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NATURAL DISASTER RESEARCH, PREDICTION AND MITIGATION

MASS TRAUMA

IMPACT AND RECOVERY ISSUES

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NATURAL DISASTER RESEARCH, PREDICTION AND MITIGATION

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NATURAL DISASTER RESEARCH, PREDICTION AND MITIGATION

MASS TRAUMA

IMPACT AND RECOVERY ISSUES

KATHRYN GOW AND MAREK CELINSKI EDITORS

New York

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Mass trauma : impact and recovery issues / editors, Kathryn Gow, Marek Celinski. p. cm. Includes index. ISBN: 978-1-62081-584-7 (eBook) 1. Psychic trauma. 2. Post-traumatic stress disorder. 3. Adjustment (Psychology) 4. Resilience (Personality trait) I. Gow, Kathryn. II. Celinski, Marek J. BF175.5.P75M377 2011 155.9'35--dc23 2012010685

Published by Nova Science Publishers, Inc. † New York

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CONTENTS

Preface ix Poem: “The Tsunami of Despair” xi Peter Sugen

PART 1: TRAUMA RELATED THEORY 1 Chapter 1 Overview: Mass Trauma Affects Whole Communities 3 Kathryn M. Gow Chapter 2 Implementing Collective Approaches to Massive Trauma and Loss in Western Contexts 21 Saliha Bava and Jack Saul Chapter 3 Rethinking the Moral Positioning of Trauma Work 41 Stevan M. Weine Chapter 4 Using the Individualism-Collectivism Construct to Understand Cultural Differences in PTSD 55 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa Chapter 5 Assessing Resilience in the Aftermath of Mass Trauma 77 Marek J. Celinski, Lyle M. Allen III and Kathryn M. Gow

PART 2: EFFECTS OF MAN MADE TRAUMA: WAR, GENOCIDE, MURDER AND TERRORISM 93 Chapter 6 Effects of Mass Homicide on Communities 95 Sandy Sacre Chapter 7 The Legacy of the Nazi Holocaust within a Theoretical Trauma Framework 111 Janine Lurie-Beck Chapter 8 Cambodia 30 Years On: A Country Recovering from Genocide 125 Roslyn Roberts

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Chapter 9 Mass Disaster Response: How Impending Health Catastrophes in the Displaced Populations of Post-War Sri Lanka were Averted 139 Eeshara Kottegoda Vithana and Loyal Pattuwage Chapter 10 21st Century Warfare: Can Deployment Resilience Assist the Return to Civilian Life? 159 Jacques J. Gouws Chapter 11 Healing Fields and Field of Flags: Commemoration of 9/11 and War in Heterotopian Space/Place 175 Catherine Ann Collins

PART 3: COMMUNITY RESILIENCE AND DISASTERS 195 Chapter 12 What Makes Children Resilient and Resourceful Despite Family Adversity and Trauma in High Risk Populations? 197 Karol L. Kumpfer and Qing-Qing Hu Chapter 13 Main Trends in Resilience and Trauma Recovery with Children, Adolescents and Families 223 Vladimír Kebza and Iva Šolcová Chapter 14 Recognising and Assisting Children at Risk of PTSD Following Natural Disasters 237 Heather Mohay and Nicole Forbes Chapter 15 When Community Resilience Breaks Down after Natural Disasters 257 Kathryn Gow and Heather Mohay Chapter 16 Facilitating Successful Community-led Recovery after Disasters 281 Suzanne Vallance

PART 4: TRAUMA IMPACT AND RECOVERY IN REFUGEE POPULATIONS 297 Chapter 17 Towards Dialogic Trauma Work 299 Stevan M. Weine Chapter 18 From Trauma Victims to Survivors: The Positive Psychology of Refugee Mental Health 313 Eranda Jayawickreme, Nuwan Jayawickreme and Martin E.P. Seligman Chapter 19 Trauma and Survival in African Humanitarian Entrants to Australia 331 Alicia Copping and Jane Shakespeare-Finch

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Chapter 20 Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants during Times of Adversity 349 Giorgio Ilacqua, Marek J. Celinski and Lyle M. Allen III Addendum Questions to be Explored When Assessing the Resilience of a Community Post Disaster 365 Ron Frey Index 375

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PREFACE

This book comes at a time when mass disasters and mass trauma abound. It is impossible to turn on the television and not see incidents of floods, earthquakes, wildfires, avalanches, and every kind of natural disaster, competing with air space with the latest updates on wars, terrorism, mass murders, civil unrest, famine and mass migration. So from Canada to the USA and down under to Australia, New Zealand and Africa, then across to Sri Lanka and Bangladesh, the stories unfold in these pages. They tell about mass disasters and traumas, and they argue about the best way of assisting communities during and after disasters and traumas on a large scale. They talk about the presence and absence of resilience and the need to keep recovery in perspective and to watch our language when we speak about post traumatic stress disorders. Almost all authors will join the admonition that communities should be not only involved in recovery, but encouraged to instigate new ways of operating in a post-disaster community. This is the fourth book in a series of texts published through Nova Science (New York) which focus on resilience and resourcefulness in some ways and recovery and trauma in other ways. This book explores certain aspects of the effects of mass trauma on individuals and communities. It is a book, not only for social scientists and those involved in disaster interventions, but it is also a book that will interest members of the public who wonder if indeed 2013 is the year for Armageddon, and hopefully will feel more empowered through the discussion of resilience and courage and solidarity to handle whatever comes their way.

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POEM

“THE TSUNAMI OF DESPAIR”

Peter Sugen

I stand alone at the water’s edge, Great waves crashing against the rocks below There's a storm coming, the sky has turned black, The rumbling of thunder and the brief flashes Of lightning streak across the swishing clouds.

I look back at the island behind me, Unable to help what is about to happen. The wind beats against my half-turned face, Nobody hears my heart break, All that can be heard, is the ominous thunder.

Then the storm strikes, annihilating trees, Destroying houses, killing ……………… People and animals are destroyed alike, In quick blinding flashes they are gone, Relentless, unforgiving, ruthless Turning back I feel the sadness as always, overcome, The anger inside me flings it aside.

My clear blue eyes flash with hate, Inside, the two remaining halves of my heart shatter, Clenching my fists, I scream at the storm.

The sea withdraws as if taken aback by my rage, Then a roar exceeds the thunder, crackling around me, The sea returns, a wall of water, unstoppable, The sky rumbles its consent as the wave crashes on the isle.

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Nothing is left as it sweeps everything away. Slowly turning around I know what is left, only bedrock, Rumbling laughter booms from the sky above, I yell again, this time louder than the thunder above, I yell the screams of a thousand dying people, I yell until there is no air left, only whispers.

I am alone again, horribly alone, I fall to my knees and beat the stone with my fists, Again and again I assail the rock, my hatred Silenced but not forgotten, tears unable to come, The storm with one final laugh disappears, A few smoking grey clouds are all that remain.

Finally the rock gives away as I pound against it, And with that, we destroyed all that I had left. I fall into the ocean, hitting the water with a dull splash, Sinking quickly into the black depths, My hope fades, and all that is left are sad painful memories.

Brisbane, Australia. © March 2011

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PART 1

TRAUMA RELATED THEORY

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Chapter 1

OVERVIEW: MASS TRAUMA AFFECTS WHOLE COMMUNITIES

Kathryn M. Gow Consulting Psychologist, Regional Australia

INTRODUCTION

The name and content of this book arose out of a request by NOVA Publishers to make our original book on trauma (albeit a rather large book) into two different texts. This was not just a matter of carving up the chapters into two separate books on individual trauma and mass trauma. New conceptualizations and material had to be gathered to make our contributions on mass trauma topical and up to date. This then had to be added and chapters realigned with the different themes. There was, of course, no shortage of mass disasters to add to our stockpile of ideas – but where to locate the authors in a very short time frame. Other authors, both existing and new, then contributed new material to the section on manmade disasters such as murders, terrorism and war. The refugee contributions were already waiting for this book, as were the theory and assessment chapters. So from Canada to the USA and down under to Australia, New Zealand and Africa, then across to Sri Lanka and Bangladesh, the stories unfold in these pages. They tell about mass disasters and mass traumas, they argue about the best way of assisting communities during and after disasters and traumas on a large scale. They talk about the presence and absence of resilience and the need to keep recovery in perspective and to watch our language when we speak about PTSD; and almost all authors will join the admonition that communities should be not only involved in recovery, but encouraged to instigate new ways of operating in a post- disaster community.

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If 2011 Was So Bad, What Would 2012 Hold?

Disasters and mass disasters surrounded me while compiling, writing for, and editing this book and while finalizing the companion book on individual trauma1. At the close of 2010, the local Council, against all opposition, had approved a quarry for operation at the back of my 90 acre, wildlife rich, and heavily treed property. Then 3 months later, our region and my property was inundated (though the buildings were spared) in the February 2011 mega Queensland floods; I was heavily involved in community post disaster interventions early in the year and then later with Local Council run community resilience and preparedness meetings. At the end of July that same year, while I was away for two hours, my property was set on fire and 30 acres burned out, just stopping short of the house by 1 metre. As I arrived home and saw what was on fire and what was still smoldering, I had difficulty keying the emergency fire brigade numbers into the little mobile phone because my hands were shaking so much; I watched in horror as the fire raced along the treed footpath towards the gate where the two loyal dogs were waiting for my return. At the same time as I was trying to determine from the road side, if the fire has gone around the back of the multiple dwelling area, and if the cattle had escaped, I was attempting to flag down passing cars and trucks, but no-one would actually stop to help with hosing down the flames and smouldering trees. A lone neighbour rushed down the road and called emergency services for me and 30 minutes later, eight fire brigades responded for one of the first bushfires of the season. It appeared indeed that no-one had called ‘000’2 to report this raging, out- of- control bushfire, something that baffled me, a fire spotter. At the time of the January floods, I was President of the local wildlife group, and I had been contacted by a wildlife group from Mission Beach, located along the north eastern coast of Queensland, and they had offered us assistance for the influx of animals following the disastrous flood in our area. Within one month, our friends who had helped us from afar and along with them the wildlife they cared for, were almost obliterated when Cyclone Yasi literally crossed the coast at Mission Beach. Around the same time, our Kiwi3 mates across the Tasman Sea were hit by a large earthquake which led to a disaster of gigantic proportions, and those quakes in and around the Christchurch area continued, as you will see in Chapter 15 where Suzanne Vallance outlines the post disaster community recovery achievements. Then the earthquake, tsunami and nuclear plant breakdown in Japan followed ‘hard on its heels’ with its massive waves of destruction (see Chapter 14). There were bushfires across Australia throughout the 2011-2012 summer and then to ‘top it off’, some natural force (and the debates continue as to what these are - solar flares, shifting tectonic plates, heating up of the earth’s cores, 60 year weather cycles - decided to send down more deluges and these managed to flood Queensland and the neigbouring state of New South Wales in a disastrous manner leading to the evacuation of many thousands of people in the month of January, 2012. The mandatory evacuation process showed at least that the

1 K. Gow, & M. Celinski. (Eds.) (2012). Individual Trauma: Recovering From Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. 2 Emergency numbers 000 = 999 in the USA. 3 ‘Kiwi’ is a term used by Australians for our New Zealand neighbours and is used with affection and acceptance and also respect and there is much bantering underlying the interactions between us. Our countries are part of the ANZAC tradition.

Complimentary Contributor Copy Overview: Mass Trauma Affects Whole Communities 5 emergency services and state authorities had learned something from the January 2011 floods in Queensland and the 2009 bushfires disasters in Victoria. We watched the television news and witnessed uprisings around the world and wondered if the predicted Armageddon in 2012 had already arrived in 2011; wars continued around the world, various countries teetered on the brink of financial collapse as did the whole global village, men came home from tours of duty hoping for some peace and understanding (see Gouws' Chapter 10) and found it difficult. Ice storms, heat waves, and monsoonal flooding rains claimed many lives, and earthquakes continued within the Ring of Fire (e.g., the Philippines), while 56 volcanic eruptions in 2011 and the more recent eruption in Italy of Mt Etna appeared to be harbingers of doom. Droughts continued in continents such as Africa and international aid volunteers asked the question about what was really causing the food shortage, with in-country fighting at a peak in that large continent with the biggest population of wildlife in the world. Throughout 2012, disastrous floods inundated many countries. In a new release of the film “Oranges and Sunshine” in mid 2011 in Australia, we were confronted with a mass trauma that occurred over a period of decades, when the British Government, without parental or child approval, had transported over 130,000 children to other countries, without any questions being raised at any time, to places and situations over which the children had no power. The gross injustice went undiscovered until one adult from Australia to where 7000 children had been transported, returned to the UK and attracted the attention of a disbelieving, but passionately caring social worker – Margaret Humphries. In the film, as the movement to reunite the ‘children’ (all adults now) with their parents grows, more traumas are revealed and mass trauma adds to the anger and suffering of the people who had been deprived of their parents and families. Not all children, however, were unhappy with their treatment in the new countries. In 2012, mass murders continued to occur in unexpected places (see Sandy Sacre's Chapter 6), as they reached ‘flashpoint, or damaged psyches emerged in anger in countries where they could legally obtain firearms easily, or through the black market. Terrorists abounded and organized warlord gangs appeared, in places they had not yet been evident, causing havoc with armed robberies in quiet seaside places such as the internationally famous Gold Coast and drive-by shootings in several city areas. Over 350 men who were prisoners in central Honduras were killed in a prison fire, just a few years after a similar fire had occurred in another prison in that same country. Relatives and friends of the prisoners suffered from the loss, as did the remaining prisoners. Across the oceans, a male nurse had deliberately started two fires in a nursing home in Sydney a few months previously and was responsible for the deaths of more than 20 elderly people (killed at the time and then dying from injuries later). Both groups of victims were powerless to escape in the Honduras prison and the Australian nursing home adding both trauma and fear for the future to all peoples who are at the mercy of others to treat them with fairness and humanity, or to feed and care for them in the case of the elderly. It was definitely a time4 to be compiling a book on mass trauma, as the survivors of Holocausts across the globe reflected on the lack of action taken by the people in other countries when millions of people had been killed (see Chapter 7 by Janine Lurie-Beck on the Jewish Holocaust and Chapter 8 on the Cambodian Genocide by Roslyn Roberts).

4 8000 lightning strikes were recorded on 21stFebruary, 2012 in South East Queensland during violent storms.

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With mass migration concerns around the world, and apparent increases in the number of people suffering from mass trauma, the mental health community started to question whether the health profession had understood what was really needed by people suffering from mass disasters, especially mega natural disasters, and whether or not they had the communities’ needs at heart or their own dogma (see Chapters 2, 3, 4, 17, 18).

TRAUMA AND RECOVERY

In January 2012, a year after the disastrous floods in our State, I opened my letterbox and pulled out an errant envelope and to my surprise - almost like a private letter from the gods - in white letters on a red background, the message to the right of the actual address section read:

STILL

STANDING

after a natural disaster

It made me smile – just what I needed. Inside was a DVD from the Salvos5 on stories of survivors from the ASH Wednesday Bushfires of 1983, the Boxing Day Tsunami in the Pacific in 2004; and Cyclone Larry in 2006. The style of presentation was just plain speaking and to the point - something that Stevan Weine (see Chapter 16) would applaud with his emphasis on the narrative. To summarise the learnings, this is what their narratives taught us: ‘This is what happened to us. It was devastating then, but we survived; and came back into living a full life over time, although a different life’. The Salvation Army website has added other stories from people who had survived other mass disasters, such as Stuart Diver, the man who had lived through terrifying conditions over 56 hours in freezing conditions after the Thredbo Ski resort landslide in 1997. Just before the DVD arrived in my letterbox, a colleague had sent me a book on natural disasters compiled with the art of photography and poetic and powerful prose. In it, we have no mention of mental health per se, but we have many insights into the toughness (resilience) of the Australian character; for example:

We are a sclerophyll people, our souls are drought-prone; we are used to, even expectant of, hard times. We are hardy, pragmatic, and not inclined to put too much trust in the future. (Mark Tredinnick, 2011, p. 122)

5 The Salvos is a colloquial name for the much respected Salvation Army in Australia. In it, Consulting Psychologist Rob Gordon, a leading trauma expert, gives viewers tips on moving forward after a natural disaster.

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Thus the concept of resilience presented itself in simple applied ways; a DVD of stories of people who had recovered from mass disasters, a book of poetic photography about natural disasters written by a man who was in touch with the tenacity of the character of the Australian people and its eco-systems. I then bought a large, well prepared and documented book on the Queensland floods; it had graphic pictures, heart wrenching stories from victims about their experiences and covered many towns and areas which had been affected by the deluges and flooding rains in 2011. When I turned to our region to see what stories had been included, there were none; only the facts and statistics about the Somerset and Wivenhoe Dams that were under investigation for their alleged part in the flooding of two cities. That absence of the stories of hundreds of people who had lost their houses, businesses and stock, along with massive infrastructure damage in our region which had been generally been portrayed in the media only as the source of much suffering, confirmed our knowledge that indeed the population in the Somerset Region had been forgotten and abandoned (see Chapter 14).

TRAUMA, RESILIENCE, RESOURCEFULNESS, AND RECOVERY

This is the fourth book in a series6 of texts which focus on resilience and resourcefulness in some ways and recovery and trauma in other ways. This book explores certain aspects of the effects of mass trauma on individuals and communities. According to the AMA, mass trauma “is the term used to describe the multiple injuries, deaths, disability, and emotional stress caused by a catastrophic event, such as a large-scale natural disaster or a terrorist attack. Increasing population density and urbanization, coupled with the propensity for larger buildings, mass transit, and mass gatherings, create the potential for a serious disaster involving multiple casualties” (Online7). Specifically, a disaster is defined as “A situation or event, which overwhelms local capacity, necessitating a request to national or international level for external assistance” (ICRC World Disaster Report, 2001). We have tended to address the issues from a psychosocial viewpoint in this text. Throughout the book series, we have endeavoured to present aspects of resilience and resourcefulness in different situations where life sends people tragedies and challenges to surmount. This book is about life threatening situations for communities or groups of people, or a number of people who can be ‘grouped’ because they were affected by the same or similar traumatic events. Ungar (2008) defines individual resilience thus: “first, resilience is the capacity of individuals to navigate their way to resources that sustain well-being; second, resilience is the capacity of individuals’ physical and social ecologies to provide these resources; and third, resilience is the capacity of individuals and their families and communities to negotiate culturally meaningful ways for resources to be shared” (pp. 22-23). Landau and Saul (2004, p.

6 M.J. Celinski & K.M. Gow. (Eds.). (2011). Continuity versus Creative Response to Challenge. The Primacy of Resilience and Resourcefulness in Life and Therapy. New York: Nova Science Publishers. K. Gow, & M. Celinski. (Eds.). (2011). Wayfinding through Life’s Challenges: Resilience, Coping and Survival. New York: Nova Science Publishers. K. Gow, & M. Celinski. (Eds.). (2012). Individual Trauma: Recovering From Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. 7 http://www.ama-assn.org/resources

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286) define community resilience as “a community’s capacity, hope and faith to withstand major trauma and loss, overcome adversity, and to prevail, usually with increased resources, competence and connectedness.” Adding another concept to our understanding of the ability of people to ‘bounce back’, Celinski and Gow (2005) explain resourcefulness as referring to a person’s ability to access and employ internal and external resources to deal with the impact of the adverse or traumatic event (after being psychologically affected by it), and as such it is linked with the concept of recovery in the literature on traumatic effects. There are a few instruments available in terms of measuring people’s resilience, but there are many more on measuring coping skills, and a wider range of abilities and strengths. Celinski and Allen’s scale - the Resilience to Trauma Scale (Research Edition) (RTS-RE) - has been included in this book (see Ch. 5) because of its potential as a measure for recovery following mass traumas. Celinski and colleagues argue that resilience “is a complex phenomena; whereas in some individuals generalized distress would lead to a breakdown of defences and result in a person being overwhelmed and unable to react, the reverse is also true that by acting in a resilient way, a person expresses autonomy of the self and utilizes a broader perspective on one’s own condition and reality, thus preventing unfavourable reactions within themselves, although they may have no control over what traumas - individual or mass - that life presents them with.” The ethos of responding may have its inspiration in people’s historic, cultural and spiritual traditions that help them develop the narrative of rebuilding and recovery. Gow and Mohay (Ch. 14) refer to the warrior culture in the heritage of both the Japanese people and New Zealanders. Ron Frey (see Addendum) brings our attention to the need to note a community’s foundation and historical traumas, following mass disasters. This book features the efforts that active social scientists have been investing in directly to assist the real world with major problems; where adults and children suffer within their own countries and where an increasing numbers of the world’s inhabitants are on the move, having been forced to leave their own countries because of the ravages of famine, natural and man-made disasters, wars and incursions. Several of our contributors address interventions in communities post disaster. There are four sections to this book:

Part 1: Trauma Related Theory Part 2: Effects of Manmade Trauma: War, Genocide, Murder and Terrorism Part 3: Community Resilience and Disasters Part 4: Trauma Impact and Recovery in Refugee Populations

The number of manmade and natural disasters is on the increase in the world and while the majority of people do get on with their lives following negative events of all kinds and severity, there is no doubt that trauma and suffering is an inherent part of being a human being. It remains for us to respond to people affected by a wide range and depth of trauma in powerfully educated and healing ways. It is through our responses, that we show that we are truly human.

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The Need for Testimonies and Narratives

The book opens with Peter Sugen’s poem titled “The Tsunami of Despair” which encapsulates both mass and individual trauma; the poem lets us enter into the inner despair and graphic thoughts of someone in agony; we are left to wonder if the person he writes about actually jumps into the crashing waves or dies an emotional death. Certainly we know that tsunamis are now a more present threat than they have been in the past century, and often individuals talk about drowning under the weight of despair, wanting to throw themselves into the sea because life is too cruel, and feeling crushed by one onslaught after the other. Stevan Weine in “Towards Dialogic Trauma Work” (Ch. 16) suggests that we should start with “better listening to those who are directly impacted by trauma in all kinds of different sociocultural contexts. Then we could also pay more attention to how the language of traumatic events, traumatic consequences, symptoms and distress, disability, treatment and rehabilitation, rights, resilience, transformations, and recovery are all framed by the language of victims, families, communities, leaders, providers, service organizations, and donors.” Weine emphasises that “dialogic trauma work creates loops of meaning that can open up new approaches to understanding and addressing trauma through focusing on speech genres, contingencies, collaborations, processes, and help seeking. These dimensions may be especially pertinent in situations of disaster or mass violence.” Without testimony, without narratives, we can easily gloss over the word trauma, the word torture, the words horror, shock and agony. Without descriptions or pictures, the words are just letters on paper/screen. Unless our journalists and photojournalists bring the reality of wars and genocides to our attention, we cannot comprehend the horror, the absolute cruelty that mankind perpetrates on one another – Germany/Poland, Bosnia, Uganda, Cambodia, all genocides that haunted the world’s psyche, mostly because we did nothing. Paul Slovic (2010a, b), in his clarity about decision making and inaction, focuses our attention on how we might tear the scales from our eyes in his articles “If I look at the mass I will never act” and “The more who die, the less we care.” Roslyn Roberts in “Cambodia 30 Years on: A Country Recovering from Genocide” speaks about this further in her chapter (8) on Cambodia where she outlines the impact that failing to bring to justice the perpetrators of the genocide has had on the restoration of peace and health in that country. The flow on effect over 30 years of war criminals not being brought to justice (as distinct from being seen to be brought to justice) has affected the whole society deeply, leaving it, in some aspects, as a place of psychosocial dissociation (often a method of coping), distrust (perhaps a sensible reaction in such situations) and psychopathology (the negative impact).

Natural Disasters and Deep Trauma

Over the past 10 years, the world has seen an increasing number of natural disasters occurring in many different countries, and climate change (see Gow, 2009) has been nominated as exacerbating the extent, frequency and ferocity of some of these natural disasters. Gow and Patton (2008) featured community resilience in their book and demonstrated how various communities rallied and ‘won through’ after natural disasters.

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However, since then, there have been even greater and more damaging natural disasters and in some places and on some occasions, community resilience has broken down when it was most needed; Gow (2011) writes about this in her article in the Queensland APS Newsletter: “We were deserted, abandoned, forgotten.” In this book, Heather Mohay and Nicole Forbes (Ch. 13; “Recognising and Assisting Children at Risk of Post Traumatic Stress Disorder following Natural Disasters”), with a focus on trauma following floods in particular, bring to our attention the plight of children in natural disasters who suffer from psychological distress and PTSD and outline what can be done to prepare people for natural disasters with respect to communities and children. Another chapter which focuses on children’s resilience is Chapter 12 (“What Makes Children Resilient and Resourceful Despite Family Adversity and Trauma in High Risk Populations?”); in this chapter, Karol Kumpfer and Qing-Qing Hu point out that “the lead author’s Social Ecology Model serves as a guide for designing effective preventive or therapeutic interventions for these high risk children, who need a high level of family support to become resilient and obtain positive developmental outcomes.” They list several helpful websites on programs that have been designed to assist communities. Dissociation or suppression of emotional states may be a normal state of mind for many cultures, and thus this may tend to dampen their reactions following a natural disaster. People who watched the reactions of the Japanese people in the early stages of the earthquake and tsunami devastation saw the inculcated culturally learned internalization of the shock and horror, and watched also as the nation and government spoke in a contained manner throughout the aftermath of the two natural disasters. Even when the manmade disaster of the nuclear plant damage came through and got worse, the ‘Face” was kept still and internal. It was only after some weeks, that other emotional reactions were observed and the internal became more externalized. This was almost the exact opposite of what happened in Australia with the floods, where the people, also more introverted as a nation than Europeans or Americans, started off expressing themselves externally and ‘acting tough’, but then as the weeks passed, they imploded with their feelings of loss and grief and fear for the future. The depression set in and other reactions were certainly made much worse when the insurance companies’ decisions were handed out and few people were covered 100% and some not at all, while the majority fell far short of what they would need to rebuild or refurnish their homes and businesses. Thus on the one hand, destruction and adversity on a mass scale may break a spirit of resilience, if the effects of the disaster overwhelm people’s ability to understand what happened, and wear down their coping abilities. This breakdown in resilience is covered by Kathryn Gow and Heather Mohay in Chapter 14 and potential missing links in our understanding of existing traumas in communities affected by mass traumas are explored by Ron Frey in the Addendum to the book. On the other hand, the necessity of facing common difficulties may mobilize people to put their efforts into understanding the causes of their suffering and finding optimal ways of responding to tragedies and losses (this is a theme of Marek Celinski’s throughout the book series). This is seen in Suzanne Vallance’s chapter (15) when she speaks about the community groups that emerged following the earthquake in February 2011 in Christchurch, New Zealand. Indeed Vallance refers to the concept of ‘bouncing forward’ (Manyena, O'Brien, O’Keefe, and Rose, 2011), a conceptual framework about an expansion of one’s possible approaches to life after disaster that is worth investigating further.

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The Trauma of Migration: Refugees and Immigrants

Weary souls displaced from their natural roots. Quietly desperate in a vacuum of loneliness. Their cries are silent. Existence in an abyss of pain and dark uncertainty. What Threads remain of the past? God, who am I now? (John Wilson, 2003, in Wilson, 2004, p. 109)

In the film “Green Dragon” (2001) set in Camp Pendleton in the USA before the fall of Saigon in 1975, we are allowed a glimpse of what Vietnamese refugees endured when dislocated from their family, their homeland, and everything they had known. While full of pathos and emotional incidents, there is evidence that here in that camp the refugees were already planning what they could do to move ahead, even though they mourned what was left behind. There was no mental health assistance given to them, but we see instances of human kindness emerging and saving people with its power. The threat of continuing and worsening mass migration in the world has been surfaced, but most individuals are unaware of what that will mean to those who are forced to relocate and to those who live in continents where millions of refugees have moved to and will continue to flee to. Along with the predicted food shortages for the coming decades, it presents one of the most challenging adaptation scenarios that modern humans will have to deal with. Giorgio Illacqua and colleagues, in Chapter 19, believe that “most immigrants are exposed to the general stressors related to immigration, but for some the immigration experience can become a source of trauma in itself. The experience of immigration can be seen as a cumulative trauma in which instead of a single episode, the sum of many minor and bigger stressors contribute to create a traumatic experience that can be felt many years after the actual migration. The adjustments required for immigration demand changing fundamental beliefs about the self which threaten people's identity and cause internal and external conflicts that are often resolved in a maladaptive manner such as through violence, higher risk of incarceration or drug use.”

Cultural Variations

In this book, several chapters focus on people who have left their own countries of origin whether as migrants or refugees. Nuwan and Eranda Jayawickreme and Edna Foa in Chapter 4 “Using the Individualism-Collectivism Construct to Understand Cultural Differences in Posttraumatic Stress Disorder”, along with Alicia Copping and Jane Shakespeare-Finch in their chapter (18) “Trauma and Survival in African Humanitarian Entrants to Australia”, report that many people make long and difficult journeys through life and across continents as refugees and succeed in new endeavours. They remind us not to expect that all cultures will react in the same way to traumas and that their trauma symptoms may vary and their ways of recovery may also be different. Indeed, Giorgio Illaqua and colleagues (Ch. 19) give us the results of their research on adjustment of refugees in a new country and how they manage to deal with adversity in “Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants during times of Adversity”. They advocate that as their research discerned significant differences in

Complimentary Contributor Copy 12 Kathryn M. Gow immigrants of different cultural backgrounds, on measures of resourcefulness and resilience, that this factor should be taken into consideration when providing health and counseling programs to immigrants. Giorgio and colleagues propose that the difference between the successful and the unsuccessful adjustment to the host country (willing, or against her or his will) may be explained in reference to the concepts of resilience and resourcefulness. In the five chapters that cover the plight of immigrants and refugees, there are stories about struggle and recovery, and struggle and renewal. In Chapter 2 “Implementing Collective Approaches to Massive Trauma/Loss in Western Contexts”, Saliha Bava and Jack Saul add their voices to the call for cultural sensitivity and the necessity to involve the affected communities in designing and conducting intervention programs. Bava and Saul also believe that resilience is both a metaphor and a process; they note that resilience taken as a metaphor from physics may have its limitations when applied to relational processes, but it is a concept that inspires hope and optimism after massive trauma. In “From Trauma Victims to Survivors: The Positive Psychology of Refugee Mental Health”, Eranda and Nuwan Jayawickreme and Martin Seligman remind us (see Chapter 17) that while “a significant proportion of refugees do suffer from PTSD, depression, or some form of psychological distress”, “it is also true that the majority of refugees do continue to function adequately, and achieve satisfactory levels of wellbeing”. They consider that a lot of “refugee research seems to have been almost completely dominated by the “medical model” which has emphasized the diagnosis of psychiatric disorders over the fact that refugees are normal individuals with strengths and resources that have been caught in abnormal situations”. Saliha Bava and Jack Saul (Ch. 2) emphasize collective approaches that focus on resiliency and socio-political construction of trauma rather than the medicalization of trauma. They “provide a collective approach to massive trauma and loss that draws on family and community, narrative and performance and relational constructionist perspectives challenges” and outline “action principles for collective approaches which embody leadership, collaboration and partnership, and measurable community engagement practices that promote resiliency as a metaphor and process using local narrative and performative practices, while honouring our universal human rights.” Weine (Ch. 3), in “The Moral Positioning of Trauma”, advocates that “Mental health professionals doing trauma work should take care not to be overly based on the moral positioning of trauma and to more seriously commit themselves to exploring alternative trauma work narratives based upon deeper engagement with the psychosocial, sociocultural, services, peace and developmental, and preventive dimensions of trauma work.” He believes that the focus of interventions should “not all be on trauma but on recovery and adjustment and the future”. Interestingly in Chapter 17, Eranda and Nuwan Jayawickreme and Martin Seligman conclude that “it would seem that positive psychology has the potential to make a serious and important contribution to the study of highly traumatized war-affected populations; but only as long as the strangle hold of irrelevant medical model approaches overemphasizing PTSD in its interventions is changed”. This does not mean that a focus on PTSD is not relevant – far from it; appropriately targeted treatments for ASD and PTSD are paramount in assisting people to tap into their inner strengths in order for them to continue their journey through life.

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Holocausts and Genocides: Deep Trauma

In the film “The Grey Zone” (2007), the story about captured Jewish men and women (and other targeted groups) who saved their own lives by processing the families who arrived by train straight into the undressing room, then into the gas chambers and then into the ovens or the mass burning sites, we are confronted with the powerful survival instinct in humanity. In her chapter (Ch. 7) “The Legacy of The Nazi Holocaust “, Janine Lurie-Beck reminds us of one of the greatest mass traumas ever endured by a people in our world with the Nazi holocaust, a tragedy that some segments of society in the world have attempted to discredit and thereby dishonor and disrespect millions of people even further by saying this did not happen. The other reminders in the two films, “The Mark of Cain” (2007) and “The Grey Zone” (2007), however, is that within the hell of war zones and concentration camps, the spirit of all that is good in humanity surfaces against all odds. We see evidence of this in the latter movie:

When the young girl, who survives the gassing in the gas chambers, is rescued by the grey coats who are very clear in their minds that they have not murdered anyone (although they move the arriving Jews to the gas chambers and then throw their dead naked bodies into the furnaces), and refuse to kill the girl (depicted wearing a long white nightdress – the one vestige of cleanliness and purity in the camp) to save themselves, a long suppressed emotion and moral value emerges. The young girl must live. However the commandant, when he discovers the girl, makes her watch the execution of all the grey coats in that section – as they are shot one by one with a single bullet to the head. When the pistol noises stop, all is quiet and nobody moves. The girl walks slowly through the ranks and just when the viewer thinks that the enemy will let the girl go, they challenge her and she runs towards the electric fences in a bid to escape, and they shoot her dead. With that one action, they kill the hope of all the workers in the camp; a cold deliberate act to destroy any hope and resilience remaining in the prisoners.

There is no one who would dispute that holocausts and genocides which span several years are in the highest ranking traumas. These events not only damage the victims and cut them to their core being, they also damage the perpetrators at levels that may not on the surface be visible. The moral transgressions which Andrew Hall and colleagues (2011) term “morally incongruent behavior” cause a disturbance in people at all levels of the human psyche; the shame, guilt and dissociation, the worsening of negative behavior as the guilt eats away unconsciously and consciously at the psyche of people who have become less than human and have not paid the price; not asked for forgiveness nor received it; and who are lost on both human and spiritual planes. This is amply demonstrated in the motion picture “The Mark of Cain” (2007) set in Iraq, where it is loyalty to the regiment versus moral courage of the individual; either way, the soldier loses out and is punished; however, he still has his moral standards, self respect, and meaning and purpose in life. Whistle blowers are always punished in modern business and government bureaucracies, as well as in the armed forces. Jacob Lindy (1988) describes the case of a Vietnam Veteran who had been awarded a Silver Star, but who had shot a woman (the woman had been armed) and could not come to terms with this personal moral transgression and thus had coped by blocking out the memory of the event, having convinced himself: “I am not a hero!”

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The motion picture “The Great Raid” (2005) reminds us about what happened to soldiers and marines held in the some of the worst war camps for the armed forces of any country. Set during January 1945, the story line follows the liberation of the Cabanatuan Prison Camp on the Philippine island of Luzon. The rescuers are met with the sight of starving, ill, and dying men. Their captives have treated them extremely badly as occurs in many war zones when the enemy has been captured. Man’s inhumanity to man knows no boundaries and in the films “The Mark of Cain” and “The Grey Zone”, we see how easily it is to make men inhuman when it comes to surviving – the most basic of all human needs. Cynthia Eriksson and Dow-ann Yeh (in press), (referring to Litz et al., 2009), comment that “the experience of combat can create a type of religious or spiritual injury, as the soldier witnesses, acts, or fails to act in ways that challenge deeply held moral beliefs”.

Witnessing and Solidarity

The essence of solidarity, a term made famous by the Polish trade union formed in the 1980’s, and actually observed through the standing side by side of workers to fight for better things for people against great odds, is defined by the Collins Dictionary of Sociology (p. 621) as “the integration, and degree and type of integration, shown by a society or group with people and their neighbours”, that is, the solid ties that bind people together within a society. In spiritual terms, when there is nothing you can say to a person in real trauma or massive grief, when you have no answers, there is still the presence of solidarity- sticking in there, being there as solid as a rock where your presence is sensed as stable, strong and sincere, and continuing through the moment in crisis and not letting go till the rescuers come, or the next stage of therapy is reached, or the person goes to hospital, or someone takes him home or to another place, or you return another day or night. This is evident in the films “Only the Brave” and “Home of the Brave” where ordinary men become leaders of men through their insight, compassion, and solidarity with the troops. The film “Kokoda” (2006), which features the fight in New Guinea along the Kokoda Track, to save Australia from Japanese invasion in 1942, is another example of how people in the armed forces and their support personnel value solidarity: the film ends with the written words: Courage, Endurance, Mateship, and Sacrifice. Interestingly some soldiers on “the other side” when they are not being attacked, can even admire the tenacity of an enemy: ‘The Japs,’ he said; ‘They never give up.’ He looked up at me: ‘And they never run away’ (Palmer, 2007, p. 111). One of the most outstanding examples of solidarity is depicted in the film “Joyeux Noel” where in 1914 in the war trenches in northern France, the Scottish, German and French forces agree on a truce for Christmas Eve and come together, not as enemies but as people belonging to a shared belief and value system that places importance on love (comradeship, new friendships), family (sharing of food and beverages and candle lit Christmas trees) and beauty (the stirring sound of bagpipe music and beautiful singing voices) at a time when the world celebrates peace and joy universally. Although their superiors did not agree, and they were reprimanded for this episode of peace in war, it was an experience that those men would never forget. The armed forces know instinctively about solidarity; however when they return to normal life in their home towns after completing tours of duty, the communities do not stand

Complimentary Contributor Copy Overview: Mass Trauma Affects Whole Communities 15 shoulder to shoulder with them. Jacques Gouws, in Chapter 10, writes: “It is this different world, to which soldiers are returning, that challenges them in a way they have not been prepared for. They are not understood, nor do they understand the society they are coming back to. Thus, they need to rely on their individual resilience and resourcefulness to manage the challenge of a society that is in a perpetual state of fluidity, this simply because of the incredible rate at which ideological beliefs and political opinions change. Returning soldiers speak a different language and, while they may be heard, they are neither understood nor listened to.” This reality is depicted in the film “Home of the Brave” a story set in Iraq, where post war injuries, in armed forces personnel, both physical and psychological, as well as spiritual, are evident when they return from tours in Afghanistan and Iraq. They find in going home that there are stark contrasts between what they left and what they return to; there is also no comprehension of what they saw and did, or suffered. So those personnel close down and go within themselves – as they encounter no real listening in their home countries, except for some of their former armed forces colleagues. The Vietnam Veteran legacy revealed a new era of non-support for veterans of non popular wars where troops are sent into other countries to fight other countries’ wars; that is, there is no overt or proven threat to the countries sending the troops. In “21st Century Warfare: Can Deployment Resilience assist the Return to Civilian Life?” (Ch. 10), Jacques Gouws addresses the resilience of soldiers in their response to extreme challenge and maintains that “an extraordinary degree of endurance, and thus resilience, is required from soldiers who are deployed in these operations”. However, if on returning from deployment, the country of origin devalues their mission, then this “results in a loss of meaningfulness for having engaged in the war on behalf of the country, and adds to the mental anguish that soldiers have regarding their war experiences”. However not all serving personnel are ignored and it is useful that the military speak about some of these issues to their communities. For example, our local country newspaper8 reports the return of one army Captain just back from Afghanistan (who was presented with the Afghanistan Campaign Medal) and who speaks as a soldier and as a leader of men:

We are working on reintegration and making it possible for insurgents to lay down their arms, go home and in doing so to take themselves out of the fight.” “It’s surreal to come home.” “One week, I’m in Eastern Afghanistan and we are out in the street in a serious situation and two weeks later you are playing Lego with your kids.” “It takes a while to adjust.” (Captain Chris Hawkins, 2012)

It is also good that the serving men who are lost in battles and wars are honoured by the community. One more contemporary way of honouring them is set out by Catherine Collins in Chapter 11 where she addresses the trauma and loss issues following 9/11 and modern wars, and explains how ‘Healing Fields’ commemorate the loss of life and the loss of belief in our invincibility. You will see how the fields of flags come alive, when you turn the pages of her chapter containing the photos, and the spirit of those people who were lost appear to be

8 Fleming, S. (2012). Soldier back home. “Gatton, Lockyer and Brisbane Valley STAR”, Wednesday, February 8, p.1.

Complimentary Contributor Copy 16 Kathryn M. Gow present in the here and now. This is an insightful commentary on commemorations of the mass loss of lives. The reactions of the home countries in the past 30 years, is a different scene in some ways from that of post WW1 and WW11, and the difference lies in the public’s perceptions of “whose war is it?”; the similarity lies in the total lack of understanding of what serving men and women go through during war and peacekeeping actions.

In the 1950’s, our family employed some builders to renovate an old house in an Australian city. After World War 11 ended, Australia had opened its doors to many people from around the world, especially those from war-torn Europe. There were three builders, all from Eastern Europe and I would talk with them and learn by watching and listening and asking questions. At lunch time, the chief builder would tell us stories of the war and show us what activities they did to occupy their time in war camps. One of the tricks was to spread out the fingers of the left hand and take a knife in the right hand and see how quickly one could stab between the fingers, starting with the outer small digit and working through to the thumb, and then start all over again getting faster and faster, without cutting the skin. Jacques was a positive man who had rebuilt his life in a new country; he had lost family in the war years and yet he was now resettled and was successful in a new business in a new country. As a child, I could not assess, nor would I have thought to do so, if this man was dissociated from the war experience, but on review he appeared to have done what most people who returned from WW1 and WW11 had done; they had compartmentalized their war experiences and time in the war away from their life at home; they had closed the book on the war on their return, except for occasions such as ANZAC Day9 when they gathered to honor the fallen and their ‘mates’.

The military had a code about ‘parking their emotions’ and still do. Recently, while being interviewed on Australian television about how he had emotionally dealt with the tragedies when he marshalled the skills and resources of the armed forces to assist with natural and manmade disasters around the world, former General Peter Cosgrove reminded us that in disaster interventions, that we had to learn to “park our emotions” and “get on with the job” (see Gow, 2011). One instance of where health professionals have to adopt this approach, is in an area that is rarely covered in mass trauma texts and it is the provision of medical treatment to communities suffering as a result of mass disasters, wars, or uprisings. In Chapter 9, “Mass Disaster Displacement: How Impending Health Catastrophes in the Displaced Populations of Post-War Sri Lanka were Averted”, Eeshara Kottegoda Vithana and Loyal Pattuwage give us a detailed account of the massive efforts required to set up hospitals and health centres for internally displaced persons (IDPs) in post war Sri Lanka.

THE NEED FOR HOPE AND A FUTURE

The film “The Postman” is a remarkable study in the need for hope and meaning in humans after catastrophes. Kevin Costner, playing the postman, is a survivor after the world’s societal systems collapse, but he gains more than survivor status as he innocently becomes a

9 ANZAC Day is celebrated each year in Australia and New Zealand on the 25th April. ANZAC stands for Australian and New Zealand Army Corps.

Complimentary Contributor Copy Overview: Mass Trauma Affects Whole Communities 17 leader of men. He is an excellent story teller, just as Pierce Brosnan, as Grey Owl, is in the film “Grey Owl” when he gave the American Indian leaders the inspiration to join forces, even though they know he was ‘a fake’. His own mission was to change the world’s attitude to killing wild animals, but in the end there was a different outcome when he gave people strength through his actions and stories (narratives). When asked to speak about a non-existent world, the Postman would tell stories as if the old world were still there and thus for the lost peoples, there was a hope of returning to normality. The American flag, as a symbol of stability and pride, also plays a key part in the drama. At the end of the film, we see a statue being unveiled and it has this inscription: "He delivered a message of hope embraced by a new generation." Here we see the critical role played by hope and the prospect of a future worth living for. Messages of hope to people in horrific circumstances do not abound in film stories, but there are some that emerge across the decades and one of those is the true story of Dieter Dengler10,whose plane crashed inside Laos during the Vietnam War. The film “Rescue Dawn” features the role of hope, when Dieter, a pilot who survives a plane crash, is tortured and incarcerated in subhuman conditions; the only thing that kept him going for a long period of time was a certainty that he would survive and escape, or be rescued. Another story is outlined in the film “Only the Brave”. During WW11, Japanese nationals in the US were placed in internment camps; when an opportunity came to demonstrate their loyalty to their adopted country, 1400 applied to serve and went to North Africa, Italy and France; they were known as the 100th infantry battalion. They joined with Hawaiian forces doing the impossible with great loss; the Buddhist spiritual beliefs about deceased persons remaining in the stratosphere for 49 days after their actual physical death, gave the film writer and director the opportunity to demonstrate the effects of hope and support from the dead as they appeared to their loved ones, on their way through to ‘the other side’. In just two years, the battalion had received 21 medals of honour, 9486 purple hearts, 8 presidential citations, 53 distinguished service crosses, 588 silver stars, and 5200 bronze stars, making them the most decorated unit of their size in American military history. But it is not their strength and courage that I wish to expand on here, but certain points in the movie where the lead character’s Buddhist father (who apparently had been seized by the CIA for being a Buddhist priest) appears psychically/spiritually to his son (while he was in the horror of the battle aftermath) twice with these messages, which gave the son the gift of hope across time:

Follow your head and your heart will follow. Accept your fate and the rest of you will follow. Whatever you do in life, do it for the next 7 generations. (Hawaiian Proverb)

It is true that love and friendship keeps hope alive, even in some impossible and improbable circumstances, such as when journalists who cover war stories go missing. The ABC broadcast the documentary film “Balibo” (2009) in January 2012 and it portrayed what happened to people in East Timor when Indonesia invaded them on December 7th just after

10 A US Naval aviator during the Vietnam. One of seven who escaped from a prison camp in Laos, but only he and one other person survived.

Complimentary Contributor Copy 18 Kathryn M. Gow their declaration of independence on 28th November 197511. The main story line was concentrated on what attempting to capture these events on film cost the five Australian media personnel involved12 – their lives.13 The coroner‘s verdict was that the media personnel had been executed when they attempted to surrender to Indonesian forces. Again the film emphasizes the way such events in neighboring countries, which are generally economically poor, are ignored or covered up. Another veteran journalist, Roger East, the key character in the drama (although portrayed at the beginning of the film as a middle aged weakling), in his quest to discover what happened to the journalists from Channel 9 and the ABC, puts himself and his East Timorese guide in danger and loses his own life). Another film on media personnel in war zones is “A Mighty Heart” (2007) which tracks the actions of two journalists who were working out of Karachi in Pakistan and had one last job to do after several years there. The husband, Daniel Pearl, was captured, tortured and killed in 2002. The Journalism Association reported that there were 56 journalists killed and 134 imprisoned across just one year as at June, 2007. Pearl’s journalist wife and the journalism world was not content to leave one more journalist or photographer’s death without taking some action, and instituted the Daniel Pearl Foundation.14 Thus taking action can help all of us make meaning out of loss, trauma and tragedy.

EDITORS’ NOTE

The Editors trust that you will find the material in this text interesting and useful in your work and in your communities. Both U.S. and U.K. spelling systems have been accepted in this book. All the chapters were submitted to a peer review process to satisfy the international standards for the quality of publications in research and theory, with the exception of this Chapter (1). Neither the Editors nor the Publishers are responsible for comments and information provided by the authors, as it is the responsibility of each author to ensure that their facts are correct, that they do not breach any aspect of copyright laws, and that their material is not libelous or defaming in any way.

REFERENCES

A Mighty Heart. (2007). Motion Picture. Director: Michael Winterbottom. USA: Paramount Vantage. Balibo. (2009). Motion Picture. Director: Robert Connolly. Australia: Arenafilm.

11 Over 183,000 people died during the invasion and incursions into East Timor. Again the neighbouring countries and the world stood by and did nothing. 12 The group, all aged under 30 years, comprised: two Australians - reporter Greg Shackleton and sound recordist Tony Stewart; a New Zealander - Gary Cunningham, cameraman for HSV-7 (Seven Network) in Melbourne; and two Britons - cameraman Brian Peters and reporter Malcolm Rennie, both from the TCN-9 (Nine Network). 13 The ‘Balibo Five’ were killed on 16th October 1975, during Indonesian incursions over the border before the actual invasion on the 7th December, 1975. 14 The Daniel Pearl Foundation (www.danielpearl.org).

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Celinski, M. and Gow. K. (Eds.). (2011). Continuity Versus Creative Response to Challenge: The Primacy of Resilience and Resourcefulness in Life and Therapy. New York: Nova Science Publishers. Eriksson, C. and Yeh, Dow-ann. (2012). Grounded Transcendence: Resilience to Trauma through Spirituality and Religion. In K. Gow and M. Celinski (Eds.), Individual Trauma: Recovering From Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. Fleming, S. (2012). Soldier back home. Gatton, Lockyer and Brisbane Valley STAR, Wednesday, February 8, p.1. Gow, K. (2009). Can We Anticipate More Heatwaves, Wildfires, Droughts and Deluges? In K. Gow (Ed.), Meltdown: Climate Change, Natural Disasters and Other Catastrophes - Fears and Concerns of the Future (pp. 157-174). New York: Nova Science Publishers. Gow, K. (2011). “A Narrative about the SEQ 2011 Flood as told by a Rural Psychologist.” Australian Psychological Society Queensland Newsletter, May. http://www.psychology.org.au/Assets/ Files/newsletter-Qld-May-2011.pdf Gow, K. and Celinski, M. (Eds.). (2011). Wayfinding through Life’s Challenges: Resilience, Coping and Survival. New York: Nova Science Publishers. Gow, K. and Paton, D. (Eds.). (2008). The Phoenix of Natural Disasters: Community Resilience. New York: Nova Science Publishers. Green Dragon. (2001). Motion Picture. Director: Timothy Linh Bui. USA: Columbia Pictures. Hall, A.H., Gow, K.M., Penn, M.L. and Jayawickreme, E. (2011). Strength of Character, Moral Emotions and Psychological Health. In M.J. Celinski and K.M. Gow (Eds.), Continuity Versus Creative Response to Challenge: The Primacy of Resilience and Resourcefulness in Life and Therapy (pp. 175-194). New York: Nova Science Publishers. Home of the Brave. (2006). Motion Picture. Director: Irwin Winkler. USA: Metro-Goldwyn- Mayer. ICRC World Disaster Report. (2001). www.ifrc.org/Global/Publications/disasters Joyeux Noel. (2005). Motion Picture. Director: Christian Carion. USA: Sony Pictures Classics. Kokoda. (2006). Motion Picture. Director: Alister Grierson. Australia: Palace Films. Lindy. J.D. (1988). Vietnam: A Casebook. New York: Brunner/Mazel Inc. Manyena, S., O'Brien, G., O'Keefe, P. and Rose, J. (2011). Disaster resilience: A bounce back or bounce forward ability? Local Environment, 16, 417-424. Only the Brave. (2006). Motion Picture. Director: Lane Nishikawa. USA: Mission from Buddha Productions. Oranges and Sunshine. (2010). Motion Picture. Director: Jim Loach. UK: Icon Film Distribution. Rescue Dawn. (2007). Motion Picture. Director: Werner Herzog. USA: Metro-Goldwyn- Mayer. Palmer, T. (2007). Break of Day. Camberwell, Victoria: Penguin. Slovic, P. (2010a). “If I look at the mass I will never act”: Psychic numbing and genocide. In S. Roeser (Ed.), Emotions and Risky Technologies (pp. 37-59). London: Earthscan. Slovic, P. (2010b). “The more who die, the less we care”. In Michel-Kerjan, E. and Slovic, P. (Eds.), The Irrational Economist: Decision Making in a Dangerous World (pp. 30-40). New York: Public Affairs Press.

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The Great Raid. (2005). Motion Picture. Director: John Dahl. USA: Miramax Films. The Grey Zone. (2007). Motion Picture. Director: Tim Blake Nelson. USA: Lionsgate. The Mark of Cain. (2007). Motion Picture. Director: UK: Red Production Company. The Postman. (1997). Director: Kevin Kostner. Based on the novel by David Brin. USA: Warner Brothers. Tredinnick, M. (2011). Australia’s Wild Weather. Canberra: National Library of Australia. Wilson, J.P. and B. Drozdek. B. (Eds.). (2004). Broken Spirits: The Treatment of Traumatized Asylum Seekers, Refugees, War and Torture Victims. New York: Brunner-Routledge.

Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 2

IMPLEMENTING COLLECTIVE APPROACHES TO MASSIVE TRAUMA AND LOSS IN WESTERN CONTEXTS

Saliha Bava*1 and Jack Saul†2 1Mercy College, New York City, NY, US; Houston Galveston Institute, Houston, TX, US 2Columbia University, New York City, NY, US

ABSTRACT

The western biomedical and psychological models of mental health and trauma response to massive trauma and political violence are being debated by the international community and in the United States. An alternate perspective, the psychosocial perspective, emphasizes collective approaches that focus on resiliency and socio-political construction of trauma rather than the medicalization of trauma. We provide a collective approach to massive trauma and loss that draws on family and community, narrative and performance and relational constructionist perspectives. We identify how collective approaches, that require critical and systemic thinking, have implications not only for people’s well-being, but also for program development, community engagement, evaluation, funding, leadership, collaboration and human rights. Eleven implications of utilizing collective approaches within the context of 9/11 and Hurricane Katrina are provided.

Keywords: Community Resilience; Narrative; Performative; Relational; Mass Trauma

* Saliha Bava, Ph.D. is Associate Professor of Marriage and Family Therapy Program, Mercy College, NY; Director of Research, International Trauma Studies Program; Faculty, Taos/Tilburg Doctoral Program in Social Sciences and Faculty, Houston Galveston Institute. Contact: [email protected] † Jack Saul, Ph.D. is Director, International Trauma Studies Program; Assistant Professor of Clinical Population and Family Health Mailman School of Public Health, Columbia University. Contact: [email protected]

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INTRODUCTION

There have been a number of recent discussions about how to provide mental health and psychosocial services during, and in the phase after, war, violent conflict, terrorism, and natural disaster. Among international government agencies and non-governmental organisations, part of what has spurred this discussion has been a need to situate western biomedical and psychological models of mental health and trauma response within a larger framework of humanitarian response. The international conversations and attempts at reaching some agreed upon guidelines have emphasised methods and stages of implementation. In the United States and in other western countries, there has been a recent surge of interest and activity in the area of collective and community-engaged responses to mass trauma and disaster.

APPROACHES TO MASSIVE TRAUMA AND LOSS

Recent attempts to conceptualise the role of mental health interventions in catastrophe response and preparedness have stressed the development of conceptual frameworks based on research and theory from the disaster management field. This is leading to new thinking about strategies for promoting community level factors that promote individual and population wellness as well as how to assess such processes. In the following section, we present some of the discussion about how mental health and wellness are being approached in non-western and western countries.

Emerging Collective Approaches: Family and Community Resilience

One of the strongest critiques of the implementation of western approaches to trauma recovery in non-western contexts is the assumption that extremely stressful experiences of war and atrocity not only cause suffering, but the consequent “traumatisation” also relocates phenomena from the social to the bio-psychological realm. This may distort a counting of the human costs of war and make of the resulting misery and distress a psychological disturbance to be solved. Trauma is viewed within this western biomedical and psychological perspective as an individual-centred event in which the singular human being is the basic unit of study and analysis. The emphasis then of this view is on similarity rather than difference and diversity. This perspective is problematic not only in that it fails to account for the ways in which war and other disasters impact families, communities and larger populations, but also in the way it privileges the “memories” of singular events in catastrophes, rather than focus on processes that are historic, ongoing, continuous and evocative of different reactions and responses over time (Summerfield, 1999). There have been attempts to place psychological programmes associated with massive trauma and loss into a larger social context. Ager (1997) has pointed to the tensions between approaches that are conceptualised as unique, indigenous and community-based and those that are conceptualised as generalisable, technical and targeted; most trauma programmes are defined by the latter characteristics. He proposed a four phase framework that puts

Complimentary Contributor Copy Implementing Collective Approaches to Massive Trauma and Loss … 23 psychological interventions within a larger context: phase one in which planned interventions avoid disrupting intact protective factors such as community structures, meanings and networks; phase two in which social resources that are considered too weak must be actively re-established – family reunification, community development, vocational training, etcetera; phase three in which particularly vulnerable groups may need compensatory support; and phase four in which there is targeted therapeutic support, only when the other phases are implemented. If a program is to be effective and sustainable, it is crucial that the people it is intended to service are able to contribute to its design, implementation and evaluation (Ager, 1997). Baron, Jensen and de Jong (2002) have proposed the “inverted pyramid” which delineates levels of mental health and psychosocial intervention, ranging from security measures that must be implemented for the entire population (the top of the inverted pyramid) to mid-level interventions that support family and community networks, to the lower and narrowest part of the inverted pyramid that includes the relatively few people who will need psychotherapeutic and psychiatric services after a catastrophe. The training of local professionals and practitioners in mental health and psychosocial response has been discussed in a set of guidelines developed by the Task Force on International Training of the International Society for Traumatic Stress Studies (Weine et al., 2002). In 2007, the Interagency Standing Committee of the United Nations published the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings (IASC, 2007) with input from over 200 NGOs. These new guidelines focus on the implementation of steps in complex humanitarian emergencies that take into consideration the particular social, political and cultural context of the recipient populations. These guidelines highlight six core principles: the promotion of human rights and equity, maximising the participation of local populations in humanitarian response, doing no harm, building on available resources and capacities, integrating support systems and developing a multi-layered set of complimentary supports that meet the needs of diverse groups. Collective trauma requires a collective response (Saul, 2006, 2007). “A collusion between therapists and patients, society and survivors, and among family members to avoid speaking about traumatic events may disrupt a sense of historical continuity, and may increase the disconnection of families and communities” (2006, p. 3). A collective response is a paradigmatic shift, which promotes resiliency and wellness. The recent focus on resiliency in western mental health and trauma response shifts our gaze from a perspective of breakdown, pathology or disorder, to one of individual and social strengths and resources accessible to the people affected by traumatic situations (Bava, 2005, Landau and Saul, 2004; Ungar, 2008; Walsh, 1998, 2003, 2007). Models of resiliency largely focus on individual resiliency or adapt empirically established principles for individual recovery to community application (Hobfoll et al., 2007). We believe that family and community resiliency needs its own conceptual framing so as to avoid falling into the trap of individualist thinking. We draw on the works of Norris, Stevens, Pfefferbaum, Wyche and Pfefferbaum, (2008), Hobfoll et al. (2007), Landau and Saul (2004), Ungar (2008), and Walsh (1998, 2007) to provide such frameworks. Below we briefly identify the key concepts provided by these various frameworks. Norris et al. (2008) provide a conceptual framework on community resiliency discourse for disaster preparedness in the West. An extensive review of the literature is utilised to develop a conceptual framework that maps out Economic Development, Social Capital,

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Information and Communication and Community Competence as four primary sets of adaptive capacities that foster community resiliency. These resources are further interfaced with robustness, redundancy and rapidity for deployment during disasters. They view “resiliency as a process - a positive trajectory of adaptation after a disturbance, stress, or adversity” (Norris and Stevens, 2007, p. 321). Their disaster preparedness framework may be partially extended to conceptualise disaster recovery by drawing on the four sets of adaptive capacities. The authors provide a rich conceptual base by synthesizing a wide array of research on resiliency from eight disciplines. However, due to the framework’s scope, the reader is not provided with a road map for operationalising these concepts within the context of intervention and/or research implementation. Further, the subtext of the paper assumes a geographically intact and stable community, rather than a dislocated and scattered community such as refugees and internally displaced people. Although the conceptual framework provides a resource-based approach rather than a psychopathological approach, it fails to highlight the family and relational perspective that is provided by Walsh (2007) and Ungar (2007). Further, although Norris et al. address culture as a caveat, they are limited by their notion of culture as a region or society - an anthropological perspective, which fails to acknowledge culture from a critical theory perspective as a performative, dynamic socio- political-economic discourse. Walsh (2007) calls for a multi-systemic, resiliency-oriented approach to recovery. She stresses the contextual factors in practice by situating the traumatising event in a communal context, while attending to the relational networks and practice focussed on “strengthening family and community resources for optimal recovery” (p. 207). She identifies belief systems, organisational patterns and communication as impacting on the family and social process in risk and resiliency (Walsh, 2003, 2007). The four key processes to facilitate resiliency include: (i) belief systems; (ii) the ability to make meaning of the traumatic loss experience and adopting a positive outlook, transcendence and spirituality; (iii) organisational patterns: flexibility, kin and community connectedness and economic and institutional resources; and (iv) communication/problem-solving, which includes clear, open emotional expression and collaboration (Walsh, 2007). While Walsh approaches resiliency as a systemic process from micro (family) to macro (communal), Norris et al. approach it as a macro-systemic process. Another distinction between Walsh’s and Norris et al.’s frameworks is that the former is applicable to the recovery phase of disaster management, while the latter is limited to the preparedness phase. The above frameworks provide conceptual perspectives on community resiliency, while Baron, Jensen and de Jong (2002), Ungar (2007), Landau, Mittal and Wieling (2008) and Landau and Saul (2007) provide frameworks for implementation. Baron, Jensen, and de Jong (2002) provide a framework for systemic organisation of interventions. They state a system of interventions can be organized according to the following 6 Cs: Coordination, Collection of Systematic Data, Community Public Health Approach, Clinical Service Development, Capacity Building and Supervision and Care for the Caretakers. Ungar (2008) presents the following five principles of resilience as applied to practice: (1) resilience is nurtured by an ecological, multi-leveled approach to intervention; (2) resiliency shifts our focus to the strengths of individuals and communities; (3) resiliency research shows that multi-finality, or many routes to many good ends, is characteristic of populations of children who succeed; (4) resiliency studies show that focus on social justice is foundational to successful development; and (5) resiliency research focuses on cultural and

Complimentary Contributor Copy Implementing Collective Approaches to Massive Trauma and Loss … 25 contextual heterogeneity related to children’s thriving. He defines resilience as: “first, resilience is the capacity of individuals to navigate their way to resources that sustain well- being; second, resilience is the capacity of individuals’ physical and social ecologies to provide these resources; and third, resilience is the capacity of individuals and their families and communities to negotiate culturally meaningful ways for resources to be shared” (Ungar, 2008, pp. 22-23). His definition emphasises the individual, family and community, while contextualising the constructive nature (meaningfulness) of how the resources are utilised. His research is focussed on pathways to resiliency and on children and youth. He approaches resiliency as a multi-level ecological intervention and moves from a micro to macro perspective of accessibility and resource availability. Landau and Saul (2004, p. 286) define community resilience as “a community’s capacity, hope and faith to withstand major trauma and loss, overcome adversity, and to prevail, usually with increased resources, competence and connectedness.” Landau (2010) presents the Linking Human Systems (LINC) model, which applies resiliency theory to individuals, families and communities facing crisis, trauma and disaster. The goal of this approach is “to engage the extended social support systems that can help empower and inspire individuals, families, and communities to reconnect and identify resources for healing” (Landau et al., 2008, p. 196). She identifies the central component of the approach as: (a) recruiting family and/or community members as agents of change; (b) assessing practical aspects of resiliency using transitional genograms, field maps, multi-systemic level map and strategic polarisation maps (detailed in Landau et al., 2008) and (c) implementing the designed interventions. The principles of the LINC Community Resilience Model (Landau, 2010; Landau-Stanton, 1986; Landau and Saul 2004) are to: (1) ensure that we have an invitation, authority, permission and commitment from the community; (2) engage the entire system of the community, including representation of individuals and subsystems from each cultural and ethnic group, and across all economic, cultural, and status strata; (3) identify scripts, themes and patterns across generations and community history; (4) maintain sensitivity to issues of culture, gender, and spirituality; (5) encourage access to all natural and ancillary resources (bio-psychosocial, cultural, ecological); (6) build an effective prevention/management context by collaborating across all systems; (7) foster a balance of agency and communion across the community; (8) build on existing resources; (9) relate programme needs to goals, future directions and best interests of the community; (10) utilise resources, turn goals into realistic tasks, and those into practical projects; (11) we provide the process, while the community takes responsibility for the content and goals; (12) encourage community links (natural change agents) to become leaders in their communities; because (13) the more peripheral we are, the more successful are the program and the community and then (14) the success of the project belongs to the community (p. 300). Landau and Saul (2004) identify four factors that were in interplay during the process of disaster recovery in the Lower Manhattan Communities project and the Buenos Aires project. These factors can be categorised into (i) disruption (family and community systems: process, function, structure and organisation); (ii) stressors (transition, catastrophic event, unresolved grief and loss); (iii) multi-systemic impact levels (loss of ability to contextualise, family dynamics, bonding patterns and communication patterns, social and community levels) and (iv) transitions (emergence of resilience and transitional pathways).

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Common to all these frameworks is the relational responsiveness or ‘joint action’ (Shotter, 1984, 2007) to traumatic events. According to Shotter, joint action refers to “mutually responsive, dialogically-structured relations with the others and othernesses around us…[we] enter into a dynamic inter-involvement with them” (2007, p. 36). This promotes connectedness and contextualising, which are bedrocks for trauma recovery (see Public Conversations Project; Weingartern, 2003). Connectedness or relational responsiveness is crucial to collective approaches. By collective approaches, we mean community resiliency and wellness practices and processes that are connected to the local people and context; promote cultural, social and emotional wellbeing; and are respectful of the historical, cultural, social, communal, familial and relational-identity discourses. Such processes, which embody relational responsibility (McNamee and Gergen, 1999) are both community-engaged and community-based in practice. Community-engaged practices are participatory activities that are designed, delivered, evaluated and sustained with the local people. Such activities supplement the local population’s resources and capacities with an outside pool of resources. Ungar identifies resource and capacity as hallmarks of resiliency-building processes (personal communication, June 2008). “Community-based” is defined as services located within access to community members (see Boss et al., 2003; Pulleyblank-Coffey, Griffith and Ulaj, 2006). Community-based services are more likely to succeed if they are based on community assessments and engagement. Such services may be designed with outside resources, but need to be located within a geographical community. Typically, community-engaged and community-based services are used interchangeably in practice.

Emerging Collective Approaches: Performative and Narrative Perspectives

Disasters are the disruptions of structures and functionality. Resilient disaster recovery is the process of returning to some aspects of functioning that existed pre-disaster and developing new ways of functioning to adapt to the newly emerging structures. The performance of disaster recovery is the process of moving through the spaces of transformation and transition. Such performances occur in the “liminal phase” of what Turner, Abrahams and Harris (1995) refer to as “anti-structure.” It is the phase in which one passes from one stage (disaster) to another (post-disaster) through social processes of reflection, dialogue and action. These processes of a resilient response are performed collaboratively to create collective structures, which in turn promote social relational processes. Performance is a perspective, process and approach that “can provide a space for communities that have endured calamities to come together to share experiences and engage in public discourse” (Saul, 2006, p. 29). Performance of trauma and healing practices can be understood as enactments that may be symbolic, or ritualistic (Schechner, 2002). Such enactments within the liminal space allows for the creation of spaces for action and reflection, which furthers transition. These processes invite multiple collaborations for making sense of the disaster and for creating post-disaster collective structures. Following the performance of these collaborations, within the liminal spaces are specific actions, or series of actions, that are initiated and accomplished. And each of the performative actions takes on significance in excesses of the ‘liminal performance of collaborative actions’ (Bava, 2010; see Schechner, 2002).

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Together, we create different forms of responsive performances to collective trauma. These responses include theatre, public spaces, community action, community dialogue, etcetera. Public spaces are convening and conversational spaces. Convening allows for values and identity to be performed. Conversation allows for respect of differences, construction of meaning, and community action. Convening people for conversation and dialogue involves invitation, inclusiveness, building trust and developing ways of negotiation, and leads to instrumental action, meaning, narrative embodiment of the new process. Such post-disaster liminal spaces that allow for community-building and action are illustrated in Saul and Bava (2009) in the performance of “Ground Zero Initiative,” which led to the formation of community forums that consequently led to the performative development of the “Downtown Community Resource Center” (see p. 17). Performance affirms agency and embodiment; performance can be improvised and/or structured. The Downtown Community Resource Center’s Video Archive Group’s project (Saul and Bava, 2009; Saul et al., 2004) is a narrative and performative action of collective response that represents structured improvisations. An important part of the communal healing process is having one’s story validated and made a part of the collective story that emerges after a complex and horrible tragedy. This affirmation by the community at large is often described by those who survive major disasters as a crucial step in recovering their sense of agency and wellbeing. As we have seen in New York City post-September 11 (2001), the emerging story after such events needs to respect and be broad enough to encompass the stories experienced by many different people - those who have lost family and friends, those who have lost their homes, those who were far away from the Ground Zero but still were deeply affected by it, those who were confused, and those who suffered discrimination and injustice as a result of the events. It can be problematic when the dominant narrative is narrow or rigid, or marginalises some segments of the population. This has particularly been the case for the Arab-speaking and Muslim communities in which many members faced harassment, detention and deportation. Often it is those people who do not have a voice in society that may be further victimised or exploited after a collective tragedy (Saul, 2004). We have observed in our work (Bava and Levin, 2007a, 2007b; Project Resiliency 2008; Saul, 1999; Saul, Ukshini, Blyta and Statovci, 2003) across cultures and communities that the western notion of the linear verbal narrative is one among many versions of how individuals and groups arrive at a sense of meaning and coherence after tragedy. These experiences may take years to comprehend as people may draw on past stories of vulnerability and/or strength to frame their current experience. As a result of work with community narrative and liminal performances, we have been interested in the way that meaning-making is both an active and dialogic process that is enacted in the social dramas of families and communities. Overwhelming experiences of stress and loss are carried as “embodied knowledge” (Taylor, 2003), and thus, through the body and action, meanings are performed and re-performed over time. This collective process of meaning-making is important especially, but not only, for people who have experienced tragedy together. There has been a recent worldwide proliferation of theatrical, ritual and other communal performance practices in response to massive trauma (Agger and Jensen, 1990; Fullilove, 2002; Reisner, 1998, 2003; Taylor, 2003; van der Kolk, 2006). We need to better understand how these practices promote individual and collective resilience and wellness.

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Emerging Collective Approaches: Relational Constructionist Perspective

The relational Constructionist perspective refers to being in concert with each other. It is the process of socially creating “the intersubjective realities that we temporarily share with each other” (Anderson and Goolishian, 1988, p. 374). Our understandings, created socially in language, define what are “problems” and “solutions.” Anderson and Goolishian (1988), in their seminal paper, state that human systems are language-generating and, simultaneously, meaning-generating systems. Communication and discourse define social organization; that is, a sociocultural system is the product of social communication rather than communication being a product of organization. The problem is created in language by those who are in conversation with each other about the issue as they view it (Anderson and Goolishian, 1988). Applied to the disaster of Hurricane Katrina that hit New Orleans in 2005, we observe how practice communities coalesce around the problem definition of “Katrina” and engage in evolving the language and meaning specific to it, which shapes the responses and services for the affected population. Locating the Katrina Disaster. Hurricane Katrina is a not just a natural disaster. It is a euphemism that captures the disasters caused not only by nature, but also by human and recovery efforts. The way Katrina is constructed creates challenges and possibilities to understand and respond to such a mass trauma. Katrina framed as “hurricane” potentially de- contextualises the disaster by stripping the historical reference to slavery in America. Also it fails to acknowledge the pre-existing and ongoing social location issues, such as family, race, geography, regional politics and economy. Norris et al.’s (2008, p. 131) label of Hurricane Katrina as an environmental disruption is based on the conceptualisation of the duration. The first author believes that the duration persisted in the form of ongoing disaster due to the lack of recovery plans, political and economic gaming, Federal Emergency Management Agency’s (FEMA) lack of resource mobilisation and attendant failure to rapidly deploy these resources. Furthermore, there was a lack of critical thinking in developing recovery plans for the nation’s largest dislocation. Relying on short-term disaster recovery models created ongoing disasters for displaced people, such as having to re-register three to four times to continue to qualify for FEMA assistance including housing benefits. The rebuilding recovery efforts were focussed on homeowners, and did not take into account intergenerational housing and the renter situation. Internally displaced persons’ (IDPs) experience of Hurricane Katrina is not very different from the people who seek refugee status due to mass violence or civil war. Baron, Jensen and de Jong (2002) describe this state for refugees:

Most often, after years in exile, the cumulative effects of the stress of their ongoing living situation seem to outweigh the memories of the initial traumatization. Van der Veer (1995) writes that traumatization is usually not a specific traumatic event in the sense of an isolated incident or a set of events that have left painful scars for refugees. More often, it is an enduring, cumulative process that continues during exile because of distinct new events, in the native county and in the country of exile. It includes a chain of traumatic stressful experiences that confront the refugee with utter helplessness and interfere with personal development over an extended period of time. (p. 248)

Similarly, New Orleans IDPs refer to their experiences of flooding, and the journey from New Orleans to Houston as a distant past, compared to the adjustment to Houston and accessing their rights to quality of life or to move towards wellness. It is the chain of

Complimentary Contributor Copy Implementing Collective Approaches to Massive Trauma and Loss … 29 traumatic events that prolongs this disaster, creating helplessness and hopelessness, and engendering a fear for the future that continues in a similar way to the aftershocks of an earthquake. We refer to this disaster as Katrina to emphasise the intersectionalities of a hurricane, features of disaster, forced migration, and acts/processes of injustice and human rights violations. Accordingly, long term recovery systems and implementation designs need to be adapted from experiences of recovery efforts following mass traumas - grief, loss and bereavement and resiliency interventions; refugee resettlement; and political action and empowerment processes. To conclude, the relational constructionist perspective is the view that “through language…we are capable of forming the shifting communities of meaning to which we belong and …the intersubjective realities in which we exist” (Anderson and Goolishian, 1988, p. 375).

EMERGING THEMES IN IMPLEMENTING COLLECTIVE APPROACHES

The first author was an academic, a local mental health professional specializing in collaborative practices at a private non-profit, and the training co-chair of the City of Houston’s Disaster Mental Health team. She was activated by the city to respond to Katrina. The second author was a community member, local mental health professional and a trauma specialist conducting academic and community programmes in New York City prior to 9/11 (Saul and Bava, 2009). Drawing on their responses to Katrina and 9/11, major mass traumas which occurred in the United States of America, they identified the following interconnected common themes in implementing collective approaches for community resiliency. Tensions in Clinical and Community Approaches. The clinical approach can be distinguished from an ecosystems or community approach in a number of ways. The clinical approach focusses almost exclusively on the individual as the client, and particularly in a post-disaster context this approach is easily stigmatising, as people do not necessarily want to be identified as having a mental health problem. It also usually offers a limited range of possibilities for healing. Frequently, clinical services are not oriented to the stated needs of clients, but to the services the clinicians are interested in providing. The clinical perspective emphasises enhancing the expertise of the providers, and little attention is paid to enhancing the competence of clients to recognise and find solutions. The clinical perspective locates the trauma in the person, and attention to the communal nature of people’s difficulties is lacking. The most common form of clinical service offered during disasters is crisis counselling. Such programmes are designed to be short-term and, in Houston, involved door-to-door canvassing using a psycho-educational component along with information and referral for services. Although Norris and Stevens (2007) report that such services were wide-reaching after Hurricane Katrina (“1.3 million counselling encounters”) (p. 326), their utility was largely questioned in Houston by both service recipients and other social service providers. Due to the lack of integration of mental health with other disaster recovery services, there was a gap that went unbridged, even though referral numbers were provided. As stated in the IASC report, “do not separate out mental health or psychosocial support” services (p. 14). Typical crisis counselling programs are not well coordinated with other social support services. This was one of the bridges that the first author was building with the Community

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Partnership for Resiliency (CPR) project, which was aimed at the enhancement and development of the public-private partnership in the area of wellness to promote community resiliency. By mapping the gaps created by lack of interfacing and coordination between these services and convening the various key players in the recovery effort, the first author was focussing on increasing community capacity. In the ecosystems, or community approach, the client is the social environment and the focus is on strengths, resources and continuity. One of the most important assumptions of this approach is that communities have the capacity to heal themselves and that the greatest resources for recovery are relationships among the community members. The activities supported by such an approach are often those that community members are already engaged in and thus non-stigmatising. In coming together around practical concerns, the connections between people may be enhanced, and as we have recognised both internationally and in New York and Houston, these become the sites for sharing information, expressing emotion and providing mutual support (Fullilove and Saul, 2006). One of the common themes we both noted in our work, was that we continuously had to explain the collective/community perspective to mental health practitioners, city agencies, funding organisations and to the media. Although, in the years following 9/11, there appeared to be greater acceptance of community approaches, as well as an emphasis on promoting strengths and resources, the changes seemed to be more in language than in conceptual understanding and knowledge of implementation. There is currently a greater willingness to explore how individual clinical approaches, both pathology- and resilience-oriented, can be implemented in the context of broader social interventions that highlight engagement and collective resiliency. We are now seeing the greater utilisation of approaches after major trauma and disaster that address mental health needs in the context of family and community interventions (see Bava, Coffey, Weingarten and Becker 2010; Fraenkel, 2007; Walsh, 2007). Inside/Outside Expertise and Competing Agendas. The IASC committee recognises that an “affected community can be overwhelmed by outsiders, and local contributions to mental health and psychosocial support are easily marginalised or undermined” (2007, p. 33). A community resiliency approach requires the systematic identification of the range of adaptive capacities of the various members within the affected communities. There is a need to focus on and improvise utilizing the available organisational resources to determine which one of these adaptive capacities are most important and which ones will be more challenging to access. Such systemic identification and focus becomes very difficult due to the continuous structural and organisational shifts that happen on the ground (Bava et al., 2010). The challenge lies in recognising and accessing communally each organisation’s strengths, rather than privileging the organisation with the most resources, or loudest voice, in determining the agenda for the community. Some communities, such as that of lower Manhattan after 9/11, might have the various expertise needed, while others, such as the community of displaced people in Houston after Katrina, might have some expertise, but not all the resources, as highlighted in the Norris et al.’s (2008) networked adaptive framework. This could be due to dislocation and other social location factors such as race, economics, politics, etcetera. So this raises the question of power discourse: how is expertise identified? Who identifies it? How effectively is local capacity tapped into before there is an import of outside expertise? The process of recognising the local expertise furthers the resiliency of the local community during disasters. Taking this perspective is critical, because such a perspective is sensitive to community organising.

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Norris and colleagues (2008) have provided a preparation framework. We believe that it is important to develop similar frameworks for displaced, disenfranchised communities rendered voiceless as a result of the break-up of their social network. Further, it is crucial to acknowledge that organizations have multiple competing agendas. Who gets positioned to oversee what is needed by the impacted community? The political process of access influences the negotiation of outside and inside resources. Such negotiations are also shaped by political agendas as seen in Katrina. Landau’s (2010) framework provides an alternative that does not rely on one entity, but rather the community as a whole, which keeps the political agenda accountable to the people. In Landau’s model, all parts of the community have to be represented. But again, such a model was challenged in Katrina, as the community did not exist in one geographical location. Who will bring all the dislocated people together? Such a practice is both resource-intensive and time-consuming, especially in the aftermath of dislocation. In addition, the individual family agenda might trump that of the community. For instance, the dislocated families may be focussed on deciding where to live in Houston, even as the community attempts to protect the collective property in New Orleans from being usurped by developers. A core group of organizers bring people together. This happened in a number of instances during Katrina. However, this process was received with scepticism by other local groups, since it was viewed as a political process aimed at building the economic resources of those with means. This raised a number of human rights issues. However, even in communities with substantial means, such as Lower Manhattan, outside forces, such as regional and/or political interests, can potentially render the local community invisible or voiceless. Cultural Silence. How do we play out the various challenging discourses? Often in a community, when something is spoken, something else goes unspoken. However, unspoken is not the same as silenced. Some discourses, however, promote silence while others promote the notion of transparency. For instance, the culture of silence was created when people who wanted to protest the war on Iraq were labelled as “unpatriotic.” At a community level, organizations seeking funding may remain silent on politically unpopular issues. In addition, competition for funding can lead to lack of information-sharing (a form of silence) thereby limiting innovation between organizations. Social change requires a combination of political transparency and collaborative innovation. So we are more likely to maintain the status quo by focusing on social service, rather than social change, in the face of cultural silence. Political and Economic Parameters. As discussed above, political and economic parameters are always present and operate in the fore- and back-ground. However, when they are not discussed openly and do not become part of the conversation of the design, they not only create the culture of silence, but also maintain the status quo. Although we may privilege the collaborative structure politically, we create remunerations systems that focus on certain positions weighted with privilege economically. This is because we privilege the expertise that represents knowledge and authority, but not expertise that draws on life experience. Such western models of funding affect implementation. Funders speak the language of collective and community resiliency approaches but may not publicly acknowledge their uncertainty on how to implement innovative local ideas that have not yet been “tested” (see Project Resiliency, 2008). The lack of transparency makes it difficult to find ways to develop community- engagement programs. Dialogues are needed to address these parameters. For instance, by not funding administrative processes and planning (essential components of community

Complimentary Contributor Copy 32 Saliha Bava and Jack Saul engagement), we fail to acknowledge the different types of efforts required in community resiliency. We need more dialogue between the implementers, recipients and funders from the outset. Rather than having economics dominate the conversation in the planning process as the primary resource, it is crucial to acknowledge the other adaptive communal resources on the table. Thus, funders have to join hands with community members to mitigate the hierarchy created by the way financial resources are allocated. Flexibility and Improvisation. Recovery is an emergent process (Bava, 2010) and one has to plan to have no plan (Norris et al., 2008). One has to have a flexible and improvisational approach (Bava and Levin, 2007a) wherein one is willing to make “mistakes.” But coming from a fear and blame perspective, the notion of “mistakes” is in and of itself an expensive prospect. Improvisation includes flexibility in funding and access to resources, especially after the honeymoon phase of recovery when exhaustion and hopelessness are more likely to take hold. Creative, flexible and communal thinking and action are enactments of adaptive resources and perform as protective factors from burnout. However keeping blame and fear, which can kill creativity and flexibility, at bay is an enormous challenge. Creating a context with servant leadership and courage becomes critical at this juncture. Leadership. Most leadership models are drawn from corporate rather than the social sector. Both corporate leadership and social entrepreneurship require similar notions of leading a team, but the latter is much more value-focussed. Such a model of leadership is in the service of a social cause rather than in service of primarily economic gain. One such model of leadership is Servant Leadership (Greenleaf, 1991). Such a leadership requires vision, goals, courage, and humility in service of the cause. To implement this, one needs collaboration, community engagement, and improvisation. The leader is a gatekeeper, a community builder, a visionary, a process facilitator, a task master, a mentor, a problem solver, a path maker, a person who makes mistakes, a course corrector, an inspiration, a motivator, a listener, a faith-keeper, a hope-builder and a resource-leveraging actor, who continuously blends these and many more roles. The City of Houston’s mayor, Bill White, showed such remarkable leadership in responding to Katrina by developing and facilitating a recovery system for the IDPs arriving in Houston. Community engagement invites two forms of leadership - individual and team. The first author’s role on the CPR project illustrates the individual leadership form, while the George R. Brown Convention (GRB) project of directing mental health services at a mega shelter illustrates team leadership (Bava and Levin, 2007a). There is more resistance to team leadership model, but it is a greater fit for collaborative practices. The elements that make it successful are time, patience and relational resources. However, if the relationships are in place, it is easier to implement such a model as experienced at GRB (Saul and Bava, 2009). Although there is a point person, the decision-making is a shared process (Walsh, 2007). Each model of leadership has different implications for task, pace, process and time; and consequently it affects output and prioritisation of tasks, in turn influencing each other’s expectations. Common to both models is partnership, as there is no leader without a team. Collaboration and Partnership. The IASC (2007) states that “effective mental health and psychosocial support (MHPSS) programming requires intersectoral coordination among diverse actors, as all participants in the humanitarian response have responsibilities to promote mental health and psychosocial wellbeing” (p. 33). In addition to coordination and collaboration, partnerships and relationships at each level are what make for successful implementation. Effective partnerships emerge from the various stakeholders engaging in

Complimentary Contributor Copy Implementing Collective Approaches to Massive Trauma and Loss … 33 dialogue to connect, collaborate and construct a mutual endeavour towards the possibility (Anderson, 1997) of development, recovery and rebuilding. Conversations and relationships go hand in hand. Harlene Anderson, originator of Collaborative Therapy (Anderson, 1997; Anderson and Gehart, 2007), states that the type of conversations form and inform the type of relationships we develop, and the relationships we have both form and inform those conversations. For effective collaborations and partnerships, conversations (dialogue) and relationships are critical actions. For instance, in conversations and in relationships (Anderson, 1997), the Lower Manhattan area developed community forums. The forums developed the Downtown Community Resource Center, which in turn led to the action of The Artist Studio Tours of Lower Manhattan. Thus through collaboration and relationships, dialogical space was created for meetings, which led to collective action and community- building. Such dialogical space becomes the praxis that strengthens community resiliency through collective practices. Resilience as Metaphor and Process. Resilience as a metaphor from physics may have its limitations when applied to the relational process, but it is a concept that inspires hope and optimism after massive trauma. As we have stressed in this chapter, the process by which individuals and groups gain access to what they need in order to recover from crises, takes place on all systemic levels. Individuals are resilient to the extent that they are sustained by resilient families and communities. Unger (2008) makes the point that the concept of resilience is a social construction (Anderson, 1997; Gergen, 1999) that is shaped by culture and many situational contexts. If resilience has to do with accessing available and potential resources, then what people define as meaningful resources is critical to the process. Many resources may be available, but not meaningful and/or considered worth pursuing. As Ungar states, the notion of meaningfulness is also socially negotiated and thus resiliency is metaphorical, as it will vary by each community’s meaning-making system. Collaborations that are intended to promote resilience must engage in a process that will identify meaningful resources, perhaps discover new untapped resources, and develop strategies that will help attain them. After major trauma, dislocation, and further victimization that often unravel the social fabric, and in which cultural leaders may no longer be present, the foundation for promoting resilience may be fragile. As we have seen in our work with refugee communities, the re- weaving of social connections and the recovery of social and cultural resources, historical continuity and identity, may be a very long journey. As observed with populations that have endured massive trauma, such as the survivors of the Nazi Holocaust, the process of adaptation takes decades and includes many practices that promote resilience that are quite unique and culturally specific. How and What to Count? How does one measure practices that promote resilience if they are unique and culturally specific? Measures of success for community resiliency are still being identified, while the need for statistics and numbers as a way to justify funding creates tension. The former is a measure of impact that is not always immediately discernable in a process-oriented approach such as community resiliency building. The latter is a measure of outputs usually reportable in numbers. Using the measure of head counts is good for accounting quantity but not quality. Head count is a good measure for reporting turnout at a community event, but should not be confused as impact of community resiliency. Thus, another challenge is what counts as “measures of success?” To apply only head counts as measures of success is to revert to an individualised model of care, thus discounting

Complimentary Contributor Copy 34 Saliha Bava and Jack Saul community resiliency. The increasing influence of the western notion of effective practice driven by evidenced-based practices that are not tested in the real world, but are driven by methodological conservatism (Kvale, 2008) increases the likelihood of utilizing clinical models under the guise of community resiliency. Such models may have no input from the local community in which the model is to be applied. Every mass trauma is a new learning experience due to the number of social location factors, not just a new context to apply a tested model. Further, mass traumas are opportunities for transformation and social change. Thus, we need measures of social transformation and not just measure of social service. We fail to acknowledge that we are still learning what works within a dynamic context while the discourses of accountability and evidence-based practices are on the rise. The culture of accountability, intended to create ethical practice is instead creating a reductionist reporting culture based on economic accounting principles. A more appropriate notion of accountability includes both the social and economic; it is both doing the right thing (ethical) and spending appropriately. However, the latter is in service of the former. “Accountability stems from late Latin accomptare (to account), a prefixed form of computare (to calculate), which in turn is derived from putare (to reckon)” (Oxford English Dictionary). As we understand and develop accountability principles and practices, we are turning to literal sources of accountability, those defined by economic principles, which form the basis for accounting. Using accounting measures for accountability limits us to using an economic model for measuring social and communal practices. Economic accounting is only one way of identifying the “right thing.” Such a practice then uses the “bottom line” priorities of commerce to measure emotional wellness. This in turn leads providers to conduct head counts and promote practices like screening for community resiliency, which again individualises recovery practices, rather than promoting collective processes. This creates a vicious economic-based accountability cycle that is self-defeating. Community Engagement and Measurement. At the risk of creating an artificial distinction between community engagement and “program” rollout, we speak to the challenges of measurement in community action. A community resiliency program includes the phases of design and delivery, program implementation and ongoing program evaluation (continuous learning). Although community engagement is part of all the phases, it is especially critical in the initial phase. However, most funding is for program implementation, thus discounting community engagement and creating an artificial distinction between the “design” and “implementation” (Bava, 2010). Consequently discounting the impacts of convening people for community action, which itself is community resiliency. Here the statistics need to include the number of meetings, the opening and challenges identified, the types of strategies discussed, the number of people attending, the new linkages created, the local perspective gained, the networks tapped or built, etcetera. Community engagement is a much harder concept to grasp given the various meanings of community (Norris et al., 2008). Further, within a transient community or a re-forming community, the notion of “community” is not present as a geographical unit but has been transformed into a virtual group of people who are now identified as internally displaced, dislocated, and/or a diasporic community, such as the Katrina-impacted citizens. Thus engagement of such a community involves different strategies from a geographically “intact” community like New York. Mapping of community resources for engagement of a geographically “intact” group may include tools developed by Landau et al. (2008), asset mapping (Kretzmann and McKnight, 1993), or community mapping (Kirschenbaum and

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Russ, 2002), etcetera. Yet mapping of virtual communities is possible and important as learned from Internet communities. We need to learn and advance such methods for practical applications to IDPs affected by mass trauma. The staging and purpose of such mapping, for community engagement is crucial for people to have the experience of genuine involvement rather than their participation being experienced as the need to access their identity (ID) numbers for headcounts to secure or maintain grants (personal communication with IDP, 2008). To do so, once again reduces people to numbers and they are left feeling that their voice does not count, but that their ID number does. We need methodologies and procedures that measure communal factors that promote community resiliency. We need various social relationship and perception indicators to measure community engagement rather than individual measures of mental health. Measures of emotional wellness are more appropriate than the current measures of mental health, which are typically an epidemiological perspective of mental disorders. We are not ruling out the occurrence of mental disorders and PTSD post disaster. Rather we are speaking to the issue of validity. Are we measuring what we say will be different when community engagement and resiliency is promoted? Rather than measure the incidence rate of illness, we need incidence rates of health. We need various measures of social relationships and social capital to measure community engagement. “Social relationships are described using various terms and measures - among them, relationships and connections to people, levels of interpersonal trust and mutual aid, social cohesion and collective efficacy, social support, group membership, mutual respect, and social power or the ability to work together to achieve desired ends” (Policylink, 2008, online). The Greenlining Institute (2002) defines social capital as relationships and connections between people that create feelings of trust, reciprocity and cooperation. Norris et al. (2008) identify social capital as one of the primary sets of networked capacities of community resiliency. They identify social capital as encompassing social support perceived and received, social embeddedness, organisational linkages, citizen participation including leadership, sense of community and attachment to a place. These components are potential entry points for community engagement, but can also serve as measures of community engagement. Human Rights. In the United States, the federal organisation that is activated in the face of an event causing mass trauma is the Federal Emergency Management Agency (FEMA). It “coordinates the federal government's role in preparing for, preventing, mitigating the effects of, responding to, and recovering from all domestic disasters, whether natural or man-made, including acts of terror” (FEMA, 2010, FEMA history). A number of Congressional Acts have shaped the formation and function of FEMA. One of the major acts that has implications from a human rights perspective is the Robert T. Stafford Disaster Relief and Emergency Assistance Act, signed into law on November 23, 1988. This Act constitutes the statutory authority for most Federal disaster response activities, especially as they pertain to FEMA and FEMA programs. The Advocates for Environmental Human Rights (AEHR), a New Orleans advocate organisation that critically reviewed the Stafford Act states that “for years, the US Government has recognized the Guiding Principles on Internal Displacement ‘as an important tool for dealing with situations of internal displacement’, and welcomed the fact that an increasing number of countries ‘are applying them as a standard’” (Advocates for Environmental Human Rights, n.d.a, US Disaster Response Law). According to AEHR, “although the U.S. government promotes human rights standards for displaced people in foreign countries, it has failed to apply these standards to protect American citizens who are

Complimentary Contributor Copy 36 Saliha Bava and Jack Saul struggling to rebuild their lives and communities on the Gulf Coast” (Advocates for Environmental Human Rights, n.d.b). The reason is that disaster recovery is federally coordinated by FEMA whose standards are different from the above guidelines. They state these standards are not a right but rather a promise, thus stripping from the local people a right to disaster recovery. The way larger systems are structured in their response mandate impacts the local community response. From our perspective, it is not enough to view access to mental health as human rights; rather it is critical to view that protection of one’s human rights is the promotion of mental health. Thus, protection of one’s human rights takes on a value similar to meeting one’s basic physiological needs. Meeting basic needs is to physical health what meeting human rights is to emotional or mental health, community health, and socio-cultural health. Such a position is in keeping with the IASC guidelines to “apply a human rights framework through mental health and psychosocial support” (2007, p. 31). While there is an increasing consensus on approaching mass trauma recovery and rebuilding from a community engagement and resiliency perspective, there still remain a number of challenges. These have to do with the types of disruptions, transitions and challenges to rebuilding in the aftermath of a mass traumatic event faced by particular communities. Future preparedness and recovery efforts can help or harm resilient recovery processes depending on how we, as a field, shape these discourses.

CONCLUSION

We believe that the response to the challenges outlined in this chapter are the action principles for collective approaches which embody leadership, collaboration and partnership, and measurable community engagement practices that promote resiliency as a metaphor and process using local narrative and performative practices, while honouring our universal human rights. Some of the practical implications of such an approach are:

 Protecting physical and enhancing virtual space for convening communal activities;  Preventing the redirection of funding from resource poor neighbourhoods and protecting post-disaster communities from political and economic exploitation;  Training mental health professionals in collective, relational, and contextual thinking in disaster situations;  Increasing research funding to develop community-engaged methodologies;  Increasing further development of thought about families and extended families’ responses and how to strengthen them, reduce stress, and promote their wellness;  Applying collective approaches to other groups suffering from the long-term effects of massive trauma - for example refugees, other displaced groups, and immigrants;  Promoting a relational and wellness perspective with families and communities and better understand and prevent the stresses that may lead to conflict and resource loss; and  Exploring how to prevent burn out and fatigue with affected community members in order to sustain the spirit of altruism and interdependence after a catastrophe.

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These suggestions raise a number of questions. As a community of mental health and psychosocial practitioners, we need to keep dialoguing such that we develop reflexive practices. Further, it is important to recognise that conceptualisation, funding, program designing, evaluation, research and administration are all forms of practice. Without this much needed critical and reflexive view of all our practices, we are at the risk of colonising the world with models such as the diseasing of America. A psychosocial approach that is relational and dialogical is more likely to promote peace and development.

ACKNOWLEDGMENTS

This chapter contains material from a paper presented at the Trauma, Development and Peace Building Roundtable at New Delhi, India, September 9-11, 2008. Hosted by International Conflict Research Institute (INCORE) and International Development Research Centre (IDRC). That paper was produced as part of the Trauma, Peacebuilding and Development Project conducted by INCORE and funded by the IDRC, for more information see http:// www.incore.ulst.ac.uk/research/projects/trauma/ We would like to thank Cyril Bennouna, Natalie Prinkerton and Reina Saiki for their editorial assistance.

REFERENCES

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Bava, S. (2010). The liminial space and systems: Disaster response and recovery. Retrieved from http://salihabava.com/academic Bava, S., Coffey, E., Weingarten, K. and Becker, C. (2010). Lessons in Collaboration, Four Years Post-Katrina. Family Process, 49(4), 543-558. Bava, S. and Levin, S. (2007a). Collaborative disaster response: Setting-up mental health services in a Mega-shelter. AFTA Monograph Series: Systemic Responses to Disaster: Stories of the Aftermath of Hurricane Katrina. DC: American Family Therapy Academy. Bava, S. and Levin, S. (2007b). Building bridges: MFTs as agents of hope during disaster. Presented at American Association for Marriage and Family Therapy Annual Conference. Long Beach, CA. Boss, P., Beaulieu, L., Wieling, E., Turner, W. and LaCruz, S. (2003). Healing loss, ambiguity, and trauma: A community-based intervention with families of union workers missing after the 9/11 attack in New York City. Journal of Marital and Family Therapy, 29(4), 455-467. Federal Emergency Management Agency. (2010). FEMA History. Available at http://www.fema. gov/ about/history.shtm Fraenkel, P. (2007). Engaging families as experts: Collaborative family program development. Family Process 45, 237–257. Fullilove, M. (2002, April). Together we heal: Community mobilization for trauma recovery. Paper presented at a meeting of Columbia University School of Public Health, New York. Fullilove, M. and Saul, J. (2006). Rebuilding communities post-disaster: Lessons from 9/11. In Y. Neria, R. Gross, R. Marshall and E. Susser (Eds.), September 11, 2001: Treatment, Research And Public Mental Health In The Wake Of A Terrorist Attack (pp. 164–177). Cambridge: Cambridge University Press. Gergen, K. J. (1999). An Invitation to Social Construction. Thousand Oaks, CA: Sage Publications, Inc. Greenleaf, R. K. (1991). The Servant as Leader. Westfield, IN: The Greenleaf Center for Servant Leadership. Hobfoll, S. E., Watson, P., Bell, C.C., Bryant, R. A. Brymer, M. J., Friedman, M. J. et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence, Psychiatry, 70(4), 283-315. Inter-Agency Standing Committee. (2007). IASC Guidelines on mental health and psychosocial support in emergency settings. Geneva: IASC. Kirschenbaum, J. and Russ, L. (2002). Community mapping: Using geographical data for neighborhood revitalization. Available at: http://www.policylink.org/pdfs/Mapping.pdf Kretzmann, J. P. and McKnight, J. L. (1993). Building Communities from the Inside Out: A Path toward Finding and Mobilizing a Community's Assets. Evanston, IL: Institute for Policy Research. Kvale, S. (2008). Qualitative inquiry between scientistic evidentialism, ethical subjectivism and the free market. International Review of Qualitative Research, 1(1), 5-18. Landau, J. (2001, November). Enhancing family and community resilience in the face of trauma: Community outreach and organization. Presentation at the International Conference of the International Family Therapy Association. Brazil, Nov. 2001.

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Landau, J. (2007). Enhancing resilience: Families and communities as agents for change. Family Process, 46(3), 351–365. Landau, J. (2010). Communities that care for families: The LINC model for enhancing individual, family, and community resilience. American Journal of Orthopsychiatry, 80(4), 516–524. Landau-Stanton, J. (1986). Competence, impermanence, and transitional mapping: A model for systems consultation. In L. C. Wynne, S. McDaniel and T. Weber (Eds.), Systems Consultations - A New Perspective for Family Therapy (pp. 253-269). New York: Guilford Press. Landau, J., Mittal, M. and Wieling, E. (2008). Linking Human Systems: Strengthening individuals, families, and communities in the wake of mass trauma. Journal of Marital and Family Therapy, 34(2), 193-209. Landau, J. and Saul, J. (2004). Facilitating family and community resilience in response to major disaster. In F. Walsh and M. McGoldrick (Eds.), Living Beyond Loss (pp. 285- 309). New York: Norton. McNamee, S. and Gergen, K. J. (1999). Relational Responsibility: Resources for Sustainable Dialogue. Thousand Oaks, CA: Sage Publications, Inc. Norris, F. H. and Stevens, S P. (2007). Community resilience and the principles of mass trauma intervention. Commentary on “Five Essential Elements of Immediate and Mid- Term Mass Trauma Intervention: Empirical Evidence” by Hobfoll, Watson et al. Psychiatry, 70(4), 320-328. Norris, F., Stevens, S., Pfefferbaum, B., Wyche, K. and Pfefferbaum, R. (2008). Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology, 41, 127-150. Project Resiliency. (2008). Project Resiliency Report. The Role of Behavioral Health and Behavioral Health Providers: A Retrospective View of the Disaster Response to Hurricanes Katrina and Rita 2005-2007. Houston, Texas: Sage Associates. Policylink. (2008). Neighborhood influences on health: Social relationships. Available at: http://www.policylink.org/CHB/SocialRelationships/default.html Pulleyblank-Coffey, E., Griffith, J and Ulaj, J. (2006). The first community mental health center in Kosovo. In A. Lightburn and P. Session (Eds.), Handbook of Community- Based Clinical Practice (pp. 514–528). New York: Oxford University Press. Reisner, S. (1998). Theater Arts against Political Violence. International Trauma Studies Program Website. Available at: http://web.me.com/jacksaul/ITSPAdvancedSeminar/ Welcome.html Reisner, S. (2003). Private trauma/public drama: Theater as a response to international political violence. In The Scholar and Feminist Online, 2.1. Available at http://www.barnard.columbia.edu/sfonline/ps/reisner.htm? Saul, J. (1999). Working with survivors of torture and political violence in New York City. Zeitschrift fur Politische Psychologie, 7(1–2), 221–232. Saul, J. (2004). Promoting community recovery in lower Manhattan after September 11, 2001. Bulletin of the Royal Institute for Interfaith Studies 5, No.2, Autumn/Winter, 1- 16. Saul, J. (2006). Trauma and Performance: Constructing Meaning after Tragedy, Theater of Witness in Lower Manhattan Post 9/11. Presented at Trauma and Research Net, Hamburg Institute for Social Research, St. Mortiz.

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Saul, J. (2007). Promoting community resilience in lower Manhattan after September 11, 2001 [monograph]. American Family Therapy Academy: Systemic Responses to Disaster; Stories of the Aftermath of Hurricane Katrina, Winter, 69–75. Saul, J. (upcoming 2012). Collective trauma, collective healing: Promoting Community Resilience in Disaster Relief Work. Abingdon, New York: Routledge. Saul, J. and Bava, S. (2009). Implementing Collective Approaches to Massive Trauma/Loss in Western Contexts: Implications for Recovery, Peacebuilding and Development. Sponsored by INCORE. Available at http://www.incore.ulst.ac.uk/pdfs/IDRCsaul.pdf Saul, J., Breindel, H., Margolies, L, Hamilton, L. and Jacobs, N. (2004). Stories from the Ground: A community initiated narrative archive in lower Manhattan post 9/11. Proceeds of the International Oral History Association World Congress. Available at http://itspnyc.org/archive/archive_history.html Saul, J. (Producer) and Ray, J. (Director). (2002). A partnership for kids: post 9/11 coping strategies for the school community. [Video]. New York: International Trauma Studies Program, New York University. Saul, J., Ukshini, S., Blyta, A. and Statovci, S. (2003). Strength-based treatment of trauma in the aging: An Albanian Kosovar case study. In J. Ronch and J. Goldfield (Eds.), Mental Wellness In Aging: Strength Based Approaches (pp. 299–314). London: Health Professions Press. Schechner, R. (2002). Performance Studies: An Introduction. New York: Routledge. Shotter, J. (1984). Social Accountability and Selfhood. Oxford: Blackwell. Shotter, J. (2007). Getting it: 'Withness'-Thinking and the Dialogical... in Practice. Available from: http://pubpages.unh.edu/~jds/bookpage.htm Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine, 48, 1449-1462. Taylor, D. (2003). The Archive and the Repertoire: Performing Cultural Memory in the Americas. Durham: Duke University Press. Turner, V., Abrahams, R. and Harris, A. (1995). The Ritual Process: Structure And Anti- Structure. Aldine Transaction. Ungar, M. (2008). Putting resilience theory into action: Five principles for intervention. In Liebenberg and M. Ungar (Eds.), Resilience in Action. Toronto: University of Toronto Press. van der Kolk, B. (2006). Trauma, Memory and Cognition. Presentation at the International Trauma Studies Program, New York. Walsh, F. (1998). Strengthening Family Resilience. New York: Guilford Press. Walsh, F. (2003). Family Resilience: A Framework for Clinical Practice. Family Process, 42(1), 1-18. Walsh, F. (2007). Traumatic loss and major disasters: Strengthening family and community resilience. Family Process, 46(2), 207-227. Weine, S. M., Danieli, Y., Silove, D., van Ommeren, M., Fairbank, J. and Saul, J. (2002). Guidelines for international training in mental health and psychosocial interventions for trauma exposed populations in clinical and community settings. Psychiatry, 65(2), 156– 164. Weingartern, K. (2003). Common Shock: Witnessing Violence Everyday. New York: Dutton.

Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 3

RETHINKING THE MORAL POSITIONING OF TRAUMA WORK

Stevan M. Weine* University of Illinois at Chicago, IL, US

ABSTRACT

The mental health field’s attitude towards the transformative power of trauma work has tended to acquire the sense of a moral position based primarily upon its association with trauma survivors. Although this position has had its advantages for building the field, it has also prompted critiques about possible unintended consequences that may negatively impact trauma work’s helpfulness in situations of mass traumatization. This chapter uses a narrative approach to rethink that moral position and to consider possibilities for reframing trauma work, such as in relation to peacebuilding, socio- economic development, psychosocial work, and prevention.

Keywords: Trauma; Peacebuilding; Moral Position; Mass Traumatization; Trauma Work

INTRODUCTION

The purpose of this chapter is to use a narrative approach to rethink the moral positioning of trauma mental health work. It considers multiple approaches to trauma mental health work (herein described in short as “trauma work”) including the diagnosis and treatment of Post Traumatic Stress Disorder, helping the damaged self through psychotherapies, public mental health approaches to mass trauma, as well as group, family, community, and preventive approaches. After first introducing some critical and supporting voices of contemporary trauma work, this chapter identifies and defines the moral positioning of trauma work in Judith Herman’s (1992) Trauma and Recovery. Next it calls into question this moral

* Contact: Stevan Weine MD, 1601 W. Taylor Street, Fifth Floor, Chicago 60612, Illinois. FAX: 312-996-7658; TEL: 312-355-5407. E-mail: [email protected]

Complimentary Contributor Copy 42 Stevan M. Weine positioning through describing some of its key limitations in relation to situations of mass trauma and then finally proposes a reframing of trauma work through exploring its use in relationship to peacebuilding, socio-economic development, psychosocial work, and prevention.

Disputed Meanings in Difficult Spots

When events of mass trauma came to the attention of mental health professionals in Western countries in the latter half of the 20th century, their responses largely reflected that era’s dominant psychiatric paradigms. The primary focus was on the individual psychopathology of traumatic stress. Diagnosing and clinically treating trauma, or what was eventually named Post Traumatic Stress Disorder (PTSD), was a professional and scientific milestone that led to the relief of suffering for scores of persons, and it redefined clinical approaches to trauma survivors globally. Despite these achievements, PTSD focused trauma work in situations of war and disaster is disputed by some:

…for the vast majority of survivors posttraumatic stress is a pseudocondition, a reframing of the understandable suffering of war as a technical problem to which short-term technical solutions like counselling are applicable. (Summerfield, 1999, p. 1449)

An emphasis on trauma, useful in an emergency context, can, subsequently, divert resources and energy from the ‘social and economic conditions [which] have a decisive effect on health and disease.’ (Stubbs and Soroya, 1996, p. 303)

The focus on trauma in trauma work, according to its sharpest critics, is not just an inappropriate explanation of the suffering engendered by political violence, but for survivors, their communities, and societies, a potentially costly one. What was intended to be a helpful approach may have instead become a substantial problem. It could drain away social and economic resources that could otherwise contribute to healing and recovery. It could create a frame of meaning that detracts from community narratives that could lead to desired outcomes. The most clear beneficiaries could be the trauma focused professionals and organisations who acquire financial, professional, and scientific capital. These critiques of trauma work are, to a degree, critiques of psychiatry. For example, in Summerfield, one hears echoes of Foucault’s (2006) arguments of a psychiatry trying to establish its foothold as a profession by gathering capital and accumulating power. One may also hear R.D. Laing (1960) and the anti-psychiatrists who saw psychiatrists unwittingly serving societal power interests by sacrificing large swaths of persons as patients. PTSD as power play; PTSD as conspiracy; PTSD for profit; PTSD as limiting human freedom. Overall, this line of critique is more of a polemic than either an inquiry, a theoretical contribution, or a blueprint for action. In contrast to the harsh tones of these trauma work’s critics, the accounts given by trauma mental health professionals of their field’s activities in situations of mass traumatization are typically positive, and at times zealous, regarding the transformative power of trauma work. For example:

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People deserve to be believed when they speak of traumatic experiences and their painful sequelea” (Kudler, 2000, p. 4).

In our opinion, PTSD is a clinically meaningful diagnosis because of universals in human experience in response to trauma” (Marsella et al., 1996, p. 531).

I propose that our next professional assignment is to go beyond the treatment of new trauma populations: the long-range cure of war-related trauma requires prevention of traumatic stress” (Chaim Shatan as quoted in Sandra Bloom, 2000, p. 46).

These statements express a very high regard for trauma work’s positive impact. Taken together with many other such statements by mental health professionals, they sound like part of a self-fulfilling and triumphant narrative about trauma work: trauma is highly prevalent, we can diagnosis it, we can treat it, we can make people better, and we can make the world a better place. However, sometimes promoting trauma work can be just as flattening of real world complexities as the critiques of trauma. To go beyond these positions, it could help to better understand the textual sources of mental health professionals’ enthusiasm for the transformative power of trauma work? How is the story of trauma work being told by trauma mental health professionals?

THE MORAL POSITIONING OF TRAUMA WORK

One defining text for contemporary trauma work is Judith Herman’s Trauma and Recovery (1992) with its insistent claim that trauma and trauma work has a “forgotten history” (p. 7). The notion of trauma’s forgotten history has been used by trauma mental health professionals to argue for the necessity of a trauma mental health movement, because the persistence and remembrance of trauma work is said to require the support of a political movement. It is not just that traumatic events cause traumatic stress and this can be treated. It is also that because our history of trauma work has been forgotten, we must remember, we must spread knowledge, we must combat forgetting. In particular, although Herman places trauma in a broader political framework, still the traumatic stress model of trauma work is prioritized above other competing or contrasting perspectives on trauma work. Note the key semantic substitution in Herman’s text which underlies the trauma work’s central claim to legitimacy: in place of the trauma survivor’s forgetting, the mental health professionals’ own forgetting is emphasised. Thus when professionals take a stand for trauma work, claiming that inadequate attention is being paid to trauma, they do so with the moral legitimacy of all trauma survivors, past, present, and future. This is the basis for the moral positioning of trauma work. The stands that mental health professionals take are sometimes social or political in nature; for example, when they recognise that their patient’s suffering comes as a consequence of social injustice or ills. Their stands are at the same time professional in nature, as when they advocate for mental health care, or mental health service or professional organisations. This admixing of the personal, social, and political with the professional creates a potentially productive, but complicated and under-examined, moral positioning for the trauma field.

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This moral positioning can be good, for it has a power which the trauma field has used to improve the care of trauma survivors and to advance the service organizations for whom they work. The moral positioning of trauma work has been further strengthened and legitimised by embracing human rights, and by forging disciplinary alliances such as that of mental health and human rights (Agger and Jensen, 1996). Although there is ample criticism of trauma work from outside the trauma field, this moral positioning seldom comes into serious question from within. The trauma fields’ insiders endeavour not to disrupt the consensus by seriously challenging this moral positioning, but rather try to better equip it for its journey to more and more places. In the trauma field, one finds little enthusiasm to stop or slow a train that is roaring down the tracks. Rather, the momentum has been to further stoke that engine with beliefs, evidence, stories, and theories that fuel the forward movement of trauma work. Yet this “not forgetting” and zealous attitude is of concern to some of those inside the trauma field, because it applies a centripetal pressure to the field to perform one kind of trauma work everywhere which is fundamentally unachievable. For example, although many people in a poor, war-torn country may have the symptoms of PTSD, it is unconceivable that mass numbers would want or could be provided with individual psychiatric treatment. Thus, the present notion of trauma work, with its focus on individual diagnosis and treatment, may have the effect of overly constricting the nature of trauma mental health work in its most centrifugal undertakings: situations of political violence in non-Western global settings. In Weight of the World, the sociologist Bourdieu (1999) called these types of situations, “difficult spots” which are, “difficult to describe and think about” and where “simplistic and one-sided images must be replaced by a complex and multi-layered representation capable of articulating the same realities but in terms that are different, and sometimes, irreconcilable” (Bourdieu, p. 3). In those situations, trauma work faces new languages and cultural differences which likely script traumatic injury, resilience, and healing very differently from the Western middle class, white, Anglo points of view which are the sociocultural context where the PTSD construct which underlies modern trauma work was derived (Bracken, 2002). No less important are major contextual differences, such as the interaction of trauma with other pressing social and economic problems (e.g., poverty and epidemics), different traditions of psychiatric and mental health work, and different types of social and cultural resources. Trauma work has faced serious difficulties in approaching these other factors (Green et al., 2003). Another reason to call the moral positioning of trauma work into question is the relative shortcomings in providing community-based services for trauma-exposed populations. For all its ambitious claims about healing the wounds of war, disaster, and other common traumatic events, the enthusiasm for trauma work has not yet sufficiently helped to position trauma mental health services to reach out very far beyond the hospital or clinic walls into the surrounding communities where people lead their lives (be they combat veterans or civilians). Large numbers of trauma survivors never seek mental health services and mental health professionals, and organizations have yet to invest as seriously in devising ways to deliver prevention and care to those who don’t seek services as for those who do. Were that to happen, it is not at all clear that it could ever be organized around a PTSD framework, because the story it tells may be too far apart from the stories by which people live in families and communities.

