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Resiliency: Enhancing Coping with Crisis and Terrorism

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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
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 Katie Cherry
Resilience After Trauma 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 Mooli Lahad
Survival? Dima Leykin 125
Chapter 8 Michal Shamai
Couples in the Line of Fire: Couples' Resilience in Guy Enosh
Preserving and Enhancing their Relationships Ronit Machmali-Kievitz
Saray Tapiro 155
Chapter 9 Limor Aharonson-Daniel
Community Resilience Assessment - Meeting the Mooli Lahad
Challenge - the Development of the Conjoint Dima Leykin
Community Resiliency Assessment Odeya Cohen
Avishay Goldberg 179
Chapter 10 Dima Leykin
Stress and Resilience in the Midst of a Security Limor Aharonson-Daniel
Tension Mooli Lahad 206
Chapter 11
A History of Political Violence in the Family as a Evaldas Kazlauskas
Resilience Factor 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.

1
Corresponding 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.

-7-
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.

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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.

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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).

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 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

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

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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 19 th 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

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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,

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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.

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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

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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

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(“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

- 22 -
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.

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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

- 24 -
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].

- 25 -
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

- 26 -
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.

- 27 -
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%.

- 28 -
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.

- 29 -
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.

- 30 -
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.

- 31 -
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

- 32 -
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

- 33 -
 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.

- 34 -
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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

3
Correspondence: 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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 Chapter 3

Resilience after Trauma

Katie CHERRYa and Sandro GALEAb4

a
Department of Psychology, Louisiana State University
b
Mailman 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

4
Correspondence: 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-
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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
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[22] J. Phifer & F.H. Norris, Psychological symptoms in older adults following
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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

5
Correspondence: 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

6
Corresponding 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

7
Correspondence: 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 1011 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

8
This search was conducted on 22.02.2014

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while still being able to continue functioning 19. The Resilience Alliance 9 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 processes 10.
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

9
A 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 mechanism 11 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
a
Community Stress Prevention Center, Kiryat Shemona, Israel
b
PREPARED center for Emergency Response Research , Ben Gurion University of the Negev
C
Tel 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

12
Corresponding 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, Emotions Role, Others, Intuition, Reality, Action,

Ideology Organiz-ation Humor Knowledge Practical

Frankl Freud Erikson Jung Lazarus Pavlov

Maslow Adler De Bono Ellis Watson

Rogers

Attitudes Listening Social Role Creativity Information Activities

Beliefs Skills Structure Play Order of Games
preference
Life-span Emotions Skills Psychodrama Exercise
Problem-solving
value Ventilation Assertive-ness "As-If" Relaxation
Self-navigation
clarification Acceptance Group Symbols Eating
Self-talk
Meaning Expression Role-play Guided Work
Imagery/
Fantasy

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 B, PH
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]
A low tendency towards problem avoidance or fatalism [24, 27] C, B
Sense of self; cognitions of self-efficacy and self-esteem; internal B, C
locus of control; high self-directed personality; self-
understanding [21, 28-30].
Availability of an emotionally stable and trustworthy person A, S
during early childhood; secure attachment style [31-32].
Higher emotional well-being; positive emotionality; emotional A, S
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].
Temperamental characteristics of a child which favour de- S, A, PH
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].
Curiosity, motivation and joy in exploratory behaviour already as I, A
an infant, as well as motivation to observe and listen; creativity

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 Factor/s BASIC Ph
[40].
The ability of the child to postpone gratification; gratitude, self- B, C, A, I
control, forgiveness, creativity and faith; self-regulation [41-44].
Optimism; positive future orientation; positive cognitions about B
the self, the world, and the future [33. 45-47].
Higher IQ; fewer cognitive complaints [33, 48]. C
An open educational climate directed towards the acquisition of B, I, C
autonomy [49].
Socially competent behaviour despite chronic stress; helpfulness; S
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].
Physical activity/attractiveness [52. 53]. Ph
Confident optimism, productive activity, insight and warmth, B, Ph, A, C, I
skilled expressiveness [54]
Responsible, conscientious, and generally exhibiting a high B, C, S, I
degree of personal integrity; low neuroticism, high extroversion
and openness to experience; agreeableness [55. 56]
Adaptive defense mechanisms such as affiliation, altruism, S, B, I, A
anticipation, humor, self-assertion, self-observation and
sublimation [30].

