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Resilience is the default: how not to miss it. Arieh Y. Shalev and Yael Errera. Introduction. Recent studies of potentially traumatic events show apparently ...
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Resilience is the default: how not to miss it Arieh Y. Shalev and Yael Errera

Introduction Recent studies of potentially traumatic events show apparently paradoxical findings; for example, during the 2001–2004 wave of terror, Bleich et al. (2003) found simultaneous reporting of optimism and of being depressed in a nationally representative sample of Israeli citizens. Shalev et al. (2006) described normal (that is, peacetime) levels of distress in a substantial majority of civilians who were directly exposed by terrorist acts. Galea et al. (2003) and Silver et al. (2002) found limited prevalence of residual distress following the September 11, 2001 attack on New York. These and similar findings have been construed as reflecting ‘‘resilience.’’ Resilience, in this context, is the absence of an expected bad outcome, such as general distress, depression, or post-traumatic stress disorder (PTSD). Following that logic, after an event of the magnitude of the September 11 attacks on New York, or following exposure to terrorist acts, one is either ‘‘traumatized’’ or ‘‘resilient.’’ Assuming that either traumatic response or resilience has a cost, like every reduction of complex realities into dichotomies, using this assumption in research, or even as a manner of speech, entails significant loss of information. It may therefore misclassify or mischaracterize survivors at both ends. Most importantly, construing ‘‘PTSD’’ and ‘‘resilience’’ as the two opposing poles of the same continuum is an assumption that requires further validation. This new use of the term resilience is not without reason. Its roots may be traced to the somewhat exaggerated emphasis placed, during the last decade, on psychopathological consequences of traumatic events, and specifically Intervention and Resilience after Mass Trauma, eds. M. Blumenfield and R. J. Ursano. Published by Cambridge University Press. ª Cambridge University Press 2008.

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PTSD (e.g., Summerfield, 2001; Wessely, 2005; Young, 2001). Whilst not the most frequent outcome of major adversities, PTSD is their better characterized, and better-studied consequence. Indeed, PTSD has become the sine-qua-non of being seriously affected by a stressful event. For example, PTSD and PTSD symptoms were the main outcome measure of studies of psychological responses to the September 11 terrorist attacks (e.g., Galea et al., 2003; Silver et al., 2002), most of whose participants weren’t directly exposed to the attacks. Furthermore, the emphasis on PTSD in the aftermath of September 11 has led to costly and rather ineffectual efforts to ‘‘prevent’’ this disorder by large-scale ‘‘early interventions’’ (e.g., Norris et al., 2002; Shalev, 2006a). A possible reaction to this ‘‘rise of PTSD’’ (Jackson, 1991), the more recent interest in resilience to the effect of traumatic events has already generated much research (e.g., Bonanno et al., 2006; Charney, 2004), including brain imaging and neuroendocrine studies (Bonanno et al., 2006; Freeman et al., 2006; Yehuda et al., 2006). This ‘‘rise of resilience,’’ however, is essentially caught in the abovementioned dichotomy between pathological responses and resilience: resilience in many studies is simply the absence of PTSD. This chapter will argue that such use of this term is poorly informed by previous knowledge about resilience and that expanding it is essential for better understanding of the responses to major adversities, and for better managing of those who endure such experiences. Following are two example of research areas in which ‘‘resilience’’ received much sophisticated elaboration. In child development studies (reviewed in Masten, 2001; Rutter, 1993; and see below) resilience often described the successful survival of major developmental challenges. Here, both ‘‘survival’’ and ‘‘challenges’’ were generic, that is capable of taking many facets, and the specifics of the related risk factors (e.g., early loss, abuse, neglect), outcomes (e.g., life trajectory, schooling, vocational career), and moderators (e.g., education, good mentorship) were defined according to the peculiarities of each case or situation. Childhood development studies of resilience also flexibly accommodated long-lasting, continuous, or ongoing risk-protective and risk-moderating factors, whereas those involving traumatic events often addressed distinct and time-limited events – such as past wars, or previous accidents. The risk factors for PTSD, however, extend from childhood to well after the traumatic event (e.g., Brewin et al., 2000). Bio-ecological studies (e.g., Holling, 1973; Walker et al., 2004) used the term resilience to address complex living systems’ successful survival of evolutionary pressures. These studies offer an interesting taxonomy of resilience, in which there is: (1) ‘‘proper resilience’’ (the system’s capacity to reorganize itself, following adversity, without changing its functioning, structure, and identity), (2) ‘‘adaptability’’ (the capacity of actors within the

