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Resiliency:EnhancingCopingwithCrisisandTerrorism

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EMERGING SECURITY CHALLENGES (ESC) DIVISION

SCIENCE FOR PEACE AND SECURITY (SPS) PROGRAMME

ADVANCED RESEARCH WORKSHOP (ARW)

Resiliency: Enhancing Coping with Crisis and Terrorism

EDITORS:

Dean Ajdukovic Shaul Kimhi Mooli Lahad

IOS

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Table of Content

page

Introduction: Where Do We Stand Regarding the Concept of Psychosocial Resilience? Dean Ajdukovic

3

Chapter 1 Indomitability, Resilience, and Posttraumatic Growth Peter Suedfeld

12

Chapter 2 Resilience From a Neuroscience Perspective Richard Bryant

40

Chapter 3 Resilience After Trauma

Katie Cherry Sandro Galea

65

Chapter 4 Coping, Conflict and Culture: The Salutogenic Approach in the Study of Resiliency Shifra Sagy

76

Chapter 5 Levels of Resilience: A Critical Review Shaul Kimhi

89

Chapter 6 National Resilience in Multinational Societies Merle Parmak

106

Chapter 7 The Integrative Model OF Resiliency: The "BASIC Ph" Model OR What DO We Know About Survival?

Mooli Lahad Dima Leykin

125

Chapter 8 Couples in the Line of Fire: Couples' Resilience in Preserving and Enhancing their Relationships

Michal Shamai Guy Enosh Ronit Machmali-Kievitz Saray Tapiro

155

Chapter 9 Community Resilience Assessment - Meeting the Challenge - the Development of the Conjoint Community Resiliency Assessment

Limor Aharonson-Daniel Mooli Lahad Dima Leykin Odeya Cohen Avishay Goldberg

179

Chapter 10 Stress and Resilience in the Midst of a Security Tension

Dima Leykin Limor Aharonson-Daniel Mooli Lahad

206

Chapter 11 A History of Political Violence in the Family as a Resilience Factor

Evaldas Kazlauskas Paulina ŽelvIene

225

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Introduction

Where Do We Stand Regarding the Concept of Psychosocial Resilience?

Dean Ajdukovic1 Department of Psychology, University of Zagreb, Croatia

Research on psychosocial resilience has a history of almost fifty years, beginning

within the context of developmental psychopathology. Pioneering scholars on

individual resilience like Garmezy [1], Werner and Smith [2], Rutter [3], Masten [4],

Ungar [5], and Luthar [6] recognized that among children who grow in highly adverse

circumstances there is a subgroup who manage to develop well and thrive.

Antonovsky [7] was among the pioneer scholars who studied resilience in adults and

recognized that surviving the most horrible experiences may not result in

psychopathological and dysfunctional outcomes.

The key question in the early studies on resilient children focused on what made a

difference in the lives of individuals who developed behavioral and mental health

problems compared to those who did not despite living under similar circumstances.

This question remains the same in contemporary research on resilience of

populations affected by disasters, major incidents and terrorist attacks. Similarly, the

ambition to identify protective factors that are relevant for resilience in children

growing up in adverse circumstances remains the same for researchers who

continue seeking correlates of resilience among adults who live in communities

exposed to destruction and violence. Consequently, current research priorities and

resource allocation focus on promoting resilience, and developing effective

preventive interventions, strategies and policies.

1Corresponding author: Dean Ajdukovic, University of Zagreb, Faculty of Humanities and Social Sciences, Department of Psychology, Zagreb, Croatia. E-mail: dean.ajdukovic@ffzg.hr

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The recent decades of increased threat of terrorist attacks and human-made

disasters have facilitated a shift in the research, theory and services related to

resilience from an approach focused on deficits towards a broader understanding of

resilience based on strengths and resources. In other words, the field has witnessed

a broadening of interest from developmental resilience of children growing up in

extremely adverse environments, to resilience-building strategies that may facilitate

recovery, help restore effective functioning and ensure positive outcomes in the

wake of major critical events that threaten the well-being of individuals, families,

communities and nations.

This shift is also evident in the changing definition of resilience over time. For

example, Garmezey [1] in 1974, considered resilient children to be those who are

“invulnerable,” who despite disadvantages adapt and perform competently. More

recent definitions of resilience focus on a system capacity and response, such as:

“Resilience is the process of adapting well in the face of adversity, trauma, tragedy,

threats or significant sources of stress” [8]. Regarding disasters, Norris and

colleagues have described resilience as a positive trajectory of adaptation after

disturbance, stress, or adversity [9].

Studying resilience is based on two fundamental assumptions [10]: (1) There has

been a threat to an individual or a social system, and (2) Resilience of an individual or

a system can be assessed only in comparison to an expected level of positive

adaptation and functioning. This means that we cannot truly assess the resilience of

an individual or a community unless their usual functioning has been seriously

disrupted. Another important methodological issue pertains to when to assess

resilience after a disruption. Based on studies of individual recovery from

posttraumatic stress symptoms [11], it seems that at least one year is the minimum

time to wait after a traumatic event. Assessment of community resilience may

require an even longer period. Shorter assessment periods may in fact assess post-

exposure coping but not necessarily resilience. In any case, operationalization and

measurements based on these assumptions remain a challenge. The chapters in this

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volume have all considered the evidence of resilience in the aftermath of major

disruption or trauma affecting groups of people.

Another challenge for fully understanding resilience is that its meaning has moved

from being understood as a personality trait, to being considered a dynamic process

over time [12]. The assumed trait of an individual, referred to as “resiliency” [12],

has no sound empirical proof. Systems theory has been helpful in understanding

resilience as a process. In fact, it is considered to be an ongoing process of positive

adaptive changes to threat and adversity, enabling further positive adaptive changes.

This recognizes the importance of various interactions as well as a history of previous

adaptations, and opens up opportunities for interventions. In a way, resilience is a

process of transactions among individual, proximal and distal social environments

which set the stage on which players like personality traits, physiology and genetic-

environment interaction, attitudes and beliefs, individual and collective identities,

cultures and values, individual and collective experiences, connectedness and

alienation, all perform at a time of threat and disruption of habitual functioning. It is

the outcome of an individual’s interactions with that environment that protects him

or her against the overwhelming influence of risk factors [13]. Masten cautions that,

among other issues, the following need to be taken into account when studying

resilience: (1) It is a complex group of concepts that always requires a careful

conceptual and operational definition; (2) It is neither a single trait nor a process, but

rather many attributes and processes are involved; (3) There are multiple pathways

to resilience [10].

The main research question in studying resilience relates to the capacities of

individuals, communities and societies to withstand and recover from highly adverse

and potentially traumatic events, such as a mass casualty terror attack, organized

violence, an economic crisis or a disaster. More resilience implies recovering or

“bouncing back” quickly after such events, successfully coping with greater stress,

and being less disturbed by the same amount of stress than someone less resilient or

more vulnerable [14]. However, there are limitations with such a view of resilience

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for it rests on the idea of “restoring conditions” or “returning to normal” after major

stress, reflecting the ideal of resuming functioning as if a disruption has not

occurred. However, people, communities and nations who overcome disasters or

mass violence do not remain the same as before. Crises generate changes that may

increase resilience to future adversities. However, studies on posttraumatic growth

indicate that only a minority of people show this capacity after trauma. There are no

studies regarding communities and nations that “grow” in this sense.

In the last two decades, research on resilience has widely expanded from an

exclusive focus on individual resilience to the broader ecological levels of the

community and society. This is due to the embracing of the social systems

perspective, alongside increasing threats from terrorism and human-made disasters.

The ideal research paradigm regarding trauma, violence and disasters would be to

assess resilience before the onset of the critical event, and then determine patterns

of relations between these assessments and the outcome criteria of subsequent

mental health and functioning of the affected individuals or community [15].

During the Advanced Research Workshop entitled Resilience: Enhancing coping with

crisis and terrorism, the concept of resilience was examined from different

perspectives. These are reflected in the chapters of the present volume. During the

workshop, a multidisciplinary group of 29 scholars met in the Upper Galilee in Israel

in January 2014, to discuss and share their views on the topic of enhancing resilience

to crisis and terror. The first chapters in this volume present a highly qualified

overview of the theoretical foundations and the state of the art knowledge about

several dimensions of understanding resilience. In the first chapter Suedfeld

reviewed responses to severe stress at the individual, community and mass levels

and presented evidence that affirms human strength, and opposes the assumption

that traumatic-level stressors cause psychological damage to almost all who survive

them. Bryant reviewed major models and evidence from a neuroscience perspective

about different ways people respond to trauma. He also discussed how stress,

gender and attachment processes may be moderated to foster resilience. He

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presented arguments for a more refined definition of resilience as long-term

functioning at a high level.

Most of the other chapters correspond to two main approaches in studying

resilience in the context of mass violence and terrorism. The first approach is based

on a long term follow-up of people who have been exposed to adversities or

potentially traumatic events, and consequential monitoring of psychological and

physiological stress criteria over time. The limitations of this approach are related to

known difficulties of longitudinal studies, as well as frequent loss of interest among

funders and researchers beyond several months of follow-up. A recent meta-analysis

on the long-term effects of disasters has revealed a paucity of studies beyond 24

months [16]. However, the unique advantage of this approach is that it enables

identifying different trajectories of resilient coping which is essential from the public

health perspective and for prevention interventions. Cherry and Galea present data

and supportive evidence on longitudinal trajectories of resilience and discuss

implications for the public health field in this volume. Such studies are very seldom

but yield a wealth of new knowledge.

The second approach in the research on resilience looks at mental health and

behavioral functioning among individuals who have been exposed to a critical event,

seeking patterns of variables that distinguish those individuals who meet criteria for

resilient coping and functioning from those who do not cope well. The limitations of

this approach are typical for any post-hoc cross-sectional research design: poor

control of the critical variables at pre-exposure, which is a threat to internal validity,

and lack of a temporal dynamic perspective which limits the knowledge about the

long-term performance of resilient individuals and communities. For practical and

funding reasons, this is the most common approach in studying the effects of

disasters [16]. However, over the years, such studies have provided fairly consistent

knowledge. In a chapter in this volume, Kauzlaskas and Želviene looked at

associations with family resilience after enduring political oppression in Lithuania.

- 8 -

The third approach to studying resilience uses comparative groups of people who

have and who have not been exposed to a critical event. If the comparative groups

are sufficiently similar and the main difference between them is the exposure, we

can learn a lot from the similarities and differences in the patterns of variables

indicative of resilience. The limitations of such designs are primarily related to

difficulties in identifying and recruiting truly comparative groups, yet this is crucial

for the internal validity of the conclusions. A unique advantage of this approach is

that it enables studying resilience at the various levels of the ecological systems: the

individual, family, community and society. In this volume such a study design was

used by Sagy, who presented findings in which the sense of coherence served as the

explanatory factor of resilience in conflict areas, both in acute and chronic situations

in Israel. Shamai, Enosh, Machmali-Kievitz and Tapiro compared the resilience of

groups of couples with a focus on their relationship, some of who were living in Israel

either under a high and prolonged threat of missile attack or a low threat. Relations

among individual, community and national resilience under perceived national

security threat, and differences between Jews and Arabs in Israel are presented in

the chapter by Leykin, Aharonson-Daniel and Lahad.

In comparison to individual resilience, community resilience is still an under-

researched area. The concept of societal or national resilience is even less well

established. However, community resilience offers the most opportunities for

prevention and interventions, and this scholarship may help inform public health

policies. A critical consideration of the three levels of resilience, i.e. individual,

community and national, and their interrelations are presented by Kimhi in a review

chapter. The theoretical model of associations among these three levels is

presented, and methods for increasing overall resilience in the face of terror are

suggested. In the same chapter, he critically analyzed the main approaches in the

study of resilience. In a chapter on the concept of national resilience, Parmak

presented a view on the relations between societal cohesion, shared culture and

resilience during periods of social instability and transition. She argues that diverse

ethnic and religious identities are a potential threat to the national social fabric.

- 9 -

Development of a multidimensional tool for the assessment of community resilience

through a multidisciplinary collaboration is presented by Aharonson-Daniel, Lahad,

Leykin, Cohen and Goldberg. This instrument standardizes measurement and in turn

enables comparisons of community resilience at different times and across different

locations. Lahad and Leykin present the integrative model of coping that has become

known as Basic Ph and was developed about 30 years ago, and its implications for

the study of resilience.

In sum, the chapters in this book illustrate a broad landscape of the current

knowledge and research topics on resilience as related to mass violence and

terrorism, which is one of the growing concerns of the world today.

- 10 -

References

[1] N. Garmezy, The study of competence in children at risk for severe psychopathology. In E. J. Anthony & C. Koupernik (Eds.), The child in his family: Vol. 3. Children at psychiatric risk (pp. 77-97). New York: Wiley, 1974.

[2] E.E. Werner, R. S. Smith, R. S. Overcoming the odds: High risk children from birth to adulthood. Ithaca, NY: Cornell University Press, 1992.

[3] M. Rutter, Psyhosocial resilience and protective mechanisms. American Journal of Orthopsychiatry 57 (1987), 316-333.

[4] A.S. Masten, Resilience comes of age: Reflections on the past and outlook for the next generation of research. In M.D. Glantz, J. Johnson, L. Huffman (Eds.), Resilience and Development: Positive Life Adaptations (pp. 289-296). New York: Plenum, 1999.

[5] M. Ungar, Nurturing hidden resilience in troubled youth. Toronto: University of Toronto Press, 2004.

[6] S.S. Luthar, Resilience in development: A synthesis of research across five decades. In D. Cicchetti, D. J. Cohen (Eds.), Developmental psychopathology: Risk, disorder, and adaptation, Vol 3. New York: Wiley, 2006.

[7] A. Antonovsky, Unraveling the mystery of health. San Francisco: Jossey Bass, 1987.

[8] American Psychological Association, The road to resilience. Retrieved from http://www.apa.org/helpcenter/road-resilience.aspx, 2014.

[9] F.H. Norris, S.P. Stevens, B. Pfefferbaum, K.F. Wyche, R.L. Pfefferbaum, Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology, 41 (2008), 127-150.

[10] A.S. Masten, J. Obradovic, Competence and resilience in development. Ann. N.Y. Acad. Sci. 1094 (2006) 13-27.

[11] I.R. Galatzer-Levy, Y. Ankri, S. Freedman, Y. Israeli-Shalev, P. Roitman, et al., Early PTSD symptom trajectories: Persistence, recovery, and response to treatment: Results from the Jerusalem Trauma Outreach and Prevention Study (J-TOPS). PLoS ONE 8(8) (2013): e70084. doi:10.1371/journal.pone.0070084

[12] A.S. Masten, Resilience in individual development: Successful adaptation despite risk and adversity. In M. Wang, E. Gordon (Eds.), Risk and resilience in inner city America: challenges and prospects (pp. 3-25). Hillsdale, NJ: Erlbaum, 1994.

[13] A.J. Zautra, J. S. Hall, K. E. Murray, Resilience: A new definition of health for people and communities. In J. W. Reich, A. J. Zautra, J. S. Hall (Eds.), Handbook of adult resilience, (pp. 3-34).New York: Guilford, 2010.

[14] P. Martin-Breen, J. M. Anderies, Resilience: A literature review. Retrieved from www.rockefellerfoundation.org/.../a63827c7-f22d-495c-a2ab-99447a88, 2014.

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[15] E.A. Hoge, E. D. Austin, M. H. Pollack, Resilience: Research evidence and conceptual consideration for posttraumatic stress disorder. Depression and anxiety, 24 (2007), 139-152.

[16] D. Ajdukovic, Meta-analysis of long-term effects of disasters on mental health and PTSD (in preparation).

- 12 -

Chapter 1

Indomitability, Resilience, and Posttraumatic Growth

Peter SUEDFELD2 The University of British Columbia, Canada

Abstract. This chapter examines responses to severe stress at the individual,

community, and mass levels. The social and behavioral sciences, and their

cognate helping professions, have long functioned with the assumption that

traumatic-level stressors cause significant psychological damage to most, if

not all, people who endure them. Concepts of indomitability, resilience, and

posttraumatic growth challenge that orthodoxy, and are increasingly being

supported by the evidence. In the chapter, I discuss such stressful events as

major accidents, natural disasters, war, and genocide, and present data that

affirm human strength.

Keywords: Posttraumatic growth, resilience, trauma

Introduction

Helping people who for one reason or another have problems in functioning under

the physical, social, and spiritual conditions that define their world is one of the foci

of psychologists as well as psychiatrists, general medical practitioners, social

workers, nurses, the clergy, and according to some studies, even bartenders [1]. The

role of psychological helper (therapist, counselor) becomes particularly salient in

situations that may adversely affect large numbers of individuals at once.

Among the most dramatic of these are traumatic environments, which induce

extraordinary stress at levels with which the people in the environment cannot cope

2Corresponding Author: Peter Suedfeld, University of British Columbia, Department of Psychology, Canada. E-mail: psuedfeld@psych.ubc.ca

- 13 -

and which therefore lead to negative life changes. The trauma can be physical or

psychological - severe physical trauma often has psychological effects as well. It is

difficult to arrive at a simple, one-size-fits-all definition of traumatic environments or

events. In any adverse environment, there are wide individual differences in how

people cope. The range includes individuals who view the situation as a challenge to

be faced and overcome (and possibly even enjoyed), through a variety of adaptive

outcomes, to those who are seriously and perhaps permanently damaged. For this

reason, it may be preferable to refer to environments as challenging, extreme, or

potentially traumatic, rather than as necessarily traumatic. Table 1 lists some

environments that fit this definition.

Table 1: A Sample of Challenging, Extreme, or Traumatic Environments

Natural or industrial disasters

Major accidents, violent crime

War zones, areas targeted by terrorists

Ethnic, religious, political, or other persecution

Isolation and confinement

Pathogenesis

Studies of the many factors related to trauma - what Antonovsky called

“pathogenesis” [2] - make up a sizeable literature. Table 2 shows a count of

pathogenic terms appearing in the titles of English-language psychological literature

published between 1981 and 2011. It is divided into two time periods, the cutoff

being the time of the increasing salience of concepts such as positive psychology [3].

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Table 2: Pathogenesis in the Titles of English-Language Psychology Publications

Term 1981-95 1995-2011

Stress 21,021 49,803

Trauma 3,533 18,102

PTSD 2,357 10,942

Victim 5,020 12,579

Victimhood 2 57

Total 31,933 91,483

The focus on pathogenesis is completely understandable. Both by self-selection and

training, many in the “helping professions” are devoted to identifying, diagnosing,

and treating those who suffer. The many events and experiences that intuitively

appear to pose significant barriers to a happy or even tolerable life (see Table 1) are

publicized by the media and communicated in person and in the new social media.

When professionals offer their expert assistance, the offer is justified by the fact that

indeed, many victims seek or at least accept the relief that eases their psychological

pain.

Therapists and counselors who have treated survivors of traumatic events report

what they found, what worked, and what did not. Although such reports do much

good, they also result in a serious distortion of the knowledge base: the “clinical

fallacy.” Concisely defined, it is the overwhelming picture of near-universal

psychological damage that has until recently permeated a literature made up mostly

of studies and reports by therapists.

As a result, the psychological and psychiatric literature has been primarily based on

samples of patients, and both the authors and the readers tend to assume that all or

almost all survivors belong in that category. Survivors who have not felt a need for

psychological help, who don’t seek it, and who avoid it even when it is offered, are

missing from professional publications.

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Salutogenesis: Indomitability, resilience, and posttraumatic growth

This has never been a unanimous view, of course. There is a considerable body of

research on courage, psychological resilience, and other positive (“salutogenic” [2])

reactions to stressors [4, 5, 6]. On the other hand, for example, Gillham and Seligman

[7] cite articles showing that there were 60,000 psychological publications on fear,

500 on courage, and 21 on negative emotions for every one on positive emotions.

This may be changing, or at least showing a changing trend: Table 3 shows the

frequency of salutogenic terms in the same period as the pathogenic terms reported

in Table 2.

Table 3: Salutogenesis in the Titles of English-Language Psychology Publications

Reference 1981-1995 1996-2011

Resilience 0 4,091

Salutogenesis 7 49

Eustress 7 26

Posttraumatic growth 0 303

Positive psychology 258 1,048

Total 272 5,516

Pathogenic terms still greatly outnumber salutogenic ones; an established viewpoint,

especially one that has been learned early in one’s career, is not altered overnight.

Both tables show substantial increases, probably a function of the proliferation of

psychologists and psychological publications. But while the increase in pathogenic

terms was three-fold, the rise in salutogenic terms was twenty-fold! Much of this

was due to the growing acceptance of the terms posttraumatic growth (PTG) and

positive psychology. Resilience, which is one of the components of both PTG and

positive psychology, had the most impressive record, accounting for almost 75% of

the total increase [3].

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I want to add to the list the third word in my title: indomitability. Indomitability, the

state or condition of being unconquerable, permeates the salutogenic reactions to

stress. It is succinctly illustrated by a 19th Century poem, whose second stanza is:

“In the fell clutch of circumstance

I have not winced nor cried aloud.

Under the bludgeonings of chance

My head is bloody, but unbowed.”

The poet is William Ernest Henley, and the poem is Invictus (Latin for unconquerable

or indomitable). The poem typifies the positive reactions to the innumerable

stressors and adversities that human beings must face [8].

Positive psychology emphasizes positive emotions, such as hope and happiness;

positive personality traits, such as courage and resilience; and positive social

institutions, which strengthen the first two components. Resilience is a trait at both

the individual and the community levels, and perhaps at the species level [9]. Among

the paeans of praise for positive psychology, there have also been some warnings

that positive processes can under some circumstances be damaging [10, 11].

When disaster threatens or actually strikes, individuals and communities react in

different ways. Many researchers have come to recognize that there is a range of

both negative and positive reactions to even the most severe levels of adverse

experiences and circumstances, including large-scale natural disasters [12] and man-

made ones such as genocide [13,14], as well as personal ones such as the dangers of

combat [15, 16] and severe abuse in early life [17]. Authors who concentrate on

either pathogenic or salutogenic reactions sometimes overlook the fact that both

can exist within the same individual, sometimes interacting in complex ways [18].

Bearing that in mind, I shall focus on the positive, in pursuit of my goal of helping to

redress the balance between the two kinds of outcomes.

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Table 4: Individual Responses to High Stress

Pathogenesis: Traumatic and post-traumatic stress symptoms

Diathesis - stress: Predisposition interacts with stressor to produce pathogenic

results

Inoculation: Previous stress is overcome, increasing strength to cope with

subsequent stress

Invulnerability: Coping resources are strong enough to prevent any impact of

stress; the individual continues as before

Resilience: Stressor has some negative impact, but the individual sooner or later

regains previous level of functioning

Post-traumatic growth: Stressor has negative impact, but the individual sooner or

later goes beyond resilience to increased strength and self-confidence, more

positive values, and personal growth

The first two of these reactions are clearly pathogenic, examples of unsuccessful

coping with stress. The others represent different forms or aspects of successful

coping and salutogenesis.

Inoculation effects have been found with regard to both psychological and

physiological stressors as well as their psychological and physiological consequences.

The principle of inoculation is used in therapy to teach clients to cope with stress

through gradual exposure [19].

Invulnerability is theoretically a personality trait, innate and learned in unknown

proportions. Non-theoretically, in other words realistically, it is certainly very rare

and quite possibly nonexistent. It is the ideal implied by “the right stuff”- the ideal

that the first groups of astronauts were supposed to embody [20]. This was not

NASA’s phrase, and NASA never defined it, measured it precisely, or checked its

components against actual job performance in space (at least not publicly) [21].

McFaden et al. [22] did develop a components analysis, but there has been little

- 18 -

evidence that invulnerability to stress is an actual possibility. The editors of a book

that promised as much in its title, The Invulnerable Child, admit in their preface that

they are really addressing “relative” invulnerability - that is, resilience [23] - although

the introductory chapter cites several publications that reported invulnerability in a

small proportion of subjects [24].

The last two, resilience and growth, will be my major focus in this chapter. The

boundary between the two is fuzzy. Many sources expand the definition of resilience

to include growth: for example, the U.S. Army calls resilience “The mental, physical,

emotional, and behavioral ability to face and cope with adversity, adapt to change,

recover, learn and grow from setbacks” [25]. However, I prefer to distinguish

between returning to the pre-trauma level (recovery) and developing new, positive

characteristics (growth).

Growth is a function of experience. Post-traumatic growth can be seen in three

areas: self-perception (coming to view oneself as a survivor rather than a victim,

increased feelings of self-reliance, and awareness of vulnerability), interpersonal

relationships (increased self-disclosure, emotional expressiveness, compassion, and

altruism), and philosophy of life (changes in priorities and appreciation of life,

existential themes and sense of meaning, spiritual development, and wisdom) [26].

More succinctly, Horswill and Duranceau describe the areas of change as greater

strength, existential re-evaluation, and psychological preparedness or resilience [27].

In the rest of the chapter, I will describe some examples of indomitability and

growth. In my opinion, there is post-stress or post-challenge growth; the stress or

the challenge does not have to be traumatic to have profound effects on personality.

For example, my research group has found changes occurring after experience in

remote, isolated, extreme environments such as polar stations and spacecraft. These

changes track with those posited by Tedeschi et al. [26] Space fliers and polar

sojourners (explorers and crews) have reported aftereffects that certainly fit the

concept of growth. They include greater personal strength, new opportunities,

- 19 -

increased appreciation of life, more concern for the Earth’s beauty and fragility, awe

at the natural environment, care for their social circle, for people in general and for

future generations, and a higher value on spirituality [28- 32].

What follows is not an exhaustive literature review. Rather, I present selected

examples of positive reactions to traumatic experiences and events, starting with

events that involve only one person and moving up.

Individual disaster

Resilience and PTG following individual disaster is by no means unusual. Many of the

books cited in this chapter, as well as thousands of autobiographies, histories,

newspaper articles, and accounts in the electronic media, feature individuals who

survived traumatic experiences and recovered, in many cases building new

perspectives and achievements. The story that follows is only one very dramatic

example.

In 2003, Aron Ralston was hiking alone in Utah. Ralston’s varied background included

mechanical engineering, French, music, sports, and travel. He was an experienced

hiker and rock-climber, and had set out to be the first to climb, in winter and alone,

all 59 of Colorado’s mountains reaching 14,000 feet or higher.

On this occasion, though, he was merely hiking through a canyon in Utah. A falling

boulder trapped his right arm. He was unable to pull his arm out, or to move or

break the rock. After four days, he had consumed all of his food and water, and

prepared to die. But on the next day, he freed himself by breaking the bones in his

forearm, using the arm as a lever against the immovable boulder. He then spent an

hour amputating the arm, using a small multipurpose tool that included a dull knife.

He next climbed out of the canyon, rappelled one-handed down a 20-meter rockwall,

and began to walk the 13 kilometers back to his car.

- 20 -

Fortunately, he encountered a vacationing family, who gave him food and water and

contacted help. Ralston was airlifted out, six hours after the amputation and having

lost 18 kilograms of body weight.

Subsequently, Ralston was on many television shows and gave many interviews. He

described his experience in a book, Between a Rock and a Hard Place [33].

A movie about his accident, 127 hours, was nominated for six Oscars in 2011. He has

embarked on a new career as a motivational speaker; he has also continued hiking

and climbing. In 2005 he reached his goal of summiting all of the Colorado 14,000-

footers.

Although probably the best known, Ralston’s self-amputation to free himself was not

unique: Wikipedia lists three other cases between 2003 and 2007 alone

(http://en.wikipedia.org/wiki/Amputation).

Community reactions to localized disaster

Natural disasters

Natural disasters are usually looked upon as unmitigated evils, and it is

certainly difficult to find beneficial aspects in their occurrence. However, their

impact on communities can reveal and strengthen cohesiveness, cooperation,

altruism and other positive characteristics.

In August, 2005, Hurricane Katrina hit the southern United States. It was the costliest

natural disaster in the history of the country, and the sixth fiercest Atlantic hurricane

ever recorded. Over 1,800 people died, and property damage was estimated at US$

80-110 billion.

Among the worst effects of Katrina were in New Orleans, Louisiana, where the

disaster was magnified by the failure of the levee system that was supposed to

protect the city from flooding. About 80% of the city and neighboring areas were

flooded, some parts under 5 meters of water, and stayed under water for several

weeks. Many residents survived because they were able to comply with a

- 21 -

government evacuation order. Returning survivors found their homes to have been

destroyed or rendered uninhabitable. Thousands had to be moved to other

communities in Louisiana as well as in Texas, Alabama, and as far away as Chicago.

One of the flooded and uninhabitable neighborhoods was the so-called Village de

L’Est, also known as Little Vietnam. It was home to many Boat People, refugees from

South Vietnam, and to an approximately equal number of African-Americans. These

proportions were not representative: in the city as a whole, the population was 68%

African-American and only about 1.5% Vietnamese. After the flood subsided,

residents began to return: by the spring of 2007, over 90% of the Boat People were

back. The Black residents, a much larger percentage of whom had been renters,

were handicapped by a lack of affordable post-Katrina rental housing, and fewer that

50% of them had returned.

The Vietnamese turned to rebuilding the neighborhood, both physically and by

organizing a multi-ethnic political pressure group to ward off having a landfill located

in their area. A major part of their success was the role of their neighborhood Roman

Catholic church and priest. Their prominence reprised their situation in Vietnam, and

had been in place before Katrina. Under the priest’s leadership, the parish of Village

de L’Est had established a council of representatives from seven zones. Each zone

had its own feasts, patron saints, and fund-raising mechanisms. After the flood, this

community organization kept track of where their members had fled and helped

them to finance their return, reconstruction, reopening of businesses, and so on. The

priest and the Vietnamese community have also reached out to African-American

churches and inhabitants, helping them to clean up and rebuild after Katrina.

Although it is clear that pre-existing organization and leadership played a major part

in the success of the Boat People [34], the fact that a high percentage of the

residents had been refugees should not be overlooked. For them, Katrina happened

after a series of stress inoculation experiences. Considerable resilience was also

shown by a group of Boat People in Biloxi, Mississippi, after their neighborhood

- 22 -

(“Little Saigon”) was destroyed by Katrina. The survivors compared the trauma of the

hurricane with their hardships in resettling after the Vietnam War, the difficult and

risky voyage from Vietnam, and the misery of life in refugee camps. One resident of

Little Saigon said, “If you endured hardship in Vietnam, nothing in the U.S. is hard”

[35].

The literature shows that in most natural disasters, mutual help, altruism, and coping

are the rule rather than the exception. The modal stress reaction is resilience;

diagnosable pathology is the exception rather than the rule, and rarely affects more

than 25% of the survivors by just one year after the event. Most symptoms decrease

in less than two years after the disaster.

War and terrorism

Community-level resilience is also demonstrated in the reaction to man-made

disasters. For example, Janis reported that many survivors of the Hiroshima nuclear

bomb came out to help the injured, provide food and water, etc. Three months after

the bombing, only 20% of uninjured Hiroshima survivors said they were worse off

than during the war, compared to 17% of all Japanese civilians [36].

According to reports, bombing strengthened civilians’ resolve, increased mutual

help, and led to lower rates of crime and psychiatric hospitalization in Great Britain

and Germany alike. In an example of the diathesis-stress concept, these effects were

reversed in Germany when eventual defeat in the war became obvious, losses of

manpower were rising, and severe bombing still continued [37].

Resilience and altruism characterize many community responses to attack. After the

terrorist attacks on 9/11, for example, citizens donated almost 36,000 units of blood

to the New York Blood Center, and gave $3 million to the Red Cross for survivors and

first responders after a link was posted on Amazon.com. Congress voted a $40 billion

disaster relief bill. Many other changes followed, including the war to topple the

Taliban government that had been the host of Osama bin Laden and refused to

- 23 -

extradite him to the U.S., the establishment of the Department of Homeland

Security, and the Patriot Act, which set up major new security regulations, domestic

surveillance, and more stringent immigration laws.

Fifty-two people were killed in the London transit (train and bus) bombings of July,

2005. As in the United States, the government response was to intensify security and

anti-terrorism arrangements. Within hours of the explosion,

several websites were established, including “We’re not afraid”

(http://www.werenotafraid.com/guidelines.html), which went on line hours after

the bombing. It asked for photos of people holding up signs or other symbols on the

theme of not being “afraid, intimidated or cowed by the cowardly act of terrorism.”

Within a month, over a thousand images had been posted. The website went

inactive in 2007 due to the high volume of traffic, but remains on the Internet in

memory of the victims.

Without belaboring the point, I want to summarize a few other community-level

responses to terrorist attacks. The Madrid train bombings of March 11, 2004

involved ten bombs placed on four commuter trains, set to go off at about 7:40 AM.

The explosions killed 191 people and injured 1,800. A call for blood donations

brought in the needed amount of blood by 10:30 that morning. The next day, an

estimated 11.4 million Spaniards (28% of the population) turned out in cities across

the nation to demonstrate against terrorism.

Last, on April 15, 2013, two bombs went off near the finish line of the Boston

Marathon, killing three people and injuring 265. At least 14 of the latter required

amputations. In marathons and shorter races around the world, runners wore the

colors of the Boston Marathon, blue and yellow, on t-shirts, ribbons, caps, and

armbands - a new type of “community” reaction. The slogan “Boston Strong”

appeared everywhere. Facebook had almost 52,000 “likes” on a page selling t-shirts

to benefit the injured, an offer of service dogs, and messages of support.

- 24 -

Community resilience and PTG are the norm in places that have organized networks

of first responders and provisions for shelter, food, water, medical treatment,

transportation, and the like. Resilience requires strong, trusted leadership and stable

organizations, information dissemination, clear instructions, and ways for citizens to

communicate. In such sites, the community is likely to recover from disasters and

other misfortunes in a reasonable time, and the lessons learned may contribute to

greater coping strengths afterward.

Individual resilience in such a traumatized community is related to traits such as

coping self-efficacy, positive emotional bonds in childhood and a support network in

adulthood, motivation, and previous experience with stress (this could lead to

inoculation, or to diathesis-stress, depending on the nature of the experience). In

general, the most common result for people who were not personally injured is

shown in Table 5 (38).

Table 5: Distribution of Post-Trauma Reactions

Chronic PTSD 5-12%

Delayed onset PTSD 0-15%

Recovery (moderate to severe symptoms that gradually decline) 15-25%

Resilience (none or slight and temporary symptoms) 35-65%

In the second month after 9/11, possible PTSD rates were 11.2% in the New York

metropolitan area, 2.7% in Washington, D.C., and 4% in the rest of the country [39].

In the first six months after 9/11, over 65% of New Yorkers were resilient by the

above criteria. Even among those who were physically injured, the resilience rate

was 32.8% while the PTSD rate was 26.1% [40]. In a study of PTSD in French survivors

of 20 terrorist bombings and a machinegun attack between 1982 and 1987, PTSD

rates were 10.5% among uninjured survivors, 8.3% among those with moderate

injuries, and 30.7% among the severely injured. Overall, the rate was 13.3% [41].

Bonanno appears to be correct: according to research findings, “the most common

reaction among adults exposed to [terrorist] events is a relatively stable pattern of

- 25 -

healthy functioning coupled with the enduring capacity for positive emotion and

generative experiences” [40, p. 135].