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Rethinking the Moral Positioning of Trauma Work

This moral positioning is called into question in the hope that the trauma mental health field will consider alternative approaches to framing trauma work that could offer better paths for reaching into people’s lives in difficult spots. This appears to call for not only minor readjustments to the trauma model, but also for wholly different strategies, including different narrative strategies. Are there better (e.g., more complex and multi-layered) ways to deploy trauma frameworks in difficult spots? What kinds of narratives would be required to explain these types of trauma work? Underlying these questions is the claim that trauma is not simply a thing in and of itself, but a subject of narration by people in many walks of life and levels of society, including both its promoters and critics. Trauma is created, revised, and negotiated through narratives. This, of course, includes survivors’ narratives but also those of observers from the professional and scientific realms, law, religion, the media, and the arts. This implies that we should be open to many different possibilities of how trauma is represented, including the possibility that there are representations where individual emotional injury is not the high priority that is ascribed to it, in the dominant trauma narrative emphasizing PTSD which is fundamental to trauma work as we know it. Yet it is obvious that trauma’s narration through the traumatic stress paradigm has been remarkably successful in the West. It was able to bridge the disparate phenomenon of railway spine, shell shock, and rape trauma, to name a few, and to create a unified trauma concept. The histories of trauma’s consolidation into PTSD have been retold many times, most recently in the many books on disaster mental health that came out after September 11, 2001 and Hurricane Katrina (Halperin and Tramontin, 2006). These narratives are not simply histories of yesteryear, but the textual site of the contemporary trauma movement and the reaffirmation of trauma work’s moral positioning. They knit together into one fabric the work that has taken place with different survivor groups, at different points in time, in different contexts, and from different vantage points. These narratives have played important roles in defining a professional and scientific community, the fruits of which are real and evident. They gave birth to the International Society for Traumatic Stress Studies (www.istss.org), which many in the trauma field consider to be a professional home base. Through annual conferences, peer reviewed journal publications, treatment guidelines, listserves, and the activities of its professional members, the trauma paradigms they promoted have had a substantial impact on the programmes, policies, and science concerning trauma globally. The trauma mental health field has had considerable success in marketing the trauma paradigm to the non-governmental sector of humanitarian aid, which also came from the West. In the 1990s, with the bourgeoning of humanitarian interventions, Western trauma experts brought trauma mental health work to various locations where those organisations worked including Indochina, Africa, and especially the Balkans. They conducted trauma trainings of local professionals and para-professionals and set up trauma-focused services to treat victims of violence. Much good work was done, but it is also of concern that human resources were wasted or inappropriately used (Perlez, 2000; Walker and Walter, 2000). Based on such concerns, I was involved in organising and leading a task force at the ISTSS that successfully produced consensus guidelines on international trauma training which critiqued the practice and tried to shape a more productive practice pattern (Weine et al.,

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2002). Although these guidelines may have contributed in some small ways to helping trauma professionals within the ISTSS community to question the appropriateness of the dominant paradigm focused on PTSD, overall the commitment to spreading the dominant trauma paradigm still appears to exceed interest in examining its appropriateness in global public mental health contexts. In recent years, we have seen the birth and growth of the disaster mental health field, which centers on mental health care during and after natural or man-made catastrophes. The trauma paradigm is a strong presence in disaster mental health - for example in the efforts to provide Cognitive Behavioural Therapy (CBT) treatment to survivors - but other paradigms have also gained a foothold, including critical incident debriefing, community resilience, risk communication, family assistance, psychological first aid, each of which poses key challenges to the central assumptions of the trauma paradigm. In the field of disaster mental health, there is a legitimate possibility for traumatic stress to interact with other points of view, leading to new insights and innovative approaches in trauma work. Nonetheless, the present era remains largely one of consolidation and expansion of professional and scientific dialogue on traumatic stress focused trauma work, especially in the U.S.A. Given the activities of professional associations (e.g., ISTSS) and government- sponsored research (e.g., NIMH and SAMSA in the U.S.A.) in promoting the dominant trauma paradigm, sometimes the NGO community has seen itself as the keeper of local knowledge. In some cases local, national, and international NGOs are able to effectively give the locals a voice, and, in other cases, this may be more of a marketing strategy. NGOs may be no less prone to creating and selling individually-focused problem-centred narratives than are these other organisations. One view is that they may be prone to taking advantage of the moral spectacle which may be created by images or narratives of victims, so as to accomplish their own public relations and fundraising goals (Hardt and Negri, 2001; Weine, 2006). In some post-conflict countries, there have been examples where local professionals were taught by international experts to embrace traumatic stress theory and trauma work without engaging in any serious inquiry regarding its relevance to their context and culture. The trauma paradigm was hard for them to resist, as it was being touted as “modern” psychiatry and psychology, and came wrapped with elite clinical, scientific, and human rights credentials. Local professionals, who had been practicing a mental health that in some respects was decades behind the rich countries, were often wowed. Besides, being paid or having the promise of being paid was also persuasive enough to have them move local views (for example that prioritize the family level of experience) into second or third place. In such situations, international trauma experts found themselves piling on the trauma with exaggerated claims regarding trauma mental health treatment. One reported: “there may be more than one million people in the former Yugoslavia who have suffered psychological trauma sufficient to merit professional help” and “there is no doubt in my mind that post- traumatic stress is going to be the most important public health problem in the former Yugoslavia for a generation and beyond” (Kinzer, 1995). After war, they claimed, trauma was everywhere. Huge numbers of persons needed trauma treatment. In the former Yugoslavia, this became a narrative which framed the work of many NGOs and grants given by government funders. However, after the emergency phase, sufficient funds never arrived to realise the expansive vision of trauma treatment for all (let alone to build a sustainable community mental health system) allowing trauma mental health professionals to claim that their visions were sound, but for the shortcoming of donors.

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Then again, even if the money came, would it ever be possible to achieve the ambitions of trauma treatment for all? Although seductive, it is implausible because it defies what is known about help-seeking behaviours and public mental health, in both rich and poor settings, as well as avoiding the obvious fiscal limitations of the latter. In some better off post-conflict countries, the vacuum created by the eventual withdrawal of international humanitarian community and the international trauma experts, led to the entry of the pharmaceutical industry. Seeing a profit to be made amidst a population of traumatised people, they courted psychiatrists and psychiatric organisations to prescribe medications for PTSD and depression. Is this the inevitable end-point of PTSD focused trauma work, or are there other avenues to be explored that could point to alternative approaches for trauma work?

Trauma Work, Peacebuilding, and Socio-Economic Development

In situations of political violence, there have been calls to better link trauma work with the concerns of peacebuilding and development. Peacebuilding (as distinct from peacekeeping and peacemaking) has been defined as the “action to identify and support structures and relationships that will strengthen and consolidate peace in order to avoid resort [ing] to, an intensification of, or a relapse to violence” (Jennings, 2003, online). Development (in a socio-economic not life-cycle sense) has been defined as, “actions that expand people’s choices and capacities to improve the economic, social, and political character of their communities” (Jennings, 2003, online). The relationships between trauma, peacebuilding, and development (as defined above) have been undertheorised, understudied, and not a sufficient focus of policymakers or of trauma mental health professionals. In some respects, the goals and methods of trauma work and peacebuilding have been moving closer together in recent years. Trauma work may overlap with peacebuilding in the sense that it aims to diminish fears and negative representations of self or others, not only in individuals but in families, communities, and society thus contributing to consolidating peace. Mass traumatisation is both a consequence of a prior failure of peacebuilding, and a possible cause of future failure. Staub has spoken of prior trauma as one possible cause of committing genocide (Staub, 1999; Staub and Bar-Tal, 2003). Peacebuilding is not only focused on governments, but on the human elements of peace, including beliefs, relationships, and communication. For example, Hamber (2003, 2005, 2007) has described the use of narrative strategies for reframing experiences of surviving violence in Northern Ireland and South Africa. Following in the footsteps of Dori Laub (Weine and Laub, 1995) and Inger Agger and Soren Jenson (1996), I have examined the use of testimony to address torture in Chile, the Holocaust, and ethnic cleaning in Bosnia-Herzegovina and Kosovo (Weine, 1999, 2006). Of course, there have been important differences in approaches between trauma work and peacebuilding. Trauma work tends to be emergency and crisis focused, whereas peacebuilding is often more preventive and involves measures being taken to strengthen structures and support relationships toward human equity to prevent violence in the future (Christie, 2006). Both trauma work and peacebuilding share the assumption that violence springs from disparities and dissatisfaction over structural conditions. But trauma work’s effects are more focused, whereas the types of structural violence which peacebuilding aims to rectify are characterised as more chronic and indirect. Another distinction lies in the targets of intervention. The trauma work perspective envisions diminishing the emotional and

Complimentary Contributor Copy 48 Stevan M. Weine cognitive impediments towards restoring peace in the status quo. However, peacebuilding approaches want to rectify structural violence, so the purpose is to challenge and transform the status quo. One additional obstacle to trauma and peacebuilding working together is that the trauma field typically focuses on work with victims, whereas peacebuilding recognizes that it is possible and necessary to deal with the so-called “perpetrators.” Some have pondered trauma work in relation to that of development. Trauma work may be considered part of development in the sense that it enhances the locals’ capacities to manage post-conflict psychosocial problems in ways that would be less of a functional burden. However, trauma work with a clinical focus cannot have much public health impact, let alone developmental impact in the sense of transforming socioeconomic conditions. Some in the humanitarian intervention field have posted the concept of the “relief-development spectrum” (Bissell and Natsios, 2001, p. 316) which to most observers is presently more of a hope than a reality. Others have claimed that development can be a tool of peacebuilding, in that it also seeks to ameliorate some of the “root causes” of political violence, namely poverty and bad governance (Scholdan, 2000). In light of these considerations, it is not difficult to appreciate that traumatic stress is a psychological theory, whereas peacebuilding and development are concepts that belong more to political and social theories. To suggest that we bring trauma work closer to peacebuilding and development, we need to ask if trauma work is prepared to enter the political and social, or at the very least, the psychosocial realm. If trauma work is going to do so, then it needs a much deeper level of engagement with the psychosocial than the present level of moral positioning.

Trauma and Psychosocial Work

Several existing concepts attempt to conceptualise trauma from psychosocial perspectives, including: Kai Erikson’s notion of “collective trauma”(1995, p. 183), Veena Das’ notion of “social trauma” (2001, p. 1), Maurice Eisenbruch’s “cultural bereavement” (Eisenbruch, 1991, p. 282), Arthur Kleinman’s “social suffering” (1997, p. ix), Pierre Bourdieu’s “positional suffering” (2003, p. 4), and Weine’s “cultural trauma” (2006, p. 119), and the “trauma bundle” (Weine et al., 2009, p. 255). These conceptualisations are rather different from the trauma of the dominant trauma work paradigm, in which the bottom line claim is that trauma causes individual emotional injury and psychological dysfunction or disability. Only those prepared to relinquish that foundational view of traumatic stress are going to be able to fully consider these more socially oriented definitions, or to devise other innovative approaches. Paralleling the expansion and specialization of the PTSD regime has been a growing number of challenges to its hegemony. As exemplified by the aforementioned examples (Summerfield, 1999), some critiques have explored the limitations of a positivistic, medicalising, individualistic approach to mass suffering, without representing helpful alternatives. Several other critics have suggested new paths. For example, one point of dispute has been over the legitimacy and appropriateness of applying the PTSD diagnosis in catastrophic situations. The tools for diagnosing PTSD get applied in more and more situations, generating epidemiologic research findings that support the claim that PTSD is a global phenomenon (Friedman and Jaranson, 1994). Cultural critics see this as an imposition of outside cultural models that are not sensitive to the needs or

Complimentary Contributor Copy Rethinking the Moral Positioning of Trauma Work 49 strengths of local families or communities and instead speak of cultural trauma or cultural bereavement (Alexander et al., 2004). Sociologists have drawn attention to the fact that trauma can happen to social units also, and called for a paradigm shift toward communal trauma (Erikson, 1995). At the heart of this dispute are differences over the definitions or trauma and differences regarding whether trauma should be the foundation of assessment. However, it should be noted that the ‘hodgepodge’ of different assessment practices that vary by academic expert, humanitarian organisation, or by country, have not yet suggested an alternative set of principles, standards, or guidelines as coherent as PTSD. PTSD still has the advantage of clarity and technical replicability over all its proposed alternatives. It is still much easier to tell a PTSD story than any other in trauma work. A second example is that the accumulated experiences of interveners and programmers globally implementing trauma focussed models, have led to an increased awareness of the key roles of context in shaping effective services. David Becker (1995), for example, rejected the diagnosis of PTSD because he claimed that survivors of human rights violations were not necessarily “post”, stressed, or disordered. He proposed a concept of “extreme traumatization” which encompasses both individual and collective processes and social context and occurs over time (1995). Trauma was defined by the feeling of death, the sense of fragmentation, and could be addressed through a special form of psychotherapy. Beyond psychotherapy, the principles of respect, comprehension, and relationship should guide psychosocial work. Nonetheless trauma, with a psychiatric slant, still remains the primary construct around which practice in trauma work is organised. Another focal point has been the concern over developing services that work in real world situations where disasters strike and help is offered. This requires attention to cultural values and practices, which may not prioritise trauma, memory, or even individuals. It also requires attention to the broad range of psychosocial contexts, especially family and community, which often become focal points for survivors. The psychosocial framework proposed by a consortium of humanitarian interveners (Psychosocial Working Group, 2003) is one example of an alternative proposition aimed at making psychosocial work in situations of mass violence less individualistic and diagnostic focused, and more attuned to broader psychosocial needs. According to the Psychosocial Working Group, “The term ‘psychosocial’ is used to emphasize the close connection between psychological aspects of our experience (our thoughts, emotions and behaviour) and our wider social experience (our relationships, traditions and culture)” (Psychosocial Working Group, 2003). Other innovations in the science of mental health interventions which emphasise community-collaboration, cultural adaptation, and qualitative research, are slowly being brought to bear upon the trauma model, encouraging further modifications (McKay and Paikoff, 2007; Trickett, 2005). One example is the emphasis on community resilience, which comes from community psychology. Norris and colleagues (2008) define resilience as “a process linking a set of adaptive capacities to a positive trajectory of functioning and adaptation after a disturbance” (p. 127). This term has been applied at individual, family, and community levels. Norris reviewed the literature on “community resilience” and described four overall strategies for mitigation: 1) developing economic resources and reducing inequities and vulnerabilities: 2) engaging everybody in the mitigation process to access social capital; 3) utilizing pre-existing organizational and social networks: 4) boosting and protecting naturally occurring social supports. To some, it is confusing to see community resilience being promoted by some of the same institutions that promote PTSD models of

Complimentary Contributor Copy 50 Stevan M. Weine trauma. Careful attention should be paid to how these terms are used, especially when community resilience collides with PTSD. For example, Norris (2008) wrote:

Communities with high rates of posttraumatic stress disorder or substance abuse or domestic violence or child maltreatment cannot be said to be well. If these or similarly severe problems emerge and persist in the aftermath of a disaster, the community has not exhibited resilience” (p. 146).

It appears that in this formulation, PTSD trumps community resilience. One wonders what kind of evidence is the basis for this conclusion or to what extent it reflects how the conceptualisation of PTSD remains more foundational then that of community resilience. In trauma work, the dominant narratives of PTSD and the damaged self are pervasive and foundational so as to displace other narratives that suggest either family or community as key levels of analysis or strength and resilience as essential properties. The trauma narrative also tends to displace other societal, community, and family problems from serious consideration, so that narratives that interweave trauma with these other present problems tend not to get produced. The difficult spot remains primarily a land of plenty of PTSD and damaged selves.

PREVENTION

Another disputed issue that can help us to rethink trauma work concerns the status of prevention. Trauma professionals have advocated early interventions post-trauma exposure to ward off developing PTSD (Halperin and Tramontin, 2006). However, research has not yet shown clear benefit (Ritchie, Watson and Friedman, 2006). Given that preventive interventions in trauma mental health may focus on primary, secondary, or tertiary prevention, there is actually a much broader array of possible interventions than the early clinical treatment literature identifies. This suggests that trauma focused prevention activities may be unnecessarily limited due to adherence to the PTSD model. Other prevention activities could be possible, but they would require further research and practice to know for sure. Unfortunately, in the trauma mental health field, there are few if any systematic evaluations of preventive interventions. Furthermore, the existing theories in trauma mental health, while helpful for thinking about clinical treatment and recovery, are not adequate to order this assortment of possibilities into a coherent strategy of preventive services that fits with the IOM1 and WHO2 frameworks. Several other challenges to prevention merit consideration. The efforts to build alternative trauma models, such as those focussed on prevention, are often not helped by the funding environment. Mental health across the board is on the defensive, having to prove its value to existing and potential funders. Depending on the established science of PTSD is a more reliable strategy than venturing into new domains in the land of prevention, which is more open to variations in culture and context. Besides, in humanitarian interventions, it may take years to build relationships and to get to know a context and culture. By the time that occurs, and one has developed a formulation based upon

1 IOM = Institute of Medicine 2 WHO = World Health Organisation

Complimentary Contributor Copy Rethinking the Moral Positioning of Trauma Work 51 local narratives, the funding is over and the humanitarian aid community has moved on to the next disaster. Furthermore, the conventions of clinical science tend to contribute to sustaining the dominant trauma paradigm in that: 1) trauma work tends to be organised largely around traumatic stress theory; 2) reliable measurement of traumatic events and traumatic stress is the overwhelming scientific priority; 3) social dimensions are relegated to the background or to secondary or tertiary variables; 4) ecological or family dimensions often defy existing measurement technology; and 5) processes or mechanisms are less easily studied than static factors. Another point of dispute concerns the tensions between clinical and public health views of trauma work. Public health critiques of mental health in complex emergencies are commonplace (de Jong, 2002). Disaster interveners find themselves trying to provide immediate services in environments that may have already been lacking in the provision of basic health or mental health services. Public health infrastructure may be weak or non- existent, not only because of damage done by the catastrophe to basic structure, but by ongoing processes of underdevelopment linked with poverty or policy failings. The effectiveness and sustainability of disaster focussed mental health interventions cannot be separated from those matters of ongoing public health. It is also necessary to question how reliable is “the local” as a reservoir of resilience. Often local resources (e.g., family and community relationships) have been overwhelmed by circumstances, or inequalities have been revealed. Instead of idealising the local, it is necessary to pay careful attention to the tension, fissures, fragments, and conflicts that are a part of local resources and narratives. Meanwhile, the pressures to change the models underlying trauma work have grown due to the proliferation of catastrophes globally. Global warming has intensified weather catastrophes (see Gow, 2009) which can cause environmental changes that can in turn increase instability and lead to conflict and war in some instances. Domestic and global terrorism and new and ongoing wars have led to mass casualties among both combatants and civilians. Experience treating Iraq and Afghani combat soldiers demonstrate that traumatic brain injury and PTSD co-occur and interact in highly complex ways, demanding new approaches (Glaessner et al., 2004). It may be considered a positive development when each new event receives attention not only from mental health professionals, but from multiple sectors and multiple professions, including first responders, physicians, nurses, lawyers, journalists, aid workers, peace advocates, and even writers and artists. Another focal point has been the interaction with multidisciplinary professionals and scholars, especially in situations of conflict and post- conflict. Journalists have evolved new approaches to reporting on trauma (see the work of Cait McMahon3 from the Dart Center for Journalism and Trauma). Legal scholars have explored new approaches to transitional justice which often has a trauma focus (Teitel, 2000). These are all examples of attempts to shape not only disciplinary practice but also the public discourse on trauma which in turn impacts on the trauma work of mental health professionals and others. In difficult situations, no paradigm exists in isolation or goes unchallenged, including trauma, and this is a good thing.

3 Cait McMahon from the Dart Center for Journalism and Trauma, and Trina McLellan who completed postgraduate work on journalism and trauma, collaborated on a chapter titled: “Journalists reporting for duty: Resilience, trauma and growth” (McMahon & McLellan, 2008) in K. Gow & D. Paton (Eds., The Phoenix of Natural Disasters: Community Resilience. New York: Nova Science Publications.

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CONCLUSION

Mental health professionals, undertaking trauma work in situations of mass traumatisation, have never seen before such opportunities for collaboration, including collaboration between local and international colleagues, collaboration with multi-sectoral and multi-disciplinary providers, and collaboration with community partners. Whether there is true collaboration depends on many factors, especially whether mental health professionals are responsive to new voices and new priorities. Mental health professionals undertaking trauma work should take care not to be overly based on the moral positioning of trauma and to more seriously commit themselves to exploring alternative trauma work narratives based upon deeper engagement with the psychosocial, sociocultural, services, peace, developmental, and preventive dimensions of trauma work.

REFERENCES

Agger, I. and Jensen, S. (1996). Trauma and healing under state terrorism. London: Zed Books. Alexander, J., Eyerman, R., Giesen, B., Smelser, N. and Sztompka, P. (2004). Cultural Trauma and Collective Identity. Berkeley: University of California Press. Becker, D. (1995). The deficiency of the concept of posttraumatic stress disorder when dealing with victims of human rights violations. In R.J. Kleber, C.R. Figley and P.R. Gersons (Eds.), Beyond Trauma: Cultural and Societal Dynamics (pp. 99-110). New York: Plenum Press. Bissel, R. and Natsios, A. (2001). Development assistance and international migration. In A. Zolberg and P. Benda (Eds.), Global Migrants, Global Refugees: Problems and Solutions (pp. 297-321). Oxford, UK: Berghan Books. Bloom, S. (2000). Our Hearts and Our Hopes are turned to Peace: Origins of the ISTSS. In A. Shalev, R. Yehuda and A S. McFarlane (Eds.), International Handbook of Human Response Trauma (pp. 27-50). New York: Plenum. Bourdieu, P. (1999). The Weight of the World. Stanford, CA: Stanford University Press. Bracken, P. (2002). Trauma: Culture, Meaning, and Philosophy. London: Whurr. Christie, D. J. (2006). What is Peace Psychology the Psychology of? Journal of Social Issues, 62(1), 1-17. Das, V., Kleinman, A., Lock, M., Ramphele, M. and Reynolds, P. (Eds.). (2001). Remaking a World: Violence, Social Suffering and Recovery. Berkeley, California: University of California Press. De Jong, J. (Ed.). (2002). Trauma, War, and Violence: Public Mental Health in Socio- Cultural Context. New York: Plenum Publishing Corporation. Eisenbruch, M. (1991). From post-traumatic stress disorder to cultural bereavement: Diagnosis of Southeast Asian refugees. Soc. Sci. Med., 33(6), 673-680. Erikson, K. (1995). Notes on trauma and community. In C. Caruth (Ed.), Trauma: Explorations in Memory (pp. 183-199). Baltimore: The Johns Hopkins University Press.

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Friedman, M. J. and Jaranson, J. (1994). The applicability of the post-traumatic stress disorder concept to refugees. In: A. M. Marsella, T. Bornemann, S. Ekblad and J. Orley (Eds.), Amidst Peril and Pain. Washington D.C.: American Psychological Association. Foucault, M. (2006). The History of Madness. New York: Routledge. Glaesser, J., Neuner, F., Lütgehetmann, R., Schmidt, R. and Elbert, T. (2004). Posttraumatic Stress Disorder in patients with traumatic brain injury. BMC Psychiatry, 4, 5. Gow, K. (Ed.). (2009). Meltdown: Climate Change, Natural Disasters and Other Catastrophes: Fears and Concerns for the Future. New York: Nova Science. Gow, K. and Paton, D. (Eds.). The Phoenix of Natural Disasters: Community Resilience. New York: Nova Science Publications. Green, B. L., Friedman, M. J., de Jong, J., Solomon, S. D., Keane, T. M., Fairbank, J. A. et al. (Eds.). (2003). Trauma interventions in war and peace: Prevention, practice, and policy. New York: Kluwer Academic/Plenum Publishers. Halperin, J. and Tramontin, M. (2006). Disaster Mental Health Theory and Practice. Belmont, CA.: Thomson Brooks Cole. Hamber, B. (2003). Healing. In D. Bloomfield, T. Barnes and L. Huyse (Eds.), Reconciliation after violent conflict: A handbook (pp. 77-88). Stockholm, Sweden: International Institute for Democracy and Electoral Assistance. Hamber, B. (2007). Forgiveness and Reconciliation: Paradise Lost or Pragmatism? Peace and Conflict: Journal of Peace Psychology, 13(1), 115-125. Hamber, B. (2005). Blocks to the future: A pilot study of the long-term psychological impact of the ‘no wash/blanket’ protest. Derry: Cunamh. Hardt, M. and Negri, A. (2001). Empire. Harvard University Press. Herman, J. L. (1992). Trauma and Recovery. New York: BasicBooks. Jennings, R.S. (2003). Military Peacebuilding: Stability Operations and the Strengthening of Peace in War-Torn Societies. The Journal of Humanitarian Assistance. http://sites.tufts. edu/jha/archives/844 Kinzer, S. (1995). In Croatia, Minds Scarred by War. The New York Times. Retrieved February 27, 2011 from http://query.nytimes.com/gst/fullpage.html?res =990CE2DC1231F3AA 35752C0A963958260 Kleinman, A., Das, V. and Lock, M. (1997). Social Suffering. Berkeley, CA: University of California Press. Kudler, H. (2000). The limiting effect of paradigms on the concept of traumatic stress. In A. Y. Shalev, R. Yehuda and A. C. McFarlane (Eds.), International Handbook of Human Response to Trauma (pp. 3-11). New York: Kluwer/Plenum. Laing, R. D. (1960). The Divided Self: An Existential Study in Sanity and Madness. Harmondsworth: Penguin. McKay, M. and Paikoff, R. (2007). Community Collaborative Partnerships. New York: Taylor and Francis. McMahon, C. and McLellan, T. (2008). Journalists reporting for duty: Resilience, trauma and growth. In K. Gow and D. Paton (Eds.), The Phoenix of Natural Disasters: Community Resilience (pp. 101-121). New York: Nova Science. Marsella, A., Friedman, M., Gerrity, E. and Scurfield, R. (1996). Ethnocultural aspects of PTSD: some closing thoughts. In A. Marsella, M. Friedman, E. Gerrity and R. Scurfield (Eds.), Ethnocultural Aspects of Posttraumatic Stress Disorder (pp. 529-538). Washington, DC: American Psychological Association.

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Norris, F.H., Stevens, S.P., Pfefferbaum, B., Wyche, K.F. and Pfefferbaum, R.L. (2008). Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am. J. Community Psychol., 41(1-2), 127-50. Perlez, J. (2000). State department faults U.S. aid for war refugees as inept. New York Times (May 9) A1. Psychosocial Working Group. (2003). Psychosocial intervention in complex emergencies: A framework for practice. Retrieved July 14, 2009 from http://www.forcedmigration. org/psychosocial/papers/A%20Framework%20for%20Practice.pdf Ritchie, E. C., Watson, P.J. and Friedman, M. J. (Eds.). (2006). Interventions Following Mass Violence and Disasters. London: The Guilford Press. Scholdan, B. (2000). Addressing the root causes: Relief and development assistance between peacebuilding and preventing refugee flows. The Journal of Humanitarian Assistance. Retrieved on July 19, 2008, from http://jha.ac/2000/06/18/addressing-the-root-causes- relief-and-development-assistance-between-peacebuilding-and-preventing-refugee-flows/ Staub, E. (1999). The Origins and Prevention of Genocide, Mass Killing, and Other Collective Violence. Peace and Conflict: Journal of Peace Psychology, 5(4), 303-336. Staub, E. and Bar-Tal, D. (2003). Genocide, mass killing and intractable conflict: Roots, evolution, prevention and reconciliation. In D. O., Sears, L. Huddy and R. Jervis (Eds.), Oxford handbook of political psychology (pp. 710-751). New York, N.Y.: Oxford University Press. Stubbs, P. and Soroya, B. (1996). War Trauma, Psycho-social Projects and Social Development in Croatia. Medicine, Conflict, and Survival, 12(4), 303-314. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine, 48, 1449-1462. Teitel, R. (2000). Transitional justice. London: Oxford University Press. Trickett, E.J. (2005). Context, culture, and collaboration in AIDS interventions: Ecological ideas for enhancing community impact. In E.J. Trickett, and W. Pequegnat (Eds.), Community Intervention and AIDS. New York: Oxford University Press. Walker, P. and Walter, J. (2000). World Disasters Report: Focus on Public Health. International Federation of the Red Cross and Red Crescent Societies. Weine, S.M. (1999). When History is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina. New Brunswick: Rutgers University Press. Weine, S.M. (1999). ‘A forgotten history’ and related risks for speech genre users in trauma mental health: A commentary. Journal of Contemporary Psychotherapy, 29 (4), 267-281. Weine, S.M. (2006). Testimony after Catastrophe: Narrating the Traumas of Political Violence. Evanston, IL: Northwestern University Press. Weine, S. M., Danieli, Y., Silove, D., Van Ommeren, M., Fairbank, J. A. and Saul, J. (2002). Guidelines for International Training in Mental Health and Psychosocial Interventions for Trauma Exposed Populations in Clinical and Community Settings. Psychiatry, 65(2), 156-164. Weine, S.M. and Laub, D. (1995). Narrative Constructions of Historical Realities in Testimony with Bosnian Survivors of ‘Ethnic Cleansing’. Psychiatry, 5(3), 246-260. Weine, S.M., Lezic, A., Celik, A., Bicic, M., Bambur, N. and Salcin, M. (2009). Tasting the World: Life after Wartime for Bosnian Teens in Chicago. In B. K. Barber (Ed.), Adolescents and war: How youth deal with political violence (pp. 255-280). New York: Oxford University Press.

Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 4

USING THE INDIVIDUALISM-COLLECTIVISM CONSTRUCT TO UNDERSTAND CULTURAL DIFFERENCES IN PTSD

Nuwan Jayawickreme*, Eranda Jayawickreme and Edna B. Foa University of Pennsylvania, Philadelphia PA, US

ABSTRACT

This chapter uses the individualism-collectivism concept from the cultural psychological literature to explain cultural differences in posttraumatic stress disorder (PTSD) manifestations. The literature on PTSD prevalence rates, symptom presentation and risk factors is reviewed for developing countries and refugee populations. Whereas PTSD is observed worldwide, many similarities and some differences (e.g., avoidance symptoms are less common in many developing countries) are observed. Relevant empirical findings from the individualism-collectivism literature are then used to explain some of the observed cultural differences in PTSD and also to suggest further hypothetical differences. The chapter ends with a review of the appropriate methodology for the study of cultural differences in PTSD.

Keywords: Culture, Post-Traumatic Stress Disorder, Trauma, Individualism, Collectivism, Refugees

INTRODUCTION

Looking back at the oldest surviving historical documents and literary texts, it is clear that since time immemorial, people all over the world have been plagued by memories of

*Correspondence concerning this article should be addressed to Nuwan Jayawickreme, Center for the Treatment and Study of Anxiety, University of Pennsylvania, School of Medicine, Department of Psychiatry, Philadelphia, PA 19104. E-mail: [email protected]

Complimentary Contributor Copy 56 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa traumatic events that fill them with sadness, fear, a sense of irreplaceable loss and sensations of dread and horror (Figley, 1993; Shay, 1994; Veith, 1965; Young, 1995).

The Sumerians and the Elamites, the destroyers, made of it thirty shekels. The righteous house they break up with pickaxe; the people groan. The city they make into ruins; the people groan. Its lady cries: "Alas for my city," cries: "alas for my house." … In its lofty gates, where they were wont to promenade, dead bodies were lying about; In its boulevards, where the feasts were celebrated, scattered they lay. In all its streets, where they were wont to promenade, dead bodies were lying about; In its places, where the festivities of the land took place, the people lay in heaps. … At night a bitter lament having been raised unto me, I, although, for that night I tremble, Fled not before that night’s violence. The storm’s cyclone like destruction - verily its terror has filled me full. Because of its [affliction] in my nightly sleeping place, In my nightly sleeping place verily there is no peace for me. (A Sumerian [Modern Southeast Iraq] Lamentation, c. 2027-2003 B.C. 1)

[I felt] disoriented as though in a dream…my body had become inured to a tragic existence, the painful disruption to my mind had become a fixed state, and whenever I thought or spoke of my [deceased] elders I felt as though I would break apart. [I had dreams] fills with sounds of cannon balls smashing the city walls; of foot soldiers and cavalry cutting and killing… (Yusheng Lu [“Record of my life beyond me due”], Memoir of Zhang Maozi [19 Years Old], China, c. 1653.2)

Posttraumatic Stress Disorder (PTSD)

Over the past 30 years, clinical psychologists have devoted considerable energy to the research of trauma sequelae. This increase in interest in post-traumatic reactions is in no small part due to the addition of posttraumatic stress disorder (PTSD) to the psychiatric nosology in 1980, a posttraumatic syndrome with a specific set of diagnostic criteria that is distinct from other types of psychopathology. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Press, 1994) the key feature of PTSD is the development of a certain set of symptoms following an event in which one is exposed to death or serious threat of injury and reacts with extreme fear, helplessness or horror (criterion A). Three symptom clusters characterize the disorder. The re-experiencing cluster (criterion B) includes recurrent and intrusive thoughts and recollections or dreams of the event, distress and psychological reactivity following exposure to trauma-related cues, and flashback episodes where the individual re-experiences at least a portion of the traumatic event. The avoidance cluster (criterion C) captures symptoms such as avoidance of trauma-related cues, inability to remember aspects of the trauma, and emotional numbing, which may involve either feeling detached from or unconnected to others, decreased interest in activities that

1 Kramer (1969, pp. 455-463), cf. Ben-Ezra (2002). 2 Struve (2004, pp. 21)

Complimentary Contributor Copy Using the Individualism-Collectivism Construct … 57 were enjoyable pretrauma, an inability to feel positive emotions, such as love and satisfaction, and a sense of a foreshortened future. Finally, the hyperarousal cluster (criterion D) includes symptoms such as an enhanced startle reaction, difficulty sleeping and/or concentrating, an increase in feelings of anger or irritability, and hypervigilance for danger. To be diagnosed with PTSD, in addition to fulfilling criterion A (responding to a traumatic event with fear, helplessness and or horror), one needs to have at least one symptom from the criterion B cluster, at least three symptoms from the criterion C cluster, and two or more symptoms from the criterion D cluster. It should be noted, however, that re-experiencing, avoidance and arousal symptoms are common reactions to traumatic events; it is only when these reactions persist for more than one month and impair functioning that a diagnosis of acute PTSD is made. If symptoms persist for more than three months, then a diagnosis of chronic PTSD is made. While the PTSD diagnosis has attracted a degree of controversy (see McNally, 2003), it has also stimulated much research on post-traumatic psychopathology. A great deal is now understood about PTSD and its consequences. PTSD sufferers are more likely than those without the disorder to divorce, report trouble raising their children, be aggressive towards their intimate partner, experience depression and other forms of psychopathology, report poorer life satisfaction and physical health problems, have legal issues, earn less and change jobs more frequently (Jordan et al., 1992, Koss et al., 1991, Kulka et al., 1990, Schurz and Green, 2004, Walker et al., 2003). Research on psychotherapy for this disorder has also made great strides in this period, with cognitive behavioral therapies in particular demonstrating the greatest efficacy compared to other psychosocial interventions (Foa, Huppert and Cahill, 2006). However, research on the ethnocultural variations in posttraumatic reactions is still in its nascent stages. There has been considerable research focusing on differences in PTSD prevalence rates and symptom presentation among ethnic minorities in the United States (Pole, Gone and Kulkarni, 2008), but comparatively only a few studies look at such differences outside the developed world. DeGirolamo and McFarlane (1996) note that many of the most traumatized populations in the world have not been studied, and that of the 135 studies of PTSD prevalence conducted in non-U.S.A. populations, only eight (6%) were conducted in developing countries. Although a number of studies have been conducted in developing countries since DeGirolamo and McFarlane’s review, there are still very few large sample studies of populations outside the U.S.A. It still remains true that the majority of research validating PTSD as a diagnostic category has been carried out in the United States (Lemelson, Kirmayer and Barad, 2007).

An Argument for the Importance of Considering Culture in the Study of PTSD

Any argument for the importance of culture in the study of PTSD should first be prefixed by an argument for why culture should be addressed in the study of psychopathology in general. Lopez and Guarnaccia (2000) argue that culture is an important variable to consider in the study of psychopathology in general, not because psychological suffering is a culturally specific phenomenon, but because expressions of psychological distress may vary according to the value or belief orientation of the culture in question. When differentiating between the

Complimentary Contributor Copy 58 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa expression of psychological distress and the underlying “core” disorder, it is useful to understand the distinction between disease and illness (Eisenberg, 1977; Kleinman, 1981, 1986). An example of the utility of this distinction can be found in the influential work of Arthur Kleinman, a psychiatrist and anthropologist who assessed the presence of mood disorders in China in the late 1970’s and early 1980’s (e.g., Kleinman, 1981, 1982, 1986). Kleinman found that neurasthenia, which is characterized by somatic complaints including headache, fatigue and muscle tension, was far more commonly diagnosed in that country than depression. His own research, however, found that 87% of patients with neurasthenia at a hospital in the Chinese province of Hunan also met the criteria for depression (Kleinman, 1982). Given this overlap between neurasthenia and depression, Kleinman posited that it would be clinically useful to conceptualize neurasthenia and depression as different expressions of the same underlying disorder or disease. He distinguished between the objective process of disease - the malfunctioning of physiological and psychological processes – and the subjective experience of illness, which is the personal, culturally determined response to the disease. He argued that these culturally determined responses may differ from culture to culture; for example, Chinese individuals’ response to an objective “depressive” disorder involves experiencing psychosomatic symptoms, while the response of Western samples involves experiencing a depressed mood. Kleinman’s (1982) findings suggest that what is identified as symptoms of illness and therefore indicators of distress in one context may not be applicable in another context. Assuming otherwise leads one to commit what Kleinman named the categorical fallacy, where “the reification of a nosological category developed for a particular group…is then applied to members of another culture for whom it lacks coherence, and its validity has not been established” (Kleinman, 1987, p. 452). Consequently, medical anthropologists and sociologists have argued that illness categories are products of social construction in that they are diagnoses that attempt to frame specific symptoms and experiences as they occur together within a specific context. Such concepts may accurately identify suffering within the context in which they were developed, but may not have any validity outside that context (Ingleby, 2005). It has been argued that culture can conceivably have a significant impact on the development and presentation of PTSD (Friedman and Marsella, 1996). Since cultural differences are tied to variations in the social construction of reality – which is in turn influenced by cultural differences in cognition and the experience and expression of emotion – the perception of what is a traumatic experience, as well as the individual and social response to it can conceivably vary greatly (Friedman and Marsella, 1996). For this reason, trauma has been a popular subject for medical anthropologists and sociologists. For example, Summerfield and Bracken, both psychiatrists with training in anthropology, have characterized PTSD as a social construction of the West, and have questioned its validity in the context of refugee mental health, where, they argue, the construct fails to capture the complex psychosocial problems this population faces (Bracken, 2002; Bracken, Giller and Summerfield, 1995; Summerfield, 1999, 2001a, 2001b, 2005). Young (1995), a medical anthropologist, conducted field research in a Veterans Administration psychiatric unit specializing in the treatment of PTSD and concluded that the PTSD diagnosis was a product of the aftermath of the Vietnam War in the U.S.A., when there was a debate on how to compensate veterans for their service. Young (1995) posits that the diagnosis is a product of its time, “glued together by the practices, technologies, and narratives with which it is

Complimentary Contributor Copy Using the Individualism-Collectivism Construct … 59 diagnosed, studied, treated, and presented by the various interests, institutions, and moral arguments that mobilized these efforts and resources” (p. 5). Young (1995) further suggests that PTSD, with its distinct symptom clusters, is a late 20th century Western-World phenomenon, which should not be noted across historical periods and across cultures. With regard to his claim that PTSD is a 20th-century phenomenon, analyses of historical data suggest a mixed picture. For example, Jones et al. (2003) analyzed war pension files from British servicemen who had fought in wars from 1854 onwards and found that the incidence of re-experiencing symptoms, a key component of the PTSD diagnosis, was mostly absent in servicemen who had fought in the Boer War (1899-1902) and the First and Second World Wars. These soldiers instead reported suffering from somatic symptoms in addition to symptoms belonging to the other clusters. However, Dean (1997) has argued that PTSD symptoms, including flashbacks, are evident in accounts of veterans of the American Civil War. An archival examination of 17,700 military records of Civil War veterans revealed high rates of what was then termed “nervous disease,” which included symptoms from all three PTSD clusters (Pizarro, Silver and Prause, 2006). Whether PTSD is a phenomenon confined to the Western world, as Young (1995) asserts, or a global phenomenon, remains open to debate. Following the arguments of Kleinman and others, it is possible that symptom presentation of posttraumatic stress could be different. Understanding such differences may be important if one is to successfully identify and treat individuals and communities from different cultures. Moreover, even if it is the case that the current construct of PTSD is applicable in other cultures (i.e., that one is able to identify the three symptom clusters across cultures, the presence of which indicates distress), there may still be considerable differences in the way people perceive or express their plight or illness and talk about distress or emotions. Understanding these local “idioms of distress” is important if one is to construct valid instruments for the assessment of PTSD (de Jong, 2002). It is possible that any perceived differences in PTSD prevalence rates and symptom presentation may be the result of the use of poorly validated measurement instruments. Lastly, one other reason why it is important to understand the relationship between PTSD and culture is that certain cultural values, beliefs and practices may act as either buffers or risk factors for PTSD. Surveying the different PTSD prevalence rates across cultures and identifying the specific beliefs/behaviors within those cultures that plausibly act as buffers or risk factors for PTSD is an important endeavor, in that such knowledge may enhance our understanding of the etiology of the disorder and also allow us to potentially identify or customize a treatment depending on the characteristics of the community in question.

Aims of the Current Chapter

This chapter aims to examine the empirical evidence for cultural variations and similarities in PTSD within a cultural psychology framework. First, the data on PTSD prevalence rates and symptom presentation in developing countries and in refugee populations will be examined, with attention being paid to large-sample studies. Risk factors in each of these samples will also be identified. Next, theories and operational definitions of culture, and empirical research on cultural differences in cognition and emotion will be reviewed with the intention of explaining observed ethnic and cross-national differences in the prevalence and development of PTSD. The focus of this review will be on the

Complimentary Contributor Copy 60 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa individualism-collectivism construct, which has received the most amount of attention from cultural psychologists. Finally, methodology will be addressed, with a focus on approaches that best facilitate the study of cultural variations in PTSD. It should be noted at the outset that the above approach has significant limitations given the goal of identifying cultural variations and similarities in PTSD. Lopez and Guarnaccia (2000) noted that ethnicity or nationality cannot be equated with culture and identified numerous instances in the clinical psychology literature where this error has been made. Although being of a certain ethnicity or nationality may make it more likely that one has certain values and beliefs (e.g., being a Japanese national may make it more likely that one values in-group harmony – this is discussed later on), there is a great deal of cultural heterogeneity within ethnic groups. Indeed, in assuming that such cultural homogeneity exists, there is a risk of polarizing communities through the reinforcing of stereotypes (e.g., Mr. X is a Japanese national, so therefore he must value in-group harmony more than Mr. Y., who is an American national). Identifying differences and similarities in both the prevalence of PTSD and symptom presentation in ethnic minorities in the USA or between countries would only be suggestive of cultural differences in the development and manifestation of PTSD and should not be regarded as evidence for such differences. Conversely, the lack of significant differences between ethnic groups does not necessarily mean the absence of cultural differences. It is possible that cultural beliefs and practices exist that are specific to a particular sub-section of an ethnic group. For example, Nisbett and Cohen (1996) found that European-Americans from the Southern U.S.A. have a concern for honor that, in turn, has considerable attitudinal and behavioral implications. It is clear that a focus on between- ethnicity and between-country differences and similarities in PTSD prevalence and presentation will result in a limited understanding of cultural variations. This limitation is unavoidable, given that there is an absence of research examining whether culture-relevant variables (e.g., specific beliefs and behaviors; Campbell, 1961) account for differences and similarities in PTSD.

PTSD in Developing Countries

As noted earlier, there is a dearth of large-sample studies examining the prevalence of PTSD in developing countries (i.e., Central and South America, Eastern Europe, Africa, and some Asian countries). The existing studies suggest that PTSD prevalence rates are higher in these countries than in the developed world. This should not be surprising, given that the majority of these studies were conducted in countries that had experienced or were currently experiencing conflict. de Jong et al. (2001) conducted an epidemiological survey of community populations that had recently seen intense conflict from four countries, namely Algeria, Cambodia, Ethiopia and the Gaza Strip in Israel/Palestine. In Algeria, of 653 respondents, 37.4% met the criteria for PTSD, with women having significantly more PTSD symptoms (43.8%) than men (32.2%). In this sample, 80.4% suffered from re-experiencing symptoms, 71.4% suffered from hyperarousal symptoms and only 52.4% experienced symptoms from the avoidance/numbing cluster. The authors note that one reason for the high rates of both PTSD and partial PTSD in Algeria may be that terrorist attacks were still happening in the community during the collection of the data. In Cambodia, 28.4% of the sample (n = 610) met

Complimentary Contributor Copy Using the Individualism-Collectivism Construct … 61 the criteria for current PTSD, with women (34.2%) having significantly more symptoms than men (20.6%). In this sample, 72.8% suffered from re-experiencing symptoms, 59.3% suffered from avoidance/numbing symptoms and only 37.7% had symptoms from the hyperarousal cluster. In the Ethiopian sample (n = 1200), 15.8% met the criteria for a current diagnosis of PTSD, with 63.8% of the sample evidencing re-experiencing symptoms, 44.4% avoidance/numbing symptoms, and 33.1% hyperarousal symptoms. Men and women had similar rates of PTSD (16.6% vs. 15.2%). In the Gaza sample, 17.8% of the 585 respondents met the criteria for current PTSD; 49.6% of the sample reported re-experiencing symptoms, 39.7% hyperarousal symptoms and 27.5% avoidance/ numbing symptoms. Men were significantly more likely to develop PTSD (22.6%) than women (13.5%). In all four countries that de Jong et al. (2001) surveyed, re-experiencing symptoms were the most common. Hyperarousal symptoms were found to be the least common in Cambodia and Ethiopia, whereas in Algeria and Gaza, avoidance/numbing symptoms were the least common. This latter finding is striking as Foa, Riggs and Gurshuny (1995) and Breslau (2001) have both argued that the avoidance/numbing symptom cluster is the critical criterion for the diagnosis of PTSD. These symptom patterns are similar to an earlier study by El Sarraj, Punamaki, Salmi, and Summerfield (1996) of 550 Gaza inhabitants who were torture survivors; they found that 20% of the sample met the criteria for current PTSD, and that re- experiencing symptoms were the most commonly reported symptoms (e.g., 77% reported having intrusive memories), whereas 43% reported having poor concentration, indicative of hyperarousal. With regard to symptoms of avoidance/ numbing symptoms, 41% reported feeling unhappy and lonely and 30% reported that they avoided reminders of their prison experiences. Similar results have been found in smaller studies of Kalahari bushmen (McCall and Resick, 2003), Sudanese refugees and Malawian torture survivors (Peltzer, 1998), Salvadorian women (Jenkins, 1996) and Sri Lankan children following war trauma (Soyza, 2003) and the 2004 Asian Tsunami disaster (Soyza, 2006). Punamaki, Komproe, Qouta, Elmasri, and de Jong (2005) assessed a random sample of 311 women and 274 men in the Gaza Strip and found that 86% of the men and 44% of the women had experienced a traumatic event. PTSD prevalence rates were 21.5% for men and 13.2% for women respectively, a similar pattern to that found by de Jong (2001). It was also found that peritraumatic dissociation made members of both genders more vulnerable to symptoms of hostility and men more vulnerable to depression. However, peritraumatic dissociation did not have any moderating effect on PTSD symptoms, which is surprising in light of previous research that identifies peritraumatic dissociation as among the strongest predictors for PTSD (Ozer, Best, Lipsey and Weiss 2003). Punamaki et al. (2005) suggested that one reason why dissociation predicted depression in men is that such responses are seen as demonstrating lack of control, shame, weakness, and therefore low self-esteem; in contrast, when women present dissociative and uncontrollable responses, they are more easily accepted, since Palestinian culture encourages strong, visible emotion in women. Pham, Weinstein, and Longman (2004) assessed PTSD symptoms from 2091 adults in four communes across Rwanda in 2002, eight years after the genocide that resulted in the death of at least 10% of the population. The sample had high levels of trauma exposure, with 75.4% being forced to flee their homes, 73% having had a close member of their family killed and 70.9% having had their property destroyed or lost. Pham et al. found that 24.8% of the sample met symptom criteria for PTSD. With regards to PTSD symptoms, more than half the sample (56.8%) reported having at least one re-experiencing symptom, whereas 43.2%

Complimentary Contributor Copy 62 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa experienced three or more avoidance/ numbing symptoms, and 25.7% had two or more hyperarousal symptoms. Pham et al. noted the high levels of avoidance/ numbing symptoms and speculated that these symptoms may be mediated by cultural norms that discourage open displays of emotion. Predictors of PTSD in this sample were cumulative traumatic experiences, being female, ethnicity (the Tutsis, who were the targets of the 1994 genocide, were more likely to have PTSD than the Hutus) and ethnic distance (the less comfortable one felt around people of different ethnic backgrounds, the more likely one was to develop PTSD). Cardozo et al. (2000) assessed a representative sample of 1358 Kosovar Albanians soon after clashes ceased in 1999 between Serbian forces and the Kosovo Liberation Army, and found that 17.1% of the sample met criteria for current PTSD. Identified risk factors included the number of experienced traumatic events, being older, having a history of mental or physical illness, and being displaced. Cardozo, Kaiser, Gotway, and Agani (2003) assessed the same community one year later and found an increase in current PTSD rates, with 25 % of the sample receiving a diagnosis of PTSD. Rosner, Powell, and Butollo (2003) assessed three smaller samples in Sarajevo three years after the city was besieged, and found that 18.6% of the sample met the criteria for current PTSD. None of these studies presented data on specific PTSD symptomatology. Kuterovac-Jagodic (2003) twice assessed 252 school children in Osijek, Croatia, once when their city was under attack from Yugoslav forces and again thirty months later when the war was over. During the time of her first assessment, 25% of her sample met the criteria for current PTSD; 10.3% of her sample met the criteria 30 months later. The most stable symptom cluster over time was hyperarousal, while re-experiencing and avoidance/numbing symptoms were more likely to decrease. Children’s personality characteristics, use of aggressive coping strategies, war experiences, and lower levels of received instrumental support were predictive of long-term PTSD. Cardozo et al. (2004) surveyed a representative sample of 799 disabled and non-disabled adults in Afghanistan following the U.S.A.-led coalition forces’ toppling of the Taliban in 2001 and found high rates of PTSD in both disabled (42.2%) and non-disabled (42.1%) adults. Levels of trauma exposure were high in this sample: 62% of the population reported experiencing four or more traumatic events (i.e., torture, bombardments by coalition forces, rape). Of the non-disabled respondents, those who focused their efforts on covering their basic needs (i.e., more income, better housing and more food) were less likely to develop PTSD, while for disabled respondents, prior mental illness, lack of income and being married were predictors of PTSD. For both disabled and non-disabled participants, women were more likely than men to develop PTSD. No data was presented on prevalence rates for specific symptom clusters. Norris et al. (2001) conducted what is to date the only study examining the structure of PTSD in a Latin American sample. Norris et al. (2001) surveyed 200 Mexicans who had been affected by Hurricane Paulina six months previously and 270 non-Hispanic Americans who had been impacted by Hurricane Andrew six months prior and found that a model consisting of intrusion, avoidance, numbing and arousal fitted with the data of both the Mexican and American samples equally well. However, when severity of trauma was controlled for, the Mexican sample was higher in intrusion and avoidance symptoms, while the American sample was higher in arousal symptoms.

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PTSD in Refugee Populations

Numerous studies have been conducted assessing PTSD prevalence rates and symptomatology among refugee populations, who are often faced with numerous aversive and potentially traumatizing events. In one of the first studies of its kind, Mollica et al. (1993) assessed a randomly selected sample of 993 adults who lived in the largest Cambodian displaced refugee camp on the Thailand-Cambodia border. It was found that 83% of the sample had experienced multiple traumatic events (e.g., brainwashing, lack of shelter, forced separation from family) and that more than half of the respondents had experienced the murder of a family member or friend. Almost 15% of the sample (14.7%) met the criteria for current PTSD, with 70.5% of the sample reporting having recurrent memories of past traumatic events and 70.9% experiencing nightmares. Furthermore, 82.6% of the sample indicated experiencing a depressive state called bebotchit, translated as “a deep sadness inside oneself.” Mollica et al. (1993) report that “bebotchit is not a free-floating feeling, but a reactive, depression-like state caused by experiencing specific unfortunate events such as the loss of or separation from loved ones or the failure of a business…the feeling of bebotchit is said to lie so deeply inside a person that it can be hidden from being noticed by others” (p. 583). Respondents also reported feeling srangotsrangat, similar to bebotchit, but visible and more severe (38.8%), ah sangkim, which translates as hopelessness (52.9%), ettdamlay (worthlessness, 37.0%), and prouychit, which is roughly translated as a worrying sadness (56.3%). A quarter of respondents also reported having a condition known as chcoot (translated as “loose mind,” or “crazy”). Furthermore, respondents in this sample indicated high levels of somatic symptoms, such as frequent headaches (74.3%), feelings of weakness (68.6%), dizziness (68.2%) and cold hands or feet (31.3%). de Jong, van Ommeren and Shrestha have worked extensively with Bhutanese refugees living in Nepal and have published a number of papers related to the prevalence rates of PTSD and other psychiatric disorders (e.g., Van Ommeren et al., 2001; Shrestha et al., 1998). de Jong and colleagues found that a sample of 418 tortured and 392 non-tortured Bhutanese refugees easily recognized and endorsed PTSD symptoms among more than 1700 assessed variables, suggesting that PTSD is a valid indicator of distress in this population (de Jong, 2005). Fazel, Wheeler, and Danesh (2005) summarized data from across studies that examined refugees who had resettled in Western countries and found considerable variability in the prevalence rates recorded in each of these studies. The range of PTSD prevalence in these studies was from 3% to 44%. When limiting their focus to methodologically rigorous studies of 200 respondents or more, it was found that the average PTSD prevalence rate was 9%, slightly higher than the prevalence rate of PTSD in the United States (6.8%, Kessler et al., 2005). Given that this population is susceptible to high rates of trauma exposure, this is a surprising finding.

Summary of Cross-Cultural Prevalence Rates, Symptom Presentation, and Risk Factors of PTSD

The reviewed research clearly indicates that PTSD is not a Western-world phenomenon, but a global one. While only a minority of the studies identified risk factors for PTSD, a Complimentary Contributor Copy 64 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa number of the risk factors identified were consistent with the meta-analytic findings of both Ozer et al. (2003) and Brewin, Andrews and Valentine (2000). For example, factors such as social support, gender and prior psychological problems appear to be predictive of PTSD in numerous contexts. However, differences in prevalence rates exist that are difficult to explain. In certain conflict-affected populations where trauma exposure was common, high rates of PTSD were found. For example, de Jong et al. (2001) found that 37.4% of a representative sample in Algeria had PTSD, and Cardozo et al. (2004) found PTSD rates of 42% in Afghanistan. However, in other populations with high trauma exposure, PTSD rates were much lower. For example, the PTSD prevalence rate among Cambodian refugees living in Thailand was 14.7% (Mollica et al., 1993) and the average PTSD prevalence rate among refugees living in the West was 9%. There were also symptom presentation patterns across countries that are difficult to explain. In a number of countries, avoidance symptoms were uncommon (e.g., the Gaza Strip and Algeria, de Jong et al., 2001, El Sarraj et al., 1996). In some countries, the hyperarousal symptom cluster was the most stable (e.g., Bosnia; Kuterovac-Jagodic, 2003), while being the least seen symptom cluster in other settings (e.g., Rwanda; Pham et al., 2004). Possibly one reason why PTSD rates are not higher in particular conflict-affected populations is that individuals fulfill only part of the PTSD criteria, and are not given a PTSD diagnosis, despite being in considerable distress. A number of findings suggested that particular risk factors were specific to particular populations. Punamaki et al. (2005) found that peritraumatic dissociation did not act as a moderator for PTSD symptoms, a surprising finding given that the meta-analysis by Ozer et al. (2003) identified peritraumatic dissociation as the most robust predictor of PTSD. Pham et al. (2004) suggested that cultural norms that discourage open displays of emotion could be the reason why Rwandans have high levels of avoidance/ numbing symptoms. These results suggest that there are universal and culturally specific risk factors for PTSD and that more research is needed to identify these predictors. A significant limitation of the reviewed research is that with the exception of Mollica et al. (1993), none of the studies discussed above utilized assessments for culturally specific symptoms and syndromes, but instead focused on symptoms identified in the DSM, such as PTSD symptoms, depression and anxiety. The fact that Mollica et al. (1993) found unique idioms of distress suggests that one may be under-diagnosing psychological pain by not detecting other culturally specific indicators of distress. de Jong (2002) notes that even though PTSD is found across the world, one cannot conclude that PTSD is similarly experienced in different communities, since there is a dearth of studies that have looked at possible subtypes and variations of the disorder. It is however important to note that these differences in PTSD rates, symptom presentation and risk factors across different countries may not solely be due to cultural differences. The types of traumatic events experienced by these non-western populations (e.g., war, genocide, torture) are generally more prolonged and result in a greater loss of both physical (e.g., one’s home and land) and psychosocial resources (e.g., one’s family and community) than the types of trauma predominantly studied in the Western world, such as rape, combat experiences, and motor vehicle accidents. Thus, it could be that the differences in PTSD prevalence rates and symptom presentation are driven by the type of trauma experienced and not by cultural factors. For example, Basoglu et al. (1994) notes that

Complimentary Contributor Copy Using the Individualism-Collectivism Construct … 65 individuals who have suffered torture often suffer from severe somatic symptoms along with symptoms of PTSD. In the same vein, Mollica and Caspi-Yavin (1991) noted that researchers who work with survivors of torture must “avoid the uncritical use of ready-made constructs such as the DSM-III-R diagnosis of PTSD” (p. 586), if they are to understand the full nature of psychological sequelae following torture. Nevertheless, the differences in symptom presentation seen in the four similarly war-worn countries studied by de Jong et al. (2001) suggest that other, potentially cultural, factors play a role as well. What these variables might be and how they impact upon the development of PTSD is the obvious next step for one who is attempting to under how culture impacts PTSD. The focus of the chapter now shifts to the cultural psychology literature.

Culture

Before moving on any further it might be prudent to examine the definition of culture, since its definition has been a source of contention and argument in both anthropology and psychology. The fact that defining culture has been so difficult is understandable, given that any context for human behavior that is so all-encompassing as culture is for the individual (Segall, Lonner and Berry, 1998) would be hard to succinctly define, and even more difficult to operationalize. Given these difficulties, it is best to keep the question of how culture is studied (which is of most interest to the current chapter) separate from the question of how it should be best defined (Atran, Medin and Ross, 2005). Thus, the current review will restrict itself to two definitions of culture that best represents what most researchers conceptualize as “culture.” One of the more prominent cultural psychologists, Richard Shweder has defined culture as consisting of “meanings, conceptions, and interpretive schemes that are activated, constructed, or brought ‘on-line’ through participation in normative social institutions and practices (including linguistic practices) [and which give] shape to the psychological processes in individuals in a society” (Shweder, 1993, p. 417). Durham (1991) further defined culture as including consensus of conceptual reality, social transmission of information, symbolic encoding of meaning, systemic organization and social history (cf. Smith, Spillane and Annus, 2006). Both these definitions suggest that culture encompasses ways of understanding, interpreting and explaining our surrounding environment. They also suggest that culture activates and constructs meaning in the individual through social participation – we learn how to think and behave by interacting with the cultural institutions in our surroundings, such as schools, religious institutions and with our family, friends and community, This is what Durham (1991) refers to as the social transmission of information. Lastly, culture gives shape to psychological processes in the individual – how we think about the world and how we behave depend of the concepts we have learned from social participation. Differences in these concepts and meaning can lead to considerable differences in behavior (Kalat and Shiota, 2007). Operationalizing culture for the purpose of identifying cultural differences has been a difficult endeavor. Cross-cultural psychologists have typically studied culture by measuring attitudes and beliefs at the individual level. These attitudes and beliefs are then treated as independent variables or are examined as moderators to see if they influence the strength of a particular relationship. An underlying assumption of such research is that there are universal

Complimentary Contributor Copy 66 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa psychological processes and that culture has an impact only on the level of development and/ or display of psychological processes (Miller, 2002). Researchers in this tradition have argued that although each culture is distinct in its own way, cultures can be compared to one another along a few, broad dimensions that have considerable implications for how people relate to one another (Kalat and Shiota, 2007). One dimension, which has received the most attention from psychologists since Hofstede (1980) first identified the dimension at the national level, is individualism-collectivism. However, many cultural psychologists and anthropologists have argued that such an approach may be invalid for the study of culture. Fiske (2002) argues that “cultures are somewhat like systems, with some fundamental qualitative differences in how they operate…and that the differences among them are not captured by any dimensions or even contrasts…” (p. 84). Thus, rather than culture influencing universal psychological process, it may be that the psychological processes themselves may be qualitatively different across cultures and may take on qualitatively distinct forms (Miller, 1999, 2002). A number of researchers have begun to examine the cultural underpinning of psychological processes and have found differences in the way in which the self is constructed across cultures, as well as differences in cognitive processes. It should be noted that the individualism-collectivism construct is still used in such research as a parsimonious framework to account for cultural differences. What follows is a review of the literature from both traditions of research, focusing on those findings that may have relevance when trying to understand potential cultural differences in both the prevalence and presentation of PTSD.

Individualism-Collectivism

The individualism-collectivism is by far the cultural construct that has stimulated the most research in psychology (Heine, Lehman, Peng and Greenholtz, 2002; Oyserman, Coon and Kemmelmeier, 2002). Hofstede (1980) first proposed the construct to account for cultural differences in work-related values at the country level. He surveyed samples of employees at a particular multinational corporation in 39 different nations and identified four distinct structures that accounted for the value differences across nations: power distance (i.e., the emphasis on social hierarchy), masculinity, uncertainty avoidance and individualism- collectivism, which Hofstede conceptualized as being a single continuum with low individualism being indicative of high collectivism. Hofstede‘s analyses suggested that the United States was the most individualistic country, with Guatemala being the least individualistic (i.e., more collectivistic) country. Hofstede (1980) was among the first psychologists to provide a structure for the study of culture and his seminal work inspired many psychologists to use his individualism- collectivism construct to explain cultural differences (Bond, 2002). Harry Triandis soon adopted the individualism-collectivism concept to explain cultural differences in the individual, using the terms idiocentrism and allocentrism as the individual-level equivalents of individualism and collectivism respectively (Triandis, 1995). Markus and Kitayama (1991) linked individualism-collectivism with the concept of the self, positing that individualistic cultures (typically western cultures) fostered the development of independent self-construals, which in turn have an impact on mental processes and behaviors. In the same vein, they posited that collectivistic cultures (typically East Asian cultures) foster the development of

Complimentary Contributor Copy Using the Individualism-Collectivism Construct … 67 interdependent self-construals, which have a differential impact on the development of mental processes and behavior. The key assumption behind individualism is that individuals are independent of one another. In their theoretical and statistical evaluation of the individualism-collectivism construct, Oyserman et al. (2002) posit the consequences of individualism on the self- concept, wellbeing, cognitive style, and relationality:

 With regard to the self-concept, creating and maintaining a positive sense of self is essential. Furthermore, value is given to feeling good about one’s self, attaining personal success, and having numerous distinct personal attitudes and opinions.  With regard to well-being, open emotional expression and attainment of one’s personal goals is seen as essential to life satisfaction.  In terms of cognitive style, judgment, reasoning, and causal inference are generally oriented towards the self rather than the situation, since the self is perceived as a bounded, coherent, stable, autonomous entity.  Lastly, with regard to relationality, relationships and group memberships are impermanent and non-intensive. Individualists need relationships and group memberships to attain self-relevant goals, but apply equity norms to the relationship’s costs and benefits and leave the relationship when the costs exceed the benefits.

The key assumption behind collectivism is that groups bind and mutually obligate individuals. Because “group” could refer to a number of entities, such as family, ethnic group, or religious group, it has been proposed that collectivism refers to a broader range of values, behaviors and attitudes than individualism (Oyserman et al., 2002; Triandis, 1995). Osyerman et al. (2002) posit the following implications of this worldview:

 Group membership is central to the self-concept, and valued personal traits are less abstract and more social-oriented, including goals like sacrifice for the common good and maintaining harmonious relationships with close others.  Wellbeing comes about from successfully carrying out social roles and obligation. Furthermore, restraint in emotional expression, rather than open and direct expression of personal feelings, is likely to be valued, as such behavior ensures group harmony.  Social context, constraints of the situation, and social roles, greatly impact cognitive style. Specifically, situational rather than dispositional attributions are made. Further, meaning is contextualized rather than generalized and memories are likely to be embedded with rich detail.  In terms of relationality, important group memberships are ascribed and fixed. Also, boundaries between in-groups and out-groups are viewed as stable, impermeable and important.

Osyerman et al. (2002) meta-analysis found support for the notion of individualism as valuing personal independence and personal uniqueness (and, in some instances, personal privacy), and for the notion of collectivism as valuing duty to the group and, for international

Complimentary Contributor Copy 68 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa comparisons, in-group harmony. However, empirical findings on individualism-collectivism suggest that rather being a continuum, individualism and collectivism are better understood as domain-specific, orthogonal constructs elicited differentially by contextual and social cues (Oyserman et al., 2002). Thus, any given society is likely to have some representation of both individualistic and collectivistic worldviews. For example, Osyerman et al. ‘s (2002) meta- analysis revealed that European-Americans were lower in both individualism and collectivism compared to most Latin American countries, with the exception of Costa Rica and Venezuela. Osyerman et al.’s (2002) analysis also revealed that relative to Americans, the Chinese are high in collectivism with an emphasis on group harmony, while the Koreans are high in collectivism with a focus on relatedness. The few studies conducted in Africa also revealed that they were substantially higher in collectivism than Americans.

Using the Individualism-Collectivism Construct to Understand Cross-Cultural Differences in PTSD

Variations in psychological functioning, along the individualism-collectivism dimension, may explain one of the more striking findings with regard to cross-national PTSD symptom presentation, namely the low prevalence of avoidance symptoms in many developing countries. The interdependent self emphasizes connectedness with others, with wellbeing arising from successfully carrying out social roles and obligations. Consequently, the daily routine of engaging with others and with one’s environment is a prominent part of the interdependent self, and such a routine may act to lessen avoidant behavior following a traumatic event. Indeed, to the interdependent self, avoidant behavior may be antithetical to their conceptualization of being a good self. In the same vein, it is also plausible that individuals in collectivistic societies may suffer more distress relative to individualist societies when their communities as a whole are disrupted in such a way that interferes with individuals’ abilities to fulfill their social roles and obligations. The fact that self-expression may not be valued across cultures may explain some of the culturally specific reactions to traumatic stress found in the literature. Distress may be expressed in ways that do not disrupt group harmony. For example, the feeling of bebotchit, identified among Cambodian refugees, is said to lie deeply within a person so that it can be hidden from others (Mollica et al., 1993). Somatic symptoms may also be a consequence of collectivistic individuals’ preference not to express their affective distress openly. Research on appraisal of emotions suggests that there are cultural differences in the way in which complex appraisals are made. Specifically, differences were found in the amount of control and responsibility the individual appears to have, anticipated effort, and perceptions of morality and fairness. While fear is central to the PTSD diagnosis, it may be that traumatic fear and its aftermath involves a more complex emotional experience. The fact that treatment models of PTSD have moved from conditioning models to more complex models that incorporate post-trauma cognitive and behavioral factors (e.g., Ehlers and Clark, 2000; Foa and Rothbaum, 1998) is in itself an indicator that the appraisal and experience of traumatic fear is a complex one that could potentially be influenced by cultural beliefs. For example, Mauro, Sato, and Tucker (1992) found that Chinese beliefs about fate and feelings of control (with the Chinese being more accepting of unpleasant actions by external agents) led them to be more likely to accept unpleasant actions by external events.

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Heine, Kitayama, and Lehman (2001) and Mesquita (2001) have found that the experience of emotion led to changes in beliefs about the self in collectivistic cultures. One can make a number of hypotheses based on this finding with regard to the development of PTSD. First, this finding suggests that the self-concept is more fluid and flexible in collectivistic cultures and that therefore there is a greater likelihood that there will not be the breakdown of the self that may occur when PTSD develops (Dalgleish, 2004). Another hypothesis is that this openness to allow experienced emotion to impact one’s belief system may result in better emotional processing of the traumatic event and thus lower rates of PTSD (Foa and Kozak, 1986). Yet another hypothesis is that allowing every emotional experience to have an impact on one’s belief system may mean that the experience of the strong affect that often accompanies a trauma may make it more likely for the individual to believe that he or she is unable to deal with adversity and is therefore incompetent, without referencing other occasions when he or she was able to deal with aversive events. Clearly, further research is needed to identify the different ways in which individuals in different cultures allow traumatic affect to impact their belief systems. A body of research suggests that East Asian cultures are more comfortable dealing with contradiction compared to other cultures (e.g., Peng and Nisbett, 1999); these findings may also have implications for the development of PTSD. Foa and Rothbaum (1998) suggest that PTSD develops when traumatic events violate existing core schematic knowledge such as “I am competent,” and “the world is a safe place,” and lead the victim to believe that the world is entirely dangerous and that the self is totally inept. Given that certain cultures (e.g., East Asians) are more tolerant of contradiction and encourage a holistic style of reasoning, people from such cultures may be more resistant to allowing a single event to destroy their core schemata of the world. In particular, being comfortable with contradiction may mean that the individuals from this culture may find it easier to accept the fact that on the occasion in question, they were unable to do anything to stop the traumatic event from happening, or that the world is sometimes a bad place. Furthermore, given that certain cultures make more situational, rather than dispositional, attributions (Fiske et al., 1998), it may be that, in such cultures, there could be less self-blaming for being the victim of a traumatic event. However, shame and guilt may come from other areas, such as not being able to fulfill one’s duties to others or disrupting one’s relationships with family and colleagues as a result of suffering from trauma-related sequelae (Miller, 2006). Furthermore, while the maladaptive schema “I am inept” following a traumatic event may be predictive of PTSD, it may mean one thing in individualist cultures (the bounded self is inept) and another thing in collectivistic cultures (the self is inept because one is unable to fulfill social obligations). Lastly, some research suggests that cultural differences exist in the way social support is conceptualized across cultures (Taylor, 2007; Taylor et al., 2004). These results suggest that the concept of social support as transactions involving the specific, intentional efforts to extract help or seek solace from others may be a Western, individualistic one that is not valid in more collectivistic cultures. Individuals from collectivistic cultures may instead draw on implicit social support, which is the feeling of connectedness that comes from being a member of an interdependent, harmonious community to which one has a role and obligations. This finding has considerable implications to the cross-cultural study of PTSD. In their meta-analysis, Ozer et al. (2003) found that perceived low social support, following a traumatic event predicted PTSD, with the relationship becoming stronger as more time lapsed between the traumatic event and the assessment. If one conducts cross-cultural research

Complimentary Contributor Copy 70 Nuwan Jayawickreme, Eranda Jayawickreme and Edna B. Foa employing a Western conceptualization of social support, it might be that one obtains dissimilar findings. Clearly, one must ensure that one’s conceptualization of social support has construct validity in the culture in question.

Methodological Issues in Studying Cross-Cultural Variations in PTSD

A great deal of research is needed in order to clearly understand just how fully the meaning or structure of PTSD generalizes across cultures. As Norris et al. (2001) note, a comparative, between-cultures study design fails to demonstrate whether there are equally important constellations of symptoms outside of those being assessed by a pre-existing instrument. As noted before, apparently very few studies outside of the USA and Europe have broadened their scope beyond PTSD symptoms (e.g., Mollica et al., 1993, the work of de Jong et al. in Nepal). If one is to fully understand the extent of traumatic stress, one needs to first conduct qualitative, ethnographic research in order to examine the ways in which an individual in a particular culture might perceive, evaluate and experience a high-magnitude stress (Keane, Kaloupek and Weathers, 1996). Even if, as the data suggest, PTSD symptoms can be found cross-nationally, how those symptoms are experienced may differ cross-culturally. For example, Bhutanese refugees living in Nepal explain their symptoms using a supernatural model and do not connect their symptoms with their traumatic experiences (Shrestha et al., 1998). Qualitative research allows one to conduct an in-depth examination of a specific culture’s conceptualization of traumatic experience to obtain systematic, replicable, reliable and valid findings (see Strauss and Corbin, 1998). Such approaches will also allow us to identify what constitutes social support in these communities, given that what is considered social support varies cross-culturally. Once the concepts and the idioms used by the community in question have been identified, questionnaires or inventories can be developed to assess these concepts. Ideally, one could then conduct an epidemiological study with a large representative sample, where one can identify individuals high in distress and in wellbeing, as well as the social correlates of those experiences (e.g., nature of social support, employment and beliefs about the future). Studies should also be conducted with clinical samples to identify specific profiles of symptomatology, which could then be used to inform treatment (de Jong and Van Ommeren, 2002; Lopez and Guarnaccia, 2000).

CONCLUSION

The aim of this chapter was to examine whether the empirical literature had identified cross-cultural differences in the presentation, prevalence rates and risk factors for PTSD. A great many similarities and a number of differences were identified. The individualism- collectivism construct provided some explanations for the observed differences (i.e., varied presentation of avoidance symptoms across populations and presentation of somatic symptoms in certain populations) and also yielded further hypotheses. Future studies should use a mixture of qualitative and quantitative methodology to assess how people react to trauma in different contexts and settings.

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REFERENCES

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Pham, P.N., Weinstein, H.M. and Longman, T. (2004). Trauma and PTSD symptoms in Rwanda: Implications for attitudes towards justice and reconciliation. Journal of the American Medical Association, 292, 602-612. Pizarro, J., Silver, R. C. and Prause, J. (2006). Physical and mental health costs of traumatic war experiences among civil war veterans. Archives of General Psychiatry, 63, 193-200. Pole, N., Gone, J. P. and Kulkarni, M. (2008). Posttraumatic Stress Disorder among ethnoracial minorities in the United States. Clinical Psychology: Science and Practice, 15(1), 35-61. Punamaki, R. L., Komproe, I. H., Qouta, S., Elmasri, M. and de Jong, J. T. V. M. (2005). The role of peritraumatic dissociation and gender in the association between trauma and mental health in a Palestinian community sample. American Journal of Psychiatry, 162, 545-551. Rosner, R., Powell, S. and Butollo, W. (2003). Posttraumatic stress disorder three years after the siege of Sarajevo. Journal of Clinical Psychology, 59, 41-55. Schnurr, P. P. and Green, B. L. (2004). Understanding relationships among trauma, posttraumatic stress disorder, and health outcomes. In P. P. Schnurr and B. L. Green (Eds.), Trauma and health: Physical health consequences of exposure to extreme stress (pp. 217-43). Washington, D.C.: American Psychological Association. Segall, M. H., Lonner, W. J. and Berry, J. W. (1998). Cross-cultural psychology as a scholarly discipline: On the flowering of culture in behavioral research. American Psychologist,53, 1101-1110. Shay, J. (1994). Achilles in Vietnam: Combat trauma and the undoing of character. New York: Scribner. Shrestha, N. M., Sharma, B., Van Ommeren, M. H., Regmi, S., Makaji, R., Komproe, I. H. et al. (1998). Impact of torture on refugees displaced within the developing world: Symptomatology among Bhutanese refugees in Nepal. Journal of the American Medical Association, 280, 443-448. Shweder, R. A. (1993). The cultural psychology of emotions. In M. Lewis and J. A. Haviland (Eds.), Handbook of emotions (pp. 417-434). New York: Guilford. Smith, G. T., Spillane, N. S. and Annus, A. M. (2006). Implications of an emerging integration of universal and culturally specific psychologies. Perspectives on Psychological Science, 1, 211-233. Soyza, C. K. (2003). Posttraumatic stress disorder symptomatology in Sri Lankan children exposed to war. Poster presented at the biennial meeting of the Society for Research in Child Development, Tampa, FL. Soyza, C. K. (2006). Tsunami and war: Sri Lankan children’s culture based PTSD responses. Poster presented at the annual meeting of the American Psychological Association, New Orleans, LA. Strauss, A. L. and Corbin, J. M. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory. Thousand Oaks, CA: Sage. Struve, L. A. (2004). Confucian PTSD: Reading trauma in a Chinese youngster’s memoir of 1653. History and Memory, 16, 14-31. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas. Social Science and Medicine, 48, 1449-1462. Summerfield, D. (2001a). The invention of post-traumatic stress disorder and the social usefulness of a psychiatric category. British Medical Journal, 322, 95-98.

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Chapter 5

ASSESSING RESILIENCE IN THE AFTERMATH OF MASS TRAUMA

Marek J. Celinski*, Lyle M. Allen III and Kathryn M. Gow Private Practice, Toronto, Ontario, Canada CogniSyst, Inc., Durham, NC, US Consulting Psychologist, Regional Australia

ABSTRACT

The major focus of this chapter is on the presentation of our Resilience to Trauma Scale (Research Edition) (RTS-RE) (Celinski, Salmon and Allen, 2007) which was designed to document how resilience can be assessed in relation to the subjective severity of life’s adversities or mass trauma events. We review and expand on the existing concepts of resilience as represented in Antonovsky’s Sense of Coherence Scale and in the Connor-Davidson Resilience Scale. We discuss how the RTS -RE might assist practitioners gauge the impact of the trauma on individuals and groups in a community affected by a major mass trauma such as a severe natural disaster, survival after experiencing war and persecution, or a leap into an unknown country by refugees or immigrants leaving war and torture threats.

Keywords: Resilience, Trauma, Resilience to Trauma Scale, Psychopathology

INTRODUCTION

In this chapter, we discuss a scale that may well assist mental health practitioners who work with individuals and communities post trauma events, and explain how it can be used for assessing the impact of the mass trauma on groups and communities. While the majority of chapters in this book address the horror of mass trauma, and others argue the case for overestimating the psychological trauma in some traumatised populations,

* Contact: [email protected].

Complimentary Contributor Copy 78 Marek J. Celinski, Lyle M. Allen III and Kathryn M. Gow we believe that most people would recover in varying degrees from most mass traumas, even though others may remain as ‘the walking wounded’ in the view of Kathryn Gow1 and authors Bava and Saul (see Chapter 2). We hope that this chapter will encourage readers to think about how this new trauma assessment scale might assist practitioners, who work with disaster recovery patients, to gain valuable insights into their client’s capacity to bounce back and in some cases to bounce forward2 (see Chapter 15). Also, it is possible that through the use of the scale, practitioners can help patients to recognise their sense of competence, their ability to tolerate setbacks, obstacles and losses, and to develop an expectation that their efforts will lead to positive outcomes. Considering that resilience becomes evident in relation to self appraisals of adversity and the associated perception of losses, evaluation of the subjective experiences of trauma is one of the central variables assessed by our RTS-RE. For those readers interested in the effects of association versus dissociation following traumatic events, we provide evidence that the RTS-RE major factors, related to the emotional impact and the cognitive processing of the trauma and management of losses, have a mediating impact on depression, anxiety and other symptoms (as measured by the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI) and Davidson Trauma Scale (DTS) and that the RTS-RE Factor One measuring pre-trauma perception of self cohesiveness has a positive correlation with the MCMI-III Axis I psychopathology, and a negative correlation with serious personality and characterological disorders. The specific feature that differentiates the RTS-RE from other resilience scales concerns a person’s cognitive and emotional association into, or dissociation from, the trauma event and its consequences, thus representing the degrees to which a person is either overwhelmed by the traumatic experience, and is unable to consider other aspects of reality and/or dissociates from such an experience with a sense of derealization and depersonalization; these reactions are contrasted with an ability to maintain a broader awareness of the cognitive and emotional content of the trauma and with reality oriented coping. We acknowledge that the latter is difficult to achieve when one’s life is directly threatened in wars, uprisings, and natural disasters and all one’s emotions and flight and fight responses are on full alert. We also acknowledge that facing reality means that we have to assess loss situations before we can move forward.

THE CONCEPT OF TRAUMA

The essential assumption underlying the scale’s design is that trauma is causing higher order principles (i.e., commitment to truth and being considerate of the views and feelings of other people), on which inner cohesiveness and engagement with the world had been developmentally established, to cease being the primary organisers of behaviour, and a person is forced to seek cohesiveness and to deal with the world on developmentally lower levels than during normal times.

1 See Chapter 1 in our companion book: K. Gow, & M. Celinski (Eds.). (2012). Individual Trauma: Recovering from Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. 2 While the expression ‘bounce back’ is often used in definitions of resilience, the term ‘bounce forward’ can be followed up in Manyena, O'Brien, O’Keefe, and Rose (2011).

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The crucial issue in this respect is the severity of the trauma. Everstine and Everstine (1993) further commented that the more intense the person’s experience of the event, the greater the trauma may be. While affecting a sense of inner cohesiveness, trauma may, by the same token, attack self worth, meaning and purpose in life, and the value of one’s own engagement. Loss of comprehensibility, confusion and extreme anxiety that follow represent catastrophizing which, from the emotional perspective, is an overwhelmingly negative experience and from a cognitive perspective prevents a more balanced view of reality from being perceived. Profoundly negative impacts of trauma may be moderated by a mental attitude that allows for a full experience of trauma, and recognition of its emotional impact, but also for cognitive processing and understanding from which the possibility of some optimal responding may occur. A tendency to emotional and cognitive dissociation through attempts at “forgetting” about it prevents people from choosing their engagement with reality at the resilient level (see Celinski, 2011).3 This was made evident by the recovery problems that some Vietnam Veterans experienced many years after they had returned home.

Aspects of Resilience

In case of mass trauma (such as caused by a war or natural disaster), seeing one’s own suffering as being shared by many others tends to lessen one’s own sense of personal failure and of being “unfairly chosen” to suffer, when others continue to enjoy their lives. Ubiquitous suffering may be overwhelming, if there is no vision about what to do to achieve common goals that depends on human solidarity to organize people’s efforts. Regressive behavior may manifest as violence and individual survival at any cost, leading to the weak suffering more through being taken advantage of by stronger and unscrupulous people. To prevent further community disintegration, optimally some leaders should emerge who will appeal to some important cultural, national, religious or personal values (including spirituality) and show the way to improve people’s lives. From recent history, the rebuilding of Germany which had been devastated and divided after its defeat in WWII is a good example. It has to be noted that the choice of fundamental values, on which the present German state is based, is vastly different from that which was chosen to inspire German people to rebuild their country after the devastation caused by WWI. Victor Frankel (1966, p. 124), himself a survivor of a Holocaust and a concentration camp, understands “...the meaning of life… as the attaining of some aims through the active creation of something of value”. The authors also agree with Frankel that the “real aim of human existence cannot be found in what is called self-actualization; human existence is essentially self-transcendence rather than self-actualization. Self-actualization cannot be attained if it is made an end in itself but only as a side effect of self-transcendence (p. 175)”. We can discover this meaning of life in three different ways: (1) by doing a deed; (2) by experiencing a value; or (3) by suffering (p. 176). Whereas resilience helps people to achieve self-transcendence by empowering them to function on a higher level of autonomy and freedom than “dictated” by their habitual reactions or circumstances, for methodological clarity we define resourcefulness primarily as

3 See Celinski, 2011: “Framing Resilience as Transcendence and Resourcefulness as Transformation”.

Complimentary Contributor Copy 80 Marek J. Celinski, Lyle M. Allen III and Kathryn M. Gow facilitating the achievement of specific goals. This may be exemplified by the economic psychosocial situation of a farmer who has endeavoured to keep the five generation farming industry going, even through long years of drought and climbing debt and who then, after breaking free from his habitual ways of thinking, decides to sell off 90% of the land holdings of the farm. Then on the remaining 10% of land, he changes to hydroponic farming with new crops which he sells at the local markets for much higher prices than he had ever obtained through crop farming and he still has his return from the farm land sale to invest securely. This example shows that resilience must be activated first for resourcefulness to be utilized, because resilience guides our efforts at seeking resources; if a person is “not ready” for certain actions, teaching specific skills or attempting to tap available resources may be futile. According to Prochaska (1991), persons wish to change and their readiness to engage in the new behavioural option are the necessary prerequisites for successful intervention. We agree with Earvoline-Ramirez (2007) that “the main antecedent to resilience is adversity” (p. 78) and that adversity is the crucial characteristic “that distinguishes resilience from other social management processes and personality traits… (and) that separates the concept of resilience from the personality trait of ego-resiliency (Luthar et al., 2000). Challenge, change, and disruption are all aspects of adversity which must be present before the process of resilience can occur” (p. 78). By reference to Richardson, Neiger, Jensen and Kumpfer’s (1990) Resilience Model, Earvolino-Ramirez noted that individuals reacting to disruptive life events make conscious or unconscious choices to restore their sense of inner integration. “It is the disruption that allows an individual to learn to tap into resilient qualities and achieve resilient reintegration (Richardson, 2002, p. 78)”. The thesis is that resilience is a pre-requisite for resourcefulness (although successful deployment of the latter can reinforce the former) and that the key to resilient functioning after mass trauma is to transcend its overwhelming impact, and to focus on core values and one’s life orientation as inspirations for active coping, in spite of trauma related symptoms typically manifesting as anxiety, depression and somatic complaints. Utilising a more practitioner focus, we might say that it is the impetus to do so following trauma that activates the neural pathways and physiological mechanisms which lead to the person moving forward into the future. Some will leave the past behind by dissociating from it in a healthy way, while others will simply dissociate from the reality of the mass disaster or trauma by denying any feelings related to the experience thus potentially leaving themselves vulnerable to later abreactions when encountering unexpected triggers to the traumatic event. For instance, at a disaster recovery group meeting for women following a major flood in their region, a range of reactions were present 10 months after the disaster impact. One woman in her early sixties, who had lost her home and her business, had finally objectively assessed the situation and was now supporting her slightly older husband emotionally because he had carried the burden for almost a year on his shoulders, but had just started to ‘crumble’. The wife spoke solidly about reality and what she could do sensibly given the situation could not change. In that room, she became a symbol of strength and an example to all without assuming any leadership role. This woman had actually “bounced forward” in terms of the resilience metaphors. Another woman of a similar age spoke with emotion about the difficulties which she had not yet come to terms with and had found it hard to move out of the feelings associated with the flood and the ensuing losses. It was not that she had not spoken about these feelings with anyone; indeed she had spoken about the losses a great deal. Her family had not lost

Complimentary Contributor Copy Assessing Resilience in the Aftermath of Mass Trauma 81 everything like the other woman, but they had suffered significant trauma and loss, and her normal personality style which was to associate into detail, was “pulling her under” in this post disaster situation. She could not transcend those feelings sufficiently to call upon her inner resourcefulness, although she was grateful for the external resources of financial support, practical assistance and care shown to them and the people around them by their own community. Taking into account her normal personality style, she was equally as brave as the other woman, but she expressed it through showing up at community meetings and helping to problem solve within the groups.

Resilience Measures

Katherine Connor and Jonathan Davidson (2003) described their 25 item scale which they called the Connor-Davidson Resilience Scale (CD-RISC). According to their conception, resilience represents “the personal qualities that enable one to thrive in the face of adversity” (p. 76). More specifically, resilience refers to a personal ability to maintain bio-psycho- spiritual balance (“homeostasis”). They explain that when confrontingdisruptive adversity, an individual faces various options: either to interpret this as an opportunity for growth with increased resilience leading to a new and higher level of homeostasis (or at least to regaining baseline homeostasis), or to put forth suboptimal efforts that would result in recovery on a lower level of homeostasis; the least favourable reaction to adversity is a dysfunctional state in which maladaptive coping strategies are adopted. Connor and Davidson concluded that resilience may thus be viewed as a measure of successful stress coping ability; however, they did not equate coping and resilience as being the same constructs. Connor and Davidson further reported that the CD-RISC items yield five factors interpreted in the following manner: Factor One reflects the notion of personal competence, high standards, and tenacity; Factor Two corresponds to trust in one’s instincts, empowering effects of strength, and tolerance of negative affect; Factor Three relates to the positive acceptance of change and secure relationships; Factor Four concerns a sense of control; and Factor Five reflects spiritual influences. These factors are consistent with our conceptualization of resilience as a mental state of being energized by a sense of personal values and of one’s own life commitments, along with the recognition of one’s competence and tolerance of negative affect. However, in our view, acceptance of change, a sense of being in control, and garnering support from relationships, are better understood in terms of resourcefulness (see our previous explanations of the differences between resilience and resourcefulness4). Compared to other measures of resilience, such as the Connor-Davidson Resilience Scale and Antonovsky’s (1987, 1993) Sense of Coherence Scale (which in our opinion partially reflects resilience and partially resourcefulness), the Resilience to Trauma Scale - Research Edition (RTS-RE) (Celinski, Salmon and Allen, 2007) assesses a broader array of constructs related to resilience. Specifically, RTS-RE explores an individual’s emotional experiences, along with cognitive ideations pertaining to trauma or adversity and whether the event

4 See Chapters 2, 7, and 29, in M.J. Celinski & K.M. Gow. (Eds.). (2011). Continuity versus Creative Response to Challenge: The Primacy of Resilience and Resourcefulness in Life and Therapy. New York: Nova Science Publishers.

Complimentary Contributor Copy 82 Marek J. Celinski, Lyle M. Allen III and Kathryn M. Gow activates a sense of self-identity, the core values of the self, and an ability to mobilize effort and utilize specific coping styles, which enable an individual to cope with its impact. In our opinion, the strength of resilience needs to be assessed in relation to the subjective severity of trauma and its perceived multiple impacts on physical, emotional, and psychosocial functioning, and also in relation to one’s perception of manageability and a sense of vulnerability now and in the future. Even more importantly, the RTS-RE addresses trauma as causing loss of meaning in life and purpose for living, and loss of one’s own worth, which can profoundly affect the individual’s adjustment. Another important area measured by the RTS-SE is the perspective on responsibility for the event, which can negatively result in excessive self-guilt (diminishing self-worth) or in blaming others (which may then be regarded as justification for not putting adequate effort into one’s recovery). We will now present a more detailed description of our own measure and summarize some of the current conceptualizations of resilience in relation to psychotraumatic experiences.

CONCEPTUAL FRAMEWORK OF RESILIENCE TO TRAUMA SCALE – RESEARCH EDITION

The specific feature that differentiates RTS-RE from other resilience scales concerns a person’s emotional absorption, interpretation (creation of meaning) and evaluation of trauma regarding its possible impact on a person’s life. In this respect, one specific goal of our scale is to assess the level of perceived control over the disturbing event, an individual’s initial reactions, one’s own and others’ responsibility, the severity of trauma (from the physical, psychological and psychosocial perspectives, and from objective and subjective points of view), and one’s expectation of how sustained losses will affect his/her future life (which may be compared to objective records and thus permit assessment of a client’s sense of subjective augmentation of the trauma). Regarding the latter, the RTS-RE also assesses the client’s post- traumatic loss of purpose and meaning in life and increased sense of vulnerability with diminished future ability to protect or care for one’s self that includes the potential for earning a living. On the positive side, as a manifestation of resilience, the RTS-RE assesses the pre- traumatic sense of self cohesiveness acquired through family relations and commitment to values, a sense of personal agency to shape one’s life, effective or less optimal coping styles (that either enhance or weaken prospects of achieving stability) and tendencies to become frustrated, angry, overwhelmed or helpless. The RTS-RE also measures the degree to which a person is prepared to suffer in order to achieve higher personal goals, for the sake of significant others or for the common good. At its core, our resilience measure (as reflected in the RTS-RE) assesses an ability of a person to transcend the impact of trauma and is reflected as readiness and empowerment to engage in life on a certain level of agentic functioning which an individual or a group of people or society at large (that provide a frame of reference for an individual’s decisions) are prepared to sustain, defend and expand on. As an expression of core values, resilient people are prepared to sacrifice gratification, comfort and some other values which are deemed less important, and to put effort into regaining the key value in life when it is diminished or partially lost. (In this sense, our model regards as the most fundamental losses related to

Complimentary Contributor Copy Assessing Resilience in the Aftermath of Mass Trauma 83 trauma, the loss of the core self, and of the value of one’s efforts to create meaning that would inspire further engagements with life.) Therapeutically, awareness of a variety of resilient options offers an opportunity to exercise personal agency in order to choose involvements that are comprehensible and meaningful above and beyond what the current situation and condition may typically “dictate” in a seemingly fatalistic, or deterministic, a manner. In the following section, we will describe how these conceptualizations are reflected in the RTS-RE responses of people who were torture victims before immigrating to Canada or who were traumatized as the result of motor vehicle and/or industrial accidents. The factor analysis studies and the factors’ relationships to the measures of trauma and psychopathology will be presented in the next section. Throughout the overview of the scale and its properties, and in the Discussion and Conclusion, we will articulate how we believe that the scale can be used in other situations of mass trauma or mass disasters.

SOME PSYCHOMETRIC PROPERTIES OF THE RTS-RE SCALE

In order to present the clinical value of the constructs that constitute the essence of psychotraumatic experience, we administered our RTS-RE to clinical samples of those people who, according to the referring agencies, were psychotraumatized and needed psychological help for their ensuing symptomatology or needed assessment as part of their claim adjudication process. The study was conducted based on usual clinical practice which requires initial assessment of the referred clients during which a number of measures addressing psychopathological sequelae are administered. The Resilience to Trauma Scale – RE served as a tool, within a structured interview setting, to address the constructs which, according to our conceptual framework, represent the dynamics underlying the client’s current psychopathological manifestations. These dynamics are based on the understanding that the traumatic experience is filtered through the attitudes, cognitions and emotional context which existed at the time when the event occurred. To document these dynamics, we outline the method and present the following findings.

Subjects

The RTS-RE was administered to a mixed group of 155 individuals, one third of who were refugee immigrants who had escaped persecution (some of whom had been tortured in their own country), while the remaining people were victims of motor vehicle and industrial accidents who had suffered traumatic reactions. The overall sample was 49.8% male and 50.2% females, with an average age for the whole sample being 43.4 years (SD = 13,0) with 12.8 years of education (SD = 3.9).

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Factor Analysis

The RTS-RE factors have been substituted for scales in our research because this instrument continues to be a work in progress. We have periodically expanded the item content and utilized different versions concurrently during its development. Initial analyses on a subset of these patients using factor analytic variables were extremely promising as per the results set out in Celinski and Allen (2007) and Celinski, Allen and Pilowsky (2007). Principal components analysis (PCA) of the RTS-RE using varimax rotation evidenced good sampling adequacy (KMO = 0.75) and produced five interpretable factors that accounted for 40% of the overall variance. Accounting for 13% of variance, Factor One (“pre-traumatic self cohesiveness”) reflects the client’s pre-traumatic perspective on their self-efficacy and self perception of having strong, enduring personal, moral, social and religious beliefs. RTS-RE multi-item questions 1 and 2 load heavily on the first RTS-RE factor which actually could be split into two separate scales with very good alpha reliability (alpha > 0.90). RTS-RE question one items (presented as statements to be rated for their correspondence to the client’s actual opinions or feelings) are along the lines of “Before the event I was in control of my life”, while question two contains items such as “I have always had strong moral beliefs.” Samples of statements and questions exemplifying the five major RTS-RE factors are presented in Table 1.

Table 1. Samples of Questions Exemplifying the Major RTS-RE Factors.

FACTOR SAMPLE ITEM CONTENT 1 Before the event I was in control of my life. I have always had strong moral beliefs. 2 How severe was your trauma (Mild, Moderate, Severe)? After the accident I felt: Pain .. Anger .. Sadness (3 separate questions) 3 In dealing with various life situations, I usually focus on finding solutions. I believe that everything will turn out well, even though I do not yet know how. 4 When I first realized that "I had just escaped death". I was sure that I would be disabled for life. 5 Do you feel that the event caused a great loss in your life? I lost my faith in myself and/or others.

Factor Two (“immediate impact of trauma”) assesses the subjective severity of trauma with respect to its endorsement as an overwhelming negative catastrophic experience, and self-perception of pain and other emotional states immediately following their traumatic experience, and accounts for 9% of the total variance. Factor Three (“facing the challenge”) accounts for an additional 6% of the variance and represents an optimistic and positive, action-oriented perspective in addressing challenges. Factor Four (“trauma ideations”) assesses the immediate impression of being a victim of a catastrophe with projection of negative consequences into the future and explains 6% of the variance, while Factor Five (“severity of losses”) assesses patients’ perceptions of the severity of their various material and personal losses from the longer life perspective and accounts for 5.8% of the variance. The remaining factors each account for less than 5% of the item variance and are not readily interpretable, with the exception of Factor Nine (“traumatic amnesia”) that comprises

Complimentary Contributor Copy Assessing Resilience in the Aftermath of Mass Trauma 85 only three questions, but reliably identifies clients with either head injury-related post- traumatic amnesia or functional dissociation resulting in poor memory of the event.

Relation of Factors to Psychopathology Measures

Considering that our primary objective was to document how the RTS-RE factors impact on clinical presentation of the traumatized clients, we chose a number of typically used diagnostic tests that refer to generalized anxiety, depression, pain and symptomatology related to Post Traumatic Stress Disorder. Correlational analyses revealed a number of significant relationships of the RTS-RE with scores on the Beck Depression Inventory-II (Beck, 1987) and Beck Anxiety Inventory (Beck and Steer, 1993) in the sample. The BDI-II was positively related to RTS-RE factors: Factor Two (r = 0.21, p < .05; immediate impact of trauma); Factor Four (r = 0.31, p =.003; immediate “traumatic ideations”); and Factor Five (r = 0.47, p < .001; severity of losses). The BAI was positively related to RTS-RE Factor Two (r = 0.22, p < .05; immediate impact of trauma) and Factor Five (r = 0.45, p < .001; severity of losses). Thus immediacy and severity are critical impacts that warrant our attention, as these impacts have been indicated in other authors’ observations (see Chapters 13 and 14) as being signals that people affected by mass trauma, and who score high on these two factors, may need psychological or psychosocial interventions. There were no significant correlations (but a trend was observed) between RTS-RE factor scales and positive and negative factors derived from the Multi-Dimensional Pain Inventory (Kerns, Turk and Rudy, 1985), a scale assessing pain (p > .06, for all). MPI factor scores were created due to observed multicolinearity in regression using the raw MPI scale scores. The lack of stronger associations between RTS-RE Factor Two and MPI factors was somewhat surprising, given that a majority of patients presented with pain complaints suggesting the presence of factors beyond, or above, those directly related to chronic pain. We present these negative findings for consideration in future research, while keeping in mind that there is a reason to believe that trauma related ideations and perception of losses, which were instrumental in modifying anxiety and depression, could also affect pain perception and ways of dealing with pain. Regarding typical Post-Traumatic Stress Disorder symptomatology, as measured by the Davidson Trauma Scale (Davidson, 1996), the three subscale scores and the overall score significantly correlated with RTS-RE Factor Two (immediate impact of trauma). The total score was significantly related to RTS-RE Factors Two (that refers to severity of trauma and initial emotional response; r = 0.28, p = .005), Four (that reflects immediate catastrophic assessment of the trauma consequences (r = 0.27, p = .006) and Five (that reflects losses; r = 0.40, p < .001). Again, here we note the signals for further intervention are indicated by the factors about immediacy, severity and loss. A number of RTS-RE factors were associated with each of the DTS subcomponents assessing avoidance, hyper-arousal and intrusive thoughts (p < .05 for all), with the strongest correlation being observed between RTS-RE Factor Five (loss) and DTS hyper-arousal (r = 0.47, p < .001). Loss is multiplied in mass disasters and mass trauma generally; the signal here is to alert us to post traumatic symptoms (ASD and possible PTSD) which need monitoring in victims of mass trauma.

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Measures of symptom validity and exaggeration were unrelated to the first four RTS factors. However, RTS-RE Factor Five (representing personal losses) was significantly related (r = -0.23, p < .03) to poorer TOMM performance5 (the higher perception of losses, the poorer the TOMM score), as well as to a composite index of symptom exaggeration derived from a number of symptom validity tests and embedded neuropsychological measures (r = 0.47, p < .001). This is a factor that may be interesting to assess with ‘victims’ of mass disasters who are not adequately recompensed by their insurance companies (See Chapters 14 and 15), or who are treated unequally in terms of grants, government financial support, or general assistance in the community. Taken together, these results indicate that the RTS-RE is a largely transparent instrument that contains unique components assessing specific aspects of resilience related to the way in which people experience (either in a catastrophic, dissociative, or resilient manner), assess, and process the impact of adversity immediately, as well as its more long lasting consequences. These findings indicate a possibility of using the RTS-RE as the cross- reference for other clinical tests that are quite transparent for their content and which address Anxiety (BAI), Depression (BDI-II), and PTSD (DTS) by knowing that the high scores on the latter measures should correlate with how the event was processed. Given that only RTS-RE Factor Five (subjective assessment of losses) is positively related to symptom exaggeration, this fact can add additional confidence to other diagnostically relevant correlations. On the other hand, it may also be an indicator of further traumatisation in the situations of mass disasters as indicated above.

Relation of RTS-RE to Personality Disorder Measures

The question of whether the RTS-RE is related to more enduring personality characteristics was addressed using partial correlation in an extension of the above analyses. (A partial correlation reveals the relationship between two variables, while statistically controlling for the potential influence of one or more additional variables.) Nearly all patients undergoing treatment were also given the Millon Clinical Multiaxial Inventory-III (Millon, 1977). Regression analyses using the MCMI-III scales revealed major colinearity problems (a number of MCMI-III scales were significantly correlated with one another which makes the results of regression analyses uninterpretable). These problems were addressed by reducing data while using PCA with a varimax rotation that produced four MCMI-III factors accounting for 69.7% of the total variance ranging between 13.5% and 22% each. The first MCMI-III factor comprises 22% of the explained variance and represents Axis I severe clinical symptomatology, which in this population likely reflects post-traumatic experience (See Table 2). Factor 2 captures 17.2% of the variance on the MCMI-III in this population and is comprised of scales related to serious personality disorders, antisocial behaviour, addiction, and impulsivity (See Table 3) – symptoms not likely to emerge in victims of mass disasters for many months, unless there is underlying pathology before the onset of the disaster. In a

5 Test of Memory Malingering (Tombaugh, 1996) is a symptom validity measure (the lower score the less probable it is that the client would put this effort into cognitive testing, and the further possibility is of deliberate presentation of being more disabled).

Complimentary Contributor Copy Assessing Resilience in the Aftermath of Mass Trauma 87 mass disaster, should people score high on this factor immediately, urgent intervention is required to explore the pre-existing conditions and the nature of the impact of the disaster/trauma on the person’s psyche.

Table 3. Factor 2 Scales of the MCMI-III for Trauma Victims.

MCMI-III Factor Component Scale Group Abbrev Scale Name 1 2 3 4 0.91 Clinical Personality Pattern 6A Antisocial 0.85 Severe Personality Pathology T Drug Dependence Alcohol 0.74 Severe Personality Pathology B Dependence -0.66 -0.49 Clinical Personality Pattern 7 Compulsive 0.60 0.44 Clinical Personality Pattern 6B Sadistic 0.59 0.44 Severe Personality Pathology N Bipolar: Manic 0.52 0.56 Severe Personality Pathology C Borderline

Factor 3 of the MCMI-III explains 16.8% of the variance and relates to less severe personality patterns reflecting personality disorders that appear to be related to withdrawal and disengagement. Factor 4 subsumes 13.5% of the explained MCMI-III variance and is associated with characteristics of paranoid and delusional disorders, along with a negativistic perspective which are freely disclosed. These latter two factors did not correlate with any RTS-SE factors in this population of patients. Although a number of significant correlations were found between RTS-RE and these MCMI-III factors, partial correlations controlling for demographics, BDI-II and BAI results revealed fewer significant relationships. This was undertaken in an attempt to control for the effects of acute distress and sharpen our focus on more enduring personality characteristics. Here we will concentrate only on the significant relationships observed between the factors of the RTS-RE and the MCMI-III that persisted, after controlling for the effects of distress (BDI–II and BAI) and demographic variables. The RTS-RE Factor One was mildly positively correlated with MCMI Factor 1 (r = .24, p = .025) and negatively correlated with MCMI-III Factor 2 (r = -.34, p = .001). These relationships deserve further consideration for their clinical significance. The first RTS-RE factor represents a positive pre-traumatic self image of a confident, capable and well-functioning individual with strong “moral”, “personal” and “social” beliefs. The validity of this self-appraisal is inherently open to question, given that such positive pre- morbid pictures are presented by both “genuine”, but also by exaggerating patients who were well represented in the subset (which subset was composed of compensation-seeking victims of accidents) of this larger sample and who failed one or more measures of symptom validity (for review of these important issues, see Larrabee, 2005). Nevertheless, in spite of samples being potentially prone to produce exaggerated responses, in our sample, the first four RTS- RE factors did not correlate with symptom validity measures and, in fact, the first RTS-SE factor was negatively related to a sensitive measure of symptom exaggeration. The first MCMI-III factor represents scales for major depression (CC), anxiety (A), dysthymia (D), PTSD (R) and somatoform (H) and thought disorders (SS). When the average TOMM score was introduced in the PCA, it evidenced significant negative loadings only on the first RTS-

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RE factor (r = -0.57) (pre-traumatic self cohesiveness), indicating that exaggeration did not affect these scores. This is interesting as it indicates that pre-trauma, the person was not only cohesive but also intact, and now strongly believes that the traumatic incident is responsible for their pain and trauma (most likely totally accurate, outside of some lawsuit cases). This is borne out in the examples of the statements given below. The RTS-RE Factor One items, with the highest factor loadings on individual variables (correlations in the 0.85 – 0.81 range), pertain to clients’ responses on the following statements (in descending order): “Before the event, I was in control of my life; Before the event, I was a well-integrated and emotionally stable individual; I was always prepared to face something unexpected”. Correlations with the RTS-RE Factor One between 0.79 and 0.71 were obtained on the following statements: “I had confidence in my ability to cope even with the most difficult situations”; “I believed that my life is meaningful and that I had a worthy purpose in life”; “I overcame successfully many misfortunes”; “I had a stable family life as a child”. Correlations between 0.67 and 0.62 refer to the following questions: “I had friends to rely on”; “I had always had strong moral beliefs, social beliefs, and personal beliefs” (the latter correlation is above 0.51). The first MCMI-III factor was also positively correlated with RTS-RE Factor Four that refers to immediate traumatic ideations (r = 0.21, p< .05). The positive association of MCMI- III scales that represent DSM-IV, Axis 1 psychopathology (which may reflect trauma incident-related sequelae) with the potentially catastrophic self-evaluation of the trauma is consistent with an understanding that higher trauma severity results in more serious psychopathology (which makes absolute sense following mass disasters). Furthermore, positive pre-traumatic self-appraisal (as reflected in RTS-RE Factor One) creates a drastic contrast to the psychopathological manifestations reflected in MCMI-III Factor 1 that may result in a client’s evaluation of experienced psychopathology as more severe. The fourth RTS-RE factor has the highest loadings with correlations in the 0.75-0.72 range, regarding the following questions and statements: “When you first realized what had happened to you, did you have any of the following thoughts? – ‘I just escaped death; and I was sure I would be disabled for life’”. Correlations on the level of 0.50 or above refer to questions such as: “Even though I was alive, I felt that my life might be ‘finished’”; “I knew that I lost everything that I worked for”. Correlations in the 0.41-0.44 range represent answers to the statements: “I knew that my community had been destroyed”; “After the accident, I felt a sense of unreality, it must be a nightmare”. These statements are often made by people who have survived mass disasters and mass murder incidents. Reviewing these correlations, it is evident that there is a great contrast between how people perceived themselves pre-traumatically and how the uncontrollable event compelled them to perceive themselves and to respond at the time of the accident. These contrasts, in essence, represent the confirmation of the discrepancy construct that is the core concept behind the model of trauma presented in Celinski and Gow’s (2005) paper. Such discrepancies become highly pronounced when whole communities face major losses as pointed out in Chapters 13, 14 and 15. The second MCMI-III factor reflects far more serious psychopathology, with strong positive loadings on scales assessing Antisocial (6A) personality characteristics and addictions and a negative correlation with the compulsive personality scale. Thus, having a good image of oneself (as reflected in RTS-RE Factor One) is incompatible with pre-existing characterological disorders represented in MCMI-III Factor 2 as reflected in the observed

Complimentary Contributor Copy Assessing Resilience in the Aftermath of Mass Trauma 89 negative correlation. A negative relationship with far more serious pre-existing psychopathology suggests that pre-existing personality characteristics have little explanatory value with respect to the presence of severe post-traumatic psychopathology of the Axis I type (in a manner analogous to how excessively positive pre-traumatic view of the self, reflected in RTS-RE Factor One may potentiate Axis I type symptomatology). Gow (2012) points out that individuals suffering from disintegration of the personality, in the acute phase of trauma, exhibit certain signs of psychopathology. This is worthy of clinical consideration, as these cross comparisons between RTS-RE and MCMI-III suggest the importance of addressing RTS-RE-based self-image apart from serious personality disorders, and enhance clinician confidence in the importance of self-ratings of trauma severity, people’s emotional experiences, and immediate and delayed cognitive processing as being primary factors related to post-traumatic manifestations.

DISCUSSION

In this chapter, we presented the Resilience to Trauma Scale (Research Edition) as a clinically useful measure of traumatic experiences both with respect to psychopathology and the mitigating aspect of resilience. To summarise, the RTS-RE yields five major factors with average alpha reliability of 0.77. Factor One (called “pre-traumatic cohesiveness”) accounts for 13% of overall variance, and its heuristically derived subscales have an excellent alpha reliability of .91 and .93 respectively. The first subscale of Factor One assesses a client’s pre- traumatic perspective on self-efficacy and the second has reference to personal, moral, social and religious beliefs. Factor Two assesses the immediate emotional and cognitive impact following a traumatic event, while Factor Three reflects the effective and optimistic engagement (coping) with the post-traumatic adjustment. Factor Four represents a catastrophic assessment of consequences immediately after the incident, while Factor Five represents the subjective severity of various losses. Factors Two, Four and Five evidence mild, yet significant, positive correlations with measures of psychological distress (i.e., BDI- II, BAI and DTS scores), whereas factors related to more serious and enduring psychopathology derived from MCMI-III have both positive and negative correlations: MCMI-III Factor 1 reflects typical symptomatology of the DSM IV Axis I type which refers to the current condition that requires medical treatment; the conditions on Axis I may be the result of psychotrauma, changes in the psychosocial environment, or one’s physical or medical condition. These are contrasted with Axis II clinical manifestations which refer to more persistent and serious characterological disorders and addictions. It is understandable that there is a positive correlation of MCMI-III Factor 1 with RTS-RE Factor One which represents pre- traumatic self-image and Factor Four which reflects an initial evaluation of trauma as catastrophic. On the other hand, the same positive pre-traumatic self-image (Factor One of RTS-RE) is incompatible with the serious personality disorders and addictions which are reflected in the negative correlation with Factor 2 of MCMI-III. However again Gow (2012) and others would remind us about what happens psychologically to normal individuals in times of severe trauma, and in some cases serious illnesses and accidents with accompanying brain injury.

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CONCLUSION

The conclusion from this study primarily refers to providing support to the conceptualization of resilience as a personality trait (that is observed and measured in relation to trauma or adversity) enabling the self to withstand the experience of trauma and to deal with its consequences. Resilience is a complex phenomena; whereas in some individuals generalized distress would lead to a breakdown of defences and result in a person being overwhelmed and unable to react, the reverse is also true that by acting in a resilient way, a person expresses autonomy of the self and utilizes a broader perspective on one’s own condition and reality, thus moderating or limiting unfavourable reactions within themselves, although they may have no control over what traumas – individual or mass - that life presents them with. In the chapter on predicting therapy outcome following psychotrauma and physical injury (Celinski and Allen, 2012), we also presented evidence that resilience is instrumental in facilitating recovery from trauma, although here we note that when mass disasters impact severely on people’s lives, normal resilience may falter and recovery may take a different path. The RTS-RE factors, that have significant relationships with other measures of psychopathology, could serve as means of cross-validation for the latter and provide guidelines for processing and reframing traumatic experiences in a less catastrophizing way. The reason we have presented this scale in this book on mass trauma is to offer its value in assessing resilience in individuals and communities following mass traumas. There are approximately 10 items in the RTS-RE scale which can be modified minimally to include the type and characteristics of different mass traumas (thus making the whole scale pertinent in such situations), as the scale items measure the person’s subjective experience of the traumatic event. We invite readers to utilise our scale as a measure of resilience in certain mass disaster and trauma situations as part of future research projects, and encourage practitioners to become familiar with its content and factors, and where appropriate to utilise it with patients to improve the outcomes of therapy with those patients affected by individual and mass traumas.