Introduction

system to influence resilience) and transformability (capacity to mutate into a new identity, when required). Understanding the array of consequences of a traumatic event in similar terms might offer new insights. This chapter mainly addresses studies of resilience within childhood development. It evaluates lessons learned in this area and their relevance to studies of traumatic events. Within traumatic events, this chapter mainly concerns the early responses and their management. Specifically, this chapter examines the idea that the occurrence of resilience and the development of mental disorders are independent and orthogonal dimensions of the response to traumatic events. It also considers the relevance to the field of traumatic stress of the consistent finding that good adaptation is the most frequent outcome of adversity; the related view that such good outcome is mainly mediated by normal regulatory processes; and the idea that a bad outcome often occurs when the normal adaptive processes are obstructed. Doing so, we hope to derive recommendations for early interventions from the view that traumatic events are a subset of the generic category of adaptation challenge. This view, for example, strongly emphasizes the perception of trauma ‘‘victims’’ as active participants in surviving adversity. It also leads to recommended interventions that organize adaptation, and provide the necessary resources. We will also explore the boundaries to the application of the construct of resilience, i.e., whether promoting resilience suffices to protect survivors from developing mental disorders. In other words, we will try to depict the interface between the biomedical and the socio-psychological models of trauma and its aftermath (e.g., Shalev 2006a; Watson and Shalev 2005). There is a lot of confusion in this area, and the direction of the observed interaction is unclear: on the one hand, those who develop PTSD may not be able to engage in normal adaptation and on the other hand those who do not engage in these processes will develop a disorder (e.g., Horowitz, 1974; Lindemann, 1944). The chapter starts by justifying the need for a new approach to resilience, in the context of potentially traumatic events. It then examines the construct of resilience, using the literature of childhood development as an anchor. The following section explores the implications of perceiving the response to major adversities as a challenge to adaptation, and illustrates the related ‘‘ordinary magic’’ view of resilience (Masten, 2001) by an example of dealing with the terror threat in Israel. Finally we will offer a template for evaluating the quality of survivors’ adaptation at each stage of the early response to traumatic events and discuss signals that should make helpers shift from the stress-management to the biomedical model. The concluding section will examine ways in which the current disease model has generated messages and practices that interfere with resilience.

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Why do we need a new perspective? The occurrence of PTSD in the aftermath of wars, disasters, and individual traumata has been extensively documented. Estimates of the lifetime prevalence of PTSD in the general population (5%–12%, e.g., Breslau et al., 1998; Kessler et al., 1995) make this disorder one of the most frequent mental health problems. Traumatic events (as per DSM IV; American Psychiatric Association, 1994) occur to almost every adult, even during peacetime (Breslau et al., 1998). The conditional probability of developing PTSD following exposure is about 9%, across studies and continents (e.g., Kessler et al., 1995; Perkonigg et al., 2000). Post-traumatic stress disorder is often chronic and very disabling (e.g., Kessler, 2000). These numbers imply an extreme vulnerability of humans to the effect of rather frequent stressors. Indeed, it is hard to conceive of another living species where being exposed to species-specific stressors (e.g., fighting, being injured, being defeated or exposed to violent death) would so frequently lead to protracted distress and dysfunction. Notwithstanding, the human race has somehow survived the 26 years that followed the delineation of PTSD in DSM III (American Psychiatric Association, 1980). Indeed, studies of the most severe stressors (e.g., the Holocaust, protracted exposure to torture or war) consistently show a limited proportion of severely affected individuals. This, along with the realization that traumatic events are widespread and virtually inevitable, have led to conclusions that: (1) a traumatic event is not a sufficient cause of PTSD (e.g., Yehuda and McFarlane, 1995), and (2) the non-traumatic consequences of exposure are worth studying (e.g., Charney, 2004; Frazier and Kaler, 2006). Studying ‘‘resilience’’ to ‘‘trauma’’ is not without difficulties. Both terms are poorly defined (e.g., Layne et al., 2007). Resilience is often the absence of something rather than something. The likelihood of effectively exploring any construct, however, requires enough homogeneity of the related phenomena. Defining resilience as the very frequent good outcome of adversities (i.e., 91% if the conditional prevalence of PTSD is 9%) implies an extremely complex array of risk factors and outcomes. Predictably, such an array will defy any effective exploration. Therefore, studying resilience in large groups, where the expected prevalence of a disorder is low is a close-to-hopeless endeavor: there are many degrees of exposure, many ways of coping with it, and many forms of successful survival. In order to become a subject of study ‘‘resilience’’ must become a specific outcome. A few recent studies used a positive definition of resilience. For example, a study of mock captivity exercises, in the US armed forces, defined resilience as the capacity to successfully cope with pressure and not break down (e.g., Morgan, et al., 2000a, 2000b). Under these specific circumstances it was

Resilience in childhood development studies

possible to identify association with that specific outcome including biological factors. Arguably, these very specific circumstances differ significantly from those encountered by civilians during trauma and disasters. The heterogeneity of exposure in the latter, the persistence of stressors following exposure (e.g., loss, separation or injury), the heterogeneity of those exposed, and the very diverse forms and degrees of harm (compare losing a loved one with seeing the World Trade Center’s towers collapse) defies any good definition of shared ‘‘good’’ outcome. An alternative to considering resilience as a specific outcome is to perceive it as being the default, i.e., that which happens in the absence of specific pathogenic factors. Not being injured in combat can be used as an analogy: it is what happens in the absence of a physical or chemical intruder. Seeing resilience as the default, and using the previously developed multifactorial model of resilience in children can better accommodate the heterogeneity of exposure, the diversity of those exposed, the array of expected responses, and the numerous legitimate and relevant adaptive outcomes. Seeing resilience as the default also assumes an inherent ability of humans to recover from transient misery (e.g., Shalev, 2006b). Practically, it perceives the facilitation of normal adaptation as being essential, and defines the main goal of early intervention as identifying and addressing barriers to adaptation. This approach also assumes that resilience might mean different things to different people at different times, that there are many ways to be resilient, and that the main generic attribute of resilience is a sufficient level of stability and regularity under adversity.