Mass disaster

In disasters that affect an entire nation, or more than one, the general

assumption has been that a high proportion will suffer severe trauma symptoms and

posttraumatic stress disorder. Examples are war, severe persecution (ethnic

cleansing, genocide), and widespread natural or industrial disaster.

It is very difficult to estimate resilience or PTG across such large populations of

survivors; the most feasible approach is to look at the reactions of individuals.

However, a recent review analyzed both the positive and the negative psychological

effects of floods, wildfires, earthquakes, tsunamis, hurricanes, and other disasters

[12].

Widespread natural disaster

The literature shows evidence of trauma symptoms, but also acknowledges

resilience and posttraumatic growth. Survivors demonstrate altruism, hope, faith,

mutual support, loving memories, greater appreciation of life, and new meaning in it.

They report feeling increased ability to cope with future crises, and many people say

that they are better off for the experience. One survivor of the horrible Indian Ocean

tsunami of 2004 (over 200,000 dead, in 15 countries) said, “I now try to build a new

life. I do not know at all what the substance of this life will be except that it will

include human warmth, love and good things” [42]. Another respondent, who had

survived a major wildfire in California in 1992, expressed a different aspect of PTG: “I

value my family so much now. It’s amazing how the little ‘things’ [in life] matter. The

fire taught me that and I owe it a debt of gratitude for teaching this lesson” [43].

- 26 -

Combat

Military combat is considered to be among the most harrowing of the range of

stressors. It is difficult to ascertain the prevalence of PTSD, resilience, and PTG

among veterans, but there are some indications. PTSD estimates for the two World

Wars and Korea hover around 15%. Veterans reported more desirable than

undesirable effects of military service, and both increased linearly with combat

exposure [15]. Those respondents who perceived positive benefits from having been

in combat reported less negative effects. The benefits mentioned were indicative of

PTG: increased feeling of mastery, higher self-esteem, and more effective coping

skills. World War II and Korean War veterans who had been in heavy combat became

more resilient and less helpless in later years compared to other men [16].

The Vietnam War differed from previous American wars. The enemy was elusive,

frequently not uniformed, the civilian population included enemy supporters, the

reason for the war was not well defined, and its eventual goal was nebulous. The

home front grew increasingly and noisily disaffected from the war. In fact, some

segments of it supported the enemy, and some Americans expressed disdain for

returning soldiers. The almost instant transition between combat and home, unlike

the long ocean voyages home from the two theatres of World War II and from Korea,

were disorienting and reportedly induced a level of culture shock. According to the

National Vietnam Veterans' Readjustment Study [44] in 1986-88 the PTSD rate

among men who had served in Vietnam was 15.2% and among women, 8.5%, both

well within the usual range. Actually, it is difficult to be certain of the prevalence of

PTSD among Vietnam veterans, because reports use different criteria, including such

vague terms as “partial PTSD.”

On the positive side, Tedeschi and McNally [45] cite studies showing that 70.1% of

Vietnam War veterans reported their experiences as mostly positive, and 61.1% of

American fliers shot down and mistreated as POWs said they had benefited from

their experiences. They particularly mentioned an enhanced sense of personal

strength and appreciation for life, both components of PTG. Interestingly, the

- 27 -

severity of their treatment in captivity was positively related to the level of self-

assessed PTG. Israeli POWs of the Yom Kippur War of 1973 had higher rates of both

posttraumatic stress symptoms and PTG than did combat veterans who had not

been captured.

As with Vietnam, the Gulf War is generally thought to have been especially hard on

the troops. American soldiers had to cope with the usual stressors of combat, plus

very adverse climatic conditions, enemies that were often indistinguishable from

civilians, innocent-looking or concealed explosives, and perhaps worst of all,

repeated and prolonged rotations into and out of the combat zone. Yet a study

reported a PTSD rate of 10.1% among personnel who had been deployed to the Gulf,

no higher than those found after earlier wars [46].

Genocide: The Holocaust

Man-made disasters are usually considered more stressful than natural ones.

Those deliberately inflicted on a peaceful, generally law-abiding segment of the

population are the worst of all. Unlike soldiers, the victims are usually unprepared,

untrained, and defenseless. The devastation is the result of human malice and

deliberate intent, unlike natural and industrial disasters. Even more traumatic, the

perpetrators include people who had previously been neighbors and compatriots: if

not friends, at least not enemies.

The most documented and most studied event of this kind is the Holocaust or Shoah,

the Nazi attempt to annihilate the Jews of Europe and eventually the world. It

proceeded step by cautious step at first, starting in Germany in 1933 with various

kinds of economic and civic discrimination. It gained momentum and became vicious

and lethal as it eventually engulfed all of the countries under German domination –

most of Europe from the Atlantic coast deep into Russia, from Scandinavia to Greece,

with the exception of a few neutral states. Despite many efforts at resistance and

rescue, and Germany’s waging a major war at the same time, two-thirds of Europe’s

Jewish population and 93% of their children died.

- 28 -

Information about what happened in the killing fields, the ghettos and concentration

camps, led the postwar world to wonder how anyone could have survived such

ordeals without severe and lasting mental damage. Psychiatrists and psychologists,

faced with trauma beyond their previous experience or even imagination, felt the

same way. It was easy for them to conclude that the survivors who came to them for

help represented the whole of the survivor population, and so to fall into the clinical

fallacy I mentioned early in this chapter. Terms such as “concentration camp

syndrome” were coined as a diagnostic label for the survivors’ symptoms. The

reification of the syndrome was the forerunner of PTSD.

The prospect was considered to be especially bleak for child survivors. Many were

orphaned, many had been separated from their families and either hidden physically

or taught to conceal their true names, families, and religion as they were sheltered

by non-Jewish individuals or institutions. Most had experienced fear, abandonment,

hunger, and cold. The danger that went with being hunted heightened the stress of

living in areas that became bombing targets and battle sites as the Allied and Axis

armies fought the war. For children who had lived in an ordered and stable family

environment, this was truly a “shattering of the assumptive world” [47].

In the words of one professional, children who survived Buchenwald were “a

homogeneous mass, with no hair, faces swollen from hunger and uniform clothes; a

group with an apathetic, unconcerned and indifferent attitude, with no laughter or

even a smile, and a marked aggressiveness towards the personnel; mistrust and

suspicion” [48]. Most experts doubted that they would ever become normal citizens

with loving families and friends, productive work, good adjustment, and sources of

enjoyment. As a rule, the conclusions were based on clinical impressions and

occasionally on symptom checklists. Signs of salutogenesis or resilience were

ignored, or attributed to denial or repression. Prevalence of concentration camp

syndrome was estimated at between 75 and 100%.

- 29 -

How valid did these prognoses turn out to be? Starting in the 1980’s - forty years

after the end of the war - researchers began to use community, rather than clinical,

samples and more objective measures [e.g., 6]. The monolithic pathogenic view

crumbled, although it was still somewhat difficult to report on resilience or PTG

among the survivors without being criticized [48, 49]. I have found it advisable to

include a disclaimer such as:

“Reporting resilience and posttraumatic growth in survivors of the Shoah is not to

deny or ignore the many survivors who continue to suffer the consequences of what

happened, nor to imply that it is unnecessary to provide support and help as needed.

We also know that we cannot obtain a representative sample of all survivors. Many

have died since the war. Others are impossible to reach, and some decline to

participate in research projects dealing with the Holocaust. The point of this research

is to broaden our understanding of the Holocaust and its psychological impact by

including a wide range of participants and measures of both strength and

vulnerability (which can, and frequently do, occur in the same person).”

My research group has addressed many aspects of the postwar lives of survivors, but

here I shall report only on two. Some studies deal directly with trauma and

resilience, and others with survivors’ history in relation to work. The latter has

seldom been examined in detail, and it is an area in which child survivors especially

were considered to be hopeless.

Perhaps the most obvious question to ask survivors is about PTSD. A set of close to

200 oral histories recorded by survivors was scored for spontaneous mentions of

symptoms closely associated with PTSD, such as depression, anxiety, sleep

disturbances including nightmares, psychosomatic symptoms, anhedonia, emotional

numbing, memory flashbacks, and avoidance of stimuli reminiscent of the traumatic

situation. Although a clinical diagnosis of PTSD requires that the symptoms result in

significant distress or dysfunction, we merely counted the number of symptoms

mentioned. Table 6 shows the results.

- 30 -

Table 6: Spontaneous Mention of Post-traumatic Stress Symptoms

Number of symptoms reported Percentage of interviewees reporting

0 40

1 30

2 10

3 10

4 10

5 or more 0

Note that 70% of the participants mentioned either zero symptoms or only one,

usually disturbed sleep (which may also be related to age). The data certainly do not

justify a conclusion of widespread PTSD in the group.

It is possible that in the course of telling their entire life stories, the participants

would not think to mention matters that are scoreable as symptoms. Therefore, at a

gathering of child survivors in Toronto we administered questionnaires directly

asking about the frequency with which they experienced stress symptoms [50]. The

scale was as follows: 1=Never; 2=occasionally; 3=frequently; 4=All the time. The

results are shown in Table 7.

Table 7: Mean Ratings of Symptom Frequency

Symptom Survivors Comparison

Dissociation 1.55 1.38

Anxiety* 1.51 1.31

Sleep disturbances* 2.29 1.93

Depression* 1.79 1.46

Overall mean* 1.78 1.40

p < .025 one-tailed

The comparison group consisted of Jewish Americans of the same age range as the

survivors but without personal experience of Nazi persecution. They reported the

symptoms at a significantly lower, but comparable frequency. All of the reported

frequencies were between Never and Rarely, except for sleep disturbances, which

the survivors reported to occur between Rarely and Occasionally.

- 31 -

Antonovsky’s Sense of Coherence Scale [2], which assesses the salutogenic

orientation, was also administered. As Table 8 shows, survivors scored slightly higher

on the total scale and two of the three subscales. The mean scores of survivors and

comparison group members were not significantly different and were all on the high

side of the midpoint.

Table 8: Mean Sense of Coherence Scores

SOC (Range: 1=Low, to 7=High Survivors Comparison

Comprehensibility 5.1 4.9

Manageability 4.9 4.9

Meaningfulness 5.6 5.4

Full scale 5.2 5.0

Survivors scored nonsignificantly higher than comparison subjects on a measure of self-esteem (mean of 3.2 vs. 2.9 on a 1 to 4 scale, with 4 being the highest possible score).

The Satisfaction with Life Scale [51] comprises five questions answered in a Likert

format (1=strongly disagree, 3=neither agree nor disagree, and 7=strongly agree).

Child survivors scored above the neutral point on: My life is close to ideal, The

conditions of my life are excellent, I am satisfied with life, and So far I have gotten the

important things I want in life. On the remaining item, If I could live my life over, I

would change almost nothing, the child survivors’ mean score was understandably

lower, but still at the neutral point. Adult survivors and comparison subjects showed

the same pattern, except that they scored above the midpoint on all seven items.

We used two items, related to the benevolence of people and of the world, from

Janoff-Bulman’s World Assumptions Scale [52]. Child and adult survivors, and the

comparison group, had mean scores above the neutral point. That is, on average, all

three groups judged that people and the world were more benevolent than not.

- 32 -

Last, we analyzed the oral history tapes for Erikson’s [4] life-span psychosocial crises.

Relevant content was heavily weighted on the side of favorable, positive outcomes:

Autonomy rather than Shame and Doubt, Initiative over Guilt, Industry vs. Inferiority,

Identity vs. Confusion, Intimacy vs. Isolation, Generativity vs. Self-Absorption, and

Integrity vs. Despair and Disgust. The one exception was that there were more

mentions of Mistrust rather than Trust. The reason may be obvious [53].

Our research on the work lives of survivors used both oral histories and interviews of

survivors attending international gatherings [54]. The achievement motivation scores

[55] of both survivors and comparison subjects were higher than those of the test’s

three standardization groups. The occupational level of the survivors was generally in

the middle- to upper-middle range of the scale. Male survivors, especially male child

survivors, were in more prestigious occupations than their female counterparts.

When asked what was important to them in the work context, survivors ranked

being useful, working with pleasant colleagues, and being able to use their skills and

talents at work as more important than income and prestige. Of the oral histories

that mentioned anything related to work, two-thirds recorded self-evaluations of

proactive behavior, dedication, competence, and hard work, persisting throughout

life.

In view of the dismal predictions about the potential achievements of child survivors,

a few individuals might be mentioned. For example, at least one child survivor has

won a Nobel Prize in every category: Peace (Elie Wiesel), Literature (Imre Kertesz),

Physics (Francois Englert), Chemistry (Roald Hoffman), Physiology/Medicine, (Rita

Levi Montalcini), and Economics (Daniel Kahneman). Many others have been

outstanding entrepreneurs, businessmen, and philanthropists. There are two whose

achievements are somewhat ironic: Major General Sidney Shachnow (U.S. Army,

Retired), who at one time commanded the American garrison in Berlin; and Jean-

Marie Cardinal Lustiger, the late Cardinal Archbishop of Paris, who was converted to

Catholicism while being sheltered from the Nazis. According to rumor, at one

- 33 -

conclave he might have had a chance at becoming the first Jewish pope since St.

Peter.

Child survivors have thought deeply and written about what their life was like

before, during, and since the war. In one collection, seventeen social scientists

whose early years were disrupted by the Shoah described their experiences. They

then discussed how those experiences had influenced their later choice of research

topics and career, theoretical orientation, and involvement in the applications of

science to the world [56].

We can leave this topic with another quote about the Buchenwald children. Some

fifty years after the end of World War II, the eminent historian Sir Martin Gilbert

collected the life stories of over 150 of the 732 children who had survived the

Buchenwald concentration camp. He wrote: “The past is an ever-present reality for

the boys, as it is for all survivors. Yet they have not allowed its pain to embitter

them, or to cloud over the constructive wellsprings of daily life, in which their own

achievements have been considerable. Theirs are the achievements of new family

circles in which their wives, deeply aware of their wartime torments, have played a

pivotal part; and the achievements of friendships, many of them born in time of

adversity, and which have been maintained and enhanced during fifty years of

constructive enterprise and charitable endeavour” [57].

Helmreich got it right when he entitled his book Against all odds: Holocaust survivors

and the successful lives they made in America [13]. PTG in child survivors of the

Holocaust is more than possible - it is a fact [58]. Nor is it only Holocaust survivors

who show PTG and make successful lives: similar findings have been published about

Vietnamese Boat People [59], survivors of the Cambodian democide [60], and mixed

groups in various places of resettlement [61, 62].

Conclusion

- 34 -

Psychology and psychiatry have come late to the understanding that has

always been there in literature, history, and people’s experiences. We are now

increasingly engaged in documenting, quantifying, and trying to understand as much

as we can about the positive as well as the negative side of human reactions to

stress. The research covers levels from the neurological to the political, but we have

learned the most important thing: people can indeed be indomitable and overcome

even the most daunting challenges.

I am often asked whether my message is that what doesn’t kill us makes us stronger.

In some cases, yes, although not in all cases; but what doesn’t kill us can enlighten us

as to just how strong we humans can be.

- 35 -

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Chapter 2

Resilience from a Neuroscience Perspective

Richard A. BRYANT3

University of New South Wales

Abstract. Neuroscience has made many advances in understanding

psychopathological responses to trauma. These developments have also led

to promising avenues for promoting adaptation following extreme adversity.

Comparable work targeting resilience has lagged behind. This chapter

provides a review of the major models and evidence from a neuroscience

perspective about the different ways people respond to trauma. Building on

animal models, this field has learnt much about human trauma response

from fear conditioning, sensitization, and memory reconsolidation models.

The neural networks underpinning these processes are being mapped.

Further, the roles of stress, gender, and attachment processes are being

identified as key to understanding differential response to trauma. This

chapter discusses how these different factors may be moderated to foster

resilience. A central theme of this review is that the vast majority of

evidence is inferred from studies that have compared people with and

without psychiatric disorder after trauma. There is an urgent need for a

more refined definition of resilience in neuroscience research that

conceptualizes resilience as long-term functioning at a high level. Whereas

neuroscience has shed light on many potential ways to promote resilience in

people during and after adversity, there is a great need for closer study of

3Correspondence: Richard A. Bryant, Ph.D.School of Psychology, University of New South Wales'

Sydney NSW 2052, Australia Ph: +61 2 9385 3640 Fax: +61 2 9385 3641 Email: r.bryant@unsw.edu.au

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these factors in populations that have been shown to be resilient over time

and under varying conditions of stress. Only through this approach can more

effective means emerge from neuroscience perspectives that can help

people manage the aftermath of trauma both in the short and long terms.

Over the past several decades there has been enormous advance in the

neuroscience underpinnings of how humans respond to trauma. This has led

to marked improvements in how we conceptualize extreme stress reactions,

such as posttraumatic stress disorder (PTSD), as well as novel treatments for

helping people to recover from these reactions. Much less work has

targeted the issue of neuroscientific bases for resilience in the face of

trauma. Nonetheless, we can learn much from neuroscience evidence about

how PTSD functions in terms of understanding the directions we need to

take to understand how to understand resilience, and importantly, how to

foster resilience in those exposed to trauma.

The Stress Response

We know from many animal and human studies that when people are faced

with stress, and particularly extreme stress, two physiological systems are

simultaneously initiated: (a) the fast-acting autonomic nervous system, and (b) the

slower-acting hypothalamic-pituitary-adrenal (HPA) axis. The faster-acting

sympathetic response involves release of epinephrine and norepinephrine

(noradrenaline in humans) by the adrenal medulla, which is reflected in a sudden

elevated heart rate, respiration rate, and blood pressure. The slower HPA response

involves a cascade of activity in which the hypothalamus secretes corticotropin-

releasing hormone, which in turn triggers the anterior pituitary to generate

adrenocorticotropic hormone (ACTH). ACTH elicits secretion of glucocorticoids

(cortisol in humans), which function to provide a negative feedback effect on the

hypothalamus, which then inhibits further activation of the corticotropin-releasing

hormone. What this means is that the release of cortisol eventually functions as a

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“brake” to the stress reaction, hopefully calming the body down after the initial

surge in arousal [1].

Conditioning Models of PTSD

One of the most influential models of traumatic stress involves fear

conditioning. This model historically emerges from research with animals, and the

findings from these basic laboratory studies have been taken up with enthusiasm by

trauma researchers. In short, this model proposes that noradrenergic and

glucocorticoid release that occurs following stress exposure is the basis of the

extremely strong overconsolidation of trauma memories that form the basis of

ongoing stress reactions. In the prototypical laboratory study, an animal (usually a

rat) receives an electric shock at the same time as a light is presented in its chamber

(this is called the ‘unconditioned stimulus’). The rat understandably reacts with much

fear (the ‘unconditioned response’). The rat will learn that this light is no longer a

harmless event but instead it has now acquired a very different meaning - it now

signals danger that a shock is about to occur (‘conditioned stimulus’). This usually

results in the rat responding to subsequent presentations of the light with fear

because it has learnt that the light is a signal of imminent threat (the ‘conditioned

response’). In the context of trauma, the fear we feel when confronted with the

traumatic event is the unconditioned response; the associations we form between

this fear and the stimuli associated with the exposure are the conditioned stimuli,

such that when we are subsequently confronted by them we experience fearful

reactions in the form of re-experiencing symptoms and anxiety [2, 3]. For example,

an individual who was injured in a missile attack may react with fear to cars

backfiring or the sight of open flames because these are associated with stimuli they

were exposed to at the time of the attack. In this context it is worth noting that the

most consistent finding in all of the PTSD literature is that people with PTSD are

characterized by having elevated psychophysiological reactivity to reminders of the

trauma (i.e., conditioned stimuli) [4-6].

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A crucial concept to understanding how we recover from trauma exposure, which is

pivotal to our understanding of resilience, is the concept of extinction learning. In

experiments, this refers to the repeated presentation of the conditioned stimulus

without the aversive stimulus being presented in association with it. The result is

new learning such that the stimuli that were previously associated with threat (e.g.,

light) are now recognized as signalling safety [7]. How does this relate to the trauma

context? Trauma survivors are exposed to many internal (memories, dreams) and

external (situations, conversations) reminders of the trauma in the days and weeks

after exposure, and typically these exposures do not lead to any aversive

consequence. In this sense, trauma survivors are potentially enjoying extinction

trials by experiencing the conditioned stimuli but learning that they are no longer

causing them harm. The person exposed to the missile attack may learn, after

hearing repeated car backfires or seeing flames many times without being harmed in

any way, that these reminders are no longer dangerous. In this way, they can learn

the threat has passed. This pattern is reflected in numerous studies of PTSD in which

the researchers have assessed incidence of PTSD at different time points after

trauma exposure. Whereas rates of PTSD are high in the initial weeks after trauma

exposure, they typically drop markedly in the following months. This pattern has

been documented in survivors of rape [8], nonsexual assault [9], motor vehicle

accidents [10], the 2001 New York terrorist attacks [11, 12], and the 2004 Asian

tsunami [13]. In these cases trauma survivors are exposed to many trauma

reminders in the following weeks and months after trauma exposure, and in most

cases this exposure leads to extinction learning. Of course a proportion of trauma

survivors will not enjoy this adaptation, which has led some to conceptualize PTSD as

failed extinction learning.

Sensitization and Resilience

In trying to understand resilience, it is important to recognize that people are

often exposed to multiple traumatic events, or possibly the threat of subsequent

events. Again, victims of missile attacks who live in a region that is vulnerable to

these incursions may have an attack every week. How is one resilient in the face of

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this ongoing threat? One helpful approach involves models of sensitization, which

posit that exposure to a severe stressor predisposes the person to more extreme

responses to subsequent stressful stimuli. At a neural level, this can be attributed to

the limbic system being more sensitized to respond to stimuli after initial stress [14].

There is much evidence from animal and human studies attesting to this pattern [15,

16]. Trauma researchers have extended this research to the context of PTSD, and

found that being exposed to a prior trauma is associated with greater reactivity to

later stressors [17, 18]. In this context it is noteworthy that one of the robust findings

in PTSD is that people with PTSD show a heightened startle response that is not

displayed in the initial month - it only emerges in subsequent months [19, 20]. This

pattern suggests that people suffering from PTSD become more sensitized to their

surroundings as time progresses.

A similar process may be operating in the case of people who do not show initial

PTSD but later develop delayed-onset PTSD, which is defined as onset of the

condition at least six months after exposure. Across studies, the major predictor of

delayed-onset PTSD is the degree to which the person is exposed to stressors after

the initial traumatic event [21-23] [22, 24]. Many stressors occur after trauma

exposure, and it appears that a core feature that characterizes those who can

maintain resilience is the ability to navigate these stressors in an efficient manner.

It seems that sensitization arising from the impact of the initial trauma is a

significant hindrance to this adaptation, and needs to be considered in any neural

understanding of resilience [25].

Neural Bases of Resilience vs. Traumatic Stress

We have a wealth of knowledge to draw on from animal, human, and clinical

studies that inform us about the neural networks associated with traumatic stress.

Understanding of these networks is largely consistent with fear conditioning models.

We know that the associations formed during the conditioning process are stored in

the basolateral nucleus of the amygdala [26], which leads to expression of fear via

the central nucleus of the amygdala [27]. Integral to traumatic stress is the role of

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the medial prefrontal cortex, whose function is to regulate the amygdala [28]. The

medial prefrontal cortex-amygdala network is implicated in extinction retention [7]

and is essential for emotional regulation for it can limit the hyper-reactivity seen in

the amygdala. Relevant to this is the evidence from many neuroimaging studies of

PTSD that have found that during processing of fear memories or frightening stimuli,

the medial prefrontal cortex is insufficiently recruited in people with PTSD as

compared to trauma survivors without PTSD [29, 30]. In this sense, theory would

suggest that greater resilience would be fostered by greater recruitment of the

medial prefrontal cortex. Consistent with this proposal is evidence that successful

response to cognitive behaviour therapy of PTSD, which is essentially a form of

extinction learning, is predicted by the volume of the rostral anterior cingulate

cortex (which is associated with the medial prefrontal cortex) [31].

What is the Evidence for Fear Conditioning Models of Traumatic Stress?

There is convergent evidence that conditioning processes do play a role in the

etiology of PTSD. A commonly studied phenomena is resting heart rate shortly after

trauma. This is based on the notion that stronger fear conditioning will involve an

excessive response of noradrenergic release, and the associated sympathetic arousal

will be reflected in higher resting heart rates after trauma. Numerous studies of

both adults and children have found that higher resting heart rates in the initial day

or two after trauma exposure predicts subsequent PTSD [32-34]. Further, an

elevated respiration rate in the first 48 hours predicts PTSD [33]. More specific

evidence for fear conditioning is the finding that phasic increases in heart rate in

response to trauma reminders is a stronger predictor of PTSD than resting state

heart rate [35].

There is also evidence that conditioning plays a role in posing risk for PTSD. A

study of newly recruited firefighters were assessed on startle response and

conditioning paradigms before they commenced active firefighting duties, and

were subsequently assessed at various points during their career. In this research

program, the levels of eyeblink EMG startle reactions in response to startling tones

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before trauma predicted acute stress symptoms among the firefighter recruits

within a month of being exposed to a traumatic event as a firefighter [36]. In a

conditioning/extinction paradigm, participants received electric shocks when they

were presented with a particularly colored shape but not when presented with a

different color. Consistent with laboratory studies, firefighters were later

presented with extinction trials on which their EMG responses were indexed during

presentation of the conditioned stimuli but without the shocks; the level of PTSD

six months after trauma exposure was predicted by impoverished extinction

learning as a recruit [37]. This finding has been replicated in prospective studies

with military personnel [38].

Cortisol and Resilience

On the premise that cortisol may function as a brake to the stress response,

one school of thought has shown that people with lower levels of cortisol are more

likely to have PTSD [39-41]. Further, lower cortisol levels shortly after trauma can

predict subsequent PTSD [42, 43]. This is a very confusing issue, however, with

numerous studies not reporting this pattern [44, 45, 46, 47,48].

The idea that cortisol may play a role in a longer-term stress response has led some

researchers to consider how resilience can be improved by moderating cortisol

levels, especially after trauma exposure. There is animal research indicating that

administering hydrocortisone to a rat after stress leads to reduced fear behavior

[49]. It has been observed that in patients in an intensive care unit, those who

receive cortisol treatment (which is common in these units) subsequently

experience fewer traumatic memories than other patients; comparable findings

have been reported in patients with septic shock [50, 51]. In a pilot study, it has

been shown that administering people cortisol, rather than a placebo, within hours

of trauma exposure, can limit the severity of subsequent PTSD [52]. It has been

noted that early cortisol treatment is only effective if provided within hours of

trauma exposure, limiting its practical utility by requiring very early intervention

[53]. This line of research is in its infancy, yet it shows promise in promoting

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resilience in people who can be treated in the very immediate phase after

exposure.

Noradrenergic Response and Resilience

The basis of many traumatic stress presentations is the persistence of trauma

memories. Accordingly, much work has focused on the role of the noradrenergic

system, because this has been shown to modulate how emotional memories are

encoded and consolidated. There is much evidence over many years that

epinephrine levels in rats (reflecting the noradrenergic system in rats) are associated

with increased learning after stress [54] [55, 56]. Comparable patterns are seen in

humans. Whereas administering yohimbine (which is an adrenergic agonist) leads to

greater memory for emotional stimuli [57], β-adrenergic blockades such as

propranolol [58] decrease amygdala activation and impair memory for emotional

(but not neutral) stimuli.

On the basis of this evidence, researchers have attempted to prevent PTSD following

trauma by early intervention of agents that reduce noradrenergic response. In the

initial trial, people admitted to an Emergency Department were administered

propranolol (which is a noradrenergic antagonist) within six hours of trauma

exposure [59]. This study found that when people were assessed three months

later, they had less psychophysiological reactivity when listening to narratives of

their traumatic memory. In France there is evidence from an uncontrolled trial that

propranolol administration immediately after trauma is associated with less PTSD

two months later [60]. However, these attempts have not always been successful.

One study administered the propranolol within 48 hours of trauma and found that it

did not limit subsequent PTSD, possibly because the drug administration occurred

too late [61]. Further, a review of medical records of children who were burnt found

that propranolol was not linked to PSTD symptoms [62].

Indirect evidence for the utility of reducing noradrenergic response immediately

after trauma exposure is also found in studies of morphine administration.

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Norepinephrine is produced in the locus coeruleus, and is inhibited by morphine.

Fear conditioning of rats has shown that administering morphine shortly after fear

conditioning limits the extent of the conditioning [63]. Extrapolating this to trauma,

it has been shown that greater morphine doses in the acute period after hospital

admission is linked to less PTSD after burns [64], traumatically injured adults [65],

combat troops [66], and injured children [67]. These studies are all observational

rather than controlled trials (because it is difficult to ethically withhold morphine

from patients in acute pain), and so this evidence is tentative at this stage.

Gender and Resilience

From a neuroscience perspective, it is critical that we understand how males

and females respond differently to a traumatic event. This is a core issue because of

overwhelming neuroscientific evidence that sex, and sex hormones in particular,

impact how people manage emotional memories. The repeated finding that females

are twice as likely to develop PTSD as males underscores this point [68]. Across many

studies, females have better memory for emotionally-arousing events than males,

for both personal autobiographical and experimentally created [69-71] emotional

memories. Females have greater noradrenergic responses than males in response to

aversive events [72], greater startle modulation in threatening contexts [73], and

greater amygdala reactivity in response to threat [74].

One reason for this gender difference may be the function of sex hormones. This is

indicated by differential responses by females at different stages of the menstrual

cycle. For example, women in the mid-luteal period (approximately days 15-28 of

the menstrual period), when progesterone is high, are more likely to experience

intrusive memories of a trauma film that was encoded in the mid-luteal phase [75],

and more likely to have flashback memories if exposed to traumatic events during

the mid-luteal phase [76]. This may occur because progesterone binds to

glucocorticoid receptors and leads to a marked increase in endogenous

glucocorticoids in the mid-luteal phase [77], which we know contributes to the

consolidation of trauma memories.

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The other key sex hormone is estrogen. There is evidence that estrogen can

modulate fear extinction. Across both animal and human studies, it has been

observed that low levels of estrogen impairs fear extinction recall [78, 79]. Further,

blocking estrogen by administration of oral contraceptives has been shown to impair

extinction learning in both rats and humans [80]. These convergent findings

regarding sex hormones point to the possibility of enhancing resilience, at least in

women, by recognizing the greater risk of traumatic stress during the luteal phase,

by timing of interventions that maximize extinction retention when estrogen is at its

peak, or even augmenting extinction following trauma by using oral contraceptives.

Memory Reconsolidation

A focus of much neuroscience attention in recent years has been on memory

reconsolidation - and the potential implications that this process may have on

trauma adaptation. We know through animal studies that when a memory is

reactivated (usually by providing some reminder of the initial event), the memory

becomes unstable as a result of synaptic plasticity. During this period, the memory is

then subsequently reconsolidated. In this period of memory instability, the memory

is susceptible to influences that can modify how it is reconsolidated [81, 82]. Studies

have shown that memories can be modified by behavioral [83, 84] or

pharmacological [85] interventions if administered during this unstable state.

In the context of trauma, this suggests that resilience may be fostered if people think

about trauma memories in an adaptive way when these memories are reactivated

following the trauma. We know that in the aftermath of trauma people think about

their experience frequently, both intentionally, and as a result of intrusive memories

triggered by reminders. Even though an individual may encode very distressing

memories as a result of the trauma, reconsolidating them in an adaptive manner

may ease the distress. There are some indications from experimental studies that

this may be achieved. One study had participants reactivate a memory that they had

previously encoded, and found that reducing glucocorticoid levels prior to

reactivation reduced subsequent emotional memory recall [86]; however, increasing

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stress during reactivation increased recall for the emotional memories [87]. Other

studies have used propranolol in the context of reconsolidation because it reduces

the noradrenergic response, and so should decrease the strength of emotional

memories. Consistent with this idea, Kindt administered healthy participants

propranolol along with memory reactivation (as well as a placebo condition), and

also propranolol without reactivation using a fear conditioning paradigm [88];

interestingly, only participants who received propranolol prior to the memory

reactivation demonstrated decreased fear responses during extinction. Taking this

further to the context of PTSD, a group in Montreal has reported that administering

propranolol after reactivation of traumatic memories led to decreased reactivity to

trauma reminders compared to a placebo [89]. Three open trials that had chronic

patients with PTSD recount their trauma memories on six occasions following

administration of propranolol have reported that propranolol in association with

reactivated trauma memories reduced subsequent PTSD symptom levels [89].

Although tentative, this research raises the possibility that at any point in the

trajectory of trauma response, trauma memories can be reconsolidated in adaptive

ways that can help survivors ‘rewrite’ their memories, and hopefully this translates

into greater resilience.

Attachment and Resilience

One of the core means humans have to cope with adversity is through

support from attachment figures. Bowlby’s initial theory posited that we learn from

an early age that we can be comforted by attachment figures (primarily parental);

however, dependent on our experiences with others, we can develop different styles

of attachment coping [90, 91]. People can have anxious attachment, in which they

are concerned that their attachments will not be available when they require them.

In contrast, avoidant attachment refers to the tendency to inhibit attachment-

seeking as a means of avoiding the distress of not having the support available.

Many experimental studies, particularly by Mario Mikulincer and colleagues, have

found that priming mental representations of security figures can promote positive

affect and buffer against experimental threat signals [92-94]. This suggests that

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attachment representations may be a useful means to help people cope with

trauma. Relevant to this possibility is evidence that PTSD severity is linked to the

insecure attachment styles [95-97]. Further, longitudinal studies indicate that

insecure attachment appears to become worse the longer one has PTSD [98]. There

is also experimental evidence that shows that priming an attachment figure in

people with posttraumatic stress also buffers against the usual attentional bias

towards threat displayed by people with PTSD [99]. This raises the possibility that

priming with attachment figure representations may provide a positive boost for

those vulnerable to PTSD. This has yet to be exhaustively tested. One study does

pose a challenge, however. Mikulincer’s team applied their paradigm to ex-POWs,

who were studied over a 17-year period [100]. They found that the normal soothing

effects of attachment primes were not beneficial for them, suggesting that perhaps

their attachment systems were so badly affected that they were more resistant to

the benefits enjoyed by others.

How do we understand this from a neuroscience perspective? Interestingly, animal

researchers have focused largely on maternal separation as a key paradigm for

studying early life stress in pup rats. Whereas there is convergent evidence across

many studies that long-term separation from the mother has enduring deleterious

effects, both behaviorally and neurobiologically [101, 102], it appears that exposure

to a degree of separation is healthy for the young [103]. Through a series of studies,

McEwen’s group has shown that an inverted U-shaped curve may best describe the

impact of early life stressors, such that having exposure to moderate stress promotes

resilience to subsequent stressors. A common way to explore this in monkeys has

been to intermittently separate the animal from its mother for short periods – 1

hour per week for 17 weeks [104]. This sort of experiment has shown that at 9

months of age, monkeys who have had regular separation display less anxiety, and

lower cortisol levels, than monkeys who were never separated [105]. These animal

findings point to the possibility that secure attachments may be formed by regular

separations from the parent, however the baby learns that there is always ongoing

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security. This is consistent with Bowlby’s initial conceptualization of how secure

attachment representations are formed.

