Select a critical incident (Palisades Fire) that has occurred within the last year that you can use to respond to the questions.? Review crisis intervention theorie

Resilience Truths: Trauma Resilience Workers’ Points of View Toward Resilience in Continuous Traumatic Situations

Orit Nuttman-Shwartz1 and Ohad Green2 1 School of Social Work, Sapir College

2 Department of Social Policy and Intervention, University of Oxford

Objective: Many people who are exposed to continuous violence show resilience. Although resilience is considered an umbrella term to describe a range of processes and theories, there is still a debate relating to its nature and definition. Therefore, the current study aimed to explore attitudes, perceptions, processes, and actionable knowledge regarding resilience, and to validate existing knowledge and conceptualizations about this concept.Method:Using a mixed-methods approach, 27 semi-structured interviews were conducted and two resilience questionnaires were administered to trauma resilience workers living in a war zone, in an attempt to describe and analyze resilience as manifested among residents living in a continuous security threat situation. Findings: Content analysis helped validate the conceptual basis for the two questionnaires, and raised three main themes related to the definition of resilience: It is an ecological phenomenon that combines four systems (micro, meso, exo, and macro); it exists during periods of routine, periods of emergency, and periods leading from one to the other; and it is a resource that can be learned and developed. Conclusions: The findings highlight that resilience is an ecological concept, as it is characterized by the interaction between the individual (micro-level) and the meso and macro circles. It is important to recognize these complex interactions in order to encourage and promote successful coping, to predict which individuals will do well, and to use this insight to promote suitable mental health interventions. Further research among different groups who live under different existential threats is also recommended.

Keywords: continuous traumatic stress, resilience, trauma work, war and terror, ways of coping

Resilience is considered to be a positive multidimensional umbrella term that describes a range of processes and theories (Bonanno et al., 2015) which include three orientations (Oshio et al., 2018): trait, outcome, and process. The trait orientation (or trait resilience) views resilience as a personality characteristic that inoculates individuals against the impact of adversity or stressful events or, according to Connor and Davidson (2003, p. 76), as a measure of the “personal qualities that enable one to thrive in the face of adversity.” Although over the years the above definition became broader, personal characteristic conceptualizations of resil- ience still focus mainly upon the inherent qualities of the individual (e.g., Hu et al., 2015), an idea that has recently been supported with evidence of a genetic influence, offering an additional explanation of psychological adaptation to adverse events (Niitsu et al., 2019). An outcome-based definition of resilience, on the other hand, sees

positive adaptation post-adversity as being central (Vella & Pai, 2019). This orientation regards resilience as a functional or behav- ioral outcome that can help individuals overcome and recover from a stressful event (Masten, 2001) as a result of their ability to “maintain a stable equilibrium” (Bonanno, 2004, p. 20). Finally, the process-oriented approach regards resilience as a

dynamic process in which individuals adapt to and recuperate quickly from major stressful events (Fergus & Zimmerman,

2005). Luthar et al. (2000) defined resilience as “a dynamic process encompassing positive adaptation within the context of significant adversity” (p. 543). That is, resilience in this conceptualization is a dynamic process characterized by constant change, activity, or progress, but it is also context-specific, with an individual poten- tially being highly resilient in one context but not in another.

In light of the above dimensions, several theories have succeeded inweaving together the social–ecological perspective (Bronfenbrenner, 1979) with the trauma resilience approach (Harvey, 1996). The first social–ecological perspective was offered by Hobfoll (1989), who proposed the Conservation of Resources (COR) theory and claimed that those individuals who possessed more resources were less vulnerable to resource loss and more capable of resource gain (Hobfoll et al., 2018). Thus, it can be argued that when individuals have numerous personal resources (e.g., trait resilience), they are less vulnerable to resource loss and in a better position to invest resources in becoming psychologically engaged—a process which, in turn, may result in positive health and well-being (Hobfoll, 2011). Drawing on COR theory (Hobfoll, 1989), one would expect that individuals with high trait resilience would remain more psychologically engaged when confronted with terrorism-related risk perceptions and feelings of fear than those with low trait resilience.