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 ()
1
Craig [70] US adults; 18-93 534 .77 NA .83 .57 .87 .76
Lahad & Undergraduates
170 .46 .34 .84 .70 .74 .70
Leykin [71]2 19-53
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 & Emergency medical
110 .54 .66 .76 .68 .87 .72
Fisher [74] 3 providers; 21-61
Erez &
Online sample, 16-76 114 .72 .87 .70 .57 .78 .70
Laviod [75] 3
Gelber & Social sciences
222 .67 .78 .87 .67 .78 .72
Dodek [76] 3 undergraduates; 21-46
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

Coping Psychological Correlates Demographic Correlates

Mode

Belief Optimism(+)1; Agreeableness (+), Female Gender2; Younger Age2;;

Conscientiousness (+) , Openness Lower Income2,3; Greater
2
to Experience (+) ; External Locus Religious Affiliation2; Single
of Control (+); Positive Belief in Just Status9
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

Affect Trait Resiliency (-)2; Emotional Female Gender2,1,3,4 , Younger

Stability (-); Self-Efficacy (-)3;
Expressive Aggression (+)2; Stress
Symptoms (+)4; Secondary
Traumatic Stress Symptoms (+)8;
Posttraumatic and Peri-traumatic
Symptoms (+)9
Age2,3; Older Age1; Lower
Income2; Higher income (when
measured by positive emotional
coping)9 ;Single Status2,9;
Divorce of Parents2;

Social Feelings of Belonging (+)5; Female Gender2,1,3; Younger

Perceived Social Support (+), Self- Age2,3; Lower Income2; Single
Efficacy (+)3; Avoidant Attachment Status2,9, Divorce of Parents2
Style (-)6; Stress (+);Peri-traumatic
Symptoms‫(‏‬+)9

Imagination Posttraumatic and Peri-traumatic Female Gender2,3,4; Single

Symptoms (+)9; Secondary Status2,9
Traumatic Stress Symptoms (+)8;
Fantasy Proneness (+)7,3; Avoidant
Attachment Style (-)6; Trait
Resiliency (-)2; Optimism (-)1;
Gratitude (-)2

Cognition Well-Being (+); Psychological Male Gender2,1,4; Older Age2;

Distraction (-); Feelings of Higher Income2; Higher
Belonging (+)5; Depression (-)5,7; Education2; Married Status2
Anxiety (-)5; Posttraumatic
Symptoms (+)9; Secondary
Traumatic Stress Symptoms and
Burnout (-)8;Positive Affect (-)5;

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Coping Psychological Correlates Demographic Correlates
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 (+)

Physiology Avoidant Attachment Style (+)6; Female Gender2,1,3; Older Age2;

Trait Resiliency (+)2; Perceived Higher Income2; Single Status9
Social Support (-)3; Inspiration (+)2;
Secondary Traumatic Stress
Symptoms (+)8; Posttraumatic and
Peri-traumatic Symptoms (+)9

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

13
Corresponding 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

Variables High Exposure Time-Limited MANOVA

Exposure

M SD M SD F Partial
Eta
Squared

Couple Resilience 5.13 1.06 5.49 0.98 4.93* .03

Loss of Couple's 2.39 0.89 1.71 0.76 27.91*** .14

Psychological Resources

Gain of Couple's 2.63 0.86 2.04 0.98 15.28*** .08

Psychological Resources

The Couple Relationship 5.36 1.04 5.67 1.06 3.40N.S. .02

Negative implications for 3.13 3.70 0.85 1.74 24.44*** .12

the Couple Relationship

Positive implications for 5.05 3.92 1.85 2.59 7.09** .04

the Couple Relationship

No-implications for the 5.36 1.04 8.30 3.14 35.28*** .17

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

Variable

Exposure
1 Level of

Resilience
2 Couple

Resources
Psychological
3 Loss of

Resources
Psychological
4 Gain of

Relationship
5 Couple

Implications
6 No-

Implications
7 Negative

Implications
8 Positive
1 1
2 -.17* 1
3 .38** -22** 1
4 .29** -.06 .56** 1
5 -.14 .83** -.12 .04 1
6 -.41** .28** -.37** -.34** -.40** 1
7 34** -40** .24** .08 .30** -.58** 1
8 .20** .01 .23** .35** -.01 -.71** -.16* 1
*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

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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).

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 Resilience
-.17 -.33
Exposure Negative
.26
Implications
-.16
.37 -.25
Resource Positive
.29 Loss Implications
.30
.50
Resource
Gain

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.