There is also good evidence that attachment representations foster neural responses

associated with emotional regulation. For example, being socially excluded activates

the same neural region (anterior cingulate cortex) as that which is activated when

experiencing physical pain, yet also appears to activate a distinct network (right

ventral prefrontal cortex) as a means of regulating this distress [106]. In a

subsequent study, it was reported that viewing attaching images of attachment

figures whilst experiencing pain reduced activation of the anterior cingulate cortex

(as well as reported pain), and also increased the ventral medial prefrontal cortex (an

area associated with safety signaling) [107]. These findings underscore the

conclusion that attachment theory has much to offer for the conceptualization of

resilience, and provides initial evidence that priming attachment representations can

alter neural processes that may assist in the management of adversity.

Understanding Resilience as More than Not Having a Disorder

Much has been written about the concept of resilience, and one of the few

points of agreement is that it represents more than the absence of mental disorder

[108]. Many people suffer subsyndromal disorders that nonetheless cause marked

impairment, and these people cannot be considered resilient [109]. Further,

increasing evidence points to the fluctuating nature of symptoms and functioning

over time [24], and so one cannot accurately portray someone as resilient if one

takes a snapshot of them at one point in their posttraumatic adjustment. It is for

these reasons that resilience is now more commonly defined as the presence of

wellness, despite a temporary rise in distress shortly after exposure to a traumatic

event, over an extended period of time. To map this, latent growth mixture

modelling (LGMM) has been applied to studying stress responses following traumatic

events [110]. LGMM is a statistical method that classifies homogenous groups to

identify groups of individual variation over time, which permits identification of

different trajectories of response. There is remarkable convergence across studies of

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PTSD severity, with four major trajectories following traumatic experience being

identified: (a) resilient class with consistently few PTSD symptoms (also referred to

as ‘resistant’ by some researchers [111], (b) recovery with initial distress then

gradual remission over time, (c) delayed reaction with worsening symptoms over

time, and (d) chronic distress with consistently high PTSD levels. These patterns

have been found in survivors of traumatic injury [112], disaster [113], and military

personnel [114].

To date, neuroscience has not taken this approach. Unfortunately, attempts to

understand resilience have largely focused on drawing inferences from comparisons

of people with PTSD (or some related disorder) and trauma-exposed people without

the disorder. This does not provide an accurate profile of resilience because it fails

to capture people who are resilient over time and who truly enjoy good levels of

functioning. If serious inroads are to be achieved in the neuroscientific

understanding of resilience, it is essential that this sampling approach be brought to

longitudinal studies. Models of fear conditioning, sensitization, sex hormones, and

neural networks need to apply definitions of resilience that build on longitudinal

data that enable the confident identification of people who are truly coping well

after adversity. It is also important to appreciate that resilience is not necessarily a

constant or homogenous characteristic. That is, a person may be resilient for

lengthy periods of time but then have a period of less effective functioning - it is

important to understand these fluctuations in resilience. Further, a person may be

resilient in one domain but not another. For example, they may be suffering marked

PTSD symptoms but are still able to function well in the workplace. Alternately, they

may have few PTSD symptoms but have marked difficulty in interpersonal relations.

We currently know little about what drives resilience in different contexts, and this

also needs to be understood from a neuroscience perspective.

Summary Comment

What can we infer from the available evidence about how neuroscience is

advancing our understanding of resilience? It is logical to speculate that people who

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are resilient are less prone to the processes implicated in fear conditioning and

possess greater capacity for extinction learning following trauma. We would assume

this would involve greater capacity to down-regulate arousal, including the

noradrenergic and glucocorticoid responses, following trauma, and thereby make

the person less susceptible to the effects of sensitization as time progresses. We

should also see greater recruitment of medial prefrontal cortex activity during

processing of stressful situations, as these people are better able to activate the

neural networks necessary for emotional regulation.

These suggestions are speculative, however. The most we can say at the moment

with reasonable confidence about neuroscience evidence for resilience emerges

largely from studies of people without disorder. In other words, we draw inferences

from biological processes that characterize disorder about how the opposite

processes may foster resilience. A more thorough science of resilience will emerge

when we strategically target resilient people and understand their neural profiles

both following trauma, as they manage subsequent stressors, and also during

periods of recovery. Ultimately, the goal of more sophisticated neuroscience

research into resilience is to develop better prevention and treatment approaches

that can alleviate the psychological demands placed on individuals and communities

by adversity.

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[111] F.H. Norris, M. Tracy & S. Galea, Looking for resilience: understanding the longitudinal trajectories of responses to stress. Social Science and Medicine, 68(12) (2009), 2190-2198.

[112] T.A. deRoon-Cassini, A.D. Mancini, M.D. Rusch & G.A. Bonanno, Psychopathology and resilience following traumatic injury: a latent growth mixture model analysis. Rehabilitation Psychology, 55(1) (2010), 1-11.

[113] R.H. Pietrzak, P.H. Van Ness, T.R. Fried, S. Galea & F.H. Norris, Trajectories of posttraumatic stress symptomatology in older persons affected by a large-magnitude disaster. Journal of Psychiatric Research, 47(4) (2013), 520-526.

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[114] G.A. Bonanno, A.D. Mancini, J.L. Horton, T.M. Powell, C.A. Leardmann, E.J. Boyko, T. S. Wells, T.I. Hooper, G.D. Gackstetter, T.C. Smith, for the Millennium Cohort Study Team Trajectories of trauma symptoms and resilience in deployed U.S. military service members: prospective cohort study. British Journal of Psychiatry, 200(4) (2012), 317-323.

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Chapter 3

Resilience after Trauma

Katie CHERRYa and Sandro GALEAb4

aDepartment of Psychology, Louisiana State University

bMailman School of Public Health, Columbia University

Abstract. In this chapter, the authors discuss resilience after trauma

exposure from a public health perspective. We begin with an overview and

relevant background information on the concept of resilience to provide a

context for discussion. Next we turn to longitudinal trajectories of resilience

and present supportive evidence. We then consider relevance, addressing

the question of why resilience matters and in doing, so we illuminate core

challenges for the trauma and public health fields. We conclude with a

hypothetical scenario to illustrate how public health could be improved by

increasing resilience at a population level.

Keywords: Resilience, longitudinal trajectories of resilience, population

health

Introduction

Adaptation to stressful events is central to the survival of many species. A

variety of behavioral responses to trauma and stressful life circumstances have been

4Correspondence: Sandro Galea office address: 722 West 168th Street, 15th floor/Rm 1508 New York, NY 10032, United States. E-mail: sgalea@columbia.edu

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documented in the psychological literature on stress and coping [1]. Individual

differences in response to the same traumatic event tend to be quite large and a full

attempt to characterize all variations in responses to trauma or different strategies

for coping with severe stress is beyond the scope of any one chapter. Resilience after

trauma, where survivors “bounce back” from severe stress and adverse

circumstances, is the central focus of this chapter.

Historical Antecedents

Generally speaking, resilience pertains to peoples’ capacity to thrive despite

having experienced trauma, a potentially traumatic event (PTE), or other harsh

circumstances [2]. Resilience has been defined as the maintenance, recovery, or

improvement in mental or physical health following challenge [3]. Contemporary

concepts of resilience rest squarely on an empirical foundation established through

basic research in developmental psychology. Early longitudinal studies examined

behavioral and mental health outcomes for children exposed to traumatic

experiences or other environmental risks, such as poverty, low socioeconomic status

or having experienced the death of a parent [4, 5]. Of particular interest is the

comprehensive work of Werner and Smith who have shown remarkable evidence of

resilience in the Kauai Longitudinal Study over a 40-year span through midlife for

children with stressful and harsh life circumstances [6, 7, 8, 9].

Another focal point for developmental researchers has been the hypothesized

internal resources that may act as protective factors that buffer risk in light of a

negative experience [8, 9, 10]. Following this tradition, numerous studies have

examined individual characteristics that enhance resilience in children, such as

autonomy, ability to solve problems, social competence, and having a sense of future.

Environmental factors external to the child have also been recognized as important.

Strong familial relationships that encourage active participation and behavioral

standards or expectations, among other external influences contribute to resilient

outcomes. In short, minimizing risk or threat characteristics and maximizing

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protective factors, like social support networks and adaptive coping, may help to

promote resilience in risk-exposed youth [4, 8, 9, 11].

Conceptual Evolution: From Early Childhood Adversity to Disaster Aftermath

Building on the empirical foundation established through longitudinal studies

with at-risk youth, scholars in the fields of traumatic stress and public health have

made substantial contributions to our understanding of resilience after mass trauma,

including disasters and also military conflicts. The trauma and loss literature extends

the conceptualization and measurement of resilience in several ways, although the

emphasis on positive outcomes despite stressful events and harsh life circumstances

builds clearly on early theoretical work in developmental psychology [12, 13].

There is broad agreement in the literature that psychological resilience is best

studied using longitudinal assessments. This approach allows researchers to measure

the temporal course of outcomes and detect possible changes in patterns of

vulnerability [14]. This approach also allows for the capture of different patterns of

stress responses that may occur over time, which reflects current emphasis on

adaptation as the hallmark of resilience [15]. A relatively new emphasis on the

nature of the stressor to which one has been exposed is also apparent in

contemporary literature [16]. Bonnano and Diminich distinguish between minimal

impact resilience (follows sudden events, like a natural disaster) and enduring

resilience (follows chronic adversity, such as poverty). Our focus in this chapter is

confined to psychological resilience as an outcome that is either observed or inferred

following severe stress with illustrative examples that cover both minimal impact

and enduring resilience.

There are differences of opinion among scholars on the best way to conceptualize

and measure resilience [17, 18]. Perhaps it is useful to recognize that researchers

have been clear on what resilience is not. To illustrate, consider these three

examples. First, Rutter has argued that resilience is not a general quality or personal

trait, social competence, or positive mental health [4]. Second, Norris and her

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associates note that resilience is not the same as resistance [13]. Resistance would

be indicated when effective coping resources are available and equal to the

challenge faced. Thus, stress responses are countered through coping and

dysfunction is minimized, although this ideal scenario seems unlikely in the presence

of extreme stress [15]. Third, Bonnano has made the point that resilience, although

common, is not the same as recovery [2]. With recovery, there is a drop in pre-event

functionality with sudden trauma, but a gradual ascent from this temporary state

follows. Recovery is a slower process that may take place over many months, if not

years, whereas there are several pathways to resilience. To be precise, Bonnano

characterizes four pathways to resilience, some of which would be expected and

others less so. These pathways include: the personality trait of hardiness, self-

enhancement bias, repressive coping, and the benefits of positive emotion and

laughter [2], although others disagree [18].

Longitudinal Trajectories of Symptoms

An important conceptual progression has been the emergence of a more

dynamic view of resilience, characterized as one of several different longitudinal

trajectories that emerge over time. To illustrate, we consider six hypothetical

resilience trajectories building on the earlier work of Norris and her associates [15].

The first three, which we referenced earlier, represent positive outcomes. These

trajectories include resistance, a pattern where no symptoms or stable but mild

symptoms occur after trauma exposure; resilience, characterized by moderate or

severe symptoms at first, with a gradual decrease; and recovery, which involves the

gradual return to pre-event functional levels over time [2]. The other three

hypothetical trajectories include; relapsing/remitting, a pattern of ups and downs

where symptoms of severe stress spike at first and then decline in alternation, and

delayed dysfunction, which is indicated when symptoms appear much later in time,

relative to the traumatic event. Interestingly, delayed PTSD onset seldom occurs for

people who have no prior symptoms. Delayed onset PTSD is more likely when

survivors’ developmental history includes prior symptoms that may be made worse

with current trauma [15]. Chronic dysfunction is characterized by the presence of

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moderate or stable stress symptoms that persist over time, which may be due to

severe trauma exposure coupled with other ongoing stressors [19].

Recent empirical work, using newer analytic techniques, such as statistical modeling

of latent trajectories, has yielded impressive evidence in support of these different

symptom trajectories generally [16]. For instance, Norris and her associates used a

statistical modeling approach to examine the temporal course of post-traumatic

stress (PTS) with archival data collected after two very different events; the terrorist

attacks against the U.S. on September 11, 2001 (referred to here as 9/11) and the

1999 mudslides in Mexico [15]. Their focus on PTS as a behavioral outcome in these

two population-based studies is noteworthy, given the ubiquity of stress responses

after disaster [20]. Analysis of archival data collected after man-made and natural

disaster addressing hypothesized trajectories of resilience is also ideal from an

external validity perspective. That is, two very different events within two years of

each other that happened in different countries affords a unique opportunity for

replication and cross-cultural generalizability of outcomes covering a much wider

span that either event considered singly. Disasters of such great magnitude also

affect a wide swath of the population, so inferences on post-event stress can be

made on a wider scale than prior research with select samples where inferences are

necessarily confined to military personnel or individuals suffering from bereavement

related to the death of a loved one.

Turning to the 9/11 data, Norris and her associates’ analyses were based on a large

sample of 1,267 residents of New York City who had participated in all four waves of

testing [21]. The empirical picture that emerged from these data yielded seven

trajectory groups. Among these, the strongest evidence favored resistance with mild

and stable symptoms for approximately half of the study sample. Importantly,

resilience was indicated for those with moderate to severe symptoms initially then a

decrease (10% of the sample) and recovery where moderate to severe symptoms

were observed initially and then decreased gradually (9% of the sample). There was

also evidence of chronic dysfunction with moderate or severe and stable symptoms

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and delayed dysfunction (only in the 9/11 sample). Together, these inferred

trajectories show the different pathways that individuals may experience after

trauma in the years after these events. These data can also be interpreted to

suggest that broad based interventions to assist survivors may be of limited value,

unless these efforts are tailored to address stress responses that may unfold

differently over time for survivors after disaster.

To summarize, Norris and her colleagues [15] found compelling evidence which they

interpreted to support the hypothesized resilience trajectories in separate analyses

carried out on the 9/11 and Mexican mudslide data sets with one exception:

relapsing/remitting which was the only trajectory not indicated in these analyses.

Other evidence has substantiated the relapsing/remitting cyclic pattern where

symptoms initially improve, but subsequently worsen based on older persons’

responses after the eastern Kentucky floods [22]. Perhaps the time span covered in

the 9/11 study (3 years) and mudslides in Mexico (2 years) was not long enough to

allow relapsing/remitting pattern to be detected. Future research spanning more

than 3 years post-event would be desirable to provide a more definitive analysis of

this issue.

Why Does Resilience Matter?

An overview of resilience concepts naturally leads to the broader question of

relevance. Simply put, “why does resilience matter?” In no way rhetorical, this

question could be answered from a number of different vantage points. From a

strictly quantitative perspective, the number of people who experience trauma in

any given year is staggering. By conservative estimates, a large percentage of the

population is directly affected by trauma. Other evidence indicates that more than

90% of the U. S. population has experienced a variety of different traumatic events

at some point in their lifetime. This estimate includes acts of violence (assaultive

traumatic events) as well as shocking events (e.g. car accident, natural disaster),

learning about traumatic events to others, the sudden unexpected death of

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someone close and any other traumatic event of personal significance (i.e.,

participant defined).

From a clinical perspective, there is further cause for concern. Epidemiological

evidence indicates that among high risk groups, half of them (50%) have experienced

trauma in the preceding year. It is widely recognized that prior history of trauma

leaves survivors vulnerable to future problems, which is one of several core

challenges to resilience. Current stressors and co-morbidities that may affect

resilience, such as pre-existing mental and physical health problems and prior

lifetime trauma, are an important concern among trauma clinicians [23].

Nevertheless, we recognize the need for effective, evidence-based interventions to

lessen the burden among those who survive traumatic experiences. We also sense

the urgency and need for policy development to address these concerns at the

federal level.

As a related point, resilience matters from a global perspective, a sentiment that is

certainly shared among major industrialized nations. It is a widely known fact that

large scale disasters and other events that are associated with mass trauma are

unfortunately common in the world [24]. To illustrate, consider recent events of

global significance, such as the Haiti earthquake (January 12, 2010) and tsunamis

such as those that struck in Asia (2004) and Japan (2011). In addition to weather-

related or geological events, traumatic events can also stem from technologically-

based incidents. By accident or by design, man-made disasters are typified by events

such as nuclear reactor accidents (e.g., Chernobyl, 1986; Japan, 2011), oil spills (e.g.,

Exxon Valdez, 1987; Deepwater Horizon Oil Spill, 2010), and strategically planned

assaults, such as the terrorist attacks on U.S. soil on September 11, 2001.

These recent events of global significance draw attention to the dire situations of

people directly affected as witnessed in the media and popular press. However,

researchers have only recently begun to examine disasters’ long-term impact on

population health. To understand the health impact of disasters and mass trauma

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more fully, both the immediate and long-term consequences of such events must be

systematically addressed [24]. To address health disparities and improve wellness,

we must first identify factors associated with individual, family and community

resilience [13]. There is little doubt that the causes of resilience are multi-factorial,

and that factors that include genetic factors, molecular processes, inter-personal

factors, and characteristics of communities all can contribute to resilience in

populations. A full review of the causes of resilience is well beyond the scope of this

chapter. We refer the reader to other works that have discussed resilience and its

causes more comprehensively [25].

Resilience, Populations, and Health: A Concluding thought

In closing, we underscore the timeliness of considering resilience in relation

to populations and health. The increasing number of events that threaten health

worldwide must be met with an equally forceful appeal for the development and

implementation of population-based strategies to offset health risks and reduce the

burden of illness. Never before has the need been as great for forward looking

strategies to increase effective preparation and management of future catastrophic

events.

Building on some of the classic tenets of public health, we offer the following

scenario to provide a new direction for improving population health. A high risk

approach targets the proportion of persons within a population who are exposed to

a factor that confers high risk (e.g, childhood traumatic events). A high risk approach

then aims to reduce psychological burden among a specific, ‘exposed’ segment of

the population. This approach may indeed find success in reducing the burden of

disease in the high risk segment of the population. However, this approach misses

that segment of the population who do not have a high burden of exposure and who

still may go on to develop disease. An alternate, population health strategy, does

not target a high risk group, but shifts the entire risk distribution, improving

psychological health in the entire group. This can be accomplished by systematically

increasing resilience capacity on a societal level, recognizing the drivers of risks in

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populations. This represents an opportunity for the field to generalize insights about

resilience to the broader rubric of the promotion of population health, setting the

stage for research and intervention in the field.

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References

[1] C.M. Aldwin & L. A. Yancura, Coping and health: A comparison of the stress and trauma literatures. In P. Schnurr & B. Green (Eds), Trauma and health: Physical consequences of exposure to extreme stress (p. 99-125). APA Books: Washington, D.C., 2004.

[2] G.A. Bonanno, Loss, trauma, and human resilience Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist 59 (2004), 20-28.

[3] C. Ryff, E. Friedman, T. Fuller-Rowell, Love, G., Miyamoto, Y., Morozink, J., Radler, B. & Tsenkova Varieties of resilience in MIDUS. Social and Personality Compass 6 (2012), 792-806.

[4] M. Rutter, Implications of resilience concepts for scientific understanding. Annals of the New York Academy of Science 1094 (2006), 1-12.

[5] S. Howard, J. Dryden & B. Johnson, Childhood resilience: Review and critique of literature. Oxford Review of Education 25 (1999), 307-323.

[6] E.E. Werner & R.S. Smith, Vulnerable but Invincible: A Longitudinal Study of Resilient Children and Youth. McGraw Hill, New York, 1982.

[7] E. E. Werner & R.S. Smith, Overcoming the Odds: High-Risk Children from Birth to Adulthood. Cornell University Press, New York, 1992.

[8] E.E Werner, Resilience in development. Current Directions in Psychological Science 4 (1995), 81-85.

[9] E.E. Werner & R.S. Smith, Journeys from Childhood to Midlife: Risk, Resilience, and Recovery. Cornell University Press, Ithaca, NY, 2001.

[10] M. Rutter, Annual Research Review: Resilience - clinical implications. The Journal of Child Psychology and Psychiatry 54 (2013), 474-487.

[11] A.S. Masten, Ordinary magic: Resilience processes in development. American Psychologist 56 (2001), 227–238.

[12] C.E. Agaibi & J.P. Wilson, Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence, and Abuse 6 (2005), 195-216.

[13] F.H. Norris, S.P. Stevens, B. Pfefferbaum, K.F. Wyche & R.L. Pfefferbaum, Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology 41 (2008), 127-150.

[14] K. Kaniasty & F.H. Norris, Longitudinal linkages between perceived social support and posttraumatic stress symptoms: Sequential roles of social causation and social selection. Journal of Traumatic Stress, 21 (2008), 274-2810.

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[15] F.H. Norris, M. Tracy & S. Galea, Looking for resilience: Understanding the longitudinal trajectories of responses to stress. Social Science & Medicine, 68 (2009), 2190-2198.

[16] G.A. Bonnano & E.D. Diminich, Annual Research Review: Positive adjustment to adversity – trajectories of minimal-impact resilience and emergent resilience. The Journal of Child Psychology and Psychiatry 54 (4) (2005), 378-401.

[17] G.A. Bonanno, Clarifying and extending the construct of adult resilience. American Psychologist, 60 (2005), 265-267.

[18] T.M. Kelley, Natural resilience and innate mental health. American Psychologist 60 (2005), 265.

[19] S. Galea, M. Tracy, F. Norris & S.E. Coffey, Financial and social circumstances and the incidence and course of PTSD in Mississippi during the first two years after Hurricane Katrina. Journal of Traumatic Stress, 21 (2008), 357-368.

[20] Y. Neria, A. Nandi & S. Galea, Post-traumatic stress disorder following disasters: A systematic review. Psychological Medicine 38 (2008), 467-480.

[21] S. Galea, D. Vlahov, H. Resnick, J. Ahern, E. Susser, J., et al. Gold, Trends of probable post-traumatic stress disorder in New York City after the September 11 terrorist attacks. American Journal of Epidemiology 158 (2003), 514-524.

[22] J. Phifer & F.H. Norris, Psychological symptoms in older adults following disaster: Nature, timing, duration, and course. Journal of Gerontology: Social Sciences 44 (1989), S207-S217

[23] J. M. Cook & G. Niederehe, Trauma in older adults. In M. J. Friedman, T. M. Keane & P. A. Resick (Eds), Handbook of PTSD (pp. 252 – 276). Guilford Press, NY, 2007.

[24] J. Johnson & S. Galea, Disasters and population health. In K. E. Cherry (Ed.), Lifespan Perspectives on Natural Disasters: Coping with Katrina, Rita and other Storms (pp. 281-326). Springer, New York, 2009.

[25] G. A. Bonnano, M. Westphal & A.D. Mancini, Resilience to loss and potential trauma. Annual Review of Clinical Psychology 7 (2011) 511-535.

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Chapter 4

Coping, Conflict and Culture: The Salutogenic Approach in the Study of Resiliency

Shifra SAGY5

Ben-Gurion University of the Negev, Beer Sheva, Israel

Abstract. In this paper, I present the salutogenic paradigm in relation to

coping, conflict and culture. The core concept of salutogenesis - sense of

coherence (SOC) - is described as a powerful explanatory factor of

resiliency, especially in conflict areas, which enables us to understand the

highly resilient levels among young Israeli Jews and Arabs. The paper also

relates to two cases in which the SOC does not contribute to moderating

stress reactions: the first refers to acute stressful situations, while the

second relates to the specific cultural-ethnic group of Bedouin-Arabs, living

in the southern part of Israel.

Keywords: Salutogenesis, coping, conflict area, cultural-ethnic groups

The salutogenic approach to the study of resiliency

In the late 1970s, Aaron Antonovsky, a medical sociologist, proposed a new way

of looking at health and illness: the salutogenic model [1]. In posing the question of

salutogenesis, Antonovsky actually detached himself from his own past research, as

well as from that of his contemporaries, which focused on explaining pathology.

Although the salutogenic theory stems from the sociology of health, it has been on

the leading edge of a class of academic movements that wish to emphasize human

5Correspondence: Shifra Sagy E-Mail: shifra@bgu.ac.il

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strengths and not just weaknesses, human capacities and not just limits, well-being

and not just illness. In this paper I present this paradigm in relation to coping, conflict

and culture.

While the pathogenic paradigm's basic assumption is that people remain healthy

unless attacked by “bugs”, salutogenesis is based on a fundamentally different

philosophical assumption about the world. The basic assumption of salutogenesis is

that human environments by their very nature are stressor-rich. Such stressors may

be microbiological, personal, economic, social or geopolitical. In any and every event,

the human being inhabits a world in which it is impossible to avoid stressors. All

human beings are subject to a stressor load. The normal state of the human

organism is one of entropy, disorder and disruption of homeostasis. The basic human

condition is stressful.

This basic assumption especially struck Antonovsky after he analyzed life stories of

Holocaust survivors [1] and found that more than a few women among them were

well adapted, regardless of how adaptation was measured. Despite having lived

through the most inconceivably inhuman experiences, followed by displaced persons

camps, illegal immigration to Palestine, going through the Israeli War of

Independence in 1948, and other wars and terror events in the long, violent Israeli -

Palestinian conflict, as well as suffering long periods of economic austerity, some

women were reasonably healthy and happy, raised families, worked, had friends and

were involved in community activities. Following these life story analyses,

Antonovsky's paradigm of questioning was first changed to ask: “Whence the

strength?” Only later, however, did his most striking understanding come that “not

only the Holocaust or the ongoing poverty can be considered as stressors. It is the

human condition itself which is stressful” (p.8)[1].

It appears that this basic philosophical assumption of the salutogenic theory

constitutes Antonovsky's most important contribution. Instead of perceiving the

human system as one which is sound unless attacked by some pathogen, the

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salutogenic approach views the human system as basically unsound, continuously

attacked by disturbing processes and elements which cannot be prevented. Reading

the newspaper in the morning, watching television in the evening, being overloaded

at work, raising children - all of these constitute a state of ongoing pressure on each

person. In this basic chaotic condition of the world, Antonovsky claimed, we human

beings have the ability to find some order. Salutogenesis, then, directs one to think

about the mystery of health rather than the causes of illness. In other words, given

the world as it is, the meaningful question is not how people get sick, but how do

people stay healthy? This brings us to the first “C” in this paper - coping.

How do we respond to the salutogenic question?

First and foremost, instead of focusing on risk factors, we ask about the

salutary factors which advance us towards the healthy side of the continuum of

health - illness. These factors can be many and varied including, among others, the

genetic, the social, and the psychological. Antonovsky's answer to the salutogenic

question related to a concept which includes cognitive, emotional and behavioral

aspects: the sense of coherence (SOC).

SOC is a concept which describes a worldview, a cognitive orientation which

expresses the tendency to see the world as logical and reasonable, rather than

chaotic, as well as manageable both emotionally and instrumentally [2].

The three components of the sense of coherence are:

(a) Comprehensibility - The extent to which one perceives the world as

predictable and one’s problems as understandable and clear.

(b) Manageability - The extent to which one perceives that s/he or others can rely

on or have access to suitable coping resources.

(c) Meaningfulness - The extent to which one feels that there is emotional

meaning to his/her life and those problems and demands posed by living are

challenges worthy of commitment and engagement.

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When a person with a high sense of coherence must confront a source of stress, s/he

will believe that the challenges are comprehensible (comprehensibility), that s/he

has the necessary resources to cope (manageability) and will aspire to cope

(meaningfulness).

Findings from all over the world over the past 30 years have confirmed the basic

hypothesis of the salutogenic model: one’s sense of coherence contributes to

successful coping and as a result, to emotional and physical health [3].

Coping and Conflict

We now reach the second “C” - conflict. The literature regarding the

psychological and behavioral effects of terrorism and wars usually poses pathogenic

questions. The cumulative data includes a wide spectrum of outcomes ranging from

mild stress reactions to a variety of problems such as anxiety, depression, somatic

complaints, aggressive behavior and anger (e.g. [4]).

But what are the data when we ask salutogenic questions? Indeed, a series of studies

conducted in Israel (among Jews and Arabs) have indicated that the majority of

children and adolescents show resilience, cope well and do not suffer major

emotional problems when facing political violence [5] [6] [7]. Moreover, data from

world surveys indicate high rates of emotional health among Israeli youth, relative to

measures of young people in other, peaceful countries. Despite their lives in the

shadow of a violent conflict, the lack of certainty and the existence of severe social

rifts in their society, Israeli youth define themselves as happy [8].

By asking salutogenic questions, we have tried to understand these findings of high

rates of well-being. Through the years we have researched various stress situations:

the evacuation of the Sinai settlements in 1982 [9], the Intifada in the West Bank,

the assassination of Prime Minister Rabin [10], Jews and Arabs during the Second

Lebanon War [6], the Kassam rocket attacks on Sderot for 8 years [11], the

disengagement from Gush Katif [12], Palestinian adolescents in the West Bank and

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Gaza living under Israeli occupation [13], and adolescents living in southern cities and

villages (Jews and Arab Bedouin) during the Gaza War (“Cast Lead” operation) [14].

Recently, we studied Bedouin - Arab teenagers living in villages in the southern part

of Israel [15].

In all of these studies, we have asked the salutogenic question: Which resources

contribute to good coping abilities and to the high rate of well-being of youth despite

their lives in the shadow of a violent intractable conflict?

The findings we have collected during these many years of research have taught us

the following:

1. The levels of distress reactions among Israeli and Palestinian teenagers are

moderate. Generally speaking, although the situation and the sources of

stress are different, both Israeli and Palestinian youth show high potential for

resiliency.

2. The level of stress reactions is not connected to the degree of exposure to

the stressor (for example, the number of Kassam rockets falling on your town

or the number of road checkpoints on your way to school).

3. The salutary factors of the adolescents which were salient in their

contribution to moderating stress reactions were the following:

Sense of Coherence [2]: the personal SOC of the teenagers was found to have the

strongest explanatory power in understanding their coping and stress reactions

[7].

Sense of Family Coherence [17].

Sense of Community Coherence [12].

When is SOC not significant in understanding health and well-being?

Having cited these very general conclusions from almost three decades of research, I

would like to present two cases in which the SOC model does not “work”, or “works”

differently, meaning that it doesn't contribute to moderating stress reactions or to

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promoting health. I trust that these two unique cases enable us to more deeply

understand the salutogenic paradigm and the concept of SOC.

The first case relates to the type of stressful situation: when is the SOC model not

significant in reducing emotional reactions? The second case refers to the third and

final “C” in the title of this article: a special cultural group for whom the SOC

paradigm is irrelevant in explaining emotional reactions.

Coping in different conflict situations

I will start with the when case. Only a few models or theories on the

resilience effects of stress focus on the issue of different stress situations and their

possible relations to stress reactions [10]. Actually, the comparative question of

when coping resources do or do not moderate psychological difficulties has not been

systematically studied. A recent study [6] examined the coping resources of

adolescents during two different stress experiences of political violence. The cross-

situational study compared the stress reactions of Israeli (Jewish and Arab)

adolescents under two environmental circumstances: chronic and acute states of

stress. The acute situations in the political conflict are mostly related to wars or

terror attacks. They can be characterized by their intensity and unpredictability. The

chronic situation is more habitual in nature. In that study, the acute situation was

investigated in the north of Israel, an area which was then suffering from intensive

missile fire. Almost 4000 rockets fell in the area during one month, approximately

200 missiles per day. There were about 900 injuries caused by the missiles in

northern communities and 52 civilians were killed. The long-term chronic stress state

was examined in the south of Israel (the city of Sderot and kibbutz communities in

the Negev), an area which, during the eight years prior to our research, had been

exposed to frequent rocket attacks, usually one or two strikes at a time, sometimes

several times a day. The question we posed was: In which situation are the coping

resources more significant in reducing emotional responses? The significant finding

of this study was the different variances explained by each situation: 35% of the

variance was accounted for in the chronic situation, but only 16% of the variance was

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explained in the acute stress situation. In the chronic situation sample the main

predictor for the two stress reactions was SOC which contributed 15% to the

variance. In the acute situation sample, the exposure variable was one of the

significant factors in explaining the variance (4%) and the SOC contributed only 4% to

the explained variance. Overall, the findings confirm crisis theories (like Caplan,

1964) which claim that the intensity of reactions in an acute situation is mainly

influenced by the overwhelming nature of the situation itself. However, our findings

also confirm salutogenesis, meaning that, in the chronic situation, which is similar to

what Antonovsky called regular life, the SOC is associated with reducing emotional

reactions.

These results support the value of developing a model that differentiates between

stress situations with the aim of understanding the different patterns of salutary

factors explaining the stress reactions. Our findings place a greater emphasis on the

chronic stressor, which was also found to have more pervasive effects, than on the

dramatic, acute war situation.

Some applications for fieldwork with children and families in conflict areas can be

suggested: In an acute situation (like a war), it is much more significant to intervene

at the situational level in order to minimize the exposure to stress and its ensuing

damage. The intervention should not focus on individuals or families at risk; rather,

emphasis should be placed on developing a strategy that encompasses the total

population within the given acute stress situation (for example, building more

shelters, publishing regulatory rules on how to behave when the siren sounds). On

the other hand, in chronic situations, personal or family SOC seems to moderate

stress responses by increasing the ability to cope with the chronic situation. In these

situations, it would be meaningful to provide interventions which strengthen the

resilience resources of individuals, families and communities.

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Coping and culture

My second case relates to the question for whom is SOC insignificant in

explaining emotional reactions. This question is relevant to the wider question of

culture and salutogenesis [17] [18]. As a committed sociologist, Antonovsky had a

deep belief in the place of culture in stress research. However, in the appendix of his

second book Unraveling the Mystery of Health, culture is mentioned only twice,

especially in connection to cultural limits for developing SOC. How can we

understand this “mystery”?

The answer may lie in Antonovsky's conviction that he succeeded in developing the

concept of SOC as a cross–cultural concept. He claimed that it is only the concrete

translation of SOC which can vary widely according to cultural codes. What he meant

was that in all cultures and at all of stages of coping with a stressor, a person with a

strong SOC is at an advantage in preventing tension from being transformed into

stress. A worldview that sees stimuli as meaningful, comprehensive and manageable

provides the motivational and cognitive basis for behavior that is more likely to

resolve the problems posed by stressors than one that sees the world as

burdensome, chaotic and overwhelming.

It is only when seeking to understand how SOC works that it will vary widely. One's

culture defines which resources are appropriate and legitimate in a given situation.

Thus, the hallmark of an individual with a strong SOC is one who is able to choose

what seems to be the most appropriate strategy from among the variety of potential

resources. However, this choice is constructed by his or her cultural mores. We

always cope with stress within cultural contexts, which defines the canon and the

rules. According to cultural rules “the confidant may be a relative of the older

generation, a holy person, a spouse, God or a friend” (p. 148). Within these cultural

constraints, however, the individual with a strong SOC will be flexible in choosing his

or her strategies and in securing better outcomes from the coping process.

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Thus, according to the salutogenic model, “culture sets limits, but within these limits,

it is the level of SOC that matters” (p. 148). Our studies among Jewish and Arab

teenagers living in northern Israel, for example, support this distinction. It was the

individual with the strong SOC, either Arab or Jew, who expressed less anxiety or

suffered fewer symptoms. However, the coping strategies were quite different

between Jews and Arabs [14].

If we accept these considerations of SOC and culture, the next question that arises is:

Does SOC matter in all cultural groups?

Our study among young Bedouins [14] examined this question. During the “Cast

Lead” operation, we compared coping resources as the explanatory factors of stress

reactions of adolescents from two different ethnic groups - Jews and their Bedouin

Arab neighbors, both living in southern Israel. We mainly examined two coping

resources - Sense of Coherence (SOC) and hope - as potential moderating factors of

stress responses.