The second social–ecological perspective emerged from research- ers and theorists who were primarily interested in the mental health and psychological well-being of adults (e.g., Bonanno, 2004). In their view, resilience was the capacity of a system to anticipate, adapt, and reorganize itself under conditions of adversity in ways that promote and sustain its successful functioning (in human terms, its well-being; Ungar, 2011). That capacity is seldom a trait of the system itself. Rather, it is the result of facilitative interactions with

Orit Nuttman-Shwartz https://orcid.org/0000-0001-5709-1343 Correspondence concerning this article should be addressed to Profes-

sor Orit Nuttman-Shwartz, School of Social Work, Sapir College, D.H. Hof Ashkelon 7619500, Israel. Email: [email protected]

1

This article was published Online First December 31, 2020.

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International Journal of Stress Management

© 2020“ American Psychological Association ISSN: 1072-5245 https://doi.org/10.1037/str0000223

2019, Vol. 1, No. 999, 0002021, Vol. 28, No. 1, 1–10

co-occurring, subordinate, and supraordinate systems that makes it possible for a system or its parts to function well during and after a disturbance. In the same vein, based on the protective model of resilience and

aiming to expand the understanding of the mechanisms behind social support’s protective effects (Lee, 2019), Ungar (2008) pro- posed a definition of resilience which focused on the interaction between person and environment: “ : : : the capacity of individuals to navigate their way to resources that sustain well-being; the capacity of individuals’ physical and social ecologies to provide those resources; and the capacity of individuals, their families, and communities to negotiate culturally meaningful ways for resources to be shared” (Ungar, 2008, p. 225). This definition reflects the ability of individuals and the dynamic system to provide essential resources, as well as the ability of the community and the individual to adapt successfully to traumatic events (Norris et al., 2008; Ungar, 2008). Resilience, as such, relates to the individual processes that increase survival as well as to the protective processes initiated by larger systems that aim to provide opportunities for individuals to cope with stress (e.g., Ungar & Liebenberg, 2011). These include individual resilience resources (i.e., personal skills, social skills, and peer support), relational resources (i.e., physical and psychological support from caregivers), and contextual resources (i.e., sense of belonging, educational adhesion, and spirituality; Liebenberg et al., 2012), the latter two of which could also be categorized as social support systems. Henceforth, individual, relational, and contextual resources will be referred to as “resilience resources.” Yet scholars have critiqued resilience theories and practice

models because the definitions, measures, and uses of resilience remain too complex and multifaceted (e.g., Masten, 2018). As the debate on the nature of resilience continues, several attempts have been made to understand this concept. A unique attempt to explore the resilience phenomenon was made by Corzine et al. (2017), who developed axioms on the basis of qualitative interviews with seven Israeli trauma resilience experts, most all of whom were men with combat service experience. The interviews focused on the partici- pants’ “resilience truths,” meaning the truths they had arrived at themselves, from their own experience, about resilience. Among these axioms were “sense of mission,” “the importance of being connected to others,” and individual characteristics such as “inner strength, coping skills, and hope” (Corzine et al., 2017, p. 8). Although the above group experiences are illuminating, they

do not reveal the whole picture, as we still lack the insights of trauma resilience workers who work under ongoing conditions of exposure to real threats in the context of persistent violence. These situations are known as continuous traumatic situations (CTS), with the term CTS having been developed to describe the situation of individuals living in areas of ongoing political violence and national security threats (Nuttman-Shwartz & Shoval-Zukerman, 2016). These CTS can be seen as circular processes characterized by periods of escalation alternating with periods of relative calm, and situations in which past and future perceptions of threat and fear are combined, profoundly affecting exposed civilian populations (e.g., Nuttman- Shwartz & Shoval-Zukerman, 2016). Several research studies have noted the positive aspects found

among mental health professionals, caregivers, and emergency volunteers who work under conditions of ongoing exposure to stress. Among these positive aspects, or resilience components, is sense of meaning (Baum, 2014; Nuttman-Shwartz, 2015). Sense of

meaning was detected among disaster responders and resilience teams who were found to be resilient in the aftermath of the 9/11 World Trade Center rescue efforts (Bonanno et al., 2007), and among volunteers doing disaster work (Harvey & Kathleen, 2015), which in and of itself is considered to be a traumatic experience with long-term effects.

