I’ve been reading a good bit on psychological responses to conflict and disaster for on-going work and am struck by the tone of discussion in the popular press soon after a potentially traumatic event. In these reports, trauma among the survivors is often presumed widespread and the focus is on its expected costs and consequences. However more recent academic work on this topic argues that an exclusive focus on the traumatized misses most of the story.
According to a 2010 review paper by Bonanno and others, this emphasis on trauma morbidity was mirrored in the early academic work on post-traumatic stress disorder (PTSD) which assumed that the near or complete absence of trauma symptoms only occurred in individuals with exceptional emotional strength. In contrast, numerous recent studies have instead indicated that the much more common response to a potentially traumatic event is characterized by what is termed “resilience”.
This resilience is not the complete absence of trauma symptoms – exposure and loss are consistently associated with high levels of reactions to post-traumatic stress such as recurrent intrusive recollections of the traumatizing event. Resilience is instead characterized as adaptability and a “bouncing back” after a harmful event rather than total immunity to the vicissitudes of disaster or conflict. Stress reactions are prominent in the immediate aftermath of a potentially traumatizing event, but these reactions typically decrease in the subsequent year and continue to attenuate even further after that. Resilience is common even in the individuals most highly exposed to the event and there are numerous protective buffers against emotional distress including perceived high levels of social support.
Three recent studies illustrate:
- In a study of New York City residents soon after the September 11th attacks, many respondents did meet the various criteria for PTSD, especially those with high exposure to the events. However the majority of respondents – 65% – reported no trauma related symptoms.
- A longitudinal study of Israelis assessed during and after rocket attacks focused on reported symptoms consistent with PTSD. In the period of attacks prevalence rates of PTSD were estimated at 20% but quickly declined to 3% two months after the attack.
- Vacationing Swedish survivors of the 2004 tsunami were assessed at 14 month and 3 years after the disaster. While psychological morbidity scores are higher for those directly exposed or bereaved even 3 years after the disaster, all scores improve dramatically between the two periods.
These studies, and numerous others, also highlight the characteristics associated with resilience. Such factors include the presence of social support, marriage, higher education, and older age. Conversely, factors associated with persistent trauma reactions are gender (women consistently report more trauma reactivity), low education, previous diagnosis of a psychiatric illness, and further traumatic experiences after the event. (One challenge in the studies mentioned above is a high level of study attrition – roughly only 50% of contacted respondents agree to participate. Improving the response rate in future work will tell us whether these low participation rates lead to any bias in inference.)
The wider review by Bonanno and others focusing broadly on post-disaster impacts concludes with the interesting points:
1. Disasters can cause psychological harm, but in a minority of exposed individuals. In the studies they review, the proportion exhibiting severe psychological distress such as PTSD rarely exceeds 30% of the exposed population.
2. There are multiple outcome patterns in the population including those with 1 or 2 year delayed onset of trauma symptoms. However the most common reaction is only transient distress which doesn’t interfere with healthy functioning. This resilience is often exhibited in more than half of those exposed.
3. Psychological impacts are mediated by a variety of risk and resilience factors such as those listed above.
4. Typically, the resources of the affected community are mobilized after the disaster and survivors often receive immediate support from their relatives and friends. This is very important to note in the design of post-disaster aid. Communities should be maintained as much as possible and the use of community resources encouraged.
Given that resilience appears to be quite high in numerous populations exposed to a potentially traumatic event, as well as the fact that much trauma resolves naturally in the following year or two, certain policy implications appear quite clear. Blanket intervention in the immediate aftermath of a potentially traumatic may be, at best, mis-targeted and, at worse, distract from more critical aid efforts. Rather, some form of screening for at-risk individuals during the period of recovery, with the offer of effective individual or small-group interventions to those with likely PTSD, appears to be a much more effective strategy.