The Bedouin of the Negev are a minority Muslim Arab group in Israel. They number

about 250,000 and make up 25% of the population of the Negev, the southern part

of Israel. They are Muslim Arabs who traditionally have been organized into nomadic

tribes. However, during the past half century, they have experienced a rapid and

dramatic-transition: approximately half of the population has been resettled into

urban-style settlements by the government. This move from a traditional semi-

nomadic life to urban villages has had social and economic consequences. The

population is characterized by low income levels and the settlements provide few

services for their residents. The growing changes in this traditional society have led

their youth to become closer to modern Israeli and Western society, but there has

also been an attempt by the elders to conserve the religious Bedouin traditions [19].

This could place the younger generation at a greater transition risk.

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Our study was conducted during one month, January 2009, while southern Israel was

under missile attack by Hamas on a daily basis. Adolescents - Jews and Bedouins -

who had never before been exposed to such experiences, were hearing sirens for the

first time in their lives and were experiencing missile barrages several times a day for

about one month. Hundreds of missiles fell on private homes, residential buildings,

schools, kindergartens and in open areas. Two hundred and twenty-two teenagers

(138 Jews and 84 Bedouin Arabs) living in southern Israel participated in the study.

We found no differences between the groups on reported levels of anxiety,

psychological distress and on a global scale of “stress reactions.” Our main

hypothesis, however, related to the coping resources of the two groups. We found

significant differences in SOC levels, which were lower among Arab Bedouin

adolescents compared to their Jewish counterparts. The picture is completely

different regarding the results relating to feelings of hope. Hope entails an

expectation for a better life without the need to see the world as coherent or

manageable. Moreover, the hope concept which was introduced to the adolescents

in our study involved both collective as well as individualistic norms. The Bedouin-

Arab adolescents reported significantly higher levels of collective hope compared to

their Jewish counterparts.

Relating to the contribution of SOC and hope in explaining stress reactions, we found

significant differences between the two ethnic groups. It appeared that in each

ethnic group the explanatory factor was completely different. While SOC contributed

15% to the explained variance of the “stress reactions” in the Jewish group, hope

contributed 15% to the explained variance of the “stress reactions” in the Bedouin

Arab group. So, while in the Jewish adolescent group, SOC was the only contributor

to well-being, among the Bedouin group it had no significant relationship at all to the

stress reactions. Thus, not only was the SOC lower among the Bedouin teenagers, it

did not moderate their stress reactions. It appears that in Bedouin society, whose

cultural roots are based on nomadism and instability, coping with life’s stressors may

be perceived in a completely different way. The feelings of hope that “God will be

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with me” perhaps explains the resilience of these youngsters much more than the

perception of the world as a coherent place. Although these adolescents were born

in a city and had never migrated, the narrative of this society still seems to express

instability and inconsistency.

Other recent studies show that in different cultural and ethnic contexts, differences

play a significant role in the process by which coping resources serve as explanatory

factors of stress reactions. Among Bedouin adolescents facing politically violent

events, for example, SOC did not serve as a protective factor [20]; similar results

were found among young Bedouins coping with house demolition [15], while among

Bedouin women in Israel, SOC even had a negative effect [21].

Therefore, it appears that we need a more contextual rather than a universal

interpretation of coping during times of threat. In other words, when looking for

salutary resources which can help us cope better and stay healthy, we must carefully

consider cultural backgrounds and perhaps we have to be more cautious in defining

SOC as well as other resilience concepts, adopting a more cross-cultural approach.

SOC perhaps better suits a Western oriented culture or other societies which

represent a more stable way of life. It was not salient among Bedouin adolescents

during a time of cultural transition.

In conclusion, our empirical studies suggest that the salutogenic approach, and

especially SOC, enables a deep understanding of the highly resilient levels among

adolescents in an intractable, violent conflict area. However, I also suggest paying

special attention to cases in which the SOC does not serve as a significant factor in

explaining stress reactions. It appears that in some acute situations, as well as for

some cultural - ethnic groups, SOC may not be a relevant resource in moderating

stress reactions. These questions of coping, conflict and culture are still open and

should be addressed in future research.

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References

[1] A. Antonovsky, Health, stress and coping, Jossey-Bass, San Francisco, 1979.

[2] A. Antonovsky, Unravelling the Mystery of Health. How people manage stress and stay well, Jossey-Bass, San Francisco, 1987.

[3] M.Eriksson & B. Lindström, Antonovsky's Sense of Coherence Scale and the relation with health: A systematic review, Journal of Epidemiology and Community health 60 (2006), 376-381.

[4] M. Lahad Posttraumatic responses in distress: A community perspective, In (eds.) K. Gow & D. Paton, Resilience: The phoenix of natural distress, Novas Science Publications, New York, 2008.

[5] M. Zeidner, Contextual and personal predictors of adaptive outcomes under terror attack: The case of Israeli adolescents. Journal of Youth and Adolescence, 34(5) (2005), 459-470.

[6] S. Sagy & O. Braun-Lewensohn, Adolescents under rocket fire: When are coping resources significant in reducing emotional distress?, Global Health Promotion, 16 (2009) 5-15.

[7] S. Sagy, Saluotogenesis: From the diary of a conflict researcher. Israel Journal of Conflict Management (in press).

[8] World Health Organization, Health behavior in school aged children, 2011, HBCC.

[9] S. Sagy & H. Antonovsky, Adolescents' reactions to the evacuation of the Sinai settlements: A longitudinal study, The Journal of Psychology, 120(6) (1986), 543-556.

[10] S. Sagy, Moderating factors explaining stress reactions: Comparing chronic-without-acute-stress and chronic-with-acute-stress situations, The Journal of Psychology 136 (4) (2002), 407-419.

[11] D. Peled, S. Sagy & O. Braun-Lewensohn, Community perceptions as a coping resource among adolescents living under rocket fire: A salutogenic approach, Journal of Community Positive Practices, 4 (2012), 661-702.

[12] O. Braun-Lewensohn, S. Sagy, H. Sabato & R. Galili, Sense of coherence and sense of community as coping resources of religious adolescents before and after the disengagement from Gaza strip, Israeli Journal of Psychiatry (2014).

[13] S. Sagy & S. Adwan, Hope in times of threat: The case of Israeli and Palestinian youth, American Journal of Orthopschiatry, 76(1), (2006), 128-133.

[14] O. Braun-Lewensohn & S. Sagy, Coping resources as explanatory factors of stress reactions during missile attacks: Comparing Jewish & Arab adolescents in Israel Community Mental Health Journal, 47 (2011), 300-310.

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[15] O. Braun-Lewensohn, S. Sagy & H. Al Said, Stress reactions and coping strategies among Bedouin Arab adolescents exposed to demolition of houses. Stress & Health (2013).

[16] S. Sagy, Chronic versus acute stress situations: A comparison of moderating factors, in K.v. Oxington (eds.) Psychology of stress, Nova Biomedical books, New York, 2005, 101-112.

[17] S. Sagy, Effects of personal, family and community characteristics on emotional reactions in a stress reaction: The Golan Heights negotiations, Youth & Society 29 (1998), 311-329.

[18] O. Braun-Lewensohn & S. Sagy, Salutogenesis and culture: Personal and community sense of coherence among adolescents belonging to three different cultural groups. International Review of Psychiatry, 23 (2011) 533-541.

[19] M.Eriksson, S. Sagy & B. Lindström Salutogenic perspective on mental health across life time. Cultural aspects on the sense of coherence. In C.H. Mayer & C. Krause (Eds.) Way finding throught life's challenges: Coping ans Survival, Nova Publishers, New York, 2012.

[20] I. Abu-Saad, Education as a tool for control vs. development among indigenous people: The case of Bedouin-Arabs in Israel, Hagar, 2, (2001), 241-261.

[21] O. Braun-Lewensohn, S. Abu-Kaf & S. Sagy, Attitudes towards war and peace and their relations with anxiety reactions among adolescents living in a conflictual area. Journal of Youth Studies (submitted).

[22] N. Daoud, O. Braun-Lewensohn, M. Eriksson & S. Sagy, Sense of coherence and depressive symptoms among low income Bedouin women in the Negev Israel, Community Mental Health Journal, (submitted).

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Chapter 5

Levels of Resilience: A Critical Review

Shaul KIMHI6

Psychology Department, Tel Hai College, Israel

Abstract. The present paper focuses on three levels of resilience: individual,

community and national. The paper presents the salient limitations of the

concept of resilience and the main approaches to the study of resilience. It

describes the limited knowledge regarding the associations among the

above three levels of resilience and the importance of the associations

between them. As a possible conclusion, the paper presents a theoretical

model of associations among the three levels of resilience and the ability to

withstand harsh events.

Key words: individual, community and national resilience.

Introduction

In recent years, as terror attacks have become prominent threats across the

world, resilience has been extensively researched. This paper aims to focus on three

levels of resilience: individual, community and national and the associations between

them. In addition, this paper provides a brief critical review of the literature that

highlights the key psychosocial markers of the three levels of resilience.

Research indicates that potentially traumatic events (PTE) [1], such as wars, natural

disasters or economic crises, quite often result in detrimental psychological

6Corresponding Author: Shaul Kimhi, Ph.D. Psychology Department, Tel Hai, College, 12210, Israel. E-mails: shaul@shamir.org.il; shaulkim@telhai.ac.il

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outcomes [2, 3, 4, 5]. It has been further argued that the effects of stressful events

are cumulative. Prolonged stress often causes various detrimental physical and

psychological symptoms [6, 7, 8, 9]. One of the few studies comparing the

psychological responses of civilians who have been exposed to continuous rocket

attacks with those who have not been exposed to a similar stress has found the

following: exposed civilians scored higher on PTSD symptoms and lower on

satisfaction with life, as compared to unexposed individuals. The negative

correlations between PTSD and satisfaction with life were significantly stronger

among the exposed participants than among unexposed individuals [10].

Resilience is a positive trajectory of adaptation after a disturbance, distress, or

adversity [11]. According to Egeland et al., resilience constitutes “the capacity for

successful adaptation, positive functioning or competence… despite high-risk status,

chronic distress, or following prolonged or severe trauma” [12] (p. 517). In recent

years, the concept of resilience has often been used in discussing people's ability to

withstand stress. According to Kimhi and Eshel [13] one's level of resilience is a key

issue in buffering negative psychological consequences of potentially traumatic

events.

Examining the resilience literature more closely indicates some salient limitations.

The following are the most prominent:

(a) The concept of resilience is often defined rather loosely [14, 15, 16]. It seems

that different conceptualizations of resilience, its operational definitions and

modes of measuring need to be systematically tested under different

circumstances in order to advance knowledge and practical use of this

concept. According to Fletcher and Sarkar, [17] despite the construct of

psychological resilience being operationalized in a variety of ways, most

definitions revolve around two core concepts: adversity and positive

adaptation. These authors claim that resilience is conceptualized as the

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interactive influence of psychological characteristics within the context of the

stress process [18, 19].

(b) There is no clear distinction between the concept of resilience and other

concepts. The boundaries of resilience in respect to other related concepts,

such as posttraumatic growth, salutogenesis, resistance response after

trauma, and adaptability to new circumstances, need to be systematically

studied [17].

(c) The validity of the tools measuring community and national resilience has not

been sufficiently substantiated. Models of specific cultural styles of coping

with crisis seem to overlap with individual, community and especially with

national resilience as evidenced in behavioral patterns. This illustrates that

further research should explore resilience from the perspective of different

disciplines [19].

(d) Various studies have used different tools to measure each level of resilience,

making it difficult to compare them. As a result of this variety of tools used by

different researchers (especially in relation to community and national

resilience) we lack an international baseline and our predictive ability is low

[20].

(e) Research on resilience focuses mostly on a single level of resilience without

examining possible links among the different levels of resilience [21, 22].

Three Levels of Resilience

Three levels of resilience have been referred to in the relevant literature:

individual, community, and national resilience. In some studies the last two levels

are regarded as social resilience. Overall, studies have indicated that all three levels

of resilience have been found to contribute to coping with the aftermath of major

potentially traumatic events. Unfortunately, only a few studies have examined the

associations among these levels of resilience [13].

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Individual resilience

Most of the research pertains to individual resilience. It has been argued that

since security and insecurity are evaluated by individuals who experience them in a

subjective manner, resilience should be regarded as an attribute of the individual

[23, 24]. Bonanno [1] defined individual resilience as the individual's ability to

maintain a stable level of functioning following traumatic events and as a "trajectory

of healthy functioning across time" (p. 136). A few tools aiming to measure

individual resilience have been proposed. For example, Antonovsky presented a

sense of coherence as a tool for measuring individual resilience [25]. Kobasa

presented the hardiness scale [26]. Connor and Davidson developed the Connor-

Davidson Resilience Scale [27]. Overall, it seems that these tools have been found to

have good predictive validity for peoples' ability to withstand potential traumatic

events.

When discussing individual resilience, one should keep in mind that there is great

variation in the ways individuals respond and react to environmental stressors. While

exposure to risk may lead to psychopathology and ill-health for some, others show a

relative resistance to a similar level of risk, or are able to overcome the stress or

adversity [28]. Studies have indicated that the variation among peoples' ability to

withstand PTEs is a result of the interplay between genetic and biological processes,

as well as different environments. Both are necessary to elucidate the causal

pathways through which individuals show resilience or vulnerability in the face of

adversity [29, 30, 31, 32]. Furthermore, different stressors are associated with

different phenotypic outcomes, and it follows that individuals may be resilient to

certain environmental stressors and not to others [29]. In other words, individual

resilience is not simply a trait that can be measured directly but an elusive

theoretical construct.

Based on a literature review of individual resilience, it may be concluded that most

people are resilient and have a high capability to cope successfully with potentially

traumatic events [1]. At the same time, those who remain negatively affected by

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traumatic events require serious attention. However, much more research is needed

in order to better understand the complexity of individual resilience.

Community resilience

Cacioppo, Reis and Zautra [33] defined community resilience as the capacity of

a community to take a positive trajectory of adaptation after distress or adversity.

Community resilience is manifested by society’s ability to readjust to changing or

hostile environments in new and innovative ways [34]. Community resilience means

more than the sum of its resilient individuals and may be guaranteed only by a

strong sense of community [11]. It expresses the interaction between individuals and

their community and pertains to the ability of the individual to get help from his/her

community and the ability of the community to help individuals and provide for their

needs. Community resilience relates to both objective and subjective components.

On the one hand, it refers to caring for physical needs such as water and food, as

well as providing physical protection. On the other hand, it reflects personal

attitudes, perceptions and feelings towards one's community, such as perceived

threats, availability of community resources, social cohesion and trust in leadership

[4, 7, 11, 35].

It has been observed that community resilience, much the same as individual

resilience, is a major predictor of coping with potential traumatic experiences. Kimhi

et al., [36] have thus demonstrated that distress symptoms as well as posttraumatic

recovery of elderly Israeli civilians after the 2006 Lebanon War were contingent on

their level of community and national resilience. The existing studies indicated that

communities characterized by higher resilience, showed a higher ability to prevail

and cope with highly stressful situations as well as greater recovery ability, compared

to communities with less resilience [37, 38, 39, 40].

A seminal review of the field suggests that community resilience is based on four

antecedents [11]. First, in accordance with data on individual resilience, it was found

that community resilience in times of stress is enhanced by economic wealth and a

more egalitarian distribution of resources [41]. Second, it is likely to be boosted by

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community social capital and social support, which refers to the actual or potential

resources that are linked to the existence of a durable network of relationships.

Third, this mode of resilience depends largely on information and communication

provided to community members in times of crisis. Fourth, community resilience is

contingent on community competence, which empowers its ability to cope with

stress and trauma.

Compared with the field of individual resilience, there is limited knowledge regarding

community resilience. Overall, there seems to be agreement among researchers that

community resilience is an important resource in coping with major disasters and in

mass trauma interventions [11, 16, 42]. Research has indicated that a high level of

community resilience enhances individuals’ coping during stress situations and is

instrumental in quicker post stress recovery.

National resilience

Several studies have referred to resilience as a wider societal phenomenon,

and have investigated it in terms of national resilience [43, 44] or social resilience

[33]. The concept of national resilience is a broad one, addressing the issue of the

society's sustainability and strength in several diverse realms [45] [35]. Friedland [34]

has argued that national resilience is probably the most elusive concept of resilience

since on the one hand it should express society's ability to withstand adversity with

its values and institutions remaining intact, while on the other hand, national

resilience is also manifested in society's ability to cope with a changing, sometimes

hostile, environment by changing and readjusting in new and innovative ways (p. 8).

According to Kimhi and Eshel [13], both community and national resilience pertain to

confidence in a larger or smaller social reference group which is supposed to provide

its members with security, a sense of belonging, and social identity.

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Four main social components were attributed to national resilience: patriotism,

optimism, social integration, and trust in political and public institutions [46]. These

authors reasoned that, during times of intractable conflict, members of a resilient

society would display durable stability in maintaining these components. Elran's

study [47] shows that this indeed was the case in coping with the El Aksa intifada

(uprising from September 2000 to 2005) by Israeli society. One of a few studies on

the antecedents of both community and national resilience has shown that they

were positively affected by the economic conditions of the respondents and

negatively predicted by level of exposure to the horrors of war [13]. It seems that the

main differences between community and national resilience are level of familiarity

and social cohesiveness, yet much more research is needed to identify the potential

differences between them. Compared with the field of individual and community

resilience, there is limited knowledge regarding national resilience.

Approaches for Measuring Resilience

Reviewing the relevant literature indicates that it is possible to identify at least

four main approaches to the study of resilience. This division is somewhat artificial

since many studies use a mixed approach. However, the common denominator of all

these approaches is the examination of possible risk and protective factors of

resilience.

(a) Longitudinal approach - In this approach, the best way to study resilience is to

follow the same people who have gone through potential traumatic events over a

period of at least two years and to measure the level of various stress symptoms,

psychological and physiological, as well as other indicators signaling a return to the

same level of functioning as before the PTE. This approach focuses on individual

resilience and tries to identify different coping trajectories. Some of the researchers

identify four main trajectories: resilient, chronic, delayed and recovery trajectories

[1].

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(b) Individual differences after a traumatic event - This approach proposes focusing

on assessing individuals who have survived the same traumatic event and looks for

possible differences between two groups: (a) Those who coped well and showed

individual resilience - have no distress symptoms and continue to function as well as

before the traumatic event; (b) Those who do not cope well - show many distress

symptoms and do not function well [36]. The differences between the individuals on

measures such as level of stress symptoms and level of everyday functioning can

indicate potential protective and risk factors of resilience.

(c) Group differences after a traumatic event - Somewhat similar to the previous

approach, this approach focuses mainly on comparing groups after a PTE has

occurred. Unlike the previous approach, this method focuses on communities and/or

nations. It measures community and/or national resilience by comparing

communities and/or countries which have experienced a traumatic event with

communities or countries that have not or examining a group of people who

experienced a traumatic event, compared to a control group who have not [10, 48].

However, like the previous approach, it compares communities or countries at only

one time point, after the event [4, 49].

(d) Prospective study - According to this approach, researchers examine a group

which lives is in a high risk area (beginning measurements before a major traumatic

event has taken place) and repeats assessments of resilience either assuming that

one day a traumatic event will occur in the future or through a process that is known

to create stress [50]. The salient characteristic of this approach is the fact that we are

measuring peoples' coping before, during and after an actual PTE and have baseline

measurements.

(e) Combination - Some studies combine two methods. For an example, Pfefferbaum

et al., [51] explored psychological resilience and recovery following the 1995

Oklahoma City bombing and assessed reactions to the incident in residents of

Oklahoma City and a comparison city over three years.

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What are we measuring?

The literature review leaves the reader wondering what we are in fact

measuring. Here are some alternatives: resilience as a process, as a trait (for

individual resilience), risk and protective factors or predictors of resilience? Actually,

it seems that different studies give different answers. For example, if we use the first

approach and examine different measures of returning to everyday life, we are

discussing measuring resilience as a process. However, if we examine people,

communities or national resilience before a disaster takes place, we may say that we

are measuring predictors of resilience. These kinds of questions await much more

research. One possible conclusion is to assume that as long as we are measuring

resilience prior to a PTE we should consider measures as predictors of resilience.

Associations among Levels of Resilience

A profound literature review revealed only three studies-conducted in Israel

which directly measured the associations between two or three levels of resilience:

individual, community and national resilience. The first study focused on

demographic antecedents of community and national resilience (a combination of

both community and national scales) [52]. The authors hypothesized that both kinds

of public resilience would be predicted by four demographic variables, which have

rarely been associated with community or national resilience in the past: community

type, level of religiosity, level of preparedness and age. The final sample of 435

participants included 92 kibbutz members (collective community), 61 moshav

members (partly cooperative agricultural community), 38 inhabitants of villages, and

244 town dwellers. To measure community resilience the authors used the

Community Resilience Assessment Measure [53, 55].

Results indicated the following: (a) When demographic variables were accounted for,

community and national resilience positively correlated with each other: r=.21,

(p<.001); (b) The four demographic variables in the path analysis model, controlling

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for each other, significantly predicted community and national resilience; (c) Older

age and higher level of religiosity positively predicted both community and national

resilience; (d) Higher preparedness positively predicted only community resilience;

(e) The results indicated that the more communal settlements (kibbutz and moshav)

scored significantly higher than the less communal settlements (village and town) on

community resilience, and members of the kibbutz scored significantly lower than

city dwellers on national resilience. The authors suggested that political attitudes

may explain the differences regarding national resilience between the different types

of communities: The more "communal" communities tend to be more leftwing

compared to less "communal" settlements.

The second study focused on the distinction between individual and public resilience

(community and national resilience collapsed into a single general construct), and

their effects on long term negative (stress symptoms) and positive (posttraumatic

recovery) war outcomes one year after the end of the war [13]. The sample included

870 adults (40% male, 60% female), residents of the border town of Kiryat Shemona.

The study took place one year after this town was targeted by hundreds of rockets

fired from Lebanon during the Second Lebanon War in 2006. Public resilience was

based on items pertaining to community resilience [4] and to national resilience [46]

combined into a general public resilience scale of 13 items. Path analysis indicated

the following: (a) Gender, age, economic situation and exposure to traumatic war

events significantly predicted recovery as well as symptoms. Being female, older,

having a lower economic status and greater exposure were all associated with a

lower level of recovery and a higher level of symptoms; (b) Individual and public

resilience (r=.37, p<.001) served as mediators between economic status and

exposure, and the two war outcomes (stress symptoms and recovery); (c) The best

predictor of posttraumatic recovery was public resilience while the best predictor of

stress symptoms was individual resilience. When the public resilience variable was

broken into community and national components, correlations among the three

levels of resilience indicated significant positive but low correlations: national and

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community (r=.357, p<.001), national and individual (r=.239, p<.001), and

community and individual (r=.160, p<.001).

The third study focused on Israeli students' perception (N=282) of two war threats:

the Iranian and the Hezbollah war hazards [54]. The researchers measured

individual resilience (using the Sense of Coherence Scale), community resilience and

national resilience [46]. Results indicated an insignificant correlation between

individual and community resilience (r=.010), a significant correlation between

individual and national resilience (r=.158, p=.008), and a significant correlation

between community and national resilience (r=.246, p<.000).

In addition to the above three studies, a qualitative study, based on interviews,

explored the association between individual and community resilience [37].

Qualitative analyses indicated that community and individual resilience affect each

other and that individual and community attributes interact to form or support

resilience.

Based on the limited studies on the associations among the three levels of resilience

we may assume the following: (a) There are significant positive low correlations

among individual, community and national resilience: as one increases, so do the

other two (based on two out of the three studies mentioned); (b) Some demographic

variables predict all three of them (such as level of exposure to traumatic events and

economic status) whereas others associate with only one of them (such as

preparedness, which associates positively only with community resilience); (c) Based

on the significant but low correlations found, we may assume that each of the three

levels represents an independent structure; (d) We hardly know if and to what

degree there are mutual influences among these levels of resilience (e.g., how each

of the three levels of community affects and is affected by the other two); (e) It

seems that all three levels of resilience significantly predict individual well-being,

good adaptation and successful coping with potential traumatic events.

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Accordingly, we suggest a theoretical model whereby each of the three levels of

resilience to some degree affects the two others and is affected by each of them. In

addition, all three levels of resilience affect the ability to withstand harsh events (see

Figure 1). However, this proposed model is far from sufficiently research-based. It is

based on a limited number of studies and much more research is needed in order to

substantiate the model.

Figure 1: Theoretical model of associations among individual, community, and national resilience and the ability to withstand harsh events

The importance of associations among the three levels of resilience

The limited knowledge regarding the associations among the various levels of

resilience pose serious challenges to our understanding of the concept of resilience.

Despite the limited studies, it seems very important to know much more about the

associations among the different levels of resilience. The following are suggested

salient points which await further research:

(a) As part of unexpected disaster events or large scale PTEs, professionals should be

able to develop future plans in order to prepare and train populations to cope

with them. The plans should focus mainly on community resilience due to lack of

knowledge about national resilience. Such plans seem to be less efficient when

they are focused only on one level of resilience.

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(b) It seems that a future plan for dealing with disaster events should include some

unique as well as common preparation and intervention plans for each of the

resilience levels.

(c) Enhanced understanding of the associations among the levels of resilience may

help set priorities for preparation and future interventions after a large scale

potential traumatic event takes place. For example, based on the present

knowledge, it appears that a major target for preparation and possible

intervention to cope with a disaster event should be community resilience, due to

the possibility of taking practical steps to influence the greatest number of people

in the shortest time.

Based on the above and due to our very limited knowledge of the associations

among the various levels of resilience, we urgently need additional studies to clarify

the matter. These associations are very important both theoretically as well as

practically, to help a large proportion of the population to prepare and cope with a

possible catastrophic event in the future and to determine how to plan large scale

interventions in such cases.

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Chapter 6

National resilience in multinational societies

Merle PARMAK7

Tallinn University of Technology Institute of Industrial Psychology

Abstract. Resilience at the level of any system reflects its capacity to

successfully manage unexpected pressures without losing its structure and

stability. The most generic level of resilience - national resilience - is closely

related with a shared vision and values in society at the level of the nation. It

refers to the ability to maintain the national social fabric and cohesion when

confronted by threats. During massive transitions, the established

boundaries of nation-states and the definition and nature of citizenship are

challenged. Risks related to diverse ethnic and religious identities may not be

apparent before crises arise. In expanded societies, societal fragmentation

poses a threat to national security, highlighting the importance of strategic

nation-building and national resilience. Nation-building is influenced by trust

and practice of communication between citizens, the state and its sub-

communities. In order to mitigate security risks and enhance the capacity of

multinational societies to cope with crisis, there is a vital need to develop a

conceptual understanding and screening methodology for national resilience.

Keywords: National resilience, national identity, multinational society, ethnic

and cultural diversity

7Correspondence: Merle Parmak E-mail merle.parmak@gmail.com

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Introduction

Migration, driven more often by vital need than free choice, transforms

human communities in a fundamental way. The nature of society can shift within a

relatively short period from national to international, from cultural to multicultural,

from monolingual to multilingual. Such profound changes are not always well-

received or readily accepted by local residents. In multinational societies, the

politically encouraged practice of multiculturalism can be perceived by the

indigenous population as a threat to their cultural self-definition and social welfare.

Despite the prevalence of the rhetoric of multiculturalism in the public discourse,

cultural diversity may not be willingly accepted and tolerated as a result. Newcomers

face a society that (at least ostensibly) values the expression and preservation of the

domicile ethnic identity 1 and are likely to create sub-communities of shared fate,

cultural beliefs and customs. The aim of this chapter is to illuminate an important

issue of national resilience in multinational societies from the perspective of national

security. The chapter covers three interrelated themes with which multinational

societies need to contend: (1) national resilience, (2) national identity, and (3)

nation-building. The section of national resilience refers to conceptual shortcomings

pointing to an urgent need for scientific attention. At the level of national resilience,

citizens’ identification with national values and shared understanding about societal

strivings are salient. In the second section, complex dilemmas related to identity

formation and dual-nationality are addressed. Finally, the importance and reciprocal

nature of nation-building processes in multinational societies is emphasised. A

comprehensive understanding needs to be developed about behavioural

antecedents and interactional relations between the individual and the society in

order to promote the formation of national identity and increase national resilience.

There are significant variations in what people consider morally and emotionally

significant and how they define themselves and others, but also in what they believe

to be the essence of a society and nation. Research reveals that diverse sets of

immigrant groups face challenges to residential incorporation in new areas of

settlement leading to heightened levels of immigrant segregation observed in new

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destinations 2. Findings reflects that in order to gain a sense of belonging and

safety, people tend to form close communities with fellow migrants who share their

values and beliefs. Settling in communities, groups find ways to protect and

propagate that which is valued and central for their survival 3. In multinational

societies those communities can be formed based on perceived similarity, ethnic or

cultural background. As a result, value-systems present within one society may differ

significantly among sub-communities. Related to the concept of shared identity,

those sub-communities can be very cohesive; however, such cohesiveness is not

necessarily generalizable to the level of society. In fact, contradictory values and

visions between sub-communities may diminish the overall cohesive capability of a

nation, as group identification appears to be a potent enough resource to lead its

members to assert their group identity in case of perceived threat 4. Based on the

well-known phenomenon of social categorization between “us” and “them”5, we

may assume that clustering into cohesive “us” groups implies the presence of

“them” groups that are not so positively perceived. When in multinational societies

“us and them” groups emerge based on ethnic and cultural backgrounds, social

unrest and tension may occur at the national level. During times of conflict,

polarization can quickly escalate to overt confrontation or terrorist acts 6.

National resilience

The issue of national resilience in multinational societies is complex in many

ways. Unfortunately, a collection of resilient individuals does not guarantee a

resilient community 7; similarly, a set of resilient communities does not necessarily

comprise a resilient nation. In addition to the conceptual ambiguity, this topic is also

politically driven and can appear to be sensitive as it refers to the responsibilities of

political leaders and state authorities in conflict hotspots around the world.

There is a fast-growing body of academic literature referring in one way or another

to the phenomenon called resilience. The concept has appeared to be attractive for

different fields, and is used within those fields at different levels. A search for

relevant Subject Terms in a scientific database (EBSCO) reveals 3462 hits for the

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word “resilience”8 from 1972 to 2014. The meaning behind the term, however, is

profoundly different, ranging from mechanics 8 to socio-ecology 9, and from

clinics 1011 to national policy 12 13. Definitions provided become vaguer

horizontally (from exact to social sciences 7) and vertically (from person to nation

14). The most criticized 15 and the least elaborated 14 is the concept of

resilience at the level of large human societies or nations, especially from a practical

perspective 16. Defining and measuring resilience becomes increasingly difficult

when relating to amorphous systems without clear structures or definable borders.

The nation, especially in the globalized world, is one of these ever-changing

phenomena; accordingly, national resilience is certainly a challenge to define and

measure. However, it seems that beyond the various definitions there is a tendency

to agree that national resilience means society’s sustainability and strength in

several diverse realms including components such as patriotism, optimism, social

integration, and trust in the political and public institutions 17.

A comprehensive framework for multi-layered social resilience is proposed,

emphasizing the interactional relationship between enabling factors and capacities

at different levels of society. Two aspects should be highlighted regarding resilience

at the national level: (1) resilience is a process and depends on the threat we

examine; and (2) some groups can be privileged by international, national and local

efforts 16. Even within the same society, all groups are not necessarily exposed to

similar threats and support, and through experience, they develop different coping

abilities. Thus, in the social world the relation is interactional, and resilience has as

much to do with shaping the challenge faced as responding to it 18. In trying to link

individual resilience with that of a community or nation, it may be useful to look for

frameworks linking resilience with the capacity of systems to absorb disturbance

8This search was conducted on 22.02.2014

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while still being able to continue functioning 19. The Resilience Alliance9 has

developed a wide body of knowledge about ‘ecosystem resilience’, encompassing

aspects of sustainability, adaptability and transformability. The group defines

ecosystem resilience as the capacity to tolerate disturbance without collapsing into a

qualitatively different state that is controlled by a different set of processes10.

Resilience as applied to ecosystems has three defining characteristics which can be

applicable to a system of communities at the national level:

The amount of change the system can undergo and still retain the same

controls on function and structure

The degree to which the system is capable of self-organization

The ability to build and increase the capacity for learning and adaptation.

A survey of the literature regarding the various levels of resilience indicates that

individual resilience has received the most, and national resilience the least, research

attention to date (for an exhaustive review, see Kimhi, in this volume). Compared

with individual or community resilience, there is limited knowledge available

regarding national resilience; we have just a few studies to rely on. This status,

however, is likely to change in the near future, as one function of community and

national resilience is to provide its members with a sense of security, sense of

belonging, and social identity 20 which is a political cornerstone of the nation and

of national security.

Weak but significant correlations found between individual, community and national

resiliencies 20 reveal variations in their content but also indicate systematic

overlaps. A heuristic model of resilience levels and relations is provided (Figure 1) to

9A research organization comprised of scientists and practitioners from many disciplines who

collaborate to explore the dynamics of social-ecological systems

10 Retrieved 09.02.2014 from: http://www.resalliance.org/index.php/resilience

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model conceptual challenges in resilience between personal attributes (individual

level), cultural factors (community level) and citizenship in political systems (nation

level). To fuel further research, potentially conjunctive mechanisms are proposed.

Ultimate interest lies in the overlap of all three levels. It is for future research to

answer whether and what overlap exists between the individual, community and

nation levels of resilience. The latter two levels (community and national) are shown

to collapse into a single construct and have been called public resilience in previous

research 20.

Figure 1. Heuristic model of resilience levels and relations for further research

Measuring resilience, two important considerations should be noted. The first is

related to where we are taking our measures. Typically, a community is considered

to be an entity that has geographic boundaries and a shared fate 7. However,

geographic boundaries do not necessarily mean a shared fate or narrative for people

or groups inhabiting the place. This very aspect may be, in fact, the source of

regional tension or conflict. Differences in the type of society or community under

assessment make it difficult to generalize current empirical findings to other types of

communities 17. We may end up with completely different conclusions about

relations between individual-community-national resilience if a small and cohesive

rural society or a large and anonymous urban city is defined as the community in a

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particular research project. Another issue relates to what we are measuring,

distinguishing between the processes of resilience building and the manifestation of

resilience after some critical event occurs 16. Especially at the level of the nation,

we need to determine whether our interest lies in resilience or in the potential

(predictors) of resilience 20.

A low level of resilience is associated with vulnerability. Considering both social and

ecological systems to be inherently dynamic, their levels of vulnerability will increase

in proportion to reduced levels of resilience, reducing options for coping with sudden

and unexpected change 21. Expanding the scale of resilience from single individuals

to multinational societies, we need to be aware that our object of interest becomes

an increasingly complex system of interactions among different actors and

environments. The scope of potentially intervening factors expands from personality

attributes to cultural aspects and trust in the political leadership, patriotism,

optimism, social integration, as well as other potential components of national

resilience waiting to be studied. At the level of the nation, the situation of society

becomes very complex since we have to face two ill-defined variables in one

equation: we do not know either what constitutes national resilience or how to

define the nation in the context of globalization and multinational societies.