REFERENCES

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Lock, J. and Kremen, A.M. (1996). IQ and Ego-Resiliency: Conceptual and empirical connections and separateness. Journal of Personality and Social Psychology, 70, 349- 361. Celinski, M. J. and Gow, K.M. (2005). Trauma clients: How understanding disintegration can help to reveal resourcefulness of the self. Australian Journal of Clinical and Experimental Hypnosis, 33, 195-217. Celinski, M.J. (2011). Framing resilience as transcendence and resourcefulness as transformation. In M. J. Celinski and K. Gow (Eds.), Continuity Verses Creative Response to Challenge: The Primacy of Resilience and Resourcefulness in Life and Therapy (pp. 11-30). New York: Nova Science Publishers. Celinski, M.J. and Allen-III, L. (2012). Resilience and resourcefulness in predicting recovery outcomes. In K. Gow and M. J. Celinski (Eds.), Individual Trauma: Recovering from Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. Celinski, M.J. and Allen-III, L. (2007). Resilience and resourcefulness as moderators of psychopathology in post-traumatic conditions. 21st Annual Conference of the European Health Psychology Society. August 15-18. Maastricht, the Netherlands. Celinski, M.J. and Allen-III, L. and Pilowsky, J. (2007). Resilience helps predict outcome in psychotherapy following trauma. 21st Annual Conference of the European Health Psychology Society. August 15-18. Maastricht, the Netherlands. Celinski, M. J., Salmon, D. and Allen-III, L. (2007). Resilience to Trauma Scale (Research Edition). Cognisyst, Durham, N.C. www.cognisyst.com Connor, K.M. and Davidson, J.R.T. (2003). Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC). Depression and Anxiety, 18, 76-82. Davidson, J.R.T. (1996). Davidson Trauma Scale. North Tonawanda, N.Y., Toronto, ON: Multi-Health Systems Inc. Dishon, T.J. and Connell, A. (2006). Adolescents’ resilience as a self-regulatory process. Promising themes for linking intervention with developmental science. Annals of New York Academy of Science, 1094, 125-138. Earvolino-Ramirez, M. (2007). Resilience: A concept analysis. Nursing Forum, 42, 73-82. Everstine, D.S. and Everstine, L. (1993). The Trauma Response: Treatment for Emotional Injury. New York: W.W. Norton and Co. Frankel, V.E. (1966). Man’s Search for Meaning. An Introduction to Logotherapy. New York, New York: Washington Square Press. Gow, K. (In press). Overview: Conceptualising Trauma as a Deep Wound while Continuing to Live One’s Life. In K. Gow and M. Celinski (Eds.), Individual Trauma: Recovering from Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. Groos, A. (2012). Trauma, Grief and Guilt in Suicide Bereavement. In K. Gow and M. Celinski (Eds.), Individual Trauma: Recovering from Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. Kerns, R.D., Turk, D.C. and Rudy, T.D. (1985). The West-Haven Yale Multidimensional Pain Inventory (WHYMPI). Pain, 23, 345-356. Larrabee, G. J. (2005). Assessment of Malingering. Forensic Neuropsychology: A Scientific Approach (pp. 115-158). New York: Oxford University Press.

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Lees-Hayley, P.R., English, L.T. and Glenn, W.J. (1991). A fake bad profile on MMPI-II for personal injury claimants. Psychological Reports, 68, 203-210. Luthar, S., Cichetti, D. and Becker, B. (2000). The Construct of Resilience. A Critical Evaluation and Guidelines for Future Work. Child Development, 71, 543-562. Manyena, S., O'Brien, G., O'Keefe, P. and Rose, J. (2011). Disaster resilience: A bounce back or bounce forward ability? Local Environment, 16, 417-424. Millon, T. (1977). Millon Clinical Multiaxial Inventory-III Manual (2nd ed.). Minneapolis, MN.: National Computer Systems. Prochaska, J. O. (1991). Assessing how people change. Cancer, 67, 805-807. Richardson, G.E. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58, 307-321. Richardson, G. E., Neiger, B., Jensen, S. and Kumpfer, K. (1990). The resiliency model. Health Education, 21, 33-39. Tombaugh, T. (1996). Test of memory malingering. North Tonawand: Toronto, Ontario: Multi-Health Systems Inc.

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PART 2

EFFECTS OF MAN MADE TRAUMA: WAR, GENOCIDE, MURDER AND TERRORISM

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 6

EFFECTS OF MASS HOMICIDE ON COMMUNITIES

Sandy Sacre* Queensland University of Technology, Australia Belmont Private Hospital, Australia

ABSTRACT

When the horror of a mass homicide is visited upon a community, the population must deal with a wide range of reactions. Fear, anger and helplessness are common responses. The community frequently also has to come to terms with how members of their own population could perpetrate such a crime and how similar circumstances could be better predicted and prevented in the future. Some communities struggle with the tragic loss of young people and their potential, such as in the case of school and university shootings. As the names of certain towns become synonymous with mass homicide and trauma, whole societies wrestle with maintaining their identity and resisting the tendency for the tragedy to define them. Sometimes the mass homicide acts as a catalyst for public, cultural, or legislative change in the immediate or wider community. Examples of such changes were the radical reform of Australia’s gun laws following the Port Arthur massacre of 19961 and the wide reform of the Virginia mental health system after the Virginia Tech tragedy of 20072. This chapter will describe some of the different types of effects that mass homicide has had on communities and some of the changes that have been triggered by incidents of mass homicide such as changes to security policy and firearms laws. It will also explore the variety of different ways that communities have responded, coped, supported one another and worked together in the aftermath of mass homicide.

Keywords: Mass Homicide; Resilience; Mass Shooting; Shared Grief; Communities

* Contact: [email protected] 1 http://en.wikipedia.org/wiki/Port_Arthur_massacre 2 http://en.wikipedia.org/wiki/Virginia_Tech_massacre

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INTRODUCTION

It is difficult to imagine a more horrifying trauma that could happen to a community than the sudden and unexpected mass murder of a large group of people committed by a member of that community. When the perpetrator comes from outside the community, there are different, but no less difficult, issues to deal with. Regardless of whether the offender is an insider or an outsider, such an event invariably forces a community to look carefully at itself and to ask questions. Could this have been prevented? Should we have seen the warning signs? Why did the offender feel this level of alienation? The most important question is: How can we reduce the likelihood of such an event occurring again? In the wake of these terrible events, it is important that communities regain a sense of control in order to feel that life can become somewhat predictable again. In an effort to take control and prevent future calamities, communities frequently make changes and reforms. It is difficult to know how effective these changes are in actually preventing similar occurrences, but they are needed nonetheless, to assist communities to rebuild and re-group in the face of dreadful loss and tragedy. Mass homicide has been referred to as spree killing or rampage killing3, but it has not proven useful to try to distinguish mass homicide from spree or rampage killing, with the latter terms falling out of favour in recent years (Knox, 2004; Morton and Hilts, 2010). The Federal Bureau of Investigation defines a mass murder as two or more homicides committed by an offender or offenders without a “cooling off period” such as that which occurs between murders committed by a serial killer (Morton and Hilts, 2010). Leyton (1999) has referred to mass homicide as the killing of three or more persons all at once, while Levin and Fox (1996) suggest that mass murders are homicides involving four or more victims. The homicidal assault can occur across more than one location and usually little or no time elapses between the assaults. For the purposes of this chapter, wartime mass murder, terrorist acts, and racial, tribal or religious genocides will not be included in the definition of mass homicide, as they most often have different origins and effects. However, as it will be shown, it can sometimes be difficult to distinguish them from one another.

Types of Mass Homicide

Mass homicide can be further sub-categorised into school massacres, workplace killings, familicides and crimes that occur in the context of political, religious or hate agendas. Kelleher (1997) has created a typology of seven categories of mass homicide, based on motivation: perverted love (usually a familicide/suicide); politics and hate (usually to make a 4 political point, such as with the recent Utøya, Norway shootings); revenge (usually to exact retaliation for some perceived injustice, such as in workplace murders or campus killings); sexual homicide (where sexual gratification and sadism is the motive, such as in the case of Richard Speck5); execution (where greed and personal gain are the motives, such as execution of witnesses for payment); psychotic (where mental illness plays a role, such as is suspected

3 http://en.wikipedia.org/wiki/List_of_rampage_killers 4 http://en.wikipedia.org/wiki/2011_Norway_attacks 5 http://en.wikipedia.org/wiki/Richard_Speck

Complimentary Contributor Copy Effects of Mass Homicide on Communities 97 in the case of Martin Bryant6); and unexplained (where no explanation exists as is sometimes the case, especially when the offender commits suicide and leaves no clues as to his or her motive). Some cases defy categorisation. For example, Timothy McVeigh7 tends to be categorised as a terrorist rather than a mass murderer, even though his crime fits both typologies. Similarly, Mark Barton8, who for five years was considered the prime suspect in the deaths of his first wife and mother-in-law, in 1999, killed his two children and second wife before setting off to kill 12 people in the Atlanta business district. His crimes fit the profile of serial killing, workplace shooting and familicide. Leyton (1999) has argued that the classification of mass homicide must not rely on numbers of victims alone, but also relate to killings that take place all at once for personal or political rather than sexual motives. Most commonly, the perpetrator acts alone. When more than one individual is involved, mass murderers usually attack in pairs with one of the pair often being slightly older, more aggrieved and more in charge. Often there is significant preparation and ceremony involved, with costumes being worn that are associated with heroism or the military, as if they are waging a private war. Breivik photographed himself in a range of grandiose costumes prior to his rampage. Klebold9, Harris, Golden10 and Johnson all wore army fatigues. One of the most deadly, and perhaps also most illustrative, cases involved the death of 69 people in Oslo and the island of Utøya, Norway in 2011. Anders Behring Breivik detonated a car bomb outside government buildings in Oslo, killing eight people, before making his way to the summer camp of the Norwegian Labour Party youth movement and shooting 69 young people dead and wounding around 200. Breivik’s motivation for the crimes seems to have been rooted in his right wing, extremist ideology that focused on nationalism, white supremacy and xenophobia. In this way, his motivations were similar to those of Timothy McVeigh, who committed the Oklahoma City bombing in 1995, killing 167 people and injuring over 684, making it the deadliest act of terrorism ever perpetrated on US soil by a US citizen. They were also not unlike the motivations of Theodore Kaczynski11, the Unabomber, who killed three people and injured 24 by letter bomb between 1978 and 1995 to bring attention to his concerns about modern technology encroaching on human freedoms and wilderness areas. In all three cases, the perpetrators argued that their actions had been an extreme, but necessary, means to bring attention to their causes. While their extreme views may lead some people to believe that these killers were insane, the evidence shows that they were all sane and highly intelligent individuals who developed extreme worldviews and acted upon these views in ways that would have been difficult to predict. In the absence of an insanity explanation, the communities must come to understand how existing legal, cultural, social and civil circumstances can facilitate the development of such worldviews within their midst. They must then grapple with what can be done to reduce the likelihood that extreme worldviews and alienation can flourish and be acted upon again.

6 http://en.wikipedia.org/wiki/Martin_Bryant 7 http://en.wikipedia.org/wiki/Timothy_McVeigh 8 http://en.wikipedia.org/wiki/Mark_O._Barton 9 http://en.wikipedia.org/wiki/Eric_Harris_and_Dylan_Klebold 10 http://en.wikipedia.org/wiki/Andrew_Golden 11 http://en.wikipedia.org/wiki/Ted_Kaczynski

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Motivations and Consequences

Most typically, the mass murderer feels betrayed, disappointed, or alienated by a group of people or a perceived type of person and then seeks to exact revenge on those people or a representative group (Fox and Levin, 1994). These people may be neighbours, family members, fellow students, co-workers, former work colleagues, or just people in general. Mass homicide tends to be seen mainly as being caused by social disappointment or disconnection, frustrated ambition, or threatened emotional or financial security (Knox, 2004). While nearly 40% of these crimes are committed against family members (Levin and Fox, 1996), mass homicides, involving large numbers of casualties, are usually perpetrated against people with whom the offender is only slightly acquainted or unknown. The purpose of the violence is to teach a community, or part of a community, a lesson and is aimed not only at the direct victims, but also at the authorities and others who will watch the media reports. In these cases, the seeming randomness of the killing along with the proximity of the killer or killers makes the event all the more terrifying and traumatic for the community. Because the motivation is often social disconnection and grievance, the community naturally tends to examine itself to try to understand how anyone could become so disenfranchised with them as to slaughter a large group of innocent victims. The motivations can also be mixed and complex as in the case of the more recent (17th December, 2011) mass homicide in Liege, Belgium, where 33 year old parolee, Nordine Amrani, opened fire on a crowded market square and bus station after murdering a cleaning woman in his apartment.12 Already facing a summons relating to an accusation of sexual assault, it is alleged that he tried to rape the cleaner before shooting her and then took grenades, a semi-automatic assault rifle and revolver to the city square. He inflicted fatal gunshot wounds on an elderly woman, two teenagers and a baby and wounded over 120 others, before turning the revolver on himself. Orphaned at a young age, Amrani grew up in foster homes and felt alienated by the court system. He had a grudge against the law and feared going back to prison. Although his ethnic background was Moroccan, he did not speak Arabic and was not a Muslim. Thus, he did not quite belong to the Belgian or Moroccan community. It could be considered that Amrani’s estrangement from justice, family, community and society made him a ticking time bomb. His propensities for collecting illegal firearms, drug offending and sexual assault placed him constantly in conflict with a society and justice system he felt were against him. He was both a serial rapist and a mass murderer, but on that fateful day in December, the two infamous roles became intertwined. Engaged to a nurse, he also faced the threat of losing perhaps the only close relationship he had ever experienced, as a result of her finding out about the sexual assault allegations. Consequences seem to carry little or no weight once a mass murderer decides to carry out the crime. Either they plan to suicide, die at the hands of the police, or give themselves up. Sometimes when they give themselves up, the explanation they plan to give for their crime also forms part of the message the homicides were designed to convey, as in Breivik’s case. Even in countries where perpetrators know they will be punished by death, such crimes are

12 http://www.bloomberg.com/news/2011-12-14/belgium-s-worst-peace-time-massacre-leaves -4-dead-122-wounded.html

Complimentary Contributor Copy Effects of Mass Homicide on Communities 99 not deterred. For example, Hu Wenhai and Liu Haiwang murdered 14 people in Shanxi Province in northern China in 200113 knowing they would be executed for these crimes (People’s Daily Online, 2002). Some, like Breivik or Kaczynski see themselves as heroes with foresight that others lack and believe they are acting to counteract threats to ways of life or culture. Such convictions are difficult to understand and are therefore difficult for communities to prevent or even detect.

EFFECTS IN THE IMMEDIATE AFTERMATH

In the immediate aftermath of a mass homicide, the first thing that must be done is to take care of the injured and uninjured survivors of the tragedy. It is extremely important that traumatised survivors and witnesses be removed to a place of safety. Even when the threat has been eliminated, it is common for survivors to continue to feel threatened or to be disbelieving of their safety. The suddenness and devastating impact of mass homicide often overwhelms survivors, families of victims and the wider community to the extent that they are incapable of functioning at a level that would allow a normal grieving process (Fulton and Gottesman, 1980). Turner (1982) has argued that mourners occupy a period of ambiguity during the immediate aftermath of traumatic death that is like a kind of limbo. It is a confused stage marked by numbness and unreality and has been called a liminal or threshold state (van Gennep, 1960). This can be compounded by all of the legal issues that must be resolved following the event, such as police investigations, criminal proceedings and other lawsuits and inquiries (Fast, 2003). Other common issues that complicate the mourning process are a sense of unreality and helplessness, survivor guilt, blame and anger (Fast, 2003).

Challenges to the ‘Just-World Hypothesis’

The ‘Just-World Hypothesis’ is a term that refers to the tendency and desire for people to believe that the world is just and fair and to look for rational explanations for terrible and unjust things happening to others (Lerner, 1980). The ‘just-world hypothesis’ is otherwise known as ‘blaming the victim’ or the ‘just-world fallacy’. Often, a type of rationalization is that victims somehow deserved to be attacked or that the victims are very different from themselves. For example, Canadians or New Zealanders might convince themselves that mass homicide is mainly an American phenomenon. People in a particular U.S. state or town might believe that a mass homicide in another state is somehow linked to the kind of people who live in that state. It is thought that people tend to believe in a just world in order to help themselves to feel safe or less vulnerable in some way than those who are targeted. By convincing themselves that such a thing as mass homicide is unlikely to ever involve them, they are able to carry on their lives as usual in the belief that they can avoid such situations. For example, after the Columbine High School massacre,14 there were many people who sympathized in online for a

13 http://english.peopledaily.com.cn/200201/26/eng20020126_89363.shtml 14 http://en.wikipedia.org/wiki/Columbine_High_School_massacre

Complimentary Contributor Copy 100 Sandy Sacre with Klebold and Harris and saw them as victims of bullying, and believed that they targeted those who had bullied them. While people at a distance from the killings can tend to cling to the ‘just-world hypothesis’, mass homicides cause the local communities to seriously challenge the fallacy, but it can be a source of anger when they sense that people in the wider community or the media revert to this theory in sometimes subtle ways. Community members may feel blamed in some way for the homicides as they are perceived as somehow inviting such a tragedy through, for example, their choice of school, workplace or town. The randomness of some mass homicides can be very unsettling for communities. Victims and their families struggle to understand why some were spared and others not. Sometimes there is only a loose thread of connection between the killer and the victims. For example, Thomas Hamilton, who was upset at losing his voluntary scoutmaster position in Dunblane, Scotland, shot and killed 17 children at Dunblane Primary School twenty years later in 1996.15

Who’s to Blame?

When the perpetrator of mass homicides is from an out-group, it is not unusual for the community to blame the crime on the cultural background of the killer, casting others from the same background in a negative light. Such was the case when Cho Seung-Hui, the South Korean-born gunman, killed 33 people on the campus of Virginia Polytechnic Institute and State University (Virginia Tech) in 2007. All over the US, Koreans faced stereotyping, hateful online comments and fear of reprisals. Although Cho had come to the US with his parents at the age of eight, his ethnicity became central to the narrative of the crime (Steinhauer, 2007). When the perpetrators are children - as in the Westside Middle School massacre, when 13 year old Mitchell Johnson and 11 year old Andrew Golden shot 15 young pupils and teachers, and as in the Columbine High School shootings, where 17 year old Dylan Klebold and 18 year old Erin Harris opened fire on 37 students and teachers – the community searches for answers from their parents. Questions are asked about the developmental environment of the perpetrators: Were they abused by their parents? Were they influenced by violent video games? Were they bullied at school? Sometimes the media is blamed, especially when perpetrators verbalise links to particular movies, games, or media coverage of similar crimes.

The Effects of Media Coverage

Media coverage can be re-traumatising to victims and communities. In the first hours after a mass homicide, media reports may be inaccurate causing unnecessary grief to loved ones. Most disturbingly, media coverage can result in imitative violence or threats of violence. For example, a Pennsylvania study found that a rash of bomb threats and threats of school violence occurred after the Columbine massacre (Kostinsky, Bixler and Kettl, 2001).

15 http://en.wikipedia.org/wiki/Dunblane_massacre

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Unbelievably, a role-playing video game called Super Columbine Massacre RPG was even developed and released in 2005 where players could assume the roles of the gunmen. After massive media coverage in 2006, the previously little-noticed game experienced thousands of downloads (Mosley, 2006). The fact that some of the victims are portrayed as enemies who are named by stereotypes such as “preppy girl”16 and “jock type”17 (Kuchera, 2007) seems to validate them as justifiable targets. Indeed, soon after 25 year old Kimveer Gill, of Laval near Montreal, opened fire on students at Dawson College in Montreal in September 2006, it was discovered that he had stated on a blog that he liked to play a role- playing Internet game about the Columbine shootings (Associated Press, 2006a). There is also evidence that media coverage of mass homicides such as that at Columbine influences others to feel helpless and unsafe (Brener et al., 2002). The Brener et al. (2002) study examined the impact of the Columbine massacre on reports of behavior related to violence and suicide among high school students across the U.S. in the year of the incident compared to the previous year. They did not find any significant change in self-reported violent behavior or intentions, but they did find a 30% increase in students feeling too unsafe to go to school. Interestingly, they also found a significant decrease in students who considered or planned suicide following the Columbine massacre, where media reports of suicide more commonly increase the likelihood of imitation. It was believed by those authors that this might have been a result of media coverage that highlighted the grief experienced by victims’ families. This was in contrast to typical media coverage of the positive aspects of suicide victims’ lives that is thought to influence susceptible young people to imagine that their lives would be similarly honored if they were to commit suicide. Another disturbing phenomenon that often results from the infamy, brought about by media coverage of the mass murderer and his or her crime, is the attention that is focused on the killer. Fans, journalists and others seek relationships of one kind or another with the killer for a range of reasons usually involving some kind of fascination with infamy (Knox, 2004).

SEEKING ORDER AND MEANING

Most often in the confusion and chaos following mass homicide and the associated tragic loss of life, survivors and mourners seek to somehow make order and create meaning. This is often done through rituals. These rituals may take different forms at different points in time. We tend to fall back on known and established rituals when we cannot make immediate sense of what is happening around us, are in a state of numbness, or are surrounded by chaos. Rituals allow us to undertake formulaic patterns of symbolic action when we are unable to control a disordered situation (Turner, 1977). Unlike deaths that are usually more private and contained within hospitals, hospices and homes, the deaths of mass homicide victims take place in the public sphere and the entire community is witness to the grief of those close to those killed. Thus, a sense of wider, even national, community is formed and unrelated individuals become involved in the grief response (Jorgensen-Earp and Lanzilotti, 1998).

16 The term preppy derives from the expensive pre-college preparatory or prep schools that upper middle-class children on the United States Northeastern states sometimes attend (http://en.wikipedia.org/wiki/Preppy). 17 The term jock, when used primarily in the United States, refers to the classic stereotype of a male athlete. In sociology, the jock is thought to be included within the socialite subculture, which also contains the preppies and Ivy-Leaguers. (http://en.wikipedia.org/wiki/Jock).

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As a community, there is a wider sense initially of danger and threat, and individuals seek security in the community group. Frequently, they come together at night to participate in candle-lit vigils, to provide both comfort and solidarity to one another. Such vigils, as well as the shrines at the sites of the tragedies, help the scene of the event to take on a kind of holiness or sacredness. In a ritual sense, they serve as a form of secular pilgrimage, where offerings and relics, that have meaning in relation to the dead, can be brought (Erhenhaus, 1988). Coming to the site of the tragedy is thought to be important to mourners also because it is the closest thing to being at the deathbed of a loved one in their hour of death, even though it is after the fact (Jorgensen-Earp and Lanzilotti, 1998). After the Oklahoma City bombing, it was reported in the Washington post 18 that many mourners “found solace at the bomb site for reasons they cannot fully explain” (Romano, 1997). One widow of a victim there said that: “Going just makes it real” (Romano, 1997). By bringing flowers and messages to the site, people can somehow gain control over the scene of the tragedy by adding to the story of it (Blair, Jeppeson and Pucci, 1991).

Memorializing and Shrine-Building

Memorializing is a common way for groups and communities to express their grief and solidarity. Sometimes large numbers of people will journey to the site of a mass homicide to participate in what has been called a “community of bereavement” (Linenthal, 1998). Shrines may appear in the form of walls to which people attach flowers, notes, poems and pictures. Sometimes the shrines bear some symbolic relationship to the victims. For example, the cars of some Columbine victims, having been found abandoned near the school, became shrines to those victims and seemed to provide a form of comfort to fellow students (Dube, 1999, cited in Fast, 2003). After the Oklahoma City bombing19, a spontaneous shrine of teddy bears, flowers and other objects began to appear even before all of the bodies were recovered from the rubble (Irving, 1995). A tall fence was built around the site and hundreds of visitors attached messages and mementos to the fence for many years afterwards until the official memorial to the victims was built (Jorgensen-Earp and Lanzilotti, 1998). A similar shrine developed outside the school at Dunblane, Scotland, where Thomas Hamilton killed 16 children and a teacher in 1996. Flowers, toys and messages were left on the footpath or tied to the school fence. Bouquets were even left there by Queen Elizabeth and Princess Anne, and the shrine was also visited by the Prime Minister and Opposition Leader (Jorgensen-Earp and Lanzilotti, 1998). It has been argued that these active expressions of grief help to serve part of a public healing process by allowing individuals to seek individual and collective solace and to communicate sorrow for the deaths (Bodnar, 1992). Flowers are often left at both temporary and permanent shrines to the victims and this likely dates back to an ancient ritual where flowers symbolised innocence and purity, with cut flowers representing lives cut short (Jorgensen-Earp and Lanzilotti, 1998). The leaving of

18 http://www.highbeam.com/doc/1P2-738784.html 19 http://en.wikipedia.org/wiki/Oklahoma_City_bombing

Complimentary Contributor Copy Effects of Mass Homicide on Communities 103 objects such as toys, food or other usable things at the shrines reflects a need to view the dead as not permanently deceased (Douglas, 1975). Browne (1995) suggests that the construction of a public monument to those who have died allows the community to fashion a shared sense of what has happened out of the symbolic resources of that community. Indeed, these collective expressions of grief and commemoration do seem to be an important focus for communities and they serve as a location for anniversary ceremonies and for community members to communicate comfort to those who have lost loved ones. Often they begin as a spontaneous shrine and later serve as the location for a formalised monument. The personal nature of objects left at these shrines serves to remind visitors of the human pain and sorrow of the mass homicide (Bodnar, 1992). Another way of memorializing the victims of mass homicide that has developed is the making of commemorative mourning quilts, sometimes with many sections being made by many different individuals. The design and sewing of such quilts allows an active expression of grief in something practical that can be passed on to others or displayed for the community (Smart, 1993-94). Web-Based Shrines. In recent decades, websites have also served as memorial shrines to victims, with websites dedicated to individuals linked to the websites of other victims of the same mass homicide via a “web-ring” (Fast, 2003). Such web-rings operate with each site having a common navigation bar and containing links to the previous and next site, as well as a moderator who decides which pages and sites are permitted to be part of the ring. As Eastgate Systems (2005) have pointed out, the fragility of the web would seem to be an unlikely place for shrines to the dead, and yet “somehow seems wholly appropriate: shrines bear witness both to the virtues of the departed and to the continuing devotion and memory of those who tend the site”. One memorial website of the Columbine High School massacre, named HOPE (Healing of People Everywhere; http://www.hopecolumbine.org/) was formed by the families and friends of students and teachers who died or were injured in the 1999 tragedy. This website provided, and continues to provide, a forum for the victims, their families and other people who wish to assist the community toward healing and they were able to use this forum to secure funding for a very significant rebuilding of the school. It is doubtful that so much could have been achieved without this web presence.

RE-BUILDING, IMPROVING SUPPORT, AND BEING FOREARMED

In many cases, the families and communities of mass homicide victims have worked together to ensure their loved one did not “die in vain”, by re-building in some way or lobbying for a related cause such as firearm reform or improved mental health care. For example, a group of Columbine parents raised over $3.1 billion to remove the existing Columbine High School library floor, convert the space into an open atrium overlooking the Rocky Mountains, and build a new library for the school (Bernall, 1999). Improved Crisis Support. A comprehensive survey of Colorado school counsellors and other key school personnel, that was conducted two years after the Columbine High School tragedy, found that there had been a large increase (over 20%) in the number of schools that had a crisis plan (Crepeau-Hobson, Filaccio and Gottfried, 2005). There was also a 9.2%

Complimentary Contributor Copy 104 Sandy Sacre increase in the number of schools that had a crisis team in place, particularly for larger urban and suburban schools. Improved Mental Health Services and Support. Most mass homicides are precipitated by some sort of social crisis affecting the perpetrator, such as job loss, relationship loss, or the prospect of either type of loss (Fox and Levin, 1994). In the cases of school mass homicides, the perpetrators have sometimes been bullied or felt harassed or excluded in some way. The Colorado school study (Crepeau-Hobson et al., 2005) found that two years after Columbine, there had been a significant increase in availability of mental health services, violence prevention programs, and bullying programs. This study also found that around three quarters of the schools have procedures in place for identifying and intervening with students who were considered at risk. Program evaluation studies have found that the school-based mental health services, that are provided in most high schools, are less effective than more structured family therapy and social skills training in preventing and reducing violent behaviour in youths (Mendel, 2000; Tolan and Guerra, 1994; U.S. Department of Health and Human Services, 2001). Firearms Legislation Reform. The weapons of choice for mass killers are clearly firearms, for their efficient lethality and also their facility to distance the attacker psychologically from the victims (Fox and Levin, 1994). This is particularly the case with semi-automatic firearms. Attempts to introduce tighter gun laws in Australia were thwarted by the powerful and influential gun lobby, but this all changed after the Port Arthur massacre of April, 1996 (Peters and Watson, 1996). With public opinion clearly in favour of restrictive gun laws, all of the state and territory laws governing gun ownership were changed within a matter of months. There was vocal and intimidating opposition from the gun lobby, but the then Prime Minister, John Howard, threatened to take it to a public referendum, and all of the states ‘fell into line’ (Peters and Watson, 1996). The new legislation essentially banned semiautomatic weapons, so that apart from military and police personnel and some other professionals, semi-automatic rifles and pump-action shotguns were outlawed (handguns were already illegal) (Coulehan, 2000). In the first year following the introduction of the new legislation, there was a tax-funded buy-back and amnesty scheme allowing gun owners to surrender more than 640,000 personal firearms to the authorities for destruction (Coulehan, 2000). Firearm-related deaths, including homicides, suicides and accidents, had averaged 537 per year for the five years from 1992 to 1996 in Australia. Following the introduction of the new firearms legislation, firearm-related deaths fell to 437 in 1997 and 327 in 1998 (Gun Control Australia, 1998). In the 10 years following the gun legislation change, no mass shootings occurred in Australia, although there had been 13 such mass homicides in the 18 years preceding it (Chapman, Alpers, Agho and Jones, 2006). Furthermore, there were significant declines in firearm-related deaths including firearm suicides and firearm homicides (Chapman et al., 2006). However, Baker and McPhedran (2007) have argued that there is insufficient evidence to make these links, suggesting that only firearm-related suicides have declined and that firearm-related homicides continue to occur at the same rate. Changes to Security Measures. The highly publicized school shootings in the U.S. in the 1990s generated massive fear and concern amongst schools and the public, creating a perception that school shootings were on the increase when, in fact, they were becoming less frequent but more highly publicized (Cornell, 2006). However, in the past 10 years, there have been studies that have shown that nearly 6% of U.S. high school students regularly carry

Complimentary Contributor Copy Effects of Mass Homicide on Communities 105 a weapon to school (DeVoe et al., 2003), and around 120,000 U.S. teachers report being physically attacked by students annually (Dinkes et al., 2007). The dramatic national response to the school massacres of the 1990s included Senate and House of Representatives hearings on youth violence, a White House conference on school violence, and FBI and Secret Service studies of school shootings (O’Toole, 2000; Vossekuil, Fein, Reddy, Borum and Modzeleski, 2002). Guidebooks were distributed to schools giving advice regarding the identification of potentially violent students (Dwyer, Osher and Warger, 1998). The majority of schools in the Colorado study (Crepeau-Hobson et al., 2005) increased security in the two years following the Columbine tragedy, with 62.7% of schools introducing tighter security measures such as metal detectors, security guards, locking doors and requiring visitors to check in. Half of the urban and suburban schools in this study introduced security guards or police officers. Local school authorities across the country adopted new security measures, implemented tough zero tolerance policies, and expanded their use of school security officers. However, several studies (e.g., Hyman and Perone, 1998; Mayer and Leone, 1999; Noguera, 1995) have found that such measures are ineffective and may even contribute to school violence by creating a prison-like atmosphere. Zero tolerance policies across the U.S. resulted in students being expelled for seemingly minor offences (Cornell, 2006; Cornell and Mayer, 2010) and there were even calls for teachers to be armed with guns, such as occurs in some schools in Israel and Thailand (Associated Press, 2006b). Cornell and Sheras (1998) have warned against school or community actions that disengage, reject, or disown problem individuals, such as school expulsion, as these may further alienate or aggravate these individuals. Increased security may result in these kinds of actions rather than more constructive strategies.

CONCLUSION

Whatever the motivation for mass homicide, it never makes sense to anyone but the perpetrator. This is probably the most difficult aspect for the individuals left behind in the community, apart from the dreadful loss of victims’ lives and potential. Those left behind in the aftermath of the tragedy of a mass homicide are often compelled to search for ways to reconceptualise the world around them in a meaningful way which still takes into account their horrific experiences (Fast, 2003). The path to recovery is often complicated by legal procedures and media attention. It can also be made difficult by lack of understanding amongst the wider community who may see the tragedy through the filter of the ‘just world fallacy’. Nevertheless, they must somehow come to terms with what has occurred and find their way through the confusion, blame, anger, police investigations, legal battles and media attention. They must decide how they will regard the perpetrators and try to understand why they visited such horrendous torment on themselves and others. In doing so, communities often create shrines, websites, quilts or other objects to memorialise the victims. Slowly then, often in groups, they determine how they will make sense of what has happened and move forward. Sometimes it involves ensuring change for the future and some positive outcome to attempt to partially balance the negatives of the tragedy. They tend to seek out ways to honour the memories of the deceased by creating change. This may take the form of legal or

Complimentary Contributor Copy 106 Sandy Sacre policy reform, support systems for victims or would-be perpetrators, or physical structures such as parks or libraries. Reforms involving tighter security seem to have been ineffective, although firearm reform, when widely and systematically implemented, has been successful in reducing the likelihood of casualties in large numbers. Nevertheless, mass homicide, like other types of homicide, is likely to recur in rare and isolated cases, regardless of the prophylactic actions of governments and law enforcement authorities.

REFERENCES

Associated Press. (2006a). Police: College shooter shoots self after hit in arm. MSNBC. Retrieved 31 October, 2011 http://www.msnbc.msn.com/id/14818183/ns/world_news- americas/t/police-college-shooter-shot-self-after-hit-arm/#.Tq0Vmc2iJzA Associated Press. (2006b). Wisconsin lawmaker urges arming teachers. Retrieved 18 November, 2011 from http://www.usatoday.com/news/nation/2006-10-05-arming- teachers_x.htm Baker J. and McPhedran, S. (2007). Gun laws and sudden death: Did the Australian firearms legislation of 1996 make a difference? British Journal of Criminology, 47, 455–69. Bernall, M. (1999). She said yes; the unlikely martyrdom of Cassie Bernall. North Farmington, PA: Plough Publishing House. Blair, C., Jeppeson, M. S. and Pucci, E. Jr. (1991). Public memorialising in post modernity: the Vietnam Memorial as prototype. Quarterly Journal of Speech, 77(3), 263-288. Bodnar, J. (1992). Remaking America: Public memory, commemoration, and patriotism in the twentieth century. New Jersey: Princeton University Press. Brener, N. D., Simon, T. R., Anderson, M., Barrios, L. C. and Small, M. L. (2002). Effect of the incident at Columbine on students’ violence- and suicide-related behaviours. American Journal of Preventative Medicine, 22(3), 146-150. Browne, S. H. (1995). Reading, rhetoric, and the texture of public memory. Quarterly Journal of Speech, 81, 237-265. Chapman, S., Alpers, P., Agho, K. and Jones, M. (2006). Australia’s 1996 gun law reforms: Faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Injury Prevention, 12, 365-372. Cornell, D. G. (2006). School violence: Fears versus facts. Mahwah, NJ: Lawrence Erlbaum. Cornell, D. G. and Mayer, M. J. (2010). Why do school order and safety matter? Educational Researcher, 39(1), 7-15. Cornell, D. G. and Sheras, P. L. (1998). Common errors in school crisis response: Learning from our mistakes. Psychology in the Schools, 35(3), 297-307. Coulehan, J. (2000). The tragic events of April 1996. Annals of Internal Medicine, 12(11), 911-913. Crepeau-Hobson, M. F., Filaccio, M. L. and Gottfried, L. (2005). Violence prevention after Columbine: A survey of high school mental health professionals. Children and Schools, 27(3), 157-165. DeVoe, J., Peter, K., Kaufman, P., Ruddy, S., Miller, A., Planty, M. et al. (2003). Indicators of school crime and safety (NCES 2004-004). Washington, DC: National Centre for

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Education Statistics, Institute of Education Sciences, U.S. Department of Education and Bureau of Justice Studies, Office of Justice Programs, U.S. Department of Justice. Dinkes, R., Cataldi, E. F. and Lin-Kelly, W. (2007). Indicators of school crime and safety (NCES 2008-021). Washington, DC: National Centre for Education Statistics, Institute of Education Sciences, U.S. Department of Education and Bureau of Justice Studies, Office of Justice Programs, U.S. Department of Justice. Douglas, A. (1975). Heaven our home: Consolation literature in the northern United States, 1830-1880. In D. E. Stannard (Ed.), Death in America (pp. 49-68). Philadelphia, University of Pennsylvania Press. Dwyer, K., Osher, D. and Warger, C. (1998). Early warning, timely response: A guide to safe schools. Washington, DC: U.S. Department of Education. Eastgate Systems. (2005). Web shrines. Hypertext now. http://www.eastgate.com/ HypertextNow/archives/Shrines.html, Retrieved 19 November, 2011. Ehrenhaus, P. (1988). Silence and symbolic expression. Communication Monographs, 55, 41- 57. Fast, J. D. (2003). After Columbine: How people mourn sudden death. Social Work, 48(4), 484-491. Fox, J. A. and Levin, J. (1994). Overkill: Mass murder and serial killing exposed. New York: Bantam Doubleday Dell. Fulton, R. and Gottesman, D. J. (1980). Anticipatory grief: A psychological concept reconsidered. British Journal of Psychiatry, 137, 45-54. Gun Control Australia. (1998). Gun killings down – gun control success. Retrieved 19 November, 2011 from http://guncontrol.org.au/2000/11/gun-killings-down-gun-control- success/ Hyman, L. A. and Perone, D. C. (1998). The other side of school violence: Policies and practices that may contribute to student misbehaviour. Journal of School Psychology, 36, 7-27. Irving, C. (1995). In their name. New York: Random House. Jorgensen-Earp, C. R. and Lanzilotti, L. A. (1998). Public memory and private grief: The construction of shrines at the sites of public tragedy. Quarterly Journal of Speech, 84(2), 150-170. Kelleher, M.D. (1997). Flash point: The American mass murderer. Westport, CT: Praeger. Klieve, H., Barnes, M. and De Leo, D. (2009). Controlling firearms use in Australia: Has the gun law reform produced the decrease in rates of suicide with this method? Social Psychiatry and Psychiatric Epidemiology, 44, 285-292. Knox, S. (2004). A gruesome accounting: mass, serial and spree killing in the mediated public sphere. Journal for Crime, Conflict and the Media, 1(2), 1-14. Kostinsky, S., Bixler, E. O. and Kettl, P. A. (2001). Threats of school violence in Pennsylvania after media coverage of the Columbine High School massacre: Examining the role of imitation. Archives of Paediatrics and Adolescent Medicine, 155(9), 994-1001. Kuchera, Ben (January 9, 2007). "Game Review: Super Columbine Massacre". ArsTechnica. http://www.msnbc.msn.com/id/14818183/from/ET/#.Tq0IZM2iJzA Retrieved 31 October, 2011. Lerner, M. J. (1980). The belief in a just world: a fundamental delusion. New York: Plenum Press.

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Levin, J. and Fox, J. A. (1996). A psycho-social analysis of mass murder. In T. O’Reilly- Fleming and S. Egger (Eds.), Serial and mass murder: Theory, research and policy (pp. 55-76). Toronto: University of Toronto Press. Leyton, E. (1999). Serial and mass murderers. In L. R. Kurtz and J. E. Turpin (Eds.), The encyclopaedia of violence, peace and conflict (pp. 229-292). New York: Academic Press. Linenthal, E. T. (1998). Memory, memorial, and the Oklahoma City bombing. Chronicle of Higher Education, 45(11), B4-5. Mayer, M. J. and Leone, P. E. (1999). A structural analysis of school violence and disruption: Implications for creating safer schools. Education and Treatment of Children, 22, 333- 356. Mendel, R. A. (2000). Less hype, more help: Reducing juvenile crime, what works – and what doesn’t. Retrieved 19 November, 2011 from http://www.aypf.org/forumbriefs/ 2000 /fb071400.htm Morton, R.J. and Hilts, M. A. (Eds.) (2010). Serial murder: Multi-disciplinary perspectives for investigators. Behavioural Analysis Unit, National Centre for the Analysis of Violent Crime, Federal Bureau of Investigation. Accessed online 19 September 2011 at http://www.fbi.gov/stats-services/publications/serial-murder. Mosley, W. (2006). Outrage over sick net game. Daily Star, May 19, 2006, p. 28. Cited in: http://en.wikipedia.org/wiki/Super_Columbine_Massacre_RPG! Retrieved 31 October, 2011. Noguera, P. A. (1995). Preventing and producing violence: A critical analysis of responses to school violence. Harvard Educational Review, 65, 189-212. O'Toole, M.E. (2000). The school shooter: A threat assessment perspective. Quantico, Virginia: National Center for the Analysis of Violent Crime, Federal Bureau of Investigation. People’s Daily Online. (2002). Two murderers who brutally killed 14 people were executed Friday in Jinzhong City, Shanxi Province in north China. People’s Daily Online, 26 January, 2002. Peters, R. and Watson, C. (1996). A breakthrough in gun control in Australia after the Port Arthur massacre. Injury Prevention, 2, 253-254. Romano, L. (1997). Oklahoma City unveils design for memorial to bomb victims. The Washington Post, Wednesday, 2ndJuly, 1997: A1, A 10. Smart, L. S. (1993-94). Parental bereavement in Anglo American history. Omega: Journal of Death and Dying, 28(1), 49-61. Steinhauer, J. (2007). Korean-Americans brace for problems in wake of killings. The New York Times, 19 April, 2007, p. A 19. Tolan, P. H. and Guerra, N. G. (1994). What works in reducing adolescent violence: An empirical review of the field. Boulder: University of Colorado, Centre for the Study and prevention of Violence, Institute for Behavioral Science. Turner, T. (1977). Transformation, hierarchy, and transcendence: A reformulation of van Gennep’s model of the structure of rites of passage. In S. F Moore and B. G. Meyerhoff (Eds.), Secular Ritual (pp. 61-62). Assen: Van Gorcum. Turner, V. (1982). Introduction. In V. Turner (Ed.), From ritual to theatre: The human seriousness of play (pp. 7-19). New York: Performing Arts Journal Publications.

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U.S. Department of Health and Human Services. (2001). Youth violence: A report of the surgeon general. Retrieved 19 November, 2011 from http://www.surgeongeneral.gov/ library/youthviolence/youvioreport.htm Van Gennep, A. (1960). The rites of passage. Chicago: University of Chicago Press. Vossekuil, B., Fein, R.A., Reddy, M., Borum, R. and Modzeleski, W. (2002). The final report and findings of the Safe School Initiative: Implications for the prevention of school attacks in the United States. Washington, D.C: U.S. Secret Service and U.S. Department of Education.

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 7

THE LEGACY OF THE NAZI HOLOCAUST WITHIN A THEORETICAL TRAUMA FRAMEWORK

Janine Lurie-Beck Queensland University of Technology, Brisbane, Australia

ABSTRACT

While there are certainly some traumatic experiences that share certain commonalities with the Holocaust, it is unique in its combination of traumatic elements. The Holocaust can be defined as a strain trauma of long duration, for which there was no readily acceptable rationalisation or reason, which was followed by little societal support for victims and in many cases indifference and which dramatically altered a survivors’ life course. Not only was the experience itself horrific, but the survivors had nothing to return to and were forcibly severed from the life course they were on. While the Holocaust is rapidly moving into more distant history, its effects are still very much felt in the present and therefore worthy of continued study within the psychological literature. It is hoped that lessons learned from the horrific Nazi Holocaust can be applied to the survivors of more recent analogous ‘Holocausts’ in different parts of the world.

Keywords: Nazi Holocaust, Trauma Framework; Holocaust Survivors, Concentration Camps, Deep Trauma

INTRODUCTION

It is an unfortunate aspect of the world we live in that there are a myriad of possible traumatic experiences that can be endured, from natural disasters to personal assaults, wars and terrorist attacks. McCann and Pearlman (1990, p. 10) define a traumatic experience as being: “sudden, unexpected, or non-normative, exceeding the individual’s perceived ability to meet its demands, and disruptive of the individual’s frame of reference and other central psychological needs and related schemas.”

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Few would disagree that the Nazi Holocaust constituted a “traumatic experience” for its victims and survivors. Millions of men, women and children were subjected to unspeakable horrors during this time and those fortunate to survive often bear psychological scars which have remained with them to this day. Most people will at least vaguely be aware of the course of events that are referred to as the Holocaust. Images of ghettos and concentration camps are easily summoned and have become part of our historical psyche. While Jews were the most commonly targeted group, others such as gypsies, homosexuals, communists, trade unionists, people with mental and/or physical disabilities, petty criminals and many others also became victims of the Nazi regime (Silverstrim, no date). While the tragedy of the millions who died during the Holocaust is what lingers in most people’s minds, it is the millions of survivors who live with the legacy of the Holocaust that is (or should be) society’s ongoing concern. These survivors had to piece their lives together as best they could and move on. The extent to which they were able to do this has been the subject of much research and theoretical discussion over the last sixty-seven years. As Chodoff (1997) says: “We have a responsibility to remember their ordeal, and we can still learn from their [Holocaust survivors’] experiences as a worst-case example to guide us in dealing with the horrible examples of mass inhumanity that we read of every day” (p. 148). It is true that the Holocaust occurred more than half a century ago and some may question why it is still relevant to investigate the impacts of the Holocaust. Quite apart from the lessons that can be learned and applied to survivors of more recent state-based traumas is the fact that survivors and their descendants continue to this day to suffer as a result of the Holocaust. The majority of survivors are now reaching the end years of their life. Many are suddenly suffering from an increase of symptoms or the appearance of symptoms from which they had, until now, been spared. The life review process that we all face in old age is one filled with traumatic memories for survivors. Recent media coverage1 has pointed to the difficulties faced by survivors in aged care facilities. This chapter will briefly outline the experiences that Holocaust survivors endured and then place Holocaust trauma within the context of theoretical trauma frameworks.

THE NATURE OF HOLOCAUST TRAUMA

By the end of World War II, roughly 11 million people had died at the hands of Hitler’s Third Reich (Simon Wiesenthal Centre, 1997). However, the Nazis were not successful in completely wiping out the societal groups that they had sought to obliterate. By the end of 1945, there were one and a half to two million displaced persons who had suffered to some degree at the hands of the Third Reich but who had managed to survive.

1 The unique problems faced by aging Holocaust survivors as they move into aged care facilities, as well as the increase or emergence of psychological symptoms, has been acknowledged in recent print (e.g., an article in the Weekend Australian Magazine on 31 March 2007 (Harari, 2007) and television media coverage (e.g., an episode of the ABC [Australian Broadcasting Corporation] program Compass which addressed Holocaust survivors with Alzheimer’s which aired on 22 October 2006 (see webpage – http:// www.abc.net.au/compass/s1748774.htm). Indeed, many aged care facilities have been forced to implement programs focusing on the specific needs of Holocaust survivor residents (e.g., the Sir Moses Montefiore Jewish Home in Hunters Hills, Sydney [as featured in the aforementioned ABC Compass program]).

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The Initial Phase: Gradual Removal of Civil Rights

From the moment Hitler was declared German Chancellor on 30 January 1933, the gradual removal of rights for German Jews began (Edelheit and Edelheit, 1994). Initially, these were only aimed at causing humiliation, but eventually they negatively affected the people’s ability to survive. The long list of humiliations included the boycott of Jewish- owned businesses, the barring of Jews from government service such as education, the restriction and later complete barring of Jewish children from attending German schools and universities, playing in playgrounds (1933), followed by removal of citizenship (1935), the banning of Jews from public streets on certain days, forbidding Jews to have driver’s licenses or car registration, forcing Jews to sell their businesses, property, investments and jewelry to the Reich at artificially low prices, forcing them to carry an identification card (1938), forcing Jews to relinquish radios, cameras and other electric objects to the police, providing them with restrictive food rations denying them foods such as meat and milk and limiting their amount of clothing (1939) (Barron, 1997). Edelheit and Edelheit (1994) note that by the beginning of the war, at least 121 laws were passed, each of which denied German Jews a fundamental right. These restrictions of freedom were extended to the Jews of Austria after the Anschluss in 1938 and Czechoslovakia in early 1939 (Edelheit and Edelheit, 1994). As the German Army marched forward into Poland in September 1939, sparking the beginning of World War II, the Jews of all occupied territories soon joined their German, Austrian and Czech counterparts in becoming bureaucratically marginalised members of society. Additional indignities were added such as the freezing of Jewish back accounts, the introduction of a curfew and compulsory Star of David armbands (Barron, 1997). Groups that later suffered at the hands of the Third Reich (such as political prisoners) did not endure these earlier years of incremental rights removals. This gradual removal of civil rights and erosion of dignity was largely unique to the Jews (although it was also applicable to Gypsies to a lesser extent) and also lasted for differing lengths of time depending on the country. German Jews had begun to experience such changes from six years prior to the onset of war, while Jews of other countries retained such rights until their countries were invaded during the war. This was indeed a very long period of time to endure an ongoing traumatic experience. Germany invaded Belgium, Denmark, France, Luxembourg, the Netherlands and Norway in 1940, Yugoslavia and Greece in 1941, and Hungary later in 1944 after initially being a German ally (Barron, 1997).

Phase Two: The Formation of Ghettos

In Nazi-occupied Poland, Jewish ghettos were established from 1939 onwards (Barron, 1997). In large cities, such as Warsaw, Lodz and Krakow, sections of the city were closed off to gentile residents and a walled ghetto was created to house the cities’ Jewish populations. Often, Jews from surrounding areas were also moved into the ghettos, and eventually Jews from other countries, occupied by the Nazis, were transported to these ghettos as well. According to Berenbaum (1993), in his own words, ghetto life was one of squalor, hunger, disease and despair. Accommodation was very cramped with 10 to 15 people occupying a space previously used by no more than four. When moving into the ghetto, people were forced to leave most of their belongings behind and could take only whatever

Complimentary Contributor Copy 114 Janine Lurie-Beck they could pile onto a wagon. Ever diminishing food rations saw the ghetto populations gradually starving (Rosenbloom, 1988). Serious public health problems led to epidemics of diseases such as typhus (Berenbaum, 1993). Despite the dramatic drop in living standards, inhabitants of the ghettos got on with life as best they could. Adjustments were made to a life of daily struggle for food, warmth, sanitation, shelter and clothing. Every effort was made to continue cultural life with clandestine schools being created and religious services and entertainment such as music and theatre productions being arranged to create at least a semblance of normal life (Berenbaum, 1993). However, ghetto inhabitants lived in constant fear as residents were soon drafted for ‘labour conscription’ and ‘deportation’. In the European summer of 1942, the ghettos of Eastern Europe began to be cleared of inhabitants, which in the majority of cases involved the separation of families. Two years later, more than two million Jews had been transported to concentration camps and there were no ghettos left in Eastern Europe (Berenbaum, 1993).

Phase Three: Labour and Concentration Camps

Life in a concentration camp can be described as nothing less than horrific. People only avoided the gas chambers by being fit to work. Bluhm (1948) explains how people interned in camps were forced to work 16 hour days. The work was often back-breaking and anyone who did not fulfil their quota or was considered to be not pulling their weight was severely punished by beatings, torture, or all too often death (Bistritz, 1988; Bluhm, 1948). Inmates were provided with very little food and often inadequate clothing with which to sustain themselves in order to do this work (Bluhm, 1948). People died from starvation or diseases resulting from unsanitary living conditions, as well as at the hands of the Nazis (Bistritz, 1988). Inmates dealt with death on a daily basis and often witnessed the deaths of family members, friends and fellow inmates, often in brutal circumstances (Bistritz, 1988). A number of camp inmates retreated into a state of ‘psychological hibernation’ because of the extreme shock of camp incarceration and all that it entailed. They became apathetic and lost the will for self-preservation and in most cases did not survive for long. Camp inmates who fell victim to this apathy were often termed ‘musselmen’ (Chodoff, 1997). [‘Musselmen’ translates to Muslim in German and is thought to have been coined to reflect the similarity between a Muslim prostrating themselves in prayer and the physical state of a Holocaust survivor.] Despite these extreme conditions many camp inmates were able to survive for many years (Bluhm, 1948), although a great number tragically died after liberation as a result of the conditions they endured. They were able to survive largely because they were the most fit and able in the first place. The very young and the very old, as well as anyone with an obvious illness or physical disability, were immediately sent to the gas chamber on arrival. Bluhm (1948) also notes that conditions differed from camp to camp with the death rates obviously being higher in camps with the worst conditions.

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Alternatives to Camp Life

Some of the Jews, and other groups targeted by the Nazis, managed to escape from ghettos and/or camps and managed to survive in hiding or with an assumed identity. Some had the opportunity of joining partisan groups and therefore could join in the fight against the Nazis. Rosenbloom (1988) explains how some Jews were provided with a hiding place such as a secret compartment in an attic or basement in the home of a sympathetic Christian. Those lucky enough to secure such a hiding place were sometimes able to survive for quite extensive periods, even years, which is remarkable when considering the often cramped confines of their sanctuary. Other Jews survived by assuming an “Aryan” identity with the help of forged papers. The success with which this was done was to some extent dependent on the person’s ability to fit in with their assumed persona with a convincing accent and role-appropriate behaviour. Of course, Rosenbloom (1988) points out that there was also a degree of luck in how long an assumed identity could be maintained. There were many obstacles to overcome, not the least of which being the willingness of some to inform authorities of likely impostors for monetary reward (Rosenbloom, 1988). However, both groups shared the constant fear of discovery which, in Niederland’s (1968) experience, often led to great levels of post-war anxiety. Rosenbloom (1988) argued that having to maintain this sustained vigilance produced a unique set of psychological stresses. It can be convincingly argued that survivors who joined partisan groups may well have had a psychological edge as they would have had the satisfaction of fighting back against the Nazis. While these survivors were also under threat of being discovered, they were in groups and could therefore look out for each other thereby dissipating some of the fear of being found. Survivors in hiding were often on their own with no one to help them feel more secure or protected. Despite these hardships, survival in hiding was much more likely than survival in the camps. Vogel (1994) quotes data that suggests that between 400,000 and 500,000 Jews survived in hiding, while no more than 75,000 survived the camps. Prior to World War II, the Jewish population of Europe exceeded nine million (United States Holocaust Memorial Museum, 2011). The generally accepted estimate is that 6 million Jews were killed throughout the internment and war periods.

Immediate Aftermath: Displaced Persons Camps

The suffering was not over for all Holocaust survivors once hostilities ceased in 1945. While survivors from Western European countries such as France, Belgium and Holland were, on the whole, willing to return home and were able to reintegrate into the community with little difficulty, survivors from Eastern Europe were far less willing to return, and with good reason. A large number of survivors were met with animosity rather than sympathy and understanding in their homelands (Berger, 1988; Bergmann and Jucovy, 1990; Danieli, 1988; Edelheit and Edelheit, 1994; Johnson, 1995). Bulgarian, Hungarian, Polish and Romanian Jewish survivors were greeted with widespread anti-semitism which frequently led to

Complimentary Contributor Copy 116 Janine Lurie-Beck bloodshed. For example, in post-war Poland, during the first seven months after the war, 350 Jews died as a result of anti-semitic violence (Gilbert, 1987; Johnson, 1995). Survivors often found it near impossible to reclaim their possessions and homes from the people who had occupied them after they had been forced to leave by the Nazis (Kestenberg and Kestenberg, 1990b). It is therefore understandable that a large proportion of these survivors wanted to get far away from Europe, to America or to the soon to be established state of Israel. A massive refugee problem soon developed with hundreds of thousands of displaced persons wanting to emigrate to countries reluctant to take them in (at least not in large numbers) (Berger, 1988; Gill, 1994; Kestenberg and Kestenberg, 1990b). The situation for those wanting to emigrate to Palestine/Israel was particularly difficult with the British Administration being very reluctant to allow sizeable refugee shipments to enter Palestine (until the establishment of the state of Israel on 15 May, 1948). It got to the stage where the British navy either sent refugee boats back to Germany or Italy or re-routed them to Cyprus where large numbers of displaced persons (of whom a very large percentage were Jewish Holocaust survivors) were housed in what was, for all intents and purposes, another concentration camp: a detention centre that opened in August 1946 (Berger, 1988; Bergmann and Jucovy, 1990; Edelheit and Edelheit, 1994; Friedman, 1948, 1949; Kestenberg and Kestenberg, 1990b). This was obviously a highly insensitive method of operation and a potentially further traumatising experience for the survivors interned there. On his numerous visits to the displaced persons (DP) camps in Cyprus, Friedman (1948, 1949) noted that “the barbed wire of Cyprus cruelly result[ed] in bringing back to many of the immigrants, either by association or by the re-stimulation of ingrained, conditioned responses, some of the behaviour patterns of the Concentration Camps. Anxieties which were held in abeyance for many years now erupt[ed] to the surface.” (1949, p. 507). He suggested that:

To attempt to revive the emotional life of people who continue to live in the precarious and threatening atmosphere of the DP camps in Europe or incarcerated on the purgatorial island of Cyprus, hemmed in by barbed wire and armed guards in an ominous re- enactment of the German chapter of their torture, might appear an impossible undertaking. (p. 507)

It took over ten years for some, but finally, the remaining survivors were able to leave Europe and set up new lives far away from the site of their suffering. The situation was eased by the establishment of the state of Israel in 1948 and legislation enacted in the United States Congress shortly afterwards admitting a large number of displaced persons to America (Berger, 1988). There are numerous and varying estimates of the number of emigrants to the various countries around the world (Krell, 1997; United States Holocaust Memorial Museum, n.d.). Hass (1996) suggests that 55% of Jewish survivors emigrated to Israel, 25% emigrated to the United States, 10% emigrated to Canada, Australia, South Africa or Argentina and the remaining 10% stayed in Europe. The last DP camp closed on 28 February 1957 (Gill, 1994), 12 years after the official end of the war.

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THE HOLOCAUST AS A UNIQUE TRAUMA OF INTEREST

Numerous models of reaction to trauma have been developed as tools to help evaluate the severity of a trauma and potentially to predict the severity of its impact on an individual (for example Green, 1993; Green, Wilson and Lindy, 1985; Wilson, 1989). In this section, the Holocaust will be discussed in terms of a combination of factors that were outlined in Green, Wilson and Lindy’s (1985) Working Model for the Processing of a Traumatic Event and Wilson’s (1989) Person-Environment Interaction Theory of Traumatic Stress Reactions. These factors include: structure of the trauma – single or multiple events; duration; role in trauma – active or passive; personal exposure to intentional or non-intentional risk/threat of death or severe physical harm; sudden violent loss of loved one/s - exposure to /witnessing death and violence against others in particular loved ones; natural versus man-made; experienced alone, with others or community based and; recovery environment – level of support, societal attitudes, cultural rituals for recovery, displacement from original community. Another key factor that was not included in either Green, Wilson and Lindy’s (1985) or Wilson’s (1989) models is the extent to which a trauma victim or survivor can attach a rational or palatable reason for their experience. The application of these factors to the Holocaust will be presented in the following subsections with key factors having lengthier discussion. It is obvious that Holocaust survivors were personally exposed to physical harm and the threat of death to both themselves and loved ones and that the Holocaust was a man-made rather than natural traumatic event. These factors are shared by many other traumas. Examination of the Holocaust on the key factors of the structure of the traumatic event, a survivor’s role in the trauma, rationalisation of the trauma and recovery environment will confirm its particular uniqueness as a trauma.

The Structure of a Traumatic Event

In the main, trauma tends to stem from a single event. The actual initial impact of natural disasters such as earthquakes, volcanic eruptions, floods, and cyclones or initiated attacks such as terrorist attacks, rapes or muggings are over quite quickly. Although the effects can be dramatic and life changing, such events constitute what Solnit and Kris (1967) refer to as a “shock trauma”. They represent a “sudden peril to life” which is momentary (Solnit and Kris, 1967) when compared to ongoing trauma such as that endured over a much more extended period of time by people in the armed forces during wartime, incarceration in a prisoner-of- war camp or repeated episodes of abuse. Solnit and Kris (1967) introduced the term “strain trauma” to describe this latter form of trauma. In other words, the form of trauma continues for an extended period and places the individual under strain; survivors of the Nazi Holocaust can certainly fall into this latter category of ‘strain trauma’. Strain trauma is viewed as potentially more damaging to the psyche than shock trauma. Bistritz (1988) argues that even the most harrowing of experiences can be handled if what is occurring is predictable and potentially time limited. In other words, if the person can see an end to their suffering they have a heightened capacity to deal with the trauma as it is occurring because it has a foreseeable end. The nature of the events of the Holocaust meant that there was a high degree of uncertainty and unpredictability of what would happen on a

Complimentary Contributor Copy 118 Janine Lurie-Beck daily basis as well as the overall chances of survival. Bistritz (1988) argues that given this background, survivors were unable to psychologically defend themselves as much as survivors of other forms of shock trauma are able.

Active versus Passive Roles in Traumatic Events

There is also the issue of active versus passive roles within traumatic experiences. Military personnel can be seen to have played an active role in the events leading up to and within their trauma events. Holocaust survivors on the whole (excepting those persecuted for resistance) played a passive role. They had not actively participated in circumstances leading to their ordeals; they were simply forced to obey their captors/persecutors. This passivity would have also contributed to the incomprehensibility of their experiences. For example, Sigal and Adler (1976) found Canadian veterans who had been in Japanese prisoner-of-war camps showed better post-war adjustment than Jewish concentration camp survivors. He argued that this was partially because the soldiers had played an active fighting role compared to the Jewish camp survivors who were not interned for anything active. As Tas (1951/1995) pointed out, soldiers in action were able to relieve pent up tensions and aggression via combat, an outlet that a Holocaust survivor was missing. Tas (1951/1995) suggested that because any expression or venting of emotion was a highly dangerous action for a survivor (because of reprisals for the individual and often for many surrounding them), their suffering was compounded by the enforced accumulation of feelings such as anxiety and rage. The mechanism of repressing these feelings during the Holocaust as a survival strategy would then become a hindrance when the cathartic release of these emotions was almost impossible for many survivors in the post-war period (Tas, 1951/1995). Recent research in Australia has found that playing an active role can minimise traumatic impact. Parslow (2005) stated that people caught by bushfires in Canberra who were allowed to play a role in trying to protect their homes and were given more warning of the need to evacuate suffered fewer post-traumatic symptoms than those forced to evacuate with minimal notice. Weisaeth (2005) reported that survivors of a number of industrial accidents in Scandinavia suffered from fewer symptoms if they had played an active role in trying to rescue fellow workers.

The Rationalisation of Traumatic Events

It can be argued that while members of the armed forces, who participated in combat and/or were interned in prisoner of war camps, certainly endured hardships for years, they were able to assign a more palatable reason to their suffering than Holocaust survivors were. Military personnel have a clear mission and ultimate goal which leads them to believe that their actions and their suffering are justified. They are involved in fighting an “enemy” which perhaps threatens their country or their way of life in some way. There is a clear cause and effect between their actions and their experiences. Even for prisoners of war who are not in control of the events that occur to them, as much as they were when in combat, can at least understand the reason for their internment. They can rationalise that they have been captured and detained because they are enemies of their captors and were fighting against them.

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Holocaust survivors in the main were subject to persecutions and incarceration in camps because of their nationality or ethnicity. They had committed no act that could be considered an attack against their captors. For Jews and Gypsies, their internment was aimed at the complete destruction of their race based on the opinion that they were a lesser group in society and not deserving of equal rights or even life. This must have been a very difficult concept to grasp and survivors must have felt a greater indignation and incomprehension at their detention than prisoners of war. Support for the notion that a more readily derived rationalisation of a traumatic event can be protective was discussed by Makhashvili, Beberashvili, Tsiskarishvili, Kiladze, and Zazashvili (2005). Makhasvili et al. (2005) reported that PTSD rates were much higher among Georgian civilians displaced during the 1990s due to internal conflict in Georgia (61%) compared to ex-Chechnyan fighters (11%) and ex-political prisoners (14%) who were persecuted for support of Georgian ex-president Gamsakhurdia who was ousted in 1992. In another study from the Baltic states, Kazlauskas, Gailiene, and Domanskaite-Gota (2005) reported higher levels of anxiety and depression among deported civilians than ex-political prisoners in Lithuania. The political prisoners could more readily explain their persecution (active opposition to their captors), whereas the displaced and deported civilians could not.

The Aftermath of Traumatic Events

How a survivor is treated and received, not only by their immediate friends and families but by society as a whole, has been cited by a number of researchers as a key factor in determining their post-trauma adjustment (Bower, 1994; de Silva, 1999; Gill, 1994; Green, 1993; Green et al., 1985; Kestenberg and Kestenberg, 1990a, 1990b; McCann and Pearlman, 1990). Symonds (1980) talks about the notion of “second injury” that occurs to survivors when they are greeted by unsupportive or blaming reactions from others. It is suggested that such a reception can be almost as damaging as the trauma itself. Certainly, it is a widely accepted view that the less than supportive reception Vietnam veterans received upon their return home did nothing for their recovery (de Silva, 1999; Lomranz, 1995; McCann and Pearlman, 1990; Solomon, 1995). Sigal and Adler’s (1976) Canadian prisoners-of-war were also theorised to have adjusted to post-war life because they returned to a homeland that honoured their ordeal. Reactions to Holocaust survivors were largely dismissive. Brom, Durst and Aghassy (2002) talk of the horror people experienced when they learned of what survivors had endured. People did not want to think about what had happened and so largely shut survivors out rather than reaching out in an effort to support them and help them recover. Kestenberg and Kestenberg (1990b) note that soon after large scale natural disasters, organised attempts to help people and support them through the initial aftermath, are put into place. Counselling services are often part of this process. While it cannot be denied that survivors were provided with a degree of material assistance upon their liberation, an organised attempt to provide psychological help was sadly lacking (Friedman, 1948). A number of researchers have suggested that the availability of social supports and networks in the survivors’ community are a key factor in determining their long term recovery (de Silva, 1999; Green, 1993; Green et al., 1985).

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While Vietnam veterans may not have had societal support, they were able to return to family and friends. For a large number of Holocaust survivors there were no surviving relatives to seek comfort from, no friends, no home and no community willing to welcome them back with open arms (Eitinger, 1973; Gill, 1994). For a majority of Holocaust survivors, there was very little to come home to (Rappaport, 1968). Many were the sole survivors of their families, and their homes and their property had long been confiscated and in most cases was irretrievable. Returning to such a “vacuum” compounded the trauma for these survivors (Kestenberg and Kestenberg, 1990b; Zolno and Basch, 2000). As Davidson (1980) states, “The destruction of the community and the previous life of the survivor damaged his basic sense of security and undermined his identity and sense of continuity with the past” (p. 11). Survivors whose communities were dismantled or destroyed must have been affected by the resulting isolation. Indeed, the intactness of the survivor’s community is included in Green et al.’s (1985) Working Model for the Processing of a Catastrophic Event as an important aspect of the recovery environment. A person’s sense of connection to their community has been significantly linked with psychological well-being (for example, Davidson and Cotter, 1991). The loss of community was felt so keenly by some survivors that even in the displaced persons’ camps which survivors found themselves in immediately after the war, they began to form social groups with survivors of the same town or region as their own. These groups appeared in much larger numbers when survivors resettled in countries such as America. Participation in such groups provided at least a small form of continuity with their destroyed pre-war lives (Zolno and Basch, 2000).

CONCLUSION

Similar events to the Nazi Holocaust have unfortunately occurred not only in Europe (Former Yugoslavia), but also in Asia (Cambodia) and Africa too (Rwanda and the Sudan) (Chodoff, 1997). Attempted genocides are, sadly, not solely the domain of history. Holocaust survivors provide us with the unique opportunity to examine the long term impacts of attempted genocides as well as intergenerational effects of such holocausts. As Wieland- Burston (2005) summarises: “Although the Shoah was a unique experience in itself, it nevertheless serves as a prototype for genocide, for massive collective trauma and its long- term effects on a population. In this respect, research on the topic is of vital importance for all who work in the field of psychotherapy, not only for us today, living and dealing with the direct descendants of the Shoah, but also for the future. We cannot suppose that genocide and mass collective trauma are a thing of the past.” (p. 513)

REFERENCES

Barron, A. (1997). A teacher's guide to the Holocaust: Holocaust time line 1933-1945. Retrieved September 2, 2002, from http://fcit.coedu.usf.edu/holocaust/timeline/ TEXTLINE.HTM Berenbaum, M. (1993). The World Must Know: The History of the Holocaust as Told in the United States Holocaust Memorial Museum. Boston: Little, Brown and Company.

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Berger, L. (1988). The long-term psychological consequences of the Holocaust on the survivors and their offspring. In R. L. Braham (Ed.), The Psychological Perspectives of the Holocaust and of its Aftermath (pp. 175-222). New York: Columbia University Press. Bergmann, M. S. and Jucovy, M. E. (1990). Prelude. In M. S. Bergmann and M. E. Jucovy (Eds.), Generations of the Holocaust (pp. 3-29). New York: Columbia University Press. Bistritz, J. F. (1988). Transgenerational pathology in families of Holocaust survivors. In R. L. Braham (Ed.), The Psychological Perspectives of the Holocaust and of its Aftermath (pp. 129-144). New York: Columbia University Press. Bluhm, H. O. (1948). How did they survive? Mechanisms of defense in Nazi concentration camps. American Journal of Psychotherapy, 2(1), 2-32. Bower, H. (1994). The concentration camp syndrome. Australian and New Zealand Journal of Psychiatry, 28(3), 391-397. Brom, D., Durst, N. and Aghassy, G. (2002). The phenomenology of posttraumatic distress in older adult Holocaust survivors. Journal of Clinical Geropsychology, 8(3), 189-201. Chodoff, P. (1997). The Holocaust and its effects on survivors: An overview. Political Psychology, 18(1), 147-157. Danieli, Y. (1988). The heterogeniety of postwar adaptation in families of Holocaust survivors. In R. L. Braham (Ed.), The Psychological Perspectives of the Holocaust and of its Aftermath (pp. 109-128). New York: Columbia University Press. Davidson, S. (1980). The clinical effects of massive psychic trauma in families of Holocaust survivors. Journal of Marital and Family Therapy, 6(1), 11-21. Davidson, W. B. and Cotter, P. R. (1991). The relationship between sense of community and subjective well-being: A first look. Journal of Community Psychology, 19(3), 246-253. de Silva, P. (1999). Cultural aspects of post-traumatic stress disorder. In W. Yule (Ed.), Post- Traumatic Stress Disorders: Concepts and Therapy (pp. 116-138). Chichester: John Wiley and Sons. Edelheit, A. J. and Edelheit, H. (1994). History of the Holocaust: A Handbook and Dictionary. Boulder: Westview Press. Eitinger, L. (1973). Concentration camp survivors in Norway and Israel. In C. Zwingmann and M. Pfister-Ammende (Eds.), Uprooting and after... (pp. 178-192). Berlin: Springer- Verlag. Friedman, P. (1948). The road back for the DPs: Healing the psychological scars of Nazism. Commentary, 6, 502-510. Friedman, P. (1949). Some aspects of concentration camp psychology. American Journal of Psychiatry, 105, 601-605. Gilbert, M. (1987). The Holocaust: The Jewish Tragedy. London: Fontana Press. Gill, A. (1994). The Journey back from Hell: Conversations with Concentration Camp Survivors. London: Harper Collins. Green, B. L. (1993). Identifying survivors at risk: Trauma and stressors across events. In J. P. Wilson and B. Raphael (Eds.), International Handbook of Traumatic Stress Syndromes (pp. 135-144). New York: Plenum Press. Green, B. L., Wilson, J. P. and Lindy, J. D. (1985). Conceptualizing post-traumatic stress disorder: A psychosocial framework. In C. R. Figley (Ed.), Trauma and its Wake: The Study and Treatment of Post-traumatic Stress Disorder (Vol. 1, pp. 53-69). New York: Brunner/Mazel. Harari, F. (2007). Haunted by the memories. The Weekend Australian Magazine, March 31.

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Hass, A. (1996). The Aftermath: Living with the Holocaust. New York: Cambridge University Press. Johnson, P. (1995). A History of the Jews. London: Phoenix. Kazlauskas, E., Gailiene, D. and Domanskaite-Gota, V. (2005). Long-term psychological effects of political violence on Lithuanian survivors of forced deportations and political imprisonment. Paper presented at the 9th European Conference on Traumatic Stress, Stockholm. Kestenberg, J. S. and Kestenberg, M. (1990a). The background of the study. In M. S. Bergmann and M. E. Jucovy (Eds.), Generations of the Holocaust (pp. 33-45). New York: Columbia University Press. Kestenberg, J. S. and Kestenberg, M. (1990b). The experience of survivor-parents. In M. S. Bergmann and M. E. Jucovy (Eds.), Generations of the Holocaust (pp. 46-61). New York: Columbia University Press. Krell, R. (1997). Psychiatry and the Holocaust. In R. Krell and M. I. Sherman (Eds.), Medical and Psychological Effects of Concentration Camps on Holocaust Survivors. Genocide: A Critical Bibliographic Review (Vol. 4, pp. 3-22). New Brunswick: Transaction Publishers. Lomranz, J. (1995). Endurance and living: Long-term effects of the Holocaust. In S. E. Hobfoll and M. W. deVries (Eds.), Extreme Stress and Communities: Impact and Intervention (pp. 325-352). Dodrecht, Netherlands: Kluwer Academic Publishers. Makhashvili, N., Beberashvili, Z., Tsiskarishvili, L., Kiladze, N. and Zazashvili, N. (2005). Complex traumatization and some societal factors as possible barriers for recovering. Paper presented at the 9th European Conference on Traumatic Stress, Stockholm. McCann, I. L. and Pearlman, L. A. (1990). Psychological Trauma and the Adult Survivor: Theory, Therapy and Transformation. New York: Brunner/Mazel. Niederland, W. G. (1968). Clinical observations on the survivor syndrome. International Journal of Psycho-Analysis, 49, 313-315. Parslow, R. (2005). The impact of pre-trauma personality attributes on recall of traumatic events and resulting PTSD symptoms. Paper presented at the 9th European Conference on Traumatic Stress, Stockholm. Rappaport, E. A. (1968). Beyond traumatic neurosis: A psychoanalytic study of late reactions to the concentration camp trauma. International Journal of Psycho-Analysis, 49(4), 719- 731. Rosenbloom, M. (1988). Lessons of the Holocaust for Mental Health Practice. In R. L. Braham (Ed.), The Psychological Perspectives of the Holocaust and of its Aftermath (pp. 145-160). New York: Columbia University Press. Sigal, J. J. and Adler, L. (1976). Effects of paternal exposure to prolonged stress on the mental health of the spouse and children: Families of Canadian army survivors of the Japanese World War II camps. The Canadian Psychiatric Association Journal, 21(3), 169-172. Silverstrim, K. (no date). Overlooked millions: Non-Jewish victims of the Holocaust. Retrieved April 14, 2011 from http://www.ukemonde.com/holocaust/victims.html Simon Wiesenthal Centre. (1997). How many Jews were murdered during the Holocaust? How many non-Jewish civilians were murdered during World War II? Retrieved January 20, 2003, from http://motlc.wiesenthal.com/site/pp.asp?c=gvKVLcMVIuG andb=394663 #2

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Solnit, A. J. and Kris, M. (1967). Trauma and infantile neurosis: A longitudinal perspective. In S. S. Furst (Ed.), Psychic Trauma (pp. 176-220). New York: Basic Books. Solomon, Z. (1995). From denial to recognition: Attitudes toward Holocaust survivors from World War II to the present. Journal of Traumatic Stress, 8(2), 215-228. Symonds, M. (1980). The "second injury" to victims. In L. Kivens (Ed.), Evaluation and Change: Services for Survivors (pp. 36-38). Minneapolis, MN: Minneapolis Medical Research Foundation. Tas, J. (1995). Psychical disorders among inmates of concentration camps and repatriates. In H. Groen-Prakken, A. Ladan and A. Stufkens (Eds.), The Dutch Annual of Psychoanalysis: Traumatisation and War (Vol. 2, pp. 16-24). Lisse: Swets and Zeitlinger. United States Holocaust Memorial Museum. (2011). Jewish population of Europe in 1933: Population data by country. Retrieved April 4, 2011, from http://fcit.coedu.usf.edu/ holocaust/timeline/TEXTLINE.HTM United States Holocaust Memorial Museum. (n.d.). Displaced Persons: Administration Retrieved January 19, 2003, from http://www.ushmm.org/wlc/article.jsp?ModuleId =10005418 Vogel, M. L. (1994). Gender as a factor in the transgenerational transmission of trauma. Women and Therapy, 15(2), 35-47. Weisaeth, L. (2005). Psychic trauma: What is the final outcome? The long-term course of the post-traumatic stress syndrome illness and prognostic stress factors. Paper presented at the 9th European Conference on Traumatic Stress, Stockholm. Wieland-Burston, J. (2005). The reception of Holocaust research in the world of psychology. Journal of Analytical Psychology, 50(4), 503-519. Wilson, J. P. (1989). A person-environment approach to traumatic stress reactions. In J. P. Wilson (Ed.), Trauma, Transformation and Healing: An Integrative Approach to Theory, Research and Post-Traumatic Therapy (pp. 3-20). Philadelphia, PA, US: Brunner/Mazel. Zolno, M. and Basch, D. (2000). Where do we belong? Feeling a part of or apart from our communities. If not Now E-journal, 1 (2). Retrieved from http://www.baycrest.org/If _Not_ Now/Volume_1_Fall_2000/7151_7380.asp

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 8

CAMBODIA 30 YEARS ON: A COUNTRY RECOVERING FROM GENOCIDE

Roslyn Roberts* CQ University, Queensland, Australia

ABSTRACT

This chapter outlines the family and social structure in Cambodia prior to the 1970s and examines the devastation caused by the Khmer Rouge during their four year rule from 1975-1979, its subsequent impact on both the generation that suffered under their rule and the future generations of Cambodians, who, although born during or since the Khmer Rouge regime, have been raised by parents who have witnessed or even perpetrated numerous atrocities leading to severe post traumatic stress symptoms for much of the population. The chapter discusses how recovery had been hindered by challenges encountered with restoring infrastructure, inadequate education and health facilities, the impact of injuries from landmines which remained in the countryside, and family relationships, including divorce and domestic violence and how this impacts on the next generation of Cambodians. In this chapter, the author analyses what measures non-government organisations and the Cambodian government have taken to promote healing and provide justice and closure for the victims who experienced the Khmer Rouge regime first hand and the unique and difficult challenges faced by second generation Cambodians who were raised by traumatised parents.

Keywords: Genocide, Cambodia, Trauma, Post-Traumatic Stress, Restorative Justice.

INTRODUCTION

The genocide inflicted during the Khmer Rouge regime was one of the worst human perpetrated disasters of the 20th Century. For four years, the crimes in Cambodia were executed behind closed doors and hidden from the rest of the world. The human toll in loss of

* Roslyn Roberts, BFinAdmin, MProfSt Peace; CPA. Email: [email protected]

Complimentary Contributor Copy 126 Roslyn Roberts lives has been difficult to quantify, however conservative figures estimate that between 1.7 million (Yale University, 2010) and 2.4 million (Rummel, 1994) people perished under the regime. Before Pol Pot’s terrorising campaign of carnage and brutality, the population of Cambodia was approximately 8 million (Cambodian Genocide Group, n.d.). With one in five Cambodians murdered under the Khmer Rouge, few, if any would have escaped the impact of traumatic loss. This chapter discusses the trauma suffered by the Cambodian people that led to intergenerational problems which continue to impact the country more than 30 years after the fall of the Khmer Rouge. Despite 70% of the population being either too young to remember or not born until after the regime’s four year rule (Cambodia General Population Census 2008, 2010), the suffering of their parents and grandparents and the continued economic hardships endured by the population as the country attempts to restore infrastructure and basic services has had ongoing repercussions on the dynamics of familial relationships.

Background

Prior to the 1970's, Cambodia was a proud race steeped in tradition and culture. Ninety- five percent of the population practised Buddhism (Care Organisation, n.d.), which provided the people with a deep sense of spirituality. The individual Cambodian had a small circle of trusted family and friends, including neighbours, who could be approached for help with physically intensive tasks that were unable to be done alone (Ross, 1987). While city residents tended to follow western ideas of romantic love, marriages were often arranged in rural areas, although theoretically a bride could veto potential husbands, Virginity was highly prized and an unwed pregnant woman brought shame to her family (Ross, 1987). Other family values were highly regarded (Arnvig, 1994), and children were raised to demonstrate courtesy, obedience and respect for elders in a loving and affectionate home environment. Legally the husband was head of the household, but the wife exerted considerable authority in family economics and served as the ethical and religious role model for the children. Divorce, though legal, was not common and was viewed with disapproval by the community. Custody was usually given to the mother although both parents had an obligation to contribute toward raising the children. By 1970, with the Indo-China war raging, King Sihanouk’s government found it increasingly difficult to assert its claim of neutrality. The Khmer Rouge, also known as the peap prey or forest army, was gaining strength in the southern villages. To the east, the Vietnam War was encroaching into Cambodia’s borders and the Khmer Rouge enjoyed control of the rural areas where they organised insurgencies across the country. Amid allegations of widespread corruption and anti-Vietnamese sentiment, the Sihanouk led government was deposed by Lon Nol, and the Khmer Republic was formally declared in October of that year. However, Lon Nol’s government was unable to quell the burgeoning economic problems and civil unrest, particularly in rural villages which were becoming increasingly influenced by the Khmer Rouge. The military was poorly trained, with little coordination between the army, navy and air force operating under the command of inept leadership, and morale suffered under insufficient wages of recruits who were unable to feed their families. The Khmer Rouge ideology began to take hold; although evident from mid 1971, the party was

Complimentary Contributor Copy Cambodia 30 Years on 127 well on its way to radically altering Cambodia by putting the country through a social revolution where “everything that had preceded it was anathema and must be destroyed” (Quinn, 1976). The Khmer Rouge targeted youth for political-psychological indoctrination. Young men and women aged 16-18 were taken to indoctrination centres for two to three weeks at a time where they were psychologically restructured to reject parental authority, condemn religion and the “old ways” and they returned to their villages with a new militant attitude that undermined traditional Cambodian family values (Quinn, 1976). By 1975, when the capital of Phnom Penh fell, word had already filtered out to the rest of the world of the regime’s violent agenda. The Khmer Rouge believed in a communist agrarian society that could become self-reliant and end economic dependency on industrialised nations. Despite the majority of its leaders coming from French educated, middle class backgrounds, the party felt that educated people posed a threat to their ideology and should be eliminated. In their attempt to create a classless society, the urban population was forced from the cities to agricultural communes in rural areas where they became farmers in labour camps. Those who were seen as having capitalistic views which could undermine the new state; teachers, professional workers, bankers were executed. Even people who wore glasses were targeted because the Khmer Rouge assumed they could read and thus were educated (Totten, 2000). The regime’s catchphrase was “To keep you is no gain, to kill you is no loss” (Gray, 2003). What followed was four years of executions, torture and deaths from illness or sheer physical exhaustion. As people were moved from the cities to the rural areas, they became aware of the lack of humanity by Khmer Rouge soldiers:

The soldiers wouldn’t let us stop to help those who were sick. I couldn’t believe what was happening. We walked for days, then weeks. Pregnant women gave birth under trees by the road. Old people died from exhaustion and lack of water. Everywhere was the sound of babies screaming and people crying for loved ones who had died and had to be left on the road...... There was no time for funerals. Soldiers threw the bodies into empty ponds and kept everyone moving. (Chan, 1997, p. 21)

What makes the Cambodia revolution so unique is the senseless rationale behind the Khmer Rouge's obliteration of the country’s social fabric. The Khmer Rouge attempted to revert their people back to the Year Zero1 subverting an entire history and society in the process. Even the most tyrannical and despotic regimes in known history were at least aware that they needed some type of structure in order to endure. Sharp (2008, online) states:

For the most part, dictatorial regimes in other nations have moderated their policies for the simple reason that most understand that there are limits to human endurance. When conditions reach a certain level of severity, societies cease to function. There is a limit to how many "enemies" one can kill before the entire population begins to understand that everyone is at risk. Fear becomes palpable, and paralysing. Moreover, the human

1 Year Zero is a phrase given to the Khmer Rouge takeover of Cambodia from 1975 onward. The origins of the term first appeared in Ponchaud’s 1977 book “Cambodge: Anne Zero” and is analogous to “Year One” of the French Revolution upon the abolition of the French monarchy in 1792.

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infrastructure needed to enact change is decimated twice: first by the loss of life, then by the destruction of the spirit.

The term “genocide” is somewhat of a misnomer in Cambodia’s case. Genocide is defined as “the deliberate and systematic extermination of a national, racial, political or cultural group” (Online Etymology Dictionary, 2010), and comes from the Greek word for race “genos”. This implies that the act is perpetrated by one group against another based on their differences of ethnicity, race or religion. However, the Khmer Rouge murdered their own people based on their evaluation of an individual’s potential for dissidence or for minor acts of “rebellion” such as a couple falling in love with a partner not chosen by the party. If an individual spoke a second language, or had been employed as a teacher or office worker or even if they wore glasses, they were a candidate for execution. The Khmer Rouge intention was to erase all history and culture from Cambodia and start again from Year Zero. Everything from the past needed to be obliterated in order to establish pure communism. In a 1997 PBS interview with Elizabeth Farnsworth, Sydney Schanberg summed up the Marxist idealism of the Khmer Rouge leadership:

Pol Pot had a design which I think was clearly a sign of madness, that he was going to push everybody into the countryside and return to the city, the country - to an agrarian lifestyle, and reject all education, all formal education, and eliminate anyone who was impure, and that is who belonged to what he regarded as the bourgeois part of society. (Sydney Schanberg Interview with Elizabeth Farnsworth, 1997, online)

Given the uniqueness of Cambodia’s mass slaughter, it has been suggested that the term genocide is not appropriate and other denotations have been offered as more fitting, such as “auto genocide” (Hawk, 1982), or “democide” (Rummel, 1994). However, for the purposes of this chapter, we accept the term “genocide” as has been generally accepted in most of the literature. Genocide is understandable to readers and does not deter or diminish the magnitude of the crime which falls under the Convention on the Prevention and the Punishment of the Crime of Genocide by the UN General Assembly in 1948. This act defines genocide as "any of the following acts committed with intent to destroy, in whole or in part, a national, ethnical, racial or religious group, as such:

a) Killing members of the group; b) Causing serious bodily or mental harm to members of the group; c) Deliberately inflicting on the group conditions of life calculated to bring about its physical destruction in whole or in part; d) Imposing measures intended to prevent births within the group; e) Forcibly transferring children of the group to another group."

Deficiency Needs

Since 1979, when the Vietnamese invaded Cambodia and discovered the horrifying legacy left by the Khmer Rouge, the recovery of spirituality and familial bonding has been a slow process. Maslow (1943) outlines how fundamental safety and security needs must be

Complimentary Contributor Copy Cambodia 30 Years on 129 met before restoring human needs. Yet, for many years Cambodians have endured continued and severe economic hardship. Even today, Cambodia remains one of the poorest countries in Asia; only 48% of the population have access to adequate drinking water during the dry season and 75% of households have no toilet (National Institute of Statistics, 2005). The country ranks 137th of 182 countries in terms of "human development" and the majority of the population lives at or near subsistence levels (Ausaid, 2010).

Education

The "enemies of the state" during the Khmer Rouge reign of terror were intellectuals, doctors, lawyers, monks, teachers, civil servants, students, former celebrities, poets, individualists and even people who wore glasses (105th Congress, 1998). Many of those who weren’t killed fled the country to never return. As a result, this “brain drain” has caused significant problems in the rebuilding process. Between 75%-80% of all teachers fled or died during the Khmer Rouge regime (Klintworth, 1989). Although the exact number is not known, some researchers place the figure even higher, estimating that up to 90% of all teachers were killed (Clayton, 1998). As a result, there is a severe shortage of trained teachers and current day education facilities remain inadequate with heavy demands being placed on existing schools which operate up to three shifts a day (Kingdom of Cambodia, 2002). As most facilities were closed or destroyed during the Khmer Rouge period, it has been a long arduous road to restore educational infrastructure back to pre-1970's levels. Added to the overburdened lack of facilities is a high population growth rate with 42% (2008) of the population being under 18 years of age (UNICEF, 2010). Moreover, teachers themselves lack an adequate education with most having completed only eight years of basic education (Curtis, 1993). In an effort to increase education and literacy, the Kingdom of Cambodia (Ministry of Education Youth and Sport, 2000) established a number of policy objectives:

 To create equal opportunities for all school-age children to attend schools so that they have the opportunity to receive nine full years of basic education.  To increase the internal efficiency of the education system by retraining teachers; increasing the number of learning hours; providing adequate textbooks and teacher's guides.  To apply modern teaching methodology; forming inspector teams; reforming methods to evaluate students' achievements; and motivating members of the local community to be more active in educational development.  To build new schools and to restore physical infrastructure.  To develop other important sub-sectors, including upper-secondary education, non formal education, education for vulnerable groups, higher education, technical education and vocational training. This will provide opportunities for more young people to further their study and to acquire technical skills according to their own interests and talents.

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 To enhance all levels of education administration and management in order to increase efficiency and effectiveness in education sector planning, administration, management, and inspection through the implementation of development of human resources programs.  To organize functional literacy classes and to launch a campaign aimed at coordinating the activities of the Literacy Commissions at provincial and district levels. To rehabilitate and develop Youth and Sport in the formal system and non- formal education (Ministry of Education Youth and Sport, 1999).

However, despite the Cambodian Government's statement of a commitment to education, education expenditure remains among the lowest in the world at 1.7% of GDP (Child Info, 2008). As a result, infrastructure and staffing in rural areas, if it is provided at all, remains inadequate despite education being compulsory for all children. Consequently, many students do not advance beyond primary education. Yet these figures should not be taken as a lack of commitment by government, but rather the consequences of an economy stretched of its resources. Despite the low public expenditure on education as a percentage of GDP, education still represents 14.6% of the total government expenditure (Child Info, 2008). As a result, Cambodia struggles to access funds for its social welfare programs and the country is reliant upon NGO's and international aid programs to assist in rebuilding. One organisation, Partners for Development (PFD), is an American, private organization that has implemented a number of programs in Cambodia. From 1992 - 2000 the PFD rehabilitated 199 schools serving over 40,841 students and teachers (Partners for Development, 2010).

Landmines and Their Impact on Health and Safety

During the internal and regional conflicts from the late 1960’s until the end of 1998, an estimated 4 - 6 million landmines were laid throughout the country and these still continue to kill and maim Cambodians (E-Mine, 2009). Between 1979 and the end of 2002, more than 54,500 people were killed or maimed by landmines and unexploded ordinances (Maslen, 2004, p. 27). Although the deaths from landmines have declined each year due to ongoing and extensive demining and education, conflicting statistics fail to accurately reveal the current toll. While the Cambodian 2008 census reports 628 deaths from landmines (Cambodia General Population Census 2008, 2010), the Cambodia Mine/UXO Victim Information System (CMVIS) recorded only 47 people killed and another 222 injured for the same year (Landmine and Cluster Munition Monitor, 2009). More recently, Newswire (2010) reported that 45 people have been killed in the first eight months of 2010. Despite the disparate available statistics, all trends indicate a steady decline each year since 1994 when almost 3,000 people, including around 1,000 children were killed or injured. Nevertheless, the legacy remains and while the United Nations and other international groups have played an active role in the removal of landmines, the process is slow and the country has acknowledged that the clearance of land mines may not be complete for another 10 or 20 years meaning that future victims are inevitable.

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As a result of almost thirty years of casualties; the country has a high proportion of physically disabled inhabitants with many of its disabled having lost at least one limb. Moreover, landmine injuries place a heavy strain on an already overloaded health infrastructure. Casualties from mine blasts are more likely to require amputation and remain in the hospital longer than those wounded by other munitions. In Cambodia, the typical landmine victim will be in the hospital for approximately three weeks and require multiple surgeries. Such medical care is costly and drains funds from other public health issues (Stover, Keller, Cobey and Sopheap, 1994). Furthermore, as most of the country's population is engaged in labour-intensive farm work, requiring the participation of every family member, a disabled individual is less able to contribute to the family income and becomes a liability, placing additional financial burden on their already struggling family. Almost 35% of surviving landmine victims exhibit major depressive disorders and suffer feelings of low self-esteem, shame and frustration at being unable to contribute in an economically viable way (Stover et al., 1994). Attempts to provide amputees with prosthetics so that they can lead productive lives have had some success. Stover et al. (1994) reports that single-below-knee amputees with properly fitted artificial limbs can recover and return to their original labour capacity. However, the affordability of prosthetic limbs is beyond most families, particularly for growing children who require a number of prostheses throughout their lives. These can cost many thousands of dollars, making the price of artificial limbs far beyond the reach of most Cambodians. Handicap International and the Ministry of Social Action operate workshops that produce artificial limbs free of charge for amputees and this has helped to defray some of the expenses. Stover et al. (1994, p. 335) suggest some measures to assist in the treatment of victims:

Cambodia's health ministry and medical, relief, and development organizations could help these efforts by encouraging local public health specialists to participate in data gathering and to train local workers in the recording and analysis methods required. Efforts must also be made to improve access to rehabilitation services and job training for the physically disabled and advocate for laws to protect against discrimination and promote the rights of the physically disabled. Mental health professionals could contribute by undertaking long- term studies of the psychiatric and social effects of mine injuries on the victims and their families and communities. These studies should be culturally appropriate and try to determine the kinds of social services, including training in new job skills, which will enable amputees to lead healthy and productive lives. Further research also needs to be undertaken to assess the actual cost of land mine injuries in terms of hospital consumption of services and resources.

Other Health Issues

By 1979, only 50 Doctors remained in Cambodia. Most had either fled the country or been murdered by the Khmer Rouge. By 1988, trained doctors had increased to 303, still far short of meeting the needs of the people (Arnvig, 1994). Infant mortality remains high and malaria and dengue fever pose a major health threat. Initiatives to address this situation, supported by UNTAC and United Nations agencies, have

Complimentary Contributor Copy 132 Roslyn Roberts been introduced; however the life expectancy at birth of Cambodians is 62, almost ten years shorter than neighbouring Vietnam and Thailand (CIA World Factbook, 2010). The increase in IV Drug use, prostitution and child sex industry also led to a HIV/Aids epidemic, however this has almost halved over the past decade from 1.5% to 0.8% of the adult population (World Health Organization, 2005). Despite the decrease in HIV cases, treatment of HIV patients remains a considerable strain on Cambodia’s overburdened health system.

Family Support Network

In the 50+ age group, women outnumber men by 10:7. This is partly due to differences in gender life expectancy, but given that the ratio is one of the lowest in the world, a likely contributing factor is that a greater number of men were killed during the Khmer Rouge regime. As a result, the burden of social restoration rests heavily on the women of the country; many of them are widowed or abandoned and they have to work long hours in physical labour, generally paid lower than their male counterparts, and are often the sole income source in families (Arnvig, 1994). As single parents working long hours, without adequate childcare facilities or family support, the stress has a profound effect on the psychological well being of family members. For those who are married, family life is very different from the traditional Cambodian values of their parents and grandparents. Domestic violence is high, with 74% of those surveyed by a Cambodian NGO stating that they knew of at least one family that experienced domestic violence (Mony and Huong, 2008). Many have lived it first hand with a quarter of all Cambodian women reporting themselves as victims of abuse at the hands of their husbands. Yet, without adequate social and welfare support networks, many women remain in abusive marriages. Boyden and Gibbs (1995) indicate that the increase of marital breakdowns and higher infidelity and domestic abuse was due to the traumas of war. Indeed, the traditional Buddhist values on "family" were difficult to restore after the Khmer Rouge terror. Few examples of “family” remained after the war, and while many of those forced into marriage by the Khmer Rouge dissolved their relationships after liberation, the children of those marriages were either raised in single parent families, or grew up as orphans and did not learn examples of traditional Khmer family values to take into their own adulthood. This combination of post traumatic stress, detachment from emotional connectivity within relationships and desensitisation to violence has created a recipe for increased violence within families and communities. Unable to cope with stress, many Cambodians have resorted to gambling or alcohol, further exacerbating financial and emotional strain on the family (Boyden and Gibbs, 1995).

Yesterday’s Children

Loung Ung (2000, online), survivor of the Khmer Rouge regime, at the Spertus Museum of Judaica, Chicago, Illinois - July 20 (2000) reports:

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I thought it was the anger that kept me safe, kept me looking for food, forced me to go on and live for that next day. I was a very angry kid. I was so angry the supervisor at one of the orphanage camps picked me out of many other children to go and be trained as a child soldier. When instead of like other kids in different parts of the world at age nine, when they were given baseball bats to hit balls, I was given a stick to hit people. When instead of running in the fields, playing soccer, I was taught to run in a zigzag line in the fields, so if people were trying to shoot me, it'd be harder for them to hit me.

Instead of learning about compassion and joy and kindness, I was taught to hate. I was taught to kill. I was taught that people wanted to hurt me. That every one of you out there wanted to kill me. And if you had come across my path, I better take you out first. Save myself. Because the children of the Khmer Rouge were the saviors of the future, and you all wanted us dead. And I grew up with that...I grew up thinking you all gonna kill me.

Few moral parameters remained after the Khmer Rouge rule. Traditional respect by children for parental authority had been eliminated during the Khmer Rouge "brainwashing" years when children were viewed as blank slates with which to indoctrinate the Pol Pot ideology. Additionally, many children were witness to, and often participants of torture, beatings and murders and grew up without any sense of loyalty to family or friends, only knowing loyalty to “Angka”, the Khmer Rouge philosophy. Pran in Greenfield and Locke (1984, p. 86) gives an insightful glimpse into the mind of the typical 1970’s child:

I think the most frightening were the 12 and 13 year old Khmer Rouge soldiers, because they didn't have any humanity, they didn't believe in God, in Buddha, only what the Angka had told them to believe. At least the adults had something in their minds, they might stop and think, 'This is a human being, an innocent person'.

Inculcated in today's adults are many of the values instilled when they were impressionable children of the Khmer Rouge era and reprogramming those values is a difficult task. Now in their thirties and forties, the children of the Khmer Rouge era are now parents themselves; some traumatised by the losses they suffered and what they witnessed in their formative years, others by their own acts of inhumanity, they have few examples of parent-child interactions and bonding to raise their own children in a loving environment. Social programs are being implemented, however there appears to be a need for a re- education process to teach people basic parenting skills and offer mentoring programs for orphans and children of single parent families.

Emotional Traumas and Mental Health

Post traumatic stress disorder and depression is thought to be widespread in Cambodia by some, although others disagree about the level of PTSD present. Certainly, the type of traumas that the Cambodians were subjected to would distress even the most hardened soldier. Witnesses describe the atrocities committed by the Khmer Rouge:

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(they) killed people by cutting out their livers with a knife. . . . Often they ate the livers. . . . Babies were thrown up in the air and came down on bayonets.'' To save bullets, the Khmer Rouge murdered innocents by practicing what they called vaychoul, which consisted of `beating people with the back of a hoe.' (Yan, 1997, p. 141)

As horrifying as it was to witness these acts, any reaction or display of emotion would have resulted in execution. Traditionally, the ability to suppress emotions is seen as a desirable trait and became even more necessary during the Khmer Rouge regime in order to survive. However, post-traumatic stress has manifested itself physically with high reports of nightmares, headaches and other physical ailments (Boyden and Gibbs, 1995). Given a number of culturally specific problems encountered when dealing with Cambodians in a psychiatric setting (Kinzie, 1989), there is a strong need for Khmer trained therapists but mental health resources are severely constrained. The single psychiatric hospital was destroyed by the Khmer Rouge in 1975 and left the country without mental health facilities until 1992. By 2002, there were only 20 trained psychiatrists and 215 individual psychiatric clinical psychologists servicing the entire country (Stockwell, Whiteford, Townsend and Stewart, 2005).

Justice, Recovery and Healing

Justice has been a slow process for the Cambodian people. While under house arrest in 1998, Pol Pot died without ever being brought to trial. Many other former Khmer Rouge leaders have either died or are living anonymously within Cambodia or its neighbouring countries. In July 2010, the trial of the first of five Khmer Rouge leaders saw the conviction of Kaing Guek Eav, also known as “Duch”. He was convicted of crimes against humanity and sentenced to 30 years jail, which sentence was immediately reduced to 19 years. Despite victims being given a voice by being permitted to speak openly at the trial, many Cambodians felt that the sentence was too light and that the light compensation did not sufficiently acknowledge their suffering.

We hoped this tribunal would strike hard at impunity, but if you can kill 14,000 people and serve only 19 years – 11 hours per life taken – what is that? It's a joke. My gut feeling is this has made the situation far worse for Cambodia. It has taken a lot of faith out of the system and raised concerns of political interference. (Theary Seng in Petty and Thul, 2010, online)

Case 0022 went to trial in November 20113,4 and is expected to carry more significance. However, unlike Case 001 where Duch accepted responsibility for most of the charges, Case 002 defendants have not demonstrated any remorse and at the time of this chapter going to the publisher had thus far been uncooperative with the investigations. Additionally, legal changes

2 Case 002 is a trial of four high ranking Khmer Rouge leaders, including Nuon Chea, considered to be the second most powerful leader after Pol Pot. As at 10 April, 2011, when this chapter was being finalised, the trial was close to beginning. http://www.bbc.co.uk/news/world-asia-15814519 3 http://www.bbc.co.uk/news/world-asia-15814519 4 http://www.radioaustralia.net.au/asiapac/stories/201112/s3394371.htm

Complimentary Contributor Copy Cambodia 30 Years on 135 have been made to the upcoming trial proceedings that may render the victims unable to speak out as they were permitted to do in the Duch case. There has been no truth and reconciliation commission for Cambodia, and it appears that the Cambodia Tribunal will be the closest that victims may come to receiving justice. While the South African Truth and Reconciliation Commission contributed toward some sort of closure post-apartheid, the processes of these commissions and tribunals only form part of the healing process. Kaminer et al. (2001) found that a more indicative predictor of healing was the forgiveness attitude of the victim. In Rwanda, there is some evidence of healing through gacaca5 courts which allow lower level perpetrators to confess and ask the families of victims for forgiveness, however King (2010) suggests that the process may be more retributive than restorative. Even after the “Duch” trial, Cambodians were divided in their views of whether Kaing Guek Eav was sincere in asking forgiveness or went far enough to express his remorse to the families of victims (Saliba, 2009). Furthermore, with almost three-quarters of Cambodia’s population too young to remember the Khmer Rouge regime, the past is alien to most and much of what the younger generation knew was gleaned from family members who had survived the regime. For many years, Khmer Rouge atrocities were not included in the school curriculum and it is only in recent years that the government has permitted Khmer Rouge history to be taught in high schools. In 2005, the Center for Victims of Torture, in conjunction with the Transcultural Pyschosocial Organization (TPO) of Cambodia, laid the groundwork for healing with the Trauma Healing Initiative-Cambodia (THI). This program aims to build a network of agencies and leaders to promote healing. However, thirty years have elapsed since the worst days of the war, and the passage of time has meant the number of directly affected survivors has dwindled. Yet, the next generation are also victims and it is today’s children who have inherited the legacy of dysfunction and loss of traditional Cambodian culture.

CONCLUSION

While the Khmer Rouge rule only lasted four years, the effects have been felt for decades. Healing has been slow for the Cambodian people, but there is evidence of a slow rebuilding. Tourism is the second largest source of income and visitors to the country have increased steadily since the Khmer Rouge was disbanded in the late 1990’s. Gradually, the life expectancy has increased and while infant mortality is still unacceptably high, deaths of children under 5 have halved over the past 20 years. There is no single model for healing, nor should there be, as the victims are as individual as the circumstances they encountered. Emotional recovery has been a long process and is still ongoing and there is no dispute as to the severity of what the Cambodian people endured. For those who have never experienced such violence first-hand, it is difficult to fathom how humanity might be restored or whether it is lost forever upon witnessing or participating in violent events. Understandably, this is a question posed by many victims, but one victim articulates her hope and faith in humanity:

5 Gacacais a Rwandan process that attempts to address past wrongs and heal psychosocial trauma.

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If an individual has been exposed to a violent environment, is that individual prone to violence? Can the effect of violence be so strong that it destroys human compassion? A violent environment need only have a short-term effect on human compassion, as it did with me, because compassion cannot be destroyed, it can only be paralysed temporarily.

Sophea Mouth in (Doheny-Farina et al., 2005, p. 179)

Cambodia is a work in progress and hope for the future now rests with its youth. Wiseman (2009) astutely suggests that the younger generation needs to be reconciled in ways that are different to that of the older generation and as such, the reconciliation process must be multi-faceted and involve opportunities to not only remember the past, but to positively impact the future. With this in mind, and an acknowledgement of the past through education and social programs, the Cambodia of tomorrow looks forward to a peaceful future.

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E-Mine. (2009). Cambodia. from http://www.mineaction.org/country.asp?c=6 Gray, T. (2003). To Keep You Is No Gain, to Kill You Is No Loss - Securing Justice through the International Criminal Court. Arizona Journal of International and Comparative Law, 20, 645. Greenfield, F. and Locke, N. (1984). 'April 20 1975 - October 9, 1979 Democratic Kampuchea'. The Killing Fields: the facts behind the film recalled by Dith Pran (p. 86). Hawk, D. (1982). The Killing of Cambodia. New Republic, 187, 17-21. Interview with Loung Ung. (2000). Children of the Holocaust, Children of the Killing Fields. http://www.mekong.net/cambodia/children.htm Kaminer, D., Stein, D. J., Mbanga, I. and Zungu-Dirwayi, N. (2001). The Truth and Reconciliation Commission in South Africa: Relation to psychiatric status and forgiveness among survivors of human rights abuses. British Journal of Psychiatry, 178, 373-377. King, R. (2010). The Healing of Psychosocial Trauma in the Midst of Truth Commissions. The Case of Gacaca in Post-Genocide Rwanda. Paper presented at the Comparative Program on Health and Society Lupina Foundation Working Papers Series 2007-2009, Munk Centre for International Studies. University of Toronto, Canada. Kingdom of Cambodia. (2002). Education for All National Plan 2003-2015. from http://www.moeys.gov.kh/Includes/Contents/Education/EducationAll/Education%20for% 20All%20National%20Plan%202003-2015.pdf Kinzie, D. J. (1989). Therapeutic approaches to traumatized Cambodian refugees. Journal of Traumatic Stress, 2(1), 75-91. Klintworth, G. (1989). Vietnam's Intervention in Cambodia in International Law. Canberra: Australian Government Publishing Office. Landmine and Cluster Munition Monitor. (2009). Cambodia 2008 Key Data. from http://www.the-onitor.org/index.php/publications/display?act=submitandpqs_year= 20 09andpqs_type=lmandpqs_report=cambodiaandpqs_section=%232008_key_data#20 08_key_data Maslen, S. (2004). Mine Action After Diana, Progress in the Struggle against Landmines. London: Pluto Press. Maslow, A. H. (1943). A Theory of Human Motivation. Pyschological Review, 50(4), 370- 396. Ministry of Education Youth and Sport. (2000). Education for all: The Year 2000 Assessment. Country Report. National EFA 2000 Assessment Group, Presented at the Asia-Pacific Conference on Education for All 2000 Assessment, UNESCO Principal Regional Office for Asia and the Pacific, Bangkok, Thailand. Mony, K. and Huong, J. (2008). Cambodian Marriage. from http://ethnomed.org/culture/ cambodian/cambodian-marriage. National Institute of Statistics. (2005). Cambodia Socio-Economic Survey 2004, from http://www.nis.gov.kh/index.php/statistics/surveys/cses/cses2004result Newswire. (2010, October 12). Old Cambodian landmine 'kill dozens in 2010' - AFP. Retrieved from http://www.asiaworks.com/news/2010/10/12/old-cambodian-landmines- kill-dozens-in-2010-afp/ Online Etymology Dictionary. (Ed.). (2010). From http://dictionary.reference.com/browse/ genocide

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Partners for Development. (2010). Cambodia - 2009 Factsheet. Partners for Development. Retrieved 29th November, 2010, from http://www.partnersfordevelopment.org /storage/documents/Cambodia_2009_Factsheet.pdf Partners for Development. (2010). Cambodia - 2009 Factsheet. Partners for Development. Retrieved 29th November, 2010, from http://www.partnersfordevelopment. org/storage/documents/Cambodia_2009_Factsheet.pdf Petty, M. and Thul, P. C. (2010). Senior Khmer Rouge cadre jailed for mass murder, torture. Alertnet.org. Retrieved from http://www.reuters.com/article/2010/07/26/us-cambodia- rouge-idUSTRE66P0EH20100726 Quinn, K. M. (1976). Political Change in Wartime: The Khmer Krahom Revolution in Southern Cambodia (1970-1974). Naval War College Review, 28(4), 3-31. Ross, R. R. (1987). A Country Study: Cambodia (3rd ed., Vol. xxxvi). Accession Number DS554.3.C34 1990 Library of Congress, Federal Research Division, Washington, D.C. Rummel, R. J. (1994). Death By Government. New Brunswick, N.J.: Transaction Publishers. Saliba, M. (2009, February 17th). Civil Parties Attend Justice and Genocide Education Tour. Sharp, B. (2008). The Khmer Rouge in Cambodia: The Unique Revolution. Retrieved 2010, from http://www.mekong.net/cambodia/uniq_rev.htm Stockwell, A., Whiteford, H., Townsend, C. and Stewart, D. (2005). Mental health policy development: Case study of Cambodia. [Article]. Australasian Psychiatry, 13(2), 190- 194. Stover, E., Keller, A. S. M., Cobey, J. M. and Sopheap, S. (1994). Letter from Phnom Penh: The Medical and Social Consequences of Land Mines in Cambodia. Journal of the American Medical Association, 272(5), 331-336. Sydney Schanberg Interview with Elizabeth Farnsworth. (1997). Continuing Unrest. USA: Newshour, June 18, USA: Public Broadcasting Service. Totten, S. (2000). Children of Cambodia's Killing Fields: Memoirs by Survivors. The Social Studies, 91(2), 92. UNICEF. (2010). Cambodia Statistics. from http://www.unicef.org/infobycountry/cambodia_ statistics.html#68 Wiseman, S. (2009). Examining Models of Justice in Post-Genocidal Cambodia. from http://www.dccam.org/Tribunal/Analysis/pdf/Examining_Models_of_Justice_in_Post- Genocidal_Cambodia_by_Savannah_Wiseman.pdf World Health Organization. (2005). Cambodia. from http://www.who.int/hiv/HIVCP_ KHM.pdf Yale University. (2010). The CGP, 1994-2010. Retrieved 16 April, 2001, 2001, from http://www.yale.edu/cgp/ Yan, A. (1997). My mother’s courage. In D. Pran and K. DePaul (Eds.), Children of Cambodia’s Killing Fields: Memoirs by Survivors (pp. 135 – 142). London: Yale University Press.

Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 9

MASS DISASTER RESPONSE: HOW IMPENDING HEALTH CATASTROPHES IN THE DISPLACED POPULATIONS OF POST-WAR SRI LANKA WERE AVERTED

Eeshara Kottegoda Vithana1* and Loyal Pattuwage† 1Monash University, Melbourne, Victoria, Australia

ABSTRACT

During March to May 2009, tens of thousands of people were sandwiched between two warring factions in a small strip of land near the coast in Northern Sri Lanka, with minimal facilities and nowhere to run to. Following the conclusion of the war which saw the end of the Liberation Tigers of Tamil Ealam (LTTE), these people were directed to IDP camps (or welfare villages) by the government of Sri Lanka, until they were resettled back in their villages. The health consequences of this complex humanitarian emergency would have been catastrophic, if not for the timely and effective interventions spearheaded by the Ministry of Health. This chapter outlines the disaster response strategy in providing health services to internally displaced people in an immediate post- war setting.

Keywords: Internally Displaced Population, Conflict Emergencies, Sri-Lanka War

*Eeshara Kottegoda Vithana (MBBS, MSc, MD) headed the Disaster Preparedness and Response Division (DPRD) of the Ministry of Health (Sri Lanka), in the capacity of National Coordinator from January 2008 to January 2010. During his tenure, the DPRD coordinated healthcare provision to nearly 300,000 displaced people in the Northern Province of Sri Lanka. He is currently a Visiting Research Fellow attached to the Monash University Department of Forensic Medicine, Victoria, Australia. † Loyal Pattuwage (MBBS, MSc, MPH) is a medical graduate from Sri Lanka currently based in Melbourne, Australia.