Despite the abovementioned findings, recent systematic reviews of resilience have claimed that there is still a dearth of knowledge and lack of clarity surrounding the term resilience, both in mental health research and in the wider resilience literature (Vella & Pai, 2019). Beyond that, in terms of the role of gender in resilience, although some researchers have found gender to be a promotive and protective factor (Ungar & Theron, 2019), others have revealed that when type of traumatic event was taken into account, these differ- ences became insignificant (e.g., Portnoy et al., 2018). As such, in order to explore the potential role of gender in resilience, it is of value to focus on men and women who were exposed to the same traumatic events. It is also important to stress that given the masculine nature of war and terror, very few studies have been conducted among front-line trauma workers of both genders (Cohen et al., 2017; Sousa et al., 2013). The question of whether gender differences are a factor that promote resilience is therefore still in need of further investigation. In addition, learning from the experi- ence of local emergency teams may shed light on what it is like to be close to the traumatic event, and to work side by side with a variety of people. This knowledge could be beneficial for understanding the complexity of the resilience construct, which is still being debated.

Against this backdrop, the current study aimed to explore attitudes, perceptions, and processes aswell as personal know-how and actionable knowledge that have helped trauma resilience workers living in war zones to cope and function in such situations (for the purposes of this paper, the term “trauma resilience workers” will be used to refer both to paid workers and community volunteers). In the current study, we aimed to deepen our collective understanding of resilience in different contexts by giving people a voice and therefore examining the validity of existing knowledge and conceptualizations regarding resilience.

The Research Context

Since 2001, Israel’s western border with the Palestinian Authority has been the target of more than 20,000 missile attacks. Over the years, the Israel Defense Forces (IDF) has engaged in three operations (2009, 2012, and 2014). Following each operation, the number of missile attacks decreased dramatically for a short period. Neverthe- less, since 2018, Israeli residents of the Gaza-envelope area have been contending with the launching of explosive kites and balloons as well as with the threat of missile attacks and terrorist penetration into Israeli territory. Accordingly, the Israeli government opened resil- ience centers in the area, which aim to help residents better cope with ongoing adversity through psychosocial interventions conducted by trained trauma resilience workers (Nuttman-Shwartz, 2015). Although the number of residents diagnosed with Post traumatic stress disorder ( PTSD) has increased over the years, people have also reported high levels of resilience (Stein et al., 2018).

Method

The present study was conducted using a mixed-methods approach: The qualitative aspect being embodied in the participant

2 NUTTMAN-SHWARTZ AND GREEN

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interviews, and the quantitative aspect embodied in the collection of quantitative data as needed (Mertens & Hesse-Biber, 2013). This approach has been found to be the most suited to revealing the “lived experience” of study participants (Eberle, 2014). The use of the mixed-methods paradigm allows for a comparison of the results of the quantitative findings with the experiences of the interviewees, thus maximizing the strengths of the interviews. The use of mixed- methods paradigms also enhances the reliability and validity of study findings (Ungar, 2011).

Participants

Twenty-seven residents (9 men and 18 women) who are trauma resilience workers in the area were asked to participate in the study. Participants ranged in age from 25 to 72 and lived in residential areas (kibbutzim) on the Israeli side of the border with Gaza. Of them, 75% were married with children, 85% defined their health as being “excellent,” and 75% considered themselves secular. All but one was exposed to missile attacks, and around 50% experienced a missile hit close to their home. Around 30% were social workers, around 40% were educators, and 30% of the participants were affiliated with an emergency team as paraprofessionals (they worked in a variety of occupations, including farming). Seventy percent had more than 10 years of professional experience.