National identity

Cultural diversity becomes a challenge if there is no willingness to integrate

with other cultures. When people feel their accustomed social fabric is at risk, they

may emotionally hold on to what they believe constitutes the roots of their existence

22, rejecting any other alternative. Building a nation-that is, creating a jointly

accepted narrative-in societies where multicultural diversity is increasing, may not

run as smoothly as political leaders might like. Political rhetoric in public discourse is

not enough. Even in historically multi-ethnic countries, the discourse of nation

building and integration of ethnic groups is often blamed as too superficial, with the

important aspects of its process ignored 23. However, the process of identity

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formation at the level of the nation is interactional, referring to potential for conflict

resolution and reconciliation. Intractable conflicts trigger changes in national

identity, but the conflicts also seem to be affected by changes in that identity 24.

The temptation to link identity and extremism with the internal (or personal) causes

of extreme behaviours should not be overestimated; identity formation and the

nature of extremist organizations (or social causes) must be emphasized. From a

collectively-held belief about what is best for the nation, means up to and including

violence can be justified as worth the sacrifice 25.

Nations are entities conjured through symbols and rituals that do not naturally arise

from a pre-existing foundation of shared blood, language or culture. Rather, they

build on shared narratives and consequent illusions of collective identity 26.

Identity is an individual comprehension about oneself as a person with unique traits

and experiences, social relations, and group affiliations. It determines personal world

interpretations and provides grounds for how to evaluate the behaviour of oneself

and others 27. National identity and patriotic feelings toward one’s country are

part of individual attitudes and values. In the case of dual-nationality, this feeling of

national identity can be ambivalent and even conflicted, finding expression in

attitudes and behaviour toward the political system of the country. People with dual

identity may endorse patriotism toward the country where they hold citizenship,

while at the same time be committed to their own ethnic group. Balancing between

ethno-cultural self-determination and common citizenship is complicated not only

for ethnic minorities but also for members of the majority community.

Human identity is not something that is formed until a certain moment and then

remains unchanged for life; rather, the process of identity development extends

across one’s lifespan. Life transitions demand that people take on new challenges

and ultimately deal with how they make sense of themselves 28. However, there

are certain limits within which we can reshape identities that are already formed. If

identity changes, it does so in response to both external stimuli and internal

realignments - but even then, some elements of identity do not change 29. Thus,

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identity is situational yet rooted in certain intrinsic characteristics limiting the extent

to which identity can be reshaped in social constructions.

Although people are usually members of multiple communities and derive their

sense of community from different sources, they are typically centred in a primary

community, that which provides values, norms, stories, myths, and a sense of

historical continuity 3. For individuals with multiple social identities, attitude

toward societal changes are important factors contributing to their dominant

identity. Considering the ethnic diversity of modern multinational societies, there is a

risk for communities to become fragmented, creating favourable soil for

confrontation among groups. Without proactive policies to promote common

citizenship and national identity, mutual understanding and respect, new immigrants

may quickly become an isolated underclass, standing in permanent opposition to the

larger society. Multiculturalism may be perceived as a risk in society when

immigrants are seen predominantly as potential carriers of practices not understood

by locals or as a social burden. Since the mid-1990s, recognition of diversity has been

replaced with ideas of nation building, common values and identity 30.

It is also known that a turbulent environment with a high degree of uncertainty

prevents collective identity formation for societies and its members. Uncertainty has

been identified as the most basic cause of anxiety in humans, increasing religious

conviction and mutual derogation among religious (as well as non-religious) groups

31. Ethnic identity is one of the most meaningful kinds of identity, which is based

on the opposition between "us" and "strangers," and in which separation from other

groups is stressed 32. It has been demonstrated that social uncertainty is related to

the choice of social identity. Two steps are proposed for individuals with identity

confusion to negotiate their intergroup attitude: in the first step, by choosing one

identity, people develop a clearer distinction between the in-group and the out-

group; in the next step, they likely develop a prototypical out-group attitude 33.

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Nation-building in multinational communities

In a globalized world, a nation cannot be defined geographically; instead, it is

defined by people or communities who have been unified by causes and values. The

quantity and quality of social cooperation at the national level is paramount, since

the applicability of individual resilience is limited without taking factors of social life

into account 34. The key to success is to understand that relations between the

society and the state are interactional and mutually reciprocal. At the national level,

comprehensive nation-building projects have important consequences for a

multinational society in terms of what values citizens are willing to stand for, with

whom they see themselves to be connected, and how they construct their individual

and collective futures.

Risks related to societal segregation based on ethnic or cultural differences tend to

remain latent until crises arise. An inward-looking approach to security has been

proposed as resilient states would lead to regional resilience, which would constitute

a foundation of national security 35. National resilience, if neglected, constitutes

an asymmetric threat to the nation’s social fabric and political stability. Resilience

thus involves planning, preventing, evading, mitigating, avoiding as well as coping

with and reacting to challenging livelihood conditions. It refers to proactive

capacities like the capability to anticipate, change and search for new options 16

and as such reflects the nation’s societal resilience. This capacity has to be

continuously assessed, particularly at times of unease or major changes to monitor

the level of resilience in different communities and make predictions relevant to

national security.

The trust and practice of communication between citizens, the state and its sub-

communities become crucial when some type of threat or risk is present in society.

Rapidly changing environments are always confusing, and the importance of a

trusted leadership should never be underestimated. To reduce ambiguity and

promote resilience in the face of danger, a process of collective sense-making has

been proposed 36. Three sub-processes of organizing ambiguity are described as

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key characteristics of goal attainment within contexts of danger: (1) framing helps to

differentiate the significant from the non-significant, providing participants with a

common focus; (2) awareness of interrelations fosters a common understanding

among people on the level of risks and danger present; and (3) adjusting is related to

constant awareness of the surrounding circumstances, reconsidering and reassessing

as necessary.

For strategic nation building, it is important to acknowledge that people do not

operate as autonomous elements in a vacuum. Expressed behaviour is

simultaneously both influenced by events in an environment (in a social

environment, in our case) while it also partly determines the nature of these events.

Behaviour as it occurs always changes both of its interacting components – the

individual and the environment. An individual, experiencing something new, may

change behaviour toward society; meanwhile, society, as result of observed

behavioural reactions, may adapt its norms, attitudes and applied control regarding

those behaviours.

In assessing resilience in societies, it is important not only to register expressed

behaviours but also to analyse active components of behavioural intention and to

understand the phenomenon of reciprocal looping. Two theoretical standpoints are

helpful to consider: the theory of reasoned action 37 38 and the concept of

reciprocal causation 39 40 41. The theory of reasoned action states that

individual behaviour is driven by behavioural intentions. Behavioural intention is a

function of an individual‘s attitude towards the behaviour (positive or negative), the

subjective norm surrounding the performance of the behaviour (acceptance by

others), and the perceived behavioural control (options to behave). The concept of

reciprocal causation postulates that the situation (environmental factors), person

(perceptions, emotions, meanings) and behaviour (reactions of a particular person in

a particular situation), all influence each other.

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Combining concepts of reasoned action and reciprocal causation from the focus of

an individual in a social environment, an interactional mechanism11 of expressed

behaviour is presented in Figure 2. The interaction between person and society does

not have a reciprocal loop to behaviour directly but instead indirectly via influencing

psychological components of behavioural intention. Reciprocal looping integrates

environmental consequences and behavioural causation. Solid arrows refer to

observable processes; dotted arrows to psychological processes that are not directly

observable.

Figure 2. Reciprocal looping between components of behavioral intention and interactional mechanism behind expressed behavior

Thus, human behaviour does not occur in a vacuum, but is systematically influenced

by the actor’s set of attitudes-norms-beliefs in interaction with diverse

environmental variables - potentially influencing and simultaneously being

influenced by this set.

11 The model does not cover behaviors outside of awareness, addictive behaviors or strong emotions that can overpower reason.

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Behavioural intention is an immediate antecedent of behaviour, and is based on

attitude toward the behaviour, subjective norms, and perceived behavioural control.

Political authorities have access to powerful means to influence necessary

preconditions from the perspective of national resilience and nation-building, such

as prevalent norms, attitudes and behavioural control in society. To guide people to

behave in a specific way or convince them to change previously expressed

behaviour, positive attitudes have to be elicited (the suggested behaviour is

positively valued), norms have to be established (engaging in the behaviour is

socially desirable), and feasibility to perform has to be warranted (the behaviour is

doable). However, acceptance of guidance and suggestions depends both on how

credible the communicator is perceived as well as on the conditions in which the

communication is received. Reception and acceptance are more likely to occur when

suggestions meet existing needs or desires of recipients. This highlights the

importance of the intercultural sensitivity needed for strategic nation building in

multinational societies. Acknowledging active components of behavioural intention

behind expressed behaviours is vital not only on a political but also on a society level.

Conclusions

Just as communities are composed of individuals, nations are composed of

communities. National resilience is closely related to trust in the authorities,

patriotism, optimism and social integration. Excluded or unintegrated sub-

communities may prove to be very resilient in themselves but not for the nation,

thus in fact posing an additional threat to political stability during times of crisis.

Nation building has become a topic of close interest in diverse and multinational

societies as large-scale immigration has challenged long and closely held notions of

national identity 42, which is a component of national resilience. Whether people

move for economic or political reasons, the issues of social positioning and identity

inevitably arise, and must be addressed. Issues related to national identity become

more and more politicized as allied nations are supposed to stand for common

values and rules.

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From the perspective of planning theory and practice, it is stated that rather than

viewing resilience as “bouncing back” to an original state following an external

shock, the term should be seen in terms of bouncing forward, reacting to crises by

changing to a new state that is more sustainable in the current environment 43.

Ethnic diversity, if perceived in society to be related to radicalization, diversion and

subversive recruitment, creates anxiety and unease. Creating a secure society and

being able to respond to both internal and external crisis disasters is one of the

central elements of the functioning of any nation or alliance of nations. National and

international security initiatives to increase national resilience are strongly

encouraged. Two of the five objectives in the EU’s internal Security Strategy 44, for

example, are directly related to the issue of national resilience as the capacity for

successful adaptation in the face of disturbance, stress or adversity 24.

The definition and composition of the nation is changing; therefore, national

resilience remains an everlasting dynamic process influenced by the interaction

between a society and its sub-communities. In multinational societies different

concerns interact with one another, with the potential to raise anxiety about ethnic

and cultural differences 42. In the context of national resilience in multinational

societies, those concerns are relevant and worth listing here for further

conceptualization:

Cultural: the sense of loss of control of the markers of one’s identity

Social: the costs to the relative social “constancy” and familiarity in

neighbourhoods

Economic: the high perceived costs of integration and redistribution of public

goods

Political: the public’s loss of confidence in the ruling classes and supranational

bodies

Security: the fear that society’s newest members might contribute to social

unrest.

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Over the last few decades, social scientists have been exploring the concept of

resilience in humans and human societies with keen interest. Until now, research on

different levels of resilience (and the relationships among them) has not been

proportional, and lacks interdisciplinarity in most cases. Clinically oriented

psychologists consider the individual the most exciting, while cultural psychologists

are attracted by the community level. Political interests and security concerns will

ideally push future research in security psychology towards further exploration of

the least elaborated and most complicated level of resilience - national resilience. To

begin with, a comprehensive conceptual framework of all three levels of resilience

has to be developed and empirically validated across different nations and

communities worldwide, including variables of ethnic identity and religiosity as well

as economic and political background.

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Chapter 7

The Integrative Model Of Resiliency: The "BASIC Ph" Model, Or What Do We Know About

Survival?

Mooli LAHADa, c,12 and Dmitry LEYKINa,b,c aCommunity Stress Prevention Center, Kiryat Shemona, Israel

bPREPARED center for Emergency Response Research , Ben Gurion University of the Negev CTel Hai College, Israel

Abstract. In recent years the question of coping and resiliency has become a

crucial element in crisis intervention. This chapter will review the model

developed some 30 years ago known as the BASIC Ph model, and its roots in

the foundational theories of psychology and in research worldwide on

coping and resiliency. Some of the concepts related to coping and resiliency

will be reviewed, together with findings from our studies and suggestions for

an integrated model to approach major incidents will be presented.

Keywords: BASIC Ph, Coping, Resiliency

How common are studies on strength

In recent years the question of coping and resiliency has become more than just

a theoretical or research issue, but a crucial element in crisis intervention.

An electronic scan of psychological abstracts since 1887, run in 2000[1] turned up

57,800 articles on anxiety, 70,856 on depression, and only 5,701 on life satisfaction (a

ratio of 1:8 or 9). Using the PsychINFO database, the same scan held recently yielded

12Corresponding author: Dima Leykin Department of Emergency Medicine, Faculty of Health Sciences,

Ben-Gurion University of the Negev PREPARED Center for Emergency Response Research Tel Hai Academic College, POBox 797 Kiryat Shmona 11016 E-mail: dimleyk@gmail.com

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18,130 abstracts for life satisfaction, 139,014 for anxiety and 171,214 for depression,

reflecting a similar publication ratio and tripling over the last 11 years. For resiliency

the ratio is even higher: with 8,415 abstracts, it comes to 1:20.

This chapter will review the model developed some 30 years ago known as the BASIC

Ph model, and its roots in the foundational theories of psychology and in research

worldwide on coping and resiliency. Some of the concepts related to coping and

resiliency will be reviewed, including our suggestion to understand the relations

between resiliency and PTSD symptoms. The chapter will conclude with some

reference to the application and adaptability of the model cross-culturally, thus

further supporting its generic application.

Historical overview of stress and coping - "The Survival Game"

Historically, there have been several theoretical attempts to describe the

human struggle to survive in the unfamiliar, harsh and demanding environment into

which the newborn human baby enters. Some of these attempts have tried to

present an exclusive explanation, whilst others have tried to highlight one aspect in

relation to previous theories. One can deduce six fundamental elements in

explaining human survival from these attempts. Freud [2] stressed the affective

world, both inner (i.e., unconscious) and overt (projection and transference), and it is

Freud who stated that early emotional experiences, conflicts and fixations determine

the way a person meets the world. Often this unconscious aspect/ dimension

overrides the transactions of the real world.

His colleagues, Erikson [3] and Adler [4], albeit from a different angle, highlighted the

role of society and the social setting in the way a person meets the world: Adler in

his theory of inferiority and the drive for power, and Erikson in his eight stages of

development.

Jung, who was originally a student of Freud's, emphasized the symbolic and

archetypal element, imagination, "the cultural heritage" and the fantastic inner and

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outer world. Jung also mentioned intuition as one of his types. "Without playing with

fantasy, no creative work has ever yet come to birth. The debt we owe to the play of

imagination is incalculable" [5, p.99]. These early theories accepted the notion of the

psyche and the unknown, the unconscious and its role in human life.

Other psychological theories have dismissed the whole idea of the psyche and

emotion and have attempted to describe human behaviour in terms of stimulus and

response. This has been called behaviourism, but we suggest that these theorists

should be called physiologists, as their theory suggests neuro-chemical chains of

reactions, resulting in behaviour [6]. Before long, the cognitive school of theorists [7,

8] suggested their own theory about the way a person meets the world and they

phrased it as "[i]t’s all in the mind", or cognitive processes with errors of thinking or

perception.

Last but not least, we have the belief and meaning stream, represented by Maslow

and later developed into a psychological theory and a psychotherapeutic approach

by Victor Frankl [9]. Based on his extreme experiences during the Holocaust, he

founded the Logotherapy Movement.

We believe that these exclusive attempts to describe human psychic life have many

disadvantages and that the human psyche is more complex than the theoretical

attempts to describe it in one or two dimensions. We have therefore concluded that

there are six major aspects that together may describe human attempts to survive

and thrive. We called them BASIC Ph: Belief and values, Affect (emotional), Social,

Imagination, Cognitive, and Physiological. We concluded that these represent an

integrative multifaceted approach that suggests that each person has a personal

combination of these elements which forms his/her unique coping style [10, 11].

Our basic assumption is that people react in more than one of these modes, and that

everyone is potentially capable of coping in all six modes, (otherwise referred to in

this article as different psycholinguistic modes or languages). As Dunstan Priscilla

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[12] suggests, all babies make the same five sounds when they are born, and then

they each develop their mother tongue. Equivalently, everyone is able to "talk" in all

six channels but over time and based on life experience and innate tendencies, each

person develops his/her own special configuration that becomes his/her preferred

mode or modes of coping and will use these "languages" extensively. From hundreds

of observations and interviews with people under stress [10, 11, 13-17], we have

confirmed that it is possible to identify each person's unique combination based on a

BASIC Ph psycholinguistic analysis that will be described below.

As research and practice have developed, there has been considerable debate over

the definition and operationalization of resiliency [18]. Is resiliency best categorized

as a process, an individual trait, a dynamic developmental process, an outcome, or

all of the above? Where does one draw the line at successful and resilient adaptation

versus non-resilient responses?

Resilient personalities are characterized by traits that reflect a strong, well-

differentiated and integrated sense of self (self-structure), and traits that promote

strong, reciprocal interpersonal relationships with others [19-22].

Zautra, Hall & Murray [23] suggest that "whereas resilience ‘recovery’ focuses on

aspects of healing of wounds, ‘sustainability’ calls attention to outcomes relevant to

preserving valuable engagements in life’s tasks at work, in play and in social

relations" (p. 44).

As early as 1992, we were referring to resiliency as the ability of the individual to

withstand and recover from adversities and crises by oneself or with the help of

others. Our references were: 1) observation and direct questioning of people who

lived under constant threat: "What is helping you to make it day by day?", and 2) a

psycholinguistic approach which proposes that the way someone describes his own

experience represents their inner sense-making structure by which they

perceive/absorb and transmit communication within and without.

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Table 1: BASIC Ph Model: Main themes

B A S I C PH

Belief Affect Social Imagination Cognition Physical

Self, Ideology

Emotions Role, Others, Organiz-ation

Intuition, Humor

Reality, Knowledge

Action, Practical

Frankl

Maslow

Freud

Adler

Erikson Jung

De Bono

Lazarus

Ellis

Pavlov

Watson

Rogers

Attitudes

Beliefs

Life-span

value

clarification

Meaning

Listening

Skills

Emotions

Ventilation

Acceptance

Expression

Social Role

Structure

Skills

Assertive-ness

Group

Role-play

Creativity

Play

Psychodrama

"As-If"

Symbols

Guided Imagery/

Fantasy

Information

Order of preference

Problem-solving

Self-navigation

Self-talk

Activities

Games

Exercise

Relaxation

Eating

Work

Resilience studies - A qualitative attempt to substantiate the BASIC Ph model

In order to assess the validity of our model, we sought studies that focused

on the subjects of coping, resiliency and other related topics, such as efficacy,

hardiness, and wellness, and we tried to classify their outcomes according to our

concept. The guiding definition that led our search was that resiliency is a self-

stabilising and overall healthy pattern of development which leads neither to

disordered behaviour (drugs, delinquency, etc.) nor to a manifestation of mental or

psychosomatic syndromes [24]. It is noteworthy that the literature on trauma and

recovery suggest temporary oscillations of individual behaviour on the health-

disorder spectrum under the impact of an acute stressor, yet in the medium and

long-term, a remission of symptoms should occur. The individual degree of resiliency

is understood as being relative insofar as quantitative and qualitative variations

cannot be ruled out.

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The empirical literature review, which dates from the 1980s and the 1990s, has shed

much light on the factors and mechanisms important to the development of a

resilient person-environment relationship. Along with a more recent review, we

examined over 30 studies, identified resiliency- promoting factors and categorised

them according to the BASIC Ph model (see Table 2).

Table 2: Resiliency- promoting factors/definitions categorised within the BASIC Ph model

Factor/s BASIC Ph

The way of coping and managing a single stressor or multiple risk

factors, the decisive question of whether a person merely reacts

or also acts; action-focused coping skills; goal-directed,

industrious and productive [21, 25, 26]

B, PH

A low tendency towards problem avoidance or fatalism [24, 27] C, B

Sense of self; cognitions of self-efficacy and self-esteem; internal

locus of control; high self-directed personality; self-

understanding [21, 28-30].

B, C

Availability of an emotionally stable and trustworthy person

during early childhood; secure attachment style [31-32].

A, S

Higher emotional well-being; positive emotionality; emotional

stability; ability to convey warmth and other feelings openly and

to trust other people with their most intimate feelings; empathic,

able to perceive and experience the feelings of others [33-37].

A, S

Temperamental characteristics of a child which favour de-

escalation and self-control in general as well as in acute crises

but which also promote an overall uncomplicated child-parent

relationship, even if both parents are in chronic discord; easy

temperament [38, 39].

S, A, PH

Curiosity, motivation and joy in exploratory behaviour already as

an infant, as well as motivation to observe and listen; creativity

I, A

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Factor/s BASIC Ph

[40].

The ability of the child to postpone gratification; gratitude, self-

control, forgiveness, creativity and faith; self-regulation [41-44].

B, C, A, I

Optimism; positive future orientation; positive cognitions about

the self, the world, and the future [33. 45-47].

B

Higher IQ; fewer cognitive complaints [33, 48]. C

An open educational climate directed towards the acquisition of

autonomy [49].

B, I, C

Socially competent behaviour despite chronic stress; helpfulness;

popularity with peers and taking on responsibility for siblings and

sometimes also for ill parents; social competence; family

cohesion and social resources; social engagement; perceived

social support [33, 50, 51].

S

Physical activity/attractiveness [52. 53]. Ph

Confident optimism, productive activity, insight and warmth,

skilled expressiveness [54]

B, Ph, A, C, I

Responsible, conscientious, and generally exhibiting a high

degree of personal integrity; low neuroticism, high extroversion

and openness to experience; agreeableness [55. 56]

B, C, S, I

Adaptive defense mechanisms such as affiliation, altruism,

anticipation, humor, self-assertion, self-observation and

sublimation [30].

S, B, I, A

Thus, we saw that BASIC Ph can serve as a meta-model for understanding coping and

resilience. Moreover, we conducted the same process on Skinner and colleagues’

(2003) exhaustive meta-analysis of 100 assessment scales/instruments of coping,

from which we compiled a list of 400 ways of coping, thus confirming that he BASIC

Ph model can characterize almost any way of coping.

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To summarize this part, we suggest the following conceptual framework:

Basic assumptions of the model:

• Humans are challenged to cope with life from birth.

• These efforts develop their coping skills.

• These coping skills are the core element of what is known as resiliency.

• Resiliency, therefore, is a process and not an outcome.

• A process that can be identified and measured both before, during, and after

a crisis.

• Therefore, it is the ability to recover following adversities, despite periodical

setbacks, by oneself, with the help of others or by other means, and not the

absence of pathology.

Coping, resiliency, and PTSD

As early as 1995, Kessler and colleagues [57] demonstrated that over a period

of six years there was no effect of psychotrauma treatment versus no treatment for

patients diagnosed with PTSD. Moreover, after six years they all had reduced

symptomatology to a below clinical threshold (see Figure 1).

Figure 1. Survival curves for respondents who did and did not receive treatment for PTSD [57]

These findings did not have much impact on the field up until 2001, following the

massive data collected after the attack on the World Trade Center on September

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11th. Galea et al. [58] found that the prevalence of probable PTSD related to the

September 11 attacks in Manhattan declined from 7.5% (95% confidence interval:

5.7, 9.3) one month after September 11 to 0.6% (95% confidence interval: 0.3, 0.9)

six months after September 11. What happened to the many others who were

exposed? The answer is: they recovered. However, scientists argue that it is not that

simple. Norris, Tracy & Galea [59] suggested that resiliency can be understood and

assessed as one member of a set of possible trajectories that may follow exposure to

trauma or severe stress. These trajectories suggest the following: 1) those who were

classified as chronically dysfunctional were not coping, and, 2) those who were

moderately dysfunctional or relapsing remitting were failing to cope or show

resiliency. In addition, those they classified as resistant were different than those

they labeled as resilient - as if they "just coped" (for further discussion, see chapter 3

this book).

We suggest that all are mobilizing their coping skills or their immune system. Some

may use these mechanisms and stay healthy (resistant), some mobilize it until they

manage it (recover), some mobilize it quickly (resilient) and some manage to mobilize

it to a manageable/tolerable measure (moderately dysfunctional/relapsing

remitting).

We base our interpretation on the model of physiological recovery in which resiliency

is the psychological "equivalent" to the body’s defense against the intrusion of an

alien virus. Upon detection of the "attack"/"intrusion" the body mobilizes its T cells

to protect it. The immediate sign is a rise in temperature which in itself is not a sign

of pathology; rather, it is a sign of active mobilization. In most cases the body will

recover on its own accord, sometimes with the outside aid of mild medicine. In a few

cases the body will fail to manage the "intrusion" and will develop a malady that will

cause a lot of suffering and will require massive outside intervention.

Before we present our findings, we wish to argue that all the studies on PTSD use

"self-report" scales, actually implying that there is no "objective" measure of the

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symptoms and their severity; there is only the individual's self-report (assessed on a

Likert scale, but these are still personal perceptions), unlike objective measures of

health, such as temperature, blood/urine samples, X-rays, CTs, etc. If this is the case,

we advocate that resiliency can also be measured based on a single question: "What

helps or helped you during the crisis, or after it?" This self-report measure is then

coded and classified according to the BASIC Ph coping modalities. It is outside the

framework of this chapter, but we would suggest a combination of self-report and

external observations, at least for children, using the method employed by

Scheeringa et al. [60].

The two studies we conducted on the connection between mobilization of the BASIC

Ph coping resources in the face of adversity indicate this direction. The first study was

done by Shacham [61]. He used random sampling to measure the level of stress

among 797 children and adolescent (aged 9-15) evacuees from the town of Kiryat

Shmona as a result of 12 days of shelling, against the level of mobilization of the

BASIC Ph.He devised a 17-item anxiety response scale and a 37-item coping modes

mobilization scale (all receiving adequate psychometric values).

Figure 2. Coping modes mobilization and stress

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Figure 2 indicates that as the stress level increased, more resources were mobilized,

and that there were resources that were activated immediately and were rather

'stable' such as Cognition, whereas others increased with the level of experienced

distress (like the Belief modality). Shacham [61] suggested that the reliance on the

help of God was "the last resource" when all other channels were exhausted.

The second study was conducted by Farchi [62] following the Second Lebanon war in

2006. Using a convenience sample, he studied male and female students (N = 146)

who were actively involved in the war. They measured their PTSD symptoms using

Foa's et al. [63] Posttraumatic Diagnostic Scale (PDS) and the use of coping resources

as classified through the BASIC Ph model. Figure 3 suggests that as a person's PTSD

symptom level increased, he or she mobilized more resources. Figure 4 describes the

associations between the BASIC Ph scores and the PTSD clusters.

Figure 3. Means of PTSD symptoms by total BASIC Ph scores (N = 146). Note: PDS = Posttraumatic Diagnostic Scale

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Figure 4. Association between PTSD symptom clusters and BASIC Ph scores (N = 146)

The correlation between the BASIC Ph and PTSD symptoms remained consistently

positive with almost no changes between the clusters. The results of the Pearson

correlations are presented in Table 3.

Table 3: Association between BASIC Ph clusters and PTSD symptom clusters (N = 164)

Intrusion Avoidance Arousal dPDS a

1. Belief .11 .18* .12 .14

2. Affect .29** .24** .29** .27**

3. Social .22** .16** .16* .13

4. Imagination .32*** .31*** .35*** .35***

5. Cognition .08 .08 .09 .11

6. Physical .12 .15 .16* .18*

7. Basic Ph Sum .23** .23** .24** .25**

Note: *p < .05 ** p< .005 ***p < .001; aPDS – Posttraumatic Diagnostic Scale, represents PTSD symptom average.

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To explore an alternative explanation to the PTSD symptom-coping resources

utilization, he later ran a multiple regression with the PTSD significant variables as

possible predictors of the BASIC Ph scores, shown in Table 4.

Table 4: Summary of multiple regression with PTSD subscales predicting BASIC Ph clusters (N = 164)

Dependent Predictor R2 Adj R2 p value

BASIC PH Sum Intrusion .044 .038 < .01

Belief Avoidance .033 .027 < .02

Affect Arousal .085 .080 < .001

Social Intrusion .046 .040 < .005

Imagination Arousal .121 .116 < .001

Cognitive N.S.

Physical Arousal .026 .02 < .05

Note: Only significant predictors are shown

The linear multiple regressions indicated that arousal was the main predictor for the

use of the Affect, Imagination and Physical clusters. Avoidance was demonstrated as

the predictor of the Belief cluster and intrusion was the predictor of all of the BASIC

Ph clusters as well as the Social cluster.

The above results clearly indicate that the perception of resiliency must be reviewed.

Until now, resiliency has been described mainly as an effective tool for coping with

threats and a preventative tool for PTSD. These study findings point out that

resiliency may also evolve from distress, as demonstrated in this case by PTSD

symptoms, while it is clear that the association between them is correlational.

Although the results are correlational, one can hypothesize that coping resources

can also be perceived as resulting and emerging from and during the threat. The

coping efficiency in this case also depends on one's ability to use the emerging

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resources or to recruit these resources when needed. These results correspond with

the latest Post Traumatic Growth (PTG) findings, indicating positive correlations

between PTG and PTSD [64-66]. PTG is described as the subjective experience of

positive psychological change reported by an individual as a result of the struggle

with trauma. It relates to an enhanced appreciation of life, setting of new life

priorities, a sense of increased personal strength, identification of new possibilities,

improved closeness in intimate relationships or positive spiritual change [65].

Measuring BASIC Ph

Although assessment of coping has been extensively criticized on

methodological and conceptual levels [67], assessment of coping strategies and

styles are generally claimed to be fundamental for the understanding of the positive

and negative impacts of stress on individual behaviour [68]. Investigation into the

role of coping as either a mediator between stressful life events or their

consequences, or as a moderator between stressors or exposure to stress and the

subsequent or the immediate adverse consequences [69], has provided researchers

with important knowledge. This refers to how coping can intervene between stress

and mental and physical health outcomes, as well as how "modifying coping

resources, coping processes, and the current environment may seem to have

significant potential for managing stress and avoiding stress-related compromises in

mental health" [69, p. 390].

Quantitative Evaluation of BASIC Ph

The first attempt to translate the BASIC Ph model into a self-report inventory

was carried out by Craig [70]. Craig's trans-situational (i.e., an incorporation of both

dispositional and situational aspects of coping), 36-item instrument consisted of six

items representing six hypothesized factors on the new Multi-Modal Coping

Inventory (MMCI). Participants used a seven-point Likert scale ranging from 0 (I

never use this method or one like it to cope) to 6 (I always use this method or one like

it to cope) to indicate how they cope when feeling stressed. Craig revised this

instrument and later established an 18-item scale excluding the affective dimension,

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which demonstrated goodness of fit via additional confirmatory factor analysis,

suggesting internal convergent and divergent construct validity. Table 5 presents the

internal consistency coefficients extracted from the main BASIC Ph studies using self-

report scales. Craig's study [70] was the only one to examine test-retest reliability of

the MMCI, which was found adequate over 4-6 weeks.

Table 5: Internal consistency coefficients of the Multi-Modal Coping Inventory (MMCI) known self-report measures

BASIC Ph

Study Sample N Internal consistency ()

Craig [70]1 US adults; 18-93 534 .77 NA .83 .57 .87 .76

Lahad & Leykin [71]2

Undergraduates 19-53

170 .46 .34 .84 .70 .74 .70

Leykin [72]3 Online sample; 13-65 128 .76 .80 .88 .75 .74 .81

CSPC [73] 3 Jewish population; 15-64 949 .71 .79 .80 .64 .77 .81

Avraham & Fisher [74] 3

Emergency medical providers; 21-61

110 .54 .66 .76 .68 .87 .72

Erez & Laviod [75] 3

Online sample, 16-76 114 .72 .87 .70 .57 .78 .70

Gelber & Dodek [76] 3

Social sciences undergraduates; 21-46

222 .67 .78 .87 .67 .78 .72

Nadim [77] 4 Adolescents; 13-18 264 .75 .77 .55 .77 .79 .80

Note: 1- MMCI (18 items with no affective dimension); 2- Hebrew MMCI (Craig's original 36 items back translated into Hebrew); 3- Brief Hebrew MMCI (abbreviated version of the 36 item scale); 4- Hebrew MMCI-Revised (Modified and revised 44 items; 8 B items, 10 A items, 5 S items, 7 I items, 6 C items and 8 Ph items).

Further evaluation of the validity of the MMCI yielded several significant associations

with measures of well-being (i.e., The Mental Health Inventory) [78], as well as with

other coping measures (i.e., Coping Orientation with Problem Experiences Inventory)

[79]). When examining its criterion-related validity, the five MMCI dimensions were

found to have adequate to strong concurrent validity as indicated by moderately

strong positive correlations with dimensions of the COPE Inventory that had similar

item consistency [70].

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Research findings and psychological correlates of BASIC Ph using the Hebrew

MMCI-Revised

The predictive role of coping modes in individual trait resiliency, measured by

the Brief Resiliency Scale [80], was investigated in a multiple regression analysis

using the data of the cross-sectional sample [73]. Only four out of the six BASIC Ph

modes were associated with resiliency: affect and imagination negatively predicted

resiliency, and physiology and cognition positively predicted resiliency (see Table 6).

In order to study the association between the model and personality traits, the

BASIC Ph coping modes were correlated with the Big Five Factors of Personality [81]

using NEO-Five Factor Inventory. The most prominent finding was that Cognition

positively correlated with all the personality factors as reported in Table 6.

A series of recent research studies have investigated the association between BASIC

Ph and mental well-being among various civil and first-responder populations.

Avraham and Fisher [74] investigated coping resources and professional quality of

life among emergency medical providers; Erez and Laviod [75] examined

psychological correlates of BASIC Ph and tested associations between coping modes

and self-efficacy, optimism and locus of control, and psychological constructs related

to resiliency [82] among college students; Gelber and Dodek [76] examined

associations between coping modes, trait anxiety, self-efficacy and social support

among college students. Results of these studies are summarized in Table 6.

Nadim [77] examined associations between the BASIC Ph modes and sense of

coherence (SOC)[83]), stress symptoms and perceived community resiliency among

Arab adolescents aged 13-18, living in political uncertainty. She used an adapted

Arabic version of the Short MMCI-Revised along with additional items added for each

coping mode. An important addition was the inclusion of several items reflecting

positive emotional coping (e.g., laughing at the situation, self-encouragement), as all

past instruments were focused on emotional expression. She found that the only

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predictor of current stress symptoms was expression of emotions (i.e., affect) and

the only significant predictor of SOC was utilization of cognitive coping.

More recently, Ogni, Ben-Dov, & Cohen [84] have explored ways of coping with

sexual harassment and its relations to psychopathology among Israeli adult women.

Controlling for peri-traumatic distress and history of sexual harassments, utilizing

belief and imagination resources during the most prominent sexual harassment

incident predicted present posttraumatic symptoms. Utilization of positive

emotional coping (also assessed in this study) interacted with peri-traumatic distress

to predict current PTSD; thus, high levels of positive affect during the event

predicted fewer posttraumatic symptoms when peri-traumatic distress was high.

Participants exceeding the threshold on the Impact of Event Scale (IES-R) [85] for

probable PTSD were significantly more likely to utilize all coping modes, except

positive affect coping.