Resilience in childhood development studies Defining resilience Borrowed from the material sciences, the term resilience refers to ‘‘the physical property of a material that can return to its original shape or position after deformation that does not exceed its elastic limits.’’ The origin of the term is the Latin resillire (rebound; re¼back þ salire¼ to jump; Steinmetz and Barnhart, 1999). The assumption of an ‘‘elastic limit’’ is an important one and will be addressed in ‘‘The boundary of resilience’’ below. Applied to psychology, the term resilience has received various definitions (Table 7.1). As can be seen, definitions differ, but all of them pertain to an essential link between a risk and an outcome. Layne et al. (2007) suggested that the term resilience should be reserved for conditions in which there is an initial deflection of the relevant outcome measure (Figure 7.1). This view is in line with Selye’s (1946) General

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Resilience is the default: how not to miss it Table 7.1. Definitions of resilience (adapted from Layne et al., 2007) Pathways to competent adaptation despite exposure to conditions of adversity (Cicchetti, 1996) The individual’s capacity for adapting successfully and functioning competently despite experiencing chronic stress or adversity, or following exposure to prolonged or severe trauma (Cicchetti and Rogosch, 1997) The possession and sustaining of key resources that prevent or interrupt loss cycles (Hobfoll et al., 2000) Good outcome in spite of serious threats to adaptation or development (Masten, 2001) The ability of adults . . . who are exposed to potentially disruptive events to maintain relatively stable healthy levels of psychological and physical functioning (Bonanno, 2004)

Pertinent outcome

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Resistance Resilience Recovery

Attrition

Failure Time

Figure 7.1. Resilience is shown as a V-shaped response in which a transient decline in an outcome measure is followed by rapid return to normal functioning (adapted from Layne et al., 2007 with permission)

Adaptation Response, which also includes an initial deflection (e.g., of blood pressure during hypovolemia). Resilience, therefore, involves an initial loss of functioning and subsequent recovery followed by a quick return to basic functioning (the V-shaped line in Figure 7.1). The absence of an initial decline is defined as ‘‘stress resistance.’’ A delayed return to a previous level of functioning bears the name ‘‘protracted recovery.’’ The failure trajectory leads to an irreversible negative change. Attrition represents good initial adaptation followed by progressive exhaustion and decline. Knowledge about response trajectories has important implications for interventions. Assuming, for example, that stress resistance is rarely followed by decline implies that survivors with little initial impairment are relatively

Resilience in childhood development studies

safe (Freedman et al., 1999). Importantly response trajectories remain open to the effect of response moderators, such as secondary stressors or lack of adequate social support (Brewin et al., 2000). Masten (2001) defines resilience as a relation between a risk factor and an outcome. The relevant outcome, however, may vary between situations and according to personal, group, or cultural expectations. Thus, it is not always explicit. Survivors of abuse are somehow ‘‘expected’’ to have a disturbed emotional life, and would be resilient if they don’t. Inversely, a soldier might be expected to go on fighting despite exposure to death and horror, in which case resilience is the capacity to preserve a military function. The same soldier will be resilient if, upon returning home, he or she does not develop PTSD, or smoothly regains a pre-war level of functioning. Expected outcomes often define what we conceive as ‘‘resilience.’’

Historical perspective Early studies of resilience (e.g., Garmezy, 1971, 1974) evaluated life trajectories of children who grew up under significant adversity. A salient occurrence in these studies was that of children who, paradoxically, showed good adaptation. These children were reverently referred to as ‘‘invulnerable’’ (e.g., Anthony and Cohler, 1987). Early research on resilience also consisted of comparing ‘‘resilient’’ with ‘‘non-resilient’’ survivors of childhood adversity. These studies have identified several personal, environmental, and biographical moderators of the relationship between exposure and outcome. The latter included intelligence, education, or good mentorship (Layne et al., 2007; Masten 2001). These protective factors were often stable and immutable (e.g., IQ, level of education) and therefore rarely amenable to change. Furthermore, the related group comparison (resilient versus non-resilient) could not address the specific ways in which these factors operated (e.g., whether higher intelligence ‘‘worked’’ via better planning, better learning, higher capacity for abstraction, or better choice of an alternative). Subsequent studies of resilience in children concerned qualities of adaptation and their underlying mechanisms (e.g., Masten and Coatsworth, 1998; Rolf and Johnson, 1999). The two salient insights from these studies were: (1) the very frequent occurrence of good adaptation, and (2) the role of normal regulatory processes (e.g., rule-driven behavior, self-monitoring) in positive adaptation. These findings are elegantly reflected in the title of Masten’s (2001) review of the field: Ordinary Magic. The ordinary magic view has lead to recommending interventions that strengthen basic protective systems, such as effective social networks. These interventions have the distinct advantage of mainly addressing behaviors and

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dispositions that concern everyday life and thereby are concrete and relevant. The following extract illustrates this view. The great surprise of the resilience research is the ordinariness of the phenomena. Resilience appears to be a common phenomenon that results in most cases from the operation of basic human adaptational systems. If those systems are protected and in good working order, development is robust even in the face of severe adversity. If these major systems are impaired antecedents of consequences to adversity then the risk for developmental problems is much greater, particularly if the environment hazards are prolonged. (Masten 2001, p. 227)