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 Resilience
-.17 -.33
Exposure Negative
.26
Implications
-.16
.37 -.25
Resource Positive
.29 Loss Implications
.30
.50
Resource
Gain

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

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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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War. Journal of Nervous and Mental Disease, 189(2010), 180-186.
[65] P.A. Joyce, R. Berger, Which Language Does PTSD Speak? The “Westernization”
of Mr. Sánchez. Journal of Trauma Practice, 5(2007), 53-67.
[66] D. A.Kenny, T. Ledermann, T. (2010). Detecting, measuring, and testing‫‏‬dyadic
patterns in the Actor-Partner Interdependence Model. Journal of Family
Psychology, 24(2010), 359-366.

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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.
b
Dep. of Emergency Medicine, Ben-Gurion University of the Negev, Beer-
Sheva, Israel
c
Dep. of Psychology, Tel-Hai College, Israel
d
The Community Stress Prevention Centre (CSPC), Kiryat-Shmona, Israel
e
Dep. 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

14
Corresponding 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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 1 1.1 Public seminar and expert panel: CR Definition 3/2010

Contextuali
zation
1.2 Literature Review seeking existing instruments

1.3 Interviews with instrument developers

1.4 Content expert first meeting: Mapping the field 10/2010

2 2.1 Identification of common fields (Table 1)

Development
Instrument

2.2 Decisions regarding tool components

1/2011
Nominal group Technique Delphi Survey
2-4/2011
CCRAM tool pilot version

3 3.1 Comparing final questionnaire to initial topics

Instrument validation

7/2011
3.2 Feedback from experts
3.3 Pilot study (n=886 participants) 9-11/2011

Statistical Analysis: Factor Analysis & SEM 12/2011

Pilot study results 1/2012

CCRAM tool final version 8/2012

Ongoing/Periodic assessment

Report Community Resiliency Indicators

Figure 1. Stages of the Conjoint Community Resilience Assessment Measure (CCRAM)

evolution.

Phase 1: Contextualization
Public seminar and expert panel: On March 15 th 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,

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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
Category/Theme A B C D E
Social relationships within community 7 2 2 7
Social support factors 7 1 3
Personal sense of security 5 5
Community organization towards crisis 2 2
Meaning of living in the community 1 3 3
Coping with crisis (community) 1 2 2
Satisfaction with municipality in routine 1 6
Continuity of municipality function in crisis 4 8
The perceived effect of the individual on the 1 1
community
Population needs in crisis situation 2 1

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 Source Questionnaire
Quality of life in the community 1 12
Future of the residential place 1 1 1 1
Community in relation to other places 5 1
Employment in or near residence 1 1 3
Prospects for involvement in the community 1 2 3 11
Local leadership 3 1
Trust in national leadership and authorities 7 4
Attitude towards military solutions to conflict 6
Total 27 7 12 28 70

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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‫‏‬

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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
a
PREPARED center for Emergency Response Research
b
Community Stress Prevention Center, Israel
c
The 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

15
Corresponding 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/
100 (52.6) 191 (78.6)
with spouse
Divorced/
13 (6.8) 27 (11.1)
Separated
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 Urban Settlement
138 (72.3) 165 (67.6) 1.09
residence
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
2
Gender .01

Family
.28* .28*
Status3

Education4 .01 -.08 -.05

Place of
-.05 .13* .06 .03
residence5

Age .56* .32* .46* -.08 .05

Income .31* .24* .36* .09+ .08 .41*

Religiosity -.26* -.07 -.10* .04 .03 -.19* -.16*

Stress
-.44* -.15* -.24* .01 -.03 -.36* -.26* .09
symptoms
Sense of
-.38* -.20 -.27* .02 -.01 -.39* -.26* .10 .63*
Danger
Individual
.51* .10 .22* .09* -.03 .39* .30* -.14* -.41* -.35*
Resilience
Community
Resilience .23* -.07 .05 .04 -.21* .17* .10* -.02 -.19* -.19* .22*

National
.58* .04 .30* -.06 -.07 .46* .25* -.16* -.30* -.31* .36* .36*
Resilience

1
0- 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

a
Department 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

16
Corresponding 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

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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.

40.0
Political violence in family
No political violence in family

39.5
Psychological well-being

39.0

38.5

38.0

37.5

37.0
No Trauma exposure Trauma exposure

Figure 1. Effects of a history of political violence in the family on psychological well-being.

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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

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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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