From the studies summarized in Table 6 and mentioned above, it is clear that

utilization of the Cognitive coping mode is consistently positively associated with

positive outcomes or constructs, such as psychological well-being, self-esteem,

positive affect, satisfaction, self-control and empowerment. Use of the cognitive

mode has been negatively associated with depression, anxiety and posttraumatic

symptoms. While we recognize the potential to utilize various modes of coping and

the individual preference for certain coping configurations, mobilization of the

cognitive coping mode should be supported - either by the media (e.g.

encouragement to gather information, set priorities, understand the situation) or by

psychosocial intervention teams. This will increase the probability of better

adaptation and recovery following stressful events.

Alternative means for assessing BASIC Ph

Although two methods for assessing BASIC Ph have been mentioned and

practiced over the last 20 years, some other un-standardized methods have also

been utilized in the research on BASIC Ph. For instance, coping modes were

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extracted from an open-ended single question, such as: "What helped you to cope

with the feelings and thoughts as a result of the disaster?" [86]. Interpretation of the

active coping channels is usually made by two or more judges with prior knowledge

of the BASIC Ph model, and based on the explicit answer. On one such occasion,

BASIC Ph was assessed among female high school students following the Island of

Peace massacre in 1997 [87]. In this study, the dominant coping channel among the

students was the Social channel (utilized by 68% of the students). Students reported

that being with friends, family members, relatives, school staff, educational staff and

the presence of other people around them was a significant help. Other channels

were mentioned as well, though much less frequently [86].

In another study, instead of asking about coping mechanisms, parents of Israeli and

Arab children who were exposed to shelling during the Second Lebanon War were

requested to report what helped their children cope with stress during the war.

Again, three expert psychologists reached a consensus and classified the answers

into a single dominant mode or a pattern that combined several coping modes. In

that particular case, the inter-judgmental agreement was 90%. Parents reported that

the most dominant ways of coping were associated with Cognitive resources (52%),

followed by Social resources (37%) and Physiological resources (32%), with no

significant nationality and gender effects.

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Table 6: Summary of psychological and demographic correlates of BASIC Ph coping modes

Demographic Correlates Psychological Correlates Coping Mode

Female Gender2; Younger Age2;; Lower Income2,3; Greater Religious Affiliation2; Single Status9

Optimism(+)1; Agreeableness (+), Conscientiousness (+) , Openness to Experience (+)2; External Locus of Control (+); Positive Belief in Just World (+), Belief in Unjust World (-) (2); Presence of Meaning in Life (+)2; Idealism (+)2; Secondary Traumatic Stress Symptoms (+)8 ; Posttraumatic and Peri-traumatic Symptoms (+)9

Belief

Female Gender2,1,3,4, Younger Age2,3; Older Age1; Lower Income2; Higher income (when measured by positive emotional coping)9 ;Single Status2,9; Divorce of Parents2;

Trait Resiliency (-)2; Emotional Stability (-); Self-Efficacy (-)3; Expressive Aggression (+)2; Stress Symptoms (+)4; Secondary Traumatic Stress Symptoms (+)8;

Posttraumatic and Peri-traumatic Symptoms (+)9

Affect

Female Gender2,1,3; Younger Age2,3; Lower Income2; Single Status2,9, Divorce of Parents2

Feelings of Belonging (+)5; Perceived Social Support (+), Self-Efficacy (+)3; Avoidant Attachment Style (-)6; Stress (+);Peri-traumatic Symptoms9(+)

Social

Female Gender2,3,4; Single Status2,9

Posttraumatic and Peri-traumatic Symptoms (+)9; Secondary Traumatic Stress Symptoms (+)8; Fantasy Proneness (+)7,3; Avoidant Attachment Style (-)6; Trait Resiliency (-)2; Optimism (-)1; Gratitude (-)2

Imagination

Male Gender2,1,4; Older Age2; Higher Income2; Higher Education2; Married Status2

Well-Being (+); Psychological Distraction (-); Feelings of Belonging (+)5; Depression (-)5,7; Anxiety (-)5; Posttraumatic Symptoms (+)9; Secondary Traumatic Stress Symptoms and Burnout (-)8;Positive Affect (-)5;

Cognition

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Demographic Correlates Psychological Correlates Coping Mode

Compassion Satisfaction (+)8; Psychological Empowerment7; Self-Esteem (+)6; Trait Resiliency2,1; Self-Efficacy (+) Extroversion (+), Agreeableness (+), Conscientiousness (+), Openness to Experience (+), Emotional Stability (+)2; Perceived Social Support (+)3; Search for Meaning in Life (+)2; Self Control (+)

Female Gender2,1,3; Older Age2; Higher Income2; Single Status9

Avoidant Attachment Style (+)6; Trait Resiliency (+)2; Perceived Social Support (-)3; Inspiration (+)2; Secondary Traumatic Stress Symptoms (+)8; Posttraumatic and Peri-traumatic Symptoms (+)9

Physiology

Note: (+) positively correlated, (-) negatively correlated; 1[75]; 2[73]; 3[76]; 4Nadim [73]; 5[70] 6 [86]; 7; 8[84]; 9[84].

International Application

Thus far we have described our model background and its measures. Over

the last 30 years, this model was applied in many parts of the world both as a basis

for post-disaster intervention and recovery planning as well as for training

psychosocial professionals in prevention, intervention and rehabilitation methods

and skills to be implemented in their respective countries.

This section will provide some insight into the level of application of the model in

Europe and Sri Lanka in a 5-year follow-up on the training given following the 2004

tsunami. In many cases we find ourselves teaching people things they actually know

intuitively, only using different terminology. As such, it is of utmost importance to

establish a dialogue with the target population in the foreign country where we plan

to intervene. To do so, we have to understand the culture and its norms [89]. Cross

et al. [90] introduced the term cultural competency as:

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"A set of congruent behaviors, attitudes, and policies that come together in a

system, agency, or among professionals that enable teams to work effectively in

cross-cultural situations. Cultural competency is the acceptance and respect for

difference, a continuous self-assessment regarding culture, an attention to the

dynamics of difference, the ongoing development of cultural knowledge, and the

resources and flexibility within service models to meet the needs of minority

populations" (cited in [90], p. 3).

The European study

In 2000, The International School Psychology Association (ISPA) launched an

International Crisis Response Network and started to train school psychologists

across Europe to be able to conduct prevention work before crisis, during crisis

interventions and in recovery work with schools.

Shacham and Niv [91] conducted a follow-up study on the application of this training

for 22 educational European psychologists. Participants had a mean age of 44.46 (SD

= 10.53, range 32-65), 82% were females, 50% were married and 58% had previous

training in crisis intervention.

When asked to evaluate the contribution of the various topics they were trained on

to their professional life, they mentioned the BASIC Ph model and its application as

two of the most helpful contributions.

Sri Lanka 2004-2006

The Tri-national Trauma Response, launched to assist Sri Lanka in response to

the 2004 Asian Tsunami disaster, was aimed at creating and training a local cadre of

trainers who would strengthen the knowledge and skills of community-based

providers and institutions to address psychosocial needs, to enhance resiliency, and

to increase system capacity to support, treat and train others. Over the course of the

first year (Sept. 2005 - June 2006) the project organized basic orientation courses,

teaching hundreds of professionals from a variety of disciplines the fundamental

concepts, methods and applied skills of trauma recovery and resiliency. Additionally,

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more than sixty master trainers (MTs) were further trained and were qualified

through advanced four-week training in order to transmit the necessary and relevant

knowledge to the local professionals.

In a follow-up study conducted 5 years later, participants were also asked to rate

which method they found to be the most effective when training adults (see Figure

5). Among the top rated methods or models were warm up exercises, storytelling

techniques, BASIC Ph, drama therapy and art therapy. As noted, BASIC Ph was

indicated as very effective for adults, and between the other top rated methods, is

the only one with a theoretical basis.

Figure 5. Trainers' perceived efficacy of methods and models for training adults

To summarize this section we would like to affirm that coming from different

countries and cultures, having unfamiliar languages, distinctive socio-economic

backgrounds, diverse values and views, and aiming to bequeath theoretical

knowledge, skills and methods to locals, requires the trainer to adapt the ideas to a

language that is familiar and understandable for locals. The above two examples

suggest that BASIC Ph as a conceptual framework and model is culturally acceptable,

culturally adaptable, and can provide a map, not a solution, to understanding and

enhancing coping and resiliency.

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Conclusions

Over 30 years of development, research and application of the BASIC Ph

model indicate that this original integrative model has the potential to accommodate

the diversity in the field of resiliency. BASIC Ph may serve as an all-encompassing

model that views the various components of different models and research as parts

of a whole, thus making use of the specific contributions of each approach as well as

the overlaps between them. It emphasizes the view that resiliency is not the

opposite of pathology just as health is not the opposite of malady. Moreover, this

model suggests possibilities for cross-cultural work, as it respects all modes of coping

that go beyond culture, race or norms.

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Chapter 8

Couples in the Line of Fire: Couples' Resilience in Preserving and Enhancing Their

Relationships

Michal SHAMAI.13, Guy ENOSH, Ronit MACHMALI-KIEVITZ, Saray TAPIRO

School of Social Work, University of Haifa, Israel

Abstract: This chapter describes a mixed-method study aimed to explore how

civilians living in the line of fire over a period of 12 years experienced and

perceived the impact of their exposure to warfare on their couple

relationship. In the quantitative part of the study the role of couple resilience,

and loss and gain of couple resources as mediators between the level of

exposure and the couple relationship was explored. Data were collected from

61 individuals living next to the border between Israel and the Gaza Strip and

112 individuals living some distance from the border. The results revealed no

differences between the groups on the couple relationship. However,

significant differences were found between the groups in their reporting of

negative, positive, and no-implications of the security threat on the couple

relationship. The high exposure group reported significantly higher negative

and positive implications of the security situation on the couple relationship,

whereas the limited exposure group scored significantly higher on their

reporting of no-implications. Couple resilience and increased couple resources

were found to be mediators between level of exposure and no-implications of

the security situation on the couple relationship. Couple resilience was also

13Corresponding Author: Michal Shamai, Ph.D, School of Social Work, University of Haifa, Mount Carmel, Haifa, 31905, Israel. E-Mail: michals@research.haifa.ac.il

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found to be a mediator between the level of exposure and negative

implications, whereas increased couple resources was found to be a mediator

between the level of exposure and positive implications. The qualitative part

aimed at exploring the way couples construct their experience of the

exposure to warfare, using grounded theory methodology. Data were

collected through in-depth semi-structured interviews with 14 couples. Five

main themes were gathered and organized into a model constituting a

continuum between no impact and an adverse impact of the security situation

on the couple relationship. The significance of these results to understanding

couples living under ongoing external stress was discussed.

Key words: resilience, couple resilience, war, marital quality

Introduction

The constant threat of exposure to war is typical of Israeli reality, in which the

non-combatant population lives within range of rockets and missile attacks. The

impact of war on individuals has been studied intensively and much of this research

indicates that war and terror undermines people’s basic sense of security and gives

rise to posttraumatic symptoms [1, 2, 3]. Compared to the amount of studies that

focus on individuals, the knowledge existing regarding the impact of war and terror on

the family system [4, 5, 6, 7] and specifically on the couple relationship is very limited.

In the few studies that indirectly addressed the couple system in warfare situations,

the focus remains on the parental role while ignoring the place of the parents as a

subsystem within the family system and the parental role as an integral part of the

couple relationship [8, 9]. The reasons for this lacuna in knowledge cannot be fully

understood, because findings of at least one study show a negative association

between the impact of stress created by war and marital relationships [10].

Thus, the goal of the present study was to examine whether and how the joint

exposure of Couples to situations of ongoing warfare is related to the couple

relationship, such as marriage quality, and whether couple resilience, and/or

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couple's psychological resources contribute to the quality of the relationship. For this

purpose, we compared two groups living in different areas with different levels of

exposure to warfare: high and long-term exposure (couples who, at the time of data

collection, had been exposed to warfare for more than a decade) and time-limited

exposure (exposed to direct warfare for one month, from December 2008 until

January 2009, during the Gaza War, also known as the Israeli military operation “Cast

Lead”).

The couple relationship in times of war

Knowledge regarding the impact of war on the couple relationship is limited.

Therefore, it was interesting to discover that the earliest conceptual foundations for

research on family reactions to stress were formed during the Second World War.

Most of the knowledge regarding family reactions to stress was acquired from

studies on the adjustment of families to the crisis of war, specifically on the impact

of separation and later, of the reunion with the father/spouse who had been

recruited to the army [4,5]. Based on this study, Hill developed the ABC-X model,

where A represents the stressful event, B represents the family resources, C

represents the way the family perceived the stressor, and X represents the intensity

of the family crisis, depending on A, B, and C. However, both Hill’s ABC-X model [4,5],

and McCubbin and Patterson's [6] Double ABC-X model, which was developed based

on Hill’s model after the Vietnam War, focused primarily on family resources rather

than on the couple relationship. Furthermore, Hill [4,5], and McCubin and Patterson

[6], studied families in the United States who were living far from the war zone itself,

which was either in Europe or in Asia, and where only one of the partners was

exposed to the warfare. This focus was appropriate to the situation in the United

States, which was involved mainly in wars far from home with no exposure of the

non-combatant population. Most of the studies revealed complex stress situations

relating to the reunion of the family after one spouse returned from the war and to

life thereafter [11,12, 13,14,15,16, 17,18,19]. Figley [12, 13, 14, 15] described the

impact of the difficulties on the veteran’s spouse, and referred to a specific

phenomenon that he defined as “compassion fatigue” or “secondary

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traumatization.” It was found that dysfunctional coping among the families of

veterans was characterized by denial and silence as an effort to protect themselves

from unpleasant memoriesand thoughts, including bitterness and the constant need

to blame someone, most often the government, for destroying their life. In contrast,

functional coping is characterized by understanding the veteran’s stress reaction,

open communication that enables discussion of painful issues, flexibility that allows

time for adjustment, and acceptance of changes [20]. Although Figley’s studies

referred implicitly to the entire family system, his descriptions and recommendations

were largely directed toward the spousal system.

Nevertheless, in most of the world’s war zones, such as Israel, the homes of the

non-combatant population are in close proximity to the line of fire. However, like in

the United States, most studies that have examined the impact of war on the

couple relationship have centered primarily on stress and how couples cope with

the psychological or physical injury of one partner, usually the male veteran [21, 22,

23, 24]. Only a small number of studies in Israel during the 1990s explored the

impact of an uncertain security situation on the couple relationship, where both

spouses were exposed to danger together. These studies identified the spousal

relationship as a central resource for the individual's ability to cope with the

ensuing stress [25, 26]. An additional mixed-method study that explored the impact

of living in a war zone was done by Shamai, Kimhi and Enosh [27], where they

attempted to assess the level of stress and life satisfaction of the Israeli population

living close to the Lebanese border following the withdrawal from Lebanon in May

2000. Among the results of the quantitative part of the study, it was found that

marital quality mediated between the level of security threat and the level of stress

(anxiety, depression and physical symptoms), level of concern and life satisfaction.

In the qualitative part of the study, we found couples that experienced both

positive and negative effects of the security situation. It was interesting to receive

the participants' reactions to the focus that was given to marital issues in a study

related to security uncertainty. Some participants just raised questions regarding

this focus in the study, others expressed their anger, while almost 30% out of

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almost one thousand participants refused to respond to items referring to marital

issues. What can be learned from these responses? First, in spite of the large group

of participants that did not report any impact of the level of threat on their marital

quality, significant differences in marital quality were found between people living

close to the Lebanese border and people who lived some distance away, in spite of

the similarity between the two groups' demographic characteristics. The results

indicated that living under a high security threat may impoverish marital quality;

additionally, due to the mediating role of marital quality, may result in higher levels

of stress and lower levels of life satisfaction. Based on the results, and along with

the participants' criticism, we assume that something about the couple relationship

in war situations requires further exploration - perhaps utilizing a different strategy

for data collection or a different measurement tool. In addition, it was interesting

to learn what enabled couples to maintain satisfactory marital quality and to resist

the possible negative impact of war on their relationships.

Resisting the impact of war: Couple resilience and resources

One term used to describe the ability to resist and cope with stressors is

resilience [28, 29,30,31]. There is an ongoing debate about the exact definition of

the term. Theoreticians and researchers have been attempting to expand the

definition to include larger systems, as well as referring to individuals. Some

theoreticians perceive resilience as an “outcome,” stressing that only couples or

families who were exposed to extreme adversity, such as war, and who had

succeeded in adapting and maintaining or enhancing the quality of their

relationships, could be considered resilient families [32]. Other theoreticians

perceive the family and couple resilience as a resource that mediates or moderates

between stressors, coping, or adaptation [33]. In the present study, it was not

possible to obtain information about couple resilience before the war situation;

therefore, we were unable to determine whether the couple resilience was an

outcome or a moderating/ mediating factor. Thus, we decided to use the

conceptualization of couple resilience, relying on evidence from studies in which

family resilience was perceived as a mediator (4, 5, 6, 33, 34, 35, 36, 37].

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Furthermore, due to the lack of literature on couple resilience, we needed to use

knowledge that was acquired in studies that focused on the family system. The

concept of family resilience, as described by Patterson [35, 36, 37] and Walsh [33],

is somewhat similar to the concept of “Family Sense of Coherence,” which predicts

family adaptation and coping and was developed in Israel [38, 39, 40] and

theoretically is perceived both as a mediator and a moderator [38, 39, 40].

An additional conceptualization that can be relevant to understanding the impact

of war on the couple relationship is the Conservation of Resources (COR) model [41,

42, 43, 44]. COR focuses on the possible and actual loss of instrumental and

psychological resources as a core element in the development of stress. Therefore,

loss or the threat of loss of resources might mediate between the stressor and its

impact. Although the COR model refers to the individual process of coping, a

careful examination reveals how it can be usefully extended beyond the individual

process to systems, such as families or couples. According to COR, individuals are

nested within a family context, which in turn is nested within a social community.

Thus, the family becomes an important instrumental and psychological resource

that affects the ability of human beings to cope with stressful situations.

Accordingly, when people perceive their couple relationship as allowing them to

make the necessary adjustments to the stressful situation, they will be able to cope

better with the stressor; additionally, they may attribute part of their coping ability

to the quality of their relationship. In the later development of COR, it was found

that in stressful situations, people can also gain resources that may be used in the

coping or adaptation process. Such positive stress-related outcomes were reported

in studies that explored situations of political violence and uncertainty regarding

the Israeli-Palestinian conflict [45, 46, 47, 48, 49]. However, these studies did not

explore the role of the gained resources among systems such as families or couples.

In sum, it may be assumed that resilient couples who have developed satisfactory

psychological resources will be able to maintain the quality of their relationship

during stressful situations such as ongoing war and may even gain additional

resources that enrich the quality of their relationship.

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Based on the existing knowledge, the quantitative part of the study included two

main hypotheses:

1. People living in situations of ongoing warfare (high exposure) compared to

people living in more secure areas (time-limited exposure) will report lower levels of

couple resilience and a lower quality of their couple relationship, higher levels of loss

and gain of couple's psychological resources, and higher levels of negative and

positive implications of warfare on marital quality.

2. Couple resilience and loss and gain of couples' psychological resources will

mediate between the level of exposure and the couple relationship and between

level of exposure and the perceived implication of the warfare on the couple

relationship.

The question presented in the qualitative part of the study was as follows:

How do couples living near the Gaza border perceive and experience the impact of

war and the continuous security threat on their couple relationship, and what are

their coping strategies with this situation?

Method- Quantitative Study

Sample and sampling

The sample consisted of two groups. The first group included 61 participants

living in communities located close to the border between Israel and the Gaza Strip,

who had experienced ongoing exposure to rockets and missiles coming from Gaza

into Israel for more than a decade (high exposure group). The second group included

112 participants living in communities situated some distance from the border, and

prior to the data collection, had been exposed to fire for one month, between

December 2008 and January 2009, during the Israeli military operation “Cast Lead”

(focused exposure group). The two groups came from communities with similar

socio-demographic characteristics and the participants had been living in the area for

at least one year before Cast Lead. All participants were married or had been living

with their partner for at least three years. As the data collection was difficult,

especially in the area close to the border with the Gaza Strip, we used a convenient

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sampling process, based on the snowball method. The population living in the area

close to the Gaza Strip border was overwhelmed by requests to participate in

different studies regarding the impact of the exposure on their lives, mainly about

the impact on individuals (both adults and children). Therefore, they generally

refused to participate, claiming that researchers were taking advantage of the

situation to develop their academic careers. This is the main reason for the

difference in size between the two groups. In most cases, we were unable to obtain

both partners’ agreement to participate, and only one partner filled in the

questionnaire [27]. When both members of the couple did participate, we randomly

used only one of them in the analysis due to the high correlation between the

partners [27].

Tools

The couple relationship

The quality of the couple relationship is often termed as marital quality even

if its definitions refer not only to legally married couples. Marital quality is the

health, well-being, and stability of intimate relationships between partners and is

often used in studies that examine the couple relationship [50, 51,52]. In the present

study, the couple relationship was measured using the Marital Quality Questionnaire

(MQS-I) developed by Lavee [53] for the Israeli population, based on the short

version of the ENRICH [52, 54]. The questionnaire includes 10 items that examine

marital quality in specific areas, including communication, conflict solving, sexual life,

financial management, and trust. For the current study, the internal consistency

(Cronbach's alpha) was .89.

Perceived implication of warfare on the couple relationship

This instrument was developed for the present study and is based on the

same items that measured marital quality (see above). The participants were asked

to evaluate whether the security situation had implications for the specific area of

marital quality, and if the answer was positive, they were asked to report whether

the implications were positive or negative. For each individual participant, we

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summed the number of marital quality areas in which there was no-implication, a

negative implication, and a positive implication.

Couple resilience

Couple resilience was measured using a modification of the Sense of Family

Coherence Scale [40] to the Couple Sense of Coherence Scale. The Sense of Family

Coherence is a version of the personal orientation scale of the Sense of Coherence

Scale [28], adapted for families. In the present study, we referred to the couple

system rather than to the family. The scale includes 12 semantically differential

items scored on a scale of 1-7. One sample item is: “Do you have the feeling that you

are being treated unfairly [in your couple relationship]? The range of answers is from

“very often” to “very seldom or never.” Another sample item: “Doing the thing you

do every day (in the couple relationship) is a deep source of pain and boredom” (on

one side of the scale) or “of pleasure and satisfaction” (on the other side). A high

score on the items denotes a strong sense of couple coherence. Previous studies that

measured family sense of coherence reported good reliability, with Cronbach's alpha

ranging between .77 [39] and .88 [55]. In the present study, Cronbach's alpha was

.87. Since resilience has cultural and contextual roots [56], we chose a scale that was

developed in Israel, even though it has been used in other cultures around the globe.

Loss and gain of the couple's psychological resources

Loss and gain of the couple's psychological resources was measured by the

Conservation of Resources Assessment Scale (COR-E) [42]. The original COR-E scale

includes two subscales: Economic and Psychological. In the current study, we used

only the psychological subscale, which covers personal, spousal, and social aspects.

We utilized the items from previous studies conducted in Israel following the second

Intifada (Palestinian uprising) [47, 49, 57] and modified them to the losses and gains

within the spousal system. Each separate scale (Gain and Loss) included 10 items.

The items in the psychological loss scale were prefaced with the question: "To what

extent has living in the line of ongoing fire harmed the following aspects?" In the

psychological gain scale, they were prefaced with the question: "Sometimes

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something good comes out of something bad: To what extent have you gained the

following?" The items in the loss and gain scales were similar and included issues

such as the feeling that you are a successful couple, the sense that you are valuable

to your partner, the sense that you have stability in your daily relationship with your

partner, closeness to your partner, feeling that the government can protect your

family, etc. Each item was scored on a scale from 1 (not at all) to 4 (very much).

Cronbach's alpha for the loss scale was .94 and for the gain scale was .86.

Procedure

Data were collected simultaneously from the two groups between March and

June 2011. Students delivered the questionnaires to participants’ homes or places of

work and collected them after 4 to 7 days. Each participant was asked to sign an

informed consent form which included a description of the participant's rights. The

study was approved by the research ethics committee of the University of Haifa,

Israel.

Results- Quantitative Study

First, it is important to indicate that the findings revealed no significant

differences between the groups regarding the measured demographic variables:

level of income, education, level of religiosity, length of marriage, and age of the

youngest child. Regarding the variables that were the focus of the present study, in

contrast to our hypothesis, the results revealed no significant differences between

the two groups (high exposure vs. low exposure) regarding marital quality. However,

the perceived implications of the exposure on the couple relationship revealed

significant differences between the groups in the three scales measured. As

hypothesized, the low exposure group reported more areas of the couple

relationship that were not impacted by the security situation compared to the high

exposure group, whereas the high exposure group reported higher levels of both

negative and positive implications of the security situation (See Table 1).

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Table 1: Differences between two levels of exposure: high exposure and time-limited exposure

MANOVA Time-Limited Exposure

High Exposure Variables

Partial Eta Squared

F SD M SD M

.03 4.93* 0.98 5.49 1.06 5.13 Couple Resilience

.14 27.91*** 0.76 1.71 0.89 2.39 Loss of Couple's Psychological Resources

.08 15.28*** 0.98 2.04 0.86 2.63 Gain of Couple's Psychological Resources

.02 3.40N.S. 1.06 5.67 1.04 5.36 The Couple Relationship

.12 24.44*** 1.74 0.85 3.70 3.13 Negative implications for the Couple Relationship

.04 7.09** 2.59 1.85 3.92 5.05 Positive implications for the Couple Relationship

.17 35.28*** 3.14 8.30 1.04 5.36 No-implications for the Couple Relationship

*p <.05, **p<.001, ***p<.0001

Regarding the hypothesized mediating variables, the results confirmed our

assumption, indicating significant differences in couple resilience: the low exposure

group reported higher levels of couple resilience than the high exposure group,

whereas for psychological and social loss and gain of resources, the high exposure

group reported significantly higher loss and gain of resources. Thus, the first

hypothesis was only partly confirmed.

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In accordance with the mediation hypothesis, the pattern of correlations between

level of exposure, couple resilience, loss and gain of couple's psychological

resources, the couple relationship and positive/negative/no implications on the

couple relationship was examined (See Table 2).

Table 2: Correlations matrix of the model's variables

8 P

ositive

Imp

licatio

ns

7 Ne

gative

Imp

licatio

ns

6 No

-

Imp

licatio

ns

5 Co

up

le R

elation

ship

4 Ga

in o

f P

sycho

logica

l

Reso

urce

s

3 Loss o

f P

sycho

logica

l

Reso

urce

s

2 Co

up

le R

esilience

1 Level of

Expo

sure

Variab

le

1 1

1 -.17* 2

1 -22** .38** 3

1 .56** -.06 .29** 4

1 .04 -.12 .83** -.14 5

1 -.40** -.34** -.37** .28** -.41** 6

1 -.58** .30** .08 .24** -40** 34** 7

1 -.16* -.71** -.01 .35** .23** .01 .20** 8

*p <.05, **p<.001, ***p<.0001

Due to the high correlation between couple resilience and the couple relationship

(r=.83, p<.01), creating a colinearity between the two variables, we could not use

both variables simultaneously in the mediation model. Therefore, we examined a

model that included only three outcome variables (negative, positive, and no

implications of warfare on the couple relationship). Another difficulty centered on

the three outcome variables. Due to the measurement methodology, these variables

are mutually exclusive and mutually dependent; therefore, statistically the three

variables cannot be placed within the same model. Thus, in order to evaluate the

impact of exposure to warfare on the couple relationship, we had to create two

separate models: one for negative and positive implications, and the other for no-

implications. The models were estimated using the AMOs-7 software for Structural

- 167 -

Equation Modeling. According to recent recommendations regarding mediation

models [58, 59], all the models were estimated using bootstrapping. Each analysis

used 2,000 bootstrap sub-samples. Examination of the 95% bias-corrected percentile

confidence intervals of the model parameters indicated that all parameters were

acceptable and in accordance with point significance results yielded by the full

information maximum-likelihood model. Therefore, for reasons of brevity, only the

significant paths are reported for these models.

As we can see in the first model (See Figure 1) there was a direct impact of level of

exposure on negative implications on the couple relationship. However, couple

resilience was the only variable that had a direct effect on negative implications to

the couple relationship, thus serving as a partial mediator between level of exposure

and negative implications on the couple relationship. Since level of exposure did not

have a direct impact on positive implications on the couple relationship, and since of

the three assumed mediators only gain of couple's psychological resources had a

direct effect on positive implications to the couple relationship, it is the only variable

that serves as a full mediator between level of exposure and positive implications on

the couple relationship. The model had an excellent fit to the data, with Chi-

square=.01, df=1, and p>.9; RMSEA<.001; other fit indices, including GFI, NFI, CFI,

RFI, and TLI were all excellent (equal to 1, or higher).

- 168 -

Figure1: Exposure and the Mediating Effects of Resilience and Gain on Positive and

Negative Implications

Regarding the second model, in terms of the impact of the level of exposure on

no-implications to couple resilience, there was a direct negative impact, meaning that

living under high exposure to warfare reduced the probability of not experiencing any

implications of the war on the couple relationship. Both couple resilience and gain of

couple's psychological resources had a direct effect on no implications of warfare on the

couple relationship; thus, those variables serve as partial mediators between level of

exposure and no implications of warfare. Overall, the model had an excellent fit to the

data, with Chi-square=.01, df=1, and p>.9; RMSEA<.001; other fit indices, including GFI,

NFI, CFI, RFI, and TLI were all excellent (equal to 1, or higher). The mediating hypothesis

therefore, was only partly confirmed.

Exposure

Resource Loss

Resource Gain

Negative Implications

-.17

Resilience

Positive Implications

.37

.29

.26

-.33

.30

-.25

.50

-.16

- 169 -

Figure 2: Exposure and the Mediating Effects of Resilience and Gain on Reports of No Implications

Method- Qualitative Part

The qualitative study was conducted using the grounded theory approach of

qualitative methodology.

Sample and sampling

The participants were recruited according to the principle of purposive

sampling (couples that were living near the Israeli border with the Gaza Strip) with

maximum variance (families at different stages- couples with young children, couples

with older children, couples without children; different levels of religiosity and types

of settlements- town, kibbutz, moshav). The size of the sample was determined by

the data saturation principle and included 14 couples [60]. The participants were

asked to refer any people they knew that may be helpful in studying the issue. The

participants were recruited using the snowball technique.

Instrument

According to the grounded theory methodology, an in-depth, semi-structured

interview was used [61]. The interview covered the following areas: 1) description of

the couple's daily life in the line of fire; 2) description of difficulties; 3) description of

Exposure

Resource Loss

Resource Gain

Negative Implications

-.17

Resilience

Positive Implications

.37

.29

.26

-.33

.30

-.25

.50

-.16

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coping strategies and the role and meaning of the couple relationship in the coping

process; 4) supportive processes between the partners and other support systems,

such as the extended family, friends, etc. 5) changes in the characteristics of the

relationship during the period of exposure to the security situation; 6) impact of the

couple relationship in the past on the characteristics of the relationship during the

period of exposure to the security situation.

Data Collection

Before starting the interview, the interviewer explained the goals of the study

to the participants, clarifying that their participation is based on their own free will

and guaranteed their anonymity. The interviews were tape-recorded and

transcribed.

Data Analysis

Data analysis utilized a thematic analysis technique based on Strauss and

Corbin's [62] model.

Findings-Qualitative Part

Five main themes emerged from the data analysis: 1) Overall perception about

the impact of the security situation on the couple relationship; 2) Dyad intimacy; 3)

Parental role during the period of exposure to war; 4) Role division and decision

making; and 5) Joint coping vs. separateness. The findings were organized into a

model constituting a continuum between no impact of the security situation and

adverse impact of the security situation on the couple relationship. Most couples

were not fixed in one place along the continuum, since the effect of the security

situation changed over time. One end of the continuum represents no impact of the

security situation on the quality of the couple relationship. Couples who were

generally located close to this end were characterized by the use of creative means

to cope and maintain their intimacy, as well as equality, flexibility, and reciprocity

between the partners. The recurring sentence used by these couples was "we are of

one mind," which evokes the association of "oneness" described by Kohut [63] as a

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relatively low stage of development. It is well-known, however, that some stress

situations require the use of primitive defense mechanisms for effective coping. The

other end of the continuum represents the negative impact of the security situation

on the couple relationship and was characterized by the partners’ use of different,

and sometimes contradictory, ways of coping, rigidity, distance in intimate

relationships, and many conflicts. Some couples from this group applied for couple

therapy, which they experienced as facilitating a positive change that allowed them

to move towards the other end of the continuum.

Discussion

The findings of the quantitative and qualitative study are consistent with the

complexity of the findings of previous studies that focused on couples living in

different type of stress situations, showing that stress may have varying impacts on

the couple relationship. Most studies have found that stress harms the couple

relationship, yet other studies have found that stress may strengthen it. The findings

of the current study complicate this picture even further by showing that positive

and negative implications are not necessarily exclusive outcomes of stress, but can

exist mutually, resembling the outcomes of some studies that found positive

relationships between PTSD and PTG [64, 65]. As the saying goes: “Nothing is so bad,

as not to be good for something.”

The current study presents an additional complexity: although the results did not

reveal statistical differences between the groups on the quality of the couple

relationship, significant differences between the groups were found regarding the

implications of exposure to warfare on the couple relationship. These results may

seem odd, since the tool used to measure the implications of exposure to warfare on

the couple relationship covers the same areas in spousal life as the tools used to

measure the couple relationship. However, the Israeli cultural context may partly

clarify these results. Based on a previous study [27] in which we found a tendency

either to avoid or even to refuse to respond to questions regarding marital issues, it

may be assumed that within the family-oriented Israeli context, spousal issues are

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considered private and participants avoid reporting to strangers, even anonymously,

about negative areas in their spousal relationship. However, when the issue is

studied in the context of an external situation, such as a security threat caused by

war or terror, the couple is considered less responsible for the quality of their

relationship, thus perhaps allowing them to report more openly on both the negative

and positive aspects of their relationship.

An additional complexity refers to the high correlation between the measurement of

the couple relationship (as measured by marital quality) and couple resilience (as

measured by the couple's sense of coherence). The high correlation between the

two variables raises the question of whether these measures tap into similar or

perhaps even identical concepts. Theoretically, when couple resilience is

conceptualized as a process, it can be considered to be either a mediator or a

moderator between the stressor and its impact. Therefore, we may expect to find a

correlation between the two variables but not so strong as to create multi-

colinearity. It is important to note that the content of the items in the two

instruments does not overlap [39, 53]. Thus, researchers still face the challenge of

developing tools that can differentiate between the two concepts since the existing

tools do not succeed in differentiating between them, as was expected when

designing the current study.

The results of the current study, as well as the explanations, should be viewed with

caution due to two main limitations. First, the correlative design of the study

prevents us from inferring causality. Since this was a field study conducted during a

security threat that existed for over a decade, pre-warfare measurements could not

be obtained, as is required in an experimental design. Second, the high exposure

group was relatively small (n=61). Third, because of the difficulties of recruiting

participants in the high exposure group, we did not succeed in creating a sample in

the quantitative part of the study that included both partners. We were unable to

analyze the impact of one spouse on the other (APIM- Actor-Partner

Interdependence Model) [66], information that may have enriched the knowledge

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on this topic. Despite these limitations, several practical suggestions can be made

based on the current study findings. In contrast to most studies that found stress as

impoverishing the couple relationship, it is important to focus also on couple

resilience as well as on the positive impact of the stressful situation on the couple

relationship. This does not mean that people should look for stressful situations

through which to gain these positive impacts, but a positive impact on the couple

relationship may reduce the anxiety that often accumulates when living in a war

zone. In addition, as was found in the qualitative part of the study, family and couple

counseling for populations living in a war zone may strengthen couple resilience and

be used as a coping resource.