Masten’s conclusion requires few transformations in order to apply to post-traumatic adaptation: Resilience does not come from rare and special qualities, but from the everyday magic of ordinary, normative human resources in the minds, brains and bodies of children, in their families and relationships, and in their communities . . . It follows that efforts to promote competence and resilience in children at risk should focus on strategies that protect or restore the efficacy of these basic systems. (Masten 2001, p. 227)

Finally, resilience theory developed from addressing static predictors of outcome to evaluating arrays of protective attributes and multiple outcomes (e.g., Layne et al., 2007). This development provided the construct of resilience with the necessary versatility to include a wide variety of situations and outcomes (for more see below). Resilience, thereby, became generic. Characteristics of resilience In a seminal overview of resilience, Rutter (1993) outlined several generic characteristics of resilience (Table 7.2). These attributes and their translation to the field of traumatic stress are the subjects of the following section. Resilience follows exposure The first attribute of resilience (Rutter, 1993) is that it could only follow an experience with stressors. Resilience cannot follow avoidance. It may start Table 7.2. Generic characteristics of resilience (Rutter 1993) Avoidance does not confer resilience Traumatic events are sources of life transitions Multifactorial view of resilience Resilience is domain-specific Similar regulatory processes confer resilience to normal and extreme conditions The individual is the active agent in shaping his or her life trajectory Resilience is significantly affected by its social context

Resilience in childhood development studies

with developing stressor-specific competency and this experience is subsequently generalized to other situations and stressors. The relevance of this point to studies of traumatic stress can be illustrated by a recent survey of two Israeli communities during a wave of terror (Shalev et al., 2006a). In this survey, residents of a highly exposed community showed lower levels of anxiety and distress than those of a community with lower exposure. Rutter’s view can explain this ‘‘paradoxical’’ finding: the highly exposed residents had daily encounters with stressful situations (e.g., taking the road to work) and consequently developed ways to better appraise the actual threat and had more experience of dealing with it. They also had a chance to develop and implement stress-reducing routines (e.g., mutual help in guarding children, radio emitters in cars) and thereby became more confident and eventually less anxious. Soldiers also gain a level of resilience from stressful exposure. However, they may also become more vulnerable. As illustrated below, the immediate outcome of exposure determines its long-term effect: Solomon et al. (1987) showed that veterans of the 1973 Yom Kippur War reacted to retuning to combat zone in the subsequent 1982 Lebanon war with lower levels of distress – except for those who had combat stress reaction in 1973. The latter had much higher levels of stress. Exposure, therefore, can be either protective or sensitizing. Expanding this lesson to the management of acute stress, almost every survivor of traumatic circumstances has both positive and negative lifetime exposure to stressors. Stress, therefore, is never entirely new. Consequently, it might be good practice to help distressed survivors create a link between current occurrences and previously successful experiences. Connecting with inner sources of competency might put survivors’ current experience into better perspective. Helpers as well might wish to perceive themselves and their clients as inherently competent survivors of adversities. Stressful events and life transitions Extending the discussion of the potential benefit of exposure, Rutter (1993) suggested that potentially traumatic life events (e.g., going to war, losing a relative) are also ‘‘transition generating events.’’ This view has important heuristic implications, since it suggests that the occurrence of such events should be evaluated for both negative and positive effects. Importantly, positive and negative effects may coexist. Keeping that perspective is particularly important in the presence of major losses with, apparently, no gain. This is because even minor gains can, sometimes, launch a process of reconstitution. Often-heard expressions, such as ‘‘I lost a son, but realized how many friends I have’’ can make the point: having friends cannot be measured against losing a son. However, the presence of a small ‘‘but’’ is of essence, because it completely denies the totality of the loss. In evaluating people’s inner resources following trauma one might wish to be tuned to the ‘‘but.’’

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The idea of bi-directional effect of exposure also implies that measuring negative outcomes (e.g., PTSD symptoms) predictably leads to showing negative reactions. It is measuring the half-empty part of the glass. In the field of traumatic stress, however, most research instruments evaluate negative responses (such as PTSD, anxiety and depression symptoms). Moreover, all current research instruments have ‘‘no response’’ as the lowest score of their items. Bi-directional instruments might better capture the essence of resilient responses (e.g., I have more or less friends following combat; I have lost or gained interest in life, etc. . . . ). Multiple risks, multiple outcomes, modulators, and moderators Studies of traumatic stress and PTSD implicitly assume a salient single stressor (a rape, an accident) and a preferential outcome (e.g., PTSD). They thereby tend to simplify the exposure proposition in their design – as well as its hypothesized outcome. In reality, however, many of the presumed exposure items (e.g., ‘‘combat exposure’’ or ‘‘rape exposure’’) are extremely heterogeneous, and parameters related to their heterogeneity (e.g., duration and incongruity of the event, perceived controllability of one’s behavior and emotions, perceived outcome) may strongly influence their outcome. The weaknesses of the related simplified outcome have been discussed before. Indeed, when multiple outcomes have been examined in combat veterans (e.g., Rosenheck et al., 1997), the effects were also diverse (e.g., no effect on PTSD symptoms, positive effect of social adaptation). Studies of resilience often consider an array of exposure and outcome variables. The latter can include multiple indicators of development, growth, social insertion, educational achievement, stable marriage, etc. The former may include neglect, abuse, inadequate parenting, lower education, etc. Two consequences of the multiple-causation/multiple-outcome view of resilience studies are worth considering here. Firstly there is, the abovementioned idea that contributing factors can be expressed in continuous and bi-directional variables – as in the following citation: . . . most risk factors actually index continuous bipolar dimensions that have a positive end associated with positive outcome (e.g., good parenting versus poor parenting, high education versus low education) as well as negative end associated with negative outcome. (Masten, 2001, p. 228)