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INTRODUCTION

After nearly three decades of hostilities with no clear winners, the protracted conflict in Sri Lanka was coming to a dramatic finale in May 2009. Between two warring factions, thousands of civilians were crammed into a narrow stretch of land, near the coast, waiting to flee. They were forced to move from one place to another, perhaps more than once, during previous months, sometimes willingly and sometimes by force. They were without basic amenities, short of food and water, tired, malnourished and most of all, scared. With government forces declaring victory, they rushed to freedom only to be directed by the security forces to the Camps of Internally Displaced Persons (IDP camps), the biggest one being situated in Vavuniya, named “Menik Farm”. The Government of Sri Lanka had to take drastic steps to look after the IDPs, and being a developing country with limited resources, they had to work in partnership with various organizations to address immediate needs and plan for the future. Even though the whole country was eager to lend a helping hand, the Ministry of Health had to take the initiative in coordinating, mobilizing and implementing health interventions. Nearly 260,000 people lived in Menik Farm, in June 2009. The Ministry of Health in Sri Lanka had to bear the responsibility of their wellbeing and also had to provide interventions to improve their health status. With almost non-existent infrastructure in the area, with thousands of people needing medical attention for acute and chronic conditions, and with the real-time threat of suicide bombers operating within the community, the Ministry of Health embarked on an ambitious project to cater for their fellow countrymen. Using a collective approach model encompassing numerous government and non-government organizations, riding on mass public support, and employing an efficient work allocation system, it provided a comprehensive health service delivery program. This well coordinated effort in Sri Lanka will be remembered as one of the success stories in mass displacement in contemporary history. The outcome was that the frequently documented high rates of communicable diseases, and higher death rates in such situations in other countries were minimal in Sri Lanka‘s case. This was possibly due to the well-planned and coordinated emergency health services, and the emphasis placed on disease prevention and health promotion.

Background to the War and IDP Crisis in Sri Lanka

Sri Lanka’s 28 year protracted civil conflict between government forces and the Liberation Tigers of Tamil Eelam (LTTE), a militant organization fighting to create a mono- ethnic Tamil state in the North and East of the country, ended in 2009 when the military forces crushed the LTTE (MoD, 2009). Since 1983, several attempts were made by various governments and the LTTE to reach a negotiated settlement. In 2001, the then Prime Minister entered a ceasefire agreement with the LTTE, brokered by Norway (The Guardian - London, 2002). This agreement remained amidst many violations, until 2006. When the LTTE forcibly closed down the “Mavil-Aru” sluice gates in July 2006, thereby preventing thousands of civilians from accessing drinking and farming water in the Eastern province, the government considered it had no option other than to use force. This was followed by retaliatory action by

Complimentary Contributor Copy Mass Disaster Response 141 the LTTE, marking the resumption of hostilities. The fighting ensued, and the government forces took control of all areas held by the LTTE in the Eastern province in July 2007. The military focus then shifted towards liberating the LTTE controlled areas of the Northern Province where the LTTE had established an administrative structure and enjoyed significant command over civilians.

Figure 1. Map of Northern and Part of the Eastern Province of Sri Lanka

HEALTH CARE PROVISION FROM JANUARY TO APRIL 2009 FOR PERSONS TRAPPED IN THE CONFLICT AREAS

As the LTTE held areas shrank with the advancement of government forces in the Northern Province, large number of civilians either willingly or unwillingly followed the retreating LTTE, while some crossed over to the government controlled areas. The people

Complimentary Contributor Copy 142 Eeshara Kottegoda Vithana and Loyal Pattuwage who came into government controlled areas were temporarily settled into IDP camps established in the Northern and Eastern Provinces (Jaffna, Trincomalee, Mannar, and Vavuniya). Medical care needed by these IDPs was initially provided by health authorities from the respective districts (Figure 1). By March 2009, thousands of civilians and the LTTE cadres were confined to a narrow stretch of land along the coast in Mullaitivu (Vellamullaivaikkal) (Figure 1). Medical care services for these people, who were unable to cross over to the government controlled areas, were provided by several government medical officers under the guidance of the Ministry of Health (MoH). The MoH ensured that the medical supplies reached those doctors through the International Committee of Red Cross (ICRC). Patients who could not be managed in the field were transported to General Hospital Trincomalee, by sea, on ships operated under the ICRC flag (ICRC ships). Later, those patients were transported from the Mullaitivu to the Pulmoddai field hospital which had been established with the support of the Government of India. Following initial emergency medical care at Pulmoddai field hospital, these patients were subsequently transferred to the recently upgraded Padaviya Base hospital for further management (refer Figure 1). The patients who needed further specialized medical care were then transported mainly to the Vavuniya General hospital from the Padaviya Base hospital.

Evacuation of People Needing Medical Care from Mullaitivu on ICRC Ships

From 16 March to 20 April 2009, a total of 13,827 people were evacuated from Mullaitivu, of whom 4,517 needed medical care, while the remainder were close family members or guardians of the patients (Table 1).

Table 1. People Needing Medical Care and Evacuated via ICRC Ships

TRINCOMALEE PULMODDAI FIELD TOTAL GENERAL HOSPITAL HOSPITAL Number of ships 10 21 31 Accompanying 3,635 10,192 13,827 family members Persons requiring 1,402 3,115 4,517 medical care

Establishment of Pulmoddai Field Hospital

As a goodwill gesture, the Government of India sent an emergency medical team of 54 members to operate the field hospital at Pulmoddai beach. They carried out the initial medical treatment with the help of medical personnel from the Sri Lanka Navy before transferring them to Padaviya Base hospital. This field facility consisted of two mini theatres, an x-ray facility, a mini laboratory and four wards. Adequate medicines and other supplies were also brought in by the team. Blood transfusion facilities were established by the Ministry of Health. More than 20 ambulances and two buses, converted to carry patients, were kept on stand-by for each ship’s arrival.

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Strengthening of Padaviya Base Hospital

The Padaviya Base hospital acted as the main referral hospital for patients brought in by ICRC ships to Pulmoddai. The Ministry of Health supported the provincial authorities in converting the adjacent garment factory to a medical ward for the patients. This hospital catered to more than 8000 patients from March 2009 to May 2009 including patients from surrounding areas. To provide services for the high number of patients, the hospital was newly equipped with an operating theatre, wards, and reinforced with surgical and medical professionals from other areas. The ICRC also provided two temporary wards to house the patients.

HEALTH CARE PROVISION FROM JANUARY 2009 ONWARDS FOR PERSONS WHO CROSSED OVER TO GOVERNMENT CONTROLLED AREAS

As mentioned earlier, some civilians managed to flee from the retreating LTTE and enter the government controlled areas in the early part of 2009. The numbers were not huge and they were temporarily settled in Jaffna, Trincomalee, Mannar and Vavuniya (city and Cheddikulum). During the early months of 2009, the government started establishing a camp complex at Cheddikulum (a small village 20 km away from the Vavuniya city center) which was later commonly referred to as “Menik Farm”. The first settlement village established at Menik Farm was named “Welfare village (Zone) zero” or “Kadiragamar village”. Two massive influxes of civilians to the government controlled areas were observed in the latter part of April and in mid-May, close to the final days of the conflict. Placing the welfare of the internally displaced population as a high priority, the Government of Sri Lanka decided to temporarily settle the majority (80%) of the civilians in the camps established in Vavuniya district. Many of them were housed in Cheddikulum. As it was unable to predict the size of population trapped in the battle zone, the number of people likely to be housed in the welfare villages could not be estimated a priori. As a result, health authorities from both national and provincial levels found it difficult to plan the services. However, the government went on building additional camps at Cheddikulum (Menik Farm). New welfare villages were therefore added (from Zone 1 – Zone 5) during March to August 2009 (see Table 2).

Table 2. Number of Displaced Persons as of 22nd May, 2009.

DISTRICT NUMBER OF DISPLACED PERSONS Vavuniya (City and Cheddikulum) 266,536 Mannar 140 Jaffna 11,086 Trincomalee 6,642 Patients and their carers in hospitals 10,100 Total 294,504 Source: Government Agent Offices (Vavuniya, Mannar, Jaffna, Trincomalee)

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Health Status of the Displaced

A considerable proportion of the displaced had some kind of illness that needed immediate medical attention. A large number of people had wounds and traumatic injuries, both chronic and acute, acquired during their passage through the Northern Province over the previous months. Dehydration and exhaustion were the immediate problems for a large number of patients who required urgent attention. As in any other emergency of this magnitude, the gathering of more than 260,000 people within a closed geographic area drastically increases the risk of epidemics of communicable diseases. The Ministry of Health Epidemiology unit found a considerable number of IDPs suffering from communicable diseases such as Chicken Pox, Dysentery, Typhoid and Hepatitis A. In addition, there were exacerbations of chronic illnesses such as asthma, diabetes and hypertension.

Communicable Diseases Identified in the Displaced Population

In addition to the above mentioned communicable diseases, there were a few suspected cases of measles, malaria, and meningitis which did not reach epidemic proportions. A significant number of tuberculosis cases were detected among the IDP population. Surprisingly, Dengue fever, which was highly prevalent in other parts of the country, was not identified among the IDP group. The main diseases are listed below. Diarrheal diseases. Diarrheal diseases were identified as the most lethal public health threat to the community, especially in children. Some cases of bacillary dysentery (shigellosis) were also detected within the IDP population. Typhoid. A number of typhoid cases were monitored by the Ministry of Health epidemiology unit and several clinically suspicious cases were reported on clinical grounds. Later arrangements were made to confirm the diagnosis using field test kits. A considerable percentage of cases were confirmed as positive and were treated accordingly. Chicken pox. An epidemic of Chicken pox affected the IDP population with the sudden influx of large numbers of new IDPs from war-torn areas in May 2009. Hepatitis A. An epidemic of Hepatitis A was also detected from IDPs in May 2009.

HEALTH COORDINATION, MASTER PLAN DEVELOPMENT AND HUMAN RESOURCE MOBILISATION

Health Coordination

In January 2008, under the directive of the Minister for Health, the Secretary of Health established the Disaster Preparedness and Response Division (DPRD) to coordinate all health sector planning interventions for emergencies. This unit was empowered to coordinate health care provision to displaced people in January 2009. The core function of the DPRD was to build the infrastructure of the health system in the areas of IDP settlement, to take rapid

Complimentary Contributor Copy Mass Disaster Response 145 measures in case of medical emergencies, to collaborate with all stakeholders involved in provision of care, and to ensure adequate service delivery for the IDP population. Since it was clearly evident that the provincial health authorities were unable to meet the growing health demands of the IDP population, a separate directorate for IDP care based in Vavuniya (called the Health Coordination Centre – HCC) was established under the directive of the Secretary of the Ministry of Health, in May 2009. The HCC acted as a field office for the DPRD, even though the HCC could make independent decisions based on information at the ground level. The DPRD fully supported the functions of the HCC by coordinating inter- ministry, donor agency and intra-ministry activities, and played an active role in mobilizing human and physical resources such as ambulances and medical supplies from other areas. The DPRD was also tasked to manage proper information flow by collecting, compiling and distributing data to the Secretary of Health, relevant government authorities and other organizations. As this entire process required the participation of a large number of stakeholders, in May 2009, the Secretary of Health appointed a National Steering Committee (NSC) as an advisory body to the Ministry of Health (MoH). The NSC comprised representatives from different units within the Ministry of Health itself, professional colleges and associations, trade unions, United Nations agencies (i.e. WHO, UNICEF and UNFPA) and representatives from the provincial health authority. The NSC provided a forum for all stakeholders involved in the process to analyze information provided by the DPRD and to recommend action and to evaluate processes.

Development of the Master Plan

The NSC identified key areas, where interventions were necessary in caring for these IDPs, and which the Ministry of Health subsequently used to develop the “Master Plan”; Key areas that needed interventions identified by the NSC included:

1. Provision of basic food and water 2. Maintenance of a healthy environment 3. Prevention of diseases 4. Treatment of acute and chronic illnesses 5. Caring of people needing special care 6. Ensuring adequate nutritional status 7. Psychological care.

The idea of the Master Plan was to provide a well-coordinated and rapid medical response to reduce avoidable morbidity and mortality among the IDPs at ground level. The Master Plan was prepared in consultation with all stakeholders involved in providing healthcare to the IDPs. The main participants were; Ministry of Health, Ministry of Rehabilitation and Relief Services, Ministry of Defense, Ministry of Disaster Management, Ministry of Social Services, Ministry of Nation Building, United Nations (UN) Agencies and local and international Non-governmental Organizations (INGOs). The capabilities and intended activities of each and every organization were identified and specific responsibilities

Complimentary Contributor Copy 146 Eeshara Kottegoda Vithana and Loyal Pattuwage based on their capacity were assigned to them, preventing duplication of tasks and thus maximizing service delivery. The Master Plan had the following objectives:

 To ensure adequate delivery of curative and preventive health services to IDPs  To provide a conducive environment with special attention to women, children and the disabled  To ensure appropriate referral  To ensure a coordinated health response  To ensure adequate staffing, medicines and equipment at all referral hospitals  To monitor nutritional status, disease trends and respond to potential outbreaks  To provide health information to relevant authorities.

In order to deliver curative and preventive health care services to meet the objectives of the Master Plan, an “Infrastructure Plan” was developed to provide services at ground level (see Figure 2).

Zone 1 Zone 2 Zone 3 Zone 4 Zone 5

Mannar-Madawachchiya Road

Referral Hospital (Centres) Health Coordination Zone 0 Centre

Medical Officer of Health (MOH) Offices MSF Field hospital

Primary health Care Centres

Figure 2. Infrastructure Plan for the IDP Welfare Villages in Menik Farm, Cheddikulum.

Curative Healthcare Services Provided in Menik Farm

Primary Health Care Centers (PHC Centers). Primary Healthcare (PHC) Centers provided basic outpatient services for the IDPs in the welfare villages. There were 21 PHC Centers; 1 PHC center per approximately 13,000 persons. These centers were manned by 2-3 doctors, one nursing officer and a pharmacist/dispenser from 8am to 4pm seven days a week.

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An ambulance was available 24 hours a day to transport the patients to zonal referral hospitals (described next). In addition to providing basic consultations and attending to minor surgeries, “well baby” and “well women” clinics were conducted in these clinics. The Nutritional Rehabilitation Centre, in which onsite nutritional supplements were provided to identified children after screening for malnutrition, was also established and adjoined some of these PHC centers. Zonal Referral Hospitals (Zonal Referral Centers. Four referral hospitals were established within welfare villages (zones 1-4). A referral hospital catered for around 50,000 people. In addition to out-patients’ department (OPD) and in-ward facilities, these hospitals were equipped to treat medical emergencies. Four to six medical officers were appointed to each hospital and in addition, consultant physicians, gynecologists and obstetricians, pediatricians and general surgeons conducted clinics. The first zonal referral hospital was established by Medical Teams International (MTI) in Zone 2 using a structure provided by the government. It contained 75 beds for inpatients, an OPD, an emergency treatment unit, a pharmacy, an emergency delivery room, on-call rooms for doctors and nurses, and a laboratory. This was the biggest referral center established in Menik Farm. The second referral hospital was established initially with the support of the MTI in Zone 4. Later, it was completed by AISPO (Associazione Italiana Solidarietàtra I Popoli), an Italian NGO supported by the Government of Italy. This 30 bed facility consisted of a pharmacy, laboratory, OPD, and an incinerator for waste disposal. The Zone 3 referral hospital was constructed by the World Health Organization (WHO) and equipped by Mercy Malaysia, a Malaysian NGO. This had a separate OPD, an Emergency Treatment Unit, on-call room for doctors and nurses, and a laboratory. The first dental clinic was established by the Ministry of Health in this referral centre. The Government of India established another referral hospital in Zone 1. This hospital was manned by medical teams from India, and no Sri Lankan medical teams were posted there. There were no referral hospitals established in Zone 0 and Zone 5, but two PHC centers in these zones carried out some of the functions of a referral center. Mobile Health Services:. Initially, health services were covered by mobile medical teams until the PHC centers were established in March 2009. Médecins Sans Frontières (MSF-France) Field Surgical Hospital:MSF France established a field surgical hospital in Menik Farm (refer to Figure 4). This 100 bed surgical facility contained two operating theatres.

Curative Healthcare Services Provided Outside Menik Farm

Base Hospital Cheddikulum: This is the closest public hospital to Menik Farm and is situated 5 kilometers away from the village. Although this hospital had been upgraded to a Base Hospital, the required facilities were not available. Following the establishment of a welfare village in Menik Farm, the Ministry of Health (MoH), along with the Provincial health authorities, took necessary steps to upgrade the facilities. The development plan for this hospital was made by the DPRD with the assistance of the provincial health authorities and consisted of a theatre, blood bank, temporary wards, a premature baby unit, a labour

Complimentary Contributor Copy 148 Eeshara Kottegoda Vithana and Loyal Pattuwage room, and an X-ray department. This project was funded by the German Red Cross, AISPO (Associazione Italiana Solidarietàtra I Popoli), and UNICEF. For the first time, teams of medical officers and nurses from other provinces worked in this hospital on a temporary basis. Later, the MoH took measures to appoint permanent staff to the hospital (see Table 3). Provision of accommodation facilities to the hospital staff was the biggest challenge faced in upgrading the hospital, but these facilities were later established with the support of the WHO.

Table 3. Improvement of Base Hospital Cheddikulum.

21 MARCH 2009 30 SEPTEMBER 2009 Beds 150 421 Consultants 0 6 Medical Officers 2 40 Nurses 5 50

Five temporary wards were added to accommodate pregnant mothers who were admitted after 37 weeks of pregnancy. Some of the mothers were willing to be admitted after 37 weeks of pregnancy, while others preferred to stay with their families until full term. Therefore, it was necessary to provide Emergency labor room facilities in referral centers established at welfare Villages in Menik Farm, even though the Base hospital of Cheddikulum acted as the main obstetric care facility. Emergency care in the French Field Hospital:.The Ministry of Health, with the assistance of the Government of France, took the necessary steps to establish a temporary hospital within the premises of the Base Hospital of Cheddikulum. It provided healthcare for the patients who needed surgical treatment. This field hospital was set up on the 27th of April 2009 and became functional by the 28th of April 2009. The hospital had 60 beds, an operating theatre, a 16 bed Intensive Care Unit (ICU) including X- ray and UltraSound facilities. The hospital was fully managed by a medical team from France and received patients from the Base Hospital Cheddikulum. General Hospital Vavuniya:This was the major referral hospital used for IDP care during the conflict; it is situated 20 kilometers away from Cheddikulum. With the help of donors, the Ministry of Health, together with the provincial health authorities, upgraded the hospital to cater to ever increasing numbers of IDPs in the emergency phase. Surgical wards were expanded to provide services for the injured; child care was also improved with the expansion of the paediatric ward. The Ministry appointed consultants for all specialties and theatre facilities were also improved in this hospital including orthopaedic care. Patients, who required further specialised care, were transferred to major hospitals such as the National Hospital Colombo and the Teaching Hospital in Kandy.

Preventive Healthcare Services Provided in Menik Farm

Before the month of May 2009, preventive health services for IDPs were provided by the Medical Officer of Health (MOH), Cheddikulum. Then, the Health Coordination Centre (HCC) established a separate preventive health care system in Menik Farm. This included the

Complimentary Contributor Copy Mass Disaster Response 149 setting up of MOH offices in each major zone. These MOH offices and supporting staff (Public Health Inspectors (PHI), Public Health Nursing Sisters (PHNS) and Public Health Midwives (PHM)) were mobilized from other provinces. They were involved in managing nutritional rehabilitation centers, carrying out immunizations of children, grass-root level provision of basic maternal services, environmental sanitation and prevention of communicable diseases.

Prevention and Control of Communicable Diseases

Prevention and control of communicable diseases, case management, and surveillance are three key components of the humanitarian response that provides major opportunities to reduce suffering and death in war-affected populations (Connolly, 2005). The Ministry of Health (MoH) responses in combating communicable diseases in IDP, in relation to the above mentioned key components, are outlined below. The key general interventions included:

1. Provision of adequate and safe water supply. 2. Provision of sufficient sanitary facilities. 3. Safe and adequate food supply to IDPs; hygienic measures at all community kitchens were regularly monitored by PHIs. 4. Establishment of prevention health facilities (Medical Officer of Health offices) in Welfare camps. 5. Deployment of adequate health staff, including doctors designated for preventive health (MOH), PHMs and PHIs. 6. Improving the nutritional status of children under five by establishing nutritional feeding centers which were attached to primary healthcare facilities in Menik Farm. 7. Vector control activities were carried out with participation of the local authorities and community. 8. Chlorination of water was monitored and regular water quality checking, including degree of bacterial contamination, was carried out at field laboratories and at the Medical Research Institute in Colombo. All drinking water tank trucks entering zones were checked for chlorine levels at the entrance to the zone by trained volunteers. Chlorine levels of water were also tested by the PHIs at delivery points (i.e., taps). 9. Routine immunization of all children at field hospitals was carried out and a mass immunization campaign was conducted. 10. Health promotion programs were conducted to educate people to maintain hygiene at the most optimal level possible.

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OUTCOME OF THE INTERVENTIONS

Incidence of Communicable Diseases in Menik Farm from June to October 2009

Diarrhea was the main threat during the initial stages among the IDPs followed by dysentery, hepatitis A and chickenpox (see Figure 3). The number of cases of diarrhea peaked during June and fluctuated thereafter with several outbreaks occurring in July and the latter part of September. Dysentery and hepatitis A peaked in June, but was kept under control thereafter. The number of typhoid cases was steady except in early part of July, when a minor outbreak was detected. Even though chickenpox remained active throughout the whole period, it did not increase to epidemic proportions except in June (Vithana, 2011).

Figure 3. Incidence of Communicable Diseases in IDP Population in Menik Farm From June To October 2009 (Vithana, 2011).

Mortality in Menik Farm from Late May to September 2009

The Crude Mortality Rate (CMR) most accurately represents the health status of emergency populations (Toole and Waldman, 1997). In complex emergencies, the CMR is often expressed as the number of deaths per 10,000 population per day (daily CMR) during the acute phase of the emergency (Checchi and Roberts, 2005; The SPHERE Project, 2004). In the case of the welfare villages in Sri Lanka, the daily CMR peaked at 0.7 at the end of May 2009 (Vithana et al., 2011) (see Figure 4). This number encompasses all the deaths of IDPs registered in Menik Farm, irrespective of whether they died in the welfare village itself or in the hospital (within the zone or outside the zone). The figure was hovering around 0.5 in June 2009, but dropped further to less than 0.25 from July onwards. Altogether, the CMR at Menik Farm was at exceptional 0.11 deaths per 10,000 persons for the 5 month period

Complimentary Contributor Copy Mass Disaster Response 151 starting from June to October 2009, compared to the entire Sri Lanka population which was around 0.16 for 2008 (Vithana et al., 2011).

Figure 4. Daily Crude Mortality Rate (daily CMR) from 27 May to 24 September in Menik Farm (Vithana et al., 2011).

ISSUES AND CHALLENGES

The conflict that raged for more than two decades had left the health services and infrastructure of the Northern Province of Sri Lanka in disarray. Even though the government ensured that the wages of health personnel were duly paid and essential medical supplies reached the hospitals during the conflict, it could not carry out the proper administration, development and quality assessment work effectively, because these areas were either under the control of the LTTE or affected by the ongoing conflict. Therefore, the development of health infrastructure to cater for IDPs was a real challenge in the initial stages. When IDPs started arriving en masse, health workers had to be mobilized from other areas of the country. It was difficult to provide accommodation and other facilities such as food to those health workers deployed in Menik Farm. This resulted in almost all health workers lodging either in Vavuniya (around 20 km away) or in Anuradhapura (around 50 Km away), leading to their having to make daily trips to the welfare villages that took more than

Complimentary Contributor Copy 152 Eeshara Kottegoda Vithana and Loyal Pattuwage an hour one-way, on very uncomfortable roads. Subsequently, with the support of several donor agencies, the Ministry was able to provide accommodation for more than 150 health workers within the Cheddikulum area. In addition to tackling health issues directly, the Ministry of Health (MoH) had to supervise the provision of clean drinking water, food, sanitary facilities and garbage collection and disposal services for the welfare villages, even though these services were provided by other ministries and provincial authorities (Ministry of Defense, Northern Provincial Council, and Ministry of Water Resources etc.). This was a real challenge initially due to shortage of manpower. To address this problem, the MoH mobilized Public Health Inspectors (PHIs) from other areas and appointed newly recruited PHIs to welfare villages which resulted in improved monitoring. Communication within and outside the area was another challenge. There were no fixed- line telephone facilities in most areas, including Menik Farm. Mobile telephone coverage by commercial service providers was also minimal or non-existent. Therefore the government had to install Code Division Multiple Access (CDMA) services for telecommunication purposes. Provision of a number of CDMA phones through various agencies facilitated communication. Control of high incidence of communicable diseases such as diarrhea, chicken pox and hepatitis and prevention of potential epidemics such as dysentery, typhoid and malaria were another challenge encountered when caring for the IDPs. By employing preventive measures, prompt case management and effective disease surveillance, the situation was brought under control within a short period of time. As the provision of healthcare in this type of complex emergency needs concerted efforts by various agencies and individuals who have various interests and agendas, coordinating their activities to achieve a common objective was also a serious challenge. However, the MoH managed to coordinate such activities and provide guidance to all stakeholders that ultimately resulted in satisfactory health outcomes.

LESSONS LEARNED

The mortality and morbidity of the IDPs were consequences of direct and indirect effects of the conflict. Injuries, disabilities, and mental trauma were the direct results of the conflict. The collapse of the health system and social structure during the protracted conflict contributed to an increase in chronic diseases, nutritional deficiencies and infectious diseases that indirectly resulted in morbidity and mortality. It is these preventable indirect effects, and not the direct effects from violence that are responsible for the vast majority of morbidity and mortality specially in developing countries (Burkle, 2006). As mentioned earlier, this was the biggest ever displacement of people known in Sri Lanka and the health sector was overwhelmed with work, as it tried to respond quickly and effectively to minimize the risk of death and diseases among the IDPs. Even though the health sector response was a huge challenge especially at the initial stages, it was ultimately a success compared to some other mass displacements that occurred in other parts of the world, during the last two decades. It was possible to successfully manage human resources and coordinate the activities due to the establishment of the Disaster Preparedness and Response Division (DPRD) in the

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Ministry of Health. The DPRD coordinated the mobilization of human and physical resources, and other logistics in a timely and efficient manner. The National Steering Committee (NSC) for IDP care directed the operations of the DPRD and would be a suitable model to manage any national scale emergency. It included representatives from different sections of the Ministry of Health, as well as professional bodies and trade unions, who would brainstorm and recommend suitable actions. The advantage was that because these representatives held considerable administrative power in their respective organizations, they took responsibility in fulfilling the tasks they agreed to, at the NSC meetings. Therefore, the MoH did not have to face bureaucratic hurdles when dealing with other stakeholders. In addition, they had the opportunity to access information at ground level and knew the roles the other stakeholders played. This prevented unnecessary criticism of other stakeholders and instituted a sense of common responsibility, promoting understanding and accountability for the actions. The trade unions, which are well known to be at loggerheads with the government, worked together with government agencies to successfully mobilize health workers. This was very useful in the initial stages, when the MoH found it difficult to authorize transfer of health workers, not because they were not willing, but because of administrative issues. Because of the support extended by the trade unions and provincial authorities, the mobilization of health workers from different parts of the country as well as motivating them to carry out a national emergency initiative became a tremendous success. Their commitment toward their fellow countrymen, who had undergone severe hardships, was commendable and showed the unity of the Sri Lankan health sector during crisis situations. Another lesson learned was the importance of developing a plan to address the issues that would immediately follow the emergency response. Transferring the patients who need further medical care to hospitals in other areas would have put more strain on the health services that were already stretched. The development of Cheddikulum hospital was an example where a long-term plan was developed alongside the emergency response plan. During the emergency period, this acted as a referral hospital for patients in welfare villages and after these villages were disbanded, it would add strength to the health care infrastructure in an area that had seen little improvement in nearly two decades. The IDPs were not a homogeneous group. They had women, children, aged persons and the disabled whose needs were quite different from the norm. Agencies dealing with this particular section of the population operated under the coordination of the MoH and helped in the provision of needed services to these target groups. For example, UNICEF supported the Nutritional rehabilitation and childhood immunization programs. The United Nation’s Population Fund (UNFPA) provided vehicles for medical professionals to conduct women’s clinics. The WHO provided vaccines and medical instruments and funded health infrastructure development. The United Nations High Commissioner for Refugees (UNHCER) provided tents for the families. Even though there were some criticisms from various quarters (Amnesty International, 2009) about holding the IDPs in camps, the MoH found that taking care of the population when they are confined to a specific geographical location has many advantages, compared to when they are scattered in different areas. Living in a camp environment helped the MoH to identify their health needs and plan appropriate health services. It was also learned that coordination of various governmental and non-governmental organizations and service delivery were feasible under such circumstances. Perhaps this lesson is not unique to Sri

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Lanka, as there is evidence to suggest that people living in properly run camps fare better than resident populations (Aaby et al., 1999). A confined population also makes it easy for data collection and interpretation with confidence. Unaccounted changes in numbers of people in a geographical area can lead to inaccurate denominators when health indicators are calculated and might lead to spurious results (Toole and Waldman, 1997); this was prevented by having a segregated community and added reliability to the outcome data. Having a confined community also made it easy to identify the role that each agency could play, thereby preventing service overlap and improving efficiency. In fact, these advantages could have turned into a disaster if there had been outbreaks of diseases, and the MoH being aware of this, strengthened its preventive, curative and surveillance activities and promptly responded to any suspected cases. It is worth noting that welfare camps in Sri Lanka attracted considerable negative publicity on international media (Amnesty International, 2009). There were unsubstantiated allegations about mass starvation, torture and rape in these camps (Unheard Voices, 2009).. Most of the issues encountered during the operations with some INGOs were mainly due to their either not attempting to understand the political and security situation, or trying to push their own agendas instead of that of the national interest.

DISCUSSION

The response of the Ministry of Health to this crisis assumes more importance than any other IDP issue handled by the same ministry for several reasons. First, it had no information on how many persons would escape to the government controlled area because of the unavailability of data; no proper census had been carried out in the Northern Province after the 1981 island-wide census. In 2001, during the time of the Norway brokered ceasefire, the LTTE refused to let the government officers carry out a census in some districts of the Northern Province. Therefore the government was left with guesstimates provided by several international organizations and the Department of Census and Statistics of Sri Lanka. During the last stages of the war, these figures proved to be underestimates. Unlike a natural disaster, there were other factors that needed consideration. There was a high possibility of LTTE suicide bombers posing as civilians and carrying out explosive attacks. This had happened before and the Ministry of Defense (MoD) wanted to avert this possibility completely; the Ministry of Health (MoH) had to ensure the safety of its staff, as well as not allowing any criminal element to escape into or from the welfare village under the guise of being a patient, family member or heath care provider. That meant it had to confine all its prevention and treatment interventions to that defined area as much as possible. The MoH was the main actor responding to the health needs of the population, but the administration of welfare villages was under the Ministry of Defense; so the MoH had to carry out its duties under the surveillance of the MoD. The establishment of the Disaster Preparedness and Response Unit (DPRD) of the Ministry of Health served as the pivotal point in this whole scenario. Support extended by donor agencies and friendly countries, including the governments of India and Italy, was excellent. The lessons learned by working with more than 80 Donor agencies in the post-tsunami health sector rehabilitation were useful for the MoH in

Complimentary Contributor Copy Mass Disaster Response 155 collaborating with donors effectively. They were given specific tasks with clear guidelines, based on the Master Plan developed by the Ministry of Health (which they were also a part of). Memorandums of Understandings (MOUs) were signed with donor agencies, enabling them to officially carry out their work. This was necessary because the camps functioned under the Ministry of Defense. It would have been difficult to provide food for the displaced during the initial stages if not for the support given by the general public. They donated dry food, bottles of water and clothes, to be given to their fellow countrymen who had become displaced. These donations came through various local charitable organizations and eased the pressure on the government sector. Comparisons between the mortality rates of the IDPs in Menik Farm with similar situations across the world give a clear picture of the effectiveness of the above outlined strategies. According to the Sphere project guidelines (Checchi and Roberts, 2005; The SPHERE Project, 2004), which is an initiative to define and uphold minimum standards in a disaster situation, the baseline reference for the Crude Mortality rate (CMR) in South Asia is 0.25 per 10,000 per day. When it reaches a daily CMR of 0.5 during an emergency, a prompt response is warranted as it signals a public health emergency. Apart from late May and early June, the CMR in the IDP population in Menik Farm never exceeded a daily CMR of 0.5 and remained below 0.25 throughout. The CMR in Afghanistan was 0.6 in 1993 and 2.6 in 2001 (Gessner, 1994; Salama, Spiegel, Talley and Waldman, 2004). In Liberia, it was 14.3 (Nabeth, Michelet, Le Gallais and Claus, 1997; Salama et al., 2004) and in Bosnia and Herzegovina, it was around 1.0 (Salama et al., 2004; Toole, Galson and Brady, 1993). In the 0-4 year age group, the CMR was 0.09 compared to national figure of 0.08 (Vithana et al., 2011). Therefore, when compared with other similar settings (Salama et al., 2004), Sri Lanka had done exceptionally well and can serve as a role model. It is also worth noting that, in most other settings, mortality data were collected using survey methods that can carry some degree of bias (Checchi and Roberts, 2005; Toole and Waldman, 1988, 1997), but in the case of IDPs in Menik Farm, all the data came from routine data collection mechanisms that were strictly monitored. Therefore it can be strongly argued that the IDPs in Menik Farm welfare village in Sri Lanka had far better mortality outcomes compared to IDPs in similar settings in many other countries. In conclusion, a major health catastrophe in the IDP population in Sri Lanka was prevented by instituting timely interventions and efficient collaboration of stakeholders lead by the Ministry of Health, and by the support given by various organizations and the general public. The existence of a well-established health care system in the country facilitated this task.

ACKNOWLEDGMENTS

This chapter is based on personal experience of Dr. Eeshara Kottegoda Vithana and the report titled “Health Sector Response to IDPs in Sri Lanka,” edited by Kahandaliyanage A, Mehta FR and De Silva S, produced by the Ministry of Health (Sri Lanka). Dr. Vithana is one of the contributing authors in that report and accepts full responsibility for the information, integrity of data and analysis given in this chapter.

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We would like to thank Dr.Thushara Ranasinghe (Ministry of Health, Sri Lanka), who was the coordinator/operations at the DPRD during Dr. Vithana’s tenure and Dr. Chandrasegarar Soloman (UNICEF, Sri Lanka) for their support in providing more information. We would also like to thank Mr. Roland Dilipkumar (WHO, Sri Lanka) for preparing the map of Northern and Eastern provinces of Sri Lanka.

REFERENCES

Aaby, P., Gomes, J., Fernandes, M., Djana, Q., Lisse, I. and Jensen, H. (1999). Nutritional status and mortality of refugee and resident children in a non-camp setting during conflict: Follow up study in Guinea-Bissau. BMJ, 319(7214), 878-881. Amnesty International. (2009). Sri Lanka: Unlock the Camps in Sri Lanka: Safety and Dignity for the Displaced Now - A Briefing Paper (10 August 2009). Retrieved 14/12/2011, from http://www.amnesty.org/en/library/asset/ASA37/016/2009/ en/5de112c8- c8d4-4c31-8144-2a69aa9fff58/asa370162009en.html Burkle, F. M. (2006). Complex humanitarian emergencies: A review of epidemiological and response models. J Postgrad Med, 52(2), 110-115. Checchi, F. and Roberts, L. (2005). HPN Network Paper 52: Interpreting and using mortality data in humanitarian emergencies: A primer for non-epidemiologists. Retrieved 14/12/2011, from http://www.odihpn.org/documents/networkpaper052.pdf Connolly, M. A. (2005). Communicable Disease Control In Emergencies: A Field Manual. Geneva: World Health Organization. Gessner, B. D. (1994). Mortality rates, causes of death, and health status among displaced and resident populations of Kabul, Afghanistan. JAMA, 272(5), 382-385. MoD. (2009). LTTE defeated; Sri Lanka liberated from terror, Ministry of Defence and Urban Development, 14/12/2011, from http://www.defence.lk/new.asp? fname =20090518_10 Nabeth, P., Michelet, M. J., Le Gallais, G. and Claus, W. (1997). Demographic and nutritional consequences of civil war in Liberia. Lancet, 349(9044), 59-60. Salama, P., Spiegel, P., Talley, L. and Waldman, R. (2004). Lessons learned from complex emergencies over the past decade. Lancet, 364(9447), 1801-1813. doi: 10.1016/S0140- 6736(04)17405-9 The Guardian - London. (2002, 22 Feb). Ceasefire raises Sri Lankan peace hopes, The Guardian (London). Retrieved from http://www.guardian.co.uk/ world/2002/feb/ 22/srilanka1 The SPHERE Project. (2004). Humanitarian charter and minimum standard in disaster response. Geneva: Steering committee for humanitarian response. From http://www.sphereproject.org/content/view/115/5/lang,english/ Toole, M. J., Galson, S. and Brady, W. (1993). Are war and public health compatible? Lancet, 341(8854), 1193-1196. Toole, M. J. and Waldman, R. J. (1988). An analysis of mortality trends among refugee populations in Somalia, Sudan, and Thailand. Bulletin of the World Health Organization, 66(2), 237-247.

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Toole, M. J. and Waldman, R. J. (1997). The public health aspects of complex emergencies and refugee situations. [Review]. Annual Review of Public Health, 18, 283-312. doi: 10.1146/annurev.publhealth.18.1.283 Unheard Voices. (2009). Protected: world in our eyes. http://reginidavid.wordpress.com/ Vithana, E. K. (2011). Provision of health services to 300,000 Internally Displaced Persons (IDPs) in Sri Lanka. Paper presented at the SPHPM Seminar, Monash University on 08 June 2011. Vithana, E. K., Ozanne-Smith, J., Samarasekara, A. and Ranasinghe, T. (Under review). Mortality rates as a measure of an emergency situation: Sri Lanka post civil - war, 2009 [Submitted to Journal of Emergency Management].

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 10

21ST CENTURY WARFARE: CAN DEPLOYMENT RESILIENCE ASSIST THE RETURN TO CIVILIAN LIFE?

Jacques J. Gouws Human and System Interface Consulting Inc., Hamilton, Ontario, Canada

ABSTRACT

Deployment in theatres of war challenges soldiers at the very core of their existence. Most soldiers display exceptional resilience, resourcefulness and creativity in dealing with the unique dilemmas of modern combat operations. However, Returning soldiers are thus faced with a new conundrum – managing not only the challenges stemming from their own deployment experiences – but also being criticised for their role in previous military operations in the light of ever changing political rhetoric. This results in a loss of meaningfulness for having engaged in the war on behalf of the country, and adds to the mental anguish soldiers have regarding their war experiences. This, in turn seriously undermines what resilience may be left to cope with the aftermath of these traumatic events. The “War on Terror” in Iraq and Afghanistan equally evokes similar challenges for the veterans of these battlefield engagements, begging the question: Can resilience demonstrated in deployment assist individual soldiers (who are without obvious mental health concerns) in adjusting to civilian life when they come home after facing the challenges posed by waging counter-terrorism warfare in the 21st Century?

Key Words: Deployment Resilience, Returning Soldiers, Modern Warfare

 Contact: [email protected]. With special contribution of psychologist, song writer, and Vietnam Veteran - Carroll Ray Thomas.

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INTRODUCTION1

Governments make policy decisions every day, mostly claiming the best interests of the nation, but in reality also seeking the public’s approval that would keep the political party in power, come the next round of elections. That is after all what democracy is about. On the other hand, the world we live in, now more than ever before, is also a much more dangerous place: since the end of the Cold War, the enemy has become all but invisible, its tactics no longer adhere to the ethics of war, nor the rules of engagement, and its weapons arsenal consists of otherwise relatively safe and harmless tools, such as box cutters, and public transportation vessels, such as aircraft. The lesson of 9/11 was a wake-up call that guerrilla warfare has finally transcended national borders and gained the ability to strike at the heart of otherwise untouchable countries. In the easily accessible high-tech world of internet, webcams, and social websites, radical political messages flow fast and furious, reaching ever greater numbers of people with images that evoke reactions in society in ways that governments cannot match, let alone control or refute. It is therefore not surprising that the political jargon espoused by government spokespersons may vary greatly from day to day in response to claims by radical groups that collectively represent the entity against whom the “War on Terror” is directed. However, politics and warfare are quite different entities that involve human endeavour at very different levels. Decisions made from the comfort of boardroom chairs are far removed from the rigours faced by the soldiers deployed in remote parts of the world, fighting an invisible enemy ensconced within the civilian communities where this war on terror is being waged. Against this background, an extraordinary degree of endurance, and thus resilience, is required from soldiers who are deployed in these operations. The main thesis of this book series2 postulates that resilience can be broadly understood, as enabling people to maintain stability and enhance continuity. The organizational structure in combat zones is such that soldiers can rely on each other and their leaders. The mutual support they give each other serves to build and strengthen resilience, even though the impact of the combat events may be severely disruptive and cause significant mental anguish. This level of support, however, changes dramatically at the end of the deployment when the soldiers return to their home countries and families. Instead of having their comrades to rely on, they often find themselves left alone to their own devices with little in common with the family and friends they are returning to.

1 Jacques J. Gouws, D.Phil., C.Psych., operates a private clinic (Gouws & Associates Psychologists) and a psychology consulting business. A former South African Air Force officer and military psychologist, Dr. Gouws both researched and gained extensive firsthand experience, of the resourcefulness required from soldiers and their commanders, when faced by the insurmountable obstacles posed by the stress of being deployed in combat zones (complicated by the pressures from the international political arena, the reactions of the civilian population to the casualties of battle, as well as the strain placed on society in general), during long term sustained military operations. He consults and lectures on the psychological effects and impact of war, and provides treatment of PTSD to veterans, police, and firefighters. 2 The Editors of this book have produced three other books concurrently and subsequently with this text. All three are published by Nova Science and can be found in the reference list under Celinski and Gow (2011), Gow and Celinski (2011), and Gow and Celinski (2012).

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THE CHALLENGE OF COMING HOME

The most significant challenge for returning soldiers is how to reintegrate successfully into society, once their tour of duty had ended. They carry with them the visible and invisible scars of their deployments, but these are not well understood, or even acknowledged, by the society that sent them into combat in the first place. Once the soldier returns to civilian life, these experiences take on a life of their own when the soldier is faced by the challenge of civilian reintegration amidst the government’s “political spin of the day” in media reports on combat events, which often convey contradictory reasons for the ongoing conflict. Soldiers’ deployment in the aftermath of combat are often denigrated by the popular, yet ever changing socio-political re-examination of past events based on hindsight and years of trying the “facts” in the court of public opinion (such as the Vietnam War). Society itself often becomes confused by the ever-changing political rhetoric as the government of the day attempts to respond to the hi-tech messages from the opposing (terrorist) forces on the one hand, but also the powerful challenges from opposition parties and pressure groups on the other hand. Where initially society saw the need for, and supported the use of military force, the passage of time changed the perspective and what previously was a clear-cut course of action, is no longer as viable a solution. Subsequently, soldiers who had been able to endure the rigours of the battlefield may now be faced with an even greater challenge: defending their role in operations, which continue to be depicted in different terms by the ideological spin put on them by friend and foe alike. These soldiers came back to a very different world and they have to find their place again, this time not with the support of the combat unit, but largely on their own, as individuals. What was familiar before the deployment had become a very changed world to which they return. Even for soldiers who are not, at least on superficial observation, affected by their experiences and presenting with diagnosable mental health concerns, it is no easy task to reintegrate in civilian society. This is aptly illustrated in the following editorial from The Lancet (January 2010):

Social readjustment can also be a problem. When soldiers return from tour, they are euphoric with survival and the return to family and friends. Normality after months of continuous exposure to life-threatening danger and adrenaline-fuelled aggression is not easy. As the euphoria subsides, some soldiers get caught up in various negative experiences: boredom, the comfort of alcohol, sleeplessness, anxiety, restlessness, and antisocial behaviour with criminal consequences. Many find their experiences difficult to talk about (p. 277).

Not only have the soldiers psychologically been altered by their combat experiences, but society has changed and it responds very differently now to the news media snippets of war, than when the soldiers departed on their deployments. The challenge, however, is not only the changes that took place because of geographical separation (society the soldier left behind going into the theatre combat), but because soldiers themselves are different from other members of their society:

Soldiers are not as other men – that is the lesson that I have learned from a life cast amongst warriors. The lesson has taught me to view with extreme suspicion all theories and representations of war that equate it with any other activity in human affairs. War undoubtedly connects, as theorists demonstrate, with economics and diplomacy and

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politics. Connection does not amount to identity or even to similarity. War is wholly unlike diplomacy or politics because it must be fought by men whose values and skills are not those of politicians or diplomats. They are those of a world apart, a very ancient world, which exists in parallel with the everyday world but does not belong to it. Both worlds change over time, and the warrior world adapts in step to the civilian. It follows it, however, at a distance. The distance can never be closed, for the culture of the warrior can never be that of civilisation itself. All civilisations owe their origins to the warrior; their cultures nurture the warriors who defend them, and the differences between them will make those of one very different in externals from those of another (Keegan, 1993, p. xvi).

It is this different world, to which soldiers are returning, that challenges them in a way they have not been prepared for. They are not understood, nor do they understand the society they are coming back to. Thus, they need to rely on their individual resilience and resourcefulness to manage the challenge of a society that is in a perpetual state of fluidity, this simply because of the incredible rate at which ideological beliefs and political opinions change. Returning soldiers speak a different language and, while they may be heard, they are neither understood nor listened to. It is therefore not surprising that soldiers will try to cope with the developing inner conflicts after their return to civilian life in what for them now is an alien society, as expressed in poems such as this one by Carroll Ray Thomas3:

I LAUGH TO KEEP FROM CRYIN’

I laugh to keep from cryin’, Everybody thinks I’m cool. I laugh to keep from cryin’, Nobody knows this fool.

Nobody knows, Nobody can tell, This young body they’re looking at Is but a corpse escaped from hell.

How could anyone really know, How could anyone really see, How that God-awful war

3 Carroll Ray Thomas (aka “The Old Man”) commenced his basic combat training on September 13, 1966, with the 4th Platoon, Company A, 2nd Battalion, 1st Brigade, Fort Campbell, Christian County, Kentucky (101st Airborne Division home base). His exemplary conduct during his military training period was recognized officially. On June 27, 1967, he was deployed to Ben Hoa, Republic of South Vietnam, Southeast Asia. His service in Vietnam was equally exemplary, and he was awarded the Vietnam Service Medal with 2 Bronze Service Stars, Vietnam Campaign Medal with Device, Purple Heart “for wounds received in action on 19 May 1968”, and the Bronze Star Medal “for meritorious achievement in ground operations against hostile forces” on 21 June, 1968. He completed his Active Duty Enlistment on September 12, 1969. After obtaining his Ph.D. from the University of Arizona, he worked as a Clinical and Counseling Psychologist, consulting with Vietnam Veterans Readjustment Counseling Center, Vet Center, Veterans Administration, Las Vegas, Nevada. He is the Writer and Co-producer of “A Vietnam Veterans Remembers,” Rabbit Trail Roads (SESAC), performed and recorded by Bob Stamper 1990; Vietnam Veterans of America, Life-time Member; 1982 to present. He is in Private Practice as a Clinical and Counseling Psychologist, Las Vegas, Nevada. The author gratefully acknowledges the kind permission granted by Dr. Thomas to use this and some of his other poems in this chapter to illustrate the journey of one soldier’s return to home after serving his country in Vietnam.

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Took its toll on me.

I laugh to keep from cryin’, Everybody thinks I'm cool. I laugh to keep from cryin’, Nobody knows this fool.

© Carroll R. Thomas, 1968/1983

More than anything else, the above poem places a perspective that is easily overlooked when observing returning soldiers: they seem changed and family and friends comment on that, but the soldier remains quiet and non-committal as people inquire about their experience and the war. It is in the anonymity, as tragically expressed in this poem, that soldiers find the tools to cope with their war-related memories in a society that does not really care as much for the human aspect as for the sensational stories that they hope to hear. Not talking about these experiences means that they do not have to explain anything to those who can only criticise from their ignorance rather than their experience, whether military or not. What happens instead is that society, when at war, starts to look for symbolic support of their views of war, as Jung (1968) observed:

In wartime, for instance, one finds increased interest in the works of Homer, Shakespeare, or Tolstoi, and we read with a new understanding those passages that give war its enduring (or “archetypal”) meaning. They evoke a response from us that is much more profound than it could be from someone who has never known the intense emotional experience of war. The battles on the plains of Troy were utterly unlike the fighting at Agincourt or Borodino, yet the great writers are able to transcend the differences of time and place and express themes that are universal. We respond because these themes are fundamentally symbolic. (p. 99)

Given what is known about the aftermath of war, and the stories that some soldiers have been telling for so long, the puzzling question remains: Why do some people still join the military and agree to go to war?

THE LURE OF A MILITARY CAREER

Given the large number of career options available today, and all the opportunities afforded by technological developments to young people, it makes little sense, at least for the outsider, why able-bodied young people would still opt to join the military. According to media reports, in the aftermath of 9/11, many young Americans signed up for duty because they felt they needed to defend the country against an external threat that was about to destroy the fabric of American life and values4.

4 See for example: http://www.nytimes.com/2008/07/15/opinion/15tue4.html, which documents the story of Pfc. Joseph Dwyer, an Army medic, whose photo of him cradling a wounded, half-naked Iraqi boy, touched the world. However, Pfc. Dwyer, who was an instant hero in the 2003 war that brought “Iraqi liberation” died tragically in June 2008, a victim of the demons of this same war and the failure of society “to bring him home.”

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With big companies competing for new employees a large number of young people indeed enter the job market with no second thought given to a possible military career. With such strong competition to capture the attention of potential employees, there can be little debate that the military has to utilise every tool at its disposal to draw new recruits. Multiple TV channels carry well-designed advertisements, explaining the advantages of a military career, yet over the past several decades there has been a significant drop in interest amongst especially talented young people to seek a career in the military. This is by no means a new phenomenon, as Dixon (1976) pointed out:

While modern warfare becomes increasingly swift and deadly, and the means by which it is waged increasingly complex, the intellectual level of those entering the armed services as officers could well be on the wane. This tentative supposition is based on the fact that fewer and fewer of the young consider the military to be a worthwhile career. One has only to look at contemporary recruiting advertisements to realise the evident difficulties of finding officer-material. They spare nothing in their efforts to convince an unresponsive youth. The services are depicted as glittering toyshops, where handsome young men enjoy themselves with tanks and missiles while basking in the respect of the lower ranks hardly less godlike than themselves. In their eagerness to drum up applicants these calls to arms attempt the mental contortion of presenting the services as a classless society in which officers nevertheless remain gentlemen. (p. 20)

Events such as 9/11 are often a powerful boost to the recruitment process, but when war breaks out, the need for increasingly greater numbers of recruits skyrockets. In events such as the tragedy of 9/11, the depiction of “the other side” in stereotypical terms becomes but another tool to lure the young and able-bodied to join the national, professional fighting machine. It is, of course, understandable, because national security is at stake and the terror in the hearts of citizens must be alleviated by strong, decisive action. However, as dangerous as stereotypes may be, so useful do they become, as aptly described by H. J. Eysenck (1953):

Stereotyped ways of looking at things have their obvious dangers. They tend to be maladaptive and may lead to disaster if taken seriously... Stereotypes also have obvious advantages. They give us an ordered, more or less consistent picture of the world to which our habits, tastes, capacities, comforts, and hopes have adjusted themselves. ‘They may not be a complete picture of the world but they are a picture of a possible world to which we are adapted. In that world people and things have their well-known place and do certain expected things. We feel at home there; we fit; we are members; we know the way around. There we find the charm of the familiar, the normal, the dependable; its grooves and shapes are where we are accustomed to find them.’ (p. 244)

Perhaps the most obvious field in which stereotyped attitudes are found is that of national differences. It is not, however, the only one. We all have mental images of certain groups of people which make us endow these groups with certain uniform characteristics... (p. 244).

But it is in the field of national differences that stereotypes appear with particular virulence, possibly because in the case of most other groups reality and acquaintance impose a certain check on us, whereas in so far as other nations are concerned we can rationalize our preferences in the complete absence of factual knowledge. Nor is it only the uneducated who hold views of this kind; many a learned professor have written tomes

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on the national characteristics of various groups, based almost entirely on passing fancies and stereotyped prejudices. (p. 245)

From what Eysenck postulated nearly six decades ago, stereotypes serve a common purpose, at least in military recruitment: it provides the labelling of a group of people (be it a nation, tribe, or ethnicity) as The Enemy, thus allowing the government of the day and its military to act with impunity against the Aggressor in defence of the society it serves, thus bringing about an acceptable morality that becomes inherent to all subsequent military operations. In this regard, the military, as an instrument of the state in its enforcement role, is made to resemble normality, as just another way of conducting business – when thing go right, all is fine, and when they go wrong, some reorganization takes place. War operations, at least politically, are managed in much the same way as benign business operations, and soldiers, being the tools to execute the policy, are given orders that would bring about “positive restructuring” so that military operations can make “common sense” to the voting public. This process is aptly described by Laurence Peter (1986) of the Peter Principle fame:

When our study of human organizations is successful, it leads us to concepts that make our lives and our world more intelligible to us. When things are intelligible we have more of a sense of participation, and when they are unintelligible we have a sense of estrangement. So, when the world appears to be a chaotic mass of unrelated elements, we are in need of a new formulation to give meaning to those events (p. 15).

A review of the media reports on the threat posed by “weapons of mass destruction” held in arsenals of the Iraqi government and military, illustrates how easily society became swept up in its support of yet another war effort, building on the aftermath of 9/11 and the successful campaign to rid Afghanistan of its Taliban government. The military, as a willing and able tool in the hands of government, followed orders and when no weapons of mass destruction were found, nevertheless continued its operations as instructed by the various governments involved in these campaigns.5 There is no question that these political messages served the purpose of bringing about a “new formulation” to make sense of a very chaotic world and to create the infrastructure that would foster a renewed sense of security in an otherwise unpredictable world situation. This said, one has to take heed of Laurence Peter’s warning when, in a book chapter titled “Proliferating Pathology”, he quotes Arnold Toynbee:

The human race’s prospects of survival were considerably better when we were defenseless against tigers than they are today when we have become defenseless against ourselves (Peter, 1986, p. 99).

This statement lies at the very core of findings published in recent research papers on the impact of the current military operations on the mental health of serving and returning soldiers. The media reports on the research data are equally enlightening, especially when the

5 A very useful summary of the historic development of the “War on Terror” and the concerns about “weapons of mass destruction” held in Iraqi arsenals, is available in the National Security Archive Electronic Briefing Book No. 80 (updated February 11, 2004), accessible at: http://www.gwu.edu/~nsarchiv/NSAEBB /NSAEBB80/

Complimentary Contributor Copy 166 Jacques J. Gouws numbers of mental health casualties are compared amongst countries.6 At the very least the research and media reports paint a picture of ever-increasing numbers of stress-related reactions and an inability of soldiers to cope with these stressors when they return to their homes. In short, it appears as if resilience, which was such a strong protective shield against mental trauma for many while on deployment, starts to wane once they return to civilian society. Their endurance has reached its limits and can no longer effectively insulate and “vaccinate” otherwise “normal” returning soldiers against the mental health challenges associated with combat deployments (peculiar to the first decade of this century) once they are back amongst family and friends. The question invariably becomes whether there is something else at work that is undermining the natural resilience that the military had developed and fostered in soldiers.

SOME OF THE FACTORS AFFECTING RESILIENCE

Much has been written about the factors inherent to military deployment that negatively affect combat readiness. Based on data he obtained in field research, Gouws (1986) identified that a prominent factor undermining both resilience and resourcefulness was the development of a conflict between perceived political motives (originating with the political leadership and senior command) and the soldier’s personal beliefs, the latter which reflected a willingness towards self-sacrificing involved in military operations. Walter Wilcox, in his discussion on the combat infantryman from the perspective of World War II, expressed similar sentiments in a Chapter titled “The Loneliness of the Long Distance Soldier” during a faculty lecture series (Walsh 1971):

In this portrait one finds something weak and something strong; something weak and somehow pathetic in that the long distance soldier must practice a degree of self-delusion and reconstitute himself psychologically and even physically in order to survive. We find something strong and perhaps even noble, not in his willingness to fight again and again, but merely in his capacity to endure. When we look at the infantryman, when we try to grapple with war and the human race, we ask ourselves: of what value is it for us to know something about the combat infantryman? Does it in any way advance our understanding of war or the human condition? I think that indeed it does. I think there is even perhaps a slender ray of illumination. We ask: why does he go on and on and on against these fearful stresses, and we found, I think most important, it is not because he is filled with hate or that he is blood-thirsty or that he covets power. He goes on because given the task assigned him by his society, he just simply must go on. He can envision no other course of action. In no sense can any of the data, either personal observation or the behavioral science material, be interpreted to mean that war is his natural environment. Rather it is the opposite. It’s about as unnatural an environment as possible. The answer, if any of course, to war and the human condition must be found really in some other arena. It’s not going to be found in the natural aggressiveness of the combat rifleman. We’ve seen that man’s capacity to endure as exemplified by the combat infantryman is almost limitless. And so the question essentially is a political or moral one.

6 See for example, the article titled: U.S. Troops Suffer More Stress than Britons, Study Says, in the New York Times of May 16, 2010, in which the US figures are contrasted with similar figures from the UK, accessible at: http:// www.nytimes.com/ 2010/05/17/world/17trauma.html.

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We ask ourselves – who indeed has a right to ask these men to go and endure what they have to endure. It is not a psychological one, because we know indeed that they will endure (pp. 88–89).

It is clear from the above that, in pushing soldiers to the limits of their endurance, Wilcox lays the responsibility with the political powers, and not with the psychological make-up of the soldier, nor the degree to which the soldier may no longer be able to endure. However, the price the soldier pays for this ability to endure in combat deployment is the subsequent emotional pain and the mental anguish soldiers go through when they attempt to reintegrate into society. This is by no means an easy task, because on top of all they went through, the “fog of war” excuse is offered much too liberally and the blame placed far too easily on the shoulders of the most junior and inexperienced of soldiers for things that went wrong and caused public outcries. Rightfully the apportionment of blame for the Abu Ghraib torture of prisoners is laid at the feet of military leadership by none other than the renowned Dr. Philip Zimbardo7, whose 1971 research in the landmark Stanford Prison Experiment (see Haney, Banks and Zimbardo, 1973) closely mirrored the events that took place in Abu Ghraib prison. However, while the actions of the soldiers involved in this atrocity cannot be excused, the responsibility of the command chain cannot be downplayed either. Even so, when things go wrong, a culprit has to be identified, regardless of the circumstances. Dixon (1976) provides an example of how blame was shifted to the “youthful, the junior and the dead” (p. 93) during the whitewashing of the role of senior commanders and generals in the failure of the Cambrai Campaign in World War I. The impact on the common soldier was such that it forever changed the dynamics between senior leadership, junior leaders and the troops. In this regard, Dixon states it very bluntly:

One of the consequences of these and other comparable events in the First World War was that they almost certainly terminated for all time the hitherto reverential and blind faith which troops had in their generals. In an organization renowned for striking loyalties between men and in junior ranks, and in a war whose frightfulness was relieved only by comradeship and altruism in dangers shared, this betrayal by senior commanders cannot but have produced a lasting cynicism (p. 94).

For the soldiers who served in Vietnam, this was certainly the case, and much has been written about that. Space does not allow for further elaboration, but suffice to note that the plight of the Vietnam Veterans and the mental health cost of that war are still felt to this day in American Society. That said, the similarities to what Dixon described, and what has been happening in various conflicts since World War I, including in Afghanistan and Iraq, are disheartening. It is therefore no wonder that many returning soldiers isolate themselves and engage in maladaptive behaviour patterns to cope with the significant emotional impact of their experiences in a society that cannot comprehend what their soldiers had been exposed to. Yet, many soldiers come back from the battlefield and seem, superficially, to be doing fine despite their experiences, at least psychologically. Perhaps this is because the capacity to endure is still as present as when they were serving in combat zones. The following poem illustrates

7 See http://www.udel.edu/PR/UDaily/2006/dec/zimbardo120705.html.

Complimentary Contributor Copy 168 Jacques J. Gouws this in a powerful way, as it tells the story of living alone with the memories of war, with no one to turn to. It also carries a message of hope, of normalization, but it comes at a terrible price:

HELL'S NIGHTMARE

Have you ever had anything bad happen to you along the way, And just when you thought your agony was over it returned to haunt your day?

Have you ever fell through the holes of hell deep dungeons dark as night, And just when you thought your battles were over you found you’d just begun to fight?

It’s hell’s nightmare, better well beware. It’s hell’s nightmare, my friend But you’re not crazy, and you’re not insane; You’re just living yesterday’s pain.

Have you ever held onto truths you couldn’t tell, weighing heavy as a ball and a chain. And just when you thought you’d found someone to turn to You realise they thought you insane?

Have you ever had anyone think you mad just because they couldn’t bear your word, And just when you thought you’d been understood you realise they’d listened but never heard?

It’s hell’s nightmare, better well beware. It’s hell’s nightmare, my friend But you’re not crazy, and you’re not insane; You’re just carrying yesterday’s pain.

Have you ever held onto truths you couldn’t tell, yet too heavy to remain untold And just when you thought you’d found someone to count on they began to buckle and fold?

Have you ever had anything so bad that you lost your way along the road. And just when you thought you were on the right track life handed you a heavier load?

It’s hell’s nightmare, better well beware. It’s hell’s nightmare, my friend But you’re not crazy, and you’re not insane; You’re just carrying yesterday’s pain.

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So don’t give in and don’t give out Don’t knuckle under should the world scream and shout ‘Cause you’re not a quitter when your back’s to the wall Hell’s nightmare is hell for us all. And don’t look up and don’t look down, don’t trade your soul for a smile or a frown, ‘Cause you’re not finished when you’re stuck in the sand. Some cares, someone understands.

It’s hell’s nightmare, better well beware. It’s hell’s nightmare, my friend You’re not crazy, you’re not insane; You’re just living yesterday’s pain.

© Carroll R. Thomas, 1984

This poem poignantly describes the emotional struggles of returning soldiers, and the difficulties they encounter in their search to reintegrate into society and the life they had before they left to serve in combat. These societies owe these soldiers a great deal of support, as their capacity to endure, when left to their own devices, is indeed limited, not infinite, in the absence of the unit support they had while deployed. Thus, no matter their resilience and resourcefulness, when these soldiers fight the demons of war on their own, they may not have sufficient reserves left to cope, nor to deal with their traumatic memories and related emotional reactivity, all at a time when society indulges itself in the luxury of re-evaluating its decisions to engage in a war effort these soldiers had no choice in. The earlier reference to Pfc. Dwyer is a tragic example of the depletion of all energy and capacity to cope. It is the tragic result of a breakdown of resilience, as the soldier’s capacity to endure, became depleted.

CAN DEPLOYMENT RESILIENCE ASSIST THE TRANSITION TO CIVILIAN LIFE?

One has to be careful to not extrapolate data obtained from a relatively small percentage of soldiers who suffer immense mental and physical disability (from the memories and mental scars of combat and the stressors of sustained military operations), to the rather large majority of soldiers who do manage their deployment experiences well and return to essentially a normal life in their civilian society of origin. That said, however, one must always remember that all soldiers carry their deployment experiences with them. It is, after all, normal to react emotionally and behaviourally to the stress arising from abnormal circumstances – and there are none as abnormal as the rigours of combat deployments. Every soldier who had been exposed to these rigours will react in some way or another, although no one reacts in exactly the same way. There are those soldiers who integrated the resilience and resourcefulness they had learned in the military into their personality to such an extent that they have developed an ‘enduring’ personality style. Others, on the other hand, find ways to deal with their experiences by expressing these in various art forms, such as poems, songs and pictures.

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Others attempt to live their lives in quiet isolation, while some find solace in their interaction with other veterans. Regardless of the various individual coping mechanisms, however, a golden theme in all of these reactions comes from the comments of friends and family of a definite and visible change in the returning soldier’s pattern of perceiving, relating to, or thinking about, the environment, as well as how these soldiers view themselves. Moreover, a recent follow-up on a 2006 cohort study was published in The Lancet (May 2010). Researchers studied the effect of the deployments to Iraq and Afghanistan on the mental health of military personnel from 2003 to 2009. The results provide a British perspective that is in stark contrast with the current American situation. Whereas in the USA the numbers of returning soldiers with serious mental health concerns are increasing, this is not the case in the United Kingdom. As such, the findings suggest that there is indeed hope that resilience learned in the military can assist the transition back into civilian life, but returning soldiers do need the support of the whole of society. The following editorial comments on this study are worth quoting:

The investigators show that the most common mental health problems reported by personnel continue to be alcohol misuse and common mental health disorders, rather than probable post-traumatic stress disorder. And, overall, the prevalence of mental health disorders in the UK armed forces remains stable. There are several important messages arising from these results. First, contrary to reports in the mainstream media, there is not an epidemic of mental health problems in this group of service personnel. Second, hazardous drinking, both before and after deployment, continues to be a serious problem for regular service men and women. This group is at increased risk of the social complications of excessive drinking such as violence and relationship breakdowns. Although having introduced some alcohol-control policies, the armed forces need to reassess whether these are rigorous enough. Third, the study showed that deployed reservists still have a higher prevalence of probable post-traumatic stress disorder than non-deployed reservists despite several initiatives by the Ministry of Defence. When reservists return to civilian life, some experience difficulties and need support not only from the Ministry of Defence, but also from across government, including the Department of Health and the Department for Work and Pensions. Finally, reassuring as the key findings of this paper are, they should not lead to complacency about the future health status of this population. The next UK Government has an ethical duty to support the continued long-term follow-up of those who have served in Iraq and Afghanistan. The end of their active service in these countries should not signal the end of society's service to them. (The Lancet, 2010, p. 1666).

This is indeed a hopeful picture, but it emphasises the need for adequate societal support for the men and women who serve at the call of their country. Unfortunately many soldiers had to find support in other places and in other ways, as the following lyric illustrates:

THUNDER ROAD

Well, I never thought I’d live past twenty-two, That ole Chevy screamin’ down Thunder Road, Burnin’ rubber on that black-top highway,

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Tryin’ to lighten that heavy load.

An’ I thought I’d-a died in that crazy war, An’ sometimes I wished that I had, yes I did. But I just kept on screamin’ down Thunder Road An’ thankin’ God for all the good ‘n’ bad.

An’ I never thought I’d learn life’s hard lessons From all of the wild seeds that I had sowed. But I learned to laugh and live once more, That ole Chevy screamin’ down Thunder Road.

Now, I’ve still got that ole Chevy. Thank God that it can’t talk. But if I had it to do all over again, I’d still rather ride than walk!

Yeah, an’ I never thought I’d live past twenty-two That ole Chevy screamin’ down Thunder Road, Burnin’ rubber on that black-top highway, Tryin’ to lighten that heavy load.

Oh, sometimes a lotta things happen in life That we don’t think we can survive. But we can learn that life’s still worth livin’ Tho’ you know we’ll never get outta it alive.

Yeah, an’ I never thought I’d live past twenty-two That ole Chevy screamin’ down Thunder Road, Burnin’ rubber on that black-top highway, Tryin’ to lighten that heavy load.

Burnin’ rubber on that black-top highway, Tryin’ to lighten that heavy load. Yeah, tryin’ to lighten that heavy load.

© Music and Lyric by Carroll Ray Thomas, 1993/2010

This lyric aptly illustrates how, for at least this soldier, his combat experiences became an integral part of his life, and as he dealt with them, he learned to continue to live his life in a positive manner despite the traumatic nature of these events. However, one can only guess at the immensity of the struggle, and the toll it took to reach the point where the integration is complete and the soldier can let go of the experiences, if not the memories, and once again become whole, a spirit set free from the trauma of the past, as resilience triumphs and life again becomes meaningful:

FREE AT LAST

From a memory a spirit remains Growing stronger each day from all of war’s pains.

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There’s a voice keeps a-calling from a distant past, “You’re free old soldier you’re free at last.”

You’re free from the fear and you’re free from the doubt. You’re free from a world that turned you out. You’re free to live, and you’re free to love. You’ve flown with the eagle you’ll fly with the dove.

There’s something about you that no harm can shake, That something about you that weathered the wake Of a storm that was raging but now has passed, “You’re free old soldier you’re free at last.”

You’re free from the fear, and you’re free from the doubt. You’re free from a world that turned you out. You’re free to live and you’re free to love. You’ve flown with the eagle you’ll fly with the dove.

Yes, the storm that was raging now has passed, “You’re free old soldier you’re free at last.”

© Carroll Ray Thomas, 1985/1990

CONCLUSION

This chapter addressed some of the difficulties that soldiers, who have no diagnosed mental health issues, face when returning from deployment. It ever so briefly touched the surface on facing the challenges of reintegrating into society after exposure to the stress factors related to present day military operations. Soldiers, in the course of their military training, have learned to deal with extremely challenging situations through essentially learned resilience and resourcefulness. In this they have had the support of their unit, their comrades, and their commanders. Returning to civilian life, however, is by far the most challenging, not because it is stressful like the combat deployments, but because the unit support is now absent and the societal values have changed while the soldier was away on deployment. In modern society, the influence of written and visual media, and in particular the internet, can quickly turn right into wrong and wrong into right. It is extremely difficult, if not impossible, to reconcile the initial demand for action that leads to a combat deployment with all its horrors, with the subsequent insistence on painting these same operations that were waged on behalf of society as unjust, unfair, and above all, morally wrong. The soldier who followed orders and did not challenge the political morality of these orders, upon returning is often faced with having to be criticised for a course of action that had been discredited by the very society whose calls for action resulted in those orders being issued in the first place. It is not the soldiers’ place to question society’s morality in demanding action, but neither should society be abhorred when soldiers execute the duties they were trained for. When soldiers have done their duty, they need the support of the society and government that sent them into combat in the first place. Without that, their capacity to endure the mental and

Complimentary Contributor Copy 21st Century Warfare 173 emotional impact of what they had experienced while serving their country will be greatly reduced. Once they lose the resilience to continue to cope with adversity, society also loses a productive member. This need not happen, provided that societies and governments support their soldiers as they reintegrate into civilian life after returning from deployment. While one may not support the cause, one should support those who serve the cause at the behest of their country’s leaders. Only then will the resilience that helped soldiers survive in deployment also assist individual soldiers to adjust to civilian life after they come home from facing the challenges posed by waging counter-terrorism warfare in the 21st Century.

REFERENCES

Celinski, M.J. and Gow, K.M. (Eds.). (2011). Continuity Versus Creative Response to Challenge: The Primacy of Resilience and Resourcefulness in Life and Therapy. New York: Nova Science Publishers. Dixon, N. (1976). On the Psychology of Military Incompetence. London: Pimlico. Editorial. (15 May, 2010). The mental health of UK military personnel revisited. The Lancet, Volume 375, Issue 9727. Eysenck, H. J. (1953). Uses and Abuses of Psychology. Aylesbury Bucks: Hazell Watson and Viney Ltd. (1978 reprint). Gouws, J. J. (1986). A Selection Battery for Security Forces Personnel. Unpublished Doctoral Thesis. Pretoria, South Africa: University of Pretoria. Gow, K.M. and Celinski, M.J. (Eds.). (2011). Wayfinding through life’s challenges: Coping and Survival. New York: Nova Science Publishers. Gow, K.M. and Celinski, M.J. (Eds.). (2012). Individual Trauma: Recovering from Deep Wounds and Exploring the Potential for Renewal. New York: Nova Science Publishers. Haney, C., Banks, C. and Zimbardo, P. (1973). A Study of Prisoners and Guards in a simulated Prison. September 1973. Naval Research Reviews. Office of Naval Research, Department of the Navy, Washington DC. Keegan, J. (1993). A History of Warfare. New York: Vintage Books. Jung, C. G. and von Franz, M.-L. (Eds.). (1968). Man and His Symbols. USA: Dell Books. Peter, L. J. (1986). The Peter Pyramid. London: Allen and Unwin. Wilcox, W. (1971). The Loneliness of the Long Distance Soldier. In M. Walsh (Ed.), War and the Human Race (pp. 83-89). Amsterdam: Elsevier. Wilson, I. H. and Freer, T. H. (January, 2010). Unseen Scars of Combat. The Lancet, Volume 375, Issue 9711.

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 11

HEALING FIELDS AND FIELD OF FLAGS: COMMEMORATION OF 9/11 AND WAR IN HETEROTOPIAN SPACE/PLACE

Catherine Ann Collins* Willamette University, Salem, OR, US

ABSTRACT

The Healing Field (Field of Flags) is a national movement to facilitate the healing process after war or tragedy, specifically 9/11. This visual rhetoric, in the form of a field of flags, began as a commemoration of the victims of 9/11 and has been extended to include memorials to veterans and casualties of the war in Afghanistan and Iraq. Promoting patriotism and American values, healing fields are also heterotopian space/place. In giving materiality to memory of loss, in creating sacred space, if only temporarily, these fields reflect the contested and subverted nature of memory. In Foucault’s terms, the space/place is both real and unreal fantasy at the same time; it facilitates memory as it simultaneously allows its inversion. The 2006 Healing Field in Oregon to commemorate the 5th anniversary of 9/11 and the Field of Flags in 2011 to commemorate the 10h anniversary serve as case studies.

Keywords: Trauma, 9/11, Heterotopian Space/Place, Healing Fields, Field of Flags, Commemoration

INTRODUCTION

On the first anniversary of the 9/11 attacks on the United States, a movement, which has since become national, began in Utah with the construction of the first Healing Field. Healing fields are memorials to those who died that day. They are a place for friends and family to

* Professor Catherine Collins, Rhetoric and Media Studies, Willamette University, Salem, OR 97301, USA. Contact: [email protected]; Phone: (503) 370-6281.

Complimentary Contributor Copy 176 Catherine Ann Collins mourn their passing and for the nation to recover from the collective trauma brought on by these attacks. Although temporary in nature, Healing Fields are, in Jay Winter’s (1995) terms, both sites of memory and sites of mourning. Individuals and communities need spaces for coming to terms with traumatic loss, for remembering and making sense of seemingly senseless deaths, and for constructing narratives to explain loss that seems unexplainable. Whether social suffering is conceived as the result of social forces or managed through human agency and imagination (Gammeltoft, 2006), researchers recognize the power of social narratives to facilitate healing (Kleinman, 1988; Ochs and Capps, 2001; Mattingly and Garro, 1999). In history and literary studies, trauma narratives and memory work turn to the role of historicizing (LaCapra, 2001), narrativizing and witnessing trauma events, especially to the role of testimonials in trying to make sense of social suffering (Greenberg, 2003; Whitehead, 2004; Young, 2003), and the appropriateness or negative consequences of telling particular kinds of stories in the face of social suffering (Polletta, 2006). Alexander (2004) reminds us that trauma “is a socially mediated attribution” (p. 8) so what might be deemed traumatic and appropriate ways of responding are dictated by the community. Commemorative acts are one way of promoting healing from traumatic loss. Sherman (1996) argues that “what we conventionally call ‘commemoration’ I take to be the practice of representation that enacts and gives social substance to the discourse of collective memory” (p. 186). Commemoration takes multiple forms, including monuments, art, parades, and other ritual reminders of social suffering. Large-scale traumatic loss demands both immediate and enduring commemoration: the community memorializes those who have died. Barry Schwartz (1982) reminds us that commemoration becomes a “register of sacred history” as it elevates some events from the regular chronology of historical events and sees them as representative of a community’s values and ideals (p. 377). For the United States, 9/11, like its analogous predecessor Pearl Harbor, became one of those events, so traumatic that it demanded a site for remembering the past and negotiating a future in which the mythic conception of an invincible and Edenic nation once again seemed inevitable. The impulse to commemoration is especially apparent on the anniversaries of trauma loss when rituals in special sites pay homage to those whose lives are regarded as having been sacrificed for the nation. Marita Sturkin (1997) argues that “the memorial is perhaps the most traditional kind of memory object or technology” and like all technologies of memory is “implicated in the power dynamics of memory’s production” (p. 10). Whether temporary or permanent, these sites and the rituals conducted there are comfortable, predictable places and acts that take participants and observers out of their routines temporally by creating a space for reflection and reverence. They encourage the individual to participate in the community, and in doing so to reinforce the beliefs and values of the community. In this chapter, I explore two anniversary commemorations of the traumatic loss of lives on 9/11, the fifth and the tenth anniversaries. Both involve the construction of temporary memorials in the form of a field of flags with additional rituals to remember lives lost and to proclaim a national identity expressed in affirmations of patriotism, and both commemorations occur in the same public space in Salem, the capital of Oregon. Because collective memory changes with time, so too do commemorative acts. I argue that while the form of commemoration - a field of flags and memorial service - remain the same for the 5th and 10th anniversaries of 9/11, the change from mourning and healing in the 5th anniversary to a reaffirmation of patriotism on the 10th anniversary merits further attention. This chapter

Complimentary Contributor Copy Healing Fields and Field of Flags 177 begins with a discussion of Healing Fields to commemorate the attacks of 9/11, specifically the 5th and 10th anniversary fields in Salem, and then turns to an explanation of these fields in Foucault’s terms as heterotopias. Finally, because Healing Fields allow space for mourning and memory work while simultaneously generating contestation, I explain why contestation inheres in these commemorative practices.

HEALING FIELDS

The term healing field is a response to the military term - killing field - which is a field of fire, often an open area where artillery can easily eliminate the enemy. Although designed to protect strongholds and fortifications, when they are employed as a site for slaughtering the enemy, killing fields convert neutral spaces into profane spaces associated with destruction and grief. Healing fields, as symbolic and cathartic responses to the trauma of large-scale deaths, are their counterpart, neutral spaces converted into sacred spaces for memory and regeneration, for killing off the pain of personal and public loss. In this sense, a military cemetery could function as a healing field. In the United States, since the events of 9/11, the term healing field has come to represent the form of a field of flags, arranged in straight rows visually reminiscent of military cemeteries. A flag, rather than a marker or religious symbol such as a cross, is used to denote each individual who has died. The choice of a flag as a marker, a visual reminder of a person lost, is a powerful symbolic act. The U.S. flag serves, in Edelman’s terms, as a condensation symbol that condenses into one symbolic sign “patriotism, pride, anxieties, remembrances of past glories or humiliations, promise of future greatness: some one of these or all of them” (1972, p. 6). The flag becomes a visual ideograph, much as patriotism is the equivalent verbal ideograph of America. Edwards and Winkler (1997) argue that the flag functions as an argument for “American ideals of liberty, equality, and democracy” (p. 291). Demo (2006) and Pineda and Sowards (2007) concur in their analyses of the impact of U.S. versus foreign national flags displayed in immigration rallies. Whether the presence of a particular flag functions positively or negatively as visual argument, flags “represent pride and remembrance, unity, and participatory civic virtue” (Pineda and Sowards, 2007, p. 167). An editorial in the Omaha World-Herald notes the “extraordinary power of a flag to amplify passions, positively or negatively cannot be denied” (“The power of symbols”, p. 6B). In the United States, healing fields had their origin in Sandy, Utah, on the first anniversary of 9/11; a spontaneous memorial in the form of a healing field was created to commemorate the tragedy and to offer a way to heal as individuals and as a nation. Paul Swenson, founder of the first field, explains that he planned the memorial as a way to come to terms with the sheer number of victims of 9/11. The scope of the victimage alone compelled commemoration. He created a temporary memorial in the form of a field of flags; each represented one life lost in that tragedy. Healing fields include official U.S. flags and additional flags that resemble the U.S. flag, but are modified to name the victims of the 9/11 attacks and the deaths of rescue workers in the aftermath of the attacks. The healing field in Sandy, Utah, became the first, in a growing movement in the United States of civic organizations erecting temporary memorials that follow the form of the Utah Healing Field.

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September 11, 2001 Attacks

On September 11, 2001, nearly 3,000 people died as a result of a coordinated al-Qaeda attack on the Pentagon and the World Trade Center’s Twin Towers in New York City, as well as a plane targeted for Washington D.C. that crashed in Shanksville, Pennsylvania. Most of those killed were civilians, of whom approximately 400 were police, firefighters and paramedics who tried to rescue the victims of the attack. By any standard, the loss of this many lives is traumatic, not only for family and friends of the dead, but also for the nation. When the casualties resulting from national political disputes involve non-combatants, the deaths are perceived as even more traumatic than the loss of military personnel. Psychoanalyst Dori Laub (2003) explains:

September 11 was an encounter with something that makes no sense, an event that fits in nowhere. It was an experience of collective massive psychic trauma. . . .We are still involved with the ongoing struggle between an imperative need to know what it is that has happened to us all - not only to those who were in the buildings into which the planes crashed and to their families and friends but to all of us in America, no matter how distant from the scene of the attacks - and an equally powerful urge to not know, a defensive wish to deny the nature of the tear in the fabric of our shared lives. (p. 204)

Memorialization came immediately with the erection of spontaneous shrines around Ground Zero and the other sites of the attack. School children drew pictures of the Twin Towers as a form of commemoration, permanent memorials were planned, and, in the case of the attack on the Pentagon were dedicated several years ago. The memorials at Ground Zero and in Shanksville were dedicated on the 10th anniversary of the attacks. The media’s early commemoration came through narratives that Kitch (2003) argues centered on the themes of sacrifice, patriotism, courage, faith, and redemption (p. 213); in 2011, the media continues these themes in their 10th anniversary coverage. Cartoonists dedicated their comic strips to a day of service and remembrance, and the New York Times set up an interactive global map telling the stories of where people were on 9/11/01. Confused, hopeful, sad, fearful, and angry; these are the memories reflected in the comments people have shared for the global map project. Despite differences in form and a span of ten years, these varied commemorations share the characteristics of social suffering and the search for meaning in such loss. Like many other cities across the United States, for Salem, Oregon’s state capital, the 5th and 10th anniversaries of 9/11 were memorialized in the erection of a Healing Field. The two anniversary commemorations, one an official Healing Field and the second a Field of Flags, in Salem were visually distinctive places that became temporary sacred spaces for memorializing, a space for respite, if not recuperation, from the traumatic response to 9/11. Like other fields of flags commemorating 9/11, both anniversary fields were combined with a Military Field of Flags honoring the American soldiers who died in Iraq and Afghanistan. I contend that the combination of these two commemorations, each appropriate and compelling in their own right, creates tensions for some participants in the rituals enacted by, and within, the commemorative site. In juxtaposing these two events - 9/11 and the wars in Iraq and Afghanistan - the Salem, Oregon Healing Field becomes heterotopian space/place of contested collective memory. Secondly, I argue that between the 5th and 10th anniversary fields, choices in visual elements in the flags, inclusion of sponsorship signage, and an

Complimentary Contributor Copy Healing Fields and Field of Flags 179 increasing emphasis on security and nationalism over time dilute the focus on trauma recovery. I begin with a description of the construction of the Oregon memorial for the 5th anniversary of 9/11, and establish the differences between the 5th and 10th anniversary fields and 9/11 ceremonies.

The 5th Anniversary Healing Field as a Visual Narrative of Commemoration

In the four years between the creation of the spontaneous memorial in 2002 and the 5th anniversary of 9/11, over 100 communities staged a Healing Field, most often memorializing the victims and heroes of 9/11, occasionally combining this with a secondary commemoration of military losses in Afghanistan and Iraq. In “creating common spaces for memory,” James Young (1993) contends that memorials “propagate the illusion of common memory” (p. 6), and once created “take on lives of their own, often stubbornly resistant to the state’s original intentions” (p. 3). The intended meaning for a monument or memorial is always subject to reinterpretation, but it strives to give closure to a memory, to serve as a bridge between the past and the imagined future. Closure is actively sought for particularly painful events, and these events may evoke a desire for hastily enacted memorials to contain the grief and allow the possibility of a brighter future. Particularly traumatic events may evoke trauma narratives - both verbal and visual - in an effort to promote healing, and in an effort to collectivize the memory, and to create a shared sense of community. The illusion of common memory is furthered by the Colonial Flag Foundation whose web site, assistance in planning Healing Fields, and provision of the necessary visual displays urges a renewal of patriotism and support for the nation. Media accounts of Healing Fields emphasize their success in bringing the community together for commemoration and regenerating the patriotism that was evident in the nation in the weeks and months following 9/11. Healing Field founder, Paul Swenson, recounts: “It became obvious as more and more volunteers showed up on the evening of September 10th to help set up, that it had become a very personal gesture of mourning and support” (2006). The display became a sacred space in which participants could mourn the loss of life and seek healing a year after the trauma of 9/11. Perhaps the public response should not have been surprising; 9/11 resulted in more than the death of a large number of people; it shattered our innocence, and our belief that we were invulnerable to what we had always regarded as irrational acts of terrorism. Healing Fields commemorate the loss of life and the loss of belief in our invincibility. The promotional materials urging communities to create a Healing Field memorial emphasize the symbolic nature of these temporary memorials; Healing Fields employ modified forms of the American flag, an emblem of the nation state and the obligation of its citizenry to support and celebrate it. In a guest commentary, Jim Burack (2006) writes:

If there is one idea I hope all of us can take from this field it is a unified inspiration to serve our nation, and not necessarily only under arms, but each of us to do the best we can in our chosen field. . . .We bear an obligation to these dead and their families and to those wounded who will carry forever scars seen and unseen to fulfill that promise. They have risen to an immense challenge not unlike the challenge with which past American generations have been presented, and their example will surely bear emulation by future generations of Americans.

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The Salem Healing Field was at the same time a visual artifact and a ceremonial site that included military flag bearers, musical elements, and formal rites of commemoration; and was a memory site for individuals and the collective to reflect on the narrative of 9/11 and the wars in Afghanistan and Iraq. The Healing Field memorial offered a temporary memorial site, a real place in the community for commemoration to occur, and it offered individuals the space for reflecting on the trauma resulting from the 9/11 attacks. The field contained rows of American flags, each one symbolizing the death of one person. The 9/11 field, for example, contained nearly three thousand 4-foot by 5-foot flags on 8-foot flagpoles with 5-10 feet between each flag. Flags were laid out in symmetrical rows and columns and were visually comparable to Arlington National Cemetery because the formality of the display is consonant with the layout of military cemeteries. The form of the field and the philosophy behind the Healing Field movement assumes that the civilian casualties, like American soldiers who are killed in combat, died for their country in the 9/11 attacks.

Photo Caption 1. 5th Anniversary Healing Field in Salem, Oregon.

Hence, visually, Healing Fields evoke the myth of citizen sacrifice for the nation, and the obligation for the remaining citizenry to honor their deaths via commemoration and re- dedication to the nation for whom the dead gave their lives. It is understandable why the viewer walking through the field can be lost in the number of flags and gain an awareness of the staggering number of deaths that occurred that day. When the 9/11 Field is combined with a display to commemorate American soldiers who have died in Afghanistan and Iraq, a Military Healing Field, approximately 4,600 additional flags are required. Most of the combined patriotic fields, however, including the Salem field, commemorate only the war dead from the host community or state, thus lowering the total number of flags needed and the space it requires to display the memorial. Healing Fields employ four different flags: the American flag is used to commemorate the soldiers killed in Afghanistan and Iraq and is organized into a Military Field; the Flag of Heroes contains the names of emergency personnel killed in the rescue work of 9/11; the Flag of Honor contains the names of those who died in the World Trade Center, the Pentagon,

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United flights 175 and 93 and American flights 11 and 77, and a final flag reads “Never Forget” above a symbol combining the Twin Towers, the shape of a pentagon, and stars for the plane crashes in the pentagon and in Shanksville, Pennsylvania. The names of the dead are written in white or dark gray respectively on the red and white stripes of an American flag for the Flag of Heroes and Flag of Honor. Combined, the Flag of Heroes and Flag of Honor, although sectioned off in the installation, become the 9/11 Field, each one representing a victim of the attack. Never Forget flags are a reminder of a primary goal of the field, to keep alive the memory of the events of 9/11, and occur infrequently in the 5thanniversary field. The Healing Field is replete with symbols and rituals of the nation and for the commemoration of sacrifice. The ceremonies for Salem, Oregon’s 5th anniversary celebration, began with a small group of bagpipers calling the public to attention, flag bearers from the National Guard presented the colors, the names of Northwest soldiers were read followed by a cannon salute and a flyover, the field was blessed, the National Anthem was sung and a series of speeches were given by representatives of the Governor’s office, the city of Salem, the military, a New Yorker who was a 9/11 survivor, and a child who was living in New York City at the time of the attacks but moved to Oregon shortly thereafter. All paid tribute to the victims of 9/11. Each of these symbolic acts and testimonials brought the viewers together as a community and sought to create a common memory that would ease the trauma of 9/11. The sale of the flags on the field following the ceremony sought to extend the sense of community and common memory that had been created and to foster further visual display of the flag throughout the city. Although the speakers and the presence of so many flags invoked patriotism, the focus was on the traumatic loss of lives on 9/11, and the site and ceremony evoked a reverence that facilitated mourning and recovery.

The 10th Anniversary Healing Field as a Visual Narrative of Commemoration

Cultural memory work always involves negotiation about how to name significant events, organize or employ memories, characterize participants, and link the past and present to best serve an envisioned future. The Healing Field name was dropped for the 10th anniversary, even though the field from the 5th anniversary was largely replicated in 2011. The new name was Patriot Day Field of Flags. When asked why there was a name change, one of the organizers present on the day that the field was constructed said the company supplying the flags for an official Healing Field could not guarantee that all of the flags were made in the United States; however, the company providing the flags for the Patriot Day Field of Flags could make that guarantee. Because the flag is emblematic of the nation, political considerations dictated the change in the sourcing of the flags; that brought with it the change in name. Unfortunately, the change in flags also brought with it an unanticipated aesthetic change as well. The 10th anniversary flags are smaller than the 5th anniversary flags - almost a foot narrower - and are made of a heavier fabric that blows less easily in the breeze. As a result, the visitor walking through the rows of flags can see to each side, and is less likely to feel enveloped by the flags. The flags no longer block the visitors’ view and thereby give less separation from the surrounding city; the sense of sacred space is lessened by the change in size and fabric fluidity of the new flags.

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Photo Caption 2. 10th Anniversary Healing Field in Salem, Oregon.

Photo Caption 3. 10th Anniversary Flag of Honor in Salem, Oregon.

Where from a distance, the 5th anniversary flags looked like a standard American flag (the names became visible only close up), the 2011 flags are constructed differently, using the red ink of the names to make the red stripe rather than employing white names on a dark red stripe of fabric as in the 2006 flags. The Flag of Honor also includes names written in blue ink to create an alternating pattern of light red and blue stripes.

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Photo Caption 4. 10th Anniversary Flag of Heroes in Salem, Oregon

Photo Caption 5. 5th and 10th Anniversary Never Forget Flags in Salem, Oregon.

The flags used in the 2011 field appear faded and distinctly different from the standard American flag employed in the military field. The visual sense of unity between the 9/11 and military fields is broken. With a primary goal of fostering patriotism, the 5th anniversary flags make a stronger statement, as they more closely resemble the iconic national flag. The never forget flags are used more frequently in the 10th anniversary field, both integrated into a border around the 9/11 field and as a standard by the signs designating the site of death for the individuals commemorated in that section of the field.

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The separated sections of the 9/11 field for the 5th anniversary were announced with simple signs. For example, black letters on a white background read Tower #1. Beside this marker was a white sign with a stripe at the top and bottom in red containing white stars. In the center in blue letters, it read American Airlines Flight 11. The signs marked another site of death, but they were small and unobtrusive. For the 10th anniversary, the signs became much larger and contained sponsorship information. Boeing sponsored the World Trade Tower 2 banner. In several ways, then, political considerations change the name and aesthetics of what physically are similar commemorative fields of flags.

Photo Caption 6. 10th Anniversary Section Sign with Sponsorship in Salem, Oregon

The Patriot Day Memorial committee responsible for planning the 10th anniversary commemoration added two additional fields of flags: a field dedicated to Oregon police lost in the line of duty; and an Oregon Firefighters Field to remember firefighters who died as a result of their service to the community. Neither of the new fields is in any way related to the events of 9/11 or the wars in Iraq and Afghanistan. As is the case with the Military Field, American flags are used to represent the death of these individuals. The rituals for the commemoration ceremony, while similar, also had differences that changed the tone of the message. Following the pattern of the 5th anniversary, the ceremony began with bagpipes, the presentation of the colors, pledge of allegiance, national anthem and opening prayer. A resolution for a national moment of remembrance was read, a politician reminded us that the Navy Seals successfully brought Osama bin Laden to justice and that currently the nation faces threats to divide us. The focus was less on remembering the victims of 9/11 and the potential of common Americans to act heroically, and more on military efforts to secure the nation’s safety from terrorists. Speakers praised the efforts of soldiers willing to sacrifice for national security. Ironically, the military focus in the ceremonies is not matched by the visual imagery; the faded flags do not create the same seamless display of American

Complimentary Contributor Copy Healing Fields and Field of Flags 185 flags as an emblem of nationhood that was present for the 5th anniversary commemoration. An appeal to patriotism, rather than an effort to heal from the trauma of 9/11, became the focus of the 10th anniversary field. For both anniversary displays, the decision was made to combine the 9/11 Field and a Military Field. This decision and the contestation it generated, creates what Michel Foucault terms heterotopian place/space, where by its very nature, memory work encounters contestation.

THE HEALING FIELD AS HETEROTOPIAN SPACE/PLACE

In his chapter “Different Spaces”, Michel Foucault argues that the great obsession of our contemporary age is space and the “relations of proximity between points or elements” which he sees as relations of emplacement (1998, p. 176). Some emplacements, utopias and heterotopias, are atypical in that they “suspend, neutralize, or reverse the set of relations that are designated, reflected, or represented [réflechis] by them” (Foucault, 1998, p. 178). These displacements of normal relations can be spatial or temporal. Heterotopias are a form of emplacement common to all cultures. They can be modified over time, but they can also take the form of contested real places as they juxtapose incompatible emplacements. One form of heterotopia disrupts time. Memorial sites collapse time thereby creating temporal discontinuities that bring the past to bear on the present and promise a utopian future. Foucault explains: “they open onto what might be called, for the sake of symmetry, heterochronias. The heterotopia begins to function fully when men are in a kind of absolute break with their traditional time” (1998, p. 182). Foucault uses the example of a cemetery to explain the concept; mourners, and eventually mere visitors, can always remember a life that is no more when they visit the site of a cemetery. The perpetual reminder of a life that has ended creates the heterochronia. Reading the names of the dead is a common memorial practice that also has become part of the 9/11 anniversary commemoration ceremonies, but the sheer number of names, the amount of time it takes to read them, and the number of readers it requires, all collapse the past and present and force the visitor to the site to experience the past trauma crashing into the present. The testimonials of 9/11 survivors, while they are given, temporarily transport the audience into the past, first five and now ten years, and then regenerate the response we all had in the immediate aftermath of 9/11. Time is displaced. An editorial blog in the local newspaper attests to the importance of these testimonials: “We also took comfort from learning and retelling stories - especially about the heroism of ordinary people” (Curtin, 18th September, 2006). In the Salem 5th anniversary ceremony, youngster Bailey Garfield recalled the family’s move from New York to Oregon after 9/11 and the way that day continues to shape her understanding of herself, her place in this country, and our country’s place in the world. In a very real sense, the visual display and ceremonies collapse time. The Healing Fields do not have the same sense of permanence we associate with memorials; they are only temporary places for bridging the past and present. This transitory memorial space similarly takes them outside of normal memorial time. For a short time, four days in the case of both of the Salem 9/11 fields, neutral community space is transformed temporarily into a more sacred memorial place/space. At the conclusion of the display, the

Complimentary Contributor Copy 186 Catherine Ann Collins flags are sold and the place returns to its previous neutral function (a riverside park in the case of Salem’s Healing Field). Although four days may seem like a short span of time, without this dedicated display the public’s attention to the 5th and 10th anniversaries of 9/11 would have been brought to mind through less compelling forms of commemoration (e.g. televised 9/11 specials, political speeches, news accounts). Instead, located in a prominent place in the community, highly symbolic visual symbols, accompanied by ritual, ask the viewer to step out of normal time and reflect on the trauma brought on by past events that remains part of who we are as Americans in the present. For the volunteers who set up the field and tear it down at the end of the ceremonies, time is slowed down further as one’s activities prepare for the collapse or return to normal time. The fields are constructed in one day with the assistance of volunteers, making the act of constructing the field part of the commemorative process. “The flag commemorates, but each stake is what got me,’ said George Duncan, a manager of the Les Schwab in King City, Oregon. ‘Each stake represents somebody’s life, their family, their hopes, what they had accomplished; and it was all taken away’” (Lynn 2006, September 8). The field gives material form to the need to honor and remember the victims. As time becomes a structuring agency in heterotopias, so too does the sense of boundary between the sacred space for commemoration and the neutral space of everyday life. Foucault argues that heterotopias have a system that “isolates them and makes them penetrable at the same time” (Foucault 1998, p. 183). He uses the analogy of a prison as a heterotopia to illustrate that entrance to this space may be restricted or demand ritual to accompany the transition from outside to inside. This is literally the case in the Salem fields because the riverfront park is fenced. Two gateways allow the visitor to enter from the downtown area into the park. Once inside, the field creates its own sense of entrance and exit. In Salem, the southern gateway brought one into the 9/11 field and the northern gateway into a green space between the 9/11 Field and the Military Field. The ceremonies were held at the furthermost southern end of the 9/11 Field thus forcing the visitor to traverse the field. Whether looking forward, to the right, or left, the same image was encountered - precise rows of flags stretched into the distance. Their height and number isolated the visitor from other visitors and from the bustle of the city several hundred yards away. The memorial shrouded the entrant, and at this proximity the names inscribed in the red and white stripes of the flag drew one’s attention and individuated the trauma; each name on the flag represented one life lost; each flag represented one life lost. Bob Lloyd captures the experience, “I got this tightness in my chest. . .and it remained there the whole time. It was absolutely like Arlington National Cemetery. There was this inspired feeling looking at all those flags, all those lives” (Briggs, 2004). At the appointed time, the dirge from a procession of bagpipers moved the visitors to the ceremonial site where the memorial rites were performed. This too became part of the ritual preparation for commemoration. As noted earlier, the smaller, stiffer, faded flags of the 10th anniversary failed to aesthetically isolate the visitor, and thereby lessen the sacrality of the experience of traversing the field. Although the 9/11 Field and the Military Field employ the same visual icon (rows of flags), the two fields have a different feel. Walking among the flags in the Military Field for the 5th anniversary, one is more likely to encounter spontaneous memorials - letters, photos, and grieving families and friends. Because these flags represent soldiers from the Northwest who died, they are more likely to have relatives present; Oregon is a long way from New York City and there are fewer names in the 9/11 field with direct connection to the local

Complimentary Contributor Copy Healing Fields and Field of Flags 187 residents. Interestingly, there were no vernacular offerings in the military field for the 10th anniversary, even though new deaths are being commemorated each year for soldiers who have died in Iraq and Afghanistan. Although the size of this field is smaller, the emotional impact is often greater. A newspaper editorial reminds the viewers, “Whatever you think of the political decisions that led to wars in Iraq and Afghanistan, spend time among the flags of the Military Field too. They honor men and women who enlisted out of sincere love of country. Many wanted to protect their homeland, even if it meant risking their lives abroad” (Curtin, 2006). Beyond the appeal to honor, the editorial also reminds the reader that the status quo is less than perfect when insufficient support is provided to the families of those who have died and injured veterans who may need support for some time. This is the chaotic world in contrast to the ordered heterotopia of the Healing Field. Foucault explains that heterotopias “have a function in relation to the remaining space” in this case “creating a different space, a different real space as perfect, as meticulous, as well-arranged as ours is disorganized, badly arranged, and muddled” (1998, p. 184). The order of the Military Field and the 9/11 Healing Field offers relief from the chaos of memory and unhealed grief. As a site for community memory work, the 9/11 and Military Healing Field memorials epitomize heterotopias. They offer a separate, sacred site for working on the traumatic memories of 9/11 and the deaths of soldiers whose presence in Afghanistan and Iraq is justified by 9/11. But the juxtaposition of these two different Healing Fields also particularly evokes the contested nature of memory work. 9/11, as popularly conceived, is a story of victimage in the face of uncontrolled aggression. American innocence is contrasted with al-Qaeda’s absolute villainy. Robert Ivie explains how American presidents, in order to justify wars of retaliation, have used the Victimage Story historically and successfully. Our motive for war is to secure rights with law and democracy as god-terms for agency (1974), but in the victimage story, the motives for war of the villainous Other are driven by fanaticism, a disregard for law and democracy and a rejection of the freedoms central to the mythic American political story. In the face of such tyranny, victimage inspires the emergence of everyman as hero. Thus, the firefighters, police and rescue workers who responded to the events of 9/11 embody the essence of Americanism. This mythic interpretation of 9/11, like all collective memory, has not gone unchallenged, but critiques enumerating American actions that brought on retaliation were elided in favor of narratives and rituals that celebrated America’s mythic identity and common Americans’ heroism. Memorial sites foster an illusion of collective memory that “might force an otherwise fragmented populace to frame diverse values and ideals in common spaces” (Young, 1993, p. 6). The meaning of any memorial is shaped, in turn, by its surroundings. It matters that the Vietnam Veterans Memorial in Washington D.C. is located on the National Mall and visually is sited with the Lincoln Memorial at one end and the Washington Monument at the other. The placement and visual links add to the sacrality of the memorial and suggest common memory. A similar argument can be made with the juxtaposition of a 9/11 field and a military field; their proximity suggests a link between these two events - the disaster of 9/11 caused by terrorism and the justified response in a war against terror. For some viewers, the visual linkage is neither questioned nor questionable; for others, the proposed linkage is fantasy and the motivations of those who would forge the connection are malevolent. Those who doubt the link contend that the Iraq War was personal to George Bush and not a justifiable response

Complimentary Contributor Copy 188 Catherine Ann Collins to 9/11. Linking the two acts becomes political and opens cultural contestation, rather than providing a respite from trauma and a place for healing.

CONTESTATION AND COMMEMORATION

The place of a 9/11 field for commemorating victims and heroes offers space for a temporary belief in “innocence lost”, but this is called into question by the focus on the “war against terror” in Afghanistan and Iraq. The Iraq War by fall 2006 and the 5th anniversary of 9/11 had lost support from large segments of society. The contestation over whether the United States should ever have gone into Iraq, over the effectiveness of our military efforts, and over the appropriate timetable for withdrawal, all militate against a shared understanding of the war. Few would contest the appropriateness of honoring the military dead or the innocent civilians in the Towers and the airplanes, but many challenge the link between 9/11 and the justification for the war in Iraq. Community organizers are aware that this associational link is contested. An editorial blog in the Statesman Journal, the local paper covering the Salem Healing Field, notes:

Between the “9/11 Field” and the “Military Field,” there’s a green space. You could call it a gulf, seeing how torn this country remains over the current war and the connection to the attack. Instead, let’s call it common ground: the place to heal on the Healing Field in our midst (“Common Ground on the Healing Field”, 2006).

Despite the acknowledged differences of opinion as to a natural link between 9/11 and the Iraq War, the field is designed to forge this link. Healing Fields are designed to mend according to Greg Pettis: “We’re mending the wounds of families whose loved ones have paid the ultimate price over the last five years and mending the wounds of our nation between those who disagree about our mission and our course” (Loredo, 2006). Mending requires calculated action, and the choice of the American flag for both memorials is strategic; embedding the names of the victims of 9/11 into the red and white stripes transforms these individuals into an embodiment of the nation. Their sacrifice, like others before them and those to come, is the essence of patriotism. Commemoration is thus owed them and the nation that shaped them into who they were. Commemoration of individual lives lost seems to work in the 9/11 field. A similar individuation is sought in the Military Field that focuses attention on the individual soldiers and not the collective military enterprise in Iraq. Yellow ribbons hanging from the flags identify individual victims with their name, rank, service, and place of death. Dean Lambert notes that “When you come out here and you see all the flags. The number of flags gets you. But really what really gets you is when you go up to the individual flags and you see a name of a person” (‘The Healing Field’, 2006). In focusing on the individual, memory of the collective is not neglected, because the representation of each dead soldier reminds the viewer that the ultimate patriotic sacrifice is giving one’s life for the nation. In this field also, commemoration on an individual level seems to work. Those who would combine the two fields argue that we should separate the individual soldier from the political dispute over the war. The rhetorical appeal is visually reinforced in the shared symbol of the American flag. The obvious goal of the combined field is to bring

Complimentary Contributor Copy Healing Fields and Field of Flags 189 people together; the form of the memorial is designed to elide the differences of opinion about the current war in Iraq and replace this with memories of the way Americans came together in 2001 with the terrorist attacks. One visitor to a Healing Field recalls: “The ability to come together was one of the blessings of five years ago” (“CommonGround on the Healing Field”, 2006). The memory of a former unity, of national pride serves the current interests, it is in Zelizer’s (1995) terms, useful, but it may not be achieved for some viewers. For others, the combined memorial allows a space for commemoration without resolving the contested memory of why, ten years after 9/11, we are still involved in Iraq1. For this viewer, the focus becomes respect for the soldiers who have died, not for the war that brought about their death. Even contested, the visual form allows some transcendence of commemoration. Even if there is contestation about the war, the commemorative site brings people together - it constitutes a community willing to memorialize those who have died, and to the extent that it does this, the site fosters the creation of a collective memory. The Healing Field and Field of Flags try to make sense of the trauma of 9/11, and the combined fields construct a narrative in which patriotism and commemoration help restore the mythic past in which Americans were unified. Ochs and Capps (2001), writing about living narrative lives, argue: “Putting the pieces of one’s life experiences together in narrative is one way in which a human being can bring a sense of coherence and authenticity to his or her life” (p. 252). The same argument holds true for nations: we work through our problems and traumatic events in the stories we tell. As we construct explanations of the events we face, we create a bridge between an idealized past before the trauma and a brighter future that awaits us if we pull together and reaffirm the values and collective action that created our mythicized past. We certainly long for the sense of unity and common resolve that was present immediately after 9/11. One visitor to a Healing Field remarks: “I wish this country had stayed like it did after 9/11 longer. People were more united. I miss the flags that everyone was flying” (“Ohio Remembers”, 2006). In creating a space for memory work, the Healing Field or Field of Flags has the potential to help visitors generate a coherent narrative that will make sense of the events of 9/11 and allow us to heal from the trauma. The focus on sacrifice for the nation was more pronounced in the 10th anniversary dedication ceremony. The featured speaker, Michael Irwin, present in Washington D.C. ten years ago, reminded the audience of the importance of keeping the thoughts and memories of 9/11 alive, especially for children who do not have firsthand memories of the event. The memories he recounted, however, focused on the leadership and planning that keeps the nation free despite continued terrorist threats, and it is this threat and belief in our security forces and national leadership that he urged the audience to remember. Additional speeches celebrated the military’s dedication to protecting the nation and the importance of all Americans helping to protect our security: healing from the collective trauma of 9/11 was replaced by calls for increased patriotism and sacrifice for the nation. Ironically, Ochs and Capps also remind us that we are also torn between the need for a coherent narrative, for example the myth of America as sacred space with the patriotic unity that narrative can provide, and a need for authenticity, for knowing the facts, the causes, the consequences of events. The focus on national security efforts and the presence of a Military Field evoke questions about U.S. culpability in creating the climate for terrorism. Lingering

1 Postscript. On December 9, 2011, 7,500 United States troops remained in Iraq with full US withdrawal of its armed forces scheduled for completion by December 31, 2011.

Complimentary Contributor Copy 190 Catherine Ann Collins doubts about the authenticity of justifications for war in Iraq pull against the desire for coherence that comes with the mythic story of America as a second Eden. Laub (2003) would explain that this is part of the trauma response:

There’s both an inability and a total refusal to keep one’s gaze centered on the eye of the trauma. Strategies are employed to avoid it, individual and collective – patriotic gestures, sentimentality, pseudo-unity, fantasies of revenge, concepts of justice or of bringing those responsible to justice. All of these in their own right can be very valid, but at this particular juncture they are definitely being used to avoid the full absorption and resumption of that internal dialogue of knowing. With this internal dialogue comes the possibility of agency and of action - informed and effective response. (p. 209)

What we need, of course is a balance between coherence and authenticity (Ochs and Capps 2001, p. 279). Perhaps confronting the tension that arises between the 9/11 and the Military Fields is a space that fosters reflection and is precisely what we need as a nation. Rowland Sherrill contends that we long for sacred space, for an orienting place. After the debacle of the Vietnam War he argued that “the very mythos of America, its blessed and exceptional character” was called into question: “The country could be seen, and certainly was felt, no longer to elude the claims of history: America was just one more erstwhile empire caught up in the finite and maculate stuff of geopolitical experience” (Sherrill 1995, p. 362). 9/11 ironically gave us back the mythos, at least temporarily, gave us that shared sense of nationalism and patriotism and a homeland. The statements about wishing we could return to that time are statements about the need for sacrality of place - for some return to the conception of America as sacred space. So we come back around to narratives and the power of our foundational myth of America as a shining city on a hill, a sacred gift, a new Eden in which to reinvent ourselves. The heterotopian nature of the Healing Field challenges the easy transformation of these temporary spaces into fully sacralized space; but the effort might be a starting point prompting the visitor to rethink the sacred and wonder again if it isn’t here, in American space, simply waiting to be discovered or created. Certainly the choice of flag as a symbol for the Healing Fields suggests freedom and the mythic conception of America as “a beacon of hope for the entire world” (‘Showalter citing Lafayette Mayor Tony Roswarski, May 2005). Bill Havekost reflects on the value of the Healing Field and its role in America’s response to 9/11:

Events like the anniversary of 9/11 and the gift of The Healing Field are chances to remember and honor death - often as a normal conclusion to life; sometimes not. We re- experience not just the pain of our loss, but the joy of our memories. Those memories help us to move on in our grief and begin to heal. . . . Everyone came to remember. They all left with new memories that will define us as individuals and as a nation” (2006).

CONCLUSION

In 2006, Salem (Oregon) was one of 15 cities to host a Healing Field memorial for the 5th anniversary commemoration of 9/11. For the four short days it remained in place, the neutral public space of a riverside park was transformed into sacred, albeit heterotopian space/place. Five years later on the 10th anniversary, the city again hosted the temporary memorial of joint

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9/11 and military fields. The visual narrative of the 9/11 and Military Healing Fields engage the participant in commemoration and facilitate an exploration of the trauma that these deaths and the loss of American innocence engendered. Healing Fields attempt to suture the rupture in the individual and the culture brought on by 9/11, but the juxtaposition of largely uncontested symbolic responses to 9/11, with highly contested responses to the war in Afghanistan and especially Iraq, bring to light the difficult process of recovery from trauma. Visual narratives in the form of a Healing Field or Field of Flags offer temporary and contested space for negotiating trauma, but like the heterochronias of the site itself, the difference between the 5th and 10th anniversary commemorations are notable. In 2011, it seemed less like a site for working through grief and more like a memorial site that was politically structured in its visual and ritual elements. This too is typical of commemorations over time. John Bodnar (1994) notes that community leaders “share a common interest in social unity, the continuity of existing institutions, and loyalty to the status quo” which is achieved by presenting “the past on an abstract basis of timelessness and sacredness” (p. 75). Visual ideographs reflecting patriotism and unity serve the political needs of the present, and the deaths resulting from the attacks of 9/11 and the subsequent wars in Afghanistan and Iraq become the compelling need for renewed patriotism. As with all collective memory, it is the needs of the present that shape the ways that communities construct their remembrance of, and duty toward, events of the past. In comparing the 5th and 10th anniversary commemorations in Salem, Oregon, over time we discover that patriotism has replaced healing as the rationale for continued commemoration.

REFERENCES

Alexander, J. C. (2004). Toward a theory of cultural trauma. In J. C. Alexander, R. Eyerman, B. Giesen, N. J. Smelser, and P. Sztompka. (Eds.), Cultural trauma and collective identity (pp. 1-30). Berkeley: University of California Press. Alexander, J. C., Eyerman, R. Giesen, B., Smelser, N. J. and Sztompka, P. (Eds.) (2004). Cultural trauma and collective identity. Berkeley: University of California Press. Bodnar, J. (1994). Public memory in an American city: Commemoration in Cleveland. In J. R. Gillis (Ed.), Commemorations: The politics of national identity (pp. 74-89). Princeton, NJ: Princeton University Press. Briggs, K. (2004, September 6). 4,000 flags will unfurl in Gresham for Sept. 11 victims, troops killed. The Oregonian, p. E01. Burack. (2006, September 14). Healing Field was a profound experience. The Tribune. Retrieved from http:www.greeleytrib.com/apps/pbcs.dll/article?AID=/20060914/TRI BEDIT/09140078 9/18/2006. Colonial Flag Foundation website. (2006). Retrieved from http://www.healingfield.org/ index.php. Common ground on the Healing Field. (2006, September 18). Statesman Journal. Retrieved from http://www.statesmanjournal.com/apps/pbcs.dll/article?AID=/20060909/BLOGS02 /60909… 9/18/2006.

