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Book Forum   |    
Intervention and Resilience After Mass Trauma
Reviewed by CAROL S. NORTH
Am J Psychiatry 2009;166:1071-1072. doi:10.1176/appi.ajp.2009.09030319
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edited by Michael Blumenfield and Robert J. Ursano. New York, Cambridge University Press, 2008, 208 pp., $80.00.

This book is ahead of its time. Four of its seven chapters comment on the dearth of empirical data to support consideration of selected postdisaster interventions (Raphael, chapter 1; Watson, chapter 3), acute stress disorder (Bryant, chapter 4), and psychopharmacotherapeutic agents in early postdisaster settings (Friedman, chapter 5). This lean empirical foundation is not ideal for trying to generate recommendations for effective early mental health responses to community catastrophe, but the authors have risen to the occasion to form a book that synthesizes available data with thoughtful analysis of topics pertinent to early disaster response. In the epilogue, which provides a summary of strategic plans for early postdisaster intervention, the editors acknowledge that the ideas presented in this book represent “a work in progress” (p. 173). They make a plea for “research to advance evidence-based interventions” (p. 177) in the early postdisaster period. This relatively young field is evolving rapidly, and this group of experts has its collective finger on its pulse.

This project, originating with work on early intervention contributed by academic leaders in the field, convened by the book’s editors to discuss early postdisaster interventions. The project subsequently evolved to focus on resilience in the early postdisaster phases, reflecting recent trends in the disaster mental health field to broadly embrace resilience rather than orienting its conceptualizations in psychopathology. Because resilience is defined in relation to an adverse event, its application is well suited to considerations of disaster response. The place of resilience in disaster mental health is skillfully articulated by Shalev and Errera in the final chapter (chapter 7) with a phrase in its title capturing the essential concept: “Resilience is the default.”

In a book designed to examine early psychological intervention and resilience following mass trauma, it is disorienting not to have “early” defined at the outset. Although two chapters allude to varying temporal parameters of the early postdisaster period—14 days (Watson, chapter 3), one month (Watson, chapter 3), and “weeks” (Bryant, chapter 4)—a consistent definition of “early” would have helped anchor the book’s content. After determining that the book was not going to tell us what constitutes the early intervention period, I started thumbing through the chapters; what awaited there was a thought-provoking collection of hard-hitting explorations of the role of resilience in postdisaster mental health. To my delight, the authors did not pull punches.

In chapter 4, Bryant reviews the history of acute stress disorder, noting that the diagnosis was introduced into diagnostic nomenclature with little substantiating evidence. He further lists criticisms of the diagnosis, including insufficient support for emphasizing dissociation as pivotal to acute trauma response, objection to predicting another diagnosis (posttraumatic stress disorder [PTSD]) as the primary role for the acute stress disorder diagnosis, potential for inappropriate pathologization of transient reactions with this diagnosis, and lack of justification for having two diagnoses (acute stress disorder and PTSD) that are differentiated by duration alone (because they share most of their symptoms). After bravely reviewing these criticisms, Bryant proceeds to examine relevant literature on the place of dissociation in acute stress disorder, limited predictability of PTSD from acute stress disorder or dissociation, and measurement problems with acute stress disorder, concluding that acute stress disorder “is a difficult construct to justify because its nature has not been objectively verified” (p. 93). Consideration of these issues is pivotal to the development and selection of early interventions following trauma.

In chapter 7, Shalev and Errera remind us that both resilience and trauma are poorly defined entities. They wrestle with mind-bending concepts, asking difficult questions, such as “What is resilience if it is not just a lack of psychopathology or of some negative outcome?” They declare that “resilience is often the absence of something rather than something” (p. 152) and proceed to advance new perspectives on considerations of on resilience through reviewing relevant literature. They further advance the idea that “the occurrence of resilience and the development on mental disorders are independent and orthogonal dimensions of the response to traumatic events” (p. 151).

All this deep thinking made me want to read more. I was not disappointed. For example, in chapter 1, Raphael reminds us of often-overlooked wisdom: “Individuals may be vulnerable through pre-existing variables, levels and severity of event exposures, and post-exposure factors” (p. 17). In chapter 2, Pfefferbaum and colleagues examine resilience at the level of community, which differs from individual resilience—the usual perspective for consideration of resilience. Chapter 3 (Watson) mentions that while psychological first aid is founded on both empirical and expert consensus findings, research on its effectiveness is needed. The remaining chapters proceed with this depth of consideration of resilience and its implications for intervention following mass trauma.

This book and the accompanying CD of the contributors’ lectures provide a wealth of expert consideration, wisdom, and provocation for general readers and members of the disaster mental health field interested in thinking critically about issues that are pivotal in early disaster intervention.

+Dr. North has received research grants from NIMH and NIAAA; she has served as a consultant for Cubic, Inc., National Center for Disaster Research Education affiliated with Research Education in Disaster Mental Health, and University of Oklahoma Health Services Center; she has also received speaker’s fees from Assisi Foundation of Memphis, University of Alabama School of Social Work at Tuscaloosa, and Magellan Health Services.

+Book review accepted for publication May 2009 (doi: 10.1176/appi.ajp.2009.09030319).

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