Secondly there is, the idea that the effect of a risk factor strongly depends on the co-occurrence of other risk or protective factors and on ‘‘contextual’’ factors. For example, authoritative parenting may be protective in a rough neighborhood, and counter-productive in more affluent areas, where much more depends on one’s capacity to choose. Rutter (1993) suggested that the occurrence of resilience is better understood by assuming multi-causality (several contributing factors needed

Resilience in childhood development studies

for an outcome to be reached), equi-finality (an outcome can be reached in many ways) and multi-finality (similar factors can lead to diverse outcomes). This view has direct implications for interventions. It makes the generic tasks of a responder to: (1) maximize resources, and (2) minimize the effect of an array of situation-specific risk factors. The perception of the resilience as an array of positive outcomes that results from a matrix of risk and protective factors places this construct in the domain of open systems. The result of using restricted clusters of contributing factors is often a significant proportion of unexplained variance of the outcome (e.g., Shalev et al., 2006). It may also explain inconsistencies across studies. A previous paper (Shalev et al., 2006b) has argued that whilst restricted models might be tolerable in studies of chronic PTSD, they are extremely counter-productive in studies of early responses to traumatic events, in which symptoms are ‘‘polymorphous and labile’’ and the surrounding reality has major and rapidly changing effects. Domain-, time-, and situation-specific resilience Another important insight from studies of resilience is the above-mentioned domain-specific resilience. Accordingly, there might be functional or emotional domains in which an exposed person reaches good adaptation (e.g., in work performance) and other areas of lesser success (e.g., emotional regulation). This is quite frequently seen in trauma survivors as well (e.g., return to work despite persistent dysphoria), specifically during prolonged adversities, during which a preference has to be given to one domain over another (e.g., one must continue to perform as an effective parent despite personal difficulties). A parsimonious formulation of this idea is that many exposed individuals are both resilient and impaired. Several insights may be derived from this view. Firstly is the need to independently assess various domains of performance. Secondly, one has to carefully choose time-, situation-, and person-specific domain(s) as relevant dimensions of resilience. Thirdly, a limited success in one domain (e.g., return to work) may lead to more optimistic self-appraisal and thereby contribute to a better general outcome. The boundary of resilience As we have suggested in the introduction of this chapter, resilience and mental disorders should be seen as independent and orthogonal dimensions of the response to traumatic events. The two may coexist, in fact; for example, a patient with PTSD can be resilient in that he or she keeps working despite significant difficulties, or successfully masters spells of anger. Conversely, the absence of PTSD symptoms or depression in exposed individuals should not be confounded with resilience: a survivor’s life may be shattered in many other ways. The orthogonal dimension argument is incomplete, however, without better specifying the difference between the two dimensions. The PTSD (or ‘‘disorder’’)

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dimension is characterized by specific symptoms – or lack thereof. Resilience, in contrast, may have different expressions. It is, therefore, a generic outcome. There are several ways to conceive of such a generic outcome. One pertains to remaining within homeostatic control. Another can be borrowed from descriptions of coping efficacy. Considering the first approximation, resilience concerns the general capacity to conserve cardinal parameters of a system despite pressure, or to change without reaching critical conditions. This is expressed by Rutter’s insistence on preserving rule-driven behavior during adversity. Applied to traumatic stress responses, a failure or resilience might be equated with the loss of the capacity to modulate the effect of, and monitor the response to, internal and external stimuli. Poor resilience is therefore an attribute of a system that had lost its buffers. An approximation of the ‘‘coping efficacy’’ view (Benight and Harper, 2002) might be sought in Pearlin and Schooler’s (1978) four dimensions of behavioral expression of a failure to cope. These four include: (1) poor emotional control, (2) negative self-perception, (3) inability to pursue task performance, and (4) loss of the capacity to enjoy rewarding interpersonal contacts (and thereby to benefit from social support). These four dimensions can be seen in some survivors and not in others – including some PTSD patients and not others. A failure to cope can also be observed under other stressful conditions, such as having cancer, or experiencing separation or loss. All these conditions may result in better controllable and less controllable reactions, and better or poor conservation of the above four parameters of coping. The nature of normal adaptation The ‘‘ordinary magic’’ view suggests that resilience principally involves continuity (i.e., of meaning, of personal identity). A ‘‘trauma’’ in contrast is often perceived as discontinuity (e.g., with previous life, with one’s earlier identity; e.g., Omer and Alon, 1994). These contrasting views have several practical implications. The resilience perspective emphasizes that which, within a stressful situation, is still stable and reliable, whereas the ‘‘trauma’’ perspective enhances novel and often incongruous experiences. Accordingly, rescue workers can be trained to expect entirely novel experiences when disaster strikes (i.e., have a ‘‘discontinuous’’ experience) or be taught to trust their life experiences in dealing with the new occurrence (the ‘‘continuity’’ view). Because both approaches create expectations and may color rescuers’ perception of realities, both can be self-fulfilling. Arguably, the emphasis on continuity within changing circumstances offers the better solution. The individual as active agent Beyond continuity of meaning and action, successful adaptation requires deliberate effort and decisions (Rutter, 1993). Ultimately, resilient individuals