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Curtin, B. (2006, September 18). Common ground on the Healing Field. Statesman Journal Editorial Blog. Retrieved from http://www.statesmanjournal.com/apps/pbcs.dll/article? AID=/20060909/B:PGS02/60909...9/18/2006. Douglass, A. and Vogler, T. A. (Eds.). Witness and memory: The discourse of trauma. New York: Routledge. Demo, A. (2005). Sovereignty discourse and contemporary immigration politics. Quarterly Journal of Speech, 91, 291-311. Edelman, M. (1972). The symbolic uses of politics. Urbana, IL: The University of Illinois Press. Edwards, J.L. and Winkler, C.K. (1997). Representative form and the visual ideograph: The Iwo Jima image in editorial cartoons. Quarterly Journal of Speech, 83, 289-310. Foucault, M. (1998). Different spaces. In J. D. Faubion (Ed.). Aesthetics, method, and epistemology (pp. 175-185). New York: New Press. Gammeltoft, T. (2006). “Beyond being”: Emergent narratives of suffering in Vietnam. Journal of the Royal Anthropological Institute (N.S.), 12, 589-605. Gillis, J. R. (Ed.). (1994). Commemorations: The politics of national identity. Princeton, NJ: Princeton University Press. Greenberg, J. (Ed.) (2003). Trauma at home after 9/11. Lincoln, Nebraska: University of Nebraska Press. Havekost, B. (2006, September 20). September 11 healing field a great gift to community. DesMoinesRegister.com. Retrieved from http://desmoinesregister.com/apps/pbcs.dll /article? AID=/20060920/OPINION1/6092003...9/20/06. Ivie, R. L. (1974). Presidential motives for war. Quarterly Journal of Speech, 60(3), 337-345. Kitch, C. (2003). “Mourning in America”: Ritual, redemption, and recovery in news narrative after September 11. Journalism Studies, 4, 213-224. Kleinman, A. (1988). The illness narratives: Suffering, healing and the human condition, New York: Basic Books. LaCapra, D. (2001). Writing history, writing trauma. Baltimore: The Johns Hopkins University Press. Laub, D. (2003). September 11, 2001 - an event without a voice. In J. Greenberg (Ed.), Trauma at home: After 911 (204-215). Lincoln, Nebraska: University of Nebraska Press. Loredo, H. E. (2006, September 8). Healing Fields visits desert. Marine Corp News. Retrieved from http://usmc.mil/marinelink/men2000.nsf/0 /AAF6BC5AD4899265852571 EF0078CF …10/5/2006. Lynn, C. (2006, September 8). Healing hits home at display. Statesman Journal. Retrieved from http://www.statesmanjournal.com/apps/pbcs.dll/article?AID=/20060908/NEWS //60908031...9/18/2006. Mattingly, C. and Garro, L. (Eds). (1999). Narrative and the cultural construction of illness and healing. Berkeley: University of California Press. Ochs, E. and Capps, L. (2001). Living narrative: Creating lives in everyday storytelling. Cambridge, Mass: Harvard University Press. Ohio remembers 9/11. (2006). 13abc.com. Retrieved from http://abclocal.go.com/wtvg/story? section=local andid=4551658 andft=print. Pineda, R.D. and Sowards, S.K. (2007, Winter and Spring). Flag waving as visual argument: 2006 immigration demonstrations and cultural citizenship. Argumentation and Advocacy, 43, 164-174.

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Polletta, F. (2006). It was like a fever: Storytelling in protest and politics. Chicago: University of Chicago Press. Schwartz, B. (1982, December). The social context of commemoration: A study in collective memory. Social Forces, 61(2), 374-402. Sherman, D. J. (1994). Art, commerce, and the production of memory in France after World War 1. In J. R. Gillis (Ed.), Commemorations: The politics of national identity (pp. 186- 211). Princeton, NJ: Princeton University Press. Sherrill, R. A. (1995). American sacred space and the contest of history. In D. Chidester and E. T. Linenthal (Eds.), American sacred space (pp. 313-340). Bloomington, Indiana: Indiana University Press. Showalter, M. (2005). Flags honor lives lost in combat. Journal and Courier. In Nipprdog. (2005, May 30). Less we forget. [Blog]. Retrieved from http://www.go2gbo.com/ forums/index.php?topic=64411.0. Sturkin, M. (1997). Tangled memories: The Vietnam War, the AIDS epidemic, and the politics of remembering. Berkeley: The University of California Press. Swenson, P. (2006). Paul’s story. In Colonial Flag Foundation website. (2006). Retrieved from http://www.healingfield.org/index.php. The healing field. (2006). KVTO.com, http://www.ktvotv3.com/global/story.asp?s =5410907 andClientType=Printable. The power of symbols. (2006, April 1). Omaha World-Herald, p. 6B. Retrieved from http://www.lexisnexis.com/hottopics/lnacademic/ Whitehead, A. (2004). Trauma fiction. Edinburgh: Edinburgh University Press. Winter, J. (1995). Sites of memory, sites of mourning. Cambridge: Cambridge University Press. Young, J. E. (1993). The texture of memory. New Haven: Yale University Press. Young, J. E. (2003). Between history and memory: The voice of the eyewitness. In A. Douglass and T. A. Vogler (Eds.), Witness and memory: The discourse of trauma (pp. 275-284). New York: Routledge. Zelizer, B. (1995). Reading the past against the grain: The shape of memory studies. Critical Studies in Mass Communication, 12(2), 214-239.

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PART 3

COMMUNITY RESILIENCE AND DISASTERS

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 12

WHAT MAKES CHILDREN RESILIENT AND RESOURCEFUL DESPITE FAMILY ADVERSITY AND TRAUMA IN HIGH RISK POPULATIONS?

Karol L. Kumpfer* and Qing-Qing Hu University of Utah, UT, US

ABSTRACT

Resilience research is becoming increasingly critical in understanding developmental outcomes for children living in families with high levels of trauma and adversity. Resilience is a product of a complex interaction of genetic, epigenetic, biological and environmental precursors as described in this chapter and is pertinent to the aftermath of mass trauma situations. The Resilience Framework (Kumpfer, 1999) is a transactional model that summarizes the interplay of moderating or mediating factors and processes leading to resilient outcomes. This chapter mainly describes the needs and primary risk and protective factors in children in special populations facing adversity (e.g., deployed military parents, immigrant or refugee parents, or those living in war torn areas; children of incarcerated parents, and those affected by parental substance abuse, family violence and foster care).

Keywords: Trauma, Resilience, High Risk Families, Family Interventions, Prevention

INTRODUCTION

Resilience has been studied for decades in a desire to understand the factors that influence healthy outcomes for people facing adversity. Broadly defined, resilience refers to the process through which positive outcomes are achieved in the context of adversity (Luthar, Cicchetti and Becker, 2000). Resilience is also considered as the achievement of competence or positive developmental outcomes under conditions that are adverse or that challenge

*Contact: [email protected].

Complimentary Contributor Copy 198 Karol L. Kumpfer and Qing-Qing Hu adaptation (Masten and Coatsworth, 1998). As our world becomes increasingly complex, the need to understand how individuals cope with adversity becomes critical. In mass trauma situations, one can conceive of children as hidden collateral damage, as they suffer silently, and the negative effects are not necessarily attributed to the actual cause of their suffering which is more likely deprivation from parental support, care, and love. Hundreds of thousands of men and women are sent to war and peace keeping situations, leaving families behind and then returning to a world which does not know what they have experienced.1 The children in refugee families and those living in war or natural disaster zones (e.g., earthquakes, tsunamis, severe drought, etc.) are rarely interviewed about the effects on them physically and psychologically during, or after, the devastating disruption to their lives. The children of prisoners, drug addicts, or mentally ill patients form a silent and unappreciated group and are often undermined by the actions of their parent/s and society around them. However, we know that children living in families with high levels of trauma and adversity sometimes achieve balanced and successful lives despite high levels of stress and maltreatment. This chapter describes the needs and prevalence of children in special populations facing adversity in their families. These children are influenced by parental abuse and neglect due to substance abuse, parental absence, stress, and neglect related to military deployment or incarceration, and children in foster care and institutions because of parental maltreatment. While we mention at the end of this chapter the importance of family interventions that increase family support and parental nurturing and reduce stress on children, these effective family interventions are covered in more detail in our chapter “Engendering Resilience in Families Facing Chronic Adversity through Family Intervention Programs” in the second book in this series (Kumpfer, Xie and Hu, 2011).These evidence-based family interventions (Kumpfer and Alvarado, 2003; Kumpfer, Whiteside, Greene and Allen, 2011) are most effective in attempts to break the intergenerational cycle of pathology and addiction in the treatment and prevention of disorders that run in families if they are culturally adapted and implemented with fidelity (Kumpfer, Xie and Magalhães, 2012).

Epigenetics: Mechanisms behind the Impact of Adversity on Gene X Environment Interactions

Research suggests that resilience is a product of a complex interaction of genetic, biological and environmental precursors. But how do environments impact the genome? Why do identical twins with the same genes, sometimes turn out to have many differences? According to epigeneticists (Jirtle, 2010), the mechanism is through epigenetics or the epigenome. Recent and future research in epigenetics will demonstrate the impact of the environment on gene expression to help us to better understand this complex ‘gene by environmental’ interaction. For instance, researchers at McGill University (Meaney et al., 2007) suggests that maternal stress and fetal under-nutrition in utero, leading to low birth weight, can result in poor birth outcomes that predict poorer health over the lifespan. These researchers hypothesize that the effect of maternal adversity on foetal growth is mediated by

1See Jacques Gouws’s chapter on returning military in this book.

Complimentary Contributor Copy What Makes Children Resilient and Resourceful Despite Family Adversity … 199 the adrenal glucocorticoids hypothalamic-pituitary-adrenal (HPA) stress response. Later environmental adversity alters maternal physiology and behaviours, which then programs the stress (cortisol HPA) response in the offspring. Environmental protective factors can reverse this negative health impact. Mouse studies (Anderson, 2010; Jirtle, 2010) suggest that increased exposure to nurturing parenting, and diets high in genesine (soy) can protect against the phenotypic expression of genetically inherited metabolic and cardiovascular diseases. Jirtle and associates (2010) have found the improved diet high in genesine (soy) can protect mice with genes for obesity, so that the phenotype of obesity is not manifest compared to litter mates with identical genes that were fed a standard diet. Also other studies on mice find that the greater the exposure to a nurturing or “licking and grooming” mother in infancy and childhood results in reduced stress reactions and improved health of the offspring throughout life. Additionally, researchers (Champagne, 2008; 2010) have found that nurturing parenting is passed on to offspring and also increases their estrogen mediated oxytosine levels so they are more likely to trust others, live in social units, and develop attachments to others. Nurturing parenting increases children’s exploratory behaviors leading to higher cognitive abilities and better performance in school and work. The effects of poverty and adversity during childhood on gene expression suggests the creation of a defensive phenotype, characterized by heightened immune and stress reactivity which may better prepare an organism for conditions of threat (Miller et al., 2009). Hence, long-term exposure to adversity and stress induces defensive responses that may increase the likelihood of physical and mental disorders. Hence, this epigenetic research will explain the mechanisms underlying how Adverse Childhood Experiences (ACEs) can have a profound impact on later mental and physical diseases and mortality (Anda et al., 2008). Earlier research reported direct effects of childhood neglect on reducing the size of the corpus callosum in children (Teicher, Dumont, Ito, Vaituzis, Giedd and Anderson, 2004). They report that sexual abuse tended to impact girls more than boys in reductions in the corpus callosum brain structure. More recently, Anderson (2010) reported that there is a difference in the impact of physical and sexual abuse on children depending on gender and age. Girls who were sexually abused as children were more affected than boys, but girls 11 to 14 years were less impacted by sexual abuse than boys of that age.

The Critical Role of Families in Child Raising

A multitude of developmental psychobiology studies and psychological theories support the critical role of nurturing families in raising healthy and happy children. Longitudinal adolescent research suggests that parents have a larger impact on their children’s development and health than previously thought (Resnick et al., 1997). Although in the 1980’s and 1990’s, peer influence was thought to be the major reason adolescents initiated negative behaviors, more recent research (Kumpfer, Alvarado and Whiteside, 2003) suggests that a positive family environment (e.g., family bonding, parental supervision, and communication of pro- social family values) is the major reason that youth do not engage in unhealthy behaviors, such as substance abuse, delinquency, and early or unprotected sex. Similar to the negative effects in girls of sexual abuse reported by Anderson (2010), these protective family factors have an even stronger influence on positive outcomes for girls (Kumpfer, Smith and Franklin

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Summerhays, 2008). The dramatic increase in criminal behavior and substance abuse in girls in the United States in the mid 1990’s and now in girls worldwide appears to be related to increased parental neglect. Parents are working harder and spending less and less time with their children. According to a recent Annenburg Center (2009) study, parents in the U.S.A. are spending about a third less time with their children in the last three years. In 2005, each child spent about 6.2 hours a week interacting with their parent/ parents. Possibly because of the economic downturn, in 2008 that number was reduced to 4.2 hours. The ways that parents and other caregivers respond to adverse situations and help a child to respond to stressors are critical to teaching children effective coping strategies. Mechanisms for role modeling and teaching stress/coping by imitation and direct coaching are explained in more detail in our chapter (Kumpfer, Fenollar, Xie, and Bluth Dellinger, 2011a)2 on the Resilience Framework - a transactional model of the interaction of environmental conditions with stressors. These interactive parent/child processes separate out those adults who promote resilience in their children from those who destroy resilience by sending confusing messages that both promote and inhibit resilience (Grothberg, 1995).

Special Populations of Children Living with Adversity

The need for resilience research in the applied prevention field is critical. Although certain factors have been found to be protective in the risk environment, there are challenging issues regarding the resilience research, including: 1) establishing and defining “high risk” environments; 2) defining positive outcomes; and 3) understanding the process of resilience across levels of varying risk (Vanderbilt-Adriance and Shaw, 2008). Also, there are few studies of protective factors in early childhood, which are related to later outcomes (Werner and Smith, 1992), as well as studies for children living in poverty, arguably the most prevalent risk factor (Gorman-Smith, Tolan and Henry, 1999; Owens and Shaw, 2003; Seidman, 1991). Many children and families have greater risks in our increasingly complex world; these multiple risks for poorer developmental outcomes are related to increased parent and extended family absence in children’s lives. For instance, as indicated earlier, parents worldwide are spending less time parenting and supporting their children. In the United States, few parents still have a meal each day with their children, although two-thirds of children in other countries still have their main meal with their parents. However, fewer children than that talk with their parents on a regular basis (UNICEF, 2007). Living with drug addicted caretakers, who spend about half as much time with their children as the average, only increases children’s stress levels. High levels of parental absence can be related to increased rates of substance abuse, divorce, separation, imprisonment, military deployment, and removal from home because of child maltreatment or neglect, and parental employment in another location. Each of these is a stressful family situation for children, and will be discussed in the following sections.

2 Kumpfer, K.L., Fenollar, J. Jing Xie, J. and Bluth Dellinger, B. (2011). Resilience framework: Resilience and resourcefulness in the face of chronic family adversity. In M. J. Celinski, & K.M. Gow (Eds.), Continuity versus Creative Response to Challenge: The Primacy of Resilience & Resourcefulness in Life & Therapy (pp. 259-272). New York: Nova Science Publishers.

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Parental Substance Abuse

One major stressor for children is parental substance use disorders (SUDs) which can result in frequent parent absences from home on alcohol or drug binges, drug getting, and attending treatment programs, or prison stays. Substance use disorders in parents greatly stretch the resources of children in the home. Too many children today are being born to parents with various addictions (e.g., psychoactive substances, food, sex, gambling, or work) whose lives are out of balance and have little time or inclination to be wise and caring parents. The misuse of alcohol and other drugs has a significant impact on global health and the economy as well as the wellbeing of children and families. Statistical evidence. It is estimated that around 48% of adults worldwide use alcohol and 4.5% use illicit drugs, although only about 15% misuse alcohol and drugs (Anderson and Baumberg, 2006). The greater the alcoholic consumption by parents, the greater the harm done to children (Babor et al., 2003; Rehm et al., 2004). Europeans have the highest amount of yearly alcohol consumption in the world, which is 2.5 times that of the world average (Anderson and Baumberg, 2006). Alcohol and other drugs misuse has a wide impact on all strata of society, including illness and disease, violence and crime rates, workplace injuries and performance, and family stability and relationship breakdown. The cost of addictions in the United States is very high and is estimated to be at about $2,000 per person in economic costs related to lost revenue, taxes, treatment costs, criminal justice costs, fires, accidents, and other related costs (Cartwright, 2000). Recent reports by the Substance Abuse and Mental Health Services Administration (SAMHSA) suggest that nearly 12% of children under the age of 18 years live with at least one parent who abused, or was dependent on alcohol or an illicit drug, during the past year. The 2009 National Survey on Drug Use and Health (NSDUH, 2009) for children living with substance-abusing or substance-dependent parents revealed that:

 8.3 million children lived with a parent who was dependent on, or abused, alcohol;  2.1 million children lived with a parent who was dependent on, or abused, illicit drugs  5.4 million children lived with a father who met the criteria for past year substance abuse or dependence, and  3.4 million children lived with a mother who met this criterion.

Violence and chaos may be more frequent when SUDs (substance abuse disorders) are part of the family dynamic. The chronic emotional stress in such an environment can damage a child’s social and emotional development and permanently impede healthy brain development, resulting in mental, social and physical health problems across the lifespan. Intergenerational Transmission for Alcoholism. Because of the intergenerational transmission of genetic and environmental risk factors for alcoholism, these children of alcoholics (COAs) are at very high risk for many neuropsychological and limbic system deficits that lead to reduced resilience, such as (a) behavioral and emotional self regulation problems and (b) reduced executive functioning (Chassin, Carle, Nissim-Sabat and Kumpfer, 2004). From Handley and Chassin’s latest research in 2009, in high-risk families, father’s alcoholic-use behavior is more influential in impacting boys’ alcohol expectancy

Complimentary Contributor Copy 202 Karol L. Kumpfer and Qing-Qing Hu development than are fathers’ expectancies, and that during emerging adulthood, alcohol expectancies may be one mechanism underlying the intergenerational transmission of drinking among males. Sons of early onset (before the age of 15 years) male alcoholics who have many alcoholic relatives across generations - a characteristic of a highly heritable type of alcoholism called Type II Male Limited Alcoholism - have been reported to be genetically vulnerable to two major syndromes: (1) the Over Stressed Youth Syndrome (e.g., poor emotional regulation, difficult temperament, autonomic hyper-reactivity, rapid brain waves); and (2) prefrontal cognitive deficits in verbal and abstract reasoning and verbal learning. Heritable dysfunctions of the prefrontal cortex and limbic systems have been posited as causing these self-regulation and executive functioning dysfunctions (Schuckit, 1991); however, cognitive impairments may also stem from environmental neglect or fetal alcohol exposure. Alcohol and drugs serve as self-medication because they smooth out the overactive autonomic nervous system (ANS) stress response (Schuckit, 1991) and increase illegal drugs (Luthar et al., 1998). However, she concludes from her research that maternal drug abuse per se is not as damaging to children’s resilience as maternal stress, depression, and anxiety disorders (Luthar, D’Avanzo and Hites, 2005). Addicted parents have been found to spend about half as much time with their children, use lax and excessive punishment, but more often simply neglect their children. With parents working more and receiving less extended family support, parental neglect is occurring in homes of both the rich and the poor. Neglect is possibly even more devastating than physical punishment to children’s brain development, as well as to their social and emotional development. Like Sumi’s peer-raised monkeys, children who do not feel protected by caring adults tend to cluster into strong peer groups. They exhibit increased levels of stress, anxiety, and reduced secure attachment and exploratory behaviors that are needed to develop their self-control and executive functioning.

Family Violence and Foster Care

Family violence presents another area where children are at increased risk for developmental problems. Rates of family violence, conflict, and child maltreatment are unacceptably high nationally and internationally with high costs to society. Family violence and child maltreatment are associated with multiple negative consequences for all family members, and include physical injury, child neglect, separation and divorce, incarceration, psychological problems, child removal from the home, multi-generational substance abuse, youth delinquency, perpetration of violence, and death. There has been an increasing focus on children of alcoholics (COAs) in western countries compared to eastern countries where little research on COAs has been completed. An Indian study, conducted by Stanley and Vanitha (2008), revealed lower self-esteem and poor adjustment in the adolescent COAs than the non-COAs because of the increased stress and the more complicated environments of the COAs. Hence, there is a need for more comprehensive investigation of the outcomes of COAs living in the East.

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Prevalence of Child Maltreatment

Nationally, substance abuse is a factor in up to 80 percent of substantiated cases of child maltreatment (Child Welfare League of America, 2003). Over 80% of state child protection agencies report that parental alcohol and drug abuse and poverty are the two major factors associated with child maltreatment (NCCAN, 2003). Parental substance abuse increases child abuse by approximately 300% and child neglect by 400% (Kumpfer, 2008). Additionally, youth who have ever been in foster care had higher rates of illicit drug use (33.6%) than youths who have never been in foster care (21.7%). Further, youth who have ever been in foster care are in need of treatment for both alcohol and drug abuse at much higher rates (17%) than are youth who have never been in foster care (9%). Despite significant need, many families and children involved in child welfare are not receiving the prevention and treatment services they need. In 1997, the Child Welfare League of America (CWLA) estimated that 43% of children and adolescents in care needed substance abuse services, while agencies obtained treatment for only around a third of these youth. For parents, it was estimated that 67% needed services, while agencies had the capacity to serve less than half or only around 31%. Beyond basic substance abuse treatment, it is unknown how many families learn parenting skills and receive family support services to raise healthy children. A small study of children involved with child protective services due to parental methamphetamine abuse, found few social resources for children related to their coping with emotions, problem solving, or talking about their experiences at home (Ostler et al., 2007). The intergenerational cycle of family violence and child maltreatment needs to be interrupted. There appears to be a clear need for development and research surrounding evidence based programs (EBP) for child welfare, substance abuse, and community setting implementation. Unfortunately, research in this area is scarce due to a lack of funding for child abuse prevention research that tests evidence-based family nurturing programs. Additionally, family intervention researchers often lack access to cross systems service delivery databases to clearly demonstrate that their interventions work to reduce child abuse. Fortunately, new grants by the Administration for Children and Families (ACF) to states and tribes are likely to show that family strengthening interventions that improve parenting skills, family communication, problem solving, and stress management will result in reductions in family violence and child abuse. Already the authors’ Strengthening Families Program (SFP) has shown positive results in several statewide implementations in reducing family and parenting risks and increasing protective factors leading to actual reductions in the number of days to reunification and reduced outplacement into foster care or kinship care (Brook, McDonald and Yan, 2012).

Incarcerated Parents and Their Children

Families with an incarcerated member may also lead to high levels of stressors and risks for its child members. Mumola (2000) presents data from the 1997 Surveys of Inmates in State and Federal Correctional Facilities. In 1999, update statistics showed that an estimated 721,500 State and Federal prisoners were parents, and 22% of their children were under the age of five. As parents and elders are role models for children, children of prisoners are at higher risk for incarceration and other problems. An amazingly high 80% of prisoners were

Complimentary Contributor Copy 204 Karol L. Kumpfer and Qing-Qing Hu raised fatherless. It is estimated that a 2 to 5 times increase in drug use in girls in USA in the mid 1990’s led to increased drug abusing women in prison today by 700%. Also 70% of women in prison are mothers. There are negative impacts on children of addicted mothers in prisons; moreover, 50% to 80% of the children were exposed to drugs in utero which leads to fetal alcohol or drug effect, decreased I.Q., learned deficits, birth complications (45%), expensive neonatal intensive care, and insecure parent/caregiver attachment (63%) (Burleson et al., 2003).

Military Parents and Their Children

The absence of a parent even for such noteworthy reasons as military service can also negatively affect members of the family. Recent research has provided new insights into the impacts of deployment and combat on soldiers. However, few studies have looked at how having a parent deployed during wartime affects children and spouses. Nearly 2 million children in US military families have been affected by a service member’s deployment, multiple deployments, and separation for training. There are increasing numbers of women in the all-volunteer military force; single parents and dual career couples are common in the current military. One third of children with a parent deployed in Operations Enduring Freedom and Iraqi Freedom are at high risk for psychosocial problems. Flake and colleagues (2009) note that deployment seems to be associated with higher risks for military children and is linked to high stress for the at-home parent. In a study of 101 families of Army personnel, they found higher stress and risks. The spouses of the deployed soldiers (mainly wives) completed a series of screening questionnaires included in a standard deployment packet. Each spouse provided information on a child aged five to twelve years of age. On a standard screening questionnaire, 32% of children scored at "high risk" for developing psychosocial problems, which was 2.5 times higher than the national norms. Forty-two percent of the at-home spouses had "high-risk" levels of parental stress. In addition, the children of parents with high stress levels were approximately seven times more likely to score at high risk for psychosocial problems. Overall, 55% of Army families in the study scored "at risk" on at least one of the questionnaires included in the deployment packet. Impact on Different Aged Children of Parental Deployment. Children older than 3 years of age are most affected by the deployment. Compared with non-deployed and civilian control groups, Kelley et al. (2001) concluded that noncombat deployment of enlisted Navy mothers of young children, with the mean age of 3.1, caused elevations of internalizing and externalizing behavior. For school-aged children, these internalizing and externalizing symptoms (Kelley 1994) - tearfulness/sadness in girls, discipline problems in boys (Rosen, Teitelbaum and Westhuis, 1993) and depression - were reported to have moderate, but not clinically significant, increases. Even the younger children of 4-5 years and particularly boys were at higher risk (Jensen, Martin and Westhuis, 1993). Among adolescents, those with deployed parents had higher measured heart rates and perceived stress levels (Barns, Davis and Treiber, 2007). Recent studies (Gibbs et al., 2007; Rentz et al., 2007) suggest that risk for child maltreatment exists in military families with repeated or prolonged deployment, and the greatest risk for child neglect is reported in young married couples with young children. On examining the behavioral effect of current wartime deployments on younger children aged 1.5

Complimentary Contributor Copy What Makes Children Resilient and Resourceful Despite Family Adversity … 205 to 5 years, the results (Chartrand, Frank, White and Shope, 2008) suggest that parents with children, aged 3-5 years old, had significantly higher depression scores, higher Child Behavior Checklist (CBCL) externalizing scores and total Teacher Report Form (TRF) scores measuring both internalizing (depression) and externalizing behavior problems, compared with same-aged peers without a deployed parent, based on their parents’ and childcare providers’ reports. Children, aged between 2 to 3 years, react differently and had significantly lower externalizing symptoms scores as reported by their caregiver parents. The researchers hypothesized that since the deployed parent is more often the father, while the mother is the primary attachment figure in early infancy, that the infants and toddlers are less affected by separation from a father than are older children and adolescents. The Need for Military Family Support Services. Military organizations can provide support to reduce these risks. It is extremely important to develop a strong working relationship between the veteran and his or her family and service agencies and clinicians (National Center for PTSD, 2004). Parents receiving support from military organizations were less likely to report psychosocial problems in their children (Flake et al., 2009); problems were also less likely to occur for children of college-educated parents. Other factors studied - including rank, the child's sex, and race/ethnicity - were unrelated to the psychological effects of deployment. The researchers state that all families of deployed soldiers should be offered support resources. These resources are most readily available for families living on military bases; however, Members of the Reserves or National Guard may live in rural settings, far from military bases offering the needed support for families of active duty members. Pediatricians and family doctors should ask about parent and child stress in families with a deployed service member. Assessing the parents' levels of stress and support could help in recognizing children at high risk of problems with psychosocial adjustment, allowing them to be targeted for appropriate and timely services and support. Many circumstances described can lead to substance use disorders in an attempt to cope with high levels of life stressors. It is well known that parental substance use can become a maladaptive stress coping pattern that is related to further life problems including substance use and other behavioral health and social problems in youth (Handley and Chassin, 2009).

OTHER TYPES OF FAMILIES AND CHILDREN LIVING WITH HIGH LEVELS OF STRESS AND TRAUMA

War, Relocation, and Neighborhood Violence

Unfortunately, war and ethnic and religious intolerance is pervasive in the world leaving many families living under circumstances of severe trauma and poverty. High levels of community disorganization follow mass migration to avoid ethnic violence or general violence war areas. Immigrant and refugee families living in camps in other countries, or areas of their country, face severe adversity and trauma. Examples include the Burmese and Karen refugees living in extreme poverty in border camps in Thailand (which the first author visited at the time of completing this chapter) or refugee camps in Africa. Even following relocation to developed or developing nations, immigrant and refugee families experience

Complimentary Contributor Copy 206 Karol L. Kumpfer and Qing-Qing Hu severe trauma because of loss of language and culture, as well as loss of extended family and community resources. In addition, illegal immigrants live in fear of discovery and deportation, as well as constant harassment and exploitation by employers. Children often assimilate faster to the new culture creating increased family conflict due to differential generational acculturation leading to children’s developmental problems (e.g., crime, prostitution, drug use, delinquency, etc.) (Rodnium and Kumpfer, 2007). Structural equations modeling (SEM) was used on youth self-report survey data to test the primary author’s Social Ecology Model (Kumpfer, Alvarado and Whiteside, 2003) in four areas of Thailand with youth in the corrections system. The outcomes revealed that differential generational acculturation was a major risk factor leading to increased family conflict that, in turn, reduced normal family protective factors of family bonding, supervision and communication of positive family values and influence. Hence, even families with parents who work in different countries or different areas of their country for economic reasons, are leaving their children at higher risk for developmental problems. Other examples of this occur after the massive migration of rural parents to cities for jobs and who leave their children at home to be raised by grandparents. This is happening increasingly in all countries of the world, but not on such a grand scale as in rapidly emerging countries such as China and India. Loss of parental supervision and support can lead to developmental problems and substance abuse in children who feel their parents didn’t love them enough to stay home. In India, one study of COAs found higher levels of family stressors, poverty, and more complicated environments (Stanley and Vanitha, 2008). Another example of children living with severe trauma and stress are children living in high crime neighborhoods that are war torn by rival drug gangs in many areas of the world, but particularly in Mexico, Columbia, USA, and Russia. Lax gun laws, street violence and random shootings increase the levels of stress and trauma for children and parents. Fewer and fewer children appear to be growing up in well connected small communities where they could just “go out and play” without fear of dangers.

Family Risk and Protective Factors

Risk Factors. Although few studies of resiliency have been conducted on children living in poverty, researchers discovered that the inner-city poor contend with a number of stressors and adversities, such as community and family violence, crowding, poor quality schools, and inadequate housing (McLoyd, 1998; Sampson, Morenoff and Earls, 1999). Moreover, children growing up in chronic poverty are exposed to a wider array of both qualitative and quantitative risks than those living in middle-class environments (Vanderbilt-Adriance and Shaw, 2008). Long Term Negative Impacts of Adverse Childhood Experiences (ACEs). Research conducted by the Centers for Disease Control and Prevention (CDC), using a retrospective self-report study of over 8,500 individuals enrolled from the Kaiser Permanente health care database, has suggested a pervasive negative impact of early childhood adverse experiences (ACEs) on children’s neurodevelopment and health outcomes leading to increased health care costs (Anda et al., 2008). Parental drug abuse and alcoholism was associated with multiple adverse early childhood circumstances (Dube et al., 2001) and increased risk for later adult alcoholism (Dube, Anda, Felitti, Edwards and Croft, 2002). However, multiple ACEs

Complimentary Contributor Copy What Makes Children Resilient and Resourceful Despite Family Adversity … 207 increased the risk from 200% to 400% for later self-reported alcoholism, heavy drinking, and marrying an alcoholic even without parental alcoholism. Those who grew up with both an alcohol-abusing mother and father had the highest likelihood of ACEs. The mean number of Aces, for persons with no parental alcohol abuse, was only 1.4, compared to about twice as many for those with an alcohol abusing father only (2.6) or mother only (3.2). Having both parents abusing alcohol increased the risk of ACEs almost threefold or a mean of 3.8 ACEs. Of interest is the lack of protection from adverse experiences in the family if the mother is an alcohol abuser. Witnessing family violence and a mother being beaten was one of the most powerful ACEs for long term stress and later health problems. This study highlights the importance of helping children to become more resilience and resourceful in the face of living with many ACEs. Teaching children stress coping, and teaching family members ways to increase their protection of children can help to reduce the lifelong detrimental health and mental health outcomes of excessive negative early childhood experiences. Impact of Multiple ACEs. Early resilience research suggests that a child’s probability of developing problems increases as family risk factors increase (Rutter, 1996) in relation to their number of resilience or protective factors. Children and youth generally are able to withstand the stress of one or two family problems in their lives; however, when they face more adversity, their probability of negative health and mental health outcomes increases (Bry, McKeon and Pandina, 1982). The research of overt and covert parental conflict and adolescent problems (Whittaker and Bry, 1991) showed that during problem-solving family discussions, 16 married parent couples of 16 adolescents, whom they had brought into an outpatient clinic for treatment, overtly disagreed with each other significantly more often than did parents with adolescents who did not require treatment. Families of clinic adolescents also exhibited significantly more silence during their discussions, and mothers spent significantly less time talking than did their non-clinic counterparts. Sameroff and associates (1987) found that the negative influence of one or two risk factors (i.e., maternal depression, anxiety, external locus of control, low education, having an unskilled head of household, negative life events, large family size, absence of a husband or partner, and minority race) had little negative effect on children's intelligence at age 4 years. However, there was a very large drop in intelligence when a third risk factor was added and another drop in intelligence when a fourth risk factor was added. It is also known that the cumulative balance of risk and protective factors or processes contributes to the final outcome in child development. In a prospective longitudinal study, Dunst and Trivette (1994) have replicated and extended the findings of Sameroff and associates (1987); this research team demonstrated the additional enhancing qualities of protective or opportunity factors. Eighteen month olds, with no risk factors, averaged a mean score of 114 on the Bayley Mental Development Index (MDI), but the mean dropped to 100 after a third risk factor was added. The MDI rose from 103 to 114 with zero to five (or more) opportunity factors. When risk and opportunity scores were summed, the average MDI score for 18 month olds was 107 with a balance of risk and opportunity factors. Interestingly, the mean MDI score was under 100, if the subject had more than four high risks that were not balanced by opportunity factors. When a child had five or more opportunity factors over and above their other risk factors, intelligence reached optimal levels of over 115 (Dunst, 1995). A meta-analysis of 47 studies investigating the relationship between family-centered help giving practices and parent, family, and child behavior and functioning was carried out by Dunst, Trivette and Hamby (2007). The results showed that the largest majority of positive

Complimentary Contributor Copy 208 Karol L. Kumpfer and Qing-Qing Hu developmental outcomes were related to parental care giving practices, with the strongest influences on outcomes being most proxymal and contextual to help giver/help receiver exchanges. Findings are placed in the context of a broader-based social systems framework of early childhood intervention and family support. As mentioned earlier, children of deployed military personnel have higher levels of depression and conduct problems. Likewise, most studies find children of substance abusers to have elevated rates of symptoms. Living with a parent who abuses alcohol or other drugs can have severe effects on every aspect of a child's life, including social acceptance, mental and physical health, and school performance (Lambie and Sias, 2005). Most studies find COSAs to have elevated rates of psychological symptoms (Cuijpers, Stuenenberg and Van Straten, 2006). Beyond the risk for addictive behaviors, children of substance abusers (COSAs) are also at higher risk for developing emotional, behavioral, academic, criminal and other social problems (Kelly and Fals-Stewart, 2002; Li, Pentz and Chou, 2002). They tend to be lower on protective factors and higher on risk factors (Mylant, Ide, Cuevas and Meehan, 2002) increasing their risk for depression, suicide, eating disorders, chemical dependency, and teen pregnancy. Children of substance abusers (COSAs) tend to have heightened levels of conduct problems in preschool (Fitzgerald et al., 1993), elementary school (Carbonneau et al., 1998) and delinquency in adolescence (Chassin, Rogosch and Barrera, 1999, Obot and Anthony, 2004), particularly if their parents also show antisocial behavior (Puttler, Zucker, Fitzgerald and Bingham, 1998). COSAs also demonstrate elevations in impulsivity and activity levels (Poon, Ellis, Fitzgerald and Zucker, 2000) as well as behavioral disinhibition (Tarter et al., 2004), leading some researchers to view them as behaviorally undercontrolled. In a longitudinal study to age 23 years, COAs have been determined to employ more of a Cognitive Coping Style and less of a Decision-Making Coping Style than children from non- alcoholic parents (Hussong and Chassin, 2004). Similarly, children with two substance use disorder (SUD) parents tend to use aggression as a major coping style, compared to children with only one SUD parent or no parent, who use a more problem solving decision making style of coping (Barco, Reynolds, Gao, Kirisci and Tarter, 2008). Earlier studies described children of substance abusers as higher in “difficult temperament” meaning a relatively stable trait, likely genetically linked, that leads to increased emotional and behavioral lability and difficulty with behavioral control (Blackson, Tarter, Loeber, Ammerman and Windle, 1996). Parental alcoholism has also been linked to anxiety and depression in children (Chassin, Rogosch and Barrera, 1999; Roosa, Sandler, Beals and Short, 1988), and West and Prinz (1987) have noted that COAs had higher levels of anxiety and depression than did controls in 10 out of 11 published studies. COSAs show lower academic achievement than do non-COSAs (McGrath, Watson and Chassin, 1999), even in comparison to depressed children or children of divorced parents (Schuckit and Chiles, 1978), and they have poorer cognitive functioning than do non-COSAs in the preschool years (Noll, Zucker, Fitzgerald and Curtis, 1992). Casas-Gil and Navarro- Guzman (2002) have identified five variables on which school performance by COAs was poorer: intelligence, repeating a grade, low academic performance, skipping school days, and dropping out of school. Sons of male alcoholics, who have many alcoholic relatives across generations, have been reported to show deficits in verbal and abstract reasoning and verbal learning (Harden and Pihl, 1995; Whipple, Parker and Noble, 1988). For this subgroup, Pihl and associates (1990) suggested that cognitive deficits may be caused by heritable

Complimentary Contributor Copy What Makes Children Resilient and Resourceful Despite Family Adversity … 209 dysfunctions of the prefrontal cortex and limbic systems. Moreover, in recent research on children who have a family history of alcoholism, some sons of male alcoholics were found to have an increased heart rate response to alcohol intoxication, which is thought to be related to increased physical aggression (Assaad et al., 2003). However, cognitive impairments may also stem from fetal alcohol exposure (Streissguth, Barr, Bookstein, Sampson and Olson, 1999), high stress levels in pregnant mothers or a lack of environmental stimulation, or conversely a chaotic home environment (Noll, Zucker, Fitzgerald and Curtis, 1992). Barr, Bookstein, O'Malley, Connor, Huggins, and Streissguth (2006) also found that binge drinking during pregnancy in young adult offspring is a predictor of psychiatric disorders based on the Structured Clinical Interviews for DSM-IV (SCID). Protective Factors. Protective factors in resiliency research are defined as characteristics of the child, family, and wider environment that reduce the negative effects of adversity on children (Masten and Reed, 2002). There are a number of factors that have been found to contribute to positive outcomes in the context of high risk, including child IQ, emotion regulation, temperament, positive parenting, low parental conflict, advantaged SES, effective schools, and so on. According to the author’s tested Social Ecology Model (Kumpfer, Alvarado and Whiteside, 2003), the most important protective factors for substance abuse, delinquency, school failure and teen pregnancy include first family bonding, next family supervision and finally communication of positive family values and expectations. Hence, these are the specific parenting practices most associated with children’s positive social adjustment. For instance, in relation to the variable of family bonding or attachment, Ingoldsby and colleagues (Ingoldsby, Shaw and Garcia, 2001) found that having a good relationship with at least one parent was associated with less conflict with siblings, teachers, and peers. Marital relationships characterized by low conflict are associated with low levels of child adjustment problems (Belsky et al., 1991; Cummings et al., 2004; McHale, Freitag, Crouter and Bartko, 1991). Intervention studies indicate that both child problem behavior and parenting skills are amenable to intervention during early childhood; and early interventions are more effective than those in later childhood (Olds, 2002; Reid, 1993; Webster-Stratton and Taylor, 2001). However, even family therapy and family skills training interventions such as the author’s Strengthening Families Program (3 to 16 Years), can have major positive impacts on adolescents already in residential treatment for drug use or other behavioral health issues (Kumpfer, Whiteside, Greene and Allen, 2011). The family protective factors have generally focused on parenting strategies, parent-child relationship quality, and marital quality. Web sites for locating effective parenting and family interventions to improve children’s outcomes can be found on the UK Parenting Academy web site, the US Office of Juvenile Justice and Delinquency Prevention’s website (www.strengtheningfamilies.org) or the new United Nations Office of Drugs and Crime (UNODC, 2010) website3of program descriptions of the most effective family interventions in the world. The translating into other languages and ensuring cultural adaptation of many of these family interventions have increased recruitment and retention rates by about 40% (Kumpfer, Alvarado, Smith and Bellamy, 2002). Suggestions for translation, cultural adaptation, training, and implementation in other cultural contexts than where the program was developed and evaluated can be found in the UNODC (2009) online guidebook. Recently publications have summarized a few of the failures in

3 http://www.unodc.org/docs/youthnet/Compilation/10-50018_Ebook.pdf

Complimentary Contributor Copy 210 Karol L. Kumpfer and Qing-Qing Hu translational research on evidence-based family interventions to other countries and highlight the critical importance of fidelity within the context of needed cultural adaptations. When strong partnerships are forged by the program developers with policy makers, researchers and implementers in the new country or cultural context, the outcomes can be excellent. For example, excellent outcomes have been found in multiple replications in almost all counties in Ireland of the first author’s Strengthening Families Program 12 to 16 Years. These results were better than in comparable USA agencies because of attention to creating local partnerships across different human services agencies, cultural adaptation, training, and fidelity to the model (Kumpfer, Xie and O’Driscoll, 2012).

Resilience in Children Facing Adversity

The pioneering researchers in the field of resilience (Garmezy, 1991; Rutter, 1985; Werner and Smith, 1992) conducted studies to determine if primary personality traits strengthened developmental assets related to positive life adaptation in the face of multiple risk factors. This longitudinal research suggests that, when tracked until adulthood, 50% to 70% of “high risk” children grow up to be successful, confident, competent, and caring individuals (Benard, 1997). Many different personality characteristics have been found to be associated with resilience making it a complex focus of study. For children’s characteristics, IQ, emotion regulation, self-esteem, and internal locus of control have been investigated as protective factors (Masten and Reed, 2002). Although significant interaction effects are relatively rare in the resilience research, there is evidence that IQ is particularly important in protecting against maladaptive outcomes, including maternal psychopathology (Tiet et al., 2001), paternal criminal behavior (Kandel et al., 1988; Kolvin et al., 1988), and negative life events (Masten et al., 1988; Masten et al., 1999). Also, children who are adept at managing their emotions are better able to proactively cope with stressors (Buckner, Mezzacappa and Beardslee, 2003). In fact, Luthar, Cicchetti, and Becker (2000) argue that “future empirical studies on resilience must be presented within cogent theoretical frameworks” (p. 553). The Resilience Framework (Kumpfer, 1999) represents an attempt to differentiate the influences of three domains of salient resilience processes (e.g., the child’s personal strengths, the family dynamics, and the community context) within a transactional model. Although similar to Bronfenbrenner’s (1977) ecological theory, Sameroff and Chandler’s (1990) transactional perspective, and Cicchetti and Lynch’s (1993) integrative ecological- transactional model of development, the Resilience Framework is unique because it is not a general child development theory. Instead, the Resilience Framework is a meta-theory specific to the resilience process. In the Resilience Framework, including the impact of parent/child transactional processes in moderating or mediating a child’s biological or environmental risks and later substance misuse (Kumpfer and Bluth, 2004), the child’s resilience characteristics are organized into five major types of strengths: (i) spiritual, (ii) cognitive, (iii) social, (iv) emotional, and (v) physical. The Resilience Framework (Kumpfer, 1999) recognizes that developmental trajectories can be changed by active individual choices in which the child or advocates can help a child to change environments. Recognizing these strengths, a type of “free will” can occur within the more common stimulus/response, deterministic world view (Bandura, 1989; Cicchetti and Tucker, 1994; Kumpfer, 1999).

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Our resilience research (Dunn, 1994; Neiger, 1991) involving different populations (adult children of alcoholics, college students, working women in several states and substance abusers) suggests that the most important characteristics promoting resilience are purpose in life and determination. Hence, the critical characteristics, that should be fostered in children, may be the vision or the ability to see a brighter future and the willingness to fight for it. Creating meaning for one’s life through goals, dreams, and a desire to use one’s talents to make the world a better place helps people to be resilient survivors in times of severe adversity (Frankel, 1959; Flach, 1988). While some risk factors are very difficult to change (e.g., physical characteristics like gender, race, age, or intelligence), many family or community status risk factors such as poverty, single parent status, socioeconomic disadvantage, poor schools, lack of community resources, maternal depression and lack of education are changeable. Other malleable family risk factors relate to family dysfunction. The qualities of the family environment and parent/caregiver skills in child raising are critical mediators of child outcomes. Research on over 10,000 high risk youth, using structural equation modeling, suggests that the most important protective factors to promote in substance use prevention programs are parent/child attachment or bonding, parental supervision or discipline, and communication of family values (CSAP, 2000; Kumpfer, Alvarado and Whiteside, 2003). While the most predictive risk factor for drug abuse has repeatedly been found to be association with drug using peers, the strongest protective factors for multiple negative outcomes (e.g., delinquency, drug abuse, school failure, or teenage pregnancy) are the three family characteristics discussed in the next section (Ary, Duncan, Biglan, Metzler, Noell and Smolkowski, 1999).

Effective Parenting and Family Interventions for Special Populations

Effective parenting or family strengthening interventions (Biglan and Taylor, 2000; Kumpfer and Alder, 2003; Kumpfer and Alvarado, 2003; Liddle, Santisteban, Levant and Bray, 2002) are those that successfully promote these three family protective processes: (1) strengthening parent/child bonding, (2) effective parenting skills, and (3) improved communication of positive values and expectations for the child’s behaviors (Kumpfer, Alvarado and Whiteside, 2003). A number of these effective programs were designed specifically for a special population of high risk children such as the Nurturing Program for children of abusive parents and the first author’s Strengthening Families Program for children of parents with substance use disorders. About 35 of these effective parenting and family programs can be found on the web site (www.strengtheningfamilies.org). A newer review of parenting and family skills training interventions is on the UN Office of Drugs and Crime (UNODC) web site4of all of the best parenting and family interventions in the world. Increased dissemination and adoption by local agencies in many countries is needed to improve the outcomes of youth raised in poverty and by parents with addictions and over- stressed lives. The websites mentioned above are helpful for policy makers and practitioners in determining where to best allocate their often shrinking funding resources to get the largest impact for their efforts. They can simply purchase the best program that most fits the special

4 www.unodc.org/docs/youthnet/Compilation/10-50018_Ebook.pdf

Complimentary Contributor Copy 212 Karol L. Kumpfer and Qing-Qing Hu needs of their families, rather than creating a new parenting program that they can’t prove works. Family programs that are skills based are expensive to implement; hence, like a few other program developers, the first author has developed a home use DVD of a new 10- session Strengthening Families Program (8 to 16 Years) (Kumpfer, Brown and Whiteside, 2011) to reduce the implementation costs dramatically from about $1,000 to $10 per family. A web version is now in development to reduce the cost even more. Of course, all evidence- based interventions should be culturally adapted and implemented following the recommended steps for international dissemination (Kumpfer, Xie and Magalhães, 2012; UNODC, 2009). See our chapter (Kumpfer, Xie and Hu, 2011)5 in this book series on a discussion of the issues in cost effective dissemination of evidence-based family interventions.

CONCLUSION

Resilience research is becoming increasingly critical for understanding children’s mental and behavioral health when facing family adversity. This chapter introduced the family role in child raising briefly and mainly described the special populations of children living with adversity, including children of incarcerated and military parents, parental substance abuse, family violence and foster care, and those who need a high level of support to become resilient and have positive developmental outcomes. The parental substance use disorders (SUDs) can result in frequent parent absences from home on alcohol or drug binges, drug getting, and attending treatment programs or in prison. Family violence and child maltreatment are associated with multiple negative consequences for all family members, and include physical injury, child neglect, separation and divorce, incarceration, psychological problems, child removal from the home, multi-generational substance, youth delinquency, perpetration of violence, and death. Families with an incarcerated member may also lead to high levels of stressors and risks for its child members. Critical family risk and protective factors were then listed to understand the importance of family roles. The risk factors such as community and family violence, crowding, poor quality schools and inadequate housing, are the main problems for Adverse Childhood Experiences (ACEs), which will lead to long term stressors and is strongly related to later health problems. Protective factors in resiliency research are defined as characteristics of the child, family, and wider environment that reduce the negative effect of adversity on child outcomes. For children’s characteristics, the variables of IQ, emotion regulation, self-esteem, and internal locus of control have been investigated as protective factors (Masten and Reed, 2002). The chapter further introduced the Resilience Framework (Kumpfer, 1999), a transactional model, which represents an attempt to differentiate the influences of three domains of salient resilience processes (e.g., the child’s personal strengths, the family dynamics, and the community context). The parent/child transactional processes will be used in moderating or mediating a child’s biological or environmental risks.

5 Kumpfer, K.L., Xie, J., and Hu, Q-Q. (2011). Engendering resilience in families facing chronic adversity through family intervention programs. In K. Gow, & M. Celinski (Eds.), Wayfinding Through Life’s Challenges: Coping and Survival (pp. 461-483). New York: Nova Science Publishers.

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A number of evidence-based parenting and family interventions have been designed to reduce chronic stress and risk in special populations of children facing adversity. They have been found in many research studies (summarized in Kumpfer and Alvarado, 2003; Kumpfer, Xie and Hu, 2011) to be the most effective way to improve family relationships, effective child raising and resilience in children living in highly stressed and traumatized families as outlined in this chapter. The application of these evidence-based family interventions in mass trauma situations is only now beginning internationally and with amazing success. Hopefully their dissemination will continue to expand to improve resilience and the lives of children and families. Unfortunately mass trauma from natural disasters (e.g., earthquakes, tsunamis, severe drought, floods hurricanes, etc.) has frequently occurred within the context of internal ethnic strife or war. However, in the past few years the escalating rate of natural disasters has also impacted many countries including Australia, New Zealand, Japan, and Thailand. Natural disasters, preceded or followed by wars, dramatically compound the negative impact of the natural disaster on children and families and lead to mass dislocation or relocation to refugee camps or other countries. As recommended in the introduction to this chapter, research on the outcomes of effective family interventions should include needs assessments of the physical and psychological impact of mass trauma on the children in refugee families and those living in war or natural disaster areas. Better understanding of the underlying causes of negative developmental outcomes and resilience of children in mass trauma situations should support improvements and outcomes of evidence-based family interventions. If families are strong, intact, and supportive of children’s positive development, mass trauma situations should have a much reduced impact on children. However, when families are torn apart and their cultural traditions stripped from them, culturally adapted family interventions, that have been proven in multiple replications to improve resilience and children’s developmental outcomes, are critically needed.

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Chapter 13

MAIN TRENDS IN RESILIENCE AND TRAUMA RECOVERY WITH CHILDREN, ADOLESCENTS AND FAMILIES

Vladimír Kebza1* and Iva Šolcová2 1 Department of Psychology, Czech University of Life Sciences, Prague 2 Institute of Psychology, Czech Academy of Sciences, Prague

ABSTRACT

Some of the concepts of resilience published to date have interpreted its meaning as the ability to adapt in the face of risk, but other authors point out that resilience does not always have to mean “invulnerability”, and that it should be examined not only as an individual quality and aptitude, but also as a developmental process involving personality, and interactions with social and situational variables, often necessitating risk- taking behaviors. Approaches focusing on the resilience of children and adolescents were introduced by the results of research implemented by Rutter, Ebata, Petersen, Conger, Moffit and Grotberg. With respect to children and adolescents, resilience is described with reference to studies by Newman, Werner, Werner, Smith, Masten, Davey, Eaker and Walters in comparison with some Czech authors such as Matějček, Dytrych, Břicháček, etcetera. Furthermore, a concept of family resilience, inspired among others by Hobfoll, Spielberger and Scanzoni, and developed especially by Patterson, Patterson, Garwick and Walsh, is presented. This chapter compares the meaning of these concepts and presents some recent directions for applied resilience research in current issues about trauma and recovery.

Keywords: Resilience, Children and adolescents, Family resilience, Trauma recovery

* Correspondence concerning this chapter should be addressed to Vladimír Kebza, Department of Psychology, Czech University of Life Sciences, Kamýcká 129, 165 21 Praha 6. E-mail: [email protected] Complimentary Contributor Copy 224 Vladimír Kebza and Iva Šolcová

INTRODUCTION

Literature dealing with the resilience of children and resilience of adolescents focuses on their individual or community-based capacity to resist and face the demands of the environment (Newman, 2002). An international investigation of resilience (The International Resilience Project) gathered data from children in 30 countries and summarises the nature of resilience as a universal capacity enabling an individual, group or community to prevent, minimize or overcome damaging effects of various undesirable factors and adversities (Grotberg, 1997). These more general definitions of resilience are sometimes incorporated in various models designed to capture the nature of resilience. The three-level model of resilience determinants (Alperstein & Raman, 2003) links the impacts of risk and the protective factors of resilience with three mutually related levels. The first level includes such variables as income, absence of poverty, social equality, employment, financial and social security, social capital, tolerance and absence of conflict in the community. The second level includes genetic dispositions, parental support, interpersonal relationships, limited and modified exposure to risks and the availability of opportunities. The third level includes personal features, positive self-assessment, localization of control, sense of personal autonomy, relationships to family and the broader community, quality of interpersonal relationships and empathic capacity. Approaches focusing on the resilience of adolescents are mostly based on the assumption that the period of early adolescence and the transition from adolescence to adult age is a period of major challenges, opportunities, but also risks (Ebata, Petersen, Conger, 1990). In this developmental period, up to 80% of adolescents engage in anti-social behavior, according to repeatedly proven data (Moffitt, 1993). While for most of them this risk behavior is only related to adolescence, in approximately 3 – 5% of them it becomes their prevalent pattern of behavior, and for some it becomes an obstacle to further social development with long-term negative consequences and associations (Rutter, 1989, 1996). In this context, a central core of adolescent resilience is assumed, probably consisting of a capacity for self-assessment, and for having a repertoire of coping skills and some personal features and predispositions (such as optimism, extraverted character, openness to new experiences, conscientiousness). In the longitudinal study carried out by the American developmental psychologist Werner on an initial set of 698 children born into poverty on Kauai island (Werner, 1992, 1993; Werner & Smith, 2001), it was discovered that from the original group of those children who were exposed to numerous biological, environmental, behavioral and psychosocial risk factors (mostly combined with premature birth and unstable housing and family situation, low socioeconomic status [SES], mental diseases or disorders of parents, etc.) approximately two thirds of them also showed serious psychological, social and health issues as adults, while the remaining one third did not. A more detailed examination of the latter subgroup identified major protective factors related to resilience:

a) In childhood, these children were able to establish and keep up at least one strong personal relationship important for establishment of a social role, including a strong connection to non-parent caring persons from the environment, such as nurses, aunts, and teachers.

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b) They demonstrated an uncomplicated temperament, were perceptive, sensitive, positive thinkers, gracious and cheerful. c) In school, they had numerous interests and hobbies, developed friendships and participated in social activities (clubs, associations, societies, church communities such as the YMCA). d) In school, they showed a higher level of intellectual abilities and language skills than the children from the other two thirds of the initial set.

Another American developmental psychologist, Masten, gathered numerous data on the creation of resilience in children based on a study of longitudinal and sectional studies of resilience (Masten, 1994), while conducting her own longitudinal project focusing on developmental aspects of resilience (“Project competence: A 20-year study of competence and resilience”). The results of this project proved that children who achieved adequate and healthy functioning despite adverse conditions had more internal and external sources of resilience, higher level of cognitive functions, good or above-average relations with others (specifically relations with adults), a predisposition to be liked by others, high self- confidence, self-respect and an ability to cope. Children who did not have these characteristics became more vulnerable adults, had more stress-generating experiences and a worse ability to cope with them (Masten, 2001). A study by Davey and collaborators (Davey, Eaker, & Walters, 2003) corroborated a similar relationship through empirical research on 181 adolescents from lower income groups in Massachusetts. Adolescent resilience, according to the results of the study, can be expressed as a combination of positive self-assessment, coping skills, extraversion, satisfaction and openness to new experiences. Positive coping skills were also identified by this study as compensation mechanisms in cases of stronger dissatisfaction or emotional instability. The author of the Davis Longitudinal Study looked for an answer to the question of whether the characteristics of vulnerability and resilience, determined in childhood, could affect stress coping ability in adulthood. It has been proven on a sample of 850 men and women that vulnerability and resilience factors in childhood had a slight but permanent impact on adaptation and coping with stress in adulthood (Aldwin, Levenson, & Spiro, 2000). Resilience in children has also been studied in the United Kingdom. Rutter focused on the impact of family and school on children’s behavior, the origin and development of autism and the relationship between the conditions in which psychological disorders originated in childhood and their further development in adulthood. His characteristics of childhood and adolescent resilience include some natural ability to limit the impact of risk experience on personality functioning, a limitation on the chaining of negative reactions, high self- confidence and self-belief, openness to new experiences and positively based cognitive processing of negative experiences (Rutter, 1989, 1995, 1996). Czech literature also provides numerous resources of knowledge related to vulnerability and resilience in childhood and adolescence. Matějček and Dytrych provided a thorough review of domestic and foreign approaches pertaining to risk and resilience in children and adolescents (1998). Much earlier, Langmeier, Matějček and others dealt with the questions of psychological deprivation and sub-deprivation (Langmeier & Matějček, 1963, 1974; Matějček, 1989, 1996). These research results were extended to applied studies which included more practical recommendations (Matějček, 1991, 2003). In a broad monograph, Dunovský, Matějček, & Dytrych (1995) described the main areas of risk and protective

Complimentary Contributor Copy 226 Vladimír Kebza and Iva Šolcová factors related to the syndrome of the maltreated, abused and neglected child (referred to in the English language literature as CAN – Child Abuse and Neglect). This syndrome, perceived by foreign and domestic literature as a relatively independent topic, has been dealt with in the Czech environment in various contexts by Provazníková, Provazník, Halfarová, Vaníčková, Hadj-Moussová, Procházková, Spilková, Mašát, Vitínová and others. The issue of resilience in pre-school children has been explored by Hoskovcová (2006). Concepts of resilience described in the literature, related mainly to personal predispositions, have been expanded in the last approximately 15 to 20 years with the interest in family resilience predispositions. In the context of the concept of so-called family stress and coping with it (Hobfoll & Spielberger, 1992), new terms have been developed since around the mid 1990s, such as family resilience, family environment, family normality, etcetera (Patterson, 1989; Patterson & Garwick, 1994; Patterson, 2002; Walsh, 1996, 1998, 2002, 2003). The growing interest in the constitution of a concept of family resilience is based on the growing interest in family issues (Scanzoni, 1995), identifying, among other things, the basic functions of a family. These include family membership, economic benefits and support as a consequence of lower living costs and a chance to share them within the frame of the family lifestyle, sources of upbringing and socialization and the protection of threatened and vulnerable family members (Ooms, 1996, as cited in Patterson, 2002). Another source of incentives for the constitution of family resilience was the concept of family perception and coping with stress, described within the FAAR (Family Adjustment and Adaptation Response) model. This model assumes a balanced equilibrium between demands on the family and the family capacity to cope with them, identifying three levels of family meaning: situation meaning, including primary assessment of requirements and secondary assessment of coping capacity; family identity related to self-awareness as a specific unit; and a family worldview related to family relations with the outer world (Patterson, 1989; Patterson & Garwick, 1994). Some sources also operate with the term “family health”, constituted as a dynamically developing process, based on continuous interactions among family members (Denham, 1999). Key processional thematic areas of family resilience include the belief of family members in themselves and the conviction that the family is able to face obstacles in unity, the area of organizational skills, adaptability and mutual support in the family, and social and economic resources of family resilience (a sort of family resilience logistics) and the area of effective communication, related to open expression of emotions, empathy, and effective, mutually supporting solving of problems (Walsh, 2002, 2003). According to Patterson (2002), other major characteristics of family resilience include: risk family status, related to a poor level of adaptation to requirements put on the family; family strength status related to successfully coping with those requirements; level of family cohesion; family flexibility; and characteristics of family communication. This latter characteristic differentiates between two basic types of communication: emotional and instrumental. Emotional communication is a tool for expressing love and support among family members; while instrumental communication explains and constitutes fundamental rules and relations, that is, establishing and creating roles, determining rules, decision making and solving conflicts. Based on Patterson’s presumption that the core of family resilience is its capacity to rebound (from Latin “resilire”) from demands of life change, a procedure of enhancing the capacity of family resilience using a web-based virtual family resource center was developed

Complimentary Contributor Copy Main Trends in Resilience and Trauma Recovery with Children, Adolescents … 227 within the Michigan Families Project (MFP). This project is based on the central supposition that family resilience is influenced by two main stimulating areas: 1) shared knowledge that our family is not the only family experiencing these life demands, and 2) mutual inspiration and encouragement in ways of coping – what other families have done to cope with such demands (for more detailed information, see https://www.msu.edu/user/imig/portal.htm). Similarly, the Internet serves as a quite useful way of disseminating relevant information within other projects related to family resilience, for example, the Project including information on the National Network for Family Resiliency (see details of publication at this website: http://www.extension.iastate.edu/ Publications/ EDC53.pdf ). In Czech specialized literature, Břicháček (2002) characterized family resilience as a dynamic balance between the keeping of family functions in stress situations and the capacity of individual family members to support each other, communicate and cope with difficulties. Family resilience is also about the creation of family identity, that is, the concept of family in the sense of a social unit. Family resilience, according to Břicháček, is a changing characteristic affected by several major risk and protective factors. Protective factors include particularly family cohesion, the flexibility of family roles and relations, comprehensible and open communication among all family members, ability, skills and willingness to solve and overcome conflicts and crises, and agreement about the meaning and tasks of the family. Risk factors, according to Břicháček, include low socio-economic status, chronic negative conditions (changes in lifestyle, disease, and conflicts), traumatizing events and the changing demands of today’s society. Family resilience is thus defined both by social and natural characteristics, and by ancient experience of the human race, as well as internal processes in the family. In another study, Břicháček (2003) mentions the importance of cross-generational research focusing on continuity or discontinuity of various personal traits. He states that the confirmation or refutation of the initial assumption of potential generational continuity is methodically limited by the retrospective nature of most previous studies; however, newer long-term prospective studies have recently been published, the results of which could bring new perspectives to this issue. Representatives of another major Czech tradition of interest in family resilience, Matějček and Dytrych, characterized essential risk family events, situations and their mutual relations from the standpoint of their potential impact on the minds of children and adolescents (Matějček & Dytrych, 2002). In a special focus study, based on a detailed investigation of empirical material in the form of case histories of specific family members, the authors dealt with extraordinarily complex relations between step parents and stepchildren, and entering new relations in new family configurations (Matějček & Dytrych, 1999). Recent Czech literature, systematically dealing with the issues of family resilience, includes family-psychology-oriented studies by Sobotková (2004, 2007).

CURRENT ISSUES AND CIRCUMSTANCES RELATING TO RESILIENCE AND TRAUMA RECOVERY

Currently, the main global situations that require resilience are associated with the prospect of terrorist attacks and natural disasters. Considering that terrorists are prepared for

Complimentary Contributor Copy 228 Vladimír Kebza and Iva Šolcová the ultimate self-sacrifice (as exemplified by the events of September 11, 2001), terrorism has not only become a much more dangerous threat particularly to “western” civilization, but also an important object for study with respect to prevention preparedness and coping with its consequences. A number of authors have focused on the research and application of resilience under harsh conditions following traumatic events (Berkowitz et al., 2003; Bonanno, 2004; Bonanno et al., 2006; Tucker et al., 2007; Yehuda, 2002; Zimbardo, 2001) and many others create a basis for effective programmes of coping with the consequences of these events (Alexander, 2005; Blythe, 2002). Bonanno (2004) remarks that research in resilience and trauma recovery focuses predominantly on pathology, and not enough on positive (protective) sources. From Bonanno’s point of view, resilience is different from recovery: resilience means the ability to maintain a stable equilibrium, while recovery represents the development from normal functioning to threshold or subthreshold psychopathology, and a gradual return to the previous level. However, resilience is not only the absence of psychopathology: resilient people are characterized also by a stable course of healthy functioning, a capacity for generative experiences, and positive affectivity (Bonanno, Papa, & O’Neill, 2001). Within the overview of multiple types or pathways of resilience, Bonanno (2004) mentioned the following concepts: hardiness (Kobasa, 1979; Kobasa, Maddi, & Kahn, 1982; Kobasa & Puccetti, 1983), self-enhancement (Greenwald, 1980; Taylor & Brown, 1988), repressive coping (Weinberger, Schwartz, & Davidson, 1979; Weinberger, 1990) and positive emotions and humour. Agaibi and Wilson (2005) reviewed the available literature on trauma, posttraumatic stress disorder (PTSD), and resilience. Based on this review, resilient coping is regarded as a complex phenomenon with a large variety of behavioral trends and manifestations. Using this information, the authors developed an integrative Person versus Situation Model – this model explains mutual relations in five groups of variables: (1) personality, (2) effect regulation, (3) coping, (4) ego defenses, and (5) the utilization and mobilization of protective resources to aid coping. The variety of traumas that people can encounter in their life includes war, violence (individual or community), disasters (man-made, natural), abuse, terminal illness, death of beloved person and others. People can face these events as victims or witnesses, as children/adolescents or adults. Moreover, traumatic events are often encountered by those working as humanitarian aid workers or rescue workers.

Development of Research Issues

Generally, the attention of researchers seems to turn to proactive coping with traumatic events, proactive responses, and proactive outcomes (Paton et al., 2004). With respect to proactive outcomes, questions relating to posttraumatic growth are often addressed. The relationship between distress and posttraumatic growth particularly engages scientists, as many studies have showed significant positive relations between measures of posttraumatic stress disorder (PTSD) and posttraumatic growth (PTG). The often addressed problem is whether the perception of benefit translates into objective life change (Jackson, 2007). As Linley and Joseph (2005) mentioned, PTG seems to be more than resilience because it

Complimentary Contributor Copy Main Trends in Resilience and Trauma Recovery with Children, Adolescents … 229 involves both growth and positive change. Zoellner and Maercker (2006) point out two different cognitive factors involved in self-perceived PTG, and outline the so called “Janus – Face-Model”1 of self-perceived PTG. According to this conception, PTG has two components: a functional or constructive side, and also a dysfunctional (illusory) side. Other newly emerging topics further include cross-cultural issues in humanitarian aid (e.g., a problem of so called ethno medical competence), ethical issues, and issues concerning values. Also being studied in detail are negative phenomena associated with disasters (violence against women and children – victims of disasters). Paton (2005, p. 2) has called attention to a cross–cultural issue concerning resilience: “...while research on readiness and resilience in western countries has flourished over recent years, fundamental research into these processes in other cultures is sparse. Similarly, little research has been undertaken into identifying resilience in indigenous populations. We may be doing affected populations an injustice if assistance is provided in ways that fail to complement these intrinsic capacities.” Misunderstandings of this type may result in dissatisfaction on both sides and even in resistance towards the efforts of those helping people. Research into the nature of interventions (measures that are taken to help reduce the accompanying psychological and physical toll that a traumatic event takes on the individual) is increasing; additionally in interventions devoted to humanitarian aid and rescue workers, attention is being paid to the emotional processing of traumatic events and its promotion. The issues addressed by the researchers relate to techniques of stress debriefing and a systematic evaluation of its effectiveness.

Measurement Tools

A very good review of child and adolescent trauma measures is provided by Strand, Pasquale and Sarmiento (2006). In the review, availability, basic psychometric properties, and contact information are provided to all, including trauma-measuring tools. The addressed tools are predominantly client self-reports, while about one third are parents’ reports. The majority of the tools are available at no cost. When the authors in the review choose their criteria for the selection of a particular tool as: (1) psychometric properties (“rigorous or promising”, p. 5), (2) cost (free of charge or minimal), and (3) accessibility, they found several measures which met well all these criteria: The UCLA PTSD Index for DSM-IV, Traumatic Events Screening Inventory (TESI), Child Dissociative Checklist (CDC), Child Report of Post-traumatic Symptoms (CORPS) are administered together with the Parent Report of Post-traumatic Symptoms (PROPS), the Clinician-Administered PTSD Scale for Children & Adolescents (CAPS-CA), and the Pediatric Emotional Distress Scale (PEDS). Information concerning all or any of these 35 measures is available at www.fordham.edu/childrenfirst. In connection with this modern need, the ACT - Assessment, Crisis Intervention, Trauma Treatment - model (Roberts, 2002) was created and continuously applied as the basis for a preparatory course designed for professionals as well as social workers, administrative workers, managers, researchers, etcetera.

1 The Roman god Janus, god of doorways and gateways, had two faces looking in opposite directions.

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With regard to traumatic experience resulting from terrorist attacks, Foa et al. (2005) reviewed potential reactions after this kind of trauma, along with on-the-ground experiences particularly following September 11, 2001, and intervention strategies related to acute and chronic stress reactions after traumatic events. Professionals (psychiatrists, psychologists, rescuers) who conduct CISM courses (Critical Incident Stress Management) use the procedures of debriefing (or defusing) in the prevention of post-traumatic psychopathology and as therapy for the effects of acute stress (Bonanno, 2004; Linley & Joseph, 2006; Waters, 2002). In recent years, these procedures have been tested and developed further and applied to mass trauma conditions in the Czech Republic (Šeblová, 2004; Šeblová & Kebza, 2005). Also across the European Union as a whole, there is an increasing awareness of the need to better prepare citizens for various types of disasters including terrorist attacks. In 2005, the European Commission allocated a grant for a project named “Citizens and resilience, the balance between awareness and fear”. The aim of the project was to develop knowledge and procedures in three main areas:

1) How to create and conduct a public information campaign that would be applicable to all EU member states and aimed at the building of resilience. 2) Develop and test an educational programme in elementary schools to help teachers in coping with emotional and other reactions of children following a threat or while facing sequelae of terrorist attacks. 3) Verification of a strategy for community-based interventions supporting professionals, workers, policy makers, administrators etc. to organise group, community, collective resilience and the procedure of recovery of the European or global population.

From 22 to 24 November 2006, an international conference and workshop of the same name took place at The Hague (Holland), focusing on resilience research and possibilities for further development and applications to prospects of terrorist attacks, natural disasters, large traffic accidents, etc. Another specific assignment concerning resilience focuses on the resistance of soldiers in peace-keeping forces. As an anonymous private serving on these forces aptly put it, “keeping peace is not a job for soldiers, but only soldiers can do it”. The members of peace-keeping forces have to mainly cope with the fact that they only have a very limited mandate for using the activities they are trained for (fight), and, on the contrary, have to perform activities they have not practised – communication with civilians, negotiations etc. Typical stressors in peace-keeping missions are considered to be feelings of helplessness in the effort to mitigate the suffering of civilians, boredom, conflict in relation to roles and duties, ridiculing and bullying from civilians, and confusion about in which situations the use of weapons is acceptable. Studies show that peace-keeping mission veterans very frequently suffer from posttraumatic stress disorder, depression and a higher rate of self-destructiveness in comparison with the population average (15% of veterans in the Norwegian study of Weisaeth, Mehlum & Mortensen, 1996), and it is still uncertain what the long-term consequences are (see e.g. Bolton, 2007). Research results are intended to be used for improving the selection process for peace-keeping missions, and for preparing methods

Complimentary Contributor Copy Main Trends in Resilience and Trauma Recovery with Children, Adolescents … 231 for better protection against the negative impact of stress on their health. Selection processes for dealing with natural disasters, serious traffic accidents such as train crashes, aircraft crashes, and multi-vehicle motorway accidents have to satisfy similar criteria.

CONCLUSION

There is perhaps agreement on the point that resilience is a multifactorially conditioned multidimensional phenomenon characterized as a comprehensive aptitude which enables an individual to mature and develop competences under unfavorable life conditions. Another consensus recognizes that the current research into resilience embraces numerous conceptualizations employing many different methods of identification resilience levels while frequently only partially or marginally relating to resilience in itself, which causes frequent problems in comparing the results. The research on resilience has also been enriched by the study of factors promoting recovery following an illness, accident or a demanding period of coping with stress, trauma, and crisis situations.

ACKNOWLEDGMENTS

This study was supported by the Czech Science Foundation, project number P407/10/2410.

REFERENCES

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Chapter 14

RECOGNISING AND ASSISTING CHILDREN AT RISK OF PTSD FOLLOWING NATURAL DISASTERS

Heather Mohay and Nicole Forbes* Queensland University of Technology, Australia

ABSTRACT

When adults and children are caught up in natural disasters they can suffer physical injury, property damage and psychological trauma. A number of factors have been identified which are associated with the development of PTSD in children in these circumstances, including individual characteristics such as gender and age, environmental factors such as degree of exposure to the event and extent of damage to property, and emotional experience of the event, for example, experiencing fear, panic and perceived life threat. Knowledge of the factors which predispose children to developing PTSD can inform strategies to reduce the risk of psychopathology. These strategies include: identifying children who are at the greatest risk of developing PTSD so that their psychological wellbeing can be monitored; providing early warning of the disaster so that exposure to the event and damage to property can be reduced; and establishing psychological recovery efforts which aim to reduce anxiety and restore a sense of safety, security and normality. In addition, programs directed at building resilience by strengthening family functioning and social connectedness and teaching positive coping strategies can both lessen the effect of a recent natural disaster and provide protection against adverse mental health outcomes if hazardous events occur in the future.

Keywords: Children, Natural Disasters, PTSD, Risk Factors, Prevention, Intervention

* Nicole Forbes now works for the Queensland Government Department of Communities, Disability Services. Contact: [email protected]

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INTRODUCTION

This chapter focuses particularly on the effects of natural disasters on children, factors which affect their susceptibility to post traumatic stress disorder and ways in which they can be helped to deal with the traumatic events which they have experienced.

In the summer of 2010/11, Australia experienced a succession of natural disasters. After many years of drought, heavy rainfall occurred in Queensland at the end of 2010, causing rivers to rise and flooding to occur in many regional and rural areas. Torrential rain in January 2011 filled the dams, exacerbated the flooding in rivers and creeks and soaked the earth. This led to flash floods in Toowoomba and the Lockyer Valley which swept away everything in their path including cars, houses, trees, power lines, and people. Flood waters moved down the rivers to inundate other cities including Brisbane, the State capital. Residents of these cities had more warning of the impending floods and had time to protect their properties as far as possible by sandbagging, to move their possessions to higher ground, and to leave their homes for the safety of evacuation centres where they spent many anxious hours awaiting news of the flood peak and the damage which it would inevitably bring. Despite the preparations, the damage to property and infrastructure was severe and many houses and businesses were inundated, and some were completely submerged. There was unprecedented damage to the road network; many areas were inaccessible; electricity and water supplies were disrupted; crops were ruined, livestock lost, and industries, such as mining, ground to a halt. At least 70 towns and 200,000 people were directly affected by the floods and 35 people including 4 children lost their lives in flood related incidents. Shortly after the Queensland floods, many areas of western and central Victoria also experienced significant flooding. Then came Cyclones Anthony and Yasi, the latter being the biggest ever to cross the Queensland coast. With Yasi, came destructive winds, rain and storm surges bringing devastation to the north Queensland coast and many inland areas. Three quarters of the State of Queensland was declared a disaster zone. Both children and adults were caught up in these events. Many have been traumatised by their experiences and some may never fully recover either financially or emotionally. Some may suffer from post traumatic stress disorder and require more in- depth intervention to prevent this from becoming disabling.

Natural disasters can occur at anytime and anywhere, although some places are more vulnerable than others and different regions are prone to different forms of disasters, such as earthquakes, cyclones, floods, and bush fires. These events may be widespread or confined to small geographical areas and strike with varying degrees of warning and severity. There may be several days to prepare or there may be no time at all. Whatever the case, natural disasters typically have profound effects on the communities involved. Nature is seen at its most devastating, threatening basic human needs for safety and control over life events. People may die, or sustain physical injuries, and may experience loss of, or damage to, their home and property and possibly lose their livelihood. The functioning of the community is severely disrupted, jeopardizing feelings of normality, security and social connectedness. These experiences are highly emotionally charged and psychological reactions may be debilitating and persistent. Victims may have to cope with grief associated with the loss of family or friends, pets, livestock, the family home, treasured possessions and the familiar landscape whilst simultaneously dealing with the fear aroused by the event itself and the havoc and destruction which it has caused. In the western world, post traumatic stress disorder (PTSD)

Complimentary Contributor Copy Recognising and Assisting Children at Risk of PTSD … 239 has been the most widely researched form of psychological reaction to natural disasters and will therefore be the focus of this chapter. It is, however, important to recognise that other types of psychological disturbance such as depression, anger, guilt, aggressive behaviour, and psychosomatic symptoms also commonly occur in these circumstances and a number of co- morbid conditions are frequently present (Hensley and Varela, 2008; Marsee, 2008; McDermott and Palmer, 2002; Yehuda, McFarlane and Shalev, 1998). Children as well as adults are caught up in natural disasters and are not immune from PTSD reactions. Indeed, they could be regarded as the most vulnerable individuals caught up in these events, because they have such limited experience of the world to draw upon. Symptoms of PTSD in children include increased regressed behaviour, clinginess and dependency, difficulties in concentrating, reduced interest in activities, sleep disturbances, irritability, aggressive outbursts, and intrusive thoughts regarding the traumatic event (Garrison et al., 1995; Norris, Friedman and Watson, 2002). Table 1 provides a summary of the symptoms of PTSD which may be observed in children; as these symptoms are somewhat different from those observed in adults, there is a danger that children’s distress will be overlooked or misinterpreted and appropriate interventions will not be provided. The chance of this occurring is exacerbated as children are often observed playing shortly after a disaster, giving a superficial impression that they not affected by the events which they have experienced.

Table 1. Symptoms of PTSD in Children and Adolescents

Symptoms Increased anxiety – especially when events reminiscent of the disaster occur e.g., a thunderstorm, or a car backfiring Recurrent thoughts about the event Increased clinginess and dependency on parents Reluctance to be separated from parents Regression to more immature behaviour e.g., bed wetting, thumb sucking Difficulty concentrating Decreased interest in activities. Reluctance to go to sleep and/or recurrent nightmares Deterioration in school achievements Increased irritability Aggressive outbursts Physical symptoms such as headaches or stomach aches. Note: Following a natural disaster, children may show any or all of the above symptoms in varying degrees of severity. If they are persistent, a referral should be made to mental health services for assessment and treatment.

There have been a number of studies examining the impact of different forms of natural disasters on the psychological well-being of children and adolescents (e.g., Green et al., 1991; Shaw et al., 1995; Yule, 1994). Green et al. (1991) determined that 37% of 2 to 15 year olds had some persisting signs of PTSD two years after the Buffalo creek collapse, while La Greca and Prinstein (2002) found 50% of children showed moderate to severe symptoms of PTSD three months after Hurricane Andrew hit the United States, and Bal (2008) reported similar findings for young people who survived an earthquake in Turkey, three years after the event. Kar and Bastia (2006) reported that 26.9 % of adolescents showed signs of PTSD one year

Complimentary Contributor Copy 240 Heather Mohay and Nicole Forbes after a super-cyclone hit the East Coast of India, and McDermott et al. (2005) provided evidence that 21% of children showed moderate to severe signs of PTSD six months after the Canberra bushfires. Following Hurricane Katrina’s devastation of the New Orleans area, Scheeringa and Zeanah (2008) reported that 50% of 3 to 6 year olds met the criteria for PTSD, whilst Hensley and Varela (2008) and Spell et al. (2008) found that PTSD symptoms in approximately 12% of school aged children. Garrison and colleagues (1993), on the other hand, reported that only 5% of 11 to 17 year olds exhibited symptoms of PTSD one year after Hurricane Hugo hit the Carolina coast (Garrison et al., 1993). The variability in research results can be attributed to a number of factors including differences in the type, extent, and severity of the disasters studied, the time elapsed between the disaster and data collection, the selection criteria and age of study participants, and the method of data collection. Despite the disparity in the results, all studies found a significant increase in the prevalence of PTSD above the population base rate of 1% reported by Helzer et al. (1987). The heightened risk of PTSD occurring in children following a range of natural disasters is therefore well documented. PTSD symptomatology is often associated, not only with behaviour difficulties, but also with a decline in academic performance. For example, Shannon, Lonigan, Finch and Taylor (1994) found that 51% of children who were diagnosed with PTSD following Hurricane Hugo experienced a decrease in school performance, compared to 28% of children without a PTSD diagnoses. PTSD can therefore have long term effects on children’s development and academic achievements (Weems and Overstreet, 2008). Clearly not all children exposed to natural disasters develop PTSD. Some children appear to be resilient whilst others seem to be at greater risk. A number of factors which influence the development of PTSD in children have been identified. These appear to be universal and to apply to any kind of natural disaster. They include individual characteristics such as gender, age and personality (Garrison et al., 1993, 1995; Hensley and Varela, 2008; La Greca, Silverman and Wasserstein, 1998; Russoniello et al., 2002), environmental factors related to the event (Evans and Oehler-Stinnett, 2006; Garrison et al., 1995; Green et al., 1991; La Greca, Silverman, Vernberg and Prinstein, 1996; Vernberg, La Greca, Silverman and Prinstein, 1996), the emotional experience of the event (La Greca et al., 1996; Lonigan, Shannon, Finch, Daugherty and Taylor, 1991; McDermott et al., 2005), and psychosocial factors associated with the disaster and recovery efforts (Weems and Overstreet, 2008). Familiarity with the risk factors associated with the development of PTSD in children and adolescents following natural disasters can aid the identification of children who are at high risk of adverse mental health outcomes. The wellbeing of these children can then be monitored and prompt referrals made to appropriate intervention services if necessary. Brewin et al. (2008), working with an adult population, demonstrated the value of this type of screening program to promote mental health and reduce psychopathology following the London bombings. It would seem reasonable to assume that a similar screening and monitoring program should also enhance the mental health outcomes of children. Furthermore, awareness of the risk factors for PTSD can prompt the instigation of a range of measures to protect children, hence limiting adverse psychological outcomes in the wake of a natural disaster. Indeed Weems and Overstreet (2008) have argued that the mental health outcomes for children and youth following natural disasters depend to a large extent on the balance between risk and protective factors.

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RISK FACTORS

Time

As the forces of nature subside and the danger abates, people often experience a sense of relief that it is over and they are safe, and at the same time a sense of shock that such events could occur. The more negative emotions may only emerge as the extent of damage and loss and the difficulties of restoring the situation become increasingly apparent. Feelings of fear, anxiety, sadness, and despair, all of which adversely affect normal social and cognitive functioning, are common and are most severe in the early post disaster period. These feelings are normal at this stage and frequently dissipate over time, often without treatment (Foy, Madvig, Pynoos and Camilleri, 1996; La Greca et al., 1996). Nevertheless, for a significant number of adults and children, disabling psychological symptoms persist and may even intensify over time.

Individual Characteristics

Gender. Gender has been identified as a significant factor related to the development of PTSD following natural disasters. Girls have consistently been found to exhibit more PTSD symptoms than boys (Bal, 2008; Goenjian et al., 1995, 2001; Green et al., 1991; Shannon et al., 1994; Vernberg et al., 1996) possibly due to their greater willingness to report psychological distress, or their proclivity for internalising symptoms in response to traumatic events thus increasing their risk of developing PTSD (Vogel and Vernberg, 1993). Age. The relationship between age and the development of PTSD appears to be less clear (Salmon and Bryant, 2002). Green et al. (1991) found that the youngest children in their study (i.e., those aged 2 to 7 years) showed the fewest symptoms of PTSD (see Lonigan et al., 1991) while both Lonigan, Shannon, Taylor, Finch, and Sallee (1994) and McDermott and colleagues (McDermott and Palmer, 2002; McDermott et al., 2005) reported that children aged 9 to 12 years reported higher rates of posttraumatic symptoms than adolescents. It has been suggested that very young children are less affected by natural disasters because of the protection offered by their parents and that adolescents are more cognitively advanced and therefore better able to adapt, leaving primary school aged children as the most vulnerable group (McDermott and Palmer, 2002). Recent research using more sophisticated statistical procedures have thrown into question these earlier findings as they detected no significant main effect of age on PTSD symptoms in those age groups (Bal, 2008; Groome and Soureti, 2004). Historically, it was believed that infants and preschoolers were not severely affected by traumatic events, because their understanding of them was limited and they were generally shielded from direct exposure. However, little research has addressed the psychological wellbeing of this age group following natural disasters because of the difficulty in obtaining information from such young children (Sprung, 2008) and the inappropriateness of existing PTSD scales for their assessment. Scheeringa and colleagues (2003) developed and validated a developmentally appropriate measure of PTSD for young children. Using this scale, 50% of preschool children were found to show signs of PTSD following Cyclone Katrina (Scheeringa

Complimentary Contributor Copy 242 Heather Mohay and Nicole Forbes and Zeanah, 2008). This suggests that very young children may be the most vulnerable to PTSD and that the relationship between age and risk of PTSD may be linear. It is also possible that different age groups show different psychological responses to exposure to trauma, with younger children becoming more clingy and dependent and adolescents showing more acting out behaviour and delinquency (Norris et al., 2005). More research is required to clarify these issues and it is possible that age specific test instruments will have to be designed. It might also be more appropriate to think of the relationship between PTSD and developmental level rather than age (McDermott and Palmer, 2002). Personality. Pre-disaster personality traits have been shown to be significant predictors of post-trauma functioning (Norris et al., 2002). For example, both La Greca et al. (1998) and Weems et al. (2007) found that pre-disaster trait anxiety level was one of the best predictors of PTSD level following the disaster (i.e., individuals with high anxiety levels under normal conditions were likely to have high PTSD levels following exposure to a natural disaster). The coping mechanisms used by children and adolescents may also impact on the development of PTSD following natural disasters. Failed attempts at emotional regulation and problem solving, and the use of avoidant coping behaviours (e.g., social withdrawal, blaming others, self-criticism, and resignation) have consistently been found to be significantly related to the development of PTSD symptoms (La Greca et al., 1996; Norris et al., 2002; Pina et al., 2008; Russoniello et al., 2002). Some researchers have reported that active problem solving reduced the risk of post disaster psychopathology (Jeney-Gammon et al., 1993), but others have failed to replicate these results (Pina et al., 2008).

Environmental Factors

Extent of Exposure to the Natural Disaster. The extent to which an individual was exposed to the natural disaster, that is, whether they were directly caught up in the event or were on the periphery, and the degree to which they witnessed the frighteningly destructive forces of nature, have been found to be the most significant event-related risk factors associated with both the emergence and severity of emotional distress and PTSD symptoms in children and adolescents (Evans and Oehler-Stinnett, 2006; Foy et al., 1996; Garrison et al., 1995; Green et al., 1991; La Greca et al., 1996; Lonigan et al., 1991; Vernberg et al., 1996). Damage to Property. Damage to the family home and possessions can range from minimal to total destruction. The loss of valued possessions, which represented safety, security and permanency and which embody one’s identity, can have a profound effect on both adults and children. The degree of damage and loss has been found to be closely linked to the extent of PTSD symptoms (Lonigan et al., 1991, 1994; Vernberg et al., 1996). For example, Lonigan et al. (1994) investigated the relationship between degree of exposure to Hurricane Hugo and extent of home damage and the development of PTSD amongst children aged 9 to 17 years. The results showed that children with extensive home damage and moderate to severe levels of exposure were the most likely to report PTSD symptoms. The trauma, associated with loss and damage to property, may be compounded by the need for relocation and consequent loss of normal sources of support, such as friends and neighbours, schools, youth groups, etcetera. Damage and Disruption to Infrastructure Services. Little research has addressed the relationship between the magnitude of the natural disaster, in terms of the degree of

Complimentary Contributor Copy Recognising and Assisting Children at Risk of PTSD … 243 destruction and the geographical area involved, and the development of PTSD. When the disaster is limited to a small geographical area, for example, local flooding or storms, victims may be distressed by seeing close neighbours, who were unaffected by the event, going about their daily business. However in these circumstances, it is usually possible to put recovery services in place with reasonable speed and thus reduce the risk of further psychological harm. In the case of a widespread disaster, such as the recent Queensland floods (2011, 2013) or Hurricane Katrina, Weems and Overstreet (2008) argue that individual responses need to be considered within the context of the disaster’s impact on social systems, ranging from interpersonal communication to community services such as transport, education, health, mass communication, disaster relief and recovery operations and issues relating to insurance, legal matters and government policy. Apart from damage to individual homes, infrastructure services are typically also damaged in large scale disasters. Water and sewerage systems may not be functional. Food may not be available or impossible to cook. There are power outages which make all electrical equipment non-operational and daily living problematic. There is communication breakdown as telephones, radios, televisions and computers do not function, making access to information and support networks extremely difficult. Roads are often blocked and rail, air and ferry services are typically suspended, making it impossible for people to get in or out of the area. As a result, people feel trapped and vulnerable, unaware of exactly what is happening, afraid, helpless and cut off from the rest of the world where they could seek support and assistance. There is likely to be damage to neighbourhood amenities, such as shops, schools, churches, sporting facilities, medical centres etcetera, resulting in a loss of services. There is a breakdown in social structure and social support systems and the normal routine of daily life is thrown into disarray creating a sense of incongruity and confusion. The ensuing turmoil makes it difficult for parents to convey a sense of security and stability to their children. Furthermore, the extent of the destruction may necessitate the evacuation of families to unfamiliar neighbourhoods where they have no friends and where people have not shared their experience and may be unable to relate to it, or to give appropriate support. For children, this relocation may necessitate attending a new school, with all the attendant anxieties and the loss of contact with friends and regular out of school activities. Weems and Overstreet (2008) argue that this breakdown in social systems adds significantly to post traumatic stress in both adults and children.

Emotional Experience of the Disaster

Witnessing Death or Injury and Perceived Life Threat. Emotions experienced during a natural disaster impact on the later development of PTSD in children and adolescents (Lonigan et al., 1991; McDermott et al., 2005). Sustaining a personal injury or witnessing the death or injury of others or fearing for one’s life or the life of others, especially members of the family or close friends have all been found to be related to the development of PTSD in children (Garrison et al., 1995; Goenjian et al., 1995; Green et al., 1991; Kar et al., 2007; La Greca et al., 1996; Lonigan et al., 1991; Marsee, 2008; McDermott et al., 2005; Pynoos et al., 1993; Thienkrua et al., 2006). McDermott et al. (2005) for example, investigated PTSD in children aged 8 to 18 years following the Canberra wildfire disaster and reported that children

Complimentary Contributor Copy 244 Heather Mohay and Nicole Forbes who perceived their life or a family member’s life to be in danger had higher PTSD scores. Similar findings were reported by Thienkrua et al. (2006) in a study of children who lived through a tsunami that inundated the south western provinces of Thailand. Both studies also found that the experience of extreme panic and fear during the natural disaster was associated with more severe PTSD symptoms (McDermott et al., 2005; Thienkrua et al., 2006). Separation from Loved Ones. Separation from one or more family members during the natural disaster and consequent uncertainty about their safety creates intense anxiety and has been shown to be linked to the subsequent development of PTSD (McDermott et al., 2005; Vogel and Vernberg, 1993). This situation can arise when some family members are evacuated in the face of an impending disaster, while others stay behind to defend the family home or to assist with disaster management. It also occurs when disasters strike without warning and family members are engaged in their normal daily activities, for example children are attending school while parents are at home or at work. Loss of Family Income. Destruction caused by a natural disaster frequently results in parental job loss, loss of income and financial hardship. Whilst this may be extremely distressing to parents, it has been found to be only weakly associated with PTSD symptoms in children, possibly because they perceive these consequences as indirect, rather than direct, results of the disaster (Lonigan et al., 1994), or because in cases of extreme poverty, the incremental change is of little significance (Scaramella et al., 2008).

Psychosocial Factors

Until recently, relatively little research examined the relationship between psychosocial factors and post traumatic stress reactions following natural disasters; however, emerging evidence suggests that these factors play a significant role in the post-disaster psychological adjustment of children. Individual Differences. Lower intelligence has been reported to be associated with higher levels of distress in other harrowing situations; however, no evidence is available on the relationship between intellectual ability and risk of PTSD following natural disasters. Nevertheless, evidence has been found of an association between developmental stage and PTSD (McDermott and Palmer, 2002). It might, therefore, be expected that children with intellectual impairment would be at higher risk for psychological distress following natural disasters than their age mates, but further research is required to verify this. The influence of personality and coping strategies on post disaster adaptation has been discussed earlier (see “Personality” above). Family Functioning. Most research on the influence of psychosocial factors on post- disaster psychopathology has focused on family functioning. Deterioration in parental mental health and wellbeing and an increase in domestic violence and marital stress have been reported following natural disasters (Foy et al., 1996; Norris et al., 2002). This degeneration of family functioning adds to the stress on children as parents are less able to provide a safe, secure, stable and consistent environment which is essential for children’s psychological wellbeing. Unstable and unsupportive family environments, which are less communicative and lack emotional closeness, have been found to negatively influence children’s and adolescent’s ability to cope with a variety of stressful situations (Tiet et al., 1998; Wyman, Cowen, Work and Parker 1991; Wyman et al., 1992). Following natural disasters, children’s

Complimentary Contributor Copy Recognising and Assisting Children at Risk of PTSD … 245 psychological distress has been found to be very closely associated with parental psychopathology and coping mechanisms (Foy et al., 1996; Green et al., 1991; Scheeringa and Zeanah, 2008; Spell et al., 2008). Bokszczanin (2008), for example, examined the levels of PTSD in a group of children and adolescents 28 months after a major flood in Poland and found that family functioning was a significant predictor of PTSD levels. She particularly highlighted the role of parental overprotection, excessive control and infantilization as behaviours which obstructed children’s recovery. Parental mental health and coping strategies therefore seem to be key factors in predicting outcomes for children.

Table 2. Summary of Risk Factors for the Development of PTSD

Risk factor Comments

Time Symptoms decrease over time. If symptoms persist for more than a month, this is indicative of psychopathology. Gender PTSD is more common in girls than boys.

Age Younger children seem to be at higher risk than older children.

Personality High trait anxiety and poor coping skills prior to the disaster increase the risk of PTSD. Extent of exposure to The greater the exposure to the disaster the greater the risk of PTSD. the disaster Damage to property The more the loss and damage, the higher the risk of developing PTSD.

Damage to Extensive disruption to services and normal activities is linked to PTSD. infrastructure Personal injury or Injury to self or others is closely linked to the development of PTSD. witnessing injury Perceived life threat Experiencing panic and fear for one’s life is closely associated with the development of PTSD. Separation from loved Separation from loved ones and fear for their safety is associated with increased ones risk of PTSD. Parental mental health Parental stress and psychopathology is closely linked to deterioration in children’s mental health. Lack of social Few friends and the lack of a social support network places children at higher risk connectedness for PTSD. Relocation can therefore add to distress. Note: A dose-response relationship appears to exist between these risk factors and the development of PTSD. Children and adolescents who experience the most intense or extensive exposure are at greatest risk of developing PTSD.

Social Connectedness. Recent research has identified social connectedness as a factor influencing how well people cope with stressful events (Donald and Dower, 2002; Duru and Poyrazli, 2007; Lee et al., 2002; Lee and Robbins, 1998; Taxis, Rew, Jackson and Kouzekanani, 2004). Social connectedness has been defined as one’s internal sense of belonging to close (family and friends) and more distant (acquaintances, community, and society) relationships (Lee, Draper and Lee, 2001; Lee and Robbins, 1998). It comprises two components, perceived availability of social support and friendship (Lee et al., 2002; Lee and Robbins, 1998). The perception that one is loved and being cared for has been found to be predictive of better psychological health than actually receiving social support following stressful occurrences (Scarpa, Haden and Hurley, 2006; Wethington and Kessler, 1986).

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Conversely, low levels of friendship and negative peer relationships have been found to be associated with increased negative outcomes amongst children and adolescents (Almqvist and Broberg, 1999; Rubin et al., 1992). Individuals with low levels of social connectedness appear to be less able to manage their emotions, are more prone to perceived stress and anxiety (Lee and Robbins, 1998; Taxis et al., 2004), and have poorer levels of psychological functioning including PTSD following distressing events (Brewin, Andrews and Valentine, 2000; Hagen, Myers and Mackintosh, 2005, Scarpa et al., 2006). Feelings of social connectedness can be severely challenged, if post-disaster social support and recovery efforts are perceived to be unequally distributed leaving some members of the community feeling discriminated against, as was the case in New Orleans (Weems and Overstreet 2008). Table 2 summarizes the risk factors associated with the development of PTSD.

STRATEGIES TO REDUCE THE RISK OF PTSD IN CHILDREN AND ADOLESCENTS FOLLOWING A NATURAL DISASTER

Reducing the Impact of the Disaster

Avoiding direct exposure to natural disasters reduces the risk of developing PTSD. When early warning is available, people can leave the area or access safe shelters, thus escaping direct exposure to the event and the risk of injury, which are key risk factors for the development of PTSD in children. Early warning also enables families to prepare appropriately to minimize damage to property and to arrange to stay together and support one another, further reducing risk factors associated with PTSD. Having a store of basic provisions, and a generator or battery operated equipment enables a semblance of normality to be restored and communication to be established, so that information can be received and the sense of isolation reduced. Explicit plans identifying what to do if a natural disaster occurs can decrease the chance of personal injury and property damage, and can curb anxiety, fear, and panic at the time of the disaster, lessening the risk of children developing PTSD. Often natural disasters strike without warning making it difficult to seek safety or to ensure that family members are kept together. Prompt, efficient and appropriate disaster relief efforts are essential to reduce the distress of people who have been exposed to traumatic events. When the disaster response is delayed or inappropriate, as happened after Hurricane Katrina, people feel abandoned, helpless and uncared for, and their psychological distress is exacerbated (Pina et al., 2008); this was also evidenced more recently in the rural areas in the Queensland Flood referred to in the preamble of this chapter (see also Gow, 2011).

Identifying Children at High Risk of Developing PTSD

Almost everyone who has lived through a natural disaster will experience shock and emotional turmoil in the immediate aftermath. These feelings are normal and for the majority of adults and children they will eventually resolve through normal healing processes, without the need for specialist intervention, providing appropriate support is available within the community. Unfortunately, for a significant number of adults and children, psychological

Complimentary Contributor Copy Recognising and Assisting Children at Risk of PTSD … 247 disturbance will be persistent and may interfere with their daily life for years to come, if it not treated. For these people, early detection of psychopathology and referral to appropriate intervention services is essential. Thus, disaster response workers need to identify those at greatest risk of developing psychological disorders, so that their wellbeing can be monitored and, if necessary, they can be promptly referred for expert assessment and treatment to prevent the crippling effects of prolonged symptomatology. The risk factors outlined above provide useful guidelines for identifying children at greatest risk for developing PTSD. Vernberg et al. (1996) reported that a combination of age, gender, race, access to social support, and children’s coping ability accounted for 62% of the variance in PTSD symptoms in 8 to 10 year olds, 3 months after Hurricane Andrew. Extent of exposure to the disaster, parental mental health and perceived threat also appear to be key factors in predicting outcomes for children. A dose-response relationship seems to exist in which children, who have the most intensive or extensive exposure to the risk factors for PTSD, are likely to develop the most serious and persistent symptoms (La Greca et al., 1998). Further research is required to design and validate a simple check list, based upon the risk factors outlined above, which would enable recovery personnel and community members, such as teachers, youth workers and health professionals, to screen children for risk of developing psychological disorders.

Psychological First Aid

There is, as yet, little evidence about the best strategies to help children and families cope emotionally in the aftermath of a natural disaster. Indeed, it has been suggested that some interventions which have been used may have been counterproductive (Rose, Bisson and Wessely, 2003). Psychological first aid is the term that has been adopted to describe community level responses aimed at assisting the psychological wellbeing of people in the immediate and mid-term periods after a natural disaster or terrorist attack (Brymer et al., 2006; Gard and Ruzek, 2006; Hobfoll et al., 2007; Reyes, 2006; Vernberg et al., 2008). Brymer et al. (2006) produced a Psychological First Aid Field Operatives Guide based on input from experts in the fields of trauma and disaster recovery and evidence from other areas of research related to stress. These guidelines provide sound general principles which can be used by disaster response teams to provide support to adults and children following horrendous events. The five basic principles which have been proposed are to promote: (1) a sense of safety; (2) calming; (3) a sense of self and collective efficacy; (4) connectedness; and (5) hope (Hobfoll et al., 2007). Any personal injuries must be dealt with immediately, after which the provision of the basic necessities of life, food, water, clothing and shelter must be provided. Homes need to be made secure and liveable if possible; where this is impossible, other safe accommodation needs to be provided preferably keeping the community, who have shared the same experiences, together. Children and adults need to be able to talk about what happened and it is often easier to do this with people who have been through the same thing. This can establish, or maintain, networks and a sense of community connectedness through which people can provide the support for one another which has been shown to reduce the risk of psychopathology following natural disasters. Community recovery workers can provide a calming presence in the midst of panic and fear. They need to be able to provide practical

Complimentary Contributor Copy 248 Heather Mohay and Nicole Forbes help, accurate information and reassurance that the environment is safe and the danger has passed, as these are important first steps in re-establishing a sense of security. They also need to facilitate access to personal, financial, psychological and community support, and assist with the development of community activities to aid recovery and enable people to put their lives together again (Queensland Government, Department of Community Services, 2009). Family members who have been separated need to be reunited as soon as possible in order to reduce uncertainty and anxiety about their wellbeing. Even if the news is bad and a family member has died or been injured, it is better to know this and to begin the grieving process than to live with uncertainty. Attachment bonds are extremely important for children’s sense of security; when they are severed, children experience feelings of loss and abandonment. The mental health of parents and children are intertwined; if parents experience serious psychological disturbance after a natural disaster, it is likely that their children will too (Scheeringa and Zeanah 2008). It is therefore essential to address the mental wellbeing of both parents and children in order to reduce the risk of children experiencing PTSD. Providing parents with information which helps them to understand their children’s responses to stressful events can enable them to respond appropriately to the behaviour of their traumatised children. Frightened children need to be given reassurance and a sense of safety and security. When parents are unable to do this, because of their own distress, the role needs to be taken on by others such as aid workers, teachers, youth leaders, sports clubs, and friends. When all is chaotic and changed around them, children need to regain a sense of routine and normality. Restoring regular school programs and re-establishing out of school activities enable children to resume their customary activities and regain a sense of familiarity, order, predictability, and safety in their environment. Replacing toys lost in the disaster and providing opportunities for children to play with friends and peers can be valuable in reducing their anxiety. The fact that children are frequently observed playing shortly after a disaster should not be taken as an indication that they were unaffected by the events, as play is frequently the vehicle through which children can deal with their fears. The willingness of outsiders to provide support and practical assistance helps to alleviate the physical and psychological effects of disasters. Often the feeling that others care is at least as important as their ability to assist in a practical way, as it indicates that they are aware of, and empathise with, those who have suffered from the disaster. Media reports can be valuable in raising awareness amongst the general public of the extent of the disaster and the need for assistance and funding to support the affected communities. Unfortunately, the media can also have a detrimental effect if they sensationalise situations, as this can cause increased distress to those involved. Media reports should therefore be handled with great care and editorial honesty and rigor. When children have been caught up in a natural disaster their exposure to subsequent media reports should be restricted, as there is a danger that these will reactivate memories and fears. Even children who were not directly involved in the events may become distressed by graphic accounts of the disaster because they place their own interpretation on what they see and hear. Determining, not only the psychological stress experienced by children and families, but also their strengths, can help to establish avenues for future positive adaptation and coping following traumatic experiences. Psychological first aid strategies should therefore aim to alleviate distress and provide emotional support, whilst at the same time promoting the use of effective coping mechanisms and building resilience.

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Schools, youth groups, sporting associations and church groups can play an important role in fostering feelings of community connectedness and belongingness for children and young people by providing both practical and emotional support and normalising activities following a natural disaster. Little research has addressed the role of social connectedness in recovery from natural disasters; however this might be a fruitful area for future research as it could identify additional strategies for alleviating the psychological distress of adults and children following traumatic experiences. Adverse psychological effects of natural disasters may be persistent, may intensify over time, or may not emerge until several weeks, months or years after the disaster. It is therefore essential to remain vigilant for the signs of PTSD in children and for community recovery initiatives to be maintained beyond the first few weeks post disaster, to ensure children’s wellbeing and ongoing positive development.

Building Resilience and Promoting Positive Adaptation

In addition to the strategies that can be put in place to reduce the risk of children developing PTSD following a natural disaster, programs can be instigated to build resilience at the individual and community level. These programs typically focus on strengthening family functioning, building social connectedness and encouraging positive coping skills. They are equally applicable to communities which have experienced a significant trauma and those which have not, as they not only aid recovery in the post disaster period, but also promote long term resilience which provides protection against the adverse psychological effects of any future catastrophes. Positive family functioning can be fostered in a variety of ways. There are many sources of parenting information, such as parenting programs, parent discussion groups, leaflets, radio and television programs, newspaper and magazine articles and the internet. Making access to this information readily available through libraries and other organisations can strengthen family functioning throughout the community. Effective and easily accessible family support services such as childcare programs, child health services, babysitting groups, mothers’ groups and play groups, can also promote positive family functioning, as can the provision of safe parks and playgrounds and family friendly facilities at local restaurants, coffee shops and cinemas. Social connectedness needs to be developed at the community and local neighbourhood level. Communication between community members is essential in establishing a sense of belonging. It is therefore crucial to focus on developing places and activities which bring people together and encourage them to talk to one another. Schools can be an important hub for both parents and children where they can experience a strong sense of acceptance, security and support. Other community groups such as youth groups, sporting associations, church groups and various interest and leisure groups, where people gather with a common purpose, can play a similar role and support the development of networks. Participation in community projects and neighbourhood celebrations creates a sense of common ownership of resources. Making spaces such as parks, shopping centres and coffee shops available for informal gatherings can be equally beneficial. Dissemination of local news via newsletters or email groups keeps people informed about community events and accomplishments and promotes

Complimentary Contributor Copy 250 Heather Mohay and Nicole Forbes feelings of inclusion. With modern communication technologies, the sense of community can be extended far beyond the geographical boundaries of a neighbourhood. Positive coping strategies, such as active problem solving, can be taught and learned, and although there is little evidence that teaching these skills in the aftermath of a natural disaster reduces the risk of PTSD in children and adolescents (Pina et al., 2008), if they are well established before the stressful event occurs, they may enable both children and adults to cope more effectively with the trauma (La Greca et al., 1998). Strategies to reduce the risk of children developing PTSD after exposure to natural disasters are summarised in Table 3.

Table 3. Summary of Strategies to Reduce the Risk of Children Developing PTSD

Strategies Reduce the Impact of the Disaster Evacuation/safe shelter Keep the family together Protect property/reduce damage and loss Have a disaster plan Identify Children at Risk of Developing PTSD Identify children with intensive or extensive expose to the disaster as they will be at greater risk of developing PTSD Monitor children’s behaviour and wellbeing Refer for specialist assessment and treatment if necessary Psychological First Aid Provide the basic necessities of life Provide reassurance re safety and security Provide accurate information Restore a sense of calm and normality Support parental wellbeing Increase Resilience and Coping Skills Strengthen family functioning Promote a sense of community connectedness Teach positive coping strategies

CONCLUSION

There is clear evidence that children can develop PTSD following exposure to a natural disaster. A number of factors related to exposure to natural disasters have been found to be associated with an increased risk of psychopathology. A dose-response relationship appears to exist, so that children and adolescents who experience the most intense or extensive exposure to the risk factors for PTSD are likely to develop the most serious and persistent symptoms. There is a need to create and validate a check list of these risk factors which can be used by recovery personnel to screen children and identify those at high risk for adverse mental health outcomes. The progress of these children can then be monitored and intervention initiated if required. As children’s mental health is closely allied to that of their parents, the psychological wellbeing of both parties needs to be checked and safeguarded. A variety of strategies have been described which can be put in place before, during or after a natural disaster to reduce the risk of children developing PTSD or other psychopathology.

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In addition, practices can be introduced which build resilience and positive coping strategies as these will both aid recovery from the natural disaster and reduce vulnerability in future stressful situations. As the emergence of symptoms of PTSD may be significantly delayed, or symptoms may intensify over time, it is important for recovery personnel to remain vigilant and to maintain recovery programs over an extened timeframe. These programs are likely to be highly cost effective especially in areas which are particularly prone to natural disasters. In conclusion, three major themes should be remembered to safeguard those who are exposed to natural disasters: (1) vigilant screening of those at risk of psychopathology to ensure early intervention; (2) provision of practical and psychological support in the post disaster period; and (3) building resilience at the individual, family and community levels.

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Chapter 15

WHEN COMMUNITY RESILIENCE BREAKS DOWN AFTER NATURAL DISASTERS

Kathryn Gow*1 and Heather Mohay†2 1Consulting Psychologist, Regional Australia 2Queensland University of Technology, Australia

ABSTRACT

In this chapter, we consider the factors that affect the resilience of people involved in a selection of natural disasters, and utilise comparisons between countries after droughts, floods, wildfires, hurricanes, cyclones and earthquakes. The countries under review are Australia, Bangladesh, Japan, New Zealand and the USA. The focus in on ascertaining the reasons for the breakdown in community resilience following unpredictably destructive natural disasters, even in areas where this kind of disaster occurs on a regular basis. Similarities and differences will be sketched between countries and disaster type, and types of resilience will be nominated where they are pertinent to the discussion. Some key factors will be nominated as contributing to a breakdown in community resilience and these should be taken into account before any post disaster interventions are activated.

Keywords: Natural Disasters, Community Resilience, Breakdown in Resilience, Disaster Interventions

INTRODUCTION

The impetus for the explorations of resilience in this chapter were sparked by the mega flood event that occurred in Queensland in January 2011, when the lead author observed that

* Contact: [email protected] † Heather Mohay has been a frequent visitor to Bangladesh and India undertaking volunteer aid work, while the first author attended Grameen Bank Training in Microfinance in Dhaka and some rural areas in Bangladesh during the late 1990’s.

Complimentary Contributor Copy 258 Kathryn Gow and Heather Mohay the usual ‘bounce’ of people living in the rural areas west of Brisbane1 (who generally deal well with drought, bushfires and storms as well as flash floods on a seasonal basis) was noticeably flat. The aim of the chapter is to discuss why resilience breaks down after some natural disasters. We will refer to different types of resilience such as eco-resilience, economic resilience, and social resilience, as well as personal resilience. Neil Adger (2000) defines social resilience as “the ability of groups or communities to cope with external stresses and disturbances as a result of social, political and environmental change” (p. 347). Adger considers that eco resilience is evident in ecosystems through their capacity “to maintain themselves in the face of disturbance” (p. 347). Obviously the economic, and thereby the personal, resilience of farmers and towns people are directly linked to ecological resilience and if these ecological resources and stability are damaged they will be adversely affected, such as in floods, bushfires and droughts. In terms of personal resilience, we refer readers to other chapters in this and the companion book2 as each has a different definition of the quality, although they all agree that it is an inner strength, a characteristic of the person that is generally stable across time and situations, even after encounters with trauma. Economic resilience is a critical term in disaster aftermaths, as failure to have adequate insurance or failure of the insurance companies to “pay out” honourably is known as a major ‘knock’ to one’s ability to regroup, to plan ahead, and to feel hopeful about the future. The destruction of businesses takes away people’s livelihoods with a flow on effect to loss of jobs for people who live in the locality. We will present selected scenarios in which we compare similarities and differences (to varying depths) between natural disasters in the same or different countries. The objective is to ascertain what factors might contribute to absent or weakened resilience in each case and how these might impair recovery. It is not to suggest what type of interventions might be attempted in terms of mental health assistance as that has been covered, in terms of floods, by Mohay and Forbes in this text, or in terms of cultural considerations generally in preparing and conducting interventions, as several chapters in this book already cover those. Indeed there is sufficient, but not a great deal of, work being done on conducting post disaster interventions, but very little has been written about why community resilience breaks down. In relation to the factors that will be seen to contribute to lack of resilience or a breakdown in individual and community resilience, these are many, but there are four that stand out as causing the greatest destruction of community resilience and perhaps by default, individual resilience. These relate to temporary and permanent displacement of persons; total area and materials destroyed and infrastructure destruction; density of loss of life and injuries; and failure to recoup damage outlays through insurance, funding, or other means. A fifth is prior trauma in individuals and the community and while we will not address this issue in the chapter, we refer readers to the Addendum where Ron Frey provides a list of questions to guide counsellors about the enduring historical or foundation trauma effects when preparing post disaster interventions.