In sum, the present study contributes to the body of knowledge on the connection

between exposure to warfare and the couple relationship. The importance of the

topic goes beyond the couple system. Couples are often parents, who are also

responsible for the well-being of the younger generation. Couples are two

individuals, who are expected to provide mutual support. The couple relationship

often has a high correlation with both parental and individual functioning and well-

being. Given that security-related stress is not exclusively an Israeli experience, it is

important to continue to explore how similar kinds of security threats in other

cultural and political contexts affect the couple relationship.

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Chapter 9

Community Resilience Assessment - Meeting the Challenge - the Development of the Conjoint

Community Resiliency Assessment

Limor AHARONSON-DANIELa,b14 Mooli LAHAD c,d, Dima LEYKIN c,d, Odeya COHENa,b, Avishay GOLDBERGa,e

a PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva, Israel.

bDep. of Emergency Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel

c Dep. of Psychology, Tel-Hai College, Israel dThe Community Stress Prevention Centre (CSPC), Kiryat-Shmona, Israel

eDep. of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Abstract. Community resiliency is a term commonly used to describe the

ability of a community to endure and survive crisis situations. It

encompasses the community's adaptability to changing circumstances and

its capability to respond effectively. As such, it is considered to be an

essential capacity for emergency preparedness and readiness to respond.

While preparedness is often linked to immediate needs, resiliency has

prospects for a longer time span, thus it is associated with sustainability and

is relevant in routine as well as in emergency situations. Despite the

abundance of material on this subject matter, a thorough search of the

literature found no practical tools for the assessment of community

14Corresponding Author: Prof. Limor Aharonson-Daniel, Department of Emergency Medicine, Recanati

School for Community Health Professions, Faculty of Health Sciences and PREPARED Center for Emergency Response Research, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva, Israel. limorad@bgu.ac.il

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resiliency. The acknowledgement that resiliency is a complex issue, entailing

input from multiple perspectives is beyond the scope of any single discipline,

and leads to a unique cooperation between expert professionals and

community leaders (stakeholders) forming the Conjoint Community

Resilience Assessment Collaboration with the aim of developing a standard

measurement tool for community resiliency.

This chapter outlines the evolution and the activities of the collaboration,

the milestones and path to the Conjoint Community Resilience Assessment

Measure - a novel multidisciplinary tool that incorporates the diverse

aspects of community resiliency into a community profile. The profile

includes aspects such as: leadership, collective efficacy, preparedness, place

attachment, and social trust. The CCRAM standardizes measurements and

facilitates comparisons of community resiliency across time and place. In this

chapter we will briefly review the theoretical background, portray the

elements that were considered, and illustrate the process which led to the

final validated instrument.

Keywords: Community Resilience, Community Resiliency, Methods,

Assessment

Introduction

Community resiliency is a complex concept touching upon a broad range of

different characteristics of the community. Essentially, community resilience may be

understood as a multi-dimensional construct describing the capacity of the

community to respond effectively to disturbance and crisis [1].

Community resiliency is a significant component in emergency preparedness and

response [2]. Despite the abundance of material on this subject matter, a thorough

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search of the literature found that standard accepted tools for assessing community

resiliency were lacking [3].

The paper "Community Resilience as a Metaphor, Theory, Set of Capacities, and

Strategy for Disaster Readiness" [4] has become central in the discussion of

community resiliency and has been quoted over 300 times to date. Nevertheless, in

their more recent article "Assessing community resilience on the US coast using

school principals as key informants", Sherrieb et al. [5] refer to the "Community

resilience as a metaphor" article stating that there is no survey instrument that

measures the sets of capacities represented in their model for community resiliency.

The tool presented here is therefore probably the first measure to practically

encompass the broad scope of elements that express the set of capacities that

community resiliency covers. This chapter presents the progress from theory to

practice regarding the measurement of community resiliency.

The tool is timely as recently, the Department of Homeland Security claimed that

there are many definitions of community resiliency, yet their operationalization

remains a challenge [6]. Furthermore, an exhaustive literature review published in

2011concluded that without some degree of standardization of methods and

outcomes for assessing resilience, it will remain difficult to make meaningful

comparisons between diverse communities facing potential crises, and that there

remains significant scope for further research in this area [7].

In this chapter, we describe the process of developing a novel tool for the

assessment of community resiliency. The scientific development process facilitated

the integration of decades of knowledge accumulated within the multidisciplinary

study group.

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Theoretical

Background Community

Many social structures are encompassed in the concept of community. Some

of them are locality-dependent or associated with the performance of some

particular activity, while others involve shared interests and ties [8].

The structure and meaning of the term community have changed in recent decades,

as has the position of the individual within it [9]. Institutions and governance have

lost importance, and instead, there is an activation process of individuals. While

Beck [10] initially argued that society has a ‘context of alienation’ that we cannot

escape individually and that affects almost every realm of society, in his later

writings, the possibilities of acting upon risk are emphasized [11]. Phillips and

Pittman [8] claim that community can be developed by increasing the ability to act

collectively and by taking action for improvement in any or all of physical,

environmental, cultural, social, political or economic fields. In our study, community

is considered to be a territorially bounded entity within which the basic needs of its

members are met [12].

Resilience

Human resilience is a metaphorical concept drawn from physics and

mathematics. In the basic sciences, resilience expresses the ability of a material or a

system to return to equilibrium after a given displacement. In people, it is seen as

the ability to recover and “spring back” from psychological trauma, yet it is also

perceived as a variation on conceptualizations of effective coping and adaptation

under adverse environmental circumstances [13].

Norris describes [4] how the concept of resilience was co-opted by the social

sciences and extended from the individual to apply to the community.

Nevertheless, the key to community resiliency is not the sum of individual strengths

alone [14], nor is it a lack of pathology in community members, thus creating some

confusion between personal and community resiliency. Liebenberg & Ungar [15]

focused on personal resiliency, yet see this resiliency as the combined qualities of

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the individual and the individual’s environment that potentiate positive

development.

Community Resiliency

The range of categories embraced in the term community resiliency makes it

particularly challenging to define. The components of resiliency belong to different

content fields, including physical components, availability of services, the individual's

perception of his community, and the experience of community members with

various situations that lead to stress [4][16]. The many classifications of community

and the abundance of definitions of resilience make it difficult to agree on a set of

components and on a standard research approach to assess community resiliency

[7].

The diversity displayed in the perception and definition of community resiliency by

various authors often reflects the background of the researcher stating them. This

variety further influences both the interpretation of the components of resilience

and the methods for assessing it. As a result, integration of the accumulated

information into reliable comparative research is not straight-forward. Chandra et al.

[3] say that this difficulty can be identified in a number of studies that offer

theoretical models but lack practical and empirical evidence regarding the different

components that comprise community resiliency. According to Cutter [17], none of

the theoretical models have progressed to the operational stages where they

effectively measure or monitor resilience.

Many researchers, as well as leaders, substitute the term resiliency with

preparedness. Castleden, McKee, Murray & Leonardi [7] report that the word

‘resilience’ is increasingly being used to describe a quality previously encompassed

by terms such as ‘preparedness’, ‘business continuity’ or ‘civil protection’.

Resilience is seen as a significant factor that affects the readiness of the population

to respond to an emergency [18][19]. Resilience is a factor that affects adaptability

and may have an impact on survivability. While preparedness or readiness to

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respond are often linked to immediate needs (predominantly a short term issue),

resilience has prospects for a longer time span. Resilience is therefore a term which

is associated with sustainability in a broader sense than with emergency

preparedness. Community resiliency is relevant in routine as well as in emergency

situations as it enables communities to withstand normal periodic fluctuations as

well as crisis situations.

The current study used an exploratory, sequential mixed methods design [20]) that

enables a deep and extensive exploration of community resiliency. In this chapter we

provide the conceptual frameworks at the basis of the development and describe

the testing and validation stages of the Conjoint Community Resilience Assessment

Measure (CCRAM).

Objectives and Methods

The main objectives of this project were: (1) To describe the systematic

development of a standard scale for community resiliency; (2) To identify

constructs/components of community resiliency; (3) To validate the instrument

created. The study methodology was comprised of three phases, as depicted in

Figure 1.

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Figure 1. Stages of the Conjoint Community Resilience Assessment Measure (CCRAM) evolution.

Phase 1: Contextualization

Public seminar and expert panel: On March 15th 2010, a public seminar on "The

definition of community resiliency" took place, followed by a panel discussion by

leading academics from diverse backgrounds. Subsequently, a group derived from

the panelists expressed interest in the common goal of developing a joint tool,

1.1 Public seminar and expert panel: CR Definition

1.4 Content expert first meeting: Mapping the field

1.2 Literature Review seeking existing instruments

3.1 Comparing final questionnaire to initial topics

3/2010

10/2010

1/2011

2-4/2011

9-11/2011

7/2011

1

2

3

1.3 Interviews with instrument developers Co

nte

xtu

ali

zati

on

CCRAM tool pilot version

3.2 Feedback from experts

2.1 Identification of common fields (Table 1)

Report Community Resiliency Indicators

Statistical Analysis: Factor Analysis & SEM

Pilot study results 1/2012

12/2011

Nominal group Technique Delphi Survey

2.2 Decisions regarding tool components

CCRAM tool final version 8/2012

Ongoing/Periodic assessment

3.3 Pilot study (n=886 participants)

Inst

rum

ent

Dev

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prompting the initiation of this study. Group participants were scholars in the

disciplines of psychology, social work, sociology, public health, medicine, healthcare

management, education and statistics.

A literature review was conducted with the aim of finding published tools for

measuring community resiliency. The search of electronic databases used the

keywords: "community resilience measurement" "community resilience" &

"methods". A clear distinction was made between "personal resilience" and

"community resilience". "Personal resilience" was excluded and studies in which the

title read "community resilience" but the instruments used were those measuring

personal stress or post-traumatic stress symptomatology with no measurement of

community traits were also excluded. Most articles found were theory based, not

founded on actual measurement of community resiliency. Surprisingly, actual

measurement in the community was conducted only in Israel, where eight authors

were identified in the literature search as reporting on tangible measurements of

community resiliency.

The authors of these papers (some of whom were in the expert panel mentioned in

section 1.1 above) were contacted and interviewed between March and September

2010. Semi-structured face to face interviews lasted about an hour each and asked

about the theoretical framework of the authors’ published study. At the end of each

interview we requested a copy of the instrument and invited the author to

participate in the developing multidisciplinary workgroup.

A content expert meeting was conducted to present and discuss the various

theoretical constructs and concepts of community resiliency and the potential

approaches for building a joint assessment measure.

Phase 2: CCRAM instrument development

Selected instruments underwent content analysis in order to identify common

content fields for the CCRAM. The questionnaires varied in their volume and view

but the analysis facilitated a preliminary discussion on the common grounds for

unification.

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Consensus methods

Consensus methods provide means for synthesizing information in situations

where published information is inadequate or non-existent. They are useful for

dealing with conflicting scientific evidence and with the potential dominance of

certain group members [21]. Two consensus decision making techniques were

applied in this study in order to overcome potential pitfalls of decision making

processes in diverse groups, and for melding the information from various

researchers and fields: the nominal group technique process and the Delphi process.

Nominal Group Technique (NGT)

NGT uses a structured meeting to gather information from relevant experts

about a given topic. NGT was applied in this study to select the core fields (or titles of

content areas) to be included in the instrument developed. Specifically, it included

two rounds in which group members had the opportunity to propose, rank, discuss,

and then re-rank a series of items (questions or statements) derived from their pre-

existing tools or from their own knowledge and expertise. The method gave all

attendees an equal opportunity to express their opinions. The outcome of this stage

was a list of eleven content fields which the various questions had to match.

Delphi method

The Delphi method is another approach for obtaining expert’s opinions in a

systematic manner and reaching the most reliable consensus among a group of

experts [22]. Experts who participate in a Delphi process are surveyed individually

and the responses are collected anonymously. The survey is conducted over several

cycles, where after each cycle the results are drawn, tabulated, and then reported to

the group. The Delphi process enables an impersonal expression of views while

ultimately providing information generated by the entire group. Delphi strategies

have been used to solve an array of problems in health and medicine that have

ranged from the needs of an individual hospital or department to those of a

statewide agency or state [23]. In this study, the Delphi process was used for

selecting the questions for inclusion in the instrument. Two Delphi cycles were

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conducted between February and April of 2011 following the principles for making

study design choices that ensure the validity of the study, as noted by Okoli and

Pawlowski [24].

The above mentioned phases produced an instrument, the CCRAM: Conjoint

Community Resilience Assessment Measure (pilot version) - a questionnaire with 22

background questions and 38 items on a five point Likert scale.

Phase 3: Instrument validation

A tabular comparison served to verify that all topics specified by the

workgroups in the preliminary phases had "survived" the process and appeared in

the pilot instrument.

Expert Group review

Group members who "contributed" their original tools to the process were

sent the pilot questionnaire for review and comments. All were approached for

semi-structured face to face interviews followed by an open discussion. The rest of

the expert group received the instrument for comments by mail.

Pilot Study

Participants: The experimentation phase included a sample of residents from

small and medium-sized communities (up to 20,000 inhabitants).

Data Collection: Data was collected between August and November 2011 in the

Southern and Northern regions of Israel. Questionnaire administration was face to

face at randomly selected addresses with surveyors going from door to door and

online in communities where complete mailing lists were available, via Qualtrics, a

web-based program (www.qualtrics.com). Questionnaires were anonymous and the

study was approved by the Ben-Gurion University, Faculty of Health Sciences

Institutional Review Board (IRB).

Statistical Analysis: Factor analysis (exploratory and confirmatory) was conducted.

Factor analysis is commonly used for data reduction and structure detection [25]. It

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finds relationships between many variables as it allows numerous inter-correlated

variables to be condensed into fewer dimensions (called factors). In this study,

Factor analysis was used to explore the factor structure of the CCRAM. Pearson

product-moment correlation analysis was used to examine the association between

CCRAM factors and background variables. One and Two way Analysis of Variance

(ANOVA) were used to examine the effects of nominal variables (e.g. type of

community) on community resiliency. Finally, ANOVA with repeated measures

examined the interaction effects between the type of community resiliency factor

with the type of community on the community resiliency level. Post-hoc pairwise

comparisons using Bonferroni adjustment were performed where necessary. Data

were analyzed using Statistical Package for the Social Sciences (SPSS) version 19.0.

Results

Phase 1: Contextualization

The Definition of Community Resiliency

The scientific meeting to define community resiliency was announced in the

professional and public media and was attended by nearly 200 people: scholars,

students, and government officials from the Ministry of Social Welfare, senior

officers of the Homefront Command, psychologists, sociologists and managers from

the healthcare system. The postulation was that an agreed and accepted definition

for resilience is a prerequisite for standardized comparative research of community

resiliency. The aim of the meeting was therefore to form a widely accepted

definition for community resiliency.

Renowned academics from various fields and senior representatives of the above

mentioned parties were invited to describe their perception of the term and to offer

a definition. At the end of the day, an academic session convened to discuss various

definitions in the context of social, behavioral and psychological theories. Several

definitions were accepted and a broad range of fields were identified as associated

with community resiliency. It was agreed by the forum that the constructs of

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resiliency can be divided into two major groups: (1) The first includes security -

physical factors such as protective devices and infrastructure and the ability to be

warned in time to seek safety; (2) The second group includes factors related to the

individuals' connection with the community - trusting one’s neighbors, involvement

in the community, satisfaction with and fairness of the municipal authority, trust in

the leadership and continuity of services. The gap previously identified between the

intuitive knowledge as to what a resilient community is composed of and the

evidence-based information in this field was confirmed by the experts. Furthermore,

difficulty in translating existing knowledge into valid measurable criteria was

repeatedly expressed. The meeting's conclusions were twofold: (1) Rather than

seeking a condensed standard definition for community resilience, a broader

definition should be accepted; (2) The acceptance of diverse content fields in the

definition promotes the practical ability to measure community resiliency for

emergency situations as it mimics real life situations.

Literature Review - seeking publications of existing instruments

The literature search found that among the large mass of publications, many

included essays with no empirical evidence, while a significant proportion of the

scarce evidence presented in the literature originated in Israel. Furthermore, despite

the growing number of studies about community resiliency in recent years, the

search did not find a published data collection tool or a replicated study.

The conclusion of this stage was that it would be desirable to gather the wisdom and

understanding of researchers that have already studied community resiliency and

are interested in sharing knowledge and building a multi-disciplinary and trans-

disciplinary tool.

Interviews with instrument developers

Based on the literature search, six projects measuring community resiliency

in Israel were selected [12][26][27][28][29][30]. The fields of expertize of the

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selected authors were: Sociology, Psychology, Social work, Community Medicine,

Public Health, Political Science and Health Systems Management.

Content expert first meeting: Mapping the field

A forum of 26 people, comprising 18 academicians with an interest in

developing the community resiliency measure and eight officials from organizations

that were interested in the outcomes of a study using this tool, gathered.

Researchers presented their perspectives and understanding of community

resiliency based on their practical experience with its measurement. A round table

discussion followed, with a special focus on the theoretical background of the

specific approach.

The relationship between past exposure to emergency situations, past behavior (as a

predictor of future behavior) and the strength and role of social networks was

demonstrated [28]. These networks have three dimensions: family - relatives, micro-

neighborhood - neighbors, and macro-neighborhood - community services. While an

interaction between the three exists, it is possible to isolate them, study them and

influence their strength. Kirschenbaum [28] found community networks to be a

reliable predictor for the ability of the individual to cope with a crisis.

Kimhi and Shamai [26] claim that in the assessment of coping with severe stress, the

community should be the investigated unit. They conducted studies on community

resiliency in communities exposed to ongoing rocket attacks and the threat of

bombardment during war [26]. Their study and subsequent studies [31], found that

personal resiliency predicted PTSD while public resiliency (consisting of community

and national resiliency) was a predictor of posttraumatic recovery.

The Ministry of Social Welfare and Community Services has been responsible for

community resiliency in Israel for over three decades. The continuous effort to

strengthen resilience encouraged the Ministry to build a measurement tool that

would facilitate the examination of the components of community resiliency and

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their level in the studied community. Peres, a renowned sociologist, was recruited to

conduct a study for the Ministry [12]. The study applied mixed research methods and

included in-depth interviews with municipality workers and residents in order to

determine the components that will constitute the community resiliency indicator.

Elements of resiliency identified in this study included past coping with a security

emergency situation, employment status, relationship with the municipal authority,

coping with an economic crisis, quality of life in the community, residents' attitude

towards their town, relationships between individuals and groups in the community

and voluntary community activity.

Sagy et al. [29], presented an approach that examines the ability of the individual

and of the community to cope with crises, based on inherent strengths. Underlying

this approach is the salutogenic model, developed by Antonovsky [32] which

proposed a new paradigm for looking at how individuals cope with crisis situations.

Table 1: The number of questions under each category by source - summary of content analysis for stage 3.2.1 of the study.

Source Questionnaire

E D C B A Category/Theme

7 2 2 7 Social relationships within community

3 1 7 Social support factors

5 5 Personal sense of security

2 2 Community organization towards crisis

3 3 1 Meaning of living in the community

2 2 1 Coping with crisis (community)

6 1 Satisfaction with municipality in routine

8 4 Continuity of municipality function in crisis

1 1 The perceived effect of the individual on the

community

1 2 Population needs in crisis situation

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Source Questionnaire

12 1 Quality of life in the community

1 1 1 1 Future of the residential place

1 5 Community in relation to other places

3 1 1 Employment in or near residence

11 3 2 1 Prospects for involvement in the community

1 3 Local leadership

4 7 Trust in national leadership and authorities

6 Attitude towards military solutions to conflict

70 28 12 7 27 Total

An additional objective of the meeting was to introduce decision makers and leaders

of organizations that take part in the national response to disaster to the complexity

of the issue and to request their input in the form of their expectations and needs

from the anticipated tool. Discussion on these matters was brief and concise, yet

contributed significantly to the value of the meeting and the commitment of its

participants.

At the conclusion of the meeting, the forum agreed to serve as an academic

consortium for the scientific support of resiliency enhancement through

identification of susceptible areas that can be reinforced based on findings of an

ongoing assessment and evaluation of the effectiveness of various interventions. The

group established a formal collaboration named the Conjoint Community Resilience

Assessment Collaboration (CCRAC). 3.2

Phase 2: CCRAM development

Identifying common fields for the CCRAM

Table 1 presents the number of questions under each category of the five

original questionnaires. These questions were the basis for the group decision

making process.

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Decisions regarding tool components

Deciding which tool components to include was a crucial stage in the

development of the measure.

Nominal Group Technique

After a brief introduction and review of the workplan, the nominal group

technique (NGT) facilitator introduced and explained the procedure. Participant

contributions were recorded, going around the table until all ideas were recorded.

The process welcomed all opinions, resulting in a list of 19 core topics that were

entered into an Excel worksheet and printed for ranking next to a five point Likert

scale (ranging from "disagree" to "very strongly agree" with "irrelevant" as a sixth

option). Each of the participants independently ranked the categories. The ranking

process determined eleven final categories: place attachment, municipality function,

knowledge and organization, preparedness, quality of life, values and ideology, social

resources, personal resources, community resources, background characteristics.

At this stage, experts were divided into workgroups where they were asked to sort

all of the items from the original instruments into the eleven categories. This

discussion suggested that community resiliency may be either the dependent or the

independent variable in different studies. Each of the groups produced a list of items

that they perceived to be the most important from their content world, totaling 61

items. It was agreed that these items will be rated using the Delphi process by all of

the group members.

The Delphi Process: Selecting the items for inclusion in the questionnaire

Cycle 1: Results of the previous stages were smoothed and phrasing of the items was

edited. Duplicate items were eliminated, resulting in 54 items for the Delphi process.

The survey was sent to all (n=18) group members. For each question, the participant

was asked to mention whether s/he supports inclusion in the questionnaire, opposes

inclusion or is indifferent. Rephrasing or changing the question was optional where

the response was positive. In addition, participants were asked to rank the

importance of every question they chose to include on a three point scale:

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important, moderately important, not important. The response rate to the first cycle

of the Delphi was 100%. Thirty three (of 54) items scored an agreement rate above

80%. Additionally, 15 new items were suggested by respondents and added to the

second Delphi cycle. The items that received less than 80% agreement were included

in the second cycle. Similar criteria were previously used in recent Delphi studies

(e.g. [33]).

Cycle 2: The second Delphi cycle included 35 items: 20 that received less than 80%

agreement and 15 newly proposed items. The response rate for this cycle was 83%

and the outcome was the acceptance of three additional items, one "old" and two

"new" ones, as proposed in the comments of the first cycle. The accepted items

were rated as important or extremely important by 98 % of the respondents.

CCRAM tool Pilot Version

The final pilot instrument was comprised of two parts. The first part

contained general information which included demographic questions and

information that was considered to be relevant to preparedness and response to

emergency events (22 questions). The second part was the product of stages 2.1.1-

2.2.2 above and included 38 items regarding community characteristics, social

networks, leadership and more, on a five point Likert scale.

Phase 3: Instrument validation

Instrument validation included three stages: (1) A comparison of the final

instrument to the initial topics that were included. (2) Validation and feedback from

experts. (3) A pilot study of 886 participants.

Comparison of the final questionnaire with the original topics raised by the

workgroup

Items in the pilot instrument were compared to the items proposed by the three

subgroups at the meeting described above (stage 2.2). Of the 23 items proposed by

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group 1, 96% were accepted (n=22). All of the twenty items contributed by group 2

were accepted, and 14 of the 18 items proposed by group 3 (78%) were accepted.

Returning to the original instrument owners for feedback

Five of the contributors who developed instruments for measuring community

resiliency prior to this project were asked to review the final instrument for missing

content. None identified a topic or theme that was missing in the instrument.

Comments were given regarding 16 of the items; six of the items had comments

from all the reviewers. Experts were asked to suggest solutions to every problem

they identified. These suggestions were incorporated into the final tool.

Pilot study and statistical analysis of data (factor analysis)

Study population

The pilot study was conducted in the Southern and Northern peripheries of

Israel during the summer of 2011 and included 886 respondents.

Responders were Israeli Jewish adults with a mean age of 45.28 years (SD = 15.40

years, range 18-86 years). The majority (55.7%) were women, and 71.4% were

married or had a permanent relationship. Approximately 42% had a post-secondary

education level.

Statistical analysis of data (factor analysis)

The preliminary CCRAM questionnaire analysis used 31 items from the self-

report assessment tool with an exploratory factor analysis that yielded five factors

explaining 63.86% of the total variance. These were: leadership (α=0.95), collective

efficacy (α=0.84), preparedness (α=0.83), place attachment (α=0.78), social trust

(α=0.85) and social relationship (α=0.72).

Data was further explored in order to shorten the questionnaire and facilitate the

identification of independent (orthogonal) factors. Items with congruent content and

high correlations (above .45) were eliminated in seven cycles resulting in 21 items

remaining in the questionnaire. Overall Cronbach's α was 0.92 with five factors

explaining 68.08% of the variance. The five factors identified were: leadership (5

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items, α = .91 explaining 38.98% of the variance), collective efficacy (5 items, α = .84,

explaining 11.16% of the variance), place attachment (5 items, α = .79, explaining

6.87% of the variance), emergency preparedness (4 items, α = .81, explaining 6.11%

of the variance), and social trust (2 items, α = .85, explaining 4.96% of the variance).

Repeated measures ANOVA resulted in significant differences between communities,

as indicated by a significant effect for type of community, F (2, 821) = 52.99, p < .001,

ηp2 = .11.

For the factors of leadership, community and preparedness, collective communities

were higher than the villages in their resiliency, and villages were higher than

midsize towns. For place attachment, both collective communities and villages

scored higher than towns. However, for the social trust factor, the most resilient

type of community was villages, while no statistically significant differences were

evident between collective communities and towns. (Figure 2).

Figure 2. CCRAM factors according to type of community

Discussion

Definitions of community resiliency vary, yet there is a consensus on the

essence: resilience is the ability for adaptability. Brown [34] defined community

resiliency as the ability to recover from or adjust easily to misfortune or sustained

life stress. Norris defined it as a process linking a set of adaptive capacities to a

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positive path of functioning and adaptation in constituent populations after a

disturbance [4][35]. In Israel, community resiliency has been defined as the ability of

a community to take intentional action to improve the personal and collective

abilities of its residents and institutions to react effectively to security, social or

economic changes in order to influence the future consequences on the community

[36]. The most popular term used is the ability "to bounce back after a disturbance."

Community Resiliency is a seemingly comprehensive topic that has (thus far) not

been subjected to replication of scientifically accepted methods for its'

measurement. Many papers about community resiliency make theoretical

assumptions, extrapolations and deductions from theoretical constructs or studies in

adjacent fields but do not report empirical assessment [7][3]. The minute amount of

papers that did report measurement, were often local, focusing on a limited

population [1][14][29]. Furthermore, study tools often measured individual, rather

than community traits and attributes [37].

The lack of common tools for a topic that has been so broadly mentioned in recent

years may perhaps be attributed to the multiplicity and breadth of fields

encompassed in the term "community resiliency" or to the inarticulacy of some of its

components. The relationship between community resiliency and its' ability to

function well during times of emergency has been mentioned [7][38], linking

community resilience to aspects that can be measured and assessed repeatedly.

The ability to define the factors involved in creating and reinforcing resiliency may

help promote engagement in actions that can enhance or maintain community

resiliency.

The current study overcame barriers of multidisciplinarity as it systematically

deciphered the complexity of the term, and methodologically built an instrument

using an analytic and scientific approach. Furthermore, community resiliency is an

example of a trans-disciplinary issue - it transcends the boundaries of disciplines as

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an issue that takes not only the collective wisdom of multiple disciplines but also

transcends the traditional boundaries and norms within those disciplines.

Focus groups and Delphi processes have been increasingly used in many fields in

recent years despite the criticism that it leaves potential leeway for improvisation

and opportunism, and that the selection of experts to be included in the expert

group may have an effect on the outcomes [39]. The current study suggests that

group dynamics within the selected group may also influence the process outcome.

Groups that convene for decision making and have dominant or persistent members

may wear out weaker members, leading to decisions that are biased towards the

strong or tireless. It is important therefore for researchers to be aware of this so as

to avoid the misapprehension that they conducted a genuine representative decision

making process, when in fact they may have not. Thus, in studies that are not based

on large samples where one can assume an approximation of the normal

distribution, investigators should be mindful of this issue.

Questionnaire building has developed from being an art to a science in recent

decades, with the application of cognitive psychology to the study of questionnaire

design [40]. Usually, the process of building a questionnaire is conducted within the

discipline, among peers, or people who share a common research question. Items

may be based on a literature review or other sources of information, where they

may ask for knowledge, opinions or practices. It is uncommon for the questionnaire-

building process itself to take the form of a scientific process– a multi-stage,

reiterative process of selecting, ranking, choosing and testing the appropriate items.

The process described in this chapter was one such process conducted by a group of

senior academics, representing various fields and several universities. The topic of

community resiliency is multidisciplinary and although (or possibly because) most

members of the CCRAC are experienced researchers, they stepped out of their "safe"

territory to meet researchers from other fields and build this tool together. The

multidisciplinary multi-institutional brainstorming and collaboration of knowledge

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resulted in an instrument which indeed proved to be satisfactory from the very first

field trials.

The results of our pilot study established the factors that portray community

resiliency. These contain many concepts, constructs and theories identified in the

literature such as preparedness, trust in leadership, social relationships, place

attachment and sense of security. The interdisciplinary nature of the group revealed

the common meanings of different nomenclatures. Trust in leadership is in many

ways in accordance with the term "good governance" which is described in the

literature as having a key role across the different disciplines dealing with resilience

[7]. Social cohesion among neighbors combined with their willingness to intervene

on behalf of the common good [41] was found in other studies as associated with

community resilience [1][16][42]. Social capital is a feature of social life, including the

networks, norms and trust that enable participants to act together more effectively

towards a purpose or shared objectives [42]. Social networks promote community

cohesion [7], increase the ability to use information, resources and communication

to respond during a disaster [3]. Social support is yet another critical dimension of

community resilience which Norris et al. [35] found to be a significant protective

resource in response to stressors [43]. A positive correlation between community

resiliency and social trust was found in a number of different studies [1][13][44][45].

Place attachment incorporates various aspects of people-place bonding and involves

the interplay of affect and emotions, knowledge and beliefs, and behaviors and

actions in reference to a place [46]. Stronger attachments may help people "hold on"

despite adversities ( [47][48].

Emergency preparedness is another one of the dimensions of community resiliency

[2][48] found to be related with authority and with a resilient infrastructure.

According to McDaniels et al., resilient infrastructure systems, particularly "lifeline"

services, are crucial for minimizing the societal impact of extreme events [50].

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The concept of sustainability is central to studies of resiliency [17].According to

Borne [51], the recurrent modern reality identified by Beck [9] as a "risk society"

requires the development of a sustainable lifestyle and a "risk governance" to match

current and future disasters. Practically, this requires considering the relationship

between the local and global levels, and accepting the role of the community in the

general context. Presuming that "risk governance" cannot take place in isolation,

there is a need for interplay between all the actors in this process [52].

Taking positive action reflects the reality of a resilient society, including collective

efficacy, involvement, social and political trust and leadership [8]. Our finding that

belonging to a Community Emergency Response Team (CERT) contributed to

enhanced resiliency supports this notion. However, a disintegrating society will find

it difficult to work together and to enhance proactive processes to promote a better

future. As disasters are increasingly on the agenda for every nation worldwide, and

since community resiliency has been associated with emergency planning and

management, the ability to measure community resiliency is of growing importance.

The CCRAM tool facilitates delineating the components of the resilience of the

investigated community [53]. The creation of a unique community profile that

portrays the community characteristics provides important information for decision

makers about the community and its needs. Conducting repeated measures by the

CCRAM tool [54] will facilitate measurement of changes. Furthermore, it will identify

the extent and direction of the change following intervention or an emergency

situation.

Modern society is increasingly adopting a responsible conduct and a sustainable

lifestyle for the potential occurrence of disasters. Resilient communities are a key

factor in this conduct. The outcome of the process described in this chapter enables

and promotes the measurement of community resiliency in a standard way.

Periodical CCRAM assessments can serve to benchmark resilient communities as the

basis for sustainable preparedness efforts [53].

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Chapter 10

Stress and Resilience in the Midst of a Security Tension

Dmitry LEYKINa,b,c 15, Limor AHARONSON-DANIELa and Mooli LAHAD b,c

aPREPARED center for Emergency Response Research bCommunity Stress Prevention Center, Israel

cThe Multidisciplinary Resilience Research Center, Israel

Abstract. Following the use of chemical weapons against Syrian citizens, US

President Obama began making preparations for a US military attack to

punish the regime of the Syrian president. With lines extending at gas-mask

distribution points, nervous Israeli citizens were preparing for a possible

Syrian attack. The present study explored the associations among individual,

community and national resilience, and the sense of danger on perceived

stress among Israeli Jews and Arabs in the midst of this security uncertainty.

Methods: Using the web-based research software - Qualtrics - a community

sample of 435 individuals (n = 244 Jews and n = 191 non-Jews, 57.5% males)

completed brief versions of a personal resilience scale (CD-RISC 2; Vaishnavi,

Connor & Davidson, 2007), a community resilience scale (CCRAM-10; Leykin,

Lahad, Cohen, Goldberg & Aharonson-Daniel, 2013), a national resilience

scale (Kimhi et al., 2013), a single item stress question (Elo, Leppanen &

Kahkola, 2003) and 3 items from the sense of danger scale (Solomon &

Prager, 1992). Results: Jews reported significantly higher levels than Arabs

on measures of resilience, ηp2 = .28, p < .001, and levels of general stress

15Corresponding Author: Dima LeykinDepartment of Emergency Medicine, Faculty of Health Sciences,

Ben-Gurion University of the NegevPREPARED Center for Emergency Response Research Tel Hai Academic College, POBox 797 Kiryat Shmona 11016 E-mail: dimleyk@gmail.com

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and sense of danger, ηp2 = .17 & ηp2 = .10, p < .001. A multiple regression

analysis revealed that for both Arabs and Jews, a sense of danger was

significantly associated with stress. Individual and community resilience also

interacted with ethnicity on stress: among Arabs, individual and community

resilience (controlling for age and personal resilience) negatively tended to

predict stress, while among Jews this effect was not evident.

Discussion: During times of uncertainty, individual and community resilience

can be an asset for reducing subjective stress among minority populations in

Israel; therefore, it is recommended to maintain and build community

capacities during routine.