Trauma as challenge to adaptation

are also those who had made proper choices (e.g., not to use drugs). Survivors of prolonged adversities might be demoralized, helpless, and defeated, and therefore at risk of drifting (e.g., gangs or drug habits) and not trusting their capacity to choose. Restoring survivors’ capacity to actively direct their lives often may start by helping them make small choices and experience small amounts of ‘‘pleasurable success.’’ A previously published descriptive study of survivors of a terrorist attack could help in ‘‘translating’’ this view to the management of acute traumatic circumstances (Shalev, 1993). In that study I described how severely injured survivors were still attempting to cope – often with secondary dimensions of the stress (e.g., having to break the news to relatives). We also described how partial success in these efforts helped survivors to regain a sense of mastery and lowered their anxieties. It seems important, therefore, to provide trauma survivors with opportunities for active participation and pleasurable success. It might also be important to validate their limited achievements, as they occur. Successful adaptation and rule-driven behavior Another insight from studies of resilience concerns the adaptive role of maintaining rule-driven behavior despite pressure (as opposed to chaotic or disorganized responses). Individuals whose behavior is guided by internal rules, norms or beliefs may better survive harsh living conditions. This is old truth, in fact: armed forces produce combat-resilient service personnel via harsh training, in which they learn to maintain rule-driven behavior under pressure (e.g., follow orders despite fatigue or anger, use ammunition sparingly and purposefully). Because rule-driven behavior is such an important mediator of resilience, the occurrence of unruly or erratic behavior during disaster should be a prime candidate for early interventions. Intervention at the aftermath of traumatic events should similarly attempt to help the survivor recover from poorly modulated states of mind, such as dissociation, paralyzing anxiety or overwhelming fear. These uncontrollable states of mind, and the subsequent sense of disarray and defeat, have been linked with maintaining PTSD symptoms over time (Ehlers, 2006; Fullerton et al., 2000; Marmar et al., 1994; Shalev et al., 1996).

Trauma as challenge to adaptation Implications of the ‘‘ordinary magic’’ view Conceiving the responses to extreme stressors as essentially engaging basic processes of human adaptation has several additional implications that may help shift the focus of observation from tracking potentially ‘‘pathogenic’’ processes to monitoring the extent to which normal reparative processes can operate. This view can be illustrated by the following text (Box 7.1), which describes various ways in which Israelis coped with continuous terrorism during the years 2001–2004 (Shalev, 2005).

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Box 7.1 Uncharted and common ways of coping Clearly, humans are more resilient than current risk-averse culture leads us to assume. Not that most humans are heroes, or otherwise extremely well trained for missions and fight: resilience is probably an attribute of ordinary people. Resilience of the normal type (as opposed to the often depicted heroic resilience under combat stress or during captivity) might be the best lesson we have learned from the response to terrorism in Israel. Having survived three years of intense terrorism in Israel, several patterns of resilience emerge as follows. A frequent way of adjusting to terrorism has been to progressively shift expectations, in ways that enabled most people to successfully live another day, and another week. When living without terror became an illusion, people would be encouraged if terrorist acts did not happen for a week, or a month. When terror occurred, a small number of casualties was a good sign. When one could not go out without risk, returning home unharmed became a small victory . . . Similarly, people came to appreciate non-conflictual areas of living and re-prioritize life accordingly. For many, the family became the focus of attention. Feeling safe was more important than being entirely free. Overcoming difficulties superseded risk aversion, etc. Importantly, for those who managed to cope well, the new priorities were chosen such that they were achievable and within reach such that relative satisfaction could follow. Consequently, most people could develop a routine of living under terror. This was particularly obvious in residents of highly threatened areas who, for example, had to plan their entire day based on roadblocks and other constraints. Within days, people found new ‘‘arrangements’’ for getting their children back from school, leaving work earlier or carefully planning previously spontaneous activities, such as driving to work or shopping. Another prevalent way of coping was to re-structure space and time into threatening and non-threatening components. This was often done by assigning degrees of threat to situations and places and organizing one’s behavior accordingly. Thus, each of us had his or her virtual map of fear, which, for some, forbade the travel to East Jerusalem, for others (e.g., residents of Tel Aviv) excluded visits to Jerusalem at all, and yet for others allowed local groceries but excluded shopping malls. These virtual maps seem to have kept people in an illusionary but functional control pertaining to the risk they were ready to take. As long as they were proven stable and reliable, fear maps worked to reduce distress and apprehension. However, as soon as the reality defied one’s virtual map, there was distress and concern. For example, it was believed, at some point, that

