument is that psychosocial resilience is substantially endogenous. However, certain practices can facili-tate or inhibit this natural resilience. Groups and crowds require practical information to act effectively. This points to the im-portance of having good and informed risk and communication strategies within disaster management plans. • Collective resilience can operate as the social–psychological basis of personal resilience and recovery. Others in the same situ-ation can support each person’s veridical view of reality. More-over, being part of a crowd helps people practically to realize goals that they cannot achieve alone. Crowds, communities, and groups allow people to express agency in doing what they can to organize the world around them in order to minimize the risks of being exposed to further trauma.

Conclusion

There are many myths about disasters. The first and most endur-ing is that crowds panic. A second is that people are inevitably immobilized by fear. A third is that chaos occurs within responding

psychiatry 8:8 29

agencies.1 Research shows that panic is rare.4,8 Many people who are directly involved are the first to take action. Often, disasters create unity and improve inter-agency cooperation.

Our summary of the concept of resilience as applied to both affected persons and collectives, including groups of strangers and teams of responding staff, enables us to explain why these common beliefs about emergencies are, usually, erroneous. We have summarized some implications of both personal and col-lective resilience for managing disasters. Our discussion of how psychosocial resilience is developed and sustained, along with our new definitions and more research into its application, also allows for optimism. We conclude that managing the psycho-social effects of disasters should begin before emergencies occur and continue during their immediate aftermath, and that facilitation of psychosocial resilience is particularly important for longer-term recovery. This requires us to harness lessons about the behaviour of people in crowds in addition to providing effective access to personal care for people who are assessed as requiring it. ◆

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