1 Brisbane is the capital city of Queensland in Australia. It was badly flooded in 1974, as was the city of Ipswich. To the west of these two cities are the Lockyer and Somerset Regions, the first being labeled as the food bowl for Brisbane and the latter being home to the Somerset and Wivenhoe Dams which supply the cities with potable water. Thus damage to these regions can jeopardize the food and water supplies to the two cities. 2 K.M. Gow, & M.J. Celinski (Eds.). (2012). Individual Trauma: Recovering From Deep Wounds and Exploring the Potential For Renewal. New York: Nova Science Publishers.

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We know that some places turn into ghost towns like Darwin after Cyclone ‘Tracey’ in 1974 and New Orleans after Hurricane ‘Katrina’ in 2005; the damage is so extensive and so severe that the whole cohesiveness of the community is lost; buildings, fencing, trees, roads, bridges, subways, railways lines, pavements, shops, factories, industrial estates, schools, hospitals all are gone; infrastructure - water, electricity, communications including telephone and internet systems - no longer function and the landscape is not recognisable as being the same well known place. Actual displacement of people appears to be a key factor when large numbers of residents are displaced locally, or relocated away from their town or city for more than a few weeks or months. While social scientists have been working on how to build resilience, both before and after natural disasters, we actually do not know a great deal about what breaks down community resilience following natural disasters; yet in the past 10 years, the world has been beset by multiple natural disasters of all kinds. Indeed, it would seem that the only natural disaster that has been studied in any depth in relation to the breaking down of resilience is the one that is the silent death of communities – drought (see Buiskstra et al., 2011; Gow, 2009a; Walker, Abel, Anderies and Ryan, 2009). The factors involved in the breakdown of communities during long droughts may be applicable to other natural disasters is some ways, but in others they are vastly different. The major difference is that drought spans a long time and erodes community resilience and undermines resourcefulness; most other natural disasters wreak havoc quickly and violently, such as earthquakes, floods, tsunamis, cyclones, hurricanes, avalanches, and volcanic eruptions, and wildfires. Thus generally, there is the severity of the disaster impact itself, immediate damage to the ecosystems, property and people, infrastructure, business, environment and animals, agricultural crops, etcetera, and an abrupt and dramatic shortage of transport, food and water in many instances. The psychological reactions and physical health issues are similar in certain ways and yet different in others. PTSD is far likelier to occur with non-drought effects, whereas severe depression (and perhaps suicide, although we have no differential figures on this) is more likely to occur in long droughts. In the latter situations, the individual’s resourcefulness is first depleted and over time their resilience is drained. The mental health effects are different and the resources that people draw on are also different; in the great drought, across 1992 to 2007 in Australia, farmers and small town business owners kept plodding on, hoping that things would improve, convinced that the rain would come again and that all they had to do was to obtain a bigger bank loan to get them through to the next crop or the next sheep/cattle sale; but the rain did not come, year after year, after year. Marriages and families separated slowly at first and then the momentum built; small business owners including hotels and grocery stores (often the meeting hub of small communities) ‘hung in there’ for many years and then, bankrupt, closed their doors in grief and loss. Small towns died, school children were bussed (transported) to other towns or moved to larger towns or cities, banks foreclosed on the farmers and graziers and property prices slumped. And when the rains came again, the farmers were met with new challenges that they could not fight, coal mining companies took out mineral rights to their lands with the threat of coals dust spreading for miles around, and later coal seam gas companies with no permission dug wells on their properties with residents concerned about the potential poisoning of underground water sources. When does one admit defeat and give up and save one’s remaining resources? When does resilience mean staying or leaving?

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The chapter will now focus on the effects and aftermath of sudden and often unpredictably destructive natural forces on communities in terms of individual and community resilience and recovery; case examples (varying in length and depth) will be utilised for the purpose of comparisons.

COMPARISONS BETWEEN NATURAL DISASTERS AND BETWEEN DISASTER LOCATIONS

There are four case examples in this section which allow us to explore the nature of the breakdown of resilience, as well as cohesiveness and resourcefulness during and after specific natural disasters, across several different locations and across time. The natural disasters of interest are droughts, cyclones, hurricanes, earthquakes, floods, and wildfires. The countries in focus are Australia, Bangladesh, Japan, New Zealand and the USA.

Hurricane Katrina in the USA and Cyclone Tracy in Darwin

In this case example, we focus on understanding the severity of the disaster and the historical and cultural effects on the recovery resilience of two cities, New Orleans and Darwin in Australia3. The events occurred 30 years apart, with Cyclone Tracy hitting Darwin in 1974 and Hurricane Katrina striking New Orleans in 2005. A great deal has been written about the long term effects of Hurricane Katrina and about the wider ramifications of the factors surrounding the breakdown of the community after the disaster to the extent that Saliha Bava and Jack Saul (Ch. 2, this text) distinguish the use of the terms “Hurricane Katrina” and “Katrina” thus:

Hurricane Katrina is a not just a natural disaster. It is a euphemism that captures the disasters caused not only by nature, but also by human and recovery efforts. The way Katrina is constructed creates both challenges and possibilities about understanding and responding to such a mass trauma. Katrina, framed as “hurricane”, potentially de- contextualises the disaster by stripping the historical reference to slavery in America. Also it fails to acknowledge the pre-existing and ongoing social location issues, such as familial, race, geography, regional politics, and economic factors. Norris et al.’s (2008, p. 131) label of Hurricane Katrina and conceptualisation of it as an environmental disruption is based on the variable of duration.

3 At the time of finishing this chapter, Darwin was on alert for Cyclone Grant to hit the city and harbor on Christmas Day 2011, 37 years after the catastrophic 1974 cyclone. This time warnings were broadcast constantly and residents were prepared; the threat passed with a whisper and then mouthed the threat of return; but many Australians, across the largest country land mass in the world, who had seen the results of the 1974 Christmas Day cyclone had waited with anxiety to what might happen this time. Nature moved its sights, and battered Melbourne with ferocious storms, Western Australia and South Australia with severe wildfires, the eastern coast of Australia with cyclonic winds from the north forcing the closure of beaches over the Christmas holidays. Then La Nina snarled again and flooded Queensland and New South Wales.

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From Christmas Eve to Christmas Day in 1974, Cyclone Tracy flattened the small city of Darwin with 250km/h winds, deluging it with precipitation of 195 mm over 9 hours (a feat becoming common place in Australia in the past 2 years); 65 people died and 25,000 were left homeless (58% of the total population). The damage was estimated at US $2.5 billion – a very large damage bill considering the value of a billion dollars 38 years ago. Darwin was forcibly evacuated leading inevitably to the breakup of families permanently; there was nothing left standing in many parts of the city – which is different from floods when often many buildings are left mostly standing, but everything inside and outside is destroyed by water and mud. It was its totally unexpected ferocity that caught the city unawares on December 25th when families were celebrating Christmas. Darwin was not a stranger to cyclones, having encountered several in the previous decades. Darwin also had a history which was relevant to the extent of the trauma suffered there; the harbour and parts of the city were destroyed in World War 11 via an air raid attack in 1942 on the 19th February4. Lives were lost, houses and businesses destroyed, along with the shipping docks and town infrastructure; it was later rebuilt. Like New Orleans, Darwin had a history of some cultural tensions; however the city was home to many indigenous people, who were integrated with the townsfolk and settlers more so than anywhere else in Australia. It had a percentage of long term Asian residents and business people owing to its closeness to the Asian continent. It was a strategic security location for Australia being based on the northern boundary of Australia, with Asian neighbours being closer than the nearest major cities of Australia. It was thus a very isolated city, with little back up support. Each area in both countries had experienced these natural disasters before the “big ones”. Both areas are located in developed western nations; they are English speaking; and their socio-economic status was approximately the same allowing for monetary fluctuations over time at the time of the disaster. Both had peoples who were oppressed by the dominant culture. Two differences relate to the population and location. While both cities were located on coast lines, Darwin in the Southern Hemisphere was extremely isolated from the majority of people in other cities; New Orleans in the Northern Hemisphere was highly populated and part of intensive urbanisation in the USA and should not have been considered as isolated, although the disaster response reactions were reported as being seriously delayed and not sufficient. Ron Frey (see Addendum in this book) calls to our attention the importance of understanding the historical and foundation traumas that may need to be addressed when working with communities in building pre- and post- disaster resilience, which if not addressed may hinder recovery.

NEW ZEALAND AND JAPANESE EARTHQUAKES

Earthquakes occur regularly in certain areas of the world and most countries have a monitoring department which record the movements. One particular area of interest in the

4 In 2012, Australia declared the 19th February each year as the Bombing of Darwin Day; 2012 marked the 70th Anniversary of the bombing of the city.

Complimentary Contributor Copy 262 Kathryn Gow and Heather Mohay world to those studying and working in seismology is the Ring of Fire. Both New Zealand and Japan are in the Ring of Fire and from 2011 to 2012 the tectonic plates were moving. New Zealand is situated on one tectonic plate, while Japan has the unfortunate position of being situated on three tectonic plates. Both countries experienced aftershocks of varying intensity and depth over many months, with New Zealand commencing theirs in 2010 and Japan in February 2011. The earthquake which erupted in 2011 at Christchurch “was a 6.3-magnitude earthquake that struck the Canterbury region in New Zealand's South Island at 12:51 pm on 22 February 2011 local time (23:51 21 February UTC), causing widespread damage and multiple fatalities. The earthquake was centred 2 kilometres (1.2 mi) west of the town of Lyttelton, and 10 kilometres (6 mi) south-east of the centre of Christchurch, New Zealand's second-most populous city” (cited by Wikipedia, 2011). The small and beautiful underpopulated country of New Zealand came centre stage on the world media scene with its tragic loss of life, and major damage to historical and business buildings and general infrastructure. The rescue and relief work was intense and New Zealand allowed rescue teams from different countries across the world to come and assist with live rescues, body retrieval and the making safe of structures. Japanese teams stepped forward and television channels showed the Japanese rescuers speaking with Japanese tourists and international students who were studying in the Christchurch area. Businesses closed and many were not likely to reopen; the economic situation deteriorated although swift and concerted action was taken by the New Zealand authorities to mend and rebuild when safe. Offers to help came in from the international community and the long hard work of clearing, mourning, planning, and reconstruction began. At the time of this book going to the publishers, the situation in Christchurch is still uncertain as outlined by Suzanne Vallance in Chapter 15 in this book and became more so because of the disturbing quakes at Christmas time, 20115 and thereafter. Again, as with the rural flood victims in Queensland, in February 2011, the focus of attention quickly turned away from the NZ disaster location towards Japan when the dramatic earthquake on March 11, 2011, and a horrific tsunami wiped out large tracks of rural land and coastal towns and villages and a great many lives were lost. Reportedly, the Japanese earthquake on March 11, 2011 was the largest to date. “The 2011 Tōhoku earthquake and tsunami (Tōhoku Chihō Taiheiyō-oki Jishin), literally "Northeast region Pacific Ocean offshore earthquake" was a 9.0-magnitude undersea megathrust earthquake off the coast of Japan that occurred at 14:46 JST (05:46 UTC) on Friday 11 March 2011. The epicenter was approximately 72 km (45 miles) east of the Oshika Peninsula of Tōhoku, with the hypocenter at an underwater depth of approximately 32km (19.9 miles)” (cited in Wikipedia, 2011). The cultural emotional display rules of the Japanese masked much of the early distress and trauma experience by the victims, rescuers, and government officials in charge of the disaster interventions. It will be a long time before we can glean the exact outcomes for individuals, except that we already know that individual fortitude was ‘wearing thin’ after 2-3 months, and the additional factor of what could be loosely termed a manmade (nuclear)

5 On 23rd December 2011, a series of large shocks harassed Christchurch and on January 7, 2012, Christchurch was hit with another aftershock of 5.2 magnitude and the following day another quake disturbed the hope of stability for residents and officials alike.

Complimentary Contributor Copy When Community Resilience Breaks Down after Natural Disasters 263 disaster was of serious concern to the whole country and their neighbours. Little information has been made available on their eco-resilience measures, and ongoing damage to the eco- systems by nuclear contamination is a continuing hazard to the health of Japan and its peoples and animals. In-country, after three months, it became obvious that the people affected by the earthquake, tsunami, and/or nuclear power station failures were suffering traumatic reactions and in some cases the effect was severe, as could be expected. The compounding of multiple disasters for Japan with the earthquake, tsunami and nuclear plant contaminations, and the unstable global financial state added to the trauma conditions for the people of Japan. However, there was no indication that there was a mass breakdown in resilience in the people affected by the disasters, even though the nuclear power plant disaster, which threatened longer term health implications, was a serious threat to mental health in terms of genuine worry and concern about what the future would hold for their physical health and for some their economic survival. Later, some television documentaries demonstrated that inside Japan there are indeed many people who are still suffering from the effects of the singular or multiple disasters in their localities. Differences and Similarities. While the land mass difference between the two countries is not great, New Zealand (about 70% land mass of that of Japan) is sparsely populated (4.2 million) compared to the high density population in Japan (128 million). The situations in both New Zealand and Japan with reference to their recovery is very serious; the areas affected and the residents, businesses, tourists and governments, while having made Olympian strides in terms of community recovery, face a difficult time for full economic recovery at a stage when the world’s financial systems are under threat of a depression and even a collapse. Both countries have long histories as a nation and are built on a warrior culture and there is no question that the affected country areas will win through these turbulent times. They will rebound and they will evidence resilience. However, we should not forget that the suffering will continue for months and even years in some cases. Both countries are within the Ring of Fire and can expect further earthquakes.

FEROCIOUS BUSHFIRES6 IN VICTORIA AND MEGA FLOODS IN QUEENSLAND

Australia is the most arid country in the world. It is beset by storms, bushfires and floods. In this section we compare responses to floods and fires within a similar time period, in the same country, but 1,600 kilometres apart.

Bushfires

Australia burns, as Mark Tredinnick (2011) would say: “Fire is one of those faces we should expect nature to wear on a continent that receives so little rain and, by contrast, so

6 The term for wildfires in Australia is bushfires, and the forested areas and farming lands are generally regarded as “the bush”.

Complimentary Contributor Copy 264 Kathryn Gow and Heather Mohay much heat and light and wind. For this is a continent rich with eucalypts, those shepherds of fire, it is a paradise of flames.” (p. 111) Bushfires hunt through Australia in every state, and even the small state of Tasmania was burned via 110 fires on 7th February 1967 in just one day, leaving 62 people dead, 1400 dwellings and buildings destroyed, and 264,270 hectares burned in the southern part of the state. Again southern states in Australia remember well the ASH Wednesday7 bushfire on the 16th February 1983 when 180 fires across South Australia and Victoria burned 520,000 hectares, 3,700 buildings (including 1,000 farms); 76 people died, and 34,000 sheep and 18,000 cattle perished. Overall, 1 million hectares were burned across South Australia and Victoria during the summer of 1982-1983.

Eco-Resilience and Bushfires

Gunderson (2010, online) believes that if we conceptualize “human communities and ecosystems as complex adaptive systems, systemic properties such as resilience or adaptive capacity can be compared”. Thus it is important to consider both these systems when speaking about the effects of bushfires. The longer that fires are excluded from these systems, the more fuel accumulates. The common example given is that to safeguard large bushfires, back burning should be undertaken to reduce the fuel loads in forest areas. In many farming areas, farmers backburn in winter months before the onset of spring when there is low precipitation and before the temperature begins to peak; however, sometimes backburns escape and in themselves are the causes of serious bushfires, particularly during droughts where access to water sources is extremely limited. Temperature rises have increased markedly in the past decade and it is forecast that with global warming effects in Australia, and in Queensland particularly, the spring and summer days will get hotter and there will be more hot days. During the periods of long droughts in Australia, wildfires were common and in summer months, residents who lived in fire prone areas, or indeed in any place where there were forests or grass lands, or even in the dry parts of cities and towns, had been warned to be alert to the possibilities of wildfires and trained in what to do in such emergencies. A great many bushfires have occurred across the most arid continent in the world during one of the driest spells for a century. Studies had been undertaken in Queensland to assess what residents knew about fire preparedness (Gow, Pritchard and Chant, 2008; Pritchard and Gow, 2008), but that was before Black Saturday and nothing like this inferno had occurred in living memory. It was not a time that Australians would forget, nor should they. Commencing on the 7th February in 2009, in regions north east of Melbourne and then across many parts of Victoria, fires torched just over a half million hectares; 173 people lost their lives and another 5000 were injured. In that one day alone, 400 separate fires were counted. The wildfires continued and spread and ‘spotted’ throughout several different locations in Victoria over a period of 5 weeks. Fanned by winds of more than 100 km/hr, with temperatures ranging from 110–120ºF, in drought conditions, firestorms sped across the land devouring everything in their paths. Over 2,030 houses and 1400 buildings were destroyed and thousands more were damaged; 7,562 people were displaced and 78 townships impacted.

7 The date coincided with the Christian services for the Ash Wednesday services in Lent (Religious observation).

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Again, climate change factors were indicated in relation to the long drought conditions and a 50 year warming trend. In those Victorian bushfires commencing on what became known as Black Saturday (2009), a shocked population watched as scenes of hungry red tongues of raging fire swept through forests in populated areas of Victoria, literally leaving nothing behind once they had leapt onto other places; the whole nation knew that nothing could have stopped that fire front in high temperatures and fast wind speeds. You had to be there after the fire and have someone with you to tell you where the houses were, because there was no evidence except for an occasional fire place or small pieces of tin from a rural water storage tank. The scene was one of eerie desolation; there was no rubbish to take away or memorabilia to search for, as occurs after floods or storms or cyclones - there was just nothing left. Shock, horror, and unease - this could happen anywhere in Australia if it happened here. The first author moved from counselling farmers in the drought to flood affected victims in Queensland to bushfire affected victims in Victoria (see Gow, 2009a, ABC online)

This was no ordinary occurrence, and when compared to their two previous worst bushfire disasters, after the shock wore off, questions were asked: how many of the fires were due to arsonists, was there too much emphasis on growing trees which were too close to homes; was there not enough back burning, should the policy of ‘to go or stay’8change?

Early in the media reports, while little mention was made about the drought conditions, or the dryness, or the nature of the fire and the atmospheric conditions which brought them about, everyone knew about the high temperatures which had left many people in hospital suffering from heat waves effects. The day the fires started (Saturday, February 7th 2009), the temperatures reached 48˚C in some places - a temperature that had never been recorded in that state before. The fuel load on the ground was massive. The role of the speed and force of the winds was factored in, but nothing before, even in hot and dry Australia, had prepared them for the firestorms and the meltdown.

People could not leave their homes after the fire storms and fire balls were jettisoned across the land. In the post analyses, fuel loads were flagged; high winds were tagged; and survivors told frightening stories that shocked the nation - there was no warning. If they had seen the fire, they had been 20 kilometres away, and even then they had little time to escape, but for most of the victims who survived the inferno, the first they knew of it was the roar or deafening crackling of the fire; decisions had to be instant; get in the car and go now, or find what might be a safe place. Many perished in their cars, on foot, or in their houses and fields. Only a couple of families had bunkers that could withstand the onslaught of hellfire.

Dryness, the new word put into use by Peter Kenny of the 2008 drought report, took on new meaning in this catastrophe; farmers lost their properties, houses, outbuildings, sheds, fences, animals crops and in some cases, their loved ones or their own lives. A few cows and alpacas, by some miracle, made their way to dams and were saved; domestic

8 The inferno of Black Saturday led to serious debates about the decision of residents ‘to go or stay’, especially when rescue groups and local and state authorities came under fire for not taking earlier or swifter action. It is obvious that the outcomes of that long and earnest debate led to immediate and decisive reactions in Queensland two years later in the floods and cyclone. With the exception of the drastic sudden flood caused by the Wall of Water from Toowoomba (January 2011) – where there was no real way of knowing what was to happen - residents were told to leave; there was no easy line to take when lives were at risk.

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cats and dogs disappeared or went missing along with other farm animals; while birds, koalas, kangaroos, possum gliders, lizards, echidnas and other creatures were incinerated; the few that made it to safe places were treated, but some were too damaged to be released and were euthanized. Trees exploded such was the heat; the sounds of the oxygen being sucked from the life in the areas was eerie and terrifying. People who had been badly burned were transported to hospital and others with injuries competed for beds with people from other parts of the state who had been admitted to hospital with heat stroke. (Kathryn Gow, 2009c, p. 167)

ON ALERT FOR BUSHFIRES, BUT UNPREPARED FOR A MEGA FLOOD IN QUEENSLAND

In the rural areas west of Brisbane, Australia’s third largest city, the residents were alert to what they had been told could be the worst bushfire season in decades. Indeed, following the disaster of the 2004/2005 summer fires which had taken place in the drought, the concern now was that, since the rains had come, there was a massive fuel load in a summer which was predicted to be one more blistering period of extreme heat waves. The first author, who lived on treed acreage, had packed her papers and essentials to make a quick escape if the situation became as grave as it had 4-5 years earlier. However, by the time December came, La Niña smiled (it later turned into a twisted snarl) on this drought stricken area and frequent deluges of climate change fame set in, with many flash floods occurring and leading to a saturation of the ground and waterways. At least it was much cooler than expected and people were lulled by the rain into acquiescence. By early January, there was some unease amongst those who knew the signs, but nothing could prepare even the forecasters or researchers for what was to happen. The deluges not only kept coming, but they grew in intensity and frequency; indeed for a period of time, the deluging rain simply did not stop. Just as had occurred in Victoria two years earlier in 2009 with the disastrous bushfires, in 2011, the Australian population nationwide watched in shock and disbelief when the television channels, on the 10th January, showed a wall of wide, deep rushing water wash away adults and children, houses, cars, tractors, farm machinery and sheds, shops and businesses, animals, roads, bridges, railway lines, and thousands of tons of topsoil and trees. In fact, anything in the path of what was instantly daubed the ‘inland tsunami’ from the Toowoomba mountain ranges was uprooted and swept away in Grantham and Murphy’s Creek and other areas9.

It wasn’t a flood it was a disaster. (Garry Campbell from Grantham10 )

I could tell by the feel of the water - it just felt wrong! Then a huge wall of water blacked out all daylight in the shop. (Marty Warburton11 )

9 Helidon, Withcott, Postman’s Ridge, and other areas were in the path of this wall of water and deluge flooding. 10 (in Agnew P & F Association, 2011, p. 193) 11 (in Agnew P & F Association, 2011, p. 193)

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A large wooden fence sign on Steve Gilmore’s Property declares that in 9 hours, 450mm of rain deluged Patrick’s Estate, Somerset Region: It says Storm Surge, 11/1/2011, 11pm. “The SES were landing choppers in the paddock beside me”. (Steve Gilmore12)

That wall of water joined other major stream and river flows to go on and flood much of the Lockyer and Somerset regions and then combined with the continuing vertical download of deluges, dam water releases, and flows from other areas, went on to flood the cities of Ipswich and Brisbane. In the meantime, other areas of Queensland went under water; it was recorded that 75% of the state of Queensland had been flooded during January. Indeed, other parts of the State continued to be flooded, as more rain kept pouring from the skies and some areas were flooded four, and up to nine times in the case of Dalby, a town west of Toowoomba. The rain that has been brought by the changes in the SOI13 continued on for months. In May, the authorities once again started warning people, living in highly vegetated areas, that we were in for a serious bushfire season.14 Overall, in the 2011 Queensland flood, over 3915 people lost their lives, many were injured, thousands of homes and properties were destroyed, hundreds of businesses were flooded and of those, 4-25% (depending on location) later closed their doors permanently. The State (and in turn Australia as a nation) suffered a collective loss of billions of dollars16 from destruction (and lost potential revenue) through destroyed buildings, infrastructure, roads and public utilities, farming and livestock, mining production, food supplies, and consequent economic impacts on the communities through loss of jobs, business and tourism downturn, etcetera.

Comparing National Responses to the Two Disasters

Because of the nature of the fierce fires in Victoria depicted on television and the manner in which people died, every Australian knew it could have been them. It was a shocking disaster and one that worried Australians in an increasingly hot arid continent. Offers of help and financial assistance poured into Victoria to help the fire victims. Inquiries and commissions were set up to determine what went wrong; how could the residents of Kinglake, Flowerdale, Marysville, Narbethong, and Strathewen, not have had any warnings of what was to come. People died in their cars trying to escape where there was no escape. Compared to the Victorian bushfires public reactions, the response this time from the wider Australian community for the Queensland flood victims was markedly different, although only two years later and with a greater range of damage, but fewer deaths. While the bushfire victims were not forgotten, the rural community knew that the people in the Lockyer

12 Sign serves as potent reminder of the floods. The Gatton, Lockyer and Brisbane Valley STAR, Wednesday, January 25, 2012, p. 18. 13 SOI = Southern Oscillation Index 14 At the end of the month of July, the first author’s rural treed 90 acre property was set alight (suspected arson) and over 30 acres burned out, but stopped short of the main residence by 1 meter. Only past and recent preparedness had saved the dwellings. 8 Fire trucks arrived for one of the first bushfires of the season that clearly threatened other homes. 15 This figure varies according to various records; see final flood commission report when finalized. 16 See IBIS World Special report January 2011- Queensland floods: The economic impact.

Complimentary Contributor Copy 268 Kathryn Gow and Heather Mohay and Somerset regions had been deserted; “abandoned is how they felt” (see Gow, 2011a). This was not generally the case in Brisbane and in parts of Ipswich17 where there was an instant and overwhelming emergence of volunteerism. The now famous ‘Mud Army’18 emerged in the capital city and truly showed the attitude of Australians to helping a ‘mate’ in trouble. This was not the case in many rural areas and made rural victims feel more isolated and alone. Whereas there had been many causes (combination of factors) of the fires in Victoria, the first author believes that only the massive deluge precipitation could be blamed for the flood events in the Lockyer and Somerset regions; although information released 12 months after the event indicated that warnings could have reduced or prevented the deaths in Grantham19 and implicated the role played by release of dam waters further downstream. Survivors of the bushfires and floods in both states still ask why no “critical warnings” were given.20 Insurance payments and access to grant monies is a key factor in assisting victims of natural disasters. While there were some problems in insurance payouts following the Victorian bushfires, the insurance debacle in Queensland on non-payment, with major delays in payouts and markedly reduced or zero payouts, added substantially to the residents’ stress and trauma impacts. Months, and even a year later, displaced people were still boarding elsewhere because their gutted houses, or in many cases their pulverised houses, were still uninhabitable; in South East Queensland, an estimated 25%-30% of the victims were in the post 55 age group and knew they could not recover financially.

RECURRENT FLOODS IN BANGLADESH AND NORTH QUEENSLAND

This case study is included here as both areas are subject to recurrent flood events, unlike other places which are hit intermittently across time. The regular occurrence and frequency of the natural disaster of flooding can both be a source of positive preparedness and also a constant wearing down of people’s resourcefulness and resilience, and an ongoing drain on economic resilience, eco-resilience and social resilience.

Floods in Bangladesh

Bangladesh is a relatively small country (less than one tenth the size of Queensland) which straddles the tropic of Cancer. It has a population over 150 million (more than 33 times the population of Queensland). Approximately 25% of the population live in cities, while the

17 However the first author and a colleague, who volunteered to rescue and provide food for domestic and farm animals in 3 flooded regions, discovered disaster - shocked residents in Ipswich suburbs who said that we were the first people to come (other than the energetic, fast working heavy vehicle clean up teams). 18 See “Brisbane statue honours 'mud army': World News Australia on SBS.” www.sbs.com.au/news /article/.../brisbane-statue-honours-mud-army 19 Warning signs to disaster. By freelance journalist Amanda Gearing. Queensland . www.crikey.com.au /topic/queensland-floods-inquiry 20 There is no doubt that the Canberra, Victorian, and Queensland Lockyer Valley deaths and destruction has led to a review of warnings and a no-nonsense approach to evacuations when residents are threatened by natural disasters. A total overhaul of disaster preparation and response has occurred across the State of Queensland in the following 18 months.

Complimentary Contributor Copy When Community Resilience Breaks Down after Natural Disasters 269 remainder live in rural villages or, in the case of the poorest of the poor, on the chars (river banks and small sand islands in the rivers) which are constantly changing due to erosion and which are subjected to annual floods. Bangladesh is bordered on three sides by hills, but 75% of its land mass is less than 10 metres above sea level. The country is traversed by three major river systems - the Ganges, Brahmaputra and Meghan - with their many tributaries which flow eventually into the funnel shaped Bay of Bengal via the massive Ganges delta. Its geographical location and topography make Bangladesh one of the world’s most disaster prone countries, with the major causes of natural disasters there being floods and cyclones. Each year, tropical storms and cyclones form in the Bay of Bengal and frequently cross the coast of Bangladesh either in the Chittagong area to the south east, or in the Ganges delta. Cyclones bring with them destructive winds, heavy rainfall and storm surges which swamp the low lying coastal regions, and destroy homes, infrastructure, crops, and livestock and sweep hundreds and sometimes many thousands of people to their death. For example, 500,000 lives were reported to have been lost as the result of Cyclone Bhola in 1970, while in 2007, 3,500 lives were lost in the wake of Cyclone Sidr. The reduction in mortality has been attributed to the fact that the cyclone struck a less densely populated area and also to the development of much better disaster warning systems, the implementation of local cyclone preparedness programs, and the establishment of evacuation centres (Anonymous, 2011). Nevertheless, the loss of life was enormous with the main victims being children and elderly people. Flooding also occurs most years. This takes three forms, all of which can be very destructive. The first is flooding due to storm surges associated with cyclones as mentioned above. The second is flash flooding, which is usually due to runoff from sudden torrential downpours which cause a rapid rise in water levels. These floods usually develop quickly and subside quickly. The third, and most common form, is riverine flooding. This occurs primarily during the monsoon season from June to September when there is a high level of rainfall which soaks the ground and runs off into the rivers which are swollen by waters from the upstream catchment areas in neighbouring India and Burma, where there is also monsoonal rain, combined with water from summer snow melt in the Himalayas. In normal years, the monsoonal rains and associated flooding are welcomed by farmers as they bring with them alluvial soil deposits to replenish their land, wash away the salt build up and irrigate the rice crops and pastures (an example of eco-resilience as described by Adger, 2000). In these times, approximately 35% of Bangladesh will be under water during the wet season. In the past, the government has placed emphasis on preventing flooding – especially major flood events – but it became apparent that this was unrealistic and probably unwise; hence emphasis has shifted to the establishment of early warning systems and local preparedness to deal with inundations (Leaf, 1997). Many people make preparations for the seasonal floods hence reducing loss of life or damage to property (Hanchett, 1997; Leaf, 1997). Hanchett (1997) provides an excellent description of one woman’s ingenuity in dealing with floods; she stored wood high in a tree to provide fuel, she placed bricks under her bed to raise it above the flood level, moved her ox and goat to high ground and built a raft out of the trunks of banana palms on which she could cook and store belongings. However, the poor who live on the chars are frequently displaced from their homes, lose their source of

Complimentary Contributor Copy 270 Kathryn Gow and Heather Mohay income, which is mainly agricultural labouring or subsistence farming, and are thrust into deeper poverty, malnutrition, and ill health. Every few years, when there are extreme weather conditions, major flooding occurs. For example in 1966, 1987, 1988, 1998, 2004, and 2007, catastrophic floods occurred affecting vast areas of the country. In these cases, the flood represented a natural disaster affecting the lives and livelihood of many thousands of people. Inhabitants of the chars and rural villages are the worst affected by these events, although occasionally urban areas are also inundated; for example, in the 1998 and 2004 floods, many houses in Dhaka were inundated (Butler, 2008). Floods of this magnitude cause significant loss of life, damage to homes, local amenities (such as schools, health centres, religious and community building) and roads, while livestock are washed away and crops ruined. Loss of life is primarily due to drowning, although the number of deaths has been reduced in recent years. Waters from the floods may remain for several weeks. People lose their source of income and are frequently left homeless or displaced and are forced to live in temporary accommodation. In addition, they may face the threat of starvation due to food shortages, and illness due to water or mosquito borne diseases (such as cholera and malaria) as a result of unsanitary conditions and lack of clean water. These natural disasters are therefore economically disastrous for individuals, communities and the national economy; they have adverse effects on people’s health and wellbeing and can have profound effects on community functioning. Following a severe flooding event, government aid and assistance from national and international aid agencies is usually provided to the affected area. This typically takes the form of the provision of clean drinking water, medical supplies and building materials. However, to a large extent, the rural communities are thrust upon their own resources to recover from the floods. With the impending flood, the char dwellers have to gather together their meagre possessions and abandon their homes, which are typically made of flimsy materials such as catkin grass, and which will be washed away by the flood waters. These communities are often fairly loosely formed and transitory, as families move from one location to another when the formation of the chars change, or because they go in search of work. Hence, at the time of a natural disaster, there is not a strong community recovery response and families have to depend upon their own resources. These people own very little, and they lose their home and their income because no work will be available. They therefore have little money, and have very little credit which would enable them to obtain loans to buy food and materials to rebuild their houses.21 Consequently, they are often forced to sell whatever assets they have (usually household goods) in order to survive. The community may disperse or they may be crowded into evacuation areas on higher ground, where they are not welcomed by the local population and where there is competition for resources, and hence violence and stealing is common. These vulnerable communities are therefore at high risk of community breakdown and, in general, it is the women who suffer the most (Hanchett, 1997; Thompson and Todd, 1998). In the villages, the situation is somewhat better. The population is more stable and many of the families have lived in the same village for several generations. Members of the villages tend to know each other well and to interact frequently. The houses tend to be more

21 After the major Bangladesh flood in 1998, the Grameen bank extended the time for flood victims to repay their loans.

Complimentary Contributor Copy When Community Resilience Breaks Down after Natural Disasters 271 substantial and made of corrugated iron and/or mud brick which may get damaged, but possibly not destroyed. The income of villagers varies widely, ranging from comparatively wealthy owners of large tracts of land through to those owning small plots in order to grow their own provisions, and the landless who work for other people or act as shopkeepers. The better off members of the community may have access to insurance and bank loans to enable them to rebuild after a natural disaster, but for most of the village people, this is not an option and they must rely on informal credit and insurance markets (Bensley, 1994; Coate and Ravallion, 1993). This community financial recovery system involves members of the village assisting one another at times of stress. However, access to this type of help depends largely upon a family’s social standing within the village, and the extent to which they are seen as reliable and trustworthy, as the help provided will be expected to be repaid in some form at a later date. For example, if Family A provides Family B with food or building materials or assists them with repairing damage, Family B will be expected to return these favours at some time in the future. This system can work quite well, but there are dangers; for example, if Family B receives a great deal of help they will have built up “in kind” debts which they may be unable to repay or which burden them for many years. Furthermore, assistance may be unequally distributed within the village as societal divisions may arise due to income, ethnicity, religion, language, political beliefs etcetera, which contribute to the development of social schisms and the erosion of social capital and community resilience. Chowdhury (2011) therefore suggests that households can recover from natural disaster losses better in those villages where social cohesion is high. However, he reports that social cohesion and hence the informal insurance network is likely to be ineffective when almost all households in the community are affected by the natural disaster.

Floods in North Queensland

The area of Queensland bordered to the north and east by the Pacific Ocean and to the West by the Northern Territory, and stretching roughly from the tropic of Capricorn in the south to Cape York and the Gulf of Carpentaria in the north is the area referred to as North Queensland for the purposes of this chapter. This vast area (approximately 900,000 square kilometres) has a population of less than 1.5 million, most of whom live in small to medium sized towns along the eastern coastal fringe. The remainder live in small towns and settlements which usually have a population of less than 10,000 (often much less), or in isolated homesteads (farms) scattered throughout the interior. The Great Dividing Range separates the coastal plains from the flat inland areas. Several rivers traverse north Queensland with the main ones being the Fitzroy, the Burnett and the Herbert each of which have a number of tributaries. Although these rivers are significant and have a major impact on flooding in the region, their size is nothing compared to the Ganges, Brahmaputra and Meghan in Bangladesh. Like Bangladesh, North Queensland’s geographical location makes it especially vulnerable to cyclones and floods. In the wet season, which extends from November to April, storms and cyclones gather in the Coral Sea and quite frequently cross the North Queensland coast bringing destructive winds, widespread heavy rain and storm surges. In February 2011, Cyclone Yasi, the strongest cyclone ever experienced in Queensland, crossed the coast at Mission Beach near Ingham leaving a trail of destruction, and dumping large volumes of rain

Complimentary Contributor Copy 272 Kathryn Gow and Heather Mohay in its path, as it travelled inland, exacerbating the already greater than usual seasonal flooding. The economy of the coastal areas of north Queensland is dependent primarily on agriculture and tourism, both of which are severely affected by the damage caused by cyclones. Hence people in these areas are subject to substantial financial losses resulting from damage to property and loss of income due to cyclone activity). The wet season is also characterised by heavy tropical rainfall which fills the local creeks and rivers often causing them to burst their banks and flood the surrounding low lying land. As in Bangladesh, the farmers in North Queensland welcome the wet season after months of dry weather. The rain fills the dams and drenches the soil ensuring good pastures and crop yields in the following season. People living in the north are familiar with the weather patterns and make provisions to cope with them. For example, houses are built to withstand cyclones if they are in cyclone prone areas, and on stilts or above the flood line, if they are in flood prone areas. Safe shelters for evacuation (should this be necessary) have been identified and early warning systems, which inform people how to prepare for coming weather, are in place. Hence in a normal wet season the greatest problem (apart from possible damage from cyclones) is that roads are impassable and communities may be isolated for a period of time, making it difficult to obtain provisions or to send goods to the market. Cottrell (2008) describes the measures which women living in the bush (i.e., the country areas) make to prepare for the wet season. These include purchasing and storing extra non- perishable food items, batteries, and medical supplies because these are likely to be in short supply and road access to the nearest town is likely to be cut. Purchasing extra fuel for the generator is normal, as there are likely to be frequent power outages. Even buying Christmas presents and Christmas fare well in advance is common, because Christmas falls in the middle of the wet season. Important documents are kept in a waterproof container to keep them safe in a flood or so that they can easily gathered up if there is a need to evacuate the properties. In addition, they must make provisions for their children to be looked after if they are unable to return home from boarding school because of floods. For most people, the seasonal floods may be an inconvenience, but they are not considered to be a major problem. The problems may be greater for some indigenous communities who set up camp in dry river beds during the winter months and have to move to higher ground when the rain sets in. These people often go to stay with relatives in less flood prone areas, as strong and extensive kinship bonds exist in aboriginal society and there is an expectation that kin will provide assistance in times of need. The income of the displaced people is usually low and it is typically reduced even further in the wet season because employment, particularly in casual work, is unlikely to be available (Cottrell, 1998). Every few years, severe flooding occurs due to particularly heavy tropical rainfall. As the area is so large, flooding is usually restricted to specific river systems. However, in some seasons, cyclones in conjunction with very high seasonal rainfall deluge vast areas, and cause extensive flooding. For example, in the summer of 2010/2011, unprecedented rainfalls, sometimes of up to six times the normal expected average, left almost 75% of Queensland affected by major flooding (Chanson, 2011). At the southern end of North Queensland, the town of Theodore with a population of 1000 had to be completely evacuated by helicopter as the Dawson River rose. Further along, the Nogoa River flooded 80% of the town of Emerald, whilst severe flooding occurred in Rockhampton causing the airport to be closed. In this area, not only were homes, businesses and agricultural land inundated, but coal mining, which is an important industry in the area, was adversely affected because mines were forced to close due

Complimentary Contributor Copy When Community Resilience Breaks Down after Natural Disasters 273 to flooding, or they were unable to export goods because road and rail lines were cut and the ports were closed (Anonymous, 2011). Further north, the towns of Ingham, Babinda, and Gordonvale were flooded when the Herbert River rose, largely due to continuing heavy rain following Cyclone Yasi, whilst in the gulf country, the town of Karumba was isolated for three months due to flooding of the Norman River. Throughout North Queensland, homes and businesses were inundated, large tracts of agricultural land were swamped, crops ruined and livestock lost. Important export industries such as coal and aluminium were disrupted and tourism ground to a halt. Electricity and water supplies were affected and stocks of food, petrol, repair materials and medical supplies ran very low. Hence the floods had grave economic implications for many people and the psychological impact of the events will leave scars which will take a long time to heal (Nancarrow, 2010). In the aftermath of this natural disaster, local and national Emergency Services were activated, however the scale of the disaster stretched their capacity to its limits. One of the biggest problems encountered was gaining access to affected areas which were cut off by flood waters. Another was providing appropriate accommodation for emergency personnel and volunteers in small towns where properties were already badly flooded and local people needed to be evacuated to whatever dry accommodation was available. Although many people volunteered to help with the clean up, the numbers were much smaller than had been the case in Brisbane due to the small local population size and the remoteness of many affected areas. There was a tendency to concentrate relief efforts in the larger towns, and people in the smaller, more isolated areas, frequently felt abandoned. As one resident of Karumba put it “people had gone from feeling isolated to feeling abandoned”. Thus, although there was some outside help to aid recovery, communities were left to a large extent to their own resources to repair damage. Many people were covered by insurance to help with recovery, but others were not insured or found that insurance companies were slow or unwilling to make payments. People throughout Australia, and further afield, contributed to disaster relief funds, but there was considerable controversy about how these were allocated and the delays in making payments. Splits also began to emerge between farmers and town people in some areas, with famers feeling that early warning systems and evacuation arrangements had been inadequate and that their losses and their need for flood recovery had been largely neglected. Thus feelings of isolation, abandonment and unequal distribution of relief and recovery resources appear to reduce the resilience of individuals and threaten the cohesiveness of communities.

Comparison of Floods in Bangladesh and North Queensland

Both Bangladesh and North Queensland are geographically situated in areas which make them particularly vulnerable to natural disasters due to cyclones and flooding. The number of people affected by these natural disasters is significantly greater in Bangladesh than in North Queensland due to the differences in population density. For the same reason, loss of life is much less in North Queensland where most deaths result from people attempting to drive through flood waters. In both countries, the poor are likely to be the most affected by floods,

Complimentary Contributor Copy 274 Kathryn Gow and Heather Mohay as they are less likely to be protected by insurance and more likely to be living on low lying land (although in Australia many people will pay a high premium for ocean or river views which leave them vulnerable to cyclones and floods). In Bangladesh, the economic impact of floods and cyclones is primarily on agriculture; whilst this is also true in North Queensland because the economy is more diverse, the impact of natural disasters is more widespread. In both countries, there are official agencies which provide assistance with recovery from natural disasters. Differences, however, seem to exist in the form of informal aid. In both places, people provide help for one another, but in Bangladesh this seems to come with an expectation of repayment which does not occur in Australia. In both countries, resilience appears to break down at the individual and sometimes at the community level, in the following circumstances:

1. The disaster is so severe that it affects a large proportion of the population so that there are insufficient resources available to help everyone. 2. There are repeated disasters in a short period of time. (For example, Theodore was flooded three times in 13 months and Karumba was isolated for up to three months in three consecutive years. Ingham was first hit by Cyclone Yasi and then by floods.) 3. There seems to be an unequal distribution of aid within a community. 4. When people feel abandoned and that no-one is aware of, or interested in, their plight. 5. When aid is slow coming; e.g., when insurance, or disaster relief funds are delayed or building materials for repairs or tradesmen are unavailable. 6. When communities have to be evacuated and are unable to return to their homes for a prolonged time. 7. When peoples’ income is severely threatened.

In North Queensland, where communities are typically situated many kilometres apart, isolation becomes a major problem during floods. Many roads (even major highways) are impassable due to flooding. Railways are also often flooded and airstrips in rural communities are often too waterlogged for planes to land, for example in Karumba. Normal commerce is therefore impossible; provisions cannot be brought in and goods for sale cannot be sent out. Communities may be cut off from the rest of the world for extended periods. In Bangladesh, this is less of a problem as communities are generally quite geographically close to one another so that the problem of isolation is less acute. Although Bangladesh and North Queensland are vastly different in terms of economic development, culture, and population density, it can be seen that many of the same factors affect the resilience of individuals and communities and threaten community cohesiveness in the wake of natural disasters. Thus while governments spend millions of dollars on preparedness campaigns in order to save lives, there is evidence that even with the best preparedness, people’s resilience can be greatly negatively affected.

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DISCUSSION

The findings relating to our hypotheses are summarized in the Conclusion. Here we focus on the natural reactions to a trauma such as a natural disaster. For instance, in these comparisons, we can discern that community resilience is affected by major disruptions to the community’s way of life and prosperity and the loss or damage to the possibility of a shared future. Because we have concentrated on the immediate and short term aftermath of the traumatic events, it could be that what we are observing may very well have little to do with resilience and more to do with immediate and early trauma response – a natural response in such a situation. So rather than viewing these reactions as a failure in resilience, we could argue that trauma effects are actually a confounding variable in the study of resilience on impacted populations in the early weeks and months after major natural disasters. The SCRA1 Task Force for Disaster, Community Readiness, and Recovery (2010) illuminates this very real possibility as set out below.

Detecting Failure in ‘Bounce Back’ of Natural Disaster Victims

Because we are focusing on issues relating to loss of resilience or breakdown in resilience following natural disasters, here we will record only the section from the SCRA1 Taskforce (2010) that concentrates on the more difficult path, rather than the swifter recovery path that people may face after a natural disaster. The SCRA (p. 13) summarizes the reactions of people who have not recovered their resilience or resourcefulness after a natural disaster, and this may be for several reasons, none of which are a failure of the persons themselves.

1. People fail to feel better after several weeks. They continue to be consumed by negative emotions such as anxiety, depression, and fear. They continue to feel they cannot think clearly and problem solve. They continue to feel “in a fog.” The pieces of life just don’t seem to be coming together and this is accompanied by intense sadness or anxiety and may be marked by more chronic forms of fear. Difficulties with sleep, work, social life, and family relations may become increasingly problematic.

2. The experience of sadness, anxiety, and fear just won’t subside enough to allow for clear thinking and planning. The ability to sleep and eat continues to be deeply disturbed, and the chronic nature of these habits takes a negative toll on physical health or one’s sense of well-being.

3. Some slippage or backsliding can occur in every case, but the backsliding can seem more precipitous, and there is more what feels like “push back” than forward movement. Individuals at this stage feel particularly withdrawn and disconnected with others. In many cases, life may not seem worth living.

4. After 3 to 6 months, when there is a failure to return to life’s routines and little feeling of satisfaction over any area of life, and people are either withdrawn or overly

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dependent on loved ones, there is a strong indication of being on a comparatively less than positive path. The sense of still being overwhelmed is as if the tragic events are still fresh.

When there is a large percentage of the affected population who are exhibiting those reactions, especially more than a year later (excluding the anniversary reminder distress), careful community involved interventions need to be implemented, or revised if already in place and not achieving the required recovery outcome. Helpers need to understand that recovery time will vary and that many people will feel the effects of the disaster for a long time, but can still function adequately.

CONCLUSION

The case examples add to the evidence of the contribution of the five key components, listed in the Introduction to the chapter, to the breakdown in individual and community resilience: temporary and permanent displacement of persons (all case examples referred to this factor, although the impact varied according to the total number of people involved); total area and materials destroyed (this impact varied according to the population density and media coverage), and infrastructure destruction (this component did not relate to ongoing resilience issues, but rather the level of early distress); density of loss of life and injuries (this component needed to be publicised to affect the wider community, but had an immediate impact on the individuals involved and their surrounding community), and failure to recoup damage outlays through insurance, funding, or other means (a component often overlooked but causing ongoing stress and adding to the trauma). A component not listed in the Introduction relates to the publicized “real” assistance rendered to the individuals and their community following the disaster, whether that be via disaster response teams, government funded interventions, or whole-of-population physical or financial assistance. Other lessons gleaned from the case studies are listed in the seven summary points at the end of the last case study (Bangladesh and North Queensland cases); also as indicated in the case study on flood and bushfires in Australia, being prevented from returning to their properties to check on their homes, animals and farms raises high anxiety and frustration in healthy functioning people. As pointed out by Chowdhury (2011), no matter how high social cohesion is, even informal insurance networks are likely to be ineffective in countries which strive to be prepared for these events, if nearly all households in the community are affected by the same natural disaster. Additionally, the feedback from residents in rural and regional areas reveal that they felt not only isolated but abandoned; they further explain that inequity in the receipt of grants, financial assistance and insurance payouts not only causes cleavage planes22 in the cohesiveness of their communities, but that because it violates the shared value of fairness, it also wears down their remaining resilience. Moreover, the likelihood of recovery in the short term is blighted when individuals and communities are once again hit by another disaster of the same type or a disaster of a different

22 Rob Gordon is a consulting psychologist who advises on natural disaster interventions Australia wide and coined the term ‘cleavage planes’ in respect of community fragmentation after disasters.

Complimentary Contributor Copy When Community Resilience Breaks Down after Natural Disasters 277 kind, within a 12 month period. Staying displaced, and/or losing one’s job or income from a business, erodes the physical, psychological and spiritual resolve: “we will get through this”, so often heard immediately after a natural disaster has struck a community. It is at this point, that post-interventions need to spread the word about previous victims of natural disasters pulling through, as depicted in the Salvation Army’s new DVD “Still Standing after a Natural Disaster”.23

REFERENCES

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23 www.stillstanding.org.au

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Pritchard, F. (2009). Can understanding backwater effects help us to prepare for and manage deluges? In K. Gow (Ed.), Meltdown: Climate Change, Natural Disasters and Other Catastrophes - Fears and Concerns of the Future (pp. 191-208). New York: Nova Science Publishers. Pritchard, F. and Gow, K. (2008). Bushfires: Preparation, Resilience and Recovery. In K. Gow and D. Paton (Eds.), The Phoenix of Natural Disasters: Community Resilience (pp. 209-233). New York: Nova Science Publications. Reynolds, H. (1999). Why Weren’t We Told? New York: Viking Press. Sameroff, A. and Bartko, W. (1998). Political and scientific models of development. In D. Pushkar, W. Bukowski, A. Schwartzman, D. Stack and D. White (Eds.), Improving Competence Across The Lifespan: Building Interventions Based On Theory And Research (pp. 177-192). New York: Plenum Press. Sanday, P. (1981). Female Power And Male Dominance: On The Origins Of Sexual Inequality. Cambridge: Cambridge University Press. Sanday, P. and Goodenough, R. (1990). Beyond The Second Sex: New Directions In The Anthropology Of Gender. Philadelphia: University of Pennsylvania Press. Schmuckler, E. (2004). Mental health considerations following a disaster. In D. Paton, J.M. Violanti, C. Dunning and L. Smith (Eds.), Managing Traumatic Stress Risk: A Proactive Approach (pp. 9-25). Springfield, Illinois: Charles C Thomas. Thompson, P. and Todd, I. (1998). Mitigating flood loss in active flood plains of Bangladesh.Disaster Prevention and Management, 7(2), 113. Tredinnick, M. (2011). Australia’s Wild Weather. Canberra: National Library of Australia. Walker, B. H., Abel, N., Anderies, J.M. and Ryan, P. (2009). Resilience, adaptability, and transformability in the Goulburn-Broken Catchment, Australia. Ecology and Society,14(1), 12. [online] URL: http://www.ecologyandsociety.org/vol14/iss1/art12/

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 16

FACILITATING SUCCESSFUL COMMUNITY-LED RECOVERY AFTER DISASTERS

Suzanne Vallance* Lincoln University, Canterbury, New Zealand

ABSTRACT

On September the 4th 2010, and February 22nd 2011, the Canterbury region of New Zealand was shaken by massive earthquakes. This chapter, set broadly within the civil defence and emergency management literature, addresses issues around community participation, social capital, and resilience that arose as a result of these events. Whilst there is a very strong consensus in the literature about the need to involve communities/civil society in recovery processes, there is a paucity of research dedicated to understanding the myriad factors that facilitate or hinder this. This chapter contributes to a better appreciation of these factors by firstly interrogating the assumption that recovery agencies and officials are both willing and able to engage communities who are themselves willing and able to be engaged in accordance with recovery best practice. Secondly, this chapter outlines research with three community groups in order to illustrate some of the difficulties associated with becoming a community during the disaster recovery phase. Based on this research which provided three case studies, the third objective of this chapter is to provide some insights into practical strategies that emerging communities (and recovery authorities) may use to strengthen people’s ability to ‘participate’ in the recovery process.

Keywords: Disaster Recovery; Community Engagement; Civil Defence; Earthquakes; New Zealand

* Contact: [email protected]

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INTRODUCTION

On September 4th 2010, at 4.36 am, the Canterbury (New Zealand) region was rocked by a large 7.1 magnitude earthquake. Although there were no casualties, certain suburbs of the city of Christchurch, and parts of Kaiapoi in the neighbouring Waimakariri District, suffered extensive land damage. This left some residents homeless and many more living in sub- standard housing. Then, almost 6 months later, a ‘smaller’ - although more devastating - earthquake occurred almost directly under the city.1 This time, 181 people were killed (most of them in the collapse of two large inner city buildings) and many more were injured. Those Christchurch residents whose homes had already been affected in the first earthquake generally suffered additional damage and some hillside suburbs also became unstable.2 It is not yet known3 how many homes will be lost altogether, but it is likely to be between 10,000 – 12,000 households. Other aspects of daily life, besides housing, have also been significantly affected: schools, churches, community halls, recreation centres, shopping malls, corner shops, restaurants, fast food outlets – many of the everyday sites and activities we take for granted – have closed or relocated. The Central Business District (CBD) suffered extensive damage and was completely cordoned off for over a month. As at the close of the year 2011, parts of this inner city are still off-limits as authorities grapple with the deconstruction of two teetering high-rise buildings and their ‘drop zone’. This has had very serious implications for businesses and residents - and even their pets - in the area.4 This widespread displacement, relocation and closure had consequences for the so-called ‘unaffected’ parts of the city: some schools were accommodating two different institutions and doing ‘double shifts’ 8 months later; ‘inner-city’ issues such as weekend drunken revelry shifted to suburban centres; and traffic delays became common. For Christchurch and Kaiapoi residents, the prospect of life ‘returning to normal’ in the near future is fairly low. In the face of these earthquakes, it has often been said that residents here have shown remarkable resilience. This concept has been employed widely in engineering, business administration and organisation behaviour models, civil defence and emergency management, social work, and socio-ecological/human-environment systems (SES/HES). ‘Resilience’ has three related definitions that reflect these various disciplinary ties. The first supposes an ideal ‘steady-state’ or equilibrium to which a system bounces back following a disturbance. The second relates to the extent to which a system is able to self-organise or cope with a disturbance without becoming dysfunctional. The third recognises that a system may have multiple ideal states and that being able to bounce back to normal might be less important –

1 The peak ground acceleration of the second quake was 2.2 times that of gravity and was one of the highest recordings taken anywhere. According to Professor Yeats, Professor Emeritus of Geology at Oregon State University in Corvallis, USA, this would have ‘flattened’ most world cities (http://www.stuff.co.nz /national/christchurch-earthquake/4711189/Tuesday-quake-no-aftershock). 2 As of January 2012, almost one year after the February quake, the Canterbury region had suffered 4 major events of 6+ magnitude or more on the Richter scale, causing significant liquefaction and lateral spread; over 3000 of 3+, many of which make the author’s picture frames move and filing cabinet rattle; and nearly 7000 of lesser magnitude. The cost of repairs is estimated to be 8 per cent of the country’s GDP. 3 At the time of the sending the book manuscript to the publishers for final formatting in March 2012. 4 The label of the ‘Red Zone’ was originally applied to parts of the CBD that had been cordoned off. The term is now applied to several suburban areas where the land damage is so extensive, and land remediation so expensive, that rebuilding is not possible in the short-term. In July 2011, residents in these Red Zones were offered a property buy-out package from the central government.

Complimentary Contributor Copy Facilitating Successful Community-led Recovery after Disasters 283 or even less desirable - than the ability to adapt and thrive in new conditions (i.e., its ‘adaptive capacity’). The adaptive capacity of a socio-ecological system refers to its ability to cope with change by observing, learning and then modifying the way it interacts with the world, over different geographic scales (Folke et al., 2002). Manyena, O'Brien, O’Keefe, and Rose (2011) have described this as a system’s ability to ‘bounce forward’. Because this last definition works with imagined futures rather than a return to the past, bouncing forward situates resilience as an expression of the way people expect and imagine the world will – and should – be. Lorenz (2010) has argued that a ‘disaster’ can essentially be seen as a gross ‘failure of expectation’. He has pointed out that the burst of stock market bubbles and the annihilation of bank money can be a disaster for a future-orientated, capitalistic society, but will have little impact on a present-orientated tribal community that lives on farm subsistence. Thus, the ability to bounce forward depends as much on our collective capacity for expectative abstract thought, as it does on our technical ability and/or financial resources. It also depends on what Lorenz has called participative capacity which speaks to the flow and distribution of power and resources in a society. It is this participative capacity that allows people’s expectations and their ideas, about what ‘improvement’ might mean, to flavour the recovery process. There are other good reasons to encourage, facilitate, and support community/civic participation in recovery processes. Kweit and Kweit (2004) compared recovery processes in Grand Forks and East Grand Forks (North Dakota, USA) following severe floods in 1997. After the disaster, East Grand Forks engaged in extensive citizen participation initiatives and subsequently reported high levels of political stability and citizen satisfaction. In contrast, Grand Forks instigated a more top-down, bureaucratic approach and has since experienced changes to their government structure, a high turnover of elected and appointed officials, and more negative citizens’ evaluations. Etye (2004) argues that ‘getting involved’ after a disaster can be cathartic and that taking positive action can make victims feel empowered and facilitate recovery. Other studies report on stalled recoveries that were only resurrected with greater citizen engagement and more deliberative democratic models (Coghlan, 2004; Coles and Buckle, 2004; Hauser, Sherry and Swartz, 2008; Murphy, 2007; Waugh and Streib, 2006; Wilson, 2009). The benefits of effective community engagement that have been documented include: the identification of workable solutions to the range of problems recovery presents; better delegation of duties; securing community ‘buy-in’ to the process; and building trust. As Norman (2004, p. 40) has succinctly argued: ‘While consensus may not be possible, recovery cannot succeed if the aims, priorities and processes do not have community support’. This sentiment is reflected in the New Zealand Ministry of Civil Defence’s Community Engagement Best Practice Guide (2010). Despite this general literary consensus about the benefits of engagement, and – if one is generous – the best efforts of recovery authorities to follow this advice, effective post-disaster community engagement appears hard to achieve. Disaster scholarship tends to assume that recovery authorities are both willing and able to engage communities who are themselves willing and able to be engaged. In contrast, my research here in Christchurch, detailed further below, suggests a certain reluctance on part of official bodies (including both the Canterbury Earthquake Recovery Commission and the Christchurch City Council) to even communicate with the public on some matters, although they have been inclusive on other issues. Numerous Letters to the Editor in the Press and on-line discussions document a litany of

Complimentary Contributor Copy 284 Suzanne Vallance complaints about poor information flows and a general paucity of communication; the recovery was even described as a 'bureaucratic, spin-doctored disaster’ (McCrone, 2011). In their discussion of recovery lessons learned in Kobe (Japan) and Northridge (California, USA), Olshansky, Johnson and Topping (2006, pp. 368-369) have noted that citizen engagement is a key component of a successful recovery but ‘to work most effectively after disasters, community organizations should already be in place and have working relationships with the city [officials]. It is difficult to invent participatory processes in the intensity of a post-disaster situation’. This raises interesting questions about the actions that community groups and recovery authorities can take to build participatory capacity ‘on the fly’ and to seize those opportunities that disaster recovery provides. This chapter offers a response to these questions. These findings are based on observations of numerous public meetings, and in-depth (usually on-site) interviews with individual residents and members of various community groups, particularly CanCERN, Greening the Rubble and the Gap Filler. These data were augmented with semi-structured interviews with officials and representatives from the Christchurch City Council (elected and non-elected), the Earthquake Commission the Canterbury Earthquake Recovery Authority, and so on.5

Becoming a Community

Disasters affect – or, rather, create – communities in different ways, thus, one of the first insights from the Christchurch earthquakes is that ‘the public’ is not a monolithic entity to be easily ‘engaged with’6. The most obvious and immediate examples of an affected community may be geography-based. In Canterbury, those who lost their homes and/or businesses to liquefaction and lateral spread clearly became communities of sorts, as did residents without electricity, those sharing busted sewerage lines, and households in the ‘red zone’. ‘Affected communities’ can also be geographically dispersed but united, for example, by the death of friends or relatives, by displacement or disadvantage; these can be described as ‘communities without propinquity’ (see Chamberlain, Vallance, Perkins and Dupuis, 2010 for a discussion of ‘community’ and Solnit, 2009 for ‘extraordinary disaster communities’). In Christchurch, many different communities have formed from the earthquakes; some of these are interest- or project-based, whilst others are bound by geography. Each has had to negotiate problems around, first, becoming a community (through engaging each other and having/developing a common purpose) and then achieving their various goals and ambitions (through engaging others). These relationships, both within and between, communities are often referred to as ‘social capital’ or networks of weak and strong, or vertical and horizontal, ties (Boettke et al., 2007; Pelling and High, 2005; Norris et al., 2008; Putnam, 1995; Vallance, 2011).

5 These organisations represent the ‘official’ network of formal recovery authorities. The Christchurch City Council (CCC, www.ccc.govt.nz) represents local government; the Earthquake Commission (EQC, www.eqc.govt.nz) is a Crown entity that provides cover for damage arising from natural disasters to those with fire insurance obtained through private insurance providers; the Canterbury Earthquake Recovery Authority (CERA, www.cera.govt.nz) was established by the central Government to lead earthquake recovery work following the events of September 2010 and February 2011. 6 I would like to acknowledge the distinction that Daryl Taylor made at the Fire and Rain conference (Aug 1st and 2nd, 2011) between ‘engaging communities’ and ‘engaging with communities’.

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The Making of CanCERN The Canterbury Community Earthquake Recovery Network (CanCERN, www.cancern.org.nz) is a grassroots organisation that advocates for residents’ rights and involvement in recovery. The network formed as a direct result of the earthquakes, and initially because of the sustained effort of two residents to address infrastructural and community issues in their immediate neighbourhood. They believed that a collective, neighbourhood-wide response was needed on a range of issues, such as some landlords’ poor treatment of local tenants, traffic safety, temporary sewage solutions, and so on. In late October, 2010, Tom McBrearty convened a small group of about 10 residents who met on the lawn of Avery House in Riverside, to eat fish and chips for tea, and listen to Evan Smith outline his street network model. In this model, street co-ordinators went house to house, noting if the house was occupied and, if so, what needs and/or skills the occupant had. The street co-ordinators then fed this information through to the ‘community’ or ‘residents’ association’ co-ordinators who took their issues and concerns to the Earthquake Commission (EQC), insurance companies, the City Council and so on. They used the same pathways to transmit information back to individual households. In those first weeks with no electricity (and therefore no internet or even telephone if one only has a portable or mobile phone that needs recharging), face-to-face communication channels were essential. It soon became clear that while some issues were fairly localised, others were more general and included a range of problems around insurance claims, evaluations from engineers and EQC, and processes common to thousands of residents across the whole Canterbury region. In light of these ‘global’ issues, the neighbourhood network model up- scaled by introducing another tier that brought the communities/residents’ association groups across the city together to become CanCERN. This ‘global’ coming together was initially facilitated by local Member of Parliament Brendan Burns, and later by the Dean of the Christchurch Cathedral, the Very Reverend Peter Beck. Different members of the CanCERN group helped in different ways, with leaflet printing and leaflet drops, providing meeting spaces and offices, and creating a website, etcetera. Though CanCERN’s place at the recovery table now seems assured, it has not always felt this way. At times, the network’s future has been threatened by a lack of progress on important issues, problems gaining access to and credibility with decision-makers, funding their activities, finding time to do anything, communicating with residents who have relocated, understanding legal processes, and so on. All this has to be balanced with substantial difficulties in homes that are barely liveable or even uninhabitable. The personal toll for some helpers and all those affected has, in some cases, been immense.

The Formation of Greening the Rubble and Gap Filler On the 1st of October, 2010, almost four weeks after the first earthquake, I received this email from Wayne McCullum, then Biodiversity Officer at the Canterbury Regional Council:

Subject: Greening the Rubble - Concept and Action

Ten days ago The Press published a letter in which the Regional Biodiversity Coordinator set out the opportunity for communities to collaborate to temporarily re-vegetate spaces left derelict by the Canterbury earthquake with native plants and shrubs, while their future uses are determined? Such a project would allow, he suggested, Christchurch

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communities to weave a response to the earthquake that merged rejuvenation and repair with the themes of the International Year of Biodiversity.7

The feedback to this letter has seen an overwhelmingly positive response from a range of people and bodies. There is interest, inspiration and initiative to move this into a firm proposal, including the opportunity to undertake a pilot project at an inner city site.

I would like to bring interested parties together to discuss this particular opportunity and others that may exist and how to develop something that is inclusive of the communities and the events that they have experienced. Please let me know if you are able to make the meeting by phone or e-mail.

An important part of the proposal, easily missed, was the emphasis on temporary installations. This idea of celebrating, rather than lamenting, the uncertainty of recovery later brought Greening the Rubble and Gap Filler together. Whilst Greening the Rubble seeks to ‘develop green spots, biodiversity hubs, pocket parks and community gardens on the sites of removed buildings, in collaboration with interested communities and the approval of site owners’ (www.greeningtherubble.org.nz) Gap Filler, led by Coralie Winn, with support from Ryan Reynolds and Andrew Just, has a slightly different focus. They write (www.gapfiller.org.nz):

Gap Filler will see vacant sites - awaiting redevelopment as a result of the September 4 earthquake or otherwise - utilised for temporary, creative, people-centred purposes. Examples include: garden cafés, outdoor cinema, live music, dance on a temporary dance floor and other creative responses to sites by local artists. Gap Filler is temporary in nature, seeking to activate gap sites for around two weeks at a time, to demonstrate that the city can grow in important ways without large capital expenditure or major construction. Gap Filler projects can move from site to site as spaces become available around the city. All projects will be able to occupy or vacate a site within a day.

Like CanCERN, the Greening the Rubble/Gap Filler alliance has gained traction, credibility and support from residents and local authorities, and they now seem embedded in the recovery process. Both groups have been mentioned in the Draft Central City Plan (2011, p. 117) and are seen as contributing to the short-term recovery of some Christchurch suburban centres. Based on these examples of emerging communities, we can offer a number of ideas for both civilians and authorities facing the early stages of disaster recovery.

Leadership

As a result of the earthquake, the landscape of ‘community leadership’ has changed as much as the city’s hard infrastructure. Some of the most obvious pre-earthquake community leaders have simply been unable to cope, have lacked the skills or motivation to act, or have left the area. Some pre-existing community groups, such as Residents’ Associations, seemed locked into well-worn, and sometimes adversarial, patterns of communicating and behaving that were simply inappropriate for the situation. New communities of ‘affected’ people have

7 2010 was the International Year of Biodiversity.

Complimentary Contributor Copy Facilitating Successful Community-led Recovery after Disasters 287 formed that do not necessarily align with any previous social network or organisation and, as a corollary, had no leader. Thus, for a number of reasons, it is not always helpful to rely on what was in the aftermath of a disaster, but to develop new roles and responsibilities more suited to the occasion. Formal interviews (and many informal cups of tea) with the leaders of CanCERN, Makeshift and other post-quake citizens’ initiatives often reveal a certain level of bemusement, on their part, at their new role. They seem mildly surprised to find themselves playing such an important part in the recovery process, and ‘never imagined’ that they would become community leaders. This may explain, in part, their leadership style which is strongly democratic, conciliatory, and based on negotiation and network formation. Rather than ‘leading’ which they are not formally used to doing, they seem to prefer to generate a consensus by bringing people together for a common purpose. CanCERN and the two Makeshift groups both have a core leadership of 3 to 5 people who meet regularly. Few of them knew each other well before the earthquake, but in the last year they have come together as a team which then co-ordinates the extended membership and formally consolidates the informal arrangements sometimes initiated by the wider group. They rarely act alone, thus they have become quite competent at collective decision-making; however, as a small, unified team they are still capable of moving quickly should the need arise. Based on these models, some insights for ‘communities’ include firstly becoming aware that disasters may generate a need for new leaders; one of them might even be you. Secondly, recovery means ‘residents’, ‘clients’ and ‘consumers’ may have to become more active ‘citizens’ and actually get involved. This seems to underpin a third point which is that disasters change the community landscape, bringing into being new communities. Whilst the commonality or cause of the community may be obvious, such as being in an ‘affected suburb’, it may take some time to find each other and come together. Citizens may actually have to work as hard at this as recovery authorities. Although it may be difficult, the benefits are substantial; for example, the hard work of the CanCERN membership gave recovery authorities a community to engage, and to engage with. As a CERA official told members of CanCERN: ‘I’m glad you are here. If you didn’t exist, we would have to invent you’.

Networking

An important aspect of forming a community is networking and this occurs in a number of ways. CanCERN, for example, emphasised face-to-face communication early on for several very good reasons. First and foremost, the electricity outage simply left few other options; hand held phones do not work without electricity, and cell phones and laptops only have limited battery life. Second, contradictory, complex, traumatic and dense information is best delivered and negotiated face-to-face. Finally, the situation often demanded quite high levels of trust. Homes were often unable to be adequately secured, neighbours needed each other for food, warmth, shelter and support, and the usually private details of sewers became unwelcome public property. Although these circumstances probably prompted the initial format of a ‘street network model’8 and the emphasis on face-to-face communication, when

8 This model looks very much like a ‘phone tree’ and works in a similar way.

Complimentary Contributor Copy 288 Suzanne Vallance the electricity returned it was later augmented with other forms of communication. In fact, as people started to re-locate, email, facebook and texts become more viable ways of keeping the community together. Other groups also used virtual space to good effect; some groups, like Greening the Rubble, came together on-line before meeting in person. Others, like the Student Volunteer Army (www.facebook.com/StudentVolunteerArmy), blended or modified, existing communities in response to the earthquake using Facebook and other social media to very rapidly mobilise students to help with the cleanup. Each of these groups gained traction and increased their effectiveness by building relationships with others people to form the group (e.g., horizontal ties or ‘bonding capital’), and with other groups, organisations and institutions (vertical ties or ‘bridging’ and ‘bracing capital’). Liaising with pre-existing civil society groups and non-governmental organisations has helped Makeshift and CanCERN secure and administer funding. The Canterbury Arts and Heritage Trust acted as a repository for funding for Gap Filler, Living Streets Aotearoa for Greening the Rubble, and Delta Community House for CanCERN. This is important because although authorities (and donors from the private sector) may be willing to provide funds to community recovery groups, they are unlikely to deposit substantial amounts into private bank accounts. Establishing a working relationship with pre-existing organisations provides breathing space whilst questions over legalities are settled (such as whether or not to become an Incorporated Society); helps with accountability; and assists with up-skilling and operations. These relationships may also serve to legitimise the group’s activities. As Klein (2007) argued in Shock Doctrine, some groups and individuals are uniquely positioned to use the period of post-disaster uncertainty and chaos to advance their interests. This may explain why, as others have noted, existing trends and patterns of inequality and privilege tend to be amplified in the ‘recovery’ phase (Anderson and Woodrow; 1998; Coles and Buckle, 2004; Mitchell 2004; Olshansky et al., 2006; Solnit, 2009). Developing a good working relationship with an ‘insider’ can help combat this tendency. A ‘patron’ can help marginalised, excluded and/or emerging communities gain access to important decision- makers and decision-making processes, promote the cause, raise the community’s profile and act as an advisor. It helps if the patron has a high public profile, good relationships with the media and other networks, and is not controversial or overtly political. The Dean of the Christchurch Cathedral, the Very Reverend Peter Beck (referred to earlier), also acts as CanCERN’s patron, and has been very supportive of their goals.

ACTION STRATEGIES

In the aftermath of a disaster, there is an incredible amount of work to be done and ‘recovery’ as an endpoint may seem impossible. Set out below are some strategies to assist in this endeavour.

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Identify Victories and Share the Good News

‘Recovery’ as a verb is much more achievable as it suggests a series of on-going, interconnected activities and accomplishments. In the face of a city rebuild, some of these activities – one small pocket park or one film projected on the side of a building - may seem trivial or insignificant; yet, the fact that a group of people managed to come together to make it happen is incredibly reassuring. It is also very inspiring. A quick perusal of Gap Filler, GtR and CanCERN’s websites show a wealth of positive feedback and enthusiasm. Celebrating even small victories, and then sharing this good news through websites, community newspapers and other media, brings the prospect of recovery (the noun) that much closer.

Have a Floating Pool of Projects

At each of the three case study group meetings, there is often some tension between addressing immediate needs and thinking strategically about long-term issues and opportunities. Consequently, each of the groups established a strategy group to work alongside those who prefer to address ‘hands on’ projects and problems. Each group therefore has a floating pool of projects (sometimes the list of ‘things to do’ looks too long) that allows them to be opportunistic and able to act quickly if, for example, a vacant site becomes available for a Gap, or a chance meeting allows a crucial question to be answered.

Balance Critique with Solutions (Expose-Oppose-Propose)

Many of the groups observed during the course of this research emphasised a ‘solutions- based’ approach to their activities. A recurrent theme from the interviews and observations was the need to avoid being seen as ‘a bunch of whingers’ and instead offer positive strategies that were seen, at least by the residents, as desirable and achievable. This strategy appears to align well with some observations discussed in the ‘insurgent’ and ‘radical’ planning literature emerging from post-colonial and developing countries (Beard, 2003; Miraftab, 2009). In such cases, NGOs have moved from ‘expose-oppose’ strategies to collaborative ‘expose-oppose-propose’ models (Etemadi, 2004). In extending this line of thinking, it is possible that some of the post-earthquake community groups may take ‘collaboration’ a step further and actually become service providers that ‘co-produce’ recovery, often through service delivery. This is one of those ‘big ideas’ in planning literature that, on the ground, is probably comprised of far more prosaic activities; funding and joining street parties, attending community meetings, disseminating information, delivering first aid packages and meals to the elderly, and so on. Yet, these small collaborative activities establish the effectiveness and trustworthiness of the participants (from both community and the state) and this paves the way for larger ventures such as rebuilding the CBD and agreeing on a good use for the suburban Red Zones.

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Form a Radical Arm to do the ‘Dirty Work’ (Expose-Oppose)

At one stage in 2011, community frustration surrounding an information vacuum and lack of progress on decisions around land remediation led to a period of hostility towards the recovery authorities. A consequence of this frustration was the resurrection or formation of more radical groups9 who focussed on an ‘expose-oppose’ strategy. Action for Christchurch East had an outspoken media liaison person who helped bring the severe difficulties of the Eastern suburbs to national news crews. Unite Union’s Tour of Shame involved picketing outside Subway, Garden City Bowl, First Security and Reading Cinemas after the first earthquake to bring attention to these companies’ poor treatment of staff (such as denying payment whilst workplaces were closed and forcing staff to use annual leave to cover those lost days). Another group organised rallies in local parks to protest against lack of progress and information after February 22nd. These shadow networks10 have been instrumental in acting as watchdogs and have subtly shaped the recovery process.

DISCUSSION

This chapter is based on a series of related ideas outlined in the civil defence and emergency management literature. The first concerns the notion of community engagement and the second revolves around that of resilience. I have highlighted scholarship that uses three different interpretations of this concept and noted that the most recent of these - the ability to ‘bounce forward’- is still subject to academic debate. It has been suggested that this particular version of resilience should be seen as much as an exercise in expectation, imagination and collective endeavour, as it is technical and financial. This recognition of people’s aspirations in successful recoveries has led to an orthodoxy stressing good community engagement and participation.11 Success is, after all, a very subjective thing that defies easy measurement and it is perhaps most easily achieved if the judges of success are also the participants. A problem highlighted by the case of these three post-quake community groups in Christchurch, New Zealand, is that underlying this orthodoxy are two assumptions. The first is that formal recovery authorities will be both willing and able to engage effectively with communities.12 The second is that communities are willing and able to be engaged. The results outlined here highlight that this is not always the case. Lorenz’s (2010) notion of participative capacity is interesting because it suggests that ‘bounce forward resilience’ demands more than formal engagement. It suggests recovery is not just the state's job; there is a vital role, or set of responsibilities, for civil society and community groups as well. The problem, however, is that in the post-disaster situation new communities often have to be created. This may occur through being geographically

9 These networks are not associated with Gap Filler, Greening the Rubble or CanCERN. 10 Often, members of these so-called ‘radical’ branches were loosely aligned prior to the earthquakes. 11 An overview of these is provided in the IAP2 Spectrum of Participation, www.IAP2.org 12 The post-quake development and deployment of the Canterbury Earthquake Recovery Authority, the overnight expansion of the Earthquake Commission from 22 to over 800 employees, and the Christchurch City Council’s consultation processes will no doubt be scrutinised in due course; such inquiries often occurs following large natural disasters in many parts of the world.

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‘affected’ as the CanCERN membership was, or they may be communities of interest, like those of Gap Filler and Greening the Rubble. Whichever way, these communities first had to become before they were able to become engaged in recovery processes. Building participative capacity may therefore be a two step process of engagement but also, before that, community formation is required. Communities can, and should, take some responsibility for this: CanCERN adopted the street model, whilst other groups used virtual space and various social media to good effect. In so doing, these communities became an entity that recovery authorities could effectively engage with, and in so doing, promoted their own recovery. In addition to using different mechanisms to become a community, these groups also sought funding for dedicated people to act as advocates and information/resource conduits, adopted collaborative leadership styles, networked both vertically and horizontally using a range of media and methods, found a patron to gain access to decision-making fora, identified and celebrated victories, had a floating pool of projects that addressed both immediate and strategic needs, were solutions-based, and connected with shadow networks if an ‘expose/propose’ approach seems necessary. With the likely exception of this last suggestion, recovery agencies can either help or hinder these emergent communities’ efforts. Importantly, authorities should realise that the community leadership landscape may have changed after a disaster and the pre-disaster leaders of community engagement might not be the best suited for the new conditions. It may take time for new leadership cohorts to develop, particularly if telecommunications are affected or large numbers of people are displaced. Further, given the range of leadership styles identified in this research, it may be that new leaders are simply overlooked. My observations here in Christchurch suggest the new community leaders of CanCERN, Greening the Rubble and Gap Filler had a fairly understated and collaborative style that made them easy to miss. Further, they may not have actually felt like leaders in the early stages of recovery, and needed some mandate - from authorities or the community – before they came to identify themselves as such. Nonetheless, they were quite visible early on. The founders of CanCERN regularly attended or, often arranged community meetings; they were present at civil defence meetings and briefings when they were open to the public; they lobbied recovery authorities on their and others’ behalf, and so on. They may not have screamed ‘leadership’ – that’s not their style - but they were incredibly active and quickly became the ‘go to’ people. Authorities can assist emerging and existing community leaders by taking the time to identify them and then helping them feel credible in what are often incredible circumstances. Other steps include, obviously, addressing their concerns where possible and also by helping them perform their role (remembering that they may not be particularly experienced). Providing funding for these community leaders is extremely helpful. In some cases, these people were still employed and walking a precarious path trying to juggle full-time work with community advocacy, whilst others had lost their jobs (and/or their homes) and were therefore unexpectedly unemployed. There were considerable costs associated with hiring babysitters, securing transport to and from meetings, photocopying and printing, supplying tea and coffee, and so on. Identifying and meeting new leaders’ needs for up-skilling (e.g. legal know-how, understanding of formal processes, and access to plans, and so on) is also important. Although the funding for dedicated community leaders and groups is, of course, extremely important, authorities cannot necessarily expect a good ‘track record’, given the

Complimentary Contributor Copy 292 Suzanne Vallance unusual circumstances and the emergent nature of these communities. Some flexibility is required around applications, administration and the definition of Key Performance Indicators or outputs. Funding needs to be easily accessible, well-publicised and, importantly, have very few compliance costs associated with it in the early stages. Initially, even small amounts are helpful as they both enable and endorse the community activity. If the group shows demonstrable success with small amounts, their funding levels could be increased accordingly. Gap Filler and Greening the Rubble received $10, 00013 and $15, 000 respectively from the Christchurch City Council just before Christmas, 2010. They each used this to fund part-time administrators (Coralie Winn and Rhys Taylor) and to source materials for their projects. On the back of these successful projects, six months later the groups received $50, 000 each for the following year. As mentioned above, both groups have been mentioned in the draft central City Plan (2011, p. 117) and are seen as contributing to the short-term recovery of some Christchurch suburban centres. The funds were held by pre- existing NGOs, pre-disaster, so it may be worthwhile keeping a register of organisations which may act as funding repositories in the way that Delta Community House, Living Streets and the Canterbury Arts and Heritage Trust have done. Performance review periods might have to be shorter than the usual annual timeframe so as to allow for a more responsive and iterative cycle of evaluation and funding increase; however, it is vitally important that this review and re-evaluation is not too onerous for communities who are usually struggling to balance a range of problems. Indeed, Evan Smith (from CanCERN) was kind enough to read a draft of this chapter and commented: “Short contract periods although being helpful for agility are actually detrimental because they lack security and require a much higher level of reporting and administration”. Overall, he disagreed with the idea of a short funding timeframe, but interviews with recovery authorities revealed practical difficulties around bestowing large sums of money to people with no track record. Funding must therefore strike a delicate balance between meeting needs for accountability and meeting the needs of the community. Although it may seem an unnecessary distraction when so much effort needs to be put towards the greater recovery effort, there is enormous value in very quickly initiating small- scale, easily achievable collaborative projects. This essentially allows some institutional and community capacity to develop, new networks to consolidate, and trust to be built. If residents (and businesses) see that recovery authorities can successfully undertake small projects, they have confidence that the larger issues can also be dealt with effectively. The collaborative nature of these projects does not need to be too onerous for authorities; my observation is that many residents and business representatives really craved something constructive to do, and the task is more one of enabling than actively doing.

CONCLUSION

In a final summation, it is now common to see scholarship around ‘natural disasters’ emphasising the way catastrophic events are socially constructed, pre-disaster, rather than being chance accidents (Hinchliffe and Woodward, 2004). Post-disaster recovery processes, when poorly managed, can also prolong and even amplify the agony associated with the

13 Approximately US $9, 000.00.

Complimentary Contributor Copy Facilitating Successful Community-led Recovery after Disasters 293 initial disaster. Clarke (2008), for example, writing of New Orleans after Hurricane Katrina noted that the trauma of the event has been exacerbated by the pain of ‘recovery’, and argued that we should recognise the very human elements that make natural disasters possible or even probable. As a corollary, this highlights the ways in which people, through their everyday decisions, collective actions and socio-ecological institutions can create, but also avoid, catastrophe, and become more resilient. Solnit (2009), from a different tradition, presents everyday life as the catastrophe and disasters more as opportunities to reduce inequities and injustices. Emphasising both the socio-politically constructed nature of disasters as well as the opportunity they present to redress past wrongs places these earthquakes in a new context. The trauma associated with the earthquakes has left those who have chosen to stay in Canterbury seeking compensation; however, it is not necessarily a financial payment they seek. It is hope. It is the hope that by staying, they will eventually be rewarded with a better city than the one they had before. Through a greater recognition of the socio-political drama that unfolds after a disaster, we might begin to shift the onus of reconstruction from technical and infrastructural issues to concerns around process and participation. In the end, whilst it is collective effort that drives recovery, it is communities’ collective expectations and their participative capacity to see their aspirations realised that define success.

REFERENCES

Anderson, M., and Woodrow, P. (1998). Rising From the Ashes: Development Strategies in Times of Disaster. Colorado: Lynne Rienner Publishers. Beard, V. A. (2003). Learning radical planning: The power of collective action. Planning Theory, 2, 13-35 Boettke, P., Chamlee-Wright, E., Gordon, P., Ikeda, T., Leeson, P., and Sobel, R. (2007). The political, economic, and social aspects of Katrina. Southern Economic Journal, 74, 363– 376. Chamberlain, P., Vallance, S., Perkins, H., and Dupuis, A. (2010). Community commodified: Planning for a sense of community in residential subdivisions. Paper presented at the Australasian Housing Researchers Conference, Auckland, 17th-19th November. Clarke, L. (2008). Worst-case thinking and official failure in Katrina. In H. Richardson, P. Gordon, and J. Moore (Eds.), Natural disaster analysis after hurricane Katrina: Risk assessment, economic impacts and social implications (pp. 84-92). Cheltenham, UK, Edward Elgar. Coghlan, A. (2004). Recovery management in Australia: A community based approach. In S. Norman (Ed.), Proceedings of the New Zealand Recovery Symposium, 12-13th July, 2004 (pp. 81-91). Napier, New Zealand, Ministry of Civil Defence and Emergency Management. Coles, E., and Buckle, P. (2004). Developing community resilience as a foundation for effective disaster recovery. Australian Journal of Emergency Management, 19, 6-15. Etemadi, F. (2004). The politics of engagement: Gains and challenges of the NGO coalition in Cebu City. Environment and Urbanization, 16, 79-94.

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Etye, A. (2004). Psychosocial aspects of recovery: Practical implications for disaster managers. In S. Norman (Ed.), Proceedings of the New Zealand Recovery Symposium, 12-13th July, 2004 (pp. 135-142). Napier, New Zealand, Ministry of Civil Defence and Emergency Management. Folke, C., Carpenter, C., Elmqvist, T., Gunderson, L., Holling, C. and Walker, B. (2002). Resilience and sustainable development: Building adaptive capacity in a world of transformations. AMBIO: A Journal of the Human Environment, 31, 437-440. Hauser, E., Sherry, E. and Swartz, N. (2008). Risk, preparation and rescue. In H. Richardson, P. Gordon, and J. Moore (Eds.), Natural disaster analysis after Hurricane Katrina: Risk assessment, economic impacts and social implications (pp. 93-120). Cheltenham, UK: Edward Elgar. Hinchliffe, S., and Woodward, K. (2004). Living with risk. In S. Hinchliffe and K. Woodward (Eds.), The natural and the social: Uncertainty, risk, change (pp. 116-151). London, New York, Routledge and the Open University. Klein, N. (2007). Shock doctrine: The rise of disaster capitalism. Camberwell (Vic.): Allen Lane. Kweit, M. and Kweit, R. (2004). Citizen participation and citizen evaluation in disaster recovery. The American Review of Public Administration, 34, 354-373. Lorenz, D. (2010). The diversity of resilience: Contributions from a social science perspective. Natural Hazards, online first, www.springerlink.com/content /jp68pv2185320301/ Manyena, S., O'Brien, G., O'Keefe, P. and Rose, J. (2011). Disaster resilience: A bounce back or bounce forward ability? Local Environment, 16, 417-424. McCrone, J. (2011). Over the Top? The Press. http://www.stuff.co.nz/the-press/news/ christchurch-earthquake-2011/4920414/Over-the-top Ministry of Civil Defence and Emergency Management (2010). Community Engagement Best Practice Guide [BPG 4/10]. Wellington, New Zealand. Miraftab, F. (2009). Insurgent planning: Situating radical planning in the Global South. Planning Theory, 8(1), 32-50. Mitchell, J. (2004). Reconceiving recovery. In S. Norman (Ed.), Proceedings of the New Zealand Recovery Symposium, 12-13th July, 2004 (pp. 47 – 68). Napier, New Zealand, Ministry of Civil Defence and Emergency Management, Murphy, B. (2007). Locating social capital in resilient community-level emergency management. Natural Hazards, 41, 297–315. Norman, S. (2004). Focus on recovery: A holistic framework. In S. Norman (Ed.), Proceedings of the New Zealand Recovery Symposium, 12-13th July, 2004 (pp. 31 – 46). Napier, New Zealand, Ministry of Civil Defence and Emergency Management. Norris, F., Stevens, S., Pfefferbaum, B., Wyche, K. and Pfefferbaum, R. (2008). Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psychology, 41, 127–150. Olshansky, R., Johnson, L., and Topping, K. (2006). Rebuilding communities following disaster: Lessons from Kobe and Los Angeles. Built Environment, 32, 354-375. Pelling, M., and High, C. (2005). Understanding adaptation: What can social capital offer assessments of adaptive capacity? Global Environmental Change, 15, 308–319. Putnam, R. (1995). Bowling alone: The strange disappearance of civic America. Journal of Democracy, 6, 65–78.

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Solnit, R. (2009). A paradise built in hell: The extraordinary communities that arise in disaster. London: Penguin Books. Vallance, S. (2011). Communities and resilience: Burning or building bridges. Lincoln Planning Review 3, 4-7. Waugh, W., and Streib, G. (2006). Collaboration and leadership for effective emergency management. Public Administration Review, 66, 131–140. Wilson, P. (2009). Deliberative planning for disaster recovery: Re-membering New Orleans. Journal of Public Deliberation, 5, 1-25.

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PART 4

TRAUMA IMPACT AND RECOVERY IN REFUGEE POPULATIONS

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 17

TOWARDS DIALOGIC TRAUMA WORK

Stevan M. Weine* University of Illinois at Chicago, IL, US

ABSTRACT

Cultural critiques of the traumatic stress model of trauma mental health contain narrative claims that suggest new innovative paths for trauma work. To facilitate further exploration of these paths, the concept of “dialogic trauma work” was developed. Dialogic trauma work is based upon Mikhail Bakhtin’s dialogic theory and Stevan Weine’s conceptualization of testimony as a polyphonic and dialogic narrative. Dialogic trauma work centers on narratives that respect the polyphonic nature of survivors’ experiences where multiple voices and positions are given a chance to speak and listen to one another openly and responsively. Dialogic trauma work creates loops of meaning that can open up new approaches to understanding and addressing trauma through focusing on speech genres, contingencies, collaborations, processes, and help seeking. These dimensions may be especially pertinent in situations of disaster or mass violence.

Keywords: Trauma, Dialogic Theory, Dialogic Trauma Work, Mass Violence, Disasters

INTRODUCTION

The professions of psychiatry and psychology appear to be no longer in a position where they are centered on narratives. This includes contemporary trauma practice which has moved away from being based upon trauma stories. Instead we have the science of traumatic stress which tends to focus on symptom detection and reduction. Has our science evolved to the point where narratives are no longer needed, except perhaps as illustrative examples? We know that if a person is exposed to a traumatic event that they are likely to develop traumatic

* Contact: Stevan Weine MD, 1601 W. Taylor Street, Fifth Floor, Chicago 60612, Illinois, e-mail: [email protected]; FAX: 312-996-7658; TEL: 312-355-5407.

Complimentary Contributor Copy 300 Stevan M. Weine stress symptoms and are at risk of developing PTSD, and that with certain forms of treatment these symptoms can be diminished. Isn’t that enough? So do we really need narratives? Yes, we need narratives, this author argues; we need narratives from survivors, family members, witnesses, patients, helpers, advocates, policymakers, and even perpetrators. We need to hear these different voices and the multiple positions that they represent. We particularly need them because what we know about trauma prevention, care, and recovery often does not work effectively enough, especially when we try to understand or address trauma in the highly complex situations of mass violence and disaster (Beristain, 2006). The overall purpose of this chapter is to describe a narrative approach to trauma work that was developed from several sources: 1) cultural critiques of traumatic stress; 2) testimony and narratives approaches; and 3) the literary concept of dialogic work. After describing the contributions derived from each of these sources, I will give examples of how dialogic trauma work and its loops of meaning can be used to understand and approach trauma in the context of disaster or mass violence.

CULTURAL CRITIQUES OF TRAUMATIC STRESS

In two books, “Rewriting the Soul’ (Hacking, 1998) and “Mad Travellers’ (Hacking, 2002), the philosopher of science, Ian Hacking, argued that psychiatry took elements of the human responses to suffering, that were originally found in religious and cultural activities, and then tried to render them accessible only to itself by employing highly privileged technical understandings. Psychiatrists have made the claim that the phenomenon of trauma could not be grasped without understanding traumatic memory as only they understood traumatic memory. Psychiatry prioritised trauma-related cognitions and consequently de- prioritised other dimensions of human experience including consciousness and ethics. Hacking critically examined the processes that led to their prioritisation by a profession trying to establish a legitimate niche in its society. Hacking questioned trauma mental health professionals’ claim that they alone could perform treatment and interpret the meaning of its content and trauma in general. Relieving survivors’ suffering through psychiatric professional activities may have been useful to build the profession, but Hacking questions if it is necessary or best for individual patients and asks, what does it contribute to society as a whole? Patrick Bracken (2002), psychiatrist and philosopher, drew on the philosophy of Heidegger to demonstrate that the focus on traumatic memory is so biased toward individual cognition that it tends to remove individuals and their stories from cultural, social, and historical contexts. Bracken wrote: “The trauma, or the traumatic memory, is understood to be ‘stuck,’ or ‘repressed’ somewhere in the individual’s mind. It has to be brought forward, centre-stage, examined and processed” (p. 210). Because trauma mental health work typically regards traumatic memory as residing in individuals, it looks to individual interventions and focuses on changing their cognitions to diminish trauma-related symptoms. Bracken strongly questioned the appropriateness of applying these western assumptions in cross-cultural settings, especially in post-war countries. Bracken also critiqued the tendency: (1) to overemphasise that trauma-disturbed cognitive mechanisms in individuals pose obstacles to peace and reconciliation; (2) to extrapolate these individual phenomena to the larger group

Complimentary Contributor Copy Towards Dialogic Trauma Work 301 level; and (3) to believe that these must be transformed through clinical or psychosocial interventions. Bracken wrote: “A Western, ‘technical’ way of thinking about suffering and loss is being introduced to people when they are weak and vulnerable. The effect is often to undermine respect for local healers and traditions and ways of coping that are embedded in local ways of life” (p. 212). Imposing the Western-based cognitive trauma approach, Bracken implied, may miss how local cultures process adverse experiences. Cultural anthropologists have critiqued the “judicial or media-oriented confessional models” (Das and Kleinman, 2001, p. 26) of knowledge of political violence and have advanced the role of ethnography in documenting histories through longer-term and community-oriented methods. The psychiatrist and anthropologist, Arthur Kleinman, referred to the “crucial mediatization of violence and trauma in the global moral economy of our times” which “creates a form of inauthentic social experience: witnessing at a distance, a kind of voyeurism in which nothing is acutely at stake for the observer” (2000, p. 232). By imposing theory-driven “social scripts” explaining collective violence, “global institutions and agencies of the state have often inhibited the mechanisms of restraint and notions of limit that have been crafted in local moral worlds” (Das and Kleinman, 2001, p. 2). Trauma narratives, as designed by trauma professionals, also find a place in the media where, Kleinman asserted, they may become culturally determined social scripts that better serve global processes than local discourses. The anthropologist Veena Das focused on “social traumas” and the “remaking of everyday life” in survivor communities (Das and Kleinman, 2001). After experiencing the extremities of atrocity and loss, she demonstrated how survivors tried to reassert ‘the normal’ in their daily lives, and how this necessarily involved their struggling with language. Das contrasted the efforts of individual survivors and communities to remake everyday life with professionals’ heavy-handed efforts to claim those experiences as a part of the clinical enterprise. Das expressed a faith in survivors’ ways of working things out in their lives. To Das, survivors were conversing, sharing, and exchanging in many ways that facilitated healing, and what her text did was document, rather than engineer, those processes. Each of these cultural critiques gives new perspectives, creates new sensibilities, and articulates new positions through narratives that challenge the traumatic stress paradigm. Meanwhile, in the field of mental health and human rights, narrative approaches have taken the form of the testimony as a way to help survivors of political violence.

TESTIMONY AND NARRATIVE APPROACHES

The testimony approach has emerged as a key concept in mental health and human rights and a foundation for narrative approaches to trauma work in situations of mass violence (Weine, 2006). When survivors give accounts of the events of political violence that they themselves have endured or witnessed, it often comes as a story, which is referred to as a testimony. Survivors of political violence give testimonies at trials and truth commissions, in families and communities, in religious institutions, in psychotherapies, documentaries, artworks, and even in solitude. These stories carry unusual intensity, beauty, truth, and power. ‘Interveners’ often seek to shape those stories to achieve the desired ends. Sometimes this is

Complimentary Contributor Copy 302 Stevan M. Weine for good reason, but when others lay hands on the testimony, some kind of price is usually paid, as is further articulated below. In 1992, the psychiatrist and psychoanalyst Dori Laub and the literary scholar Shoshana Felman used the concept of testimony in their influential work “Testimony: Crisis of Witnessing in Literature, Psychoanalysis, and History”, which combined literary criticism and psychoanalysis. Their writings are key texts of Holocaust studies and trauma work with survivors of the Shoah and other forms of political violence. Their approach emphasised listening to the entire story with a deep psychological and textual analysis that reflects the practices of both psychoanalysis and literary criticism. For example, Felman wrote of teaching an undergraduate course on testimony where a crisis in the class was approached as a crisis in the student’s capacity for witnessing, which though difficult, permitted deeper learning about trauma and testimony. Dori Laub described how, in doing testimony work in a psychotherapeutic setting "I observe how the narrator, and myself as listener, alternate between moving closer and then retreating from the experience - with the sense that there is a truth that we are both trying to reach, and this sense serves as a beacon we both try to follow" (Felman and Laub, p. 76). The Danish mental health professionals, Inger Agger and Søren Jensen (1996), described “the testimony method” (first derived by the Chileans) in their book “Trauma and Healing Under State Terrorism”. Inger Agger (1994) authored “The Blue Room: Trauma and Testimony among Refugee Women”, based upon testimonies that she conducted with women refugee survivors of trauma and torture. These works are widely read and cited by humanitarian workers and scholars concerned with political violence. Agger, in particular, showed how testimony is shaped by gender and women’s lives and offers an arena for both meaning making and for individual and social healing. Richard Mollica (2000) described the trauma story and argued for the healing potential of storytelling. Telling trauma stories can establish connections, diminish isolation, and enhance the biological extinction of traumatic memories. The “full trauma story”, rather than the “toxic trauma story”, encompasses more than just the horrific details of an attack; it also includes the broader experiences and knowledge of the person, including their spirituality. Through trauma experiences, a person may come to find new spiritual meanings, and through spiritual practices they may enhance their resilience to traumas. Each of these uses of a testimony approach attempt to put the qualities of the narrative at the service of individual and social healing. They are deploying particular characteristics of narratives to bring about the types of changes that trauma psychotherapy deems worthwhile. In the testimony approach, trauma stories can be constructed by respecting or facilitating the survivor’s need for a plot, which lends structure by establishing a sequence of events over time. Trauma stories offer a means for including disparate and extreme experiences, memories, and emotions, which are otherwise ‘non-articuable’, into one coherent narrative. Trauma stories convey a point of view and actively attempt to represent the individual’s interpretation of events. However, in testimony work, although there tends to be more emphasis on the production of these narratives, their ‘reception’ clearly matters to the professional producers of trauma testimony. In “Testimony after Catastrophe” (Weine, 2006), I discussed how key narrative principles are often not adhered to by the purveyors of trauma testimony. For example, often the professional, not the survivor, is given the power of authorship to shape, interpret, and communicate the narrative. Although many aspects of the survivors’ unique local perceptions

Complimentary Contributor Copy Towards Dialogic Trauma Work 303 come through, some do not, and that can be a limitation in a narrative sense. In clinical settings, the foundational assumptions of trauma often are not questioned and so the story is framed as a clinical trauma story. The difficulty in conceiving of reception is in part the difficulty of making the shift from a focus on individual truth telling and healing, to community, cultural, and societal discourses and to the human strivings for resilience or resistance in the face of violence, deprivation, or degradation. It is much more difficult to conceptualise, let alone operationalize and assess, multi-level approaches to narration, which tend to be far more diffuse than that of individual trauma discourse. That is one reason why, in order to achieve this type of trauma work so necessary in situations of disaster or mass violence, we need to draw further upon narrative approaches both from literature and philosophy.

Dialogic Work

“…[F]ollowing the lead of novelists such as Faulkner, Joyce, Woolf we must relinquish the single, central, dominant, in a word, quasi-divine, point of view that is all too easily adopted by observers – and by readers too, at least to the extent they do not feel personally involved. We must work instead with the multiple perspectives that correspond to the multiplicity of coexisting, and sometimes directly competing, points of view” (Bourdieu, 1999, p. 3). Those who work in situations of disaster, or mass violence, labor in worlds saturated with narratives, as well as a plethora of factors that, according to the literary scholar Saul Morson (2003), contribute to narratives being essential: factors such as presentness, contingency, messiness, unpredictability, the need for alertness, and possibilities in excess of actualities. Were we novelists, then we could ask: what do the narratives want from us? A novelist strives to maximise the status of the narrative in their books. As mental health professionals, who undertake trauma work, our position is not as totally committed to the narrative as a novelist. However, given all the pressures, and our proximity to survivors’ narratives, it is remarkable what little hold the narrative has on our professional and scientific approaches in trauma mental health. Perhaps we should learn from how similar challenges have been approached in other fields. Stewart and Rappaport (2005) have described a community narrative approach for HIV/AIDS, which lends itself well to the trauma field as “an especially useful means to understanding, cultivating, and/or mobilizing shared experience and conceptualizations” (p. 57). Community narratives create narrative communities, whereby people are more than problem-ridden victims, and for example, can better commit to preventive activities. In the trauma field, we need community narratives that not only tell trauma stories, but also story resilience as it is found in individuals, families, and communities caught up in difficult spots (Bourdieu, 2003). I would never claim that narratives are all that we need to do trauma work. We need, for example, theory, methods, assessments, lists, and information that are not necessarily dependent upon narratives. We especially need science, in that it provides us with a reliable means of systematically understanding complex phenomenon; for example, with new psychosocial interventions, we are better able to conduct rigorous evaluations of their effects through quantitative methods. However, the science we need is not restricted to one

Complimentary Contributor Copy 304 Stevan M. Weine methodology or theoretical framework, as can sometimes happen in an overly narrow focus on traumatic stress. We might ask, for example, do we emphasize cognitive-behavioral therapy because it suits the science of the randomized-control trial, or because it suits the populations that need help? Would a greater emphasis on narratives increase the likelihood of finding a better fit of existing interventions with those populations, as in Devon Hinton’s adaptations of cognitive behavioural therapy with Cambodian refugees (Hinton et al., 2008)? Nevertheless, we are mental health professionals, not novelists, so the narrative is never going to be our dominant organising principle. However, we can also use narrative approaches to better understand how it is to live in those difficult spots associated with mass disaster and violence and use that understanding to try to develop and deliver innovate care and support that works in real word contexts.

Elements of Dialogic Trauma Work

In his book on Dostoevsky, Bakhtin (1963) described what he called “dialogic work,” which Caryl Emerson explained as follows: “Each word contains within itself diverse, discriminating, often contradictory ‘talking’ components. The more often a word is used in speech acts, the more contexts it accumulates and the more its meanings proliferate” (p. 36). Words carry meanings, that when repeatedly used accumulate more and more meanings, creating ever more complex webs of memories, emotions, and experience. Dialogic work holds that truth must be sought through a “responsible and active discourse” (Bakhtin, 1981, p. 349) involving the dynamic interactivity of multiple voices or points of view. One point of view is always shaped by its connections to other points of view, and all are held together in a dialogic relationship. Consequently, dialogic work is never easy or rapid. That is certainly true when applied to trauma and testimony as I have described in my book “Testimony after Catastrophe” (Weine, 2006). One example is how painstakingly hard survivors may work in testimony to either disavow, redefine, or invent particularly meaning laden words, such as in the Bosnian context, where testimonies have tellers and receivers trying to make or remake meanings embedded in such terms as neighbor, multi-ethnic, Bosniak, mixed-marriage, memory, ethnic cleansing, and genocide (Weine, 1999a). By applying and extending the narrative philosophy of the Russian literary scholar Mikhail Bakhtin, it is possible to move beyond the dichotomous thinking that has polarised the trauma field, such as where trauma either exists or does not exist and where the focus is either on the individual or on the collective. For example, testimony is many kinds of stories, told for multiple purposes, in different contexts, towards different ends. For some, testimony reflects an emphasis on the individuals’ experiences of traumas. For others, testimony is more telling a family story, which may refer to intergenerational transmission of traumatic memories, or to the impact of the traumas on all family members and the family system. Whereas for others, testimony is a community story about how ethnic cleansing and war targeted the multi-ethnic shared space. In approaching testimony, I took inspiration from Bakhtin, who was strongly against narrative approaches that brought false closure to catastrophe, writing: “Catastrophe is not finalization. It is the culmination, in collision and struggle, of points of view (of equally privileged consciousnesses, each with its own world). Catastrophe does not give these points

Complimentary Contributor Copy Towards Dialogic Trauma Work 305 of view resolution, but on the contrary reveals their incapability of resolution under earthly conditions …” (Bakhtin, 1963, p. 298). For example, the givers of testimony don’t necessarily know how events are going to turn out. Thus in testimony work, we did not ask them to commit to knowing in any way that would foreclose possibilities, real or imagined. As described in “Testimony after Catastrophe”, when giving testimony the survivor works with a receiver to create a story that offers that survivor an enhanced sense of completeness and responsibility over their experiencing of political violence. The testimony’s capacity to effect these individual changes depends upon its properties as a polyphonic and dialogic narrative that actively facilitates the survivor’s struggles concerning consciousness and ethics. According to Bakhtin, polyphony, which means multiple voices, was an attribute of Dostoevsky’s novels. Dialogism means that the voices speak and listen to one another openly and responsively. As mentioned earlier, dialogism also means that a word embodies, as Emerson stated, “within itself diverse, discriminating, often contradictory ‘talking’ components” (Emerson, 1997, p. 36). Whether testimony helps to make such changes, and whether this diminishes suffering, is always difficult, by no means certain, and sometimes not even achievable; but under the right conditions, for the survivor, testimony can provide the survivor with an opportunity to make these kinds of personal transformations which for some can be a hopeful act when few other sources of hope are available. Testimonies are meant to be living documents that, through their narrative powers, enter into and change existing discourses or form new ones. Testimonies can be shared and used to make changes in families, schools, religious institutions, political institutions, the media, on the internet, or in artworks. However, precisely because testimony narratives (and other literary narrative models (Sebald, 1996; 2001) often resist finalization, dialogic trauma work is opposed to non- narrative codification. Thus it follows that my approach in this chapter is to move towards dialogic trauma work through identifying statements of principle and reflecting on how they might become manifest in trauma work in real world conditions. The remainder of this chapter uses that approach and describes some considerations for dialogic trauma work in situations of mass disaster or mass violence. Speech Genres. Thomas Kent wrote that Bakhtin’s concept of the speech genre referred to a body of language responses “to something within a specific social situation” (Kent, 1998, p. 35). Mass trauma itself is shaped by multiple speech genres, including those of survivors, of politicians, of the media, of religion, of law, and of health and mental health professionals. Each of these groups has explicit rules or implicit expectations governing how trauma is named and expressed. The concept of the speech genre, as originally described by Bakhtin, could assist those of us who work in situations of disaster or mass violence to pay more attention to understanding the impact of these patterns of spoken language upon trauma work. Perhaps we could start with better listening to those who are directly impacted by trauma in all kinds of different sociocultural contexts. Then we could also pay more attention to how the language of traumatic events, traumatic consequences, symptoms and distress, disability, treatment and rehabilitation, rights, resilience, transformations, and recovery are all framed by the language of victims, families, communities, leaders, providers, service organizations, and donors. When I was in Bosnia-Herzegovina not long after the Dayton Peace Accords, I led a group of junior investigators from the U.S. National Academy of Sciences on a tour where we met a myriad of different types of persons and listened to them talk about trauma and reconciliation. As we listened, I thought that although they often repeated the same words,

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“trauma” and “reconciliation”, these people were not participating in one conversation, or even speaking one language. Their views of trauma and reconciliation couldn’t be more different from one another’s or ours, and were being shaped by basic assumptions concerning nation, self, morality, religion, and war. The problem was that it was very difficult to ever get to the point where these deeper levels of meaning were made explicit or could be ‘interrogated’ because they were hiding underground beneath the accepted speech patterns of trauma and reconciliation. As I listen to how we talk about trauma in many different places, it strikes me that there are two examples of the vulnerabilities with the language of trauma that we must take special care about. Each concerns an error that we, who engage in mass trauma work are prone to make, more than any others. The first is that we are prone to believing that people who experience traumas are necessarily wounded. Perhaps we say that because trauma is a confusing term, in that it refers both to the event that may have wounded and to the wound itself (Erikson, 1995). As a consequence, we are too prone to thinking that they are one and the same thing and thus too often we represent that all or most persons are pathologically wounded and need professional help. A second error that we are prone to is inflating the social significance of our trauma work or our roles as trauma professionals. Trauma work almost always borders on the social. But this does not mean that the work we do is essentially social. The language of trauma, however, is prone to slippage between the individual and the social and societal, as when we link our work with human rights. We may be prone to thinking that our trauma work is accomplishing something broader than the individual, when it really isn’t. As a consequence, we may not be paying adequate attention to the intermediate social fields of family and community. Contingencies. Our traumatic stress science prizes predictability, as in the emphasis on risk factors, protective factors, moderators, and mediators. If we know a particular set of characteristics, then we can be certain to a finite degree of the outcomes of trauma. We want to be able to predict what happens as a consequence of traumatic events and what happens as a consequence of interventions. But sometimes the worlds we enter are full of too many factors for us to be able to meaningfully predict the outcomes. We may have built a predictive science that has described the factors to points of perfection, but may have lost their correspondence with the realities of life in situations of mass disaster or violence. Rather than focus on prediction, we might try to focus more upon contingencies, which are conceived of as possibilities, but for which uncertainty can never be eliminated. Of the many different types of contingencies, the most oft mentioned contingencies, with respect to trauma response, are context, culture, and time. Contingencies in these realms cannot be described only by factors that are present or absent, or even quantifiable in degree, although this information would tell us something. We need to see how those factors are being storied or how the stories being told about individuals, families, or communities are built upon those contingencies. It is the stories enveloping the factor, not just the factors themselves, which are determinants of peoples’ lives. If our aim is to change behaviour, then we could be trying to look for the stories that matter the most in people’s lives. If we knew those stories, and could incorporate them into our interventions, then our helping efforts would likely be more compelling, making people want to participate more and perhaps having a bigger impact.