Dimensional view of early responses to adversity

Fridays are relatively safe because of their meaning for Islam. When a terrorist bomb exploded one Friday this particular map was betrayed and distress followed. The same distressing shift happened when a bomb hit the Frank Sinatra cafeteria, at the Hebrew University, a would-be safe place that hosted Jews and Arabs in the presumed sanctuary of Academia. Similarly, when a suicide bomber exploded in the midst of a large Pesach celebration in a hotel, readjustment had to be made and strong emotions emerged. The case of the ‘‘Moment cafe´’’ in Jerusalem is similar: this hub of left-wing liberals and international media crowd was supposedly safe, and many Jerusalemites were utterly shocked by its being targeted by terror. But virtual safety maps took a few days to reconstruct, and within such time, most people regained a sense of orientation and relative mastery over their acts and whereabouts. In that sense, one might say that terror did not succeed in creating prolonged havoc and fear, mainly because of the simple, unintended, day-by-day capacity of ordinary people to adjust. The necessities of daily living were another obvious reason for people’s perseverance and persistence. One had to work. One had to have one’s children go to school. Exams were waiting for students, investments for businessmen, babies were born, and weddings planned in families. None of these could be stopped or critically postponed. No one could seriously afford to stop living. Ultimately, the major resilience factor, in Israel, and probably elsewhere, is life’s immense attraction. For as long as one is not depressed or pathologically anxious, life is fundamentally appealing, pleasure and satisfaction are found – or invented – and terrorism, at least at the dimension in which it was present in Israel, does not stop it.

Dimensional view of early responses to adversity To further illustrate the perspective of normal adaptation, Figure 7.2 (adapted from Shalev, 2006b) depicts a way in which interventions can be tailored to time-dependent needs. The figure offers a schematic three-dimensional space within which the early responses take place. It comprises a stressor severity (‘‘demands’’) dimension, a temporal progression axis, and a resources dimension. It illustrates the idea that the early responses to traumatic events are demand-dependent, resource-dependent and time-dependent. The schema is meant to help guiding early interventions as now described. Interventions, tailored on this schema, should address three core targets: the presence and intensity of ongoing demands (e.g., a missing child in a disaster scenario), the intensity and the adequacy of current responses (e.g., the occurrence of uncontrollable dissociation), and the availability of resources

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Demands

Figure 7.2. Three-dimensional depiction of the interaction between stressor (‘‘Demands’’) resources and time in the early aftermath of a traumatic event

(acceptable and willing supporters). Helpers should assess these three dimensions and address one that is (1) critically problematic and (2) manageable. At another level, this schema communicates what we found to be the case in recent terror attacks: there is always something to do to help distressed survivors. When little can be done to reduce the main stressor (as in the case of sudden traumatic loss), reducing survivors’ loneliness is not a bad idea. When reality is truly terrible (as in the case of repeated terror, torture, siege, or captivity) a sense of belonging becomes a major resource. There is much to do before, and often instead of, formal treatment interventions.

Identifying the boundaries of resilience Clarity concerning the boundary between assuming ‘‘resilience’’ and reacting to the risk of developing a mental disorder is extremely important. Unfortunately, drawing this boundary is not an easy task. Conceptually, the boundary might be traced to differences between stress (a homeostatic approach) and mental trauma (a breakdown of defenses) (Shalev, 2006b). The metaphor of ‘‘elastic boundaries’’ can illustrate this view. From a practical perspective, however, some specific symptoms and behaviors might indicate that such a boundary has been reached. Following are some hints that should make helpers shift from a ‘‘stress-management’’ to view preventing PTSD. Post-traumatic stress disorder symptoms persist in those who develop the disorder (Shalev, 2007). The persistence of early PTSD symptoms in survivors who have been brought to safety is a good indication of risk. Some early symptoms have been identified as robust risk indicators of PTSD. Survivors who express the full syndrome of acute stress disorder (ASD, DSM IV) are at a very high risk of developing chronic PTSD (Harvey and Bryant, 2000). Identifying survivors with full ASD including its dissociation component (Ursano et al., 1999) should lead to early and dedicated treatment. The association of depression and PTSD should also be considered as a robust risk indicator of the disorder (Freedman et al., 1999).

How to miss or weaken resilience

Finally, a pathological course may be inferred when (1) PTSD symptoms, or symptoms of depression dominate the survivor’s inner experiences (2) when such symptoms are pervasive and do not allow other experiences; (3) when the emotional consequences of a trauma forcefully determine behavior or interfere with biological functions (sleep, appetite). Importantly, many people who develop these symptoms are still resilient – at least resilient to the point of not seeking help or continuing to try to pursue whatever function they have in life despite feeling overwhelmed. These ‘‘resilient’’ ASD patients should not be mistaken for being out of risk. During years of experience we have seen many such survivors seek help too late, or hesitantly, or in the wrong place. An advantage of not confounding PTSD with resilience is that such survivors should be advised to seek professional help in time.

How to miss or weaken resilience A discussion of resilience to traumatic circumstances cannot be complete without critically appraising some current attitudes towards traumatic stressors, and their potential outcome. Spoken harshly, during recent decades every possible effort has been made to emphasize the potentially pathogenic outcome of stress. Pertinent examples include formally defining virtually every sudden and negative occurrence as a putative cause of a mental disorder (DSM IV; American Psychiatric Association, 1994). Handing the prevention of the presumed consequences to medical and psychiatric experts, who know how to ‘‘intervene’’ and ‘‘prevent,’’ is another aspect of this trend. Disregard for normal and adaptive reactions and confounding them with symptoms of a disease followed. Finally, belief in the wisdom of ordinary people was rarely expressed, if ever, in advice given to the public, which often consisted of instructions to follow. Arguably, this has led to disseminating fear and weakening resilience. The following table depicts several ‘‘great’’ ways to miss or weaken resilience (Table 7.3). It requires few commentaries – other than to specify what it alludes to. Dramatize refers to a general preference given to particularity, emotionality, and turbulence (at the expense of factual reporting and referring to generic elements of a situation). Exploring the roots of dramatic reporting (e.g., in the struggle to draw attention) is beyond the scope of this paper, but its negative effect on how people (and particularly children) perceive events and recover from their consequences received ample attention following the September 11 attacks. Pathologize refers to emphasizing the potential health hazards of psychologically stressful events or referring to early reactions as symptoms of mental disorders. Since humans generally overestimate potential losses (e.g., Kahneman