Keywords: Personal Resilience, Community Resilience, Stress, Syria, Threat

Introduction

Following the use of chemical weapons against Syrian citizens [1-3], US

President Obama began preparing for a US military attack to punish the regime of

the Syrian president [4]. With queues extending at gas-mask distribution points,

nervous Israeli citizens were preparing for a possible Syrian attack [5]. In some

distribution centers, the crowd even forcibly took gas masks [6]. According to an

online representative sample of the Israeli population, most of the public were

certain and supportive regarding a possible American attack in Syria and were not

personally afraid of being attacked by Syrian retaliation. While showing trust in the

IDF and the Israeli prime minister, approximately 57% believed that the Israeli home

front was not well prepared against a potential Syrian attack [7]. The purpose of the

present study was to explore the associations among individual, community and

national resilience, and the sense of danger on perceived stress among Israeli Jews

and Arabs in the midst of this security uncertainty.

Studies suggest that security-related stress is perceived as the main source of stress

for members of the major ethnically-affiliated groups in Israel [8]. Studies also show

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that ethnicity is a significant contributor in explaining stress reactions and

psychological impact after military related events [9, 10].

Previous studies on Israeli populations have identified the sense of danger as a

significant contributor to various negative consequences of exposure to terrorism,

including violence [11], expression of posttraumatic stress disorder [12] and stress

symptoms [13, 14].

Over the years, several conceptualizations of resilience have emerged to describe

the capacity to cope with adversity and “bounce back” after negative incidents [15].

According to the most recent systematic review of the various concepts of resilience,

these include: community resilience, disaster resilience, social-ecological resilience,

infrastructure resilience, individual resilience, organizational, network, urban, and

system resilience [16]. The present study focused on three types of resilience:

individual, community and national, in the context of a security threat.

Masten and Obradovic [17] defined individual resilience as the capacity of individuals

or groups of people to cope with adversity and continue functioning. According to a

study that examined trajectories of resilience and resistance among a national

sample under ongoing threat of mass destruction in Israel [18], being Jewish was

related to a greater likelihood of the resilience trajectory.

Community resilience has been used to describe a community’s ability to deal with

crises or disruptions [19]. A recent work that compared the level of community

resilience using the Conjoint Community Resilience Assessment Measure (CCRAM)

[19] among three ethnic groups in one urban settlement in Israel, found that Israeli

Jews scored significantly higher than Israeli Christians and Muslims [20].

National resilience, also termed social resilience, relates to society members'

capacity to display durable stability in times of intractable conflict, showing

heightened patriotism, optimism, social integration, and trust in the political and

public institutions [21, 22]. According to 'The Israeli Democracy Index 2013" report

[23], based on a representative sample of the Israeli adult population, about 80% of

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Jewish Israelis are proud to be Israeli and 67% feel part of the State. Among Arabs,

only a minority feel pride in being Israeli (40%) or have a sense of belonging to the

State (28%). Moreover, significant differences were found between Jews and Arabs

in their trust in institutions and public figures (e.g. IDF, the president, Supreme

Court, police and government, etc.), and Jews reported more trust in these

institutions than Arabs. These results converge with recent evidence based on a 10

year period of semi-annual sampling of the Israeli public [21].

The aim of the present study was to examine the relationship between resilience

(individual, community and national), the sense of danger and perceived stress,

among Israeli Jews and Arabs in the midst of a security threat. Based on the

reviewed literature, we posed three hypotheses: (a) Ethnicity will have an effect on

the sense of danger and the stress symptoms: Arabs will experience a greater sense

of danger and more stress symptoms than Jews; (b) Ethnicity will have an effect on

the subjective perceptions of personal and community resilience: Jews will display

greater personal and community resilience than Arabs. c) Jews will display

significantly higher national resilience than Arabs.

Methods

Participants

Participants of the study were an adult (18-85 years) convenience community

sample of 435 individuals (n = 244 Jews and n = 191 non-Jews, 57.5% males). All

volunteered to participate and had the eligibility to participate in a lottery with a

prize of 250 NIS (approximately 70US$). Demographic characteristics of the

participants are presented in Table 1. While no differences were found between

Jews and Arabs in the representation of gender, education and place of residence in

Israel - significant differences were found in terms of family status, age, income and

religiosity - more Jews were married, older, had a higher income and tended to be

less religious.

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Table 1: Demographic variables of the participants (N = 435)

Arabs Jews χ2

n (%) n (%)

Gender Male 81 (42.6) 103 (42.4) .01

Female 109 (57.4) 140 (57.6)

Family Status Single 77 (40.5) 25 (10.3) 54.19***

Married/ with spouse

100 (52.6) 191 (78.6)

Divorced/ Separated

13 (6.8) 27 (11.1)

Education High School 27 (14.2) 31 (12.8) 8.71

Professional 35 (18.4) 44 (18.1)

Academic 125 (65.8) 162 (66.7)

Other 3 (1.6) 6 (2.5)

Place of residence

Urban Settlement 138 (72.3) 165 (67.6) 1.09

Other 53 (27.7) 79 (32.4)

M (SD) M (SD) t

Age 32.93 (11.80) 50.81 (13.93) -14.45***

Income 2.72 (0.93) 3.40 (1.10) -6.94***

Religiosity 1.99 (0.85) 1.67 (1.12) 3.38**

*p < .05 ** p < .01 *** p < .001 Tools

The reported measures are part of an extended questionnaire containing

additional aspects of stress and coping. The current paper focused on the following

measures:

Demographic information. Gender, age, family status, education, ethnicity,

religiosity, income and average income were assessed.

Stress Symptoms. A single-item measure of stress symptoms was utilized [24].

Participants read the following description: "Stress means a situation in which a

person feels tense, restless, nervous or anxious or is unable to sleep at night because

his/her mind is troubled all the time. Do you feel this kind of stress these days? ",

and were requested to respond on a 5-point Likert scale, ranging from 1 (not at all)

to 5 (very much). A higher score indicated greater reported stress. Elo et al. [24]

showed satisfactory content, criterion, and construct validity for group level analysis.

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Distressing intrusive memories. The occurrence of intrusive distressing memories

due to the security threat was assessed by a single binary question asking whether

the participant had distressing and sad memories from the past, against his or her

will. This question was devised for the purpose of the present study and was adapted

from the PTSD item bank [25]. If the participant responded positively, they were

asked to rate their distress intensity on a 5-point Likert scale, ranging from 1 (not at

all) to 5 (to a great extent).

Sense of Danger. This scale included three items taken from Solomon and Prager’s

[26] sense of safety scale, which originally included 11 items. Participants were

requested to rate their level of personal safety during the last two weeks in a

number of different areas on a 5 point Likert-like scale ranging from 1 (not at all) to 5

(very much). Items included personal sense of life danger, sense of danger to the

state of Israel and sense of danger to family and significant others. Internal

consistency of this measure was excellent in the present study (α = .89).

Individual Resilience. A brief, two item scale, named CD-RISC2 [27], was used. The

Items ("Able to adapt to change" and "Tend to bounce back after illness or

hardship") were selected by the authors of the CD-RISC as etymologically capturing

the essence of resilience, i.e., the ability to spring back and successfully adapt to

change. Participants were asked to respond on a 5-point Likert scale. Internal

consistency of this measure was adequate in the present study (α = .71).

Community Resilience. The 10-item version of the Conjoint Community Resiliency

Assessment Measure (CCRAM10) [19] was used to capture perceived factors

contributing to a community’s ability to deal with crises or disruptions. The

CCRAM10 detects the strength of five constructs of community functioning following

disaster: leadership, collective efficacy, preparedness, place attachment and social

trust. The CCRAM10 has been shown to be a valid practical tool for assessing

community resilience. Participants rate their agreement with items concerning

different aspects of their community (e.g. "The municipal authority of my town

functions well" or "There are people in my town who can assist in coping with an

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emergency") on a 5-point scale ranging from 1 (very strongly disagree) to 5 (very

strongly agree). The present study showed excellent internal consistency (α = .91).

National Resilience. Nine-items were chosen to estimate national resilience. These

items were taken from a number of studies concerning perceptions regarding public

resilience, Israeli identity and patriotism [28-31]. The items are rated on a 6-point

scale ranging from 1 (very strongly disagree) to 6 (very strongly agree), and refer to

trust in leadership and the Israeli Defense Forces, patriotism and optimism.

The reliability of the scale in the present study was α = .93.

Procedure

The questionnaire was distributed via social media and social networking

sites (e.g. Facebook) through an invitation link to a web-based research site

(Qualtrics Labs Inc, Provo, UT) with a brief invitation to participate in the survey.

Data collection took place between August 29th and September 17th, 2012. The

survey was distributed via several sources - including Facebook-focused

advertisements (targeting Israeli adults aged 18-65), distribution via panels on the

Israeli Dun & Bradstreet (D&B) site and through personal online social networks. The

survey was designed and adapted for two platforms - desktop and smartphone. On

the landing screen participants were informed regarding the aims of the survey and

were told about their eligibility of entering into a lottery. Next they went through

three screens, and to finalize their response, were requested to submit the survey.

86.5% of the participants answered the survey through desktop computers, while

the rest answered via compatible tablets and smartphones.

Results

Data Analysis

Out of a total of 623 participants who began responding to the

questionnaires, 435 completed them (70%). The interquartile range for survey

completion was 5 minutes, and the median was 7 minutes. Statistical Package for

Social Sciences (SPSS; version 19) was used to perform all the data analyses. To

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examine the correlations between the different study variables, a zero-order

correlational analysis using Pearson product moment was conducted. To examine

differences in mean scores of outcome variables between Israeli Jews and Arabs, a

multivariate ANOVA (MANOVA) was used. To predict stress symptoms using other

study variables, a multiple regression was conducted.

Correlational Analysis

Table 2: Zero-order correlations of study variables (N = 435)

1 2 3 4 5 6 7 8 9 10 11 12

Ethnicity1

Gender2 .01

Family Status3 .28* .28*

Education4 .01 -.08 -.05

Place of residence5 -.05 .13* .06 .03

Age .56* .32* .46* -.08 .05

Income .31* .24* .36* .09+ .08 .41*

Religiosity -.26* -.07 -.10* .04 .03 -.19* -.16*

Stress symptoms

-.44* -.15* -.24* .01 -.03 -.36* -.26* .09

Sense of Danger

-.38* -.20 -.27* .02 -.01 -.39* -.26* .10 .63*

Individual Resilience

.51* .10 .22* .09* -.03 .39* .30* -.14* -.41* -.35*

Community Resilience .23* -.07 .05 .04 -.21* .17* .10* -.02 -.19* -.19* .22*

National Resilience .58* .04 .30* -.06 -.07 .46* .25* -.16* -.30* -.31* .36* .36*

10- Israeli Arab, 1- Israeli Jewish; 20-Female, 1-Male; 30-Single/Divorced, 1-Married/with spouse, 40-Non-academic degree, 1-Academic degree, 50- Non-urban settlement, 1- Urban settlement. *p < .001 +p < .05

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Sense of danger, stress symptoms and reactivation of distressing memories

In line with the first hypothesis, Israeli Arabs reported a significantly greater

sense of danger compared to Israeli Jews, F (3, 431) = 29.16, p < .001, µp2 = .169.

Specifically, the greatest difference was found regarding the perceived sense of

danger to the Israeli state. After controlling for age, income and family status, Arab

participants reported a significantly higher level of stress symptoms, F (1, 427) =

45.22, p < .001, µp2 = .096. For instance, 66.4% of the Jewish participants reported

no stress at all, compared to 27.7% of the Arabs, χ2 (df = 4) = 89.96, p < .001. Almost

30% of the Arabs reported that due to the security situation they were having

intrusive distressing memories, as compared to only 15% of the Jewish participants,

χ2 (df = 1) = 12.79, p < .001. Moreover, the intensity of these distressing memories

was significantly greater among Arabs than Jews, F (1, 93) = 4.99, p < .05.

Individual, Community and National Resilience

A multivariate analysis of variance (MANOVA), controlling for age, income,

religiosity, and family status, showed that compared to Israeli Arabs, Israeli Jews

reported significantly higher levels of overall resilience, F(3, 405) = 51.08, p < .001,

µp2 = .275. The most significant differences were observed in national resilience, F(1,

407) = 93.09, p < .001, µp2 = .186. Differences were evident as well in individual

resilience, F(1, 407) = 68.88, p < .001, µp2 = .145, and in community resilience, F(1,

407) = 11.26, p < .001, µp2 = .03 (see Figure 1). These findings support our second

and third hypotheses.

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Figure 1. Differences in types of resilience between Israeli Arabs and Jews. Note: Error bars denote the standard error of the means; all differences are significant

Prediction of Stress Symptoms

Two multiple regression analyses predicting stress symptoms with personal

demographic variables (age, gender, income, religiosity, family status entered at step

one), and sense of danger and the three types of resilience (individual, community

and national entered at step two) were conducted and are presented in Table 3. For

Arabs, among the demographic variables, only gender negatively predicted stress

symptoms, showing that female gender is associated with greater stress among

Arabs (β = -.17), while for Jews, a lower income was associated with greater stress (β

= -.16). Both models were significant and explained 25% and 26% (respectively) of

the variance in stress symptoms. Adding the sense of danger and the three types of

resilience to the model significantly increased the explained variance for both Arabs

and Jews to 66% and 53% (respectively). The sense of danger was a significant

positive predictor of stress among Arabs (β = .60), and Jews (β = .44). Betas were

found to be statistically significantly different, t (431) = 2.39, p = .017, using the

difference between two slopes calculator [32]. In the full model, there was no

influence of demographic variables, and sense of danger emerged as the most

significant contributor in explaining stress. For Arabs, individual resilience and

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community resilience appeared to have only a marginally significant contribution to

the level of stress (β = -.11 & β = -.11 respectively).

Table 3: Prediction of stress with demographic variables, sense of danger and three types of resilience for Arabs and Jews (N = 435)

Step 1

Arabs Jews

Variable B SE B β B SE B β

Age .00 .01 -.05 .00 .01 -.08

Gender1 -.36 .18 -.17** -.10 .14 -.07

Income -.09 .09 -.08 -.04 .07 -.16**

Religiosity -.10 .12 -.07 .01 .10 -.08

Family Status2 -.13 .17 -.06 -.05 .14 -.03

Sense of Danger

IR3

CR4

NR5

R2 .25 .26

F for change in R2 2.28* 3.24*

Step 2

Arabs Jews

B SE B β B SE B β

Age .00 .01 .03 .00 .00 -.04

Gender1 -.10 .14 -.04 -.02 .09 -.02

Income -.04 .07 -.03 -.05 .04 -.08

Religiosity .01 .10 .01 -.05 .05 -.06

Family Status2 -.05 .14 -.02 -.05 .11 -.03

Sense of Danger .64 .07 .60*** .42 .06 .44***

IR3 -.13 .07 -.11* -.08 .05 -.10

CR4 -.13 .07 -.11* .08 .05 .09

NR5 .06 .05 .07 -.05 .05 -.07

R2 .66 .53

F for change in R2 29.08** 16.48**

10-Female,1-Male; 20-Single/Divorced,1-Married/with spouse,3IR - Individual Resilience, 4CR- Community Resilience, 5NR - National Resilience *p < .06 ** p < .05, *** p < .001

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Discussion

The aim of the present study was to examine how types of resilience are

associated with the sense of danger and stress symptoms among two ethnic groups

in Israel, during a security threat. As hypothesized, the sense of danger was

significantly greater among Arabs, compared to Jews. Arabs reported they felt that

their life was in danger, the state of Israel was under threat of destruction and their

family's lives were in danger.

The strong significant association between the sense of danger and stress symptoms

found among Arabs and Jews (β = .60 & β = .44 respectively), supports the abundant

research that has already confirmed such an association [13, 14, 33]. Braun-

Lewensohn et al. [13] found that feelings of endangerment appeared to explain the

largest amount of variance in stress reaction outcomes. In the present study, sense

of danger was the most significant contributor in predicting stress symptoms,

explaining the largest amount of variance as well. Promotion of a sense of safety is

considered to be one of the key principles facilitating positive adaptation following

trauma [34, 35]. Although the present study does not deal with post-trauma,

promoting a sense of safety or reducing the sense of danger is significant, for it can

help decrease an array of negative stress reactions and reduce the risk of developing

long term stress related psychological problems [33].

The security situation itself may serve as a reminder of past distressing memories. In

the second Lebanon War, many Israeli Arabs were exposed to missile attacks for the

first time in their lives [36]. In a recent report on emergency preparedness in the

Arab sector in Israel, it was found that in most Arab villages there were no public

bomb shelters, as well as physical resources for handling emergency situations. In

these villages there is a considerable shortage in basic life rescue services like

emergency medical services, police, fire departments and more [37]. Confronting a

security uncertainty with constant intimidations from Syria and the US, the

developing chaos around gas mask distribution, the notion of being exposed,

combined with negative past experiences with almost no protective resources [37]

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as well as poor psychosocial preparedness (reflected as low individual and

community resilience), placed Israeli Arabs at greater risk for stress.

We found that Arabs were significantly different from Jews in their level of individual

resilience. These results are in line with previous evidence which argued that being

Jewish is associated with resilience and resistance under ongoing threat of mass

destruction [18], and with results indicating that Israeli Arabs are 5.9 times less likely

to be resilient to traumatic stress [33]. Although Arabs are not targeted by terrorism,

the current literature argues that the Israeli Arab minority as well as the Palestinian

population has become psychologically vulnerable to terrorism [32, 38].

Decreased community preparedness, as described here, can also explain differences

in community resilience between Arabs and Jews. Decreased perceived

preparedness is associated with lower levels of perceived community resilience,

conceptualized as the ability to deal with crises or disruptions [19]. Not surprisingly,

we found significant differences between Jews and Arabs in measures of national

resilience. These findings support recent reports that only a minority of Arabs feel

pride in being Israeli or have a sense of belonging to the State [23]. Ben-Dor et al.

[21] reported that over the years of public sampling, compared to Israeli Arabs,

Israeli Jews show increased support of the IDF, national optimism, trust in the

national institutions and patriotism. Our results support their most recent results (in

November 2012) in all domains of national resilience.

Although ethnic differences were found in individual and community resilience, we

observed a trend toward a negative association only between the Arab participants

and individual and community resilience as well as a small contribution of these two

types of resilience on stress among Arabs. No such associations were found among

the Jewish participants. Since measures of association were generally weak and

almost non-significant, further research should re-examine these findings and

determine the strength of the associations between the various resilience measures

and ethnicity.

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Implications

The present study recognizes the importance of the subjective sense of

danger, and the need to promote the public’s psychological sense of safety.

According to our results, promoting a psychological sense of safety is of great

importance particularly among the Arab sector, as in this population, a feeling of

endangerment was a stronger predictor of stress symptoms. Some of the suggested

strategies to promote safety include activation of social systems (or social support

networks) and limiting media exposure [34]. One possible channel to enhance the

sense of safety and resilience may be through the social media. This field for

emergency communication has gained support in recent emergencies [39-41],

suggesting that officials use ethnically-adapted communication plans during times of

security unrest that will include communication distribution via various channels.

Page et al. [42] noted that preparation of a crisis communication plan can help lessen

fear among the public, decrease their sense of uncertainty, and help enhance the

credibility of responders. We therefore recommend that policy makers should

consider allocating appropriate resources to minority groups specifically in Israel to

enable effective crisis communication with the Arab public. We believe that this

recommendation can serve as a guideline elsewhere as well. This policy may have an

effect on the level of the three types of resilience - specifically individual and

community resilience, which significantly contributed to explaining the variance in

stress among the Arab participants. Additional recommendations support previous

research recommendations that suggest investing adequate resources for civil

protection in the Arab sector [43]. Currently, only the educational institutions in the

Arab villages have shelters, which is definitely not enough for villages with thousands

of inhabitants.

The study also has some limitations, as it used a convenience sampling method to

recruit participants. In addition, the Arab and Jewish participants differed in their

age. Thus, generalization of the findings should be done with great caution. Even

though Internet-based data collection has been utilized for more than 15 years and is

widely accepted, there are still ongoing debates in some fields about whether this

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new method should be accepted [44]. With limited resources, using internet

sampling (instead of random-dial sampling) methods is rather an adequate

alternative when time is limited.

During periods of uncertainty, community resilience can be an asset for reducing

subjective stress among minority populations in Israel. Therefore, it is recommended

to maintain and build community capacities during times of peace. One common

approach for this task is community capacity building (CCB) (sometimes also called

community development)[45].We suggest that such activities should be supported

and promoted by the local authorities, alongside the allocation of additional

governmental physical and economic resources for the Arab sector.

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Chapter 11

A History of Political Violence in the Family as a Resilience Factor

Evaldas KAZLAUSKASa,16, Paulina ŽELVIENĖ a aDepartment of Clinical and Organizational Psychology, Vilnius University, Lithuania

Abstract. Lithuania regained its independence about 20 years ago and is a

member of the EU with a population of nearly three million... Traumatic

experiences and coping with trauma are important topics for Lithuanians, as

a large part of the population experienced persecution during the

oppressive Soviet regime before these social changes began. The aim of the

present study was to evaluate the relationship between psychological well-

being, exposure to traumatic events, and exposure to political violence by

family members during the Soviet regime in a Lithuanian sample. Method: a

non-clinical sample of 626 participants (59.9% female, 40.1% male) with a

mean age of 39.00 (SD = 18.13) (range: 18 to 89) participated in the present

study. Self-report measures were used to assess trauma exposure and

psychological well-being. Life-time trauma exposure was measured using

the Brief Trauma Questionnaire (BTQ). Psychological well-being was

measured using the 10-item short Psychological Well-Being Questionnaire

(WBQ) developed by the authors of the study. Results: the study revealed

that 69.8% of our sample experienced at least one traumatic event; 55.4%

reported experiences of political violence in their families during the Soviet

Regime. A family history of political violence was a more significant factor in

16Corresponding author: Evaldas Kazlauskas, Department of Clinical and Organizational Psychology, Vilnius University, Universiteto 9/1, LT-01513, Vilnius, Lithuania; E-mail: evaldas.kazlauskas@fsf.vu.lt.

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predicting psychological well-being than personal life-time trauma

exposure. Conclusion: social factors of trauma are important in

understanding the resilience of individuals.

Keywords: Trauma exposure, psychological well-being, political violence,

family.

Introduction

Resilience can be defined as the ability of an individual to recover and

“bounce back” after a significant impact. Traumatic events are an example of a

significant impact that may impair an individual’s health and functioning; however,

the majority of survivors recover, with rather small numbers of survivors having

long-term stress-related disorders in the general population [1]. Resilience may be

viewed as a person's recovery from stress without any mental health disorders later

in life. The lack of stress-related disorders can be an indicator of resilience in a

sample of survivors of traumatic events. However, resilience may also be defined

from a positive perspective, using the terms of “health” and “well-being” rather than

defining as resilient someone who does not have a disorder. We propose that well-

being can be an important dependent variable if we want to measure an individual’s

resilience and we use psychological well-being as an indicator of resilience in this

chapter.

This chapter focuses on the traumatic experiences and psychological well-being in a

post-conflict country with a history of long-term political oppression. Lithuania is a

European Union member with a population of about 3 million, but it was part of the

Soviet Union for almost 50 years. Immediately after the Soviet army entered

Lithuania towards the end of World War II in 1944, large scale persecution of the

Lithuanian population began. Many Lithuanians were arrested and imprisoned for

political reasons as not acceptable for the Soviet political regime. Thousands of

Lithuanians were displaced to remote regions of Siberia, or imprisoned into Gulag

camps [2]. Intense political violence occurred between 1944 and 1953. Soon after

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the restoration of the Independence of Lithuania in 1990, a Law of Acknowledgment

of survivors of political oppression was accepted by the Lithuanian Parliament. After

that, thousands of survivors of political violence and persecution were fully

rehabilitated, a National registry of survivors was founded, and a financial

compensation system for survivors was developed [3].

Political violence can take different forms, but it is always ideology-driven mass

interpersonal violence, and can affect individuals and communities. It is very well

known from world-wide political violence and torture studies, including studies in

Eastern Europe and Lithuania, that political violence has long-term posttraumatic

effects on survivors [4, 5]. These studies revealed that even after decades of political

imprisonment or torture, there are still significant post-traumatic effects on

survivors.

While political violence affects the health of survivors, the impact of political

violence is not limited to survivors of violence only. We must realize that in a post-

conflict society many individuals have histories of parents, grandfathers and other

family members who experienced political violence and persecution. Only two

decades have passed since Lithuania regained its independence; thus, trauma

related to political violence is still vivid in the memories and stories of families, and

we assume that it can still have a significant effect on the psychological well-being of

individuals.

Very few studies have been conducted on the effect on families of political violence

related to the Soviet Regime. Studies from Lithuania [6] and Russia [7] provide

insights about the negative effects of political violence on families, but our

knowledge about the effects of political oppression in former Soviet East European

countries is very limited due to the lack of such studies. However, we know from

meta-analytic studies of intergenerational Holocaust survivors that second- [8], and

third-generation Holocaust survivors [9] do not have significant clinical problems.

These studies demonstrate the resilience of the offspring of Holocaust survivors,

revealing no intergenerational trauma transmission.

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The aim in this study was to evaluate the relationship between psychological well-

being, prevalence of traumatic experiences, and exposure to political violence by

family members during the Soviet Regime in Lithuania.

Method

Participants

A total of 626 adult participants from the Lithuanian general population

participated in the present study and fully completed self-report questionnaires.

Sampling was based on the 2011 Lithuanian Population and Housing Census data.

Age, education level and gender in this study correspond with the Lithuanian

population data.

About half of the sample 59.9% (N = 375) were women, and 40.1% (N = 251) were

men. Age of the participants ranged between 18 and 89 years with a mean of 39.00

(SD = 18.13). The majority of the sample were Lithuanians by their nationality 95.8%

(N = 593); other nationalities were Russians 2.4% (N = 15), Polish 1.1% (N = 7) and

other 0.6% (N = 4). More than half of the participants (63.2%, N = 381) were from the

largest cities in Lithuania (with a population between 100,000-500,000), 21.7% (N =

131) were from towns (with a population between 20,000-100,000), and 15.1% (N =

91) were from rural areas and villages with a population of less than 20,000.

Most of the participants were unmarried 40.5% (N = 251), 35.8% (N = 222) were

married, 10.6% (N = 66) were living with a partner, 6.1% (N = 38) were divorced, and

6.9% (N = 43) were widowed. 51.2% (N = 320) had a university degree, 28.8% (N =

180) had a secondary education, and 20% (N = 125) had an elementary school

education. The vast majority of the participants - 82.9% - were working or studying,

14.7% were retired, and 4.9% were unemployed.

Procedure

The research team included psychology students and PhD level university

researchers, who underwent training before this study and received supervision

during the collection of data. The data collection took place in different regions of

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Lithuania in order to obtain a representative sample of the Lithuanian population.

Participants aged ≥ 18 years who understood the Lithuanian language were invited

to participate and 90.9% of the invited potential participants agreed to participate.

Printed self-report questionnaires were presented to participants individually or in

small groups. The researcher waited until the participant filled in the questionnaire,

offered assistance, and answered questions if the participant did not understand the

instructions or the items. The research was conducted according to Lithuanian

research ethics standards. Signed informed consent was obtained from the

participants. The data was collected in 2013.

Assessments

Life-time trauma exposure

The Brief Trauma Questionnaire (BTQ) [10, 11] was used to assess exposure

to ten potentially traumatic events (e.g. participation in a war zone, serious car

accident, major natural or technological disaster, life threatening illness, physical

abuse in childhood, physical assault, unwanted sexual contact, other situation in

which respondent was seriously injured or feared being seriously injured or killed,

violent death of a close friend or family member, witnessing a situation in which

someone was seriously injured or killed or in which the respondent feared someone

might be seriously injured or killed). Participants had to indicate whether they

experienced a particular event and they assessed how dangerous these events were.

The Lithuanian language version of the BTQ questionnaire demonstrated good

internal consistency with a Cronbach’s alpha coefficient = .74.

Exposure to political violence

Questions about political violence in the family were developed by the

authors of this study. Participants were asked whether a family member or members

were exposed to political violence during the Soviet regime. There were also

questions on the nature of the political violence, family members being imprisoned

for political reasons, forced displacement, or other forms of violence.

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Psychological well-being

The short version of the Psychological Well-Being Questionnaire (WBQ); [12]

was developed by the authors of this study according to Ryff & Keyes’ (1995) theory

of psychological well-being [13]. The questionnaire was comprised of 10 items

reflecting 6 dimensions of psychological well-being: autonomy, environmental

mastery, personal growth, positive relations with others, purpose in life, and self-

acceptance. Respondents indicated their agreement with each item on a 5-point

scale (1, strongly disagree; 2, disagree; 3, neither agree nor disagree; 4, agree; 5,

totally agree). Previous analysis of the WBQ structure including exploratory and

confirmatory analysis revealed that one factor solution explained WBQ the best [12].

The WBQ had good internal consistency in the present sample with a Cronbach’s

alpha coefficient = .85.

Results

The average number of traumatic events in the sample was 1.64 (SD = 1.63),

ranging from 0 to 8. Exposure to at least one life-time traumatic event was reported

by 69.8% (N = 437) of the study participants. One potentially traumatic event was

experienced by one quarter of the participants (25.1%, N = 157), two events were

experienced by 18.5% (N = 116), three or more events were reported by 26.2% (N =

164) of the participants. The most prevalent potentially traumatic events were:

physical assault 31.7% (N = 199), motor vehicle accidents 28.8% (N = 180), and abuse

in childhood 22.5% (N = 141). Men experienced significantly more potentially

traumatic life-time events M = 2.51 (SD = 1.78) than women M = 1.24 (SD = 1.37),

t(624) = 7.53, p < .001.

Political violence was a part of the family history in nearly half (55.4%) of the sample.

No history of political violence experienced by a family member was reported by

28.8% (N = 180) of the participants. 15.2% (N = 95) did not know about the

experiences of political violence in their families. The percentage of participants that

experienced political violence in their families did not differ by exposure to traumatic

events χ2 (1, N = 527) = 0.93, p = 1.00. Political imprisonment of a family member

- 231 -

was reported by 12.4% (N = 77) of the sample, forced displacement - 34.8% (N =

216), other forms of political violence - 20.6% (N = 128).

There was no significant effect of trauma exposure on psychological well-being.

Psychological well-being of participants exposed to at least one traumatic event (M =

38.48, SD = 5.62) did not differ from the well-being (M = 39.22, SD = 5.82) of

participants not exposed to traumatic events, t (590) = -1.46, p = .15. We found a

small correlation between number of life-time traumatic events and psychological

well-being: r = -.09, p < .05.

The two-factor analysis of variance yielded a significant main effect for political

violence experiences in families on psychological well-being, F (1, 496) = 5.85, p =

.02, indicating that the psychological well-being of participants from families with a

history of political violence was higher (M = 39.21, SD = 5.41) than that of

participants from families without a history of political violence (M = 37.91, SD = 5,

75). However, no significant effect was found for trauma exposure F (1, 496) = 1.23,

p = .28, nor was there an interaction effect for a history of political violence in the

family and trauma exposure: F (1,496) = 1.78, p = .68.

Figure 1. Effects of a history of political violence in the family on psychological well-being.

37.0

37.5

38.0

38.5

39.0

39.5

40.0

No Trauma exposure Trauma exposure

Psy

cholo

gic

al w

ell-

bei

ng

Political violence in family

No political violence in family

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Discussion

The prevalence of traumatic events in the Lithuanian sample was similar to

epidemiological data from other European countries [1]. The results also indicated

that political violence during the Soviet regime had a large impact on Lithuanian

society, with half of the population (55.4%) having a history of political persecution

in their family.

Surprisingly, exposure to potentially traumatic events was not related to

psychological well-being. This finding can be interpreted as a manifestation of the

individual ability to recover from trauma, and therefore indicates the resiliency of

individuals after confronting traumatic events. Although we do not take into account

important aspects of trauma, like the severity of the traumatic events, the nature of

the trauma, and the time that elapsed since the traumatic events, the results invite

us to explore factors of resilience. We assume that although traumatic events are

significant life events, exposure to adverse situations are not the main factor

contributing to an individual’s psychological well-being.

Our results confirmed that a history of political violence in the family is a significant

factor contributing to an individual’s psychological well-being. Study participants

from families with a history of political violence reported higher psychological well-

being. Interestingly, we found that a family history of political violence is a more

significant factor in predicting psychological well-being than personal life-time

trauma exposure. These results not only indicate the importance of social factors in

understanding trauma, but also suggest that exposure to political violence can

facilitate resilience and well-being in the offspring of survivors. The importance of

the political aspect of trauma has been demonstrated in previous studies, which

revealed political activity as an important resilience factor in survivors of political

violence [14].

There are several possible explanations why family exposure to political violence can

have such an important role on the well-being of survivors. We may hypothesize that

those resistance fighters and their family members perhaps more easily adapted to

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the social changes of the last two decades for two reasons. First,, the social

acknowledgment of their contribution to Lithuania’s independence may have

contributed to their well-being, as it is known to be very important for healing

processes after massive trauma [15]. Second, perhaps they were more eager to start

a new life, because they experienced many restrictions during the Soviet regime. We

may further assume that families with no history of persecution were better adapted

during the oppressive regime, with some conforming or even collaborating with the

regime. Thus, there is a higher probability that coming from such a family made it

more difficult to adapt to the major social changes of the political system.

Families with a history of political violence due to the Soviet oppression are different

from other families in Lithuania. Target groups of political violence after the

occupation of Lithuania by the Soviet regime were highly educated persons who had

important positions and roles in the community: politicians, priests, teachers,

university professors, etc. [16]. There is a possibility that education and professional

achievements were more valued by the families of victims and survivors of political

violence, even though family members of political prisoners or forced deportees

were restricted in their application to Universities and in their professional positions

during the Soviet regime [6]. A family’s subjective appraisal of political violence-

related stress could have contributed to more efficient coping with stress behaviors

and increased family resilience [17].

Summarizing our findings, we conclude that better adaptation to changes in the

social situation, attitudes and values in families, and a benevolent social context for

survivors of political violence may have contributed to the better psychological well-

being and resilience in families with a history of political violence in Lithuania.

Limitations of the study and future directions

Resilience can be best understood as a process of coping with stress that

takes into consideration the dimension of time. Our study was a cross-sectional

study by its design. In some instances of trauma research, especially in political

violence research, it is nearly impossible to conduct research during times of political

- 234 -

persecution and oppression. The political regime may view such studies as a threat

to the authorities and scientists may be persecuted for trying to investigate torture

and the effects of political violence. Due to this reason, the effects of political

violence are mostly conducted in refugee populations or in post-conflict countries

after the political situation changes. Longitudinal studies that begin immediately

after social changes may reveal important information on human adaptation and

resilience in post-conflict zones, and may be started in the future in other countries

with the help of researchers from other countries.

While we found that family exposure to political violence is an important social

factor contributing to resilience, we didn’t include measures of the relationship

between family members and other family factors, which may be explored further in

future studies.

The study was conducted in Lithuania and the application of the present findings to

other countries may be debated. We could assume that similar results may be found

in other post-Soviet countries in Eastern and Central Europe with a similar history,

e.g. Poland, Estonia, Czech Republic. Even though Lithuanian history and political

oppression related experiences are specific to Lithuanian history, our study indicated

that social factors of trauma are important, and further cross-cultural studies could

reveal more about the role of political violence on the families of victims and

survivors.

Acknowledgements

This research was funded by a grant (No. SIN-01/2012) from the Research

Council of Lithuania. We are especially grateful to Prof. Ask Elklit from the University

of Southern Denmark for his valuable comments and insights during the preparation

of this chapter.

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