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Time may be the least well understood contingency with respect to traumas. Ironically, it is often the one most elaborated. We have an excess of frameworks that describe set phases of trauma response. Why is it so difficult for many of us in the trauma field to appreciate the openness of time? Could it be our response to the sudden maximal collapse of time that traumatic events often bring? Or is it our heavy-handed attempt to limit the possibility for events being unpredictable? When experience is robbed of open time, then we know what is going to happen next. Because of a time characteristic of the traumatic event, we have deprived individuals who have experienced trauma of all possibilities and replaced them with known actualities. We have also collapsed, into a unitary time sense, the layers of time that pertain to individual development, families, communities, trauma recovery, etcetera. What if like, in the television show “Lost”, we allowed our sense of time to become loosened or even unhinged, so that we were open to considering how a trauma survivor could simultaneously experience their life both as if they had died, and as if they had been rescued, and as if nothing had ever happened. A narrative perspective enables us to not let such time biases go unexamined. Instead of binding ourselves to fixed frameworks of time (e.g., viewing trauma in terms of chronological time phases), we can consider alternative models of time such as heterochrony, that give survivors, communities, and professionals more flexibility to explore and represent trauma experiences. Both in the language of survivors (through testimony, memoirs, and interviews) and in artistic representations of the survivor experiences (e.g., W.G. Sebald’s 2001 book “Austerlitz”), we may find brilliant examples of narratives with an open time sense. Our challenge is to learn from such examples how to apply these narrative approaches, so as to build innovative professional and scientific models that similarly respect the openness of time, as well as other contingencies. Collaborations. If we are committed to narratives, then we are committed to the many voices and positions from which narratives can be told. We want to hear what these others, be they survivors, family or community members, or elites, have to say. We want to respond to them with our own words, and let the dialogue begin. We despair about how mistrust and competitiveness, amongst and between professional disciplines, academic institutions, and service organizations, obstructs and limits the possibilities for dialogue. We would always prefer a vigorous debate to a false consensus or silent withdrawal. But too often the debates are not held, because different disciplines or institutions do not find themselves in the same rooms talking with one another. Or if they are held, then they get stuck arguing about the same tired old arguments, rather than exploring the more seldom addressed, but more potentially generative questions, such as: how do families and communities help people to survive traumas and move on with their lives? Some of the most important collaborations that we can form are with survivors/victims groups, local professionals, religious persons, journalists, policymakers, and artists. These are the persons who have the knowledge, perspective, information, moral positioning, and relationships that we want to know, if we want to understand and influence life in situations of mass trauma. It is not possible for us to claim legitimacy, if we are not actively soliciting and responding honestly to all these voices. However, to be able to respond to them means that we need to prepare ourselves and clarify our approaches. Aside from partners in the social sciences and humanities, I have derived incredible benefit learning from other types of scholars and professionals including those from rhetoric, anthropology, sociology, family studies, communications, history, as well as the health

Complimentary Contributor Copy 308 Stevan M. Weine disciplines of nursing, public health, and social work. As has been written about the impact of reading the poet Allen Ginsberg: Never underestimate what can happen when you encounter a great work of art or artist (Rosenthal, 2006). This may serve as a reminder to us that literature and the arts provide us with many powerful examples of narrative means of representation of the experiences of trauma and resilience. One example can be found in the song stories of the American rock and roll songwriter, Bruce Springsteen, telling the stories of those peope caught up in the social traumas of economic collapse, war, migration, and terrorism (Weine, 2008). Some songs listen to the dead (“Souls of the Departed”), some try to meet them (“Into the Fire” and “Paradise”), and some see through their eyes (“Matamoros Banks”). These songs convey truthfully the consciousness of those people inside of social traumas, producing a socially contingent view of their hope and dreams. How do we live in a world in which our hopes and dreams are often not enough to effect meaningful change? How do we live, and dream, after hope? In 1978, Spingsteen wrote: “We’ll keep pushin’ till it’s understood / and these badlands start treating us good.” Keeping Springsteen lyrics in your mind can be a helpful starting point for close listening to try to understand the resilience of a survivor group that is new to you. How or why do they push? How do they imagine they can turn bad to good? Processes. Bakhtin used the concept of “eventness” to indicate that the meanings of a given event were open, and were created and recreated through dialogue (Bakhtin, 1963). Eventness is another way of focussing on the processes by which changes occur or not, and the presence of these processes means that the story is not over. Eventness claims that we do not yet know how things are going to turn out; there are several possible futures from any given past. Eventness reminds us that for situations of disaster or mass violence, there are so many important processes about which we actually know little. For example, what are the mechanisms through which protective factors confer resilience? How do family protective factors, such as parents talking with children about difficult topics, lead to better outcomes? The answers to these questions about processes could be well represented by narratives. The social science methodology that maximizes looking at narrative process is ethnography. The ethnographer looks at the world from the inside and tries to see how others see it. If changes occur, then they are seen to occur in the context of daily lives. The ethnographer begins with a set of questions or tentative claims and then goes to the field to listen and observe and collect data. For example, an ethnographer after war could ask: How is family storytelling amongst parents and children changing? Or, what kinds of images, stories, and conversations are teenage refugees seeking on the Internet and how are they making use of these experiences to create new meanings and relationships? Using an iterative process, questions and claims are refined, leading to more focused data collection, and so on, until a set of more complete narrative understandings emerges. Nevertheless, it is quite possible to use ethnography or other qualitative methods, but to not be concerned with process. In the trauma field, this is done when ethnographers turn to narrative simply to illustrate the ready- made trauma paradigms. Ethnography, like any narrative approach, offers that potential, but it is by no means guaranteed, especially in situations of mass trauma. Yet the study of process does not belong only to ethnography or to qualitative methodology. Another dynamic way of modelling processes of change can be found in hierarchical linear modelling (Hedeker and Gibbons, 2006). By not reducing variables to means, and instead by characterising the trajectory of individual variables, we are able to

Complimentary Contributor Copy Towards Dialogic Trauma Work 309 capture the sense of the process of change. For example, one analysis showed that adolescent refugees follow not one, but three, different pathways - thriving, managing, or struggling - which each tells a very different story. Another analysis showed that it was not information alone, but family communication about difficult topics, that led to changes in vulnerable family members, which prompted an interest in exactly how some families were managing to have these difficult conversations. This recognition gets us away from simplistic thinking that narrativeness is equivalent to qualitative research and is not a part of quantitative research. Help Seeking. Most of us who work in situations of disaster or mass violence want to be helpful and recognize that this means we have to be practical. We want to offer help that fits with the needs, meanings, and strengths of persons in the places where mass traumatisation strikes. If so, then instead of telling trauma stories based largely upon the traumatic stress core set of assumptions, then we should shift to telling stories about seeking, receiving, and offering help in difficult situations. Those stories may go something like this: After a disaster, someone you know has a problem for which help is needed beyond the capabilities of those to which they would ordinarily turn. They neither caused the problem, nor can they solve it either. But now it’s up to them to get help. Who are they going to go seek help from, facing what obstacles, and at what coststo them or their loved ones? If you are one of those persons offering help, then you may ask, what environmental situations do I need to build, with what kinds of doors, windows, walls, and seats, informed by what kinds of values and practices, to get people to come and get the help that they need? With what words and gestures should we welcome them so that they might see us as open to their situation and capable of providing help, without making them feel worse about themselves. In such stories, help seeking is not just the province of the mental health services. Help seeking includes the help which is offered by mental health workers and health workers, teachers, religious leaders, attorneys, aid workers, community organisers, and even artists. The stories speak not only to individual experiences of help seeking, but to the experiences at other social levels, such as family and community, for which there are likely no readily available measurements. The stories of help seeking tell us something different from objective measures, if any are even available. Instead of just telling us what people want after trauma, they tell us why they want it, and how they go about trying to get it, in particular settings, with particular players, at specific points in time. Given the complexity of living and working in situations of disaster or mass violence, these help seeking stories would very likely show just how social the experience of trauma can be. Rather than standing alone, trauma coexists with other major social problems and demands, meanings, and resources, including of course, peacebuilding, and socio-economic development.

CONCLUSION

Trauma, especially in the complex situations of mass disaster or mass violence, is knowable through narratives. Because trauma is to a significant degree subjective and

Complimentary Contributor Copy 310 Stevan M. Weine indeterminant, and is highly shaped by culture, context, and time, narratives are necessary to build understandings. Dialogic trauma work, which was derived from cultural criticism of traumatic stress, Mikhail Bakhtin’s dialogic theory, Stevan Weine’s conceptualization of testimony as a polyphonic and dialogic narrative, and the literary concept of dialogic work, is an innovative way of approaching trauma work. Future efforts to conceptualize, operationalize, and investigate dialogic trauma work are needed to further develop this approach, especially in situations of disaster or mass violence.

REFERENCES

Agger, I. (1994). The Blue Room: Trauma and Testimony among Refugee Women. London: Zed Books Ltd. Agger, I. and Jensen, S. (1996). Trauma and Healing Under State Terrorism. London: Zed Books. Agger, I. and Jensen, S. (1990). Testimony as ritual and evidence in psychotherapy for political refugees. Journal of Traumatic Stress, 3(1), 115-130. Bakhtin, M. (1963). Problems of Dostoevsky’s Poetics. Edited and Translated by Caryl Emerson. Minneapolis: University of Minnesota Press. Bakhtin, M. (1981). The Dialogic Imagination: Four Essays, translated by Caryl Emerson and Michael Holquist. Austin: University of Texas Press. Bakhtin, M. (1986). Speech Genres and Other Late Essays. Trans. by Vern W. McGee. Austin, Texas: University of Texas Press. Beristain, C. M. (2006). Humanitarian Aid Work: A Critical Approach. Philadelphia: University of Pennsylvania Press. Bourdieu, P. (1999). The Weight of the World. Stanford, CA: Stanford University Press. Bracken, P. (2002). Trauma: Culture, Meaning, and Philosophy. London: Whurr. Bracken, P. J. and Petty, C. (1998). Rethinking the Trauma of War. London: Free Association Books. Das, V., Kleinman, A., Lock, M., Ramphele, M., and Reynolds, P. (Eds.). (2001). Remaking a World: Violence, Social Suffering and Recovery. Berkeley, California: University of California Press. Emerson, C. (1997). The First Hundred Years of Mikhail Bakhtin. Princeton, New Jersey: Princeton University Press. Erikson, K. (1995). Notes on trauma and community. In C. Caruth (Ed.), Trauma: Explorations in Memory (pp. 183-199). Baltimore: The Johns Hopkins University Press. Felman, S. and Laub, D. (1992). Testimony: Crises of Witnessing in Literature, Psychoanalysis and History. New York and London: Routledge. Hacking, I. (1998). Rewriting the Soul. Princeton, New Jersey: Princeton University Press. Hacking, I. (2002). Mad Travelers: Reflections on the Reality of Transient Mental Illness. London: Harvard University Press. Hedeker, D. and Gibbons, R.D. (2006). Longitudinal Data Analysis. New Jersey: Wiley Publishers.

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Hinton, D.E., Hofmann, S.G., Pitman, R.K., Pollack, M.H., and Barlow, D.H. (2008). The panic attack-PTSD model: Applicability to orthostatic panic among Cambodian refugees. Cognitive Behaviour Therapy, 27, 101–116. Kent, T. (1998). Hermeneutics and genre: Bakhtin and the problem of communicative interaction. In F. Farmer (Ed.), Landmark Essays on Bakhtin, Rhetoric, and Writing (pp. 33-49). Nahwah, New Jersey: Hermagon. Kirmayer, L. (2003). Failures of imagination: The refugee’s narrative in psychiatry. Anthropology and Medicine, 10(2), 167-185. Kleinman A., Das V and Lock, M. (1997). Social Suffering. Berkeley, CA: University of California Press. Kleinman A., Das V., Ramphele M. and Reynolds, P. (2000). Violence and Subjectivity. University of California Press. Mollica, R. (2000). Invisible wounds: Waging a new kind of war. Scientific American, 282(6), 54-57. Morson, G.S. (2003). Narrativeness. New Literary History, 3, 59–73. Rosenthal, B. (2006). A witness. In J. Shinder (Ed.), The Poem that Changed America (pp. 44-46). New York: Farrar, Straus and Giroux. Sebald, W.G. (1996). The Emigrants. Translated by Michael Hulse. New York: New Directions. Sebald, W.G. (2001). Austerlitz. Translated by Anthea Bell. New York, Random House. Springsteen, B. (1978). Darkness on the Edge of Town. LP. New York City: Columbia Records. Stewart, E. and Rappaport, J. (2005). Narrative insurrections: HIV, circulating knowledges, and local resistances. In E.J. Trickett and W. Pequegnat (Eds.), Community Intervention and AIDS (pp. 56-87). New York: Oxford University Press. Weine, S.M. (1999a). When History is a Nightmare: Lives and Memories of Ethnic Cleansing in Bosnia-Herzegovina. New Brunswick: Rutgers University Press. Weine, S.M. (2006). Testimony after Catastrophe: Narrating the Traumas of Political Violence. Evanston, Illinois: Northwestern University Press. Weine, S.M. (2008). Blood not oil: Narrating social traumas in Springsteen’s song stories. Interdisciplinary Literary Studies, 9(1), 37-46.

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 18

FROM TRAUMA VICTIMS TO SURVIVORS: THE POSITIVE PSYCHOLOGY OF REFUGEE MENTAL HEALTH

Eranda Jayawickreme*, Nuwan Jayawickreme and Martin E.P. Seligman University of Pennsylvania, PA, US

ABSTRACT

This chapter examines the literature on refugee well-being within a positive psychological framework and evaluates calls that the field should complement the medical model with a positive psychology approach in evaluating the mental health of highly traumatized displaced populations. The “medical model”, which has emphasized the diagnosis of psychiatric disorders over the fact that refugees are normal individuals with strengths and resources who have been caught in abnormal situations, has dominated much refugee research. Research in positive psychology has the potential to make a serious and important contribution to the study of highly traumatized war-affected populations.

Keywords: Civil War, Post-Traumatic Stress Disorder, Trauma, Well-Being, Growth

INTRODUCTION

When you come and say ‘now my refugees, I have come, I know that you are suffering...’ surely they will tell you problems. But if you come and ask them ‘how are things, how is your harvest, what have you done this year?’ you get a different answer. ... Very often

* All authors are based at the University of Pennsylvania; Eranda Jayawickreme in the Positive Psychology Center; Nuwan Jayawickreme in the Department of Psychiatry; and Martin E.P. Seligman in the Positive Psychology Center. Contact: [email protected]

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people come to find out what problems are here, what can still be done, and that is maybe sometimes the reason that only negative answers are given. (Adi Gerstl1, in Hoeing, 2004, p. 12)

The United Nations High Commission for Refugees estimated in 2005 that one out of every 335 people in the world - 19.2 million individuals - are refugees, internally displaced, asylum seekers, returned refugees, or stateless (UNHCR, 2005), and there is evidence that this figure may be even higher, given the impossibility of conducting precise surveys of most refugee populations, and the haziness surrounding the definition of the label “refugee’ (Zetter, 1991, 2007), and political interests that lead governments to either underestimate or exaggerate official figures (Harrell-Bond, Voutira and Leopard, 1992; Leopard and Harrell- Bond, 1994). In 2006, the International Displacement Monitoring Center (IDMC) estimated that at least 24.5 million people were displaced from their homes by civil and inter-state conflict, as well as by state-sponsored persecution, an estimate that is probably closer to the truth and reflective of the spread of ethnopolitical warfare, sociopolitical change, and ultra- nationalism that has engulfed many areas of the world in the years following World War II (Chirot and Seligman, 2000). The adverse mental health consequences of “refugeehood” - involving factors such as the trauma of war, persecution of one’s self and one’s group, violence experienced both directly and vicariously, escape, refugee camp internment and resettlement - has been widely documented in more than 1,000 research articles and book chapters (Miller and Rasco, 2004). Not surprisingly, refugees generally experience higher levels of psychological distress than the general population or other immigrants (Williams and Westermeyer, 1986). More specifically, a large body of research has posited a link between exposure to political violence and a variety of post-traumatic stress reactions (de Jong, 2002). We argue that research on these populations should consider seriously the value of wellbeing and positive psychological constructs in researching and assisting these populations. We examine the literature on refugee well-being within a positive psychological framework and evaluate calls that the field should complement the medical model with a positive psychology approach in assessing the mental health of highly traumatized displaced populations. Much refugee research seems to have been almost completely dominated by the “medical model” which has emphasized the diagnosis of psychiatric disorders over the fact that refugees are normal individuals with strengths and resources that have been caught in abnormal situations. Far from being irrelevant, therefore, it would seem that positive psychology has the potential to make a serious and important contribution to the study of highly traumatized war-affected populations.

Refugees: Victims or Survivors?

During the past decade, the field of positive psychology has supported and stimulated research aimed at redressing the imbalance between psychopathology and disease relative to human strengths and wellbeing (Linley et al., 2006) and furthering the field’s goal of the creation of “a psychology of positive human functioning…that achieves a scientific

1 Adi Gerstl, DED Program Coordinator in Rhino Camp, Uganda, in Hoeing, 2004, p. 12.

Complimentary Contributor Copy From Trauma Victims to Survivors 315 understanding and effective interventions to build thriving individuals, families and communities” (Seligman and Csikszentmihalyi, 2000, p. 13). The pace at which the field has grown has been substantial, in part because positive psychology afforded opportunities for researchers to investigate new topics that had previously been ignored (Gable and Haidt, 2005). For example, the field has played a significant role in placing the study of happiness (Lyubomirsky, King and Diener, 2005), character strengths and virtues (Peterson and Seligman, 2004), positive emotions (Fredrickson, 2001), and the relationship between optimism and psychological and physical health (Schueller and Seligman, 2008) at the forefront of psychological research. In short, positive psychology represents an established and serious perspective within the wider discipline, and represents a significant antidote to the medical model, which emphasizes a deficit-centered “repair-shop” conception of health as the “return to normal” (Ryff and Singer, 2002). Given positive psychology’s focus on health, wellbeing and optimal human functioning as opposed to pathology, deficits and dysfunction, it would seem at first glance unclear what this field’s potential impact would be on refugees and refugee mental health. Moreover, in light of the unusual and dysfunctional ecological situation that many refugees find themselves in - on the run from militants or government forces who are theoretically supposed to protect their interests, without their possessions, landless and homeless, uncertain of their future - one could argue that the primary task of mental health professionals working with such populations would be to focus on healing the psychological scars that have marked these populations. A closer look at the research on the mental health of refugees, however, reveals that the vast majority of the studies focus on identifying patterns of psychiatric symptomatology and syndromes such as post-traumatic stress disorder (PTSD) (Miller and Rasco, 2004). While this approach has undoubtedly yielded important findings regarding refugee distress, this also means that we know very little about the mental health of refugees apart from the prevalence rates of PTSD, depression and other psychiatric disorders.

LIMITATIONS OF THE PSYCHIATRIC TRAUMATOLOGY APPROACH TO REFUGEE MENTAL HEALTH

The increase of interest in the psychological health of refugee populations began in the 1980s, a fact clearly marked by the increase in the number of articles referencing refugees in the psychology literature relative to articles in the medical literature; while the ratio was one psychology article to seven (1:7) medical articles between 1968 and 1982, the ratio between 1982 and 2004 rose to 1:2 (Ingleby, 2005). Perhaps the main factor behind the increased interest in refugee mental health was the inclusion of PTSD in the diagnostic nosology in 1980. Indeed, critics of the PTSD concept have argued that the increasing prominence of the trauma concept in the 1980s became a social phenomenon that arguably took precedence over the actual problems that individuals had (McNally, 2003). In particular, the study of refugee mental health came to be dominated by trauma researchers. This point is nicely demonstrated by Ingleby (2005), who found through a multiple regression analysis, that publications on “refugees and trauma” primarily related to the level of interest in trauma and not to the level

Complimentary Contributor Copy 316 Eranda Jayawickreme, Nuwan Jayawickreme and Martin E.P. Seligman of interest in refugees; this suggests that rather than refugee researchers becoming interested in trauma, trauma researchers were focusing their explanatory lens on refugee populations. The evaluation of the refugee condition in terms of their experience of trauma had the effect of both focusing attention on the mental health of refugee populations for the first time, and identifying individuals within those populations who were suffering from significant psychological distress. However, this focus meant that in many studies, only data on PTSD symptomatology was collected, and alternative approaches of assessing refugee mental health were not undertaken. This approach has resulted in a number of problematic outcomes, which are outlined below. As Hoeing (2004) has pointed out, much research on refugees focuses predominantly on analyzing and describing negative and harmful aspects of refugee life and living conditions (Cernea and McDowell 2000; Strachan and Peters 1997). Hoeing argues that the deficit- focused emphasis in research and in the general perception of refugees as weak and deficient has serious consequences. First, it perpetuates the label of refugees as helpless and powerless victims (Eastmond 2000; Harrell-Bond 1999; Pupavac 2002; Wessels 1998). In addition, it reinforces and justifies the humanitarian ‘aid regime’ in assuming primacy in taking care of refugee populations, since ‘unfit’ people cannot be agents of their own recovery or participate in finding solutions to their problems (De Voe 1981; Dick 2002; Harrell-Bond 1986). Moreover, a deficits approach pays less attention to the social and political context in which the refugees’ experiences are embedded and denies refugees the role of being social and political actors and agents of their own recuperation (Bracken, Giller and Summerfield 1995; Dick 2002; Jamal 2003; Punamäki 2000; Pupavac 2002; Rieff 2002; Summerfield 1995; 1999). Summerfield (1995, 1999, 2000, 2002, 2005) has been one of the most stringent critics of the trauma-centric deficit approach in refugee mental health. He has argued that for the vast majority of people whose lives have been affected by ethnic conflict, the conception of post- traumatic stress is little more than a pseudo-condition; an ‘over-hyped’ label to the normative stress that individuals endure in times of conflict. Despite the marshalling of mental health resources to help refugees ‘cope’ with their traumatic experience, Summerfield (1999) argues that little evidence exists that these populations seek or desire such therapies, which in themselves may not be culturally sensitive, relate to their priorities or tie in significantly with their systems of meaning. Indeed, even if individuals do indeed have symptoms of PTSD, they may not see them as being the most serious problem that they face, and the presence of such symptoms may not lead to much impairment in their day-to-day functioning. Summerfield (2002) conducted an epidemiological study of 824 Kosovo asylum seekers and found that their most pressing concerns were work, schooling and family reunification. However, while few of them mentioned psychological distress as a pressing factor, it was estimated that at least half of this same group of asylum seekers met the diagnostic criteria for PTSD. Such findings have lead Summerfield to characterize PTSD as a social construction of the West, and question its validity in the context of refugee mental health, where the construct fails to adequately capture the complex psychosocial problems that they endure. In some instances, among populations where stoicism and repressive coping are seen as positive attributes, cognitive-behavioral therapies could in fact result in negative outcomes. Moreover, many trauma-related individual clinic-based therapies designed to improve refugee wellbeing overlook a number of important factors. For one, the PTSD concept posits (or at the very least encourages) a simplistic and singular reason for the psychological distress

Complimentary Contributor Copy From Trauma Victims to Survivors 317 of refugees: a single traumatic event, or a finite sequence of traumatic events. One problem with this explanation is that there is a significant difference between an individual who is subjected to a traumatic event (for example, a rape victim in Philadelphia) and the everyday travails - which may include threat, lack of security, deprivation and sadness - that are part and parcel of a refugee’s everyday life. Moreover, PTSD researchers have tended to focus on past trauma (usually caused by the ethnopolitical violence that forced refugees to flee in the first place), and have paid little attention to the stressors that refugees may face in their place of exile. An increasing body of research has found that lack of meaningful roles, loss of community and social support, economic concerns, relative powerlessness, social isolation, lack of environmental mastery, discrimination and unwanted changes to their way of life can cause high levels of distress among refugee populations in exile settings (Gorst-Unsworth and Goldenberg, 1998; Silove et al., 1997; Sinnerbrink et al., 1997). At the very least, the PTSD construct only focuses on one aspect of their experience. It also serves to deemphasize the potential role that pre- and post-displacement stressors, not directly related to the cause of displacement (financial worries, pre-existing psychological disorder, family/ marital problems), can play in refugee mental health. Seeing refugees as victims can hide the fact that they are also normal human beings with ‘normal’ worries (Miller and Rasco, 2004). In addition, despite the best efforts by mental health professionals, very few refugees have access to their services, as such services are in short supply in developing countries, and are frequently prohibitively expensive in developed countries (Miller and Rasco, 2004). Individual-centered interventions can also be seen as culturally inappropriate and even potentially harmful in that they could lead to a worsening of mental health (Strawn, 1994), and many refugees are wary of the stigma of seeking psychological assistance (Miller, 1999). An additional concern is that there is little advantage in offering psychological assistance when many refugees have more pressing social and economic needs (Pejovic, Jovanovic and Djurdic, 1997). Finally, the conception that refugees are helpless and powerless hides the fact that many of them “are victims, but they are also survivors. ... and even the most destitute still exercise active interpretations and choices” (Summerfield, 1995, p. 353). Perhaps the most striking loss in seeing refugees as "victims" of trauma is that it obscures the fact that human beings actively engage in finding a meaning in what happens to them, and refugees frequently cite faith, religion, spirituality and political convictions as resources that help them to put meaning to, and to endure, even the worst atrocities (Bracken, Giller and Summerfield 1995; Cornish, Peltzer and MacLachlan 1999; Eastmond 2000; Harrell-Bond 1999; Hoeing, 2004). Trauma- focused interventions pay little attention to mending damaged social relations or strengthening naturally occurring resources that could facilitate healing and adaptation.

TOWARDS A POSITIVE PSYCHOLOGY OF REFUGEE MENTAL HEALTH

Mollica et al. (2002) has argued that despite decades of research on the mental health of refugees, “a credible paradigm for the identification, treatment, and prevention of the mental health sequelae of refugee and civilian violence has not been forthcoming” (p. 158), in part because of the emphasis played by most researchers on the trauma model. As noted earlier, this over-emphasis has led to less weight being placed on the risk factors associated with

Complimentary Contributor Copy 318 Eranda Jayawickreme, Nuwan Jayawickreme and Martin E.P. Seligman psychiatric disorders, and on the coping strategies that many refugees (who do not develop a psychiatric disorder) utilize to deal with the intense and (in many instances) long-lasting stressors of their everyday lives, and also on the factors that may protect refugees from developing significant functional impairment, both in terms of individual differences and environmental conditions. While recent research has begun to shed light on some of these issues, the question of how many refugees are able to withstand terrible life experiences without developing mental illness should receive more attention. Positive psychology has done much to broaden the scope of how researchers examine mental health, as noted earlier, and has the potential to provide a paradigm within which the many remaining questions in refugee mental health research can be explored. Lent (2004) argues that the different variables and processes associated with psychological wellbeing can be divided into three major categories: demographic variables; personality, emotion-related and biological variables; and cognitive, behavioral, and social- relational variables. Of these three categories, he identifies the third as being the most important from an intervention perspective, as “they can be conceptualized as acquirable skill sets and environmental resources as opposed to innate temperamental qualities” (p. 493). Cognitive variables include goal mechanisms, which relate to the individual’s desire to produce a particular outcome (Locke and Latham, 1990); personal control beliefs, best expressed in social cognitive theory which views human behavior as issuing from an interaction of personal characteristics, behavior and the environment (Bandura, 1989); and future-outcome expectancies, which include learned optimism (Seligman, 1998). With regards to behavioral and social contributors to wellbeing, Cantor and Sanderson’s (1999) life task participation theory holds that people actively contribute to their wellbeing by engaging in personally valuable activity. Such engagement may fulfill self-set or culturally-valued goals and afford individuals the opportunity to achieve eudemonic benefits. Similarly, specific social resources, such as family support and close relationships, as well as socially relevant personal resources, such as social skills and self-confidence, were predictive of life satisfaction, especially when these resources were congruent with valuable personal goals (Diener and Fujita, 1995). Additionally, coping skills fall into the category of cognitive and behavioral skills, and have been linked to increased life satisfaction (Aspinwall and Taylor, 1992; Carver and Scheier, 2002). Likewise, Robbins and Kliewer (2000) describe three general types of wellbeing models in the positive psychology literature: (1) temperament and personality trait models, (2) process-participation models which focus on the process of participating in goal-directed activity, and (3) coping models which focus on coping processes in response to stressful life events. The next section focuses of coping processes that can promote wellbeing in times of severe stress.

REACTING POSITIVELY TO NEGATIVE EVENTS: POSITIVE COPING AND REFUGEE MENTAL HEALTH

One area of research within positive psychology that has great relevance for refugee mental health is positive coping which focuses on how individuals deal with past, present, or upcoming stressors, compensate for or accept the harm caused by the stressors, derive

Complimentary Contributor Copy From Trauma Victims to Survivors 319 meaning from those experiences and, in some instances, achieve personal growth (Schwarzer and Knoll, 2003). It should be noted here that this salutogenic approach has also been advocated in sociology (Antonovsky and Bernstein, 1986), although few studies have attempts to assess the positive outcomes of severe stress (Breznitz and Eshel, 1983; Collins, Taylor and Skokan, 1990).

Types of Coping

Generally defined, coping is the effort to manage and overcome demands and critical experiences that pose a challenge, harm, or benefit to an individual. While some researchers have equated coping with trait differences (e.g., Beutler, Moos and Lane, 2003), this chapter focuses on coping defined in terms of conscious and self-directed strategies to either regulate or adapt to one’s environment under conditions of stress (Compas, Conner-Smith, Saltzman, Thomson and Wadsworth, 2001). Early research focused on the distinction between problem- focused coping - instrumental, attentive, vigilant coping - and emotion-focused coping - avoidant, palliative coping (Lazarus, 1993). Following Taylor (1983), Schwarzer and Knoll (2003) term these two coping processes as “mastery” and “meaning” respectively. However, in a recent review, Skinner, Edge, Altman, and Sherwood (2003) found that more that 100 coping categorization schemes had been published in the literature. Connor-Smith and Flachsbart (2007) have attempted to collect all these schemes within a hierarchical coping model that emphasizes three core families of coping: Disengagement coping, which includes strategies such as avoidance, denial, wishful thinking and withdrawal; primary control engagement coping, which focuses on challenging the stressor or stressor-related emotions through problem-focused thinking; and secondary control engagement coping, which emphasizes adaptation to stress through acceptance or cognitive restructuring. For the purpose of this chapter, mastery and meaning will be assumed to be equivalent to primary control engagement coping and secondary control engagement coping respectively. To provide an example of the difference between the two processes, a refugee may initially attempt to fight against his imposed exile in some way, or call attention to his compromised position within the confines of a refugee camp. This type of active, problem- solving, assimilative coping is called mastery. However, another refugee who is in a settlement far away from her homeland with little real chance to see her country again may attempt to see her current situation as a new beginning. This type of cognitive restructuring and benefit finding is an example of accommodation or meaning. If one were to frame this in terms of goals, assimilation would be the process through which goals provide a continuous, coherent through-line in a person's life, thus promoting a sense of wellbeing. Accommodation, on the other hand, is reflected in a close examination of goals that are now lost and the identification of and investment in new goals, equal to the goals that have been lost. In short, accommodation spurs individuals to alter their future life plan (King and Hicks, 2007). Mastery Coping. When addressing mastery, Schwartzer and Knoll (2003) distinguish between reactive, anticipatory, preventive, and proactive coping, and outline how each type of coping helps individuals grapple with past, present and future events. While reactive coping relates to harm or loss experienced in the past, anticipatory coping concerns imminent threat in the near future. Preventive coping foreshadows an uncertain threat potential in the distant

Complimentary Contributor Copy 320 Eranda Jayawickreme, Nuwan Jayawickreme and Martin E.P. Seligman future, and proactive coping involves addressing upcoming challenges that are potentially beneficial to the self. Reactive coping may either focus on solving problems, dealing with emotional reactions to the stressor, or tending to social relationships. In order to effectively deal with stress and loss, individuals need to be resilient to the negative effects of the stressor, and since they hope to compensate for their loss and potentially recover from its effects, they need to draw on “recovery self-efficacy,” a particular optimistic belief in their capability to overcome setbacks (Schwarzer, 1999). In anticipatory coping, the event has not come to pass, but is instead pending, and the individual has to successfully manage this perceived risk. In this instance, one successful method of coping would involve downplaying the risk at hand. Situation-specific “coping self-efficacy” (Schwarzer and Renner, 2000), an optimistic self-belief in being able to cope successfully with the particular situation, is a potential resource when engaging in anticipatory coping. Preventive coping attempts to prepare individuals for uncertain events in the long term. In a sense, the individual adapts to the stressful nature of the event so that the impact of the stress is minimized. Here, Schwartzer and Knoll (2003) note that general “coping self- efficacy” could be related to the successful implementation of preventive actions that help build up resilience against threatening non-normative future life events. They also term proactive coping as the “prototype” of positive coping, as it does not require negative appraisals. Here, proactive coping is defined as attempts to build resources that facilitate personal growth and goal-attainment. In this context, stress becomes “eustress” - an opportunity for productive activity. While preventive and proactive coping are associated with similar overt behavior - skill development, accumulation of resources and long-term planning - the motivation for such behavior stems from negative appraisals in the former, and not in the latter. It should be noted that Aspinwall and Taylor’s (1997) conception of proactive coping is almost identical to the concept of preventive and proactive coping. Meaning Coping. While meaning was a central topic in the humanistic psychology tradition (Frankl, 1959; Maslow, 1954; Rogers, 1961), the anti-empirical stance of the field led to the topic being largely abandoned after the 1960’s (Yalom, 1980). However, the notion that meaning could be seen as a potential component of wellbeing has become established in psychology during the last 20 years (Jayawickreme and Seligman, 2011; Seligman, 2002). In particular, recent research points to happiness (as defined by SWB – subjective well being) and meaning being seen as two distinct concepts of wellbeing (Ryan and Deci, 2001). Meaning has been associated with decreased psychological harm (Davis, Nolen- Hoeksema and Larson, 1998; Nolen-Hoeksema and Davis, 2002). Research by King and colleagues (e.g., King and Hicks, 2007) has connected positive forms of coping with personal growth and a deeper form of happiness or flourishing. When events that are incongruent with individuals’ cognitive structures occur, those structures are modified or replaced with new structures - a process of accommodation. These changes are relevant for what Loevinger (1976) terms ego development - the level of complexity with which one experiences oneself and the world. Loevinger defines the ego’s essence as “the striving to master, to integrate, and make sense of experience” (Loevinger, 1976, p. 59; quoted in King and Hicks, 2007). In light of Block’s (1982) discussion of the role of accommodation in personality, this process can be viewed as the mechanism that drives changes in ego development over time (King and Hicks, 2007), and forces individuals to change their source of meaning (King et al., 2000).

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RESILIENCE AND GROWTH

The measures of individual differences in how people deal with stressful situations have been associated with psychological resilience which has been defined as flexibility in response to changing situational demands, and the ability to bounce back from negative emotional experiences (Block and Kremen, 1996; Lazarus, 1993). Individuals who are trait- resilient (that is, who have particular personality traits that make them less susceptible to the effects of stress) experience positive emotions even in the midst of stressful events, which may explain their ability to rebound successfully despite adversity. Tugade and Fredrickson (2002, 2004) have argued that trait-resilient people may use their knowledge of the benefits associated with positive emotions to their advantage when coping with stressors in their daily lives. Additionally, there is a large and growing literature indicating that people who have experienced adversity are able to identify positive ways in which their lives have changed as a result of the traumatic event. The names that have been assigned to these positive changes are most frequently referred to as “posttraumatic growth,” “stress-related growth,” or “benefit finding” (Helgeson, Reynolds and Tomich, 2006). Tedeschi and Calhoun’s (1995) conceptualization of posttraumatic growth involving five domains - relating to others, new possibilities, personal strength, spiritual change, and appreciation of life - has perhaps been the most predominant construct in the literature. Carver (1998) notes that resilience and PTG are related, but different concepts. While resilience is associated with a homeostatic return to the levels of functioning that existed before the experience of trauma, PTG is associated with an ultimate improvement on pre- trauma levels of functioning. In short, while resilience constitutes hardiness in the face of trauma, PTG has the potential to exert a transformative effect on individuals. However, Maercker and Zöllner (2004) have argued for a Janus-faced model of posttraumatic growth, in which a constructive, strengths-based side of growth is paired with an illusory, maladaptive and self-deceptive side. Thus, perceptions of PTG may, in part, be distorted positive illusions that help people cope with distress (Taylor and Armor, 1996). While most research on PTG has focused on the constructive component of the construct, such an approach may ignore some of the deleterious effects of growth. For example, Hobfoll and colleagues (2007; 2009) have found that PTG (measured as resource gain following trauma) was associated with right- wing political beliefs, support for violence, and ethnocentric beliefs. Zöllner and Maercker (2010) have argued that the two-component model can explain why a positive relationship between PTG and psychological adjustment exists in longitudinal studies, but not in cross-sectional assessments. In longitudinal studies, the constructive side of PTG has the opportunity to develop and exhibit its adaptive effects, while cross-sectional studies may include participants who exhibit both constructive and illusory PTG. One possibility is that while illusory PTG is deployed relatively quickly as a coping mechanism following a traumatic experience, constructive PTG requires time to grow and develop. Distinguishing between the two sides of PTG is an important empirical question (Helgeson, Reynolds and Tomich, 2006). Moreover, given the long period of displacement suffered by many refugee communities, it may be that those individuals who have successfully habituated to their life situation would have had the opportunity to develop constructive PTG. On the other hand, since it has been argued that major life stressors need to stop having a significant

Complimentary Contributor Copy 322 Eranda Jayawickreme, Nuwan Jayawickreme and Martin E.P. Seligman impact for the benefits of PTG to become manifest (Calhoun, Cann and Tedeschi, 2010), it could be that illusory PTG may dominate among this population. Unpacking this question remains an important area for future research.

The Corrective Strengths of Character: Strengths and Refugee Mental Health

We have already noted the uniquely multifaceted nature of the challenges that refugees face. These challenges may include substantial resource loss. Becoming a refugee often threatens or leads to a depletion of resources, such as status, position, economic status, relatives and friends, worldview, and self-esteem. Hobfoll (1989) defined important psychosocial resources as objects, personal characteristics, conditions, or energies that are valued by an individual or that serve as a means for attainment of these objects, personal characteristics, conditions, or energies. While people can adapt relatively well to certain isolated incidents of trauma, adapting to a long-term situation involving significant loss of these resources (Hobfoll et al., 2003) may be much harder. In this context, it should be noted that the factors that serve to bolster refugees’ wellbeing (be it material goods, social relationships or personal resources) could also serve a protective role in preserving their subjective quality of life in the face of adverse life conditions. Identifying the resources and strengths at work in uplifting these individuals’ wellbeing and resiliency would enhance the ability of psychosocial caregivers to create effective interventions. This presents another opportunity for positive psychology to contribute towards a more complete understanding of refugee mental health, given that the identification of human strengths has been one of its most important research concerns. The question of assessing the positive traits that facilitate human flourishing is a central task of positive psychology. Peterson and Seligman (2004) asserted that two fundamental questions needed to be at the heart of any assessment program: how can one define the concept of a human “strength” and “highest potential”; and how does one know that the approach has worked? The Character Strengths and Virtues classification (Peterson and Seligman, 2004) represents a first attempt to scientifically classify human strengths and virtues, and is, to a significant extent, influenced by the Diagnostic and Statistical Manual of Mental Disorders. While the text distinguishes between virtues, character strengths, and situational themes, the focus of the classification is on the concept of character strengths. Twenty-four character strengths, classified under six master virtues, were identified in this classification (Peterson and Seligman, 2004). One area of research in character strengths has been the study of how challenging life experiences influence character strengths. For example, Peterson, Park, and Seligman (2006) found that among individuals who had a history of physical illness, those who rated highly on the character strengths of bravery, kindness, and humor had their levels of life satisfaction less negatively impacted. For individuals suffering from psychological disorders, a similar result was found for the strengths of appreciation of beauty and love of learning. Moreover, individuals who had experienced a personal crisis reported higher levels of these strengths compared to those who had not experienced such a crisis. Thus, it could be argued that one result of successful coping is the nurturing and building of character strengths that could enable individuals to flourish following a crisis.

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In light of the above information, it would seem imperative to establish which character strengths would enable refugees to successfully endure their travails, and which strengths they would be able to build as a result of their experience. While this remains an area for future empirical research, a number of speculations can be made. As we noted earlier in the discussion on situational meaning, Tugade et al. (2004) found that positive emotions play a crucial role in enhancing coping resources in the face of negative events. Given the importance of positive emotions in successful coping, strengths such as humor and appreciation of beauty may be associated with positive outcomes for refugee populations. Moreover, consider Mollica et al.’s (2002) finding among Cambodian refugees, where positive work status was shown to be a protective factor against major depression, while religious practices was a strong protective factor against PTSD. Strengths such as zest, persistence and religiousness/spirituality may play a protective role here, meaning that interventions designed to bolster them could improve refugees’ mental health. (Note, however, that given the study’s additional finding that care-giving for other camp members was a risk factor for PTSD, the strength of kindness and other positive interpersonal traits may not always be associated with positive outcomes). In addition, Tennen and Affleck (1998) found that stable characteristics such as dispositional optimism and hope, cognitive- and self-complexity, and intrinsic religiosity have been associated with posttraumatic growth (PTG). Strengths such as hope, gratitude, social intelligence and persistence may thus be linked to increased levels of meaning and PTG. Other strengths may be important for the long-term wellbeing of refugee communities. For example, strengths such as forgiveness/mercy, open-mindedness, teamwork and social intelligence would be important for the long-term prospects of the community. Interventions designed to improve the relevant character strengths could be important for refugee populations in at least two ways. For one, it further increases the resources that the refugees have at their disposal in order to successfully cope with their life situation. Secondly, these interventions would offer refugees the opportunity to find meaning and to experience personal growth even in the most dire of circumstances, and see themselves more as survivors than as victims. In combination with other resources, such interventions could potentially help refugees to not only survive their experience, but also to flourish in the future.

TOWARDS A MODEL OF REFUGEE WELLBEING

As noted above, wellbeing takes many forms, with multiple predictors and processes contributing (Jayawickreme, Forgeard and Seligman, in press). A first attempt at a model of wellbeing should highlight those coping mechanisms discussed above, as they play a pivotal role in restoring and sustaining wellbeing under stressful conditions. Lent (2004) has presented an active-agent coping model through which wellbeing is restored, and positive adaptation and growth potentiated, following the experience of extreme stress. Personality variables (such as trait affectivity, extraversion and neuroticism), cognitive and behavioral coping strategies involving mastery and meaning, coping self-efficacy, and social support and resources, negotiate this process. Such a model represents a good starting point for a more specific conception of refugee mental health.

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To summarize this model briefly, individuals react to a negative event by appraising its severity and their own coping efficacy. This reaction is mediated by personality variables such as extraversion or dispositional optimism (Carver and Scheier, 2002), as well as by environmental and social support, such as interventions, therapy, or the facilitation of activities that assist in coping (i.e., religious activities). These factors in turn mobilize a wide range of coping strategies, which have been discussed in some detail earlier in this chapter. These coping strategies positively impact both the individual’s coping efficacy and the problem resolution process. Coping efficacy - the perceived capability to manage domain- specific stressors or obstacles - is also affected by environmental and social resources, and, in turn, can facilitate use of active coping and support-seeking methods, encourage persistence at coping efforts despite setbacks, and promote domain-specific satisfaction and affect (Lent, 2004). What is the relation of this model to the unique situation of refugee populations? The most important distinction that needs to be made about refugees is with regard to the nature of stressful events that they experience. Miller and Rascoe (2004) have identified two major types of stressors, documented in the literature, that may affect and threaten refugee wellbeing. One type of stressor relates to the violent events that individuals experienced prior to their displacement; this can be termed political violence-related stressors. The second set of stressors relates to the challenges and losses that refugees face following their displacement, and can be defined as displacement-related stressors. The effects of political violence and displacement on the lives of refugees are considerable, and may include the following: (1) Loss of social networks, leading to social isolation; (2) Loss of social roles and role-related activities; (3) Unemployment and subsequent poverty-related stressors; (4) Loss of environmental mastery; (5) Discrimination; (6) Separation from family members and loved ones, and concerns for their wellbeing; and/or (7) Intergenerational differences in rates of acculturation: younger individuals generally find it easier to adapt successfully to post- displacement conditions than older individuals. In addition, two other factors that may contribute to the mental wellbeing of refugees can be identified: (i) pre-displacement stressors that may not be directly the result of political violence, and (ii) post-displacement stressors that occur following displacement that are not directly linked to the experience of displacement as such. Most research examining refugee wellbeing has overlooked these factors, and more attention should be paid to the roles of such stressors, since it is likely that the psychological distress and lack of wellbeing that refugees experience cannot be accounted for completely by stressors related to political violence and displacement, as substantial as those stressors may be. In addition, prior exposure to stressful experience may influence the extent to which refugees successfully cope with the stressors directly associated with political violence and displacement (Miller and Rascoe, 2004).

CONCLUSION

The aim of this chapter was to present research in positive psychology as complementing current research on refugee mental health, particularly with respect to the extensive literature on wellbeing, mastery and meaning coping. Note that the arguments in this chapter are not intended to belittle or deny the fact that many refugees do suffer severe psychological distress

Complimentary Contributor Copy From Trauma Victims to Survivors 325 and trauma that requires extensive treatment. It is true that a significant proportion of refugees do suffer from PTSD, depression, or some form of psychological distress. However, it is also true that the majority of refugees do continue to function adequately, and achieve satisfactory levels of wellbeing. This chapter advances our understanding of how we can investigate the reasons for this phenomenon, and how such resilience and meaning-making can be promoted among refugee populations, including war survivors. Researchers and clinicians working with war-affected populations should be careful to consider the role of culture and the value of wellbeing constructs in order to have a sensitive and complete understanding of their mental health.

REFERENCES

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Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 19

TRAUMA AND SURVIVAL IN AFRICAN HUMANITARIAN ENTRANTS TO AUSTRALIA

Alicia Copping1 and Jane Shakespeare-Finch*1,2 1University of Tasmania, Australia 2Queensland University of Technology, Australia

ABSTRACT

Former refugees have been resettled in Australia since the 1940’s through the Humanitarian Migration Stream. This chapter highlights the impact of forced migration and the refugee experience of trauma on survival. The journey from pre-migration crises, to the process of fleeing one’s country, through to the challenges associated with resettlement, can have a significant impact on the mental health of Humanitarian Entrants to Australia. Differences in culture can have an impact on the meaning constructed from these experiences, and on help-seeking behaviour and preferred methods of intervention. To date, Western mental health services have used an understanding of trauma based on pathology and largely individualist intervention techniques. In this chapter, however, we seek to understand the experience of trauma for former refugees from a salutogenic perspective, and acknowledge community based coping methods and the strengths and resilience of former refugees. Using the construct of posttraumatic growth, adaptive factors of strength, religion, compassion, and new possibilities are identified as relevant to African Humanitarian Entrants in Australia.

Keywords: Refugees, Posttraumatic Growth, Strengths, Community Based Coping, Culturally Responsive Services

INTRODUCTION

By virtue of the label “refugee”, such persons have been displaced from their country of origin due to a threat to their life. In countries like Sudan, the southern Sudanese people have

* Contact: [email protected]

Complimentary Contributor Copy 332 Alicia Copping and Jane Shakespeare-Finch spent over 50 years in civil war, and the traumatic experiences endured during this time include assault, arbitrary arrest or kidnapping, witnessing loved ones being killed, enduring severe torture, and sexual assault. Even following escape, en route to a country of relative safety, refugees in transit are often exposed to continued trauma such as insufficient food, water, and shelter, protracted violence from rebel or military groups, and continued instability in their sense of safety and security. The average time from leaving war-torn places like Sudan and Burma, to finding refuge in a country like the USA, the United Kingdom, or Australia, has increased to being an average of 17 years in transit (Piper, 2006). Years of protracted violence, fear, horror, and hardship can wreak psychological havoc for those displaced, and their family and friends; hence developed nations committed to resettling refugees from war-torn nations must be equipped to respond to such trauma. In this chapter, we begin by examining some of the salient refugee experiences that are documented to have occurred in countries of origin, during the journey to relative safety and in the country of refuge. Drawing on current literature and qualitative data collected by the authors, the plight of refugees is illuminated as is their strength and resilience.

WHAT HAVE REFUGEES EXPERIENCED?

The definition of a refugee is one who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable, or owing to such fear, is unwilling to avail himself of the protection of that country” (United Nations High Commissioner for Refugees, 2007). This definition highlights the fact that those who have resettled in Australia from refugee situations have experienced human rights violations in their home country to the extent that they are unable to return. In other words, Humanitarian entrants to Australia have, by definition, experienced what mental health professionals in the West term ‘trauma’. Nevertheless, refugees are generally thought to recover quite well from their experiences and do not typically display high levels of overt traumatisation. The following section focuses on the traumatic experiences that Sudanese, Liberian, and Sierra Leonean migrants to Australia have faced, not only in their lives as refugees pre-migration and whilst en route to a country of refuge, but also highlights the difficulties they encounter upon their resettlement in Australia.

Pre-Migration Challenges

Perhaps the most graphic and publicised of the traumatic events that former refugees experience are those they have faced during periods of protracted civil conflict. These experiences can all impact upon feelings of safety, security, and trust in authority, and result in loss, bereavement, fear, isolation, and severe distress. In Sudan, rebel and government troops alike routinely violate the human rights of civilians, robbing them of resources, conscripting them into the armed forces, and raiding villages. Rebel groups have been accused of contributing to famine by diverting food aid, and burning houses and crops

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(United Nations High Commissioner for Refugees [UNHCR], 2000). Violations of religious freedom by the Islamic government are prolific, with the demolition of Christian churches, violence towards and harassment of Christian civilians, discrimination, and the mass executions of student demonstrators (UNHCR, 2000) being evidence of this. Arbitrary detention and torture of suspected rebel or government collaborators is common, and women and children are often enslaved by rebel forces. In a study of 63 Sudanese Humanitarian Entrants in Queensland (Australia), 85.7% had faced forced separation from their loved ones, 68.3% had witnessed or learned of the murder of loved ones, 30.2% had been close to death and 11.1% had been raped or sexually abused (Schweitzer, Melville, Steel and Lachareaz, 2006). It is highly likely that the latter figure is underreported. The West African rebel groups in Sierra Leone and Liberia have been described as some of the most brutal in history (Department of Immigration and Citizenship, 2007a, 2007b). Theft, looting, raiding and burning of villages and homes, rape, and sexual slavery are all common experiences of refugees from these areas (Kamara, 2003; UNHCR, 1994, 1998). Like refugees from the Sudanese conflict, many have witnessed their family and friends being murdered, and have experienced arbitrary and prolonged detention, abduction, and torture (DIaC, 2007a; UNHCR, 1994, 1998). Several massacres have been staged during the Liberian and Sierra Leonean civil conflicts, often targeting civilian areas including hospitals (Kamara, 2003). In Sierra Leone, the RUF was particularly brutal, and they used torture techniques including the mutilation or amputation of limbs, beheadings, disembowelment of pregnant women, and the branding of civilians by carving or burning the Revolutionary United Front logo into their flesh (UNHCR, 1998). In a study of 55 Sierra Leonean refugees in a Gambian refugee camp, 82% had experienced forced separation from loved ones, 62% had been close to death, and 55% had witnessed or learned of the murder of loved ones (Fox and Tang, 2000). In a study of West African refugees that included Liberian and Sierra Leonean nationals, 85.8% had experienced physical abuse, 27.8% had experienced rape or sexual assault, and substantial numbers had experienced torture techniques such as degradation, burning of flesh, electric shock, asphyxiation, and amputation or mutilation (Rasmussen, Smith and Keller, 2007). An estimated 35% – 50% of all refugees have experienced some level of torture (Gorman, 2001).

En Route Challenges

Alongside the horrific experiences people face whilst their country is in civil conflict, refugees are forced to flee their homes for fear of persecution, or having actually experienced it. The decision to leave is often an unplanned one, and refugees therefore often leave with nothing, are not able to say goodbye to loved ones, and have no means of transport (Refugee Council of Australia, 2006). People who have resettled in Australia from Sudan, Liberia and Sierra Leone tell of the weeks and months they spent walking from their home to a refugee camp in a country “many miles away”. It is only the strong who are able to reach a camp or United Nations (UN) agency and attain their refugee status. Internally Displaced Persons en route to a country of asylum are often mistaken for rebel collaborators, and are arbitrarily detained, tortured, and some are executed (Kamara, 2003). Refugee camps are intended to be places of refuge in which personal safety and fundamental human rights are ensured, and where an asylum seeker can have access to basic

Complimentary Contributor Copy 334 Alicia Copping and Jane Shakespeare-Finch clean water, food, education and healthcare (da Costa, 2006). The reality in Africa, however, is quite different. Water is often scarce in refugee camps, food is limited and aid is often delayed or intercepted. Shelter is crude and unsanitary, and limited resources make the possibility of education and adequate healthcare rare. Malnutrition and disease are epidemic within these conditions (DIaC, 2007a, 2007c). Each of these conditions only serves to exacerbate the loss of safety, security, and control over one’s life. Due to poverty, some women resort to prostitution or unwanted marriage in order to survive, and are often subject to exploitation. Rape, sexual assault, and gender related violence is rife (da Costa, 2006; DIaC, 2007c). Racism from the local population and within the camp itself often leads to violence. Violence is also perpetrated due to poverty, and armed forces from outside stage raids in some camps (da Costa, 2006; DIaC, 2007c; Shakespeare- Finch and Wickham, 2010). A lack of willingness, and often resources, on the part of host governments to police refugee camps, and the limited capacity of UNHCR staff to monitor camp conditions allows this situation to continue (da Costa, 2006). In addition to these experiences of poverty, illness and continued human rights abuse, refugees have uncertain political and legal status, leading to instability and limited employment opportunities (da Costa, 2006; Shakespeare-Finch and Wickham, 2010). These factors perpetuate a cycle of dependency and can lead to a diminished capacity for autonomy and sense of identity (Mackenzie, McDowell and Pittaway, 2007). All of these challenges add increasing distress to the traumatic experience.

Post-Migration Challenges

Despite their arrival in a country of relative peace and safety, former refugees are faced with significant challenges to resettlement, many of which exacerbate psychological distress as a result of pre-migration and en route experiences. Employment is often difficult to obtain due to language and cultural barriers and racial discrimination, resulting in low socio- economic status for many Humanitarian migrants (Flanagan, 2007; Sweeney, 2008; Tilbury and Rapley, 2004). Qualifications and skills acquired in the countries from which many of Australia’s Humanitarian migrant population come are commonly disregarded by Australian employers and tertiary institutions, causing a great deal of stress and anxiety for many people, and contributing to acculturation stress (Flanagan, 2007; Sweeney, 2008; Tilbury and Rapley, 2004). While continued education is extremely important for many former refugees (Tilbury and Rapley, 2004), they often face difficulties adjusting to the Australian system of education, along with language and literacy difficulties (Flanagan, 2007). Gaining access to affordable housing, health care, child care, and transport are all additional challenges to resettlement (Flanagan, 2007). Many challenges, such as these resource access difficulties, are exacerbated by previous torture and trauma experiences, which can lead to impaired concentration and attention, and a distrust of bureaucracy and authorities (Flanagan, 2007; Tilbury and Rapley, 2004). Along with these challenges to resettlement, Humanitarian Migrants also often experience additional distress due to post-migration crises. The most significant post- migration crises reported in the literature are family separation, marginalisation and discrimination (Schweitzer et al., 2006; Sweeney, 2008). Schweitzer et al. (2006) found that separation from loved ones left behind in Africa was the highest contributor to depressive

Complimentary Contributor Copy Trauma and Survival in African Humanitarian Entrants to Australia 335 symptomatology in a sample of Sudanese migrants. Similarly, Tilbury and Rapley (2004) reported that family separation was the most commonly reported precursor to anxiety in their sample of African women. Australia provides a limited family reunion program with its Special Humanitarian Program (SHP), however the fees are large, families arriving under the SHP do not receive the support given to former refugees, and the Australian cultural construction of ‘family’ is vastly different for many African people (Flanagan, 2007). Thus, family separation is a factor that continues to cause distress amongst the former refugee population. Resettlement in Australia is conveyed to refugees as a chance to rebuild lives and exist in peace and safety. However, depending on exactly where the Humanitarian migrants are located, this experience can be marred by discrimination, instances of overt racism, and ignorance in the mainstream population about refugee issues (Flanagan, 2007; Sweeney, 2008; Tilbury and Rapley, 2004). Discrimination due to cultural and linguistic diversity often limits the employment opportunities of former refugees, perpetuating their low socio- economic status, limiting their opportunities to develop an understanding of the cultural norms of their host country, and preventing the formation of new social networks (Flanagan, 2007). Qualitative research conducted by Flanagan (2007) in Launceston, Tasmania, demonstrated that of their 78 participants, a number of African people had been subject to racial taunts regarding the colour of their skin, and were often told to go back to their home countries. They also had objects thrown at them from moving cars and at times this extended into more violent assault. The report states that groups of young white people were the common culprits. This is due in part to the ignorance of some mainstream Australians as to the situation of refugees, and the stereotyping that ensues (Flanagan, 2007; Sweeney, 2008). It is important to point out that acculturation is a two way process, with adaptation being necessary on the part of the host country as well as the migrant. In her research investigating settlement experiences for Sierra Leonean migrants, Sweeney relates the surprise that many refugees felt when Australians did not know where Sierra Leone was, and that they assumed all refugees were impoverished, uneducated, and ignorant of Western society. In facing ignorance, discrimination and racism, many African migrants may feel they have not escaped the persecution of their former homes, and continue to live in fear of their safety. This fear contributes to their continued distress, depression and anxiety (Schweitzer et al., 2006).

REFUGEES AND WESTERN THERAPEUTIC INTERVENTIONS

Due to the experiences described in the sections above, refugees are often said to be particularly vulnerable to developing PTSD, and generally have been labelled as ‘traumatised’, ‘emotionally scarred’, or ‘psychologically damaged’ (Pupavac, 2002). The general consensus of Western mental health professionals, humanitarian aid agencies, media, and the general public, is that refugee populations are therefore in need of mass psycho-social interventions (Pupavac, 2002). As evidenced by the trend in sending teams of Western mental health professionals to administer ‘psychological first aid’ in disaster areas, humanitarian aid agencies often judge symptoms of trauma to be best treated by Western mental health intervention strategies (e.g., Asia Australia Mental Health sponsored by AusAID, and US organisation Psychology Beyond Borders sponsored by the UNHCR). This is despite there

Complimentary Contributor Copy 336 Alicia Copping and Jane Shakespeare-Finch being little evidence that these strategies are effective within non-Western settings (Almedom and Summerfield, 2004; Pupavac, 2002; Summerfield, 2000) or for survivors of mass trauma (Hobfoll et al., 2007). Despite the perception that refugees are the most in need of psychological assistance, they are unlikely to access these services (Almedom and Summerfield, 2004; Pupavac, 2002). This is often perceived by Western mental health professionals as largely being due to linguistic or cultural barriers (Bracken, Giller and Summerfield, 1997). However, the idea of debriefing or individual psycho-social therapy is quite literally a foreign concept to many members of non-Western cultures (Almedom and Summerfield, 2004; Copping, Shakespeare- Finch and Paton, 2010). Therefore, lack of access may in fact reflect the cultural inappropriateness of Western forms and mechanisms of intervention. For example, it has been proposed that the individual focus of Western psychology is a reflection of the egocentric nature of Western culture, and does not reflect the values or experience of the majority of people from many non-Western cultures (Bracken, 2001). The majority of the world’s refugees come from collectivistic nations, in which the focus is on social and community connections; on the interpersonal, rather than on the individual psyche or intrapersonal. In addition, war trauma has an inherently collective focus, including the breakdown of familial and community networks (Bracken, 2001; Summerfield, 2000). It may be the loss of these networks that is more distressing than individual trauma (Summerfield, 1997). Furthermore, many former refugees state that pre-migration experiences, often targeted in therapeutic interventions, are in fact not as distressing as the other experiences they have faced along their refugee journey (Sweeney, 2008). For example, Almedom and Summerfield (2004) argue that the suffering of poverty and malnutrition is no less traumatic than war, however it is the distress caused by the latter that is the focus of international aide campaigns. Therefore, the post World War II focus of Western psychology on providing therapy to individuals may not target key aspects of the war-trauma experience. Rather, intervention may be better targeted toward social reconnection, practical assistance, and community development (Shakespeare-Finch and Wickham, 2010; Summerfield, 1997; Westoby, 2009).

Acknowledging Strengths and Local Perspectives

In addition to the focus on individualised interventions, the Western preoccupation with pathology singles out former refugees as an inherently traumatised group, and can therefore ignore or even deny their potential for resilience and growth (Almedom and Summerfield, 2004; Pupavac, 2002). The construal of whole populations as ‘traumatised’ creates an assumption that all members of that population are therefore dysfunctional, and places them at risk of further marginalisation (Kienzler, 2008). Marlowe (2010) calls for a shift in the focus and discourse that have been automatically associated with being a refugee within the Western context. Extreme distress after war related trauma can be conceived of as a normal reaction to a fundamentally abnormal situation, and therefore a focus on the adaptive capacity of these communities may be more beneficial in ameliorating this distress (Almedom and Summerfield, 2004; Kienzler, 2008; Pupavac, 2002; Summerfield, 1997; Tilbury and Rapley, 2004; Westoby, 2009). Moreover, a large proportion of people from cultures that value determinism, fate, and religion or spirituality may not perceive suffering as psychologically

Complimentary Contributor Copy Trauma and Survival in African Humanitarian Entrants to Australia 337 damaging, and may not agree with the need to provide psycho-social interventions for this suffering (Almedom and Summerfield, 2004; Copping, 2010). The focus on Western intervention techniques largely ignores local therapy strategies, with humanitarian aid agencies suggesting local professionals be trained in psychological first aid and core psychological skills, and supervised by those experienced in these techniques (Kienzler, 2008; Pupavac, 2002; Westoby, 2009). Kienzler states that many Indigenous coping strategies have been misidentified as dysfunctional, leading to a misdiagnosis of adaptive mechanisms as PTSD symptomatology. For example, the re-experiencing of trauma through dreams may be a reason to seek help for one person, unimportant to another, and a message from ancestors for a third leading to their positive adaptation (Summerfield, 1997, 2000). This pathologising of potentially adaptive and/or normal responses to extreme conditions can lead to whole communities feeling disempowered (Almedom and Summerfield, 2004; Pupavac, 2002; Westoby, 2009). What may therefore be more beneficial to humanitarian entrants to Australia is the mainstreaming of culturally appropriate care, and the acknowledgement of coping methods that are indigenous to these communities. Western mental health professionals have a responsibility to ensure that all voices and visions are heard, rather than imposing constructions that have little relevance to non-Western populations upon them (Bracken, 2001). Experiencing psychological phenomena from the cultural and historical perspective of Western psychology means that we often tend to ignore the equally real accounts of the same psychological phenomena when presented to us within another culture (Gergen, 1985; Summerfield, 1997). The imposition of the ideals of psychological theory or practice of the dominant culture onto members of a minority group, such as people from refugee backgrounds, without taking into account the culturally constructed reality of that group, has the potential to be more damaging than helpful (Gergen, 1997; Pupavac, 2002; Summerfield, 2000). A trauma response that differs from that which Western mental health professionals are accustomed to should not be seen as pathological or abnormal, but rather one that must be understood within the context of the culture of the trauma survivor in order to construct a culturally responsive psychology.

STRENGTHS, COPING, AND GROWTH

The study of trauma in refugee populations is therefore best situated within a salutogenic paradigm, investigating the gamut of potential post-trauma adaptation pathways and outcomes – both positive and adverse. Shifting the focus away from mental illness helps to empower people who have experienced trauma, as it allows them to perceive themselves as survivors with the potential to flourish, rather than as victims. Survival is one of the triumphs of the refugee experience.

Posttraumatic Growth

Richard Tedeschi and Lawrence Calhoun (Calhoun and Tedeschi, 2006; Tedeschi and Calhoun, 1995; Tedeschi and Calhoun, 2004) developed what is arguably the most

Complimentary Contributor Copy 338 Alicia Copping and Jane Shakespeare-Finch comprehensive salutogenic model of the experience of trauma, Posttraumatic Growth (PTG), which acknowledges not only distress, but also the potential for growth and the gaining of wisdom in the aftermath of trauma. Tedeschi and Calhoun (1995) define Posttraumatic Growth as “significant beneficial change in cognitive and emotional life, beyond previous levels of adaptation, psychological functioning, or life awareness” (Tedeschi and Calhoun, 2003, p. 1). Unlike other related constructs, PTG is a model of both the process and the outcomes of experiencing a traumatic event. Further, PTG refers to actual changes in the person’s cognitive and emotional life as a result of their struggle to cope with the enormity of their experience (Tedeschi and Calhoun, 2003). PTG is an evolving construct, and research continues to be conducted to further develop this model. In the PTG model (Calhoun and Tedeschi, 2006), the traumatic event is referred to as a ‘seismic event’. Tedeschi and Calhoun use this metaphor in so far as it conjures an image of Janoff-Bulman’s (1992) shattering of fundamental assumptions theory of trauma. Janoff- Bulman suggested that the experience of trauma is psychologically damaging because it has the effect of shattering a person’s fundamental assumptions: that the world is benevolent; the world is meaningful; and the self is worthy. The shattering of these assumptions forces the individual to reconstruct meaning and purpose in their life, resulting in the journey to adaptation. A number of factors have been demonstrated to impact one’s experience of growth including the immediate intrusive ruminations that result from the seismic event. Rumination is often perceived as an adverse reaction to trauma and a symptom of post- traumatic stress. However Calhoun and Tedeschi (2006) suggest that over time rumination becomes a deliberate process of making meaning and the development of new schemas, thereby leading to positive adaptation. Emotional and social support is thought to benefit survivors of trauma due to its facilitation of the deliberate rumination process (Tedeschi and Calhoun, 2003). Five domains have been demonstrated as the outcomes of the PTG process in Tedeschi and Calhoun’s US based research. These are: 1) Appreciation of life; 2) Relating to others; 3) Personal strength; 4) New possibilities; and 5) Spiritual change (Tedeschi and Calhoun, 2004). Tedeschi and Calhoun have also proposed that wisdom is an important outcome of the trauma adaptation journey that appears outside the positive cognitive and emotional changes represented by these five factors. In keeping with the salutogenic paradigm, the PTG model also includes the enduring distress that many face in the aftermath of their experience as a potential outcome, concurrent with the development of growth and wisdom as outcomes (Tedeschi and Calhoun, 2004). Cross-cultural validation studies of these five growth outcomes has demonstrated some similarities and some differences between the way in which PTG process and outcome factors are experienced and expressed for people from a range of cultural backgrounds (Weiss and Berger, 2010). Research investigating the experience and expression of PTG process and outcomes in African refugees in Australia (or elsewhere) is sparse. The authors of this chapter have conducted a number of long term and cross-sectional research projects examining the experiences of trauma for Sudanese and West African Australians. This research has been qualitative and exploratory in nature, and was interested in eliciting data that is grounded in the lived experience of the research participants. Copping and Shakespeare-Finch have found that factors contributing to positive adaptation for African refugees living in Australia include Religion, Strength, Compassion, and New Possibilities/ Better Times Ahead. Each of these

Complimentary Contributor Copy Trauma and Survival in African Humanitarian Entrants to Australia 339 factors can be related to facets of the construct of PTG explained above, and therefore are interpreted as being indicative of the process by which PTG occurs. Data that appears in the sections that follow is in the form of quotations elicited during this research (as referenced) and data is further linked with results from other researchers lending additional support to the variables identified as important in the adaptation of refugee people to their new home country.

Religion

For African-Australian former refugees who express religious faith, a majority tend to attribute their survival to God (Shakespeare-Finch and Wickham, 2010). For example, “One day God will hear, God will not always abandon his people, he will do something for them” (Interview with Copping et al., 2010). The cultures of many African nations have strong spiritual and/or religious values built into them, with connection between the present generations and the ancestors, and between members of a community often being formed along spiritual lines (Greeff and Loubser, 2007). In these cultures, it appears that “God” plays an active role in one’s life as a matter of fact, not faith alone, and the belief that it was by God’s will that they survived, provides comfort to those who have survived war in African nations (Goodman, 2004; Schweitzer, Greenslade and Kagee, 2007). Due to this faith in God, the effect of prayer as a healing mechanism for African- Australian survivors of trauma is significant. The act of praying allows them to have the hope that God will guide them through difficulties. Similarly, reading a passage in the Bible can give former refugees hope, guidance, or counsel (Schweitzer et al., 2007). Prayer has also been noted as an effective coping mechanism in South Africans (Demmer, 2007; Greeff and Loubser, 2007; Peltzer, 2000; Reckson and Becker, 2005), Latin, African and Asian Americans (Constantine, Alleyene, Caldwell, McRae and Suzuki, 2005), Congolese women (Maman, Cathcart, Burkhardt, Omba and Behets, 2009), and Malian women (Hess and McKinney, 2007). In addition to the specific faith in religion, a sense of fatalism is apparent for many African-Australian trauma survivors. For example:

We say that everything has its time, maybe it’s not my time so I have to be patient, you always get what you deserve and if you are in a hurry you will get something that you don’t deserve, so we are being patient. (Interview with Copping, 2010)

In much Western psychological literature, the internal, individualistic locus of control is indicative of resilience (Harvey, 2007). However for African-Australian former refugees, a fatalistic locus of control appears to be: a) culturally appropriate for this highly religious and collectivistic population; and b) appropriate given the intense lack of control these survivors of trauma have had over the war situation and in their day-to-day lives. The reliance on religion as a form of adaptation to trauma may reflect a process of cultural or societal growth, rather than the personal growth outcomes perceived by Western survivors of trauma. Fatalism has been displayed as a coping mechanism in other collectivistic cultures; for example, in Asian-Americans in their response to the 9/11 World Trade Centre attacks (Yeh, Inman, Kim and Okubo, 2006) and in Malian women living with HIV/AIDS (Hess and McKinney, 2007).

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Unlike Caucasian-Australian survivors of trauma (e.g., Copping, Shakespeare-Finch and Paton, 2008; Shakespeare-Finch and Morris, 2010), African-Australians appear to feel the greatest comfort in relinquishing control to a higher power, rather than in taking back control again, perhaps as a method of secondary control (Weisz, Rothbaum and Blackburn, 1984). Along with providing a secondary sense of control, a fatalistic and religious orientation may allow African-Australians to make meaning from the experiences they have had in alternative ways to Caucasian-Australians (Tse, Lloyd, Petchkovsky and Manaia, 2005). This has interesting implications for culturally appropriate practice in Australia; for example, religion may be seen as a negative coping mechanism or as a form of denial in Western psychological practice (e.g., Znoj, 2006). A Western mental health professional who holds this as a cultural norm may negate the importance of religion for their client and therefore ignore a ‘local’ coping method that can contribute to the client’s well-being. Unlike much of the western literature on PTG, religion in African-Australian former refugees does not tend to be expressed as a strengthened religious faith, nor as a greater understanding or appreciation of religious or spiritual matters, but as a means by which people are able to make meaning of the experiences they have had, to cope with the survival period, and to be resilient to the adverse effects of trauma. It therefore appears to be part of the process by which adaptation to the post-trauma journey can occur; that is, religion is part of the process of PTG, rather than a growth outcome. Religion is thought to help people to grow through providing “enhanced meaning of life, increased social support, acceptance of difficulties and having a structured belief system” (Shaw, Joseph and Linley, 2005, p. 2). It appears that, for African-Australian survivors of trauma, religion and spirituality are mechanisms by which people are able to adapt positively to hardship, and this way of creating a sense of meaning around their experiences has developed as a culturally sanctioned norm.

Strength

Strength has been expressed by African-Australian survivors of trauma; however rather than being articulated as a growth outcome (I feel stronger because of my experiences), it is articulated as a survival and coping mechanism (I survived this hardship because I am strong) (Shakespeare-Finch, 2008). Similarly, Strength is not only expressed as a personal quality, but as a necessary factor for success in life for all people (Copping, 2010; Schweitzer et al., 2007). Strength has a number of facets that reflect the higher order concept of having the strength to manage emotional distress and to adapt to post-trauma life. Hope and determination is one such factor that refers to the individual believing in their own ability to survive, being determined to survive and create a good life for themselves, as well as placing hope in religion (Schweitzer et al., 2007). Often the only thing to do is to hope and struggle to survive, despite the hardship that is being faced by African people in their homeland. Another factor that resonates with many African-Australian survivors of trauma is the notion of working hard for their own survival. Through all of the struggles that African- Australians have faced, in Africa, en-route, and in their resettlement in Australia, these former refugees have had to work extremely hard to survive and achieve (Copping et al., 2010). This is expressed not only from a personal perspective, but is also central to African-Australian’s cultural values. For example, great emphasis is placed on the importance of education,

Complimentary Contributor Copy Trauma and Survival in African Humanitarian Entrants to Australia 341 employment, and providing for one’s children (Schweitzer et al., 2007). It is believed that hard work will enable one to survive through hardship, combined with having hope, determination, and personal strength. Also integral to the notion of having strength is that success is possible in the face of adversity. This is most akin to the PTG construct, in that struggle is seen as a precursor to growth (Calhoun and Tedeschi, 2006), and that through hope, determination, personal strength, and hard work, one will achieve success. It also raises the possibility that growth for African-Australians, whilst not articulated as a personal outcome, may have been developed over time as a response to societal hardships and therefore is perceived as cultural or community growth. African Australians are not likely to see these notions of strength as being as a result of their experiences, but rather that it is their ability to accept hardships, and have the hope and determination to survive, that has enabled them to be resilient to the effects of trauma. It appears that rather than being an outcome that is personally applicable, strength is instead a cultural value that promotes resilience to adversity; for example, one participant explained: “Because we have in-built mechanisms, you’re born in Africa, you’re born into the survival race, that’s it” (Interview with Shakespeare-Finch, 2009).

Compassion

Having an increased compassion for others is a facet of growth in Caucasian Australian trauma survivors (Copping et al., 2008; Shakespeare-Finch and Copping, 2006), but Compassion is also expressed as a cultural value for African-Australians. Their collectivistic ideals influence African-Australians to help one another, and is particularly expected of the individual once they have become successful. However, compassion can come also from witnessing the suffering of others within their community, and from going through the challenges that they have personally experienced. For example, in Copping’s (2010) research a Sudanese participant said: “If you can get money to help people when your friend is suffering, yeah you can help… I will say in my life in my future I want to help orphans”. This expression of compassion is similar to a Caucasian-Australian samples cited above, who expressed increased empathy or understanding once they themselves had experienced trauma. In their work with African-Australian survivors of trauma, Copping et al. (2010) found that they are likely to express a desire to work with Africans, to contribute to charity causes in Africa such as orphanages, or to work hard to send money back to their families in Africa. Compassion is thus expressed as a form of growth. The day to day lived experience of hardship allows these survivors to feel compassionate towards members of their community, and is expressed as a cultural value to help one another. There is also a sense within African- Australian people of wanting to contribute to the Australian community in terms of becoming integrated into the community, being a good person, and working hard (Copping, 2010). Compassion may have developed over time to allow individuals within these cultures to be resilient to adversity, in a process of cultural or societal growth. Compassion in African- Australian survivors of trauma also appears as a process through which one may grow, for example: “each time I had to sort of encourage people or talk to people… I think all of those things helped me go through my own situation”, and as a potential growth outcome, for example: “In Africa it’s not that easy for medical treatment, it’s very hard, so I just want to be a nurse so I will be able to help others in need or others that don’t have money, help the poor

Complimentary Contributor Copy 342 Alicia Copping and Jane Shakespeare-Finch and be able to get the medical treatment and stuff” (quotes from interviews with Copping, 2010). Whilst Compassion may reflect a cultural norm that was previously present in African- Australian trauma survivors, the targets of that compassion seem to develop due to their personal experiences with trauma. For example, a Sudanese woman (who was herself orphaned at a young age) stated: “When I came here [Australia] after I was a little bit settled, I went back to school, I studied, I got a job; maybe one day I will sponsor orphans” (Interview with Copping, 2010). In this way, compassion has manifested in a consistent fashion as it is most often expressed in Caucasian Australian populations.

New Possibilities/Better Times Ahead

The anticipation of New Possibilities is confounded and hence cannot be differentiated from the resettlement of the African-Australian people to Australia, a country in which opportunities for education in particular, enables them to explore new life paths. The transition from the refugee camp to Australia can be seen as an opportunity to begin a new life after the hardship of war and life in the camp. For example, the quotation: “Going through hardship has shown me that anything is possible” indicates a feeling that the slate has been wiped clean and now there is the opportunity to begin life anew (in Copping, 2010). This new life is seen as an opportunity for African-Australian trauma survivors to move on with their lives, to forget the hardship they have faced, and to take advantage of the new opportunities that present themselves. Goodman (2004) states that the young Sudanese boys in her sample were able to replace the hopelessness they previously felt about their lives with the hope for a better life. Emphasis is placed on new opportunities in education, with education viewed as “the means of being somebody” (Goodman, 2004, p. 1190). In a study of Oromo and Somali refugees who had resettled in the US, having a focus on new possibilities, thinking they had made the right choice in migrating, and having no plans to return to their home country permanently was shown to have a significant effect in reducing PTSD symptomatology (Halcon et al., 2004). Focusing on creating a new life in Australia may be similarly effective in supporting the mental health of the African-Australian population. New Possibilities can therefore be seen as a PTG outcome that has personal significance to African-Australian participants as they rebuild their lives. The notion of there being better times to come is a combination between having hope and the New Possibilities concept described above. Rather than the focus on the tangible aspects of New Possibilities in their new country, however, there is a focus on more esoteric notions that one day, life will be better. For example, a Sudanese woman reported, “I was suffering positively in the sense that yes I’ve been suffering, but I was looking for a direction which would give me a future” (Interview in Shakespeare-Finch, 2009). It appears to be another cultural variable that promotes resilience, which may have developed over protracted periods of hardship, rather than as a resettlement outcome. This theme reflects a faith that there will be a good future, rather than an appreciation for what is in the present. Broadening the context of trauma in African populations, Demmer (2007) found that hope for the future was important for South African participants who had experienced an AIDS related loss, particularly in their own economic circumstances and the hope they had

Complimentary Contributor Copy Trauma and Survival in African Humanitarian Entrants to Australia 343 for their children. Similarly, McGadney-Douglass and Douglass (2008) found that their elder Ghanaian sample were likely to express more concern for the younger generation than for themselves. This is in keeping with the concerns that collectivistic cultures have for their family and community. Therefore, the idea that there are better times to come is reflective of concern for community welfare rather than being reflective of future orientation per se. Summerfield (1997) suggests such themes can be explained by the fact that war trauma is an inherently collective experience, disrupting familial and community networks (Summerfield, 1997), and therefore any sense of growth from the experience must be targeted towards the group, rather than the individual.

CONCLUSION

This chapter has described the potentially traumatic experiences that African-Australian Humanitarian Entrants have faced pre-migration, whilst en-route through refugee camps (such as Uganda, Botswana, Kenya and Namibia) and in their resettlement to Australia. Whilst traditional western psychology may focus on the vulnerabilities and potential for PTSD, depression and various other pathological outcomes in refugee groups, it is important to focus on community strengths and local coping mechanisms in an effort to avoid perpetuating the cultural imperialism of the past. This chapter has also described the adaptation of African-Australian survivors of trauma to their experiences, focussing on strengths and dimensions of posttraumatic growth. Personal strength, religion, compassion, and an appreciation for new possibilities and hope for a better future ahead are key adaptive factors leading to resilience, coping, and personal growth. It is hoped that by considering strengths, adaptive capacity, and community based coping methods, mental health professionals will consider the culturally-constructed realities of their clients in order to maintain a culturally responsive psychology into the future of our increasingly diverse society.

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Kienzler, H. (2008). Debating war-trauma and post-traumatic stress disorder (PTSD) in an interdisciplinary arena. Social Science and Medicine, 67, 218-227. Mackenzie, C., McDowell, C. and Pittaway, E. (2007). Beyond 'do no harm': The challenge of constructing ethical relationships in refugee research. Journal of Refugee Studies, 20(2), 299-310. Maman, S., Cathcart, R., Burkhardt, G., Omba, S. and Behets, F. (2009). The role of religion in HIV-positive women's disclosure experiences and coping strategies in Kinshasa, Democratic Republic of Congo. Social Science and Medicine, 68, 965-970. Marlowe, J. M. (2010). Beyond the discourse of trauma: Shifting the focus on Sudanese refugees. Journal of Refugee Studies, 23(2), 184-198. McGadney-Douglass, B. F. and Douglass, R. L. (2008). Collective familial decision making in times of trouble: Intergenerational solidarity in Ghana. Journal of Cross-Cultural Gerontology, 23, 147-160. Peltzer, K. (2000). Trauma symptom correlates of criminal victimization in an urban community sample, South Africa. Journal of Psychology in Africa, South of the Sahara, the Caribbean and Afro-Latin America, 10(1), 49-62. Piper, M. (2006). Refugees and human rights. Plenary address given at the Australian and New Zealand Society of Criminology 19th Annual Conference, Hobart, Australia. Pupavac, V. (2002). Therapeutising refugees, pathologising populations. International psycho-social programmes in Kosovo: United Nations, New York, Geneva, Vienna. Rasmussen, A., Smith, H. and Keller, A. S. (2007). Factor structure of PTSD symptoms among West and Central African refugees. Journal of Traumatic Stress, 20(6), 271-280. Refugee Council of Australia. (2006). Australia's refugee program. Retrieved 29/1/2009, from http://www.refugeecouncil.org.au Reckson, B. and Becker, L. (2005). Exploration of the narrative accounts of South African teachers working in a gang-violent community in the Western Cape. International Journal of Social Welfare, 14, 107-115. Schweitzer, R. D., Greenslade, J. and Kagee, A. (2007). Coping and resilience in refugees from the Sudan: A narrative account. Australian and New Zealand Journal of Psychiatry, 41(3), 282-288. Schweitzer, R. D., Melville, F., Steel, Z. and Lachareaz, P. (2006). Trauma, post-migration living difficulties, and social support as predictors of psychological adjustment in resettled Sudanese refugees. Australian and New Zealand Journal of Psychiatry, 40, 179- 187. Shakespeare-Finch, J. and Copping, A. (2006). A Grounded Theory approach to understanding cultural differences in Posttraumatic Growth. Journal of Loss and Trauma, 11, 355-371. Shakespeare-Finch, J. (August, 2008). Cultural similarities and differences in conceptions and misconceptions of posttraumatic growth. Paper presented at the meeting of the 115th American Psychological Association convention, Boston, MA. Shakespeare-Finch, J. (November, 2009). Post-trauma Adaptation in Adult Refugees in Australia: Extraordinary Resilience in Sudanese, West Africans, and Minority Groups from Burma. Poster presented at the International Society for Traumatic Stress Studies conference, Atlanta, GA. Shakespeare-Finch, J. and Morris, B. A. (2010). Posttraumatic Growth in Australian Populations. In T. Weiss and R. Berger (Eds.). Posttraumatic Growth and culturally

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competent practice: Lessons learned from around the globe (pp. 157-186). New York: Jon Wiley and Sons. Shakespeare-Finch, J. and Wickham, K. (2010). Adaptation of Sudanese refugees in an Australian context: Investigating helps and hindrances. International Migration, 48, 23- 46. Shaw, A., Joseph, S. and Linley, P. A. (2005). Religion, spirituality, and posttraumatic growth: A systematic review. Mental Health, Religion, and Culture, 8(1), 1-11. Summerfield, D. A. (1997). The impact of war and atrocity on civilian populations. In D. Black, M. Newman, J. Harris-Hendriks and G. Mezey (Eds.), Psychological trauma: A developmental approach (pp. 148-155). London: Gaskell. Summerfield, D. A. (2000). War and mental health: A brief overview. British Medical Journal, 321, 232-325. Sweeney, A. J. (2008). Bumps in the Yellow Brick Road: Sierra Leoneans in Launceston, Australia and their settlement experiences. The International Journal of Diversity in Organisations, Communities and Nations, 7(6), 283-293. Tedeschi, R. and Calhoun, L. (1995). Trauma and Transformation. Thousand Oaks, CA: Sage. Tedeschi, R. and Calhoun, L. (2003). Routes to Posttraumatic Growth through cognitive processing. In D. Paton, J. Violanti and L. Smith (Eds.), Promoting Capabilities to Manage Posttraumatic Stress (pp. 12-26). Chicago, Illinois: Thomas Books. Tedeschi, R. and Calhoun, L. (2004). The foundations of Posttraumatic Growth: New considerations. Psychological Inquiry, 15(1), 93-102. Tilbury, F. and Rapley, M. (2004). 'There are orphans in Africa still looking for my hands': African women refugees and the sources of emotional distress. Health Sociology Review, 13(1), 54-64. Tse, S., Lloyd, C., Petchkovsky, L. and Manaia, W. (2005). Exploration of Australian and New Zealand indigenous people's spirituality and mental health. Australian Occupational Therapy Journal, 52, 181-187. UNHCR. (1994). UNHCR CDR background paper on refugees and asylum seekers from Liberia. Retrieved 29/1/2009, from http://www.unhcr.org/refworld UNHCR. (1998). UNHCR CDR background paper on refugees and asylum seekers from Sierra Leone. Retrieved 29/1/2009, from http://www.unhcr.org/refworld UNHCR. (2000). Background paper on refugees and asylum seekers from the Sudan. Geneva: UNHCR. UNHCR. (2007). Convention and protocol relating to the status of refugees. Retrieved 9/12/2008, from www.unhcr.org/basics Weiss, T. and Beger, R. (Eds.). (2010). Posttraumatic Growth and culturally competent practice: Lessons learned from around the globe. New York: Wiley and Sons. Weisz, J. R., Rothbaum, F. M. and Blackburn, T. C. (1984). Standing out, standing in: The psychology of control in America and Japan. American Psychologist, 39(9), 955-969. Westoby, P. (2009). The sociality of refugee healing. Australia: Common Ground.

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Yeh, C. J., Inman, A. G., Kim, A. B. and Okubo, Y. (2006). Asian American families' collectivistic coping strategies in response to 9/11. Cultural Diversity and Ethnic Minority Psychology, 12(1), 134-148. Znoj, H. (2006). Bereavement and posttraumatic growth. In L. G. Calhoun and R. G. Tedeschi (Eds.), Handbook of Posttraumatic Growth (pp. 176-195). Lawrence Erlbaum: Mahwah, New Jersey.

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Chapter 20

RESILIENCE AND RESOURCEFULNESS AS FACILITATORS OF ADJUSTMENT IN IMMIGRANTS DURING TIMES OF ADVERSITY

Giorgio Ilacqua*1, Marek J. Celinski1, and Lyle M. Allen III2 1Private Practice, Toronto, Canada 2CogniSyst Inc., Durham, NC, US

ABSTRACT

The experience of immigration can be seen as a cumulative trauma in which the sum of many minor and bigger stressors contribute to create a traumatic experience that can be felt many years after the actual migration. Consistent findings have shown that the positive predictors of successful resettlement are related to personal and available external resources such as: an ability to integrate with the host culture, family and community support, perceived improvement in personal or family condition, and better access to psycho-social services. In this study, the Resourcefulness for Recovery Inventory – Research Edition (Celinski, Antoniazzi and Allen, 2007) administered to immigrants of various ethnic backgrounds provides evidence that personal resourcefulness can be measured and this can differentiate between ethnic groups, based on the measures utilised. Cultural factors may disadvantage certain groups, when facing immigration stress and additional psychotraumas, and this may require special attention and effort at integration with the host country’s social environment, and sensitivity to cultural issues when interpreting clinical test data and providing therapy.

Keywords: Immigration, Adjustment, Culture, Resourcefulness, Cumulative Trauma

* Contact: Dr. Giorgio E. Ilacqua, C. Psych; Ilacqua, Marino, Costa El-Hage (Registered Psychologists); Centre for Psychological Assessment, Treatment and Education, 951 Wilson Avenue, Suite 9, Toronto, ON M3K 2A7. E- mail: [email protected]

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INTRODUCTION

Shin, Han and Kim (2005) described the immigration experience as “one of the most significant stressful life events that are often linked to increased levels of depression” (p. 415). A new immigrant faces a choice of either embracing new challenges or responding with fear, hostility, withdrawal and clinging to the “old ways” which will cause further frustration. To better understand the dynamics of immigration, we will refer to a model of trauma described first in Celinski and Gow’s (2005) paper and subsequently in Celinski (2012). According to these conceptualizations, immigration experience contains two essential components of trauma: a sense of discrepancy and disunity. Immigration forces people to confront attitudes, ideas and emotions associated with the “old country” with the new and this can threaten personal integration and create confusion and uncertainty. In some instances, the necessary changes may be relatively superficial (i.e., acquisition of the language alongside knowledge of values and laws of the new country, etc.); however, in instances when the new reality threatens the integrity of the self and successful participation in various social roles, loss of social support that existed in the country of origin and served as a buffer against regressive disintegration, may have serious negative consequences for the individual in the new country. An important distinction about the prospect of integration with the host country is made regarding immigrants’ attitudes; there are people who, after they have left their country of origin, are not willing to return versus those whose work or leisure requires that they spend extended period of time abroad. This second group (who can be described as “long term travelers”) is characterized by a continuous emotional connection with their country of origin and they are not likely to regard the host country as a permanent residence. For the long term travelers, the need to accommodate to the new country loses intensity and pertinence, and instead they are likely to be more interested in learning about cultural differences and in exploring exotic nuances. In contrast to such a frame of mind, for the first group of migrants, it will be a personal failure if they return to the reality that had compelled them to migrate to begin with; they would rather deliberately decide to “shipwreck” and “burn their returning ticket” (very much like the mutineers of ‘The Bounty’ who burned their own vessel). This group interests us more because they have to accept the typical resettlement challenges and make a serious effort at adjustment with uncertain results. Whereas psychosocial research has already identified some factors that facilitate or hamper adjustment, Uskul and Greenglass (2005) still commented that little is known about “the psychological ways in which adjustments takes place” (p. 271). Admission of ignorance is not surprising, given the complex issues that have to be dealt with; immigrants not only have to re-invent themselves vocationally, educationally, socially, and financially, but they are also compelled to adjust to new social and legal norms, as well as to assimilate the unwritten ways of how to socially navigate in the host country. The factors that are often mentioned as potentially buffering the immigrant’s experience include a degree of racial and cultural acceptance of the host country, an individual’s education and socio-economic status, along with social support from an akin cultural group, from extended family groups and from marital relations. As factors that potentially would interfere with successful adjustment, Phinney, Madden and Santos (1998) noted that decreased employment opportunities, lower salary, and social ambiguity may affect the immigrant’s sense of self and at the same time,

Complimentary Contributor Copy Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants … 351 test his or her sense of resilience and resourcefulness. Whereas immigration from their own country is usually a high risk situation for almost everybody, it is even more disadvantageous if the migrants possess fewer internal resources that could be specifically needed for successful adjustment; in such instances, it is more probable that they would develop emotional and psychological problems (Moghaddam, Ditto and Taylor, 1990). This chapter proposes that the difference between the successful and the unsuccessful adjustment to the host country may be explained with reference to the concepts of resilience and resourcefulness. Resilience is defined as the ability to endure (i.e., without showing serious emotional symptoms) and to continue with efforts at adjustment (Celinski and Pilowsky, 2008) while facing the inevitable decline in social status, the prospect of rejection, and various frustrations typically associated with migrating. Resourcefulness is defined as the person’s ability to use one’s own ideas, emotions and skills (Celinski and Gow, 2005, Celinski and Allen, 2011) in order to fully engage with the new psychosocial reality and to achieve chosen levels of adjustment and specific goals. The successful immigration is therefore determined by the two different (although intertwined) personal characteristics; one, referring to the person’s ability to make sense out of the new environment and to establish priorities and commitments to their implementation (representing primarily resilience); and two, manifesting as hope and belief in one’s own ability to make an impact on his or her own environment (Phinney, Madden and Santos, 1998) which characteristics, in our view, pertain to resourcefulness. Utilising such an understanding of either construct, resilience and resourcefulness have common features with social intelligence which is described by Pan et al. (2007) as a “personal trait or process of bouncing back from, overcoming, surviving, and/or successfully adapting to a variety of adverse conditions or life stresses” (p. 741). For some people, resilience and resourcefulness or social intelligence (that determine successful versus unsuccessful resettlement) represent a personality trait that allows a person to be “intuitively” adaptive and appropriately flexible, while for the others, it is a learning process that needs to be skillfully and sympathetically guided. It may be noted with reference to Lam (2007) that, although resilience and resourcefulness have been researched and accepted in the field of psychology, their application to the immigration and acculturation experience is still in its “infancy”. It is therefore the primary intention of this chapter to provide further arguments that personal characteristics of successful immigrants can be reframed with reference to the resilience and resourcefulness constructs representing the mindsets, and self-referring concepts and behaviors that are different from the cases of the unsuccessful ones. (At the same time, one has to be cautious not to generalize these characteristics to the people in the country of origin because immigrants are already a pre-selected group; due to the challenges of immigration, only highly resilient and resourceful people would take such a drastic step while hoping to succeed in a new country in spite of overwhelming odds). There is still the question of what is the yardstick of successful adjustment. In our view, this should not be measured in terms of acquired material assets alone. It is an oversimplification to believe that better financial prospects in themselves are a sufficient motive to initiate an emotionally challenging immigration process, although frequently it could be one of the reasons. Likely migration decisions and perseverance in the host country are a reflection of the sense of self worth and perceived possibility to influence the course of one’s life. From this perspective, the material wealth could be seen as an added bonus and a natural outcome of being able to appropriately channel one’s own efforts at participation in the life of the host country.

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Similarly, the degree of acculturation described by Shin, Han and Kim (2005) as the “process of changing an immigrant’s attitude and behaviors in the direction of the dominant cultural group” (p. 416) is not always associated with psychological well-being, even though they may also manifest as financial success. This suggests that mere acceptance of different social values is not, in itself, the factor that determines a successful immigration experience.

WHAT DO RESILIENCE AND RESOURCEFULNESS ADD TO THE UNDERSTANDING OF THE IMMIGRATION PROCESS?

The concepts of resilience and resourcefulness are not new to the field of positive psychology. Related concepts such as “self-mastery” or “well-being and happiness” are frequently utilized in the literature although, at times, and in spite of the many good intentions of the authors, they appear as lackadaisical, and as coming from everyday parlance rather than conveying a clear meaning in a philosophical or scientific sense which limits their potential for furthering knowledge. Applying the concepts of resilience and resourcefulness, as previously defined, is consistent with the current emphasis on positive psychology and provides a prospect of developing a cohesive theoretical framework within the field of applied psychology, specifically in reference to the migration research. In this respect, especially relevant for understanding effective coping is Antonowsky’s (1987) internal Sense of Coherence. He described SOC as the “global orientation that expresses the extent to which one has a pervasive enduring though dynamic feeling of confidence” (p. 19) that internal and external reality is “structured, predictable and explicable” (which refers to “comprehensibility”). Individuals possessing a Sense of Coherence should also perceive themselves as having sufficient resources “to meet the demands posed by these stimuli” (which represents manageability) and to see these demands as challenges “worthy of investment and engagement” (which pertains to meaningfulness) (Antonowsky, 1987, p. 19). He also believed that people with high “resistance resources” are better equipped (personally and socially) to cope with society’s demands. Antonovsky thus appears to have laid the ground work for the studies of resilience and resourcefulness as further described in the present volume. Specifically, this chapter will attempt to clarify how the current wealth of knowledge on psychological experience of immigration could be integrated within the conceptual framework of resilience and resourcefulness. A study conducted by Shin, Han and Kim (2005) is an example of how personal resources could mitigate the risk of depression in Koreans immigrating to the United States. They clarified personal resources by referring to a “sense of mastery” which is consistent with Antonovsky’s formulations of manageability and which could be interpreted as also boosting the immigrant’s resilience when confronted with distressing experiences. They further noted that the immigrant’s ability to tap into the available resources in the host country to obtain social support “may buffer the effect of stress on negative feelings while increasing positive feelings of happiness” (p. 423). These authors designed a 7-item instrument to assess “sense of mastery” which they described as the “belief in one’s capabilities to overcome life adversities” (p. 419).

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A similar concept of self competence was researched by Phinney, Madden and Santos (1998) in relation to perceived discrimination in groups of Armenian, Mexican-American, and Vietnamese adolescents. Their findings again can be seen as further support for the hypothesis that resilience and resourcefulness need to be viewed as the essential characteristics of the migration experience. Adolescents, with a higher sense of mastery and competence, perceived less discrimination from the host culture and suffered less depression and enjoyed higher self-esteem. The authors concluded that a positive outlook generally appears to decrease the likelihood of perceiving events negatively, specifically with regard to social discrimination. Brisette and Scheier (2002) conducted a study on optimism and its effects during life transitions which may be extended to the life transition associated with immigration. They concluded that “greater optimism has been found to be associated with less mood disturbance in response to a variety of stressors” (p. 102) and the different coping strategies used by optimists, rather than those adopted by pessimists, contribute to their better adjustment (p. 102). Brisette and Scheier emphasized the importance of social networks as “stress buffers.” According to them, optimists are more socially accepted, have more social support and enjoy increased levels of support in times of crisis. Furthermore, Brisette and Scheier (2002) regarded individuals manifesting a more optimistic outlook as more likely to be perceived as worthy for initiating social contacts and as being more attractive to others. Brisette and Scheier also noted that “a greater friendship network size” and “higher quality friendships” (p. 107) are important in life transitions. Perceived social support, according to both authors, is a reflection of stable positive expectations established through past experiences. Individuals, who were effectively able to integrate with their social environment and obtain support in their country of origin, would also find it natural to transfer these skills to the requirements of the host country; this would give them an opportunity of getting a higher level of support that would diminish the negative impacts of their stressors. In other words, resilience and resourcefulness are the essential and necessary innate characteristics of successful immigrants and both constructs help make sense and provide directions for their adaptation processes. Resilient and resourceful people can also be described as having “proactive coping skills” (Seligman, 1990) which are necessary in overcoming challenges and reaching personal goals, and which indirectly promote psychological wellbeing. People with proactive coping skills tend to face the perceived challenges boldly, directly, and realistically, and through committed efforts try to change situations that cause negative emotions and distress. People with these skills do not resort to the dysfunctional strategies of avoidance, withdrawal or over-rationalization. Resilient and resourceful individuals, who have chosen to leave their native country, are likely to be more proactive and self-assured in managing their integration in the new country, while less competent, unhappy or psychologically ill adjusted immigrants are perhaps more likely to perceive their immigration as a hopeless and negative experience with little personal power to change or direct it. Resilient and resourceful immigrants are also more likely to perceive the experience of immigration in more positive terms than immigrants possessing a lesser degree of these characteristics, specifically with respect to being able to see immigration as a challenge and an “opportunity” (e.g., being inspired by “the Canadian dream”). Uskul and Greenglass (2005) regard proactive coping as an essential variable in facilitating the achievement of challenging goals and in promoting personal growth and

Complimentary Contributor Copy 354 Giorgio Ilacqua, Marek J. Celinski and Lyle M. Allen III psychological wellbeing that is considered one of the hallmarks of physical and psychological health. They confirmed the importance of these personal orientations in their study on a sample of Turkish-Canadians immigrants; although, in that group, depression was a common finding, the deleterious effects of this condition was easily counterbalanced by “proactive coping”, or the active and self-initiating process of integrating oneself in the host country. Adapting these authors’ results to the thrust of the present chapter, it can be said that debilitating depression, as it relates to the immigration experience, can be described as resulting from a passive and dysfunctional approach to life’s challenges, while resilience and resourcefulness manifest in an active orientation that is essential to achieve a well balanced psychological status. Another reference to the concepts of resilience and resourcefulness is presented by Lam (2007) in a study on Vietnamese-American college students. That author proposed that “collective self-esteem”, namely “an individual’s appraisal of one’s self-esteem derived from interaction with others” (p. 370) was associated with lower distressing emotional findings in this sample group. The author expanded further Antonovsky’s idea in that a low Sense of Coherence would start a snow-balling effect on individuals that would in turn affect their cognition, their sense of accomplishment and would terminally undermine their sense of perceived control over the external environment. As the author posits, the Sense of Coherence has “an important role” in “developing resilience to stress” (p. 374). From such a perspective, Lam’s study of the Sense of Coherence represents an essential step toward an integrative theory of the psychological impact of immigration that refers to resilience and resourcefulness, as his findings provide the link between theory (referring to Antonovsky’s broadly accepted model) and the replicable research findings. Similarly, Polek, van Oudenhoven and ten Berge’s (2008) findings also can be reinterpreted within the resilience and resourcefulness conceptual framework. They compared the attachment styles of Polish, Russian and Hungarian immigrants to the native Dutch attachment style. A secure attachment style, characterized by internal self-confidence and assurance and devoid of outward fears, can be regarded as representing a high sense of resilience and resourcefulness. Interestingly, when accounting for other confounding variables, the secure attachment style was positively correlated with psychological health in all the national groups analyzed. Moghaddam, Ditto and Taylor (1990) findings can also be reinterpreted in a similar way. After evaluating a sample of Indian immigrant women to Canada, they found that demographic and societal variables did not differentiate between high and low emotional distress, while “fundamental social psychological variables” such as attitudes, attributions, self perceptions and desired sex roles did. These findings are, in our opinion, easily explainable in the context of the resilience and resourcefulness framework, namely that migrants (in this case Indian women relocating to Canada) are to be looked at in terms of their innate potentials and not primarily with respect to their basic socio-economic characteristics. Simply put, social and demographic variables represent only a fraction of the issues causing immigration to be a stressful experience which could be made less painful, if the newcomers’ sense of resilience and their need for broadening their resourcefulness are properly addressed. To document that cultural background creates a predisposing variable to either more or less effective utilization of personal resources at the time of crisis (such as in cases of accident-related injuries and psychotrauma), we compared some data from clients referred to psychological practice for assessment and treatment because of their accident-related

Complimentary Contributor Copy Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants … 355 sequelae. We recognize that the groups were not matched regarding severity of their accidents; however, we attempted to balance other factors. This study, in our view, cannot be over generalized to the whole ethnic group, but may have relevance to practice regarding assessment and treatment of individuals from the studied ethnic groups.

CULTURAL BACKGROUND AND RESOURCEFULNESS IN RESPONSE TO PSYCHOTRAUMA

The following study was undertaken to compare the resourcefulness in some immigrant samples as measured with the Resourcefulness for Recovery Inventory – Research Edition (RRI-RE).

METHOD

Subjects

Our subjects were selected from more than 450 cases of multi-ethnic clients who were referred for psychological assessment due to industrial or motor vehicle accidents and who were seeking financial compensation and eligibility for treatment because of their sustained psychological and physical injuries.

Instruments

The following diagnostic measures that are normally utilized in psychological practice were administered: (1) the Beck Anxiety Inventory (Beck 1987) that refers to the most frequent symptoms of anxiety pertaining to somatic aspects of anxiety, behavioural manifestations and ideations; and (2) the Beck Depression Inventory-II (Beck, 1996) that refers to major manifestations of depression with respect to ideations, psychophysiological reactions, mood and behaviour. As potential for symptom exaggeration is well recognized in the literature - referring to the population which seeks monetary compensation for their injuries and losses (McDermott and Feldman, 2007; Kunst, Winkel and Bogaerts, 2011) - additionally two symptom validity measures were utilized: (3) the TOMM (Test of Memory Malingering, Tombaugh, 1996) and (4) the CARB (Computerized Assessment of Response Bias, Allen et al., 1997). The Resourcefulness for Recovery Inventory – Research Edition (Celinski, Antoniazzi and Allen, 2007) (5) helps to identify both health inhibiting and health promoting factors which are currently present in an individual’s life. The scale compares an individual to others who were post-traumatically affected and who also suffered bodily injuries. The RRI-RE is a two-dimensional instrument representing positive and negative aspects of various constructs addressing knowledge, skills, ideations, attitudes, and personal characteristics which can be activated when an individual is facing challenging and novel situations. The RRI-RE contains 239 items with minimal scale overlap (less than 5%). There

Complimentary Contributor Copy 356 Giorgio Ilacqua, Marek J. Celinski and Lyle M. Allen III are 18 bipolar scales each with positive and negative components (with an understanding that negative subscales are health-inhibiting and positive subscales health promoting). There are also two positive and negative image scales which serve as embedded symptom validity and one fundamental value scale. Mean and median RRI-Full Scale alpha reliability is equal to. 90 and .91 respectively. The RRI-RE subtests tap:

 Control (over one’s condition and situation) vs. Being Controlled  Positive vs. Negative Cognitions and Beliefs  Intentionality vs. Lack of Directions  Broadening Awareness vs. Being Uninformed  Healthful Attention vs. Physical Neglect  Positive vs. Negative Relationship with Health Care Providers  Positive vs. Negative Expectations / Hope  Perceived Choice vs. Restricted Options  Time Focus: Past vs. Present / Future  Self-Responsibility vs. Dependency  Adequate vs. Inadequate Stress Management  Acceptance vs. Non-Acceptance / Denial  Communication vs. Alexithymia and Withdrawal  Social Isolation vs. Social Integration and Support  Internal Integration vs. Disintegration  Minimizing vs. Maximizing Loss  Fundamental Values and Core Beliefs.

Alpha reliability of the subscales and a detailed description of the RRI-RE psychometric properties and its clinical usefulness are described in the “Resourcefulness as the Art of Succeeding” chapter (Celinski and Allen, 2011).

RESULTS

Initially, for the purpose of comparing resourcefulness in various ethnic groups, we selected seven broadly defined groups. Classification was established with reference to country of birth and years of residence in Canada; however, living in a discernable ethnic neighborhood was ignored because they could not be reliably assessed. As such, these criteria may not have been sufficiently differentiating the groups by diluting the power of subsequent comparisons between the groups. First, a series of one-way ANOVAs was conducted to investigate ethnic group differences on demographic and other key variables. Significant overall differences between the ethnic groups were observed for age (F = 3.90, p < .0001), years of education (F = 8.49, p< .0001), symptom exaggeration based on our “genuine” versus “exaggerating” classification variable related to the combined score from CARB, TOMM and multiple measures derived from standard neuropsychological instruments (F = 2.51, p = .01), English

Complimentary Contributor Copy Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants … 357 as a first language (F = 11.21, p< .0001) and English Comprehension (F = 3.08, p = .002). There were no significant differences between ethnic group with respect to gender (p = .19), CARB total score (p = .38), TOMM average score (p = .37), proportion of TOMM Failure (p = .24), the Beck Depression Inventory- II (BDI-II; p = .28) or the Beck Anxiety Inventory (BAI; p = .23). We do not know with certainty which ethnic groups in our sample deviate from their respective overall mean and differ from other groups; nonetheless, the degree to which these variables influenced the differences between our groups can easily be expressed using the ETA statistic (it is scaled like a correlation coefficient and when squared, it provides an estimate of the proportion of variance observed between ethnic groups for each variable; Field, 2005). Table 1 shows that whereas English Comprehension and English as a first language accounted for 12% and 38% of the variance when separately assessed, their true impact was difficult to assess due to significant amounts of missing data that precluded their effective use in subsequent analyses (described below) that utilized various methods of regressions. Multivariate analysis of variance (MANOVA) and covariance (MANCOVA) procedures were considered to be the most reliable and efficient methods of investigating differences between ethnic groups. These analyses also provide a measure of the amount of variance accounted for in the form of the partial eta-square statistic, which “is a nonlinear analog to R- square in regression, similarly interpreted as percent of variance explained” (Garson; http://faculty.chass.ncsu.edu/garson/PA765/manova.htm).

Table 1. Measures of Association

Eta Eta Squared Age .336 .113 Sex .208 .043 Education (years) .469 .220 Exaggeration .361 .130 TOMM (T1+T2) .203 .041 TOMM Fail (T2 < 45) .220 .049 FLTMExt .231 .054 CARB Total .284 .080 Eng. Comprehension .346 .119 Eng. First Language .614 .377 Beck Depression Inv .208 .043 Beck Anxiety Inv .221 .049

This procedure compared the four largest groups (Canadian-born, Polish, Russian and Hispanic born clients) on the RRI-RE full scales using only age and BDI scores as covariates. The overall MANCOVA results, as well as the effects of age and BDI scores, were all highly significant and exhibited excellent observed power. A series of follow-up ANOVAs was undertaken using the least squares difference correction for multiple comparisons that revealed a number of significant group differences on specific RRI-RE scales. Polish and Russian patients were very similar in their presentation on the RRI-RE, and scored consistently below the levels endorsed by either Canadian-born or Hispanic patients, who scored highest on nearly every subscale. A graph of these results is displayed in Figure 1.

Complimentary Contributor Copy 358 Giorgio Ilacqua, Marek J. Celinski and Lyle M. Allen III

Pairwise comparisons between selected ethnic groups were undertaken using binary logistic regression (BLR) in order to identify differentiating variables. Although BLR is best known as a tool for optimally classifying patients, it employs logarithmic data transformations that permit use of both skewed and categorical data (such as gender) and in many ways make it more robust than standard parametric regression methods. Each BLR analysis utilized the backwards stepwise likelihood ratio (Backwards-LR) method that minimizes suppression effects for variables with shared variance, as compared with other methods. All dependent variables are initially included in the model, with each regression step iteratively eliminating the least significant predictor and re-computing the individual contributions until prediction can no longer be improved. Collinearity diagnostics were undertaken using options available within standard multiple linear regression in SPSS.

Note: a. Canadian-born > Polish (p < .01); b. Canadian-born < Hispanic (p < .01); c. Polish < Hispanic (p < .01); d. Russian < Hispanic (p < .01)

Figure 1.Comparisons across Groups on RRI-RE Scales.

Comparing Canadian-born with Polish clients produced a highly significant overall BLR model (Chi2= 49.3, df =10, p< 0.0001). The individual contributions of variables to the final solution are displayed in Table 2 in decreasing order of significance. Wald statistics are known to be somewhat insensitive and to underestimate the true influence of variables in BLR models because they tend to artificially inflate standard errors (Field, 2005, p. 224). Nonetheless, the above results represent the most important retained variables that independently contribute to differences between these two ethnic groups. It is noteworthy that the demographic variables of age and years of education were less predictive than results related to a number of the full RRI-RE scales, suggesting potentially broad utility

Complimentary Contributor Copy Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants … 359 for the RRI-RE, but also highlighting the fact that ethnicity may matter when interpreting RRI-RE scale results. As noted at the beginning, this population did evidence a significant amount of symptom exaggeration, as measured by specially designed cognitive symptom validity tests and other embedded (derived) neuropsychological measures (all victims of various accidents were seeking some compensation). Symptom exaggeration increases sample variance and therefore reduces statistical power, making it hard to observe group differences. Additionally, non-Canadian born ethnic populations are known to have a significantly elevated rate of symptom validity test failure (Allen et al., 1997). When failure on TOMM trial two was included in the initial model, it produced very similar overall results, but was not retained in the final solution. This indicates that symptom exaggeration by itself cannot explain the observed group differences which are better accounted for by RRI-RE scales and certain demographic variables.

Table 2. Individual Contributions of Variables to Solution

Variable B S.E. Wald df Sig. Exp(B) Control -0.164 0.046 12.697 1 0.000 0.849 Health 0.115 0.042 7.582 1 0.006 1.122 Acceptance 0.093 0.034 7.262 1 0.007 1.097 Hope 0.091 0.037 5.937 1 0.015 1.095 Integration -0.077 0.036 4.710 1 0.030 0.925 Intentionality 0.075 0.035 4.451 1 0.035 1.078 Responsibility -0.096 0.046 4.387 1 0.036 0.909 Age 0.028 0.015 3.509 1 0.061 1.028 Emotion -0.055 0.030 3.454 1 0.063 0.946 Educ.Years 0.114 0.064 3.202 1 0.074 1.121

Canadian-born clients were also compared with those of Hispanic origin using the same BLR models used above, which produced a highly significant overall BLR model (Chi2 = 35.8, df = 8, p< 0.0001). The individual contributions of variables differing between these groups are displayed below in Table 3 for the full RRI-RE scales differentiating these groups.

Table 3. Group Differences on RRI-RE Scales

Variable B S.E. Wald df Sig. Exp(B) Time 0.283 0.090 9.878 1 0.002 1.327 Responsibility 0.322 0.106 9.279 1 0.002 1.379 Control -0.246 0.098 6.312 1 0.012 0.782 Acceptance 0.172 0.074 5.425 1 0.020 1.188 Fund. Values -0.180 0.099 3.302 1 0.069 0.835 Family 0.128 0.076 2.821 1 0.093 1.137 Integration -0.165 0.101 2.682 1 0.101 0.848 Loss -0.144 0.088 2.671 1 0.102 0.866

Furthermore, Russian and Polish patients also evidenced differences (see Table 4) derived from using this BLR model (Chi2 = 27.4, df = 6, p< 0.001). Although age was the strongest predictor of group identification, five other full RRI-RE scales made significant

Complimentary Contributor Copy 360 Giorgio Ilacqua, Marek J. Celinski and Lyle M. Allen III contributions to the model. Arguably these two groups appear to be most similar among the four groups assessed using these methods (see Figure 1), but nonetheless evidenced important differences in their response pattern on the RRI-RE.

Table 4. Russian and Polish Patients Differences on RRI-RE scales

Variable B S.E. Wald df Sig. Exp(B) Age -0.059 0.024 5.973 1 0.015 0.942 Responsibility 0.144 0.064 5.154 1 0.023 1.155 Loss 0.118 0.053 5.056 1 0.025 1.126 Alexithymia -0.137 0.062 4.934 1 0.026 0.872 Beliefs -0.105 0.048 4.666 1 0.031 0.901 Health -0.125 0.070 3.195 1 0.074 0.882

Canadian-born clients were also easily differentiated from Russians, producing a significant overall BLR model (Chi2 = 25.1, df = 7, p<.001) with no demographic variables except for years of education retained in the final results that are shown in Table 5.

Table 5. Differences between Canadian-born clients and Russians on RRI-RE Scales

Variable B S.E. Wald df Sig. Exp(B) Family 0.177 0.065 7.510 1 0.006 1.194 Awareness -0.220 0.084 6.921 1 0.009 0.803 Educ.Years 0.307 0.120 6.531 1 0.011 1.360 Alexithymia -0.165 0.071 5.433 1 0.020 0.848 Fund.Values -0.154 0.073 4.390 1 0.036 0.858 Health 0.159 0.080 3.958 1 0.047 1.173 Doctors 0.093 0.053 3.026 1 0.082 1.097

Finally a comparison of Polish versus Hispanic patients was undertaken (see Table 6). The same BLR model produced highly significant overall results (Chi2= 40.7, df = 7, p <.0001) with retained predictors indicating that demographic variable differences may have obscured our ability to measure RRI-RE scale differences between these two groups.

Table 6. Differences between Polish and Hispanic Patients on RRI-RE Scales

Variable B S.E. Wald df Sig. Exp(B) Responsibility 0.273 0.083 10.823 1 0.001 1.314 Age -0.086 0.027 9.825 1 0.002 0.918 Educ.,Years -0.219 0.089 6.005 1 0.014 0.803 Fund.Values -0.145 0.064 5.066 1 0.024 0.865 Sex -1.349 0.721 3.505 1 0.061 0.259

In summary, these results indicate that significant differences may be expected between various ethnic groups when resourcefulness is assessed using the RRI-RE. We decline to comment on the specific direction of the observed differences beyond the summary graph, believing that such information should be derived from larger sample sizes (i.e., genuine

Complimentary Contributor Copy Resilience and Resourcefulness as Facilitators of Adjustment in Immigrants … 361 normative samples) that do not differ significantly on demographic variables. However, our analyses that controlled for these demographic differences clearly demonstrate that the groups differ significantly on a number of scales assessing resourcefulness, and that when interpreting results from the RRI-RE, clinical correlation in relation to cultural differences is recommended.