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Resilience is the default: how not to miss it Table 7.3. Eight ways to miss and weaken resilience Dramatize Pathologize Catastrophize Create negative expectations Blur boundaries (e.g., between mental disorder and responses) Lie, mislead, misinform or otherwise manipulate information ‘‘Intervene’’ (and emphasize the role of experts) Ignore, show distance or indifference, lack of sharing

and Tversky, 1979), the fact of emphasizing a dreadful risk (i.e., of developing a mental disorder) is a powerful modulator of appraisal and behavior. Catastrophize, mainly refers to the use of extreme expressions (e.g., evil) and to other ways of depicting events as totally out of the ordinary, entirely unrelated to one’s daily experience and competences. Creating negative expectations refers to expectations embedded in information given about expected bad reactions (e.g., it is normal to experience nightmares, anxieties, and restlessness) in the absence of eventual good reactions (e.g., you might be poised to act, and eager to share your experience and help). Blur boundaries, for example address, in treatment, the fact that everyone has been exposed to a stressor. Manipulating information, for example when ‘‘informing’’ is too heavily contaminated by a desire (and a skill) to shape the recipient’s behavior. This often comes at the expense of providing information that is timely, accurate, and reliable and may ultimately lead to mistrust, confusion, and anxiety. Information during trauma should be treated as a major resource, the prime qualities of which are its accuracy and reliability. ‘‘Intervene’’ refers both to emphasizing the need for specialized expertise and giving preference to top-down processes – at the expense of individuals’ resourcefulness. Finally, these and other mistakes often lead to allocating too much attention and too many resources to ‘‘therapeutic’’ interventions based on a disease model; within such intervention, to individuals (rather than groups); within individuals, to symptoms (rather than adaptation); and in the context of symptoms, to putative biological processes (rather than to perceived stressors, responses, and resources).

Conclusion This chapter examined the construct of resilience, as applied to traumatic stress disorders, and especially to the acute responses to traumatic events.

Conclusion

Attempting to offer a new perspective, we described resilience not as the absence of a disorder or a bad outcome, but rather as the frequent occurrence of successful survival of adversities. We suggested that one should disassociate the fact of resilience from the occurrence of mental disorders. We discussed the practical implications of this view, such as identifying resilience within illness in trauma survivors, and delineating the boundaries between assuming resilience and observing precursors of mental disorders. Resilience has been defined here as the mediator between risk and outcome. We suggested that among the relevant risk factors for appraising resilience one should count the realities of traumatic exposure, its meaning for the survivor, its place in the survivor’s life trajectory, the survivor’s perceived goals and situational constraints, and communities’ appraisals of an expected behavior. The pertinent outcomes of resilience should similarly concern many levels of emotional, cognitive, social or vocational adaptation. We argued that there are many resilience trajectories and many ways in which survivors can fully or partially recover and ultimately return to an ‘‘ordinary’’ life. We perceive resilient survivors as having scars, and diseased trauma survivors as having open wounds. Because resilience concerns different domains of adaptation, defining it is not a simple goal. We suggested that the capacity for resilience is acquired via repeated exposures with successful resolution. The idea that resilience is the default, and that it is mediated by normal adaptive processes has led us to suggest that it is essential to identify and monitor barriers to normal adaptation in the early aftermath of traumatic events. We further suggested that every trauma survivor has a track record of successfully coping with adversities in the past (as well as a track record of failures) and that evoking the former might lead to better dealing with the present. We proposed that survivors are not only active participants in their recovery, but that they often have to make difficult choices in order to recover and regain their autonomy. Using an example of population under the threat of terror, we addressed the importance of flexibility in coping with continuous adversity and the specific advantages of being able to shift priorities, recalibrate expectations, re-create safe territories and continue with life despite constraints and hazards. Addressing the boundaries of resilience, we suggested that resilience does not end when symptoms begin, but rather when, with or without specific symptoms, survivors fail to cope with novel situations, give up, and lose their ability to modulate the effect of internal and external demands. The specific indicators of a failure to cope (demoralization, loss of emotional control, declining task performance, and interpersonal gap) might be taken as signaling problematic resilience. Specific and unrelenting symptoms should be seen as precursors of PTSD and lead to targeted interventions. The consequences of traumatic events are essentially bi-directional. Some people gain, in that they successfully deal with the opportunities for life

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transitions that such events can create. Other people lose, and in many different ways. Intervention in the acute aftermath of highly stressful events should address their potential for a bi-directional solution, and instruments that evaluate these interventions should also be tailored to the task.

Acknowledgments This work was supported by PHS/NIMH research grant MH071651 to Dr. Arieh Shalev.

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