CONCLUSION

In this chapter, we provided some examples of the current research on the psychology of the immigration seen from the perspective of trauma as counterbalanced by resilience and resourcefulness. Trauma of immigration is related to experience of cognitive discrepancy and disunity with an individual’s internal and external social reality compelling men and women to reinvent themselves in almost all aspects of life and to reconnect with their new social environment. A review of the literature suggests that personal characteristics of a successful immigrant are basically similar to what would belong to well adjusted individuals anywhere in this world; self-assured attachment style, optimism, proactive coping, and community-based self- esteem are also some of the common important characteristics. Some of these psychological constructs are reflected as differences between the ethnic groups on the RRI-RE variables. In this manner, we documented that immigrants of various cultural background also have diverse capacities to cope with stresses that not only include immigration itself, but also result from subsequent psychotraumas. There is some indication that one of the factors that might prove useful in further research is that of the role of prior stress inoculation. Sensitivity to cultural diversity is recommended in clinical practice. Regarding hypothetical unitary framework that would integrate the current available wealth of disparate information on the immigration experience, we believe that resilience and resourcefulness constructs could be used for this purpose. Considering that changing country is becoming a more and more common experience, better understanding of the psychological mechanisms which could help in this respect represents an overdue recognition of the many migrants’ efforts who contribute with their often unnoticed daily resilience and resourcefulness to a more receptive and tolerant world.

REFERENCES

Antonowsky, A. (1987). Unraveling the mystery of health: How people manage stress and stay well. San Francisco: Jossey-Bass. Allen, L. M., Conder, R. L., Green, P., and Cox, D. R. (1997). CARB ’97: Manual for the Computerized Assessment of Response Bias. Durham, NC: CogniSyst, Inc. Beck, A.T. (1996). Beck Depression Inventory-II. San Antonio, Texas: The Psychological Corporation. Beck, A.T. (1987). Beck Anxiety Inventory. San Antonio, Texas: The Psychological Corporation

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Brisette, J., and Scheier, M. F. (2002). The role of optimism in social network development, coping and psychological adjustment during a life transition. Journal of Personality and Social Psychology, 82, 102-111. Celinski, M. J. (2012). Challenge-Resilience-Resourcefulness as the essential components of recovery. In K.M. Gow and M.J. Celinski (Eds.), Individual trauma: Recovering from deep wounds and exploring the potential for renewal (2012). New York: Nova Science Publishers. Celinski, M. J., Antoniazzi, M. and Allen-III, L. (2007). Resourcefulness to Recovery Inventory – Research Edition. Durham, NC: CogniSyst, Inc. Celinski, M. J. and Allen-III, L. (2011). Resourcefulness as the art of succeeding. In M. J. Celinski and K. M. Gow (Eds.), Continuity versus creative response to challenge: The primacy of resilience and resourcefulness in life and therapy (pp. 343-357). New York: Nova Science Publishers. Celinski, M. J. and Gow K. M. (2005). Trauma clients: Into how understanding disintegration can help to reveal resourcefulness of the self. Australian Journal of Clinical and Experimental Hypnosis, 33, 195-217. Celinski, M.J and Pilowski, J. (2008). Measuring resilience to psychological outcomes of natural disasters: more question than answers (pp. 73-86). In K. Gow and D. Paton (Eds.), The Phoenix of Natural Disaster. Community Resilience. New York: Nova Science Publishers, Inc. Field, A. (2005). Understanding Statistics Using SPSS (2nded.). Thousand Oaks, California: Sage Publications. Kunst, M., Winkel, F.W., and Bogaerts, S. (2011). Recalled peritraumatic reactions, self reported PTSD, and the impact of malingering and fantasy proneness in victims of interpersonal violence who have applied for state compensation. Journal of Interpersonal Violence, 26, 2186-2210. Lam, B. T. (2007). Impact of perceived racial discrimination and collective self-esteem on psychological distress among Vietnamese-American college students: Sense of coherence as mediator. American Journal of Orthopsychiatry, 77, 370-376. McDermott, B. E., and Feldman, M.D. (2007). Malingering in the medical setting. Psychiatric Clinics of North America, 30, 645-662. Moghaddam, F.M., Ditto, B., and Taylor D.M. (1990). Attitudes and attribution related to psychological symptomatology in Indian immigrant women. Journal of Cross-Cultural Psychology, 21, 335-350. Pan, J., Keung Wong, D.F., Joubert, L., and Wan Chan, C.L. (2007). Acculturative stressors and meaning of life as predictors of negative affect in acculturation: A cross-cultural comparative study between Chinese international students in Australia and Hong Kong. Australian and New Zealand Journal of Psychiatry, 41, 740-750. Phinney, J.S., Madden, T., and Santos, L.J. (1998). Psychological variables as predictors of perceived ethnic discrimination among minority and immigrant adolescents. Journal of Applied Social Psychology, 28, 937-953. Polek, E., van Oudenhoven, J.P., and ten Berge, J.M. (2008). Attachment styles and demographic factors as predictors of sociocultural and psychological adjustment of eastern European immigrants in the Netherlands. International Journal of Psychology, 43, 919-928. Seligman, M. E. P. (1990). Learned optimism. New York: Simon and Schuster.

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Shin, H.S., Han, H.R., and Kim, M. T. (2005). Predictors of psychological well-being amongst Korean immigrants to the United States: A structured interview survey. International Journal of Nursing Studies, 44, 415-426. Tombaugh, T. (1996). Test of memory malingering. Toronto, Ontario: Multi-Health Systems Inc. Uskul, A.K., and Greenglass, E. (2005). Psychological wellbeing in a Turkish-Canadian sample. Anxiety, Stress, and Coping, 18, 269-278.

Complimentary Contributor Copy Complimentary Contributor Copy In: Mass Trauma: Impact and Recovery Issues ISBN: 978-1-62081-557-1 Editors: Kathryn Gow and Marek Celinski © 2013 Nova Science Publishers, Inc.

Addendum

QUESTIONS TO BE EXPLORED WHEN ASSESSING THE RESILIENCE OF A COMMUNITY POST DISASTER

Ron Frey Queensland University of Technology, Australia

INTRODUCTION

While my colleagues have set out some of the causes for a breakdown in community resilience following natural disasters (see Chapter 14), I contend that there are at least two other general factors, besides the nature of the disaster itself, which need to be considered when predicting a community’s ability to sustain itself during and following a natural disaster (and indeed in other sorts of disasters, such as economic disasters). The first relates to the traumatic history of the community and the second relates to the social capital of the community, or what Fukuyama referred to as ‘trust’ (Fukuyama, 1995). These factors closely parallel the individual strands of prior traumatic history and supportive social relationships which the noted North American child psychiatrist Bruce Perry (2006; 2009; Perry and Szalavitz, 2006; Perry and Szalavitz, 2010) argues contribute to the resilience of abused, neglected, and otherwise traumatised children (see in particular Perry’s application of his principles to the recent economic crisis in Iceland [Perry and Szalavitz, 2010]). Perry points out that much traditional therapy with traumatised children (and even with adults), such as cognitive behavioural therapies and some forms of relationship-based therapies, are misdirected because they do not take into account the developmental history of the child and the nature, severity, and impact of the trauma relevant to the child’s chronological age when the trauma first occurred (Perry, 2006). There is much evidence that early occurring trauma interferes with, and alters, the development of a variety of brain structures (see for example, Kumpfer and Hu, Ch. 12 in this text; Ogden, Minton and Pain, 2006; van der Kolk, McFarlane and Weisaeth, 1996) which in turn alters the child’s ability to be receptive to therapies which target higher brain functions; Perry (2006) makes a compelling case that a thorough developmental history of the child is necessary to determine which neuropsychological level should be targeted for the most effective intervention.

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Indeed, if we extend these insights based on individuals to communities affected by natural disasters, we can argue that the previous trauma history of the community, combined with its current social capital, will have a profound impact on the resilience (or otherwise) of that community in a manner analogous to the impact of an individual history of trauma, and - depending on the presence or absence of supportive social relationships - that it has on an individual’s ability to rebound following a contemporary life trauma (see Chapters 2 and 14 in this volume on the effects of prolonged drought, and the compounding effects of negative historical factors in the aftermath of Hurricane Katrina). Some communities, just as some individuals, will have been exposed to multiple and varied traumas both collective and individual, so that the current disaster comes as a further trauma in a broad mosaic of traumatic experiences. For other communities (spared from the onslaught of multiple disasters for various historical, geographic, economic and demographic reasons - and often just through good fortune - ) the disaster, whilst traumatic, does not form the same pattern of traumatisation which has already affected the community’s resilience negatively. It follows that, just as individual therapy plans, which do not take into account traumatic histories and current social supports, risk being ineffective and even detrimental to the traumatised individual, recovery plans, which do not take the factors of prior community trauma and current social capital into account, may overestimate the community’s resilience and thus fail, in whole or in part, further lowering the community’s collective sense of agency and exacerbating the community’s trauma. This can also lead to the attribution of negative judgments about the community by social authorities, and actually lead to a redistribution of resources away from communities which need them most. Therefore, it is my contention that every recovery plan for a particular natural disaster should undertake a thorough appraisal of the traumatic developmental factors in a community, as well as its current strengths and weaknesses, in a manner similar to the way that individual developmental assessments are made of traumatised adults and children. As this addendum is offered only as a preliminary exploration of these issues, I hope that, over time, these factors may be able to be quantified in some fashion, so that community leaders and disaster planners may be able to predict quite closely which communities will be resilient in the face of disasters and which will require an extra concentration of resources, both prior to and preceding a disaster, in order to rebound successfully. We will consider some of the major questions in a general sense in the paragraphs which follow. A list at the end of this treatise summarises these and indicates some of the questions that I think disaster planners ought to consider when measuring the expected resilience of a community during and following a disaster. However, it is important to state that I do not regard this list of questions as being at all comprehensive; and I hope that other researchers will add further questions and perhaps further refine the questions in the list through future research. Indeed, the intention of supplying this list is to encourage the reader to begin to develop a list of their own making, and to give some serious thought to the large number of factors which have a negative impact on the recovery of communities (and indeed of individuals) following any kind of disaster.

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PRIOR TRAUMA HISTORY OF A COMMUNITY

The prior trauma history of a community is both individual and collective; it contains both large events which have affected virtually everyone in the community simultaneously, but also more individualised and singular events such as individual acts of violence which have a cumulative influence on an entire community over time as they erode the resilience of individuals in the same community, thereby creating a collective weakness in that same community. Further, some of these events may be historic, in that they may have occurred many years (sometimes even centuries) prior to the current disaster, yet still exert an influence on the living community (such as a history of slavery [Eyerman, 2001], invasion, or Indigenous dispossession). The concept of a ‘foundation trauma’ has been articulated in the literature (Levy and Sznaider, 2006; Suber, 2006); this is a form of traumatic memory which is passed from generation to generation in both conscious and unconscious forms to affect the behaviour and to colour the psyches of people far removed in time from the initial trauma (the Jewish Holocaust being one of the best researched examples of this; see Baranowsky et al., 1998; Faye, 2001; Lev-Wiesel, 2007; Lurie-Beck, Ch. 7 in this text; Rowland-Klein and Dunlop, 1997; Sagi-Schwartz et al., 2003; Scharf, 2007; Sigal, 1998). Other events (such as the terrorist attack on New York in 2001, or the Columbine High School massacre – see Chapters 11 and 6 respectively in this text) will be of a much more recent origin, embedded in the consciousness of every person in the community who has experienced them directly or indirectly. In addition, yet other traumas will be experienced as quite individual in nature, even though they may occur widely enough across a community to have a significant impact on that community collectively (for instance, it was found that individuals who had lost family members to suicide or to an earlier natural disaster were doubly traumatised by the major flood devastation [Gow, Personal Communication, 2011]). Communities with high rates of domestic violence and child abuse, or other forms of interpersonal violence, will be collectively affected by these problems, even though the problems appear to be confined to families and to interpersonal relationships (at the time of the finalising of this addendum, a conference on natural disasters and domestic violence was being held in Melbourne1.) In addition, the collective and individual traumas might be quite different in character, so that their impact is not cumulative in a mathematical sense of the term, but rather they interact in a complex and unpredictable manner; thus the psychological and personal skill set needed to survive one set of traumas may be totally unhelpful, or even counter-productive, when dealing with a different type of trauma. For example, a sustained economic crisis such as the Great Depression of the 1930s, or the Global Financial Crisis of 2008 and the years following, often leave a deep psychological impact on an entire generation of people, yet rarely leaves any actual visible scars or injuries. The same generation which survived the Great Depression was subsequently subjected to the horrors of World War II, horrors which varied depending on factors of military service, geography (citizens living in London had a very different war experience from those living in Sydney), social and demographic factors such as ethnicity and class, and again often through pure chance (for example, the children

1 Identifying the Hidden Disaster: The First Australian Conference on Natural Disasters and Family Violence. Friday, 9 March 2012 The William Angliss Conference Centre, Melbourne.

Complimentary Contributor Copy 368 Ron Frey being evacuated from England to Canada who were placed and later died (most, not all) on the torpedoed ocean liner, the Benares [Nagorski, 2006]. To my knowledge, there have been few attempts to trace the interactive impact of the Great Depression and World War II on the personalities and resilience(s) of those who have had to survive both. For example, was the loss of faith in societal structures, that many experienced with the Great Depression, further reinforced by the experience of World War II? Or did the effective leadership of many of the allied leaders restore some measure of faith in these structures, at least in allied countries? One further example of this complex interaction is the multiple losses sustained by most Indigenous communities world-wide (e.g., Dudgeon, Garvey and Pickett, 2000). These losses are of a qualitatively different nature, of land, of language, of culture, of extended family, and of children (in the Australian case, through the removal of Indigenous children from their parents and their placement into the white social welfare system, who have come to be known as the Stolen Generation). Other cases of mass trauma occurred when over 130,000 children were removed from orphanages in England and then transported to other countries over a period of decades without any knowledge of this by their parents (see Ch. 1 in this text). To recover from one of these losses does not necessarily equip a person to recover from another, yet their impact occurs on the same community, the same family, and the same person. This suggests that all persons in a community and all communities become sites of a compilation of different events, all of which in this case have been interpreted by that person and that community to have been traumatic. Therefore, when assessing a community for trauma, consideration must be given to the type of disaster, as well as to the number of traumatic events that have occurred in this context. Further, both the type and the number will vary across a community from individual to individual and from family to family. Whilst it is probably artificial to dichotomise these factors because all events have individual and communal affects, there may be some heuristic value in separating them for more detailed consideration. Therefore, the following list will set out large scale events which affect everyone in the community at around the same time although in different ways (such as floods in Bangladesh, droughts in Africa, and wildfires in Australia), and small scale events which may only affect individuals or families, but nonetheless have a collective impact, if they occur with sufficient frequency such as rural suicides, domestic violence, and closure of local industries which provide a lot of employment to the residents.

EXPLORATION LIST OF PAST TRAUMAS

The experts in disaster interventions will always do their homework before they become involved in disaster recovery operations; that is, they would obtain all the data they can from internet sources about all the relevant issues of a particular community. Next, they would consult with governing bodies, local associations, libraries, police, emergency services etcetera, about what has happened in this community in this disaster and in other disasters and obtain the timing of these events. There will obviously be times when you have to make contacts in the community, especially several months after the disaster event, when reports have come back that community recovery has not proceeded in the manner that was desired or expected. Generally

Complimentary Contributor Copy Questions to be Explored When Assessing … 369 the best approach when targeting communities for information is not to ask people directly, but to explore delicately around the edges; seeking general information from those most likely to know at the beginning and only then approaching individuals or groups to glean information that you, as an interventionist, deem most appropriate and most useful in a given circumstance. There is a danger in interrogating disaster affected individuals and groups, and this Addendum is not supplied for careless utilisation. Only highly skilled social scientists who have worked in communities before and who have all the necessary counselling skills should be involved in any ‘audit, or survey, or interview’, as they have the power to further damage persons, if the action is poorly thought through or carried out. If the ‘audit’ is carried out in a professional, respectful, and caring manner, involving community members in it, as part of a reconstruction effort, and using only questions that fit the disaster impact situation and recovery issues, then it will provide important data for how to approach and implement community based (and where possible community run) interventions.

Question 1. Was there trauma in the foundation of the Community? Discussion Note. For many American and Australian communities, the answer here will be yes, as they have been built on lands seized and withheld, often by violence, from the Indigenous people of the region. Further, many American and Australian communities have a history of the forced servitude of minorities, including slavery (for the United States) and what has been effectively indentured servitude of Indigenous peoples (for Australia) (Kidd, 1997; see also Cocker, 1998 and Reynolds, 1999), and lawlessness and ‘frontier’ violence (for both Australia and the United States). In other cases, the community may have had a long history of the imposed domination of a single town leader, or a single family, or governing group. Question 2. Has this trauma ever been acknowledged and has the community made an attempt to learn from its past mistakes? Discussion Note. Quite often, the answer here will be no, particularly where crimes against the Indigenous populations have gone unnoticed and un-atoned. Question 3. Is there a ‘foundation trauma’ to which most citizens relate? Discussion Note. The concept of ‘foundation trauma’ was first applied to the ethnic conflict in the Balkans to indicate an unresolved and unresolvable trauma which underpins the founding of a nation and to which the nation appeals when it violates human rights and its own ethics (see for example, Obradovic, 2012, Suber, 2006); however, it could equally apply to communities in Israel or Kurdistan, or to many other places in the world. Question 4. What has been the settlement pattern of the community? Discussion Note. Has it been used as a collection place for the nation’s impoverished people; disadvantaged minority groups; refugee resettlement; diseased group (such as lepers or HIV sufferers)? Question 5. What has been the recent history of community trauma? Discussion Note. Include all kinds of traumatic events; including natural disasters, wars, droughts and flooding, civil unrest, nuclear fallout, massacres (including school and workplace shootings). Question 6. Have there been controversies which have seriously divided the community?

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Discussion Note. Some small American communities have been bitterly divided over whether ‘intelligent design’ should be taught in schools for instance; some labour disputes have had similar effects. The protest in Australia about the shipping of live cattle to Indonesia from Australia and some consequent cruel killing practices in a few Indonesian abattoirs, depicted on television, divided country and city people within Australia, as the graziers lost major income from the blocking of the exports, and some long standing cattle producers collapsed financially because of the Government’s decision to ban live cattle exports.

Current Profile of the Community

It is always useful for practitioners and outside interventionists to know what the current situation is in a specific place, and who it is they will be assisting. Some of the points below may be difficult for some practitioners to address, but without acknowledging the truth of what is happening in a community, it will be difficult to really assist them. Question 7. How healthy is this community? Question 8. How traumatised are the individuals who comprise the community? Discussion Note. For example, is any form of abuse institutionalised (Ron Frey has heard reports of specific small communities in parts of rural Queensland, Australia, for example, in which the sexual abuse of children in their own families is endemic and indeed routine-ised; see the further example of Pitcairn Island [e.g., Marks, 2008]). We also suggest examining traditional parenting and other socialising processes; do these processes tend to be extreme or severe; is bullying encouraged, do parents beat their children? Question 9. How much violence is there in the community currently? Discussion Note. (A colleague of Ron Frey’s who worked on the Southside of Chicago once told him that every child in the primary age school programme that he had conducted there had witnessed the death of at least one school friend caught in the crossfire of ‘shoot- outs’ between rival gangs, often on the school playground [cf. Garbarino, 1994]). Question 10. Does the community have high rates of mental illness, depression, substance abuse, alcoholism, or suicide? Question 11. Is there a high rate of domestic violence? Question 12. Are the citizens of the community expected to conform to rigid and traditional gender roles? Discussion Note. Are women traditionally segregated from men and are they accorded less respect (as often occurs when men and women are strictly segregated)? (c.f., Fry, 2006; Sanday, 1981; Sanday and Goodenough, 1990) Question 13. How well are children treated in this community? Discussion Note. Read Chapter 12 where Karol Kumpfer and Qing Qing Hu address major issues confronting children across a wide range of situations in the USA, with the message that things may be getting worse, not better, for children worldwide in many communities. Kumpfer and colleague provide internet addresses for resources for practitioners working with troubled children and families. Question 14. What is the general education level in the community? Question 15. Does the community sponsor sporting and cultural events for the enrichment of the citizens?

Complimentary Contributor Copy Questions to be Explored When Assessing … 371

Discussion Note. Are parks and other recreational areas provided, and if so, are they safe and well utilised? Question 15. How well does this community tolerate diversity in race, class, lifestyle, sexuality and multi-culturalism? Discussion Note. How tolerant is the community of minority groups and diversity generally? Is the community relatively homogenous and ‘closed’ to the outside world (which can be either a strength or a weakness, depending on the circumstances)? Question 16. Does the community share common values and ethics (at least with regard to the treatment of others and respect for human rights)? Question 17. How transient is the population in the community? Discussion Note. Have people lived in the community for a sufficient period of time to develop a loyalty to each other and to the community as a whole? (Some mining communities come to mind where councils have not even installed sidewalks, as no one intends to stay in the community longer than a few years of earning substantial sums in mine work.) In fact, a further question which could be asked is whether the community exists primarily to exploit some local resource, this might include communities based around the gaming industry as well; e.g., Las Vegas and some Indian Reservations are economically dependant on the gambling industry). Question 18. Are there large differences in wealth in the community? Discussion Note. Are the social classes largely segregated from each other so they fail to understand each other’s perspectives, and perhaps even view each other as potential enemies (see Perry and Szalavitz, 2010, pp. 259-287; cf. Sameroff and Bartko, 1998)? See Chapter 14 about the differences in class and wealth impacts following the floods in Bangladesh. Question 19. Does the community have a reputation for illegal activities? Discussion Note. For example, is the area the regional centre of drug cultivation or production, the home base for criminals and criminal activities, smuggling arms and other goods, or for houses of prostitution? Question 20. Is the community the centre of religious or other cults with abusive leaders (c.f., Perry and Szalavitz, 2010, pp. 232ff, and Perry and Szalavitz, 2006, pp. 57-80 which discuss San Angelo and Waco, Texas, respectively)? Question 21. Are there entrenched and sometimes violent feuds and quarrels between leading citizens, families or clans in the community?

TRUST

Frances Fukuyama (1995), in a fascinating book that he entitled Trust, suggests that many countries in the world can be classified as either high or low trust societies, depending on the ability of citizens to trust each other and work together cooperatively. As examples of ‘high trust’ societies, he cites the United States, Great Britain, Germany and Japan. As examples of ‘low trust’ societies he cites Italy, France, Korea and China. Many of Fukuyama’s signs of a high-trust society are also signs of a resilient society and signs of societies with high social capital.2 For example, responses to the following questions about

2 See also the chapter “Wisdom, Awareness of Life’s Purpose, and Happiness: The Cognitive Informatics Approach” by Andrew Targowski in another book in this series, outlined in the reference list.

Complimentary Contributor Copy 372 Ron Frey the community may assist greatly in working with the community in the best way to approach interventions post disasters, especially multiple disasters. Question 22. Does the community have a rich network of non-governmental interlinkages such as church groups, volunteer societies, professional organisations, clubs and neighbourhood societies? Question 23. Do people in the community usually help each other out in times of difficulty? Do people feel they can depend on their neighbours? Question 24. Do they take a communal responsibility to protect and assist the vulnerable including children and the elderly? Question 25. Are the people who live in the community friendly with each other? Do they maintain close relationships outside of their nuclear and extended families? Question 26. Is there trust in civil authorities or do people react sceptically and cynically towards all levels of government (often for good reason)? Do citizens feel a sense of civic duty? Do citizens have sufficient leisure to act on their sense of civic duty? Question 27. Are there community resentments which prevent people from cooperating with each other to achieve recovery?

POSTSCRIPT

It is not expected that an audit about a community’s history which answers some, or all, of these questions (and others which I have not included here) to be a simple task; it also may not be a particularly popular one, if a community is guarded about aspects of its past. But it is proposed that interventions which have been designed on the basis of responses to these questions will have a much better chance of more effectively addressing the community’s ability to respond positively to the intervention. Further, for communities which have not recently been affected by a natural disaster, addressing the developmental history of the community could be a very helpful way of planning ahead for future emergencies and perhaps considering issues which would helpfully be resolved in advance of further trauma. I would be most interested in feedback and further suggestions from readers as to what you have discovered about foundational and historical trauma affecting communities following natural disasters.

REFERENCES

Baranowsky, A.B., Young, M., Johnson-Douglas, S., Williams-Keeler, L. and McCarrey, M. (1998). PTSD Transmission: A review of secondary traumatization in Holocaust survivor families. Canadian Psychology, 39(4), 247-256. Cocker, M. (1998). Rivers of Blood, Rivers of Gold: Europe’s conflict with tribal peoples. London: Jonathan Cape. Dudgeon, P., Garvey, D. and Pickett, H. (2000). Working With Indigenous Australians: A Handbook for Psychologists. Perth: Gunada Press, Curtin Indigenous Research Centre.

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Eyerman, R. (2001). Cultural Trauma: Slavery and the Formation of African American Identity. New York: Cambridge University Press. Fry, D. (2006). The Human Potential for Peace: An Anthropological Challenge to Assumptions about War and Violence. Oxford: Oxford University Press. Fukuyama, F. (1995). Trust: The Social Virtues and the Creation of Prosperity. New York: Free Press. Garbarino, J. (1994). Raising Children in a Socially Toxic Environment. San Francisco, California: Jossey-Bass. Kidd, R. (1997). The Way we Civilise Aboriginal Affairs - the untold story. Brisbane: University of Queensland Press. Kumpfer, K.L. and Hu, Q.Q. (In press). What Makes Children Resilient and Resourceful Despite Family Adversity and Trauma in High Risk Populations? In K.M. Gow and M.J. Celinski (Eds.), Mass Trauma: Impact and Recovery Issues. New York: Nova Science Publishers. Levy, D and Sznaider, N. (2006). The politics of Commemoration: The holocaust, memory and trauma. In G. Delanty (Ed.), Handbook of Contemporary European Social Theory (pp. 289-297). New York: Rutledge. Lev-Wiesel, R. (2007). Intergenerational transmission of trauma across three generations: A preliminary study. Qualitative Social Work, 6, 75-94. Marks, K. (2008). Pitcairn: Paradise Lost. London: Fourth Estate Books. Nagorski, T. (2006). Miracles on the Water: The Heroic Survivors of a World War II U-Boat Attack. New York: Hyperion. Obradovic, J. (2012). Ethnic Conflict and War Crimes in the Balkans: The Narratives of Denial in Post-conflict Serbia. London: I. B. Tauris and Co Ltd. Ogden, P., Minton, K. and Pain, C. (2006). Trauma and the Body: A Sensorimotor Approach to Psychotherapy. New York: W.W. Norton and Company. Perry, B. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatised children: The neurosequential model of therapeutics. In N. Boyd Webb (Ed.), Working with Traumatized children in Youth and Child Welfare (pp. 27-52). New York: Guilford Press. Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: Clincial applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14, 240-255. Perry, B. and Szalavitz, M. (2006). The Boy Who was Raised as a Dog and Other Stories from a Child Psychiatrist’s Notebook. New York: Basic Books. Perry, B. and Szalavitz, M. (2010). Born for Love: Why Empathy Is Essential – And Endangered. New York: HarperCollins. Reynolds, H. (1999). Why Weren’t We Told? Ringwood, Victoria: Viking Press. Rowland-Klein, D. and Dunlop, R. (1998). The transmission of trauma across generations: Identification with parental trauma in children of Holocaust survivors. Australian and New Zealand Journal of Psychiatry, 32(3), 358-369. Sameroff, A. and Bartko, W. (1998). Political and scientific models of development. In D. Pushkar, W. Bukowski, A. Schwartzman, D. Stack and D. White (Eds.), Improving Competence Across The Lifespan: Building Interventions Based On Theory And Research (pp. 177-192). New York: Plenum Press.

Complimentary Contributor Copy 374 Ron Frey

Sanday, P. (1981). Female Power and Male Dominance: On the Origins of Sexual Inequality. Cambridge: Cambridge University Press. Sanday, P. and Goodenough, R. (1990). Beyond the Second Sex: New Directions in the Anthropology of Gender. Philadelphia: University of Pennsylvania Press. Sigal, J. and Weinfeld, M. (1989). Trauma and rebirth: Intergenerational effects of the Holocaust. New York: Praeger. Suber, D. (2006). Myth, collective trauma and war in Serbia: A cultural–hermeneutical appraisal. Anthropology Matters, 8(1), S. 1-9. Targowski, A. (2011). Wisdom, Awareness of Life’s Purpose, and Happiness: The Cognitive Informatics Approach. In M.J. Celinski and K.M. Gow (Eds.), Continuity versus Creative Response to Challenge. The Primacy of Resilience and Resourcefulness in Life and Therapy (pp. 73-91). New York: Nova Science Publishers. Van der Kolk, B., McFarlane, K. and Weisaeth, L. (Eds.). (1996). Traumatic Stress: The Effects Of Overwhelming Experience On Mind, Body And Society. New York: Guilford Press.

Complimentary Contributor Copy

INDEX

adolescents, 199, 203, 204, 207, 209, 214, 216, 220, # 239, 240, 241, 242, 243, 245, 246, 250, 251, 252, 253, 254, 353, 362 9/11, vi, 15, 21, 29, 30, 38, 39, 40, 160, 163, 164, adrenaline, 161 165, 175, 176, 177, 178, 179, 180, 181, 183, 184, adulthood, 132, 202, 210, 220 185, 186, 187, 188, 189, 190, 191, 192, 339, 347 adults, 5, 8, 61, 62, 63, 71, 74, 133, 200, 201, 202, 20th century, 42, 59, 73 213, 237, 238, 239, 241, 242, 243, 246, 247, 249, 250, 251, 266, 365, 366 A advancement, 141 adverse conditions, 351 abolition, 127 adverse effects, 270, 340 abuse, 117, 132, 198, 199, 200, 203, 211, 215, 217, advertisements, 164 334, 370 advisory body, 145 academic performance, 208, 219, 240 advocacy, 291 access, 8, 25, 26, 30, 31, 32, 33, 35, 36, 49, 129, 130, aesthetic, 181 131, 153, 203, 243, 246, 247, 248, 249, 264, 268, aesthetics, 184 271, 272, 273, 278, 285, 288, 291, 317, 333, 334, Afghanistan, 15, 62, 64, 71, 155, 156, 159, 165, 167, 336, 349 170, 175, 178, 179, 180, 184, 187, 188, 191 accessibility, 25 Africa, ix, 3, 5, 45, 60, 68, 74, 120, 205, 327, 334, accommodation, 148, 151, 247, 270, 273, 319, 320, 340, 341, 345, 346, 368 325 age, 73, 80, 83, 98, 100, 129, 132, 133, 155, 185, accountability, 34, 153, 288, 292 199, 201, 202, 203, 204, 207, 208, 211, 215, 218, accounting, 33, 34, 86, 107, 354 237, 240, 241, 244, 247, 254, 268, 342, 356, 357, acculturation, 206, 324, 334, 335, 351, 352, 362 358, 359, 365, 370 acquaintance, 164 agencies, 22, 30, 83, 131, 135, 145, 152, 153, 154, activity level, 208 203, 205, 210, 211, 270, 274, 281, 291, 301, 335, adaptability, 279 337 adaptation, 11, 24, 33, 49, 121, 198, 209, 210, 244, aggression, 118, 161, 187, 208, 215, 253 248, 294, 317, 319, 323, 328, 329, 335, 337, 338, aggressiveness, 166 339, 340, 343, 353 agility, 292 adaptations, 210, 217, 304 agriculture, 272, 274 adjustment, 11, 12, 28, 82, 89, 118, 119, 202, 205, AIDS, 54, 193, 311, 342, 344 209, 216, 218, 219, 244, 254, 321, 327, 345, 350, Air Force, 160 351, 353, 362 alcohol abuse, 207, 215 Administration for Children and Families (ACF), alcohol consumption, 201 203 alcoholics, 201, 202, 208, 211, 215, 216, 218, 219, administrators, 292 220 adolescent development, 253 alcoholism, 201, 202, 206, 208, 209, 214, 215, 216, adolescent problem behavior, 214 219, 221, 370 alertness, 303

Complimentary Contributor Copy 376 Index

Algeria, 60, 61, 64 authorities, 98, 104, 105, 106, 115, 142, 143, 145, alienation, 96, 97 146, 147, 148, 152, 153, 262, 267, 281, 282, 283, alters, 199, 365 284, 286, 287, 288, 290, 291, 292, 334, 366, 372 altruism, 36, 167 authority, 25, 31, 126, 145, 332 aluminium, 273, 277 autonomic nervous system (ANS), 202 American Psychiatric Association (APA), 71, 90, autonomy, 8, 79, 90, 334 251 avoidance, 55, 56, 60, 61, 62, 64, 66, 68, 70, 85, 319, American Psychological Association, 53, 71, 72, 73, 353 75, 218, 253, 326, 327, 328, 329, 345 awareness, 49, 78, 83, 180, 240, 248, 338 amnesia, 84 amputation, 131, 333 ancestors, 337, 339 B ancient world, 162 Balkans, 45, 369, 373 anger, xi, 5, 57, 95, 99, 100, 105, 133, 239 Baltic states, 119 annihilation, 283 ban, 370 anthropologists, 58, 66, 301 Bangladesh, ix, 3, 257, 260, 268, 269, 270, 271, 272, anthropology, 58, 65, 71, 73, 307 273, 274, 276, 277, 278, 279, 368, 371 antisocial behavior, 208, 217 bankers, 127 anxiety, 64, 72, 78, 79, 80, 85, 87, 115, 118, 119, banks, 259, 269, 272 161, 202, 207, 208, 237, 239, 241, 242, 244, 246, barriers, 122, 334, 336 248, 252, 253, 260, 275, 276, 334, 335, 355 base, 24, 45, 162, 240, 371 anxiety disorder, 202, 252 base rate, 240 apathy, 114 basic education, 129 applied psychology, 352 basic needs, 36, 62 appraisals, 68, 78, 320 basic services, 126 Argentina, 116 batteries, 272 armed forces, 13, 14, 15, 16, 117, 118, 170, 189, Beck Depression Inventory, 78, 85, 90, 355, 357, 332, 334 361 Armenia, 252 behavioral problems, 252 arousal, 57, 62, 85 behaviors, 59, 60, 66, 67, 199, 202, 208, 211, 215, arrest, 134, 332 329, 351, 352 arson, 267 Belgium, 98, 113, 115 Asia, 120, 129, 137, 278, 335 belief systems, 24, 69 Asian Americans, 339 beneficiaries, 42 Asian countries, 60 benefits, 67, 283, 287, 318, 321, 322, 328 assault, 72, 96, 98, 332, 333, 334, 335 benign, 165 assessment, 3, 49, 59, 62, 69, 73, 78, 82, 83, 85, 86, beverages, 14 89, 151, 239, 241, 247, 250, 293, 294, 322, 354, bias, 155 355 bible, 339 assets, 210, 270, 351 binge drinking, 209 assimilation, 319 biodiversity, 286 asthma, 144 birds, 266 asylum, 314, 316, 329, 330, 333, 346 birth weight, 198 atmosphere, 105, 116 births, 128 atrium, 103 black market, 5 atrocities, 125, 133, 135, 317 blame, 32, 99, 100, 105, 167 attachment, 35, 202, 204, 205, 209, 211, 354, 361 blends, 32 attacker, 104 blood, 147, 166, 214 attitudes, 65, 67, 71, 75, 83, 117, 164, 350, 354, 355 blood pressure, 214 attribution, 176, 362, 366 blueprint, 42 audit, 369, 372 boat, 373 Austria, 113 bonding, 25, 128, 133, 199, 206, 209, 211, 288 authenticity, 189, 190 bonds, 248, 272

Complimentary Contributor Copy Index 377 boredom, 161 303, 320, 322, 324, 331, 334, 341, 350, 351, 352, Bosnia, 9, 47, 54, 64, 155, 305, 311 353, 354 Bosnia-Herzegovina, 47, 54, 305, 311 chaos, 101, 187, 201, 288 Botswana, 343 charitable organizations, 155 brain, 89, 129, 199, 201, 202, 365 charm, 164 brain drain, 129 chemical, 208 brain functions, 365 Chicago, 41, 54, 76, 109, 132, 193, 220, 299, 346, brain structure, 199, 365 370 brainwashing, 63, 133 chicken, 152 Brazil, 38 chicken pox, 152 breakdown, 4, 8, 10, 23, 69, 90, 169, 201, 243, 257, child abuse, 203, 217, 367 258, 259, 260, 263, 270, 275, 276, 336, 365 Child Behavior Checklist, 205 breathing, 288 child development, 207, 210, 219 brutality, 126 child maltreatment, 50, 200, 202, 203, 204, 212, 215, Buddhism, 126 220, 373 bullying, 100, 104, 370 child protection, 203 bureaucracy, 334 child protective services, 203 Burma, 269, 332, 345 childcare, 132, 205, 249 burn, 36, 350 childhood, 153, 199, 200, 206, 208, 209, 213, 215, burnout, 32 218, 219, 220, 221, 326 businesses, 7, 10, 113, 238, 258, 261, 263, 266, 267, Chile, 47 272, 273, 282, 284, 292 China, 56, 58, 73, 99, 108, 126, 206, 371 Butcher, 344 chlorine, 149 cholera, 270 chronic diseases, 152 C chronic illness, 144, 145 chronic obstructive pulmonary disease, 213 Cambodia, v, 9, 60, 61, 63, 74, 120, 125, 126, 127, CIA, 17, 132, 136 128, 129, 130, 131, 132, 133, 134, 135, 136, 137, cities, 7, 113, 127, 178, 190, 206, 238, 258, 259, 260, 138 261, 264, 267, 268, 282 campaigns, 165, 274, 336 citizens, 35, 164, 367, 369, 370, 371, 372 capital expenditure, 286 citizenship, 113, 192 capitalism, 294 city, 21, 27, 29, 32, 38, 39, 97, 102, 108, 143, 178, cardiovascular disease, 199 181, 186, 217, 219, 220, 283, 284, 285, 286, 290, caregivers, 200, 254, 322 292, 293, 311, 343 Caribbean, 345 civil rights, 113 case examples, 260, 276 civil servants, 129 case studies, 175, 276, 281 civil society, 281, 288, 290 case study, 40, 268, 276, 289 Civil War, 28, 59, 71, 75, 156, 313, 332 casting, 100 clarity, 9, 49, 79 catalyst, 95 classes, 130 catastrophes, 16, 22, 46, 51, 249 classification, 97, 322, 328, 356 categorization, 319 cleaning, 47, 98 category d, 58 cleanup, 288 cattle, 4, 259, 264, 370 cleavage, 276 causal inference, 67 clients, 29, 83, 85, 88, 91, 287, 326, 343, 354, 355, causality, 220 357, 358, 359, 360, 362 CBD, 282, 289 climate, 9, 189, 265, 266 CDC, 206 climate change, 9, 265, 266 ceasefire, 140, 154 clinical application, 71, 72, 73 cell phones, 287 clinical presentation, 85 census, 126, 130, 136, 154 clinical psychology, 60 challenges, 7, 12, 15, 28, 34, 36, 46, 48, 50, 84, 125, close relationships, 318, 372 159, 161, 162, 166, 172, 173, 190, 259, 260, 293,

Complimentary Contributor Copy 378 Index closure, 125, 135, 179, 260, 282, 304, 368 comprehension, 15, 49 clothing, 113, 114, 247 computing, 358 clusters, 56, 59, 62 conception, 81, 176, 190, 315, 316, 317, 320, 323 coal, 259, 272, 273 conceptualization, 68, 70, 81, 90, 299, 310, 321 coastal region, 269 condensation, 177 coffee, 249, 291 conditioned response, 116 cognition, 58, 59, 74, 300, 354 conditioning, 68 cognitive abilities, 199 conduct disorder, 220 cognitive deficit, 202, 208 conference, 105, 284, 345, 367 cognitive function, 208, 241, 254 confinement, 74 cognitive impairment, 202, 209 conflict, 22, 36, 46, 47, 48, 51, 53, 54, 60, 64, 72, 98, cognitive perspective, 79 108, 119, 140, 143, 148, 151, 152, 156, 161, 166, cognitive process, 66, 78, 79, 89, 346 202, 206, 207, 209, 216, 221, 277, 314, 316, 332, cognitive profile, 221 333, 344, 369, 372, 373 cognitive style, 67 confounding variables, 354 cognitive testing, 86 congress, 40, 116, 129, 136, 138 cognitive theory, 214, 318, 325 connectivity, 132 cognitive-behavioral therapy, 304 consciousness, 300, 305, 308, 367 coherence, 27, 58, 189, 190, 362 consensus, 36, 44, 45, 65, 281, 283, 287, 307, 335 Cold War, 160 consolidation, 45, 46 collaboration, 12, 21, 24, 32, 36, 49, 52, 54, 155, conspiracy, 42 286, 289 construct validity, 70 collateral, 198 construction, 12, 21, 27, 58, 74, 103, 107, 175, 176, collateral damage, 198 179, 192, 286, 335 collectivism, 55, 60, 66, 67, 68, 70, 72, 74, 76 constructive strategies, 105 college students, 211, 354, 362 consulting, 160, 162, 276 colleges, 145 consumers, 287 collusion, 23 consumption, 131, 201 commerce, 34, 193, 274 contamination, 149, 263 commercial, 152 contingency, 303, 307 common sense, 165 contradiction, 69 communication, 24, 25, 28, 46, 47, 199, 203, 206, control group, 204 209, 211, 243, 246, 250, 284, 285, 287, 309 controversial, 288 communication patterns, 25 controversies, 369 communication technologies, 250 convention, 345 communism, 128 conversations, 22, 33, 308, 309 community connectedness, 24, 247, 249, 250 conviction, 134 community links, 25 cooling, 96 community psychology, 49 cooperation, 35 community relations, 51 coordination, 30, 32, 126, 153 community service, 243 coping strategies, 40, 62, 81, 200, 237, 244, 245, community support, 248, 283, 349 250, 251, 318, 323, 324, 337, 345, 347, 353 community-based services, 26, 44 copyright, 18 comorbidity, 73, 252, 254 copyright law, 18 compassion, 14, 133, 136, 331, 341, 342, 343 corpus callosum, 199, 221 compensation, 87, 134, 293, 355, 359, 362 correlation, 78, 85, 86, 88, 89, 357, 361 competition, 31, 164, 270 correlation coefficient, 357 competitiveness, 307 correlations, 85, 86, 87, 88, 89 compilation, 368 corruption, 126 complement, 313, 314 cortisol, 199 complexity, 309, 320, 323 cost, 18, 79, 131, 167, 201, 212, 251, 282 compliance, 292 Costa Rica, 68 complications, 170, 204 counsel, 339

Complimentary Contributor Copy Index 379 counseling, 12, 328 deconstruction, 282 counseling psychology, 328 defence, 156, 165, 281, 282, 290, 291 country of origin, 15, 331, 350, 351, 353 defendants, 134 covering, 62, 188 deficiency, 52 creativity, 32, 159 deficit, 315, 316 credentials, 46 degradation, 303, 333 crimes, 96, 97, 98, 100, 125, 134, 369 delinquency, 199, 202, 206, 208, 209, 211, 212, 221, criminal behavior, 200, 210 242 criminals, 9, 112, 371 Delta, 288, 292 crises, 33, 325, 331, 334, 344 delusion, 107, 166 critical analysis, 108 democracy, 160, 177, 187 critical thinking, 28 Democratic Republic of Congo, 345 criticism, 44, 153, 242, 302, 310 demographic factors, 362, 367 Croatia, 53, 54, 62 demonstrations, 192 crop, 80, 259, 272 dengue, 131 crops, 80, 238, 259, 265, 269, 270, 273, 332 dengue fever, 131 cross-cultural comparison, 73 denial, 123, 319, 340 cross-cultural differences, 70 Denmark, 113 cross-validation, 90 Department of Education, 107, 109 cues, 56, 68 Department of Health and Human Services, 104, 109 cultivation, 371 Department of Justice, 107, 219 cultural beliefs, 60, 68 dependent variable, 358 cultural differences, 44, 55, 58, 59, 60, 64, 65, 66, depersonalization, 78 68, 69, 345, 350, 361 deployments, 161, 166, 169, 170, 172, 204, 216 cultural imperialism, 343 deposits, 269 cultural norms, 62, 64, 335 depression, 10, 12, 47, 57, 58, 61, 63, 64, 73, 78, 80, cultural tradition, 213 85, 119, 133, 202, 204, 207, 208, 211, 239, 252, cultural values, 49, 59, 340 253, 255, 259, 263, 275, 315, 325, 329, 335, 343, culture, 8, 24, 25, 31, 33, 34, 46, 49, 50, 54, 57, 58, 350, 352, 353, 354, 355, 370 59, 60, 61, 65, 66, 69, 70, 72, 73, 74, 75, 99, 126, depressive symptomatology, 251, 335 128, 135, 137, 162, 191, 206, 261, 263, 274, 306, depressive symptoms, 252 310, 325, 331, 336, 337, 344, 349, 353, 368 deprivation, 198, 217, 303, 317 cure, 43 depth, 8, 70, 238, 259, 260, 262, 284 curriculum, 135 despair, 9, 113, 241, 307 cycles, 4 destruction, 4, 10, 56, 104, 119, 120, 128, 165, 177, cyclones, 117, 238, 257, 259, 260, 261, 265, 269, 238, 242, 243, 258, 267, 268, 271, 276 271, 272, 273 detachment, 132 Cyprus, 116 detection, 247, 299 detention, 27, 116, 119, 333 determinism, 336 D developed countries, 317 developed nations, 332 daily living, 243 developing countries, 55, 57, 59, 60, 68, 152, 289, dance, 286 317 danger, 18, 57, 102, 161, 239, 241, 244, 248, 369 developing nations, 205 data collection, 154, 155, 240, 308 development assistance, 54 data gathering, 131 developmental factors, 254, 366 database, 206 diabetes, 144 death rate, 114, 140 Diagnostic and Statistical Manual of Mental deaths, 5, 7, 97, 101, 102, 104, 106, 114, 127, 130, Disorders, 56, 90, 322 135, 150, 176, 177, 178, 180, 187, 191, 267, 268, diagnostic criteria, 56, 316 270, 273 diarrhea, 150, 152 debts, 271 diet, 199 decision-making process, 288

Complimentary Contributor Copy 380 Index dignity, 113 diplomacy, 161 E disability, 7, 9, 48, 71, 114, 169, 305 early warning, 237, 246, 269, 272, 273 disappointment, 98 earthquakes, ix, 5, 117, 198, 213, 238, 253, 257, 259, disaster area, 335 260, 263, 281, 282, 284, 285, 290, 293 disaster relief, 243, 246, 273, 274 East Asia, 66, 69, 277 disastrous flood, 4, 5, 6 East Timor, 17, 18 disclosure, 345 Eastern Europe, 16, 60, 114, 115 discrimination, 27, 131, 253, 317, 333, 334, 335, eating disorders, 208 353, 362 ecology, 214 discussion groups, 249 economic crisis, 365, 367 diseases, 114, 140, 144, 145, 149, 152, 154, 199, 270 economic development, 41, 42, 274, 278, 309 dislocation, 28, 30, 31, 33, 213 economic downturn, 200 disorder, 23, 50, 52, 55, 56, 57, 58, 59, 64, 71, 72, economic problem, 44, 126 73, 74, 75, 76, 133, 208, 214, 220, 238, 251, 252, economic resources, 31, 42, 49 253, 254, 255, 317, 318, 328 economic status, 261, 322, 334, 335, 350 displaced persons, 28, 73, 112, 116, 120, 327 economics, 30, 32, 126, 161 displacement, 35, 117, 140, 152, 258, 259, 276, 282, education, 83, 113, 125, 128, 129, 130, 133, 136, 284, 317, 321, 324, 327 207, 211, 243, 278, 329, 334, 340, 342, 350, 356, dissatisfaction, 47 358, 360 dissociation, 9, 13, 61, 64, 75, 78, 79, 85 elaboration, 167 distress, 8, 9, 22, 56, 58, 59, 63, 64, 68, 70, 87, 90, elders, 56, 126, 203 121, 133, 239, 244, 245, 246, 248, 262, 276, 305, electricity, 238, 259, 284, 285, 287 315, 317, 321, 325, 327, 332, 334, 335, 336, 338, elementary school, 208, 254 353 e-mail, 286, 299 distribution, 273, 274, 283 emergency, 4, 5, 38, 42, 46, 47, 76, 139, 140, 142, diversity, 22, 72, 294, 335, 361, 371 144, 147, 148, 150, 152, 153, 155, 157, 180, 273, dizziness, 63 281, 282, 290, 294, 295, 329, 343, 368 doctors, 129, 131, 142, 146, 147, 149, 205 Emergency Assistance, 35, 326 dogs, 4, 266 emergency management, 281, 282, 290, 294, 295 DOI, 217 emergency response, 153 domestic violence, 50, 125, 132, 244, 367, 368, 370 emotion, 13, 30, 58, 59, 61, 62, 64, 69, 73, 74, 80, donations, 155 118, 134, 209, 210, 212, 318, 319 donors, 9, 46, 148, 155, 288, 305 emotion regulation, 209, 210, 212 dose-response relationship, 245, 247, 250 emotional distress, 242, 253, 340, 346, 354 down syndrome, 327 emotional experience, 68, 69, 81, 89, 163, 237, 240, draft, 292 321, 330 drawing, 24 emotional intelligence, 330 dream, 56, 308, 353 emotional reactions, 10, 320 drinking water, 129, 149, 152, 270 emotional state, 10, 84 drive-by shootings, 5 empathy, 341 drought, 6, 80, 198, 213, 238, 258, 259, 264, 265, empirical studies, 210 266, 366 employees, 66, 163, 290 drug abuse, 202, 203, 206, 211, 217, 218 employers, 206, 334 drug addict, 198, 200 employment, 70, 272, 334, 335, 341, 350, 368 drug treatment, 215 employment opportunities, 334, 335, 350 drugs, 201, 202, 204, 208 empowerment, 29, 82, 278 DSM, 89 encoding, 65, 219 DSM-IV-TR, 90 endurance, 15, 127, 160, 166, 167 dumping, 271 enemies, 14, 101, 118, 127, 129, 371 dysthymia, 87 energy, 42, 56, 169 enforcement, 165 engineering, 282

Complimentary Contributor Copy Index 381

England, 368 exposure, 50, 56, 61, 62, 63, 64, 75, 117, 122, 161, entrepreneurship, 32 172, 199, 202, 209, 237, 241, 242, 245, 246, 247, environment, 50, 65, 68, 89, 100, 117, 120, 123, 126, 248, 250, 253, 314, 324 133, 136, 145, 146, 153, 166, 170, 198, 200, 201, expulsion, 105 209, 212, 244, 248, 259, 282, 318, 319, 351 external environment, 354 environmental change, 51, 258 external locus of control, 207 environmental conditions, 200, 318 externalizing behavior, 204, 217 environmental factors, 237, 240 extinction, 302 environmental resources, 318 extraversion, 323, 324 environments, 51, 198, 200, 202, 206, 210, 218 extreme poverty, 205, 244 epidemic, 132, 144, 150, 170, 193, 334 epidemiologic, 48 epidemiology, 71, 72, 144 F epigenetics, 198 Facebook, 288 epistemology, 192 facilitated communication, 152 equality, 177 factor analysis, 83 equilibrium, 282 factories, 259 equipment, 146, 243, 246 factual knowledge, 164 equity, 23, 47, 67 Fairbanks, 37, 252 erosion, 113, 269, 271 fairness, 5, 68, 276 estrangement, 98, 165 faith, 8, 25, 32, 84, 134, 135, 167, 178, 301, 317, estrogen, 199 339, 340, 342, 368 ETA, 357 families, 5, 7, 9, 13, 22, 23, 25, 27, 31, 33, 36, 38, ethics, 160, 300, 305, 369, 371 39, 44, 47, 49, 73, 99, 100, 101, 103, 114, 119, ethnic background, 62, 98, 349 120, 121, 126, 131, 132, 133, 135, 148, 153, 160, ethnic groups, 60, 349, 355, 356, 357, 358, 360, 361 178, 179, 186, 187, 188, 197, 198, 199, 200, 201, ethnicity, 60, 62, 100, 119, 128, 165, 205, 271, 359, 203, 204, 205, 206, 212, 213, 215, 216, 217, 218, 367 220, 221, 243, 246, 247, 248, 254, 259, 261, 265, ethnographers, 308 270, 301, 303, 305, 306, 307, 309, 315, 319, 335, etiology, 59, 72 341, 344, 347, 367, 368, 370, 371, 372 euphoria, 161 family behavior, 215 Europe, 16, 70, 114, 115, 116, 120, 123, 213, 277, family characteristics, 211 372 family conflict, 206, 251 European Commission, 213 family environment, 199, 211, 244 eustress, 320 family factors, 199, 217 evacuation, 4, 238, 243, 269, 270, 272, 273 family functioning, 237, 244, 249, 250 everyday life, 186, 293, 301, 317 family history, 209, 214 evidence, 11, 13, 34, 38, 44, 50, 59, 60, 78, 89, 90, family income, 131 97, 101, 104, 135, 154, 198, 201, 203, 210, 212, family life, 88, 132 213, 216, 217, 240, 244, 247, 250, 252, 263, 265, family members, 23, 98, 114, 132, 135, 142, 202, 274, 276, 278, 310, 314, 316, 333, 336, 344, 349, 207, 212, 214, 244, 246, 300, 304, 309, 324, 367 359, 365 family relationships, 125, 213 evidence-based practices, 34 family studies, 307 evolution, 54, 71 family support, 10, 132, 198, 202, 203, 208, 249, 318 exaggeration, 86, 87, 355, 356, 359 family system, 304 execution, 13, 96, 128, 134 family therapy, 104, 209 executive function, 201, 202 family violence, 197, 202, 203, 206, 207, 212 exercise, 83, 290, 317 famine, ix, 8, 332 exile, 28, 317, 319, 326 fanaticism, 187 expertise, 29, 30, 31 fantasy, 175, 187, 362 exploitation, 36, 206, 334 farm land, 80 exports, 370 farmers, 127, 258, 259, 264, 265, 269, 272, 273 farms, 264, 271, 276

Complimentary Contributor Copy 382 Index fast food, 282 free will, 210 fatalism, 339 freedom, 42, 79, 113, 140, 190, 333 fear, 5, 10, 29, 32, 56, 68, 72, 100, 104, 114, 115, freezing, 6, 113 172, 206, 237, 238, 241, 244, 245, 246, 247, 275, friendship, 17, 245, 353 332, 333, 335, 350 fruits, 45 fears, 47, 248, 354 fuel loads, 264, 265 Federal Bureau of Investigation (FBI), 96, 105, 108 funding, 21, 30, 31, 32, 33, 34, 36, 37, 50, 103, 203, Federal Emergency Management Agency (FEMA), 211, 248, 258, 276, 285, 288, 289, 291, 292 28, 35, 38 fundraising, 46 federal government, 35 funds, 46, 130, 131, 273, 274, 288, 292 feelings, 10, 35, 57, 63, 67, 68, 71, 78, 80, 84, 118, future orientation, 343 131, 238, 241, 246, 248, 249, 250, 273, 330, 332, 352 fencing, 259 G fever, 144, 193 gambling, 132, 201, 371 fidelity, 198, 210 gangs, 5, 206, 370 films, 13, 14 garbage, 152 financial, 5, 32, 42, 81, 86, 98, 131, 132, 244, 248, garment factory, 143 263, 267, 271, 272, 276, 283, 290, 293, 317, 351, Gaza Strip, 60, 61, 64 352, 355 GDP, 130, 282 financial resources, 32, 283 gene expression, 198, 199 financial support, 81, 86 general education, 370 financial system, 263 general surgeon, 147 firearms, 5, 95, 98, 104, 106, 107 genes, 198, 199 fires, 5, 201, 238, 263, 264, 265, 266, 267, 268 genocide, 9, 19, 47, 61, 64, 120, 125, 128, 136, 137, first aid, 46, 247, 248, 251, 254, 255, 289, 335, 337 304 first responders, 51 genome, 198 fish, 285 genre, 54, 305, 311 flashbacks, 59 geography, 28, 260, 284, 367 flavour, 283 Georgia, 119 flexibility, 24, 32, 292, 307, 321 Germany, 9, 79, 113, 116, 330, 371 flight, 78 gestures, 190, 309 flights, 181 glasses, 127, 128, 129 flooding, 5, 7, 28, 238, 243, 266, 268, 269, 270, 271, global village, 5 272, 273, 274, 369 global warming, 264 floods, ix, 4, 5, 6, 7, 10, 117, 213, 238, 243, 257, globalization, 330 258, 259, 260, 261, 263, 265, 266, 267, 268, 269, glucocorticoid, 219 270, 271, 272, 273, 274, 277, 283, 368, 371 glucocorticoids, 199 flowers, 102 goal setting, 327 fluctuations, 261 God, 11, 133, 162, 171, 339 fluid, 69 governance, 48 food, 5, 11, 14, 62, 103, 113, 114, 133, 140, 145, government expenditure, 130 149, 151, 152, 155, 201, 247, 258, 259, 267, 268, government policy, 243 270, 271, 272, 273, 287, 332, 334 governments, 47, 106, 140, 154, 160, 165, 173, 263, force, 4, 45, 126, 140, 161, 185, 187, 204, 265 274, 334 forced migration, 29, 331 grants, 35, 46, 86, 203, 276 formal education, 128, 129, 130 graph, 357, 360 formation, 27, 35, 270, 287, 290, 291, 335 grass, 149, 264, 270 foundations, 346 grassroots, 285 fragility, 103 gravity, 282 fragments, 51 Great Britain, 371 framing, 23, 45 Great Depression, 367, 368 France, 14, 17, 113, 115, 147, 148, 193, 371 Greece, 113

Complimentary Contributor Copy Index 383 greed, 96 helplessness, 28, 29, 56, 95, 99 group identification, 359 hepatitis, 150, 152 group interests, 350 hepatitis a, 152 group membership, 35, 67 heroism, 97, 185, 187 growth, 46, 51, 53, 81, 198, 319, 320, 321, 323, 327, heterogeneity, 25, 60 328, 330, 331, 336, 338, 339, 340, 341, 343, 345, high school, 101, 104, 106, 135 346, 347, 353 high winds, 265 guardian, 156 higher education, 129 Guatemala, 66 highways, 274 guidance, 142, 152, 339 hiring, 291 guidelines, 22, 23, 36, 45, 49, 90, 155, 218, 247 historical data, 59 guilt, 13, 69, 82, 99, 239 history, 17, 25, 35, 38, 40, 43, 54, 62, 65, 76, 79, Guinea, 14, 156 108, 111, 120, 127, 128, 135, 140, 176, 190, 192, Gulf Coast, 36 193, 220, 261, 307, 322, 327, 333, 365, 366, 367, gun control, 107, 108 369, 372, 373 HIV, 132, 303, 311, 339, 344, 345, 369 HIV/AIDS, 303, 339, 344 H homeostasis, 81 homeowners, 28 happiness, 315, 320, 327, 328, 352 homes, 10, 27, 61, 98, 101, 116, 118, 120, 166, 202, harassment, 27, 206, 333 238, 243, 265, 267, 269, 270, 272, 273, 274, 276, harmony, 60, 67, 68 282, 284, 285, 291, 314, 333, 335 HCC, 145, 148 homework, 368 head injury, 85 homicide, 95, 96, 98, 99, 100, 101, 102, 103, 105, headache, 58 106 healing, 8, 25, 26, 27, 29, 40, 42, 44, 52, 73, 102, homogeneity, 60 103, 125, 135, 175, 176, 177, 179, 188, 189, 191, homosexuals, 112 192, 193, 246, 301, 302, 303, 315, 317, 328, 339, Honduras, 5 346 honesty, 248 health, 6, 9, 12, 16, 22, 29, 30, 32, 35, 36, 37, 39, 41, Hong Kong, 362 42, 43, 44, 45, 46, 47, 50, 51, 52, 71, 72, 73, 74, hopelessness, 29, 32, 63, 342 75, 76, 104, 125, 131, 132, 134, 138, 139, 140, host, 12, 180, 190, 334, 335, 349, 350, 351, 352, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 353, 354 152, 153, 154, 155, 156, 157, 165, 170, 198, 199, hostilities, 115, 140, 141 201,205, 206, 207, 209, 212, 213, 219, 240, 243, hostility, 61, 290, 350 245, 247, 249, 250, 251, 263, 270, 279, 303, 305, hotels, 259 307, 309, 315, 316, 317, 325, 326, 328, 329, 331, house, 105, 106, 107, 285, 288, 292, 311 334, 335, 337, 355, 356, 361 House of Representatives, 105 health care, 43, 46, 144, 146, 148, 153, 155, 206, 334 housing, 28, 62, 206, 212, 282, 334 health care costs, 206 housing benefit, 28 health care system, 148, 155 hub, 249, 259 health information, 146 human, 8, 11, 12, 13, 14, 21, 22, 23, 28, 29, 31, 35, health problems, 207, 212, 219 36, 42, 43, 44, 45, 46, 47, 49, 52, 65, 71, 72, 73, health promotion, 140 74, 79, 97, 103, 108, 125, 127, 129, 130, 133, health psychology, 76 136, 137, 145, 152, 160, 161, 163, 165, 166, 176, health services, 44, 51, 104, 139, 140, 146, 147, 148, 189, 192, 210, 214, 216, 238, 260, 264, 278, 282, 151, 153, 157, 249, 331 293, 300, 301, 303, 306, 314, 315, 317, 318, 322, health status, 140, 150, 156, 170 326, 328, 332, 333, 334, 345, 369, 371 heart rate, 204, 209, 214 human agency, 176 heat stroke, 266 human behavior, 65, 318 heat waves, 5, 265, 266 human condition, 73, 166, 192 heavy drinking, 207 human development, 129, 214 hegemony, 48 Human Development Report, 330 height, 186

Complimentary Contributor Copy 384 Index human existence, 79 income, 62, 71, 132, 135, 244, 270, 271, 272, 274, human experience, 43, 300 277, 326, 370 human resources, 45, 130, 152 incongruity, 243 human right, 12, 21, 23, 29, 31, 35, 36, 44, 46, 49, independence, 18, 67 52, 71, 137, 301, 306, 326, 332, 333, 334, 345, independent variable, 65 369, 371 India, 37, 142, 147, 154, 206, 240, 253, 257, 269 humanistic psychology, 320 indirect effect, 152 humanitarian aid, 45, 51, 335, 337 individual character, 237, 240 humanitarian intervention, 45, 48, 50 individual development, 307, 366 Hungary, 113 individual differences, 214, 318, 321 Hurricane Andrew, 62, 239, 247, 252, 253, 254, 255 individualism, 55, 60, 66, 67, 68, 70, 72, 74 Hurricane Katrina, 21, 28, 29, 37, 38, 40, 45, 240, individuals, ix, 7, 8, 9, 11, 12, 24, 25, 27, 33, 39, 47, 243, 246, 252, 253, 254, 255, 260, 293, 294, 366 49, 58, 59, 64, 65, 67, 68, 69, 70, 77, 80, 83, 89, hurricanes, 213, 257, 259, 260 90, 97, 101, 102, 103, 105, 152, 161, 177, 180, husband, 18, 80, 126, 207 183, 184, 188, 190, 198, 206, 210, 239, 242, 258, hygiene, 149 262, 270, 273, 274, 276, 288, 300, 303, 304, 306, hyperarousal, 57, 60, 61, 62, 64 307, 313,314, 315, 316, 318, 319, 320, 321, 322, hypertension, 144 324, 330, 336, 341, 353, 354, 355, 361, 366, 367, hypothesis, 69, 99, 100, 353 368, 369, 370 individuation, 188 indoctrination, 127 I Indonesia, 17, 370 industries, 238, 273, 368 Iceland, 365 industry, 47, 80, 132, 272, 371 icon, 186 inequality, 288 ideal, 282 inequity, 276 idealism, 128 infancy, 199, 205, 219, 351 ideals, 176, 177, 187, 337, 341 infant mortality, 135 identical twins, 198 infants, 205, 241 identification, 30, 105, 113, 240, 283, 317, 319, 322 infrastructure, 7, 51, 125, 126, 128, 129, 130, 131, identity, 11, 26, 27, 33, 35, 95, 115, 120, 162, 187, 140, 144, 151, 153, 165, 238, 243, 245, 258, 259, 191, 242, 330, 334 261, 262, 267, 269, 276, 286 ideology, 97, 126, 127, 133 injuries, 5, 7, 15, 125, 131, 144, 201, 238, 247, 258, illicit drug use, 203 266, 276, 354, 355, 367 illumination, 166 injury, 14, 44, 45, 48, 56, 89, 90, 92, 119, 123, 202, illusion, 179, 187 212, 237, 243, 245, 246 illusions, 76, 321, 329 inmates, 114, 123 image, 87, 88, 89, 186, 192, 327, 338, 356 innocence, 102, 179, 187, 188, 191 imagery, 184 inoculation, 361 images, 44, 46, 160, 308 insane, 97, 168, 169 imagination, 176, 290, 311 instinct, 13 imitation, 101, 107, 200 institutions, 49, 59, 65, 191, 198, 277, 282, 288, 293, immigrants, 11, 12, 36, 77, 83, 116, 206, 314, 349, 301, 305, 307, 334 350, 351, 353, 354, 361, 362, 363 instrumental support, 62 immigration, 11, 177, 192, 329, 349, 350, 351, 352, integration, 14, 29, 75, 80, 171, 349, 350, 353 353, 354, 361 integrity, 155, 350 immunization, 149, 153 intelligence, 207, 208, 211, 244, 323, 351 imprisonment, 122, 200 interaction effect, 210 improvements, 213 interdependence, 36 impulsivity, 86, 208 interdependent self-construal, 67 in utero, 198, 204 interference, 134 incarceration, 11, 114, 117, 119, 198, 202, 203, 212 internalization, 10 incidence, 35, 59, 152 internalizing, 204

Complimentary Contributor Copy Index 385 internally displaced, 16, 24, 34, 37, 139, 143, 314, kindergarten, 254 330 kinship, 203, 272 internally displaced persons (IDPs), 16 Korea, 371 International Criminal Court, 137 Kosovo, 39, 47, 62, 71, 316, 328, 345 international migration, 52 international standards, 18 internationalization, 72 L interpersonal communication, 243 lack of control, 61, 339 interpersonal relations, 367 landscape, 238, 259, 286, 287, 291 intervention, 12, 23, 24, 25, 38, 39, 40, 47, 54, 80, languages, 44, 209 85, 87, 91, 203, 208, 209, 212, 216, 218, 220, Laos, 17 238, 240, 246, 250, 251, 252, 278, 318, 330, 331, Latin America, 62, 68, 345 335, 336, 337, 344, 365, 372 law enforcement, 106 intervention strategies, 335 laws, 95, 104, 106, 113, 131, 206, 350 intoxication, 209, 214 lawyers, 51, 129 inversion, 175 lead, 8, 10, 17, 31, 36, 42, 44, 51, 65, 69, 78, 80, 90, investment, 319, 352 97, 131, 154, 155, 164, 170, 201, 203, 205, 206, investments, 113 212, 213, 257, 284, 303, 308, 314, 316, 317, 328, Iraq, 13, 15, 31, 51, 56, 159, 167, 170, 175, 178, 179, 334, 337, 366 180, 184, 187, 188, 189, 190, 191, 219, 326 leadership, 12, 21, 32, 35, 36, 80, 126, 128, 167, 189, Iraq War, 187, 188, 219 286, 287, 291, 295, 368 Ireland, 210 leadership style, 287, 291 iron, 271 learning, 34, 129, 133, 185, 202, 208, 283, 302, 307, irritability, 57, 239 322, 350, 351 islands, 269 learning process, 351 isolation, 51, 120, 169, 246, 273, 274, 302, 317, 324, legal issues, 57, 99 332 legislation, 104, 106, 116 Israel, 60, 105, 116, 121, 325, 327, 369 leisure, 249, 350, 372 issues, 7, 15, 25, 28, 31, 87, 96, 99, 131, 152, 153, lending, 339 154, 172, 200, 209, 212, 242, 243, 259, 260, 275, lens, 316, 373 276, 281, 282, 283, 285, 289, 292, 293, 318, 329, liberation, 14, 114, 119, 132, 163 335, 349, 350, 354, 366, 368, 369, 372 Liberia, 155, 156, 333, 344, 346 Italy, 5, 17, 116, 147, 154, 371 liberty, 177 life course, 111 J life expectancy, 132, 135 life experiences, 189, 318, 322 Japan, 4, 213, 257, 260, 262, 263, 284, 346, 371 life satisfaction, 57, 67, 318, 322 Jewish Holocaust, 5, 116, 367 light, 48, 61, 100, 134, 159, 182, 191, 264, 285, 315, Jews, 13, 112, 113, 114, 115, 116, 119, 122, 327 318, 320, 323 job skills, 131 Likert scale, 73 job training, 131 limbic system, 201, 202, 209 Jordan, 57, 73 linear model, 308 journalism, 18, 51 literacy, 129, 130, 334 journalists, 9, 17, 18, 51, 101, 307 Lithuania, 119 justification, 82, 188 livestock, 238, 267, 269, 270, 273 juvenile crime, 108 living conditions, 114, 316 loans, 270, 271 lobbying, 103 K local authorities, 149, 286 local community, 30, 31, 34, 36, 129 Kenya, 343 local government, 284 kidnapping, 332 locus, 210, 212, 339 kill, 13, 32, 97, 127, 130, 133, 134, 137 logistics, 153

Complimentary Contributor Copy 386 Index loneliness, 11 measles, 144 longitudinal study, 207, 208, 220 measurement, 34, 51, 59, 72, 290 love, 14, 17, 57, 96, 126, 128, 172, 187, 198, 206, measurements, 309 322 meat, 113 loyalty, 13, 17, 133, 191, 371 Médecins Sans Frontières, 147 lying, 56, 269, 272, 274 media, 7, 18, 30, 45, 98, 100, 101, 105, 107, 112, 154, 161, 163, 165, 170, 172, 178, 248, 262, 265, 276, 288, 289, 290, 291, 301, 305, 335 M median, 356 medical, 12, 16, 58, 73, 89, 131, 139, 140, 142, 143, machinery, 266 144, 145, 147, 148, 151, 153, 243, 270, 272, 273, Mackintosh, 246, 252 313, 314, 315, 341, 362 magnitude, 70, 128, 144, 242, 262, 270, 282 medical care, 131, 142, 153 major depression, 87, 323 medication, 202 major depressive disorder, 131 medicine, 73 major issues, 370 melt, 269 majority, 8, 10, 12, 42, 57, 60, 77, 85, 105, 112, 114, membership, 67, 287, 291, 332 120, 127, 129, 143, 152, 169, 207, 246, 261, 315, memory, 13, 49, 85, 92, 103, 106, 107, 171, 175, 316, 325, 336, 339 176, 177, 178, 179, 180, 181, 185, 187, 188, 189, malaria, 131, 144, 152, 270 191, 192, 193, 264, 300, 304, 363, 367, 373 Malaysia, 147 meningitis, 144 malingering, 92, 362, 363 mental disorder, 35, 71, 72, 199, 215, 251 malnutrition, 147, 270, 336 mental health, 6, 11, 21, 22, 23, 29, 30, 32, 35, 36, maltreatment, 198, 202, 203, 216 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 49, 50, man, 6, 7, 8, 14, 16, 35, 46, 117, 166 51, 52, 54, 58, 71, 73, 74, 75, 76, 77, 95, 103, management, 22, 24, 25, 78, 80, 130, 142, 149, 152, 104, 106, 122, 134, 159, 161, 165, 167, 170, 172, 203, 244, 293 173, 207, 237, 239, 240, 244, 245, 247, 248, 250, man-made disasters, 8 251, 252, 253,255, 258, 259, 263, 299, 300, 301, MANOVA, 357 302, 303, 304, 305, 309, 313, 314, 315, 316, 317, manpower, 152 318, 322, 323, 324, 326, 327, 328, 329, 330, 331, mapping, 30, 34, 38, 39 332, 335, 336, 337, 340, 342, 343, 344, 346 marginalisation, 334, 336 mental health professionals, 36, 42, 43, 44, 46, 47, marital conflict, 215 51, 52, 106, 300, 302, 303, 304, 305, 315, 317, marital quality, 209, 218 332, 335, 336, 337, 343 marketing, 45, 46 mental illness, 62, 74, 96, 318, 337, 370 marketing strategy, 46 mental image, 164 marriage, 132, 137, 304, 334 mental processes, 66 married couples, 204 mental state, 81 married women, 215 mentor, 32 masculinity, 66 mentoring, 133 mass, ix, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 16, 19, 22, 28, mentoring program, 133 29, 34, 35, 36, 38, 39, 41, 42, 44, 48, 49, 51, 52, messages, 17, 102, 160, 161, 165, 170, 200 54, 77, 79, 80, 83, 85, 86, 88, 90, 95, 96, 97, 98, meta-analysis, 64, 67, 69, 74, 207, 326 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, metaphor, 12, 33, 36, 39, 54, 278, 294, 338, 373 112, 120, 128, 138, 140, 149, 152, 154, 165, 197, meter, 267 198, 205, 213, 243, 252, 260, 263, 269, 278, 299, methodology, 55, 60, 70, 129, 304, 308 300, 301, 303, 304, 305, 306, 307, 308, 309, 310, Mexico, 74, 206, 253 333, 335, 344, 368 mice, 199 mass communication, 243 middle class, 44, 127 mass loss, 16 migrant population, 334 materials, 179, 258, 270, 271, 273, 274, 276, 292 migrants, 11, 332, 334, 335, 350, 351, 354, 361 maternal care, 215 migration, ix, 6, 11, 73, 205, 206, 308, 327, 329, matrix, 72 331, 332, 334, 336, 343, 345, 349, 351, 352, 353 matter, 3, 104, 106, 169, 178, 276, 306, 339, 359

Complimentary Contributor Copy Index 387 military, 15, 16, 17, 59, 97, 104, 126, 140, 159, 160, National Academy of Sciences, 219, 305 161, 162, 163, 164, 165, 166, 167, 169, 170, 172, national borders, 160 173, 177, 178, 179, 180, 181, 183, 184, 187, 188, national character, 164 189, 191, 197, 198, 200, 204, 205, 208, 212, 215, National Child Traumatic Stress Network, 251 216, 217, 220, 332, 367 national emergency, 153 Millon Clinical Multiaxial Inventory, 86, 92 national identity, 176, 191, 192, 193 Ministry of Education, 129, 130, 137 national security, 164, 184, 189 Minneapolis, 92, 123, 310 National Survey, 201, 219 minorities, 57, 60, 75, 369 nationalism, 97, 179, 190, 314 minority groups, 369, 371 nationality, 60, 119, 332 misconceptions, 345 natural disaster, ix, 6, 7, 8, 9, 10, 22, 28, 77, 78, 79, mission, 15, 17, 118, 188 111, 117, 119, 154, 198, 213, 237, 238, 239, 240, misuse, 170, 201, 210, 217 241, 242, 243, 244, 246, 247, 248, 249, 250, 251, mobile phone, 4, 285 252, 253, 257, 258, 259, 260, 261, 268, 269, 270, models, 21, 22, 28, 31, 32, 34, 37, 48, 49, 50, 51, 68, 271, 273, 274, 275, 276, 277, 278, 284, 290, 292, 117, 156, 203, 279, 282, 283, 287, 289, 301, 305, 362, 365, 366,367, 369, 372 307, 318, 325, 358, 359, 373 negative consequences, 84, 176, 202, 212, 350 moderators, 65, 91, 306 negative coping, 340 modern society, 172 negative effects, 198, 199, 209, 320 modernity, 106, 343 negative emotions, 241, 275, 353 modifications, 49 negative experiences, 161 momentum, 44, 259 negative outcomes, 211, 246, 316 monks, 129 negative relation, 89 monsoonal flooding rains, 5 neglect, 198, 199, 200, 202, 203, 204, 212, 215, 221 mood disorder, 58 negotiating, 176, 191 moral beliefs, 14, 84, 88 negotiation, 27, 31, 181, 287 moral standards, 13 Nepal, 63, 70, 75, 76 morale, 126 Netherlands, 91, 113, 122, 362 morality, 68, 165, 172, 306 networking, 287 morbidity, 145, 152 neurasthenia, 58 mortality, 131, 145, 152, 155, 156, 199, 269 neutral, 177, 185, 186, 190 mortality rate, 155 New England, 252 mosaic, 366 New South Wales, 4, 260 Moses, 112 New Zealand, ix, 3, 4, 8, 10, 16, 18, 99, 121, 213, motivation, 74, 96, 97, 98, 105, 286, 320 251, 253, 257, 260, 261, 262, 263, 281, 282, 283, mountain ranges, 266 290, 293, 294, 345, 346, 362, 373 MPI, 85 next generation, 125, 135 MSF, 147 NGOs, 23, 46, 289, 292 MTI, 147 nightmares, 63, 134, 239 multi-ethnic, 254, 304, 355 North Africa, 17 multiple regression, 315 North America, 362, 365 multiple regression analysis, 315 Northern Ireland, 47 murder, 63, 88, 96, 107, 108, 138, 333 Norway, 96, 97, 113, 121, 140, 154 music, 14, 114, 286 nurses, 51, 147, 148, 219 mutilation, 333 nursing, 5, 146, 308 mutual respect, 35 nursing home, 5 nurturing parent, 199 nutrition, 198 N nutritional deficiencies, 152 nutritional status, 145, 146, 149 Namibia, 343 narratives, 6, 9, 12, 17, 42, 45, 46, 50, 51, 52, 58, 73, 176, 178, 179, 187, 190, 191, 192, 299, 300, 301, 302, 303, 304, 305, 307, 308, 309

Complimentary Contributor Copy 388 Index

parents, 5, 100, 103, 122, 125, 126, 132, 133, 197, O 199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 211, 212, 215, 216, 219, 220, 239, 241, 243, 244, obedience, 126 248, 249, 250, 308, 327, 368, 370 obesity, 199 Parliament, 285 obstacles, 78, 115, 160, 300, 309, 324 participants, 32, 62, 133, 145, 176, 178, 179, 181, occupied territories, 113 240, 289, 290, 321, 335, 338, 342 oceans, 5 pastures, 269, 272 offenders, 96 pathology, 23, 30, 86, 121, 198, 315, 331, 336 Office of Justice Programs, 107, 219 pathways, 25, 80, 220, 285, 309, 337 officials, 262, 281, 283, 284 patriotism, 106, 175, 176, 177, 178, 179, 181, 183, oil, 311 185, 188, 189, 190, 191 Oklahoma, 97, 102, 108 PCA, 84, 86, 87 old age, 112 peace, 5, 9, 12, 14, 16, 37, 47, 48, 51, 52, 53, 56, 98, open-mindedness, 323 108, 156, 198, 300, 330, 334, 335 openness, 69, 307 peacekeeping, 16, 47, 330 Operation Iraqi Freedom, 214 peer group, 202 operations, 15, 153, 154, 156, 159, 160, 161, 162, peer influence, 199 165, 166, 169, 172, 243, 251, 288, 368 peer relationship, 246 opportunities, 34, 52, 129, 136, 149, 163, 248, 284, peer review, 18, 45 289, 293, 315, 335, 342 Pentagon, 178, 180 opposition parties, 161 perceived control, 82, 354 optimism, 12, 33, 315, 318, 323, 324, 329, 353, 361, perinatal, 219 362 permission, 25, 162, 259 organisational patterns, 24 permit, 82, 358 organism, 199 perpetration, 202, 212 organize, 79, 130, 181 perpetrators, 9, 13, 48, 97, 98, 100, 104, 105, 135, organized warlord gangs, 5 300 Oromo, 342, 344 perseverance, 351 outpatient, 146, 207 personal communication, 26, 35 outreach, 38, 329 personal control, 318 overlap, 47, 58, 154, 355 personal development, 28 ownership, 104, 249 personal goals, 67, 82, 318, 353 oxygen, 266 personal qualities, 81 personal values, 79, 81 P personality, 62, 78, 80, 81, 86, 87, 88, 89, 90, 122, 169, 210, 240, 242, 244, 318, 320, 321, 324, 325, Pacific, 6, 137, 262, 271, 344 326, 328, 351 pain, 11, 84, 85, 88, 103, 167, 168, 169, 177, 190, personality characteristics, 62, 86, 87, 88, 210 293 personality disorder, 86, 87, 89 pain perception, 85 personality traits, 80, 210, 242, 321 Pakistan, 18 Perth, 372 palliative, 319 pessimists, 353 panic attack, 311 pharmaceutical, 47 paradigm shift, 49 phenomenology, 121 parallel, 162, 365 phenotype, 199 parental authority, 127, 133 Philadelphia, 55, 107, 123, 279, 310, 317, 374 parental care, 208 Philippines, 5 parental employment, 200 photojournalists, 9 parental maltreatment, 198 physical abuse, 333 parental support, 198 physical aggression, 209 parenting, 133, 199, 200, 203, 209, 211, 212, 213, physical characteristics, 211 217, 249, 370 physical health, 36, 57, 201, 208, 259, 263, 275, 315

Complimentary Contributor Copy Index 389 physical structure, 106 predictability, 248, 306 physicians, 51, 147 prefrontal cortex, 202, 209 physics, 12, 33 pregnancy, 148, 208, 209, 211, 214 physiological mechanisms, 80 preparation, 31, 97, 186, 268, 294 physiology, 199 preparedness, 4, 22, 23, 24, 36, 264, 267, 268, 269, pilot study, 53, 74 274 plants, 285 preschool, 208, 241, 254 playing, 15, 16, 113, 118, 133, 239, 248, 287 preschool children, 241, 254 Poland, 9, 113, 116, 245 preschoolers, 241 police, 98, 99, 104, 105, 106, 113, 160, 178, 184, preservation, 114 187, 334, 368 president, 4, 119 policy, 51, 53, 95, 106, 108, 129, 138, 160, 165, 210, pressure groups, 161 211, 265, 328 prevalence rate, 63, 64 policy makers, 210, 211 prevention, 25, 41, 42, 43, 44, 50, 54, 104, 106, 108, policy reform, 106 109, 140, 149, 152, 154, 198, 200, 203, 211, 217, policymakers, 47, 300, 307 300, 317 political leaders, 166 preventive approach, 41 political party, 160 primacy, 316, 362 political power, 167 primary school, 241 political refugees, 310 principles, 12, 23, 24, 25, 34, 36, 39, 40, 49, 78, 247, politics, 28, 30, 96, 160, 162, 191, 192, 193, 260, 302, 365, 373 293, 373 prisoners, 5, 13, 72, 113, 118, 119, 167, 198, 203 ponds, 127 prisoners of war, 118, 119 population, 5, 7, 22, 23, 26, 27, 28, 47, 58, 61, 62, prisons, 204 63, 86, 87, 95, 115, 120, 123, 125, 126, 127, 129, private sector, 288 131, 132, 135, 143, 144, 145, 150, 153, 154, 155, probability, 207 160, 170, 211, 240, 252, 254, 261, 263, 265, 266, problem behavior, 209, 215, 217 268, 270, 271, 272, 273, 274, 276, 314, 322, 334, problem drinkers, 215 335, 336, 339, 342, 355, 359, 371 problem solving, 24, 203, 207, 208, 242, 250, 319 population density, 7, 273, 274, 276 problem-focused coping, 319 population growth, 129 producers, 302, 370 population size, 273 professionals, 12, 16, 23, 42, 43, 45, 46, 50, 51, 52, Portugal, 215 104, 131, 143, 153, 247, 301, 306, 307, 335, 337 positive correlation, 78, 89 profit, 29, 42, 47 positive emotions, 57, 315, 321, 323, 326, 330 programming, 32, 219 positive feedback, 289 project, 25, 27, 30, 32, 140, 148, 155, 178, 284, 285, positive relationship, 321 286 post traumatic stress disorder (PTSD), v, vi, 3, 10, proliferation, 27, 51 12, 35, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, prophylactic, 106 53, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 68, proposition, 49 69, 70, 71, 72, 73, 74, 75, 76, 85, 86, 87, 119, prosperity, 275 121, 122, 133, 160, 1701, 205, 219, 237, 238, prostheses, 131 239, 240, 241, 242, 243, 244, 245, 246, 247, 248, protection, 36, 207, 237, 241, 249, 332 249, 250, 251, 252, 254, 255, 259, 300, 315, 316, protective factors, 23, 32, 197, 199, 200, 203, 206, 323, 325, 329, 335, 337, 342, 343, 345, 362, 372 207, 208, 209, 210, 211, 212, 217, 218, 240, 251, post traumatic stress, 42, 50, 52, 55, 56, 59, 71, 72, 306, 308 73, 74, 75, 76, 255, 328 protective role, 322, 323 poverty, 44, 48, 51, 199, 200, 203, 205, 206, 211, proteins, 219 214, 216, 221, 270, 278, 324, 334, 336 prototype, 106, 120, 320, 328 power lines, 238 psychiatric disorders, 12, 63, 209, 214, 313, 314, praxis, 33 315, 318 prayer, 114, 184, 339 psychiatric illness, 76 precipitation, 261, 264, 268 psychiatrist, 58, 300, 301, 302, 365

Complimentary Contributor Copy 390 Index psychiatry, 42, 46, 73, 255, 299, 300, 311 psychoanalysis, 302 R psychobiology, 199 race, 28, 30, 119, 126, 128, 165, 166, 205, 207, 211, psychological distress, 10, 12, 57, 89, 241, 244, 245, 247, 260, 332, 341, 371 246, 249, 253, 314, 316, 324, 334, 362 racism, 335 psychological health, 245, 315, 354 radio, 249 psychological pain, 64 rainfall, 238, 269, 272 psychological phenomena, 337 rape, 45, 62, 64, 72, 98, 154, 317, 333 psychological problems, 64, 202, 212, 351 rash, 100 psychological processes, 58, 65, 66 rating scale, 328 psychological stress, 115, 248, 327 rationalisation, 111, 117, 119 psychological variables, 354 reactions, 8, 10, 16, 22, 56, 57, 68, 78, 79, 80, 82, 83, psychological well-being, 120, 239, 352, 363 90, 95, 119, 122, 160, 165, 169, 220, 238, 239, psychologist, 159, 160, 276 252, 253, 259, 261, 263, 265, 267, 275, 276, 355, psychology, 12, 19, 46, 54, 59, 65, 66, 71, 72, 74, 75, 362 121, 123, 160, 252, 278, 299, 313, 314, 315, 318, reactivity, 56, 169, 199, 202, 214, 216 320, 322, 324, 325, 326, 327, 328, 329, 330, 336, reading, 308, 339 337, 343, 344, 346, 351, 352, 361 reality, 8, 9, 15, 48, 58, 65, 78, 79, 80, 90, 160, 164, psychometric properties, 356 334, 337, 350, 351, 352 psychopathology, 9, 42, 56, 57, 74, 78, 83, 88, 89, reasoning, 67, 69, 74, 202, 208 90, 91, 210, 216, 220, 221, 237, 240, 242, 244, rebel groups, 333 245, 247, 250, 251, 253, 254, 314 recall, 122 psychopharmacology, 214 reception, 119, 123, 302 psychosocial dissociation, 9 reciprocity, 35 psychosocial factors, 240, 244 recognition, 79, 81, 123, 290, 293, 309, 361 psychosocial functioning, 82, 217 reconciliation, 54, 75, 135, 136, 300, 305 psychosocial interventions, 40, 57, 85, 301, 303, 328 reconstruction, 262, 293, 326, 369 psychosocial support, 29, 30, 32, 36, 38 recovery, ix, 3, 4, 7, 8, 9, 11, 12, 22, 23, 24, 25, 26, psychosomatic, 58, 239 28, 29, 30, 32, 33, 34, 36, 38, 39, 42, 50, 78, 79, psychotherapy, 49, 57, 91, 120, 302, 310, 330 80, 81, 82, 90, 91, 105, 117, 119, 120, 125, 128, public health, 46, 48, 51, 114, 131, 144, 155, 156, 135, 179, 181, 191, 192, 237, 240, 243, 245, 246, 157, 308 247, 249, 250, 251, 254, 258, 260, 261, 263, 270, public opinion, 104, 161 271, 273, 274, 275, 276, 277, 281, 283, 284, 285, public support, 140 286, 287, 288, 289, 290, 291, 292, 293, 294, 295, punishment, 202 300, 305, 307, 316, 320, 328, 362, 366, 368, 369, purity, 13, 102 372 recovery plan, 28, 366 Q recovery process, 36, 281, 283, 286, 287, 290, 291, 292 qualitative differences, 66 recreation, 282 qualitative research, 49, 75, 309 recreational, 371 quality of life, 28, 322 recreational areas, 371 quantitative research, 72, 309, 328 recruiting, 25, 164 Queensland, 4, 5, 7, 10, 19, 95, 111, 125, 237, 238, redevelopment, 286 243, 246, 248, 252, 254, 257, 258, 260, 262, 263, redistribution, 366 264, 265, 266, 267, 268, 271, 272, 273, 274, 276, redundancy, 24 277, 278, 333, 365, 370, 373 reform, 95, 103, 104, 106, 107 query, 53 reforms, 96, 106 questionnaire, 204 refugee camps, 205, 213, 328, 334, 343, 344 refugee flows, 54 refugee group, 343 refugee resettlement, 29, 369 refugee status, 28, 333

Complimentary Contributor Copy Index 391 refugees, 11, 12, 24, 28, 36, 37, 52, 53, 54, 61, 63, restructuring, 165, 319 64, 68, 70, 72, 73, 75, 76, 77, 137, 205, 304, 308, retaliation, 96, 187 309, 311, 313, 314, 315, 316, 317, 322, 323, 324, retaliatory action, 140 326, 327, 328, 329, 330, 331, 332, 333, 334, 335, retention rate, 209 336, 338, 339, 340, 342, 343, 345, 346 revenue, 201, 267 regenerate, 185 rhetoric, 106, 159, 161, 175, 307 regeneration, 177 rights, 9, 28, 35, 36, 44, 113, 119, 131, 187, 259, regression, 85, 86, 357, 358 285, 305 regression method, 358 rings, 103 rehabilitation, 9, 131, 149, 153, 154, 305 risk, 10, 11, 24, 34, 37, 46, 55, 59, 60, 62, 63, 64, 70, rejection, 187, 351 71, 104, 117, 121, 127, 144, 152, 170, 197, 200, relationship quality, 209 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, relatives, 120, 186, 202, 208, 272, 284, 322 211, 212, 213, 214, 215, 216, 217, 218, 220, 221, relevance, 46, 66, 71, 318, 337, 355 237, 240, 241, 242, 243, 244, 245, 246, 247, 248, reliability, 84, 89, 154, 356 249, 250, 251, 252, 265, 270, 277, 294, 300, 306, relief, 42, 48, 54, 131, 187, 241, 262, 273 317, 320, 323, 336, 351, 352, 366 religion, 45, 127, 128, 271, 305, 306, 317, 331, 332, risk factors, 55, 59, 62, 63, 64, 70, 71, 201, 207, 208, 336, 339, 340, 343, 345 210, 211, 212, 214, 220, 221, 240, 242, 245, 246, religiosity, 323 247, 250, 251, 306, 317 religious beliefs, 84, 89 risks, 54, 200, 203, 204, 205, 206, 207, 210, 212 remediation, 282, 290 river flows, 267 remorse, 134, 135 river systems, 269, 272 repair, 273, 286, 315 robberies, 5 replication, 73, 219 role-playing, 101 reputation, 371 root, 48, 54, 149 requirements, 353 roots, 11 research funding, 36 routes, 24 researchers, 65, 66, 119, 129, 176, 198, 199, 203, routines, 176, 275 205, 206, 208, 210, 242, 266, 315, 317, 319, 339, RTS, 8, 77, 78, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90 366 rubber, 170, 171 reservations, 371 rules, 160, 262, 305 reserves, 169 runoff, 269 resettlement, 314, 330, 331, 332, 334, 340, 342, 343, rural areas, 126, 127, 130, 238, 246, 257, 258, 266, 349, 350, 351 268, 278 resistance, 32, 118, 220, 303, 327, 352 Russia, 206 resolution, 184, 305, 324 Rwanda, 61, 64, 75, 120, 135, 137 resource availability, 25 resources, 7, 8, 12, 16, 23, 24, 25, 26, 28, 30, 31, 32, 33, 34, 42, 44, 51, 59, 64, 80, 81, 103, 130, 131, S 134, 140, 145, 153, 201, 205, 206, 211, 249, 254, sadism, 96 258, 259, 270, 273, 274, 283, 309, 313, 314, 316, sadness, xi, 56, 63, 204, 241, 275, 317 317, 318, 320, 322, 323, 327, 332, 334, 349, 351, safety, 99, 106, 107, 128, 154, 184, 237, 238, 242, 352, 354, 366, 370 244, 245, 246, 247, 248, 250, 285, 332, 333, 334, response, 15, 21, 22, 23, 26, 27, 32, 35, 36, 38, 39, 335 43, 58, 85, 101, 105, 106, 107, 139, 145, 146, Salvation Army, 6, 277 149, 152, 153, 154, 155, 156, 160, 163, 177, 178, sample variance, 359 179, 185, 187, 190, 199, 209, 210, 214, 216, 241, Sarajevo, 62, 75 246, 247, 252, 255, 261, 267, 268, 270, 275, 276, saturation, 266 278, 284, 285, 286, 288, 306, 307, 318, 321, 337, Scandinavia, 118 339, 341, 347, 353, 360, 362 schema, 69 restaurants, 249, 282 schemata, 69 restoration, 9, 132 scholarship, 283, 290, 292 restrictions, 113

Complimentary Contributor Copy 392 Index school, 40, 62, 65, 95, 96, 100, 101, 102, 103, 104, SES, 209, 267, 282 105, 106, 107, 108, 109, 113, 114, 129, 130, 135, settlements, 271 199, 204, 206, 208, 209, 211, 212, 216, 218, 219, severe stress, 318, 319 220, 239, 240, 242, 243, 244, 248, 251, 254, 259, sewage, 285 270, 272, 282, 305, 342, 369, 370 sex, 132, 199, 201, 205, 354 school achievement, 239 sex role, 354 school activities, 243, 248 sexual abuse, 199, 370 school community, 40 sexual behavior, 325 school failure, 209, 211 sexuality, 371 school performance, 208, 240 shame, 13, 61, 69, 126, 131 schooling, 316 shape, 36, 45, 51, 65, 82, 181, 185, 191, 193, 301, science, 45, 49, 50, 91, 166, 214, 294, 299, 300, 303, 302 304, 306, 308 sheep, 259, 264 scientific understanding, 315 shelter, 32, 38, 63, 114, 247, 250, 287, 332 scope, 24, 70, 177, 318 shock, 9, 10, 45, 114, 117, 241, 246, 265, 266, 333 scripts, 25, 301 shoot, 13, 133, 370 sea level, 269 shoots, 106 second generation, 125 short supply, 272, 317 second language, 128 shortage, 3, 5, 129, 152, 259 Second World, 59 showing, 81, 242, 351 secondary education, 129 shrubs, 285 Secret Service, 105, 109 siblings, 209 security, 23, 95, 98, 102, 105, 106, 120, 128, 140, Sierra Leone, 332, 333, 335, 344, 346 154, 165, 179, 189, 237, 238, 242, 243, 248, 249, signals, 85, 155 250, 261, 292, 317, 332, 334 signs, 89, 96, 183, 184, 239, 241, 249, 266, 268, 371 security forces, 140, 189 silver, 17 security guard, 105 skills base, 212 self-actualization, 79 skills training, 209, 211 self-concept, 67, 69 skin, 16, 335 self-confidence, 318, 354 slavery, 28, 260, 333, 367, 369 self-control, 202 sleep disturbance, 239 self-efficacy, 84, 89, 320, 323, 329 small communities, 206, 259, 370 self-esteem, 61, 131, 202, 210, 212, 253, 322, 353, smuggling, 371 354, 361, 362 snippets, 161 self-expression, 68 soccer, 133 self-identity, 82 social acceptance, 208 self-image, 89 social adjustment, 209, 251 self-regulation, 202, 325 social capital, 35, 49, 220, 271, 281, 284, 294, 365, self-worth, 82 366, 371 semi-structured interviews, 284 social change, 31, 34 senate, 105, 136 social class, 219, 371 sensations, 56 social construct, 33, 58, 316 sensitivity, 12, 25, 217, 252, 349 social context, 22, 49, 193 separateness, 91, 325 social environment, 30, 349, 353, 361 September 11, 27, 38, 39, 40, 45, 178, 192, 343 social fabric, 33, 127 Serbia, 373, 374 social group, 120, 332 service organizations, 9, 44, 305, 307 social hierarchy, 66 service provider, 29, 152, 289 social identity, 253 services, 4, 5, 12, 22, 23, 26, 28, 29, 32, 38, 44, 45, social institutions, 65 49, 50, 51, 52, 104, 108, 114, 119, 131, 142, 143, social justice, 24 146, 148, 149, 152, 153, 164, 203, 205, 210, 215, social life, 275 239, 240, 243, 245, 247, 249, 264, 309, 317, 336, social network, 31, 49, 287, 324, 335, 353, 362 368 social obligations, 69

Complimentary Contributor Copy Index 393 social organization, 28 Sri Lanka, vi, ix, 3, 16, 61, 75, 139, 140, 141, 142, social participation, 65 143, 147, 150, 151, 152, 153, 154, 155, 156, 157 social problems, 205, 208, 309 stability, 17, 82, 160, 201, 243, 258, 262, 283 social programs, 136 staffing, 130, 146 social psychology, 72 Stafford Act, 35 social reality, 361 stakeholders, 32, 145, 152, 153, 155 social relations, 35, 317, 320, 322, 365, 366 standard error, 358 social relationships, 35, 320, 322, 365, 366 stars, 17, 181, 184 social resources, 23, 203, 318, 324 starvation, 114, 154, 270 social roles, 67, 68, 324, 350 state, 4, 10, 15, 24, 28, 36, 52, 56, 63, 79, 81, 99, social sciences, 307 101, 104, 112, 114, 116, 127, 129, 140, 162, 165, social services, 131, 349 178, 179, 180, 203, 205, 263, 264, 265, 266, 267, social skills, 104, 318 282, 289, 290, 301, 314, 336, 362, 366 social skills training, 104 state authorities, 5, 265 social standing, 271 states, 32, 33, 35, 101, 104, 120, 127, 167, 203, 211, social status, 351 264, 268, 282, 335, 337, 342 social structure, 125, 152, 243 statistics, 7, 33, 34, 130, 136, 137, 138, 203, 358 social support, 25, 29, 35, 49, 64, 69, 70, 76, 119, status of refugees, 346 243, 245, 247, 252, 254, 317, 323, 324, 338, 340, statutory authority, 35 345, 350, 352, 353, 366 stereotypes, 60, 101, 164, 165 social support network, 245 stereotyping, 100, 335 social units, 49, 199 stigma, 317 social welfare, 130, 368 stimulation, 116, 209 social withdrawal, 242 stimulus, 210 society, 9, 13, 14, 15, 23, 24, 27, 45, 47, 65, 68, 82, stock, 283 98, 112, 113, 119, 127, 128, 160, 161, 162, 163, stomach, 239 164, 165, 166, 167, 169, 170, 172, 188, 198, 201, storage, 138, 265 202, 245, 272, 283, 300, 335, 343, 352, 371 storms, 5, 243, 258, 260, 263, 265, 271 sociocultural contexts, 9, 305 storytelling, 192, 302, 308 sociology, 101, 307, 319 stress, 7, 24, 27, 28, 36, 42, 43, 45, 46, 48, 51, 53, SOI, 267 68, 70, 71, 72, 73, 74, 75, 81, 122, 123, 125, 132, solidarity, ix, 14, 79, 102, 345 133, 134, 160, 165, 169, 172, 198, 199, 200, 201, solitude, 301 202, 203, 204, 205, 206, 207, 209, 213, 214, 218, solution, 161, 358, 359 238, 243, 244, 245, 246, 247, 251, 252, 253, 254, Somalia, 156 255, 268, 271, 276, 299, 300, 301, 304, 306, 309, somatization, 73 310, 314, 316, 319, 320, 321, 323, 326, 327, 329, South Africa, 47, 116, 135, 137, 160, 173, 339, 342, 334, 338, 349, 352, 353, 354, 361 344, 345 stress coping ability, 81 South America, 60 stress factors, 123, 172 South Asia, 155 stress reactions, 123, 199, 244, 253, 314 South Korea, 100 stress response, 199, 202 Southeast Asia, 52, 162 stressful events, 245, 248, 321, 324 specialists, 131 stressful life events, 318, 350 specialization, 48 stressors, 11, 25, 121, 165, 169, 200, 203, 205, 206, speech, 9, 54, 299, 304, 305, 306 210, 212, 317, 318, 321, 324, 329, 349, 353, 362 spelling, 18 stretching, 271 spending, 34, 200 structural equation modeling, 211 spin, 161, 284 structure, 25, 26, 31, 51, 62, 66, 70, 72, 90, 108, 117, spine, 45 127, 141, 147, 160, 283, 302, 329, 345 spirituality, 24, 25, 79, 126, 128, 302, 317, 323, 336, structuring, 186 340, 346 style, 6, 69, 81, 169, 208, 291, 354, 361 Spring, 192, 344 subjective experience, 58, 78, 90 subjective well-being, 121, 326, 327, 328

Complimentary Contributor Copy 394 Index subsistence, 129, 270, 283 teachers, 100, 103, 105, 106, 127, 129, 130, 209, subsistence farming, 270 247, 248, 309, 345 substance abuse, 50, 197, 198, 199, 200, 201, 202, teams, 129, 147, 148, 247, 262, 268, 276, 335 203, 206, 208, 209, 211, 212, 214, 217, 221, 370 techniques, 331, 333, 337 Substance Abuse and Mental Health Services technological developments, 163 Administration (SAMHSA), 201 technologies, 176 substance use, 201, 205, 208, 211, 212, 214, 217, technology, 51, 97, 176, 278 218, 220 teens, 218 substance use disorders, 201, 205, 212 telecommunications, 291 substitution, 43 telephone, 152, 259, 285 succession, 238 telephones, 243 SUD, 208 tellers, 304 Sudan, 120, 156, 331, 332, 333, 344, 345, 346 temperament, 202, 208, 209, 214, 318 suicide, 96, 98, 101, 106, 107, 140, 154, 208, 259, temperature, 264, 265 367, 370 tenants, 285 suicide bombers, 140, 154 tension, 33, 51, 58, 190, 289 supernatural, 70 tensions, 22, 51, 118, 178, 261 supervision, 199, 206, 209, 211 tenure, 139, 156 supervisor, 133 territory, 104 suppression, 10, 358 terrorism, ix, 3, 22, 51, 52, 97, 159, 173, 179, 187, surveillance, 149, 152, 154 189, 253, 308, 327 survival, 13, 77, 79, 115, 118, 161, 165, 263, 331, terrorist acts, 96 339, 340, 341 terrorist attack, 7, 60, 111, 117, 189, 247, 343, 367 survivors, 5, 6, 23, 33, 39, 41, 42, 43, 44, 45, 46, 49, terrorists, 184 61, 65, 99, 101, 111, 112, 115, 116, 117, 118, test data, 349 119, 120, 121, 122, 123, 135, 137, 185, 211, 251, textbooks, 129 253, 265, 299, 300, 301, 302, 303, 304, 305, 307, texture, 106, 193 317, 323, 325, 329, 336, 337, 338, 339, 340, 341, Thailand, 63, 64, 74, 105, 132, 136, 137, 156, 205, 342, 343, 344, 373 206, 213, 244, 255 susceptibility, 238 theatre, 27, 108, 114, 143, 147, 148, 161 sustainability, 51 theoretical assumptions, 74 sustainable development, 278, 294 therapeutic interventions, 10, 336 suture, 191 therapeutics, 373 Sweden, 53, 251 therapy, 14, 72, 90, 217, 304, 324, 328, 336, 337, symmetry, 185 349, 362, 365, 366 sympathy, 115 Third Reich, 112, 113 symptoms, 9, 11, 44, 55, 56, 58, 59, 60, 61, 62, 63, thoughts, 9, 49, 53, 56, 85, 88, 189, 239, 254 64, 65, 68, 70, 72, 73, 74, 75, 76, 78, 80, 85, 86, threat assessment, 108 112, 118, 122, 125, 204, 208, 239, 241, 242, 244, threats, 77, 99, 100, 184, 189, 329 245, 247, 250, 251, 252, 254, 255, 300, 305, 316, time frame, 3 335, 345, 351, 355 tin, 265 syndrome, 56, 121, 122, 123 toddlers, 205 tones, 42 top-down, 283 T torture, 9, 39, 47, 61, 62, 64, 71, 72, 74, 75, 77, 83, 114, 116, 127, 133, 138, 154, 167, 302, 326, 332, tactics, 160 333, 334, 344 takeover, 127 tourism, 267, 272, 273 Taliban, 62, 165 toys, 102, 103, 248 tanks, 164 tracks, 18, 44, 262 target, 153, 336, 365 trade, 14, 112, 145, 153, 169 Task Force, 23, 275 trade union, 14, 112, 145, 153 task performance, 327 traditional gender role, 370 taxes, 201

Complimentary Contributor Copy Index 395 traditions, 8, 44, 49, 66, 301 United Nations (UN), 23, 37, 128, 130, 131, 136, training, 23, 29, 40, 45, 58, 131, 162, 172, 204, 209 145, 153, 209, 211, 221, 314, 330, 332, 333, 345 trait anxiety, 242, 245, 252, 255 United Nations Development Program, 330 traits, 67, 322, 323 United Nations High Commissioner for Refugees trajectory, 24, 49, 308 (UNHCR), 153, 314, 330, 332, 333, 334, 335, transactions, 69 344, 346 transcendence, 24, 79, 91, 108, 189 United States (USA) , ix, 3, 4, 11, 18, 19, 20, 21, 22, transcripts, 219 29, 35, 41, 55, 57, 60, 63, 66, 70, 74, 75, 101, transformation, 26, 34, 91, 190, 329 107, 109, 115, 116, 120, 123, 138, 170, 173, 175, transformations, 9, 294, 305, 358 176, 177, 178, 181, 188, 189, 197, 200, 201, 204, transfusion, 142 206, 210, 219, 220, 239, 257, 260, 261, 282, 283, transgression, 13 284, 299, 313, 332, 343, 352, 363, 369, 370, 371 translation, 209 universities, 113 transmission, 65, 123, 201, 216, 304, 373 up-skilling, 288, 291 transparency, 31 urban, 104, 105, 127, 216, 220, 255, 270, 345 transport, 147, 185, 243, 259, 291, 333, 334 urban areas, 270 transportation, 160 urban population, 127 traumatic brain injury, 51, 53 urbanisation, 7, 261 traumatic events, 7, 9, 23, 26, 29, 43, 44, 51, 56, 57, 62, 63, 64, 69, 78, 122, 159, 179, 189, 238, 241, 246, 275, 305, 306, 307, 317, 332, 368, 369 V traumatic experiences, 43, 62, 70, 89, 90, 111, 118, vacuum, 11, 47, 120, 290 248, 249, 332, 343, 366 validation, 338 traumatic incident, 88 variables, 51, 60, 63, 65, 78, 84, 86, 87, 88, 208, 212, treatment, 5, 9, 16, 40, 41, 43, 44, 45, 46, 50, 58, 59, 251, 253, 308, 318, 323, 324, 339, 354, 356, 358, 68, 70, 72, 86, 89, 131, 132, 142, 147, 148, 154, 359, 360, 361, 362 160, 198, 201, 203, 207, 209, 212, 239, 241, 247, variations, 50, 57, 58, 59, 60, 64, 219 250, 285, 290, 300, 305, 317, 325, 341, 344, 354, varimax rotation, 84, 86 355, 371 vehicles, 153 trial, 134, 135, 304, 359 vein, 65, 66, 68 triggers, 80 Venezuela, 68 tropical storms, 269 vessels, 160 trustworthiness, 289 veto, 126 tuberculosis, 144 victimization, 33, 73, 254, 326, 345 Turkey, 71, 239 victims, 5, 7, 9, 13, 45, 46, 48, 52, 83, 85, 86, 87, 96, turnout, 33 97, 98, 99, 100, 101, 102, 103, 104, 105, 108, turnover, 283 111, 112, 122, 123, 125, 130, 131, 132, 134, 135, typhoid, 144, 150, 152 175, 177, 178, 179, 181, 184, 186, 188, 191, 243, typhus, 114 253, 262, 265, 267, 268, 269, 270, 277, 278, 283, 303, 305, 307, 316, 317, 323, 337, 359, 362 U video games, 100 Vietnam, 13, 15, 17, 19, 58, 71, 73, 75, 79, 106, 119, UNESCO, 137 120, 126, 132, 137, 159, 161, 162, 167, 187, 190, uniform, 164 192, 193 unions, 153 Viking, 279, 373 united, 21, 22, 23, 29, 35, 37, 57, 63, 66, 74, 75, 101, violence, 9, 11, 21, 28, 39, 42, 44, 45, 47, 48, 49, 54, 107, 109, 115, 116, 120, 123, 130, 131, 136, 145, 56, 72, 74, 79, 98, 100, 101, 104, 105, 106, 107, 153, 170, 175, 176, 177, 178, 181, 188, 189, 200, 108, 109, 116, 117, 122, 132, 135, 136, 152, 170, 201, 209, 219, 221, 239, 314, 330, 332, 333, 343, 201, 202, 203, 205, 206, 212, 215, 221, 254, 270, 345, 352, 363, 369, 371 277, 299, 300, 301, 302, 303, 304, 305, 306, 308, United Kingdom (UK), 5, 19, 20, 52, 165, 170, 173, 309, 310, 314, 317, 321, 324, 326, 332, 333, 334, 209, 293, 294, 332 343, 362, 367, 369, 370 violent behavior, 101, 104

Complimentary Contributor Copy 396 Index virtual communities, 35 West Africa, 333, 338, 344, 345 vision, 32, 46, 79, 211, 326 Western Australia, 260 visions, 46, 337 Western countries, 42, 63, 72 vocational training, 23, 129 western culture, 66 volunteerism, 268 Western Europe, 115 voting, 165 wetting, 239 vulnerability, 27, 82, 216, 217, 219, 251, 253 White House, 105 wild animals, 17 wilderness, 97 W wildfire, 243, 253 wildlife, 4, 5 wages, 126, 151 wind speed, 265 walking, 78, 180, 181, 291, 333 windows, 309 war, 3, 9, 12, 13, 14, 15, 16, 17, 18, 22, 31, 37, 40, Wisconsin, 106 42, 43, 44, 46, 51, 53, 54, 59, 61, 62, 64, 71, 73, withdrawal, 47, 87, 188, 189, 307, 319, 350, 353 75, 77, 79, 97, 113, 115, 116, 117, 118, 119, 120, witnesses, 14, 96, 99, 300 126, 132, 135, 139, 142, 143, 144, 147, 148, 149, wood, 269 154, 156, 157, 159, 160, 161, 162, 163, 164, 165, workers, 13, 14, 38, 51, 98, 118, 127, 131, 151, 153, 166, 167, 169, 170, 171, 175, 180, 187, 188, 189, 177, 187, 247, 248, 302, 309, 329 190, 191, 192, 197, 198, 205, 206, 213, 219, 277, working women, 211 300, 304, 306, 308, 311, 313, 314, 325, 326, 328, workplace, 96, 100, 201, 369 329, 332, 336, 339, 342, 343, 344, 345, 346, 367, World Bank, 326 374 World Health Organization (WHO), 50, 76, 132, War on Terror, 159, 160, 165 138, 145, 147, 148, 153, 156, 220, 277, 329 war years, 16 World Trade Center, 178, 180 warning systems, 269 World War I, 112, 113, 115, 122, 123, 166, 167, 314, Washington, 53, 71, 72, 73, 75, 91, 102, 106, 107, 336, 367, 368, 373 108, 109, 138, 173, 178, 187, 189, 215, 218, 219, worldview, 67, 322 251, 253, 326, 327, 328, 329 worldwide, 27, 55, 200, 201, 370 waste, 147 worry, 263 waste disposal, 147 water, xi, xii, 127, 140, 145, 149, 155, 238, 247, 258, 259, 261, 264, 265, 266, 267, 269, 270, 273, 278, X 332, 334 water quality, 149 xenophobia, 97 water supplies, 238, 258, 273 waterways, 266 weakness, 61, 63, 367, 371 Y wealth, 289, 351, 352, 361, 371 Yale University, 126, 136, 138, 193 weapons, 104, 160, 165 yield, 81 weapons of mass destruction, 165 young adults, 251 wear, 10, 263 young people, 95, 97, 101, 129, 163, 239, 249 weather patterns, 272 Yugoslavia, 46, 113, 120 web, 39, 103, 179, 209, 211, 212 websites, 10, 103, 105, 160, 211, 289 welfare, 132, 139, 143, 146, 147, 148, 150, 151, 152, Z 153, 154, 155, 203, 214, 343 well-being, 7, 21, 25, 67, 221, 275, 313, 314, 327, Zone 1, 143, 147 328, 340, 343, 352 Zone 2, 147 wellness, 22, 23, 26, 27, 28, 30, 34, 35, 36, 37, 277, Zone 3, 147 328 wells, 259

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