Procedure

The study was approved by the School of Social Work’s Institu- tional Review Board. Beginning in January 2018, nine research students used a snowball approach to choose trauma resilience workers in the exposed area to ask them to participate in the study. To ensure that the interviewers were sufficiently skilled in the ques- tioning processes, the primary researcher trained them in the qualitative interview process, and guided them throughout data collection. All interviews took place in the participants’ homes and were recorded and later transcribed verbatim and then anonymized. At the beginning of each interview, the rationale and course of

the research were explained, informed consent forms were signed, and the potential challenges of dealing with sensitive issues were mentioned again. In addition, ways of receiving future support were reviewed. Upon receiving informed consent, semi-structured in- depth interviews (Patton, 2015) were conducted in accordance with an interview guide that addressed the issue of resilience. Questions referred to ways of coping, perceptions of resilience, coping strate- gies, and concepts regarding coping that the participants had developed over the years on both the personal and interpersonal level. Interviews lasted 90 min on average. At the end of the interview, the participants were asked to answer three questionnaires:

1. A sociodemographic questionnaire, which included age, marital status, education, and health status (Dekel & Nuttman-Shwartz, 2009).

2. The Resilience Research Center Adult Resilience Measure (RRC-ARM), which measures social–ecological resil- ience in adult populations (Liebenberg & Moore, 2018; Hebrew version by Al-Krenawi, 2017). This measure consists of 28 statements reflecting individual, relational, and contextual resilience processes (Liebenberg et al., 2012). The scale is scored by summing the responses to

each item answered on a 5-point Likert scale ranging from 1 (not at all) to 5 (all the time). The minimum scale score is 28, and the maximum is 140. It has excellent psychomet- rics (e.g., high internal consistency, Jefferies et al., 2019; test–retest reliability of ≥7 at 2-week and 3-month inter- vals, Daigneault et al., 2013; face validity, Daigneault et al., 2013). In the current study, the measure’s internal consistency was 86.

3. The Resilience Truism Scale (RTC; Corzine et al., 2017). This scale contains 17 statements that pertain to individual and community-based issues. The scale was developed on the basis of findings revealed by seven Israeli experts on trauma resilience, and reflects their knowledge, experi- ences, and the perceptions they derived from an online trauma resilience survey conducted with 13 other members of an expert Israeli panel. The scale is scored by summing responses to items answered on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The minimum scale score is 19, and the maximum is 95. A higher score reflects higher resilience. The tool was first translated into Hebrew by one of the authors of this paper for the purpose of the current research. In the current study, the internal consistency of the scale was 82.

Data Analysis

Data analysis was conducted using a mixed-methods approach. First, data analysis was carried out separately for each research tool, and then a comparison wasmade between the two analyses. As such, the data were first analyzed in accordance with thematic content analysis (Clark et al., 2015) and in keeping with an interpretive phenomenological approach (Shinebourne, 2011). This approach follows participants’ descriptions in the construction of meanings derived from the data, which enables the deconstruction and recon- struction of the text beyond what is actually said in the interview. Then, to enhance the reliability of these findings and based on deductive content analysis, the abovementioned themes were com- pared with the three main subthemes derived from the resilience tool (Bengtsson, 2016; Ungar, 2011). This method involves identifying the components of theoretical concepts and showing the interplay between the thematic analysis and the areas that appear in the research questionnaires. We also relied on the Sandelowski et al. (2012) framework of a mixed-methods synthesis, or “synthesis by aggregation,” to integrate and explore the relationships between the quantitative and qualitative types of data and to see whether there was any repetition of the findings. All statistical procedures were performed with International Business Machines (IBM SPSS 24 (International Business Machines [IBM], 2016). No missing values or outliers were found. In order to control for multiple comparisons, we used the Benjamini-Hochberg (1995) false discovery rate (FDR), with a q value of .1 (i.e., 10% of the significant results will be false positives at p < .05).

Rigor

To maintain an observant, inquisitive, and unbiased attitude (Finlay, 2009), the interviewers did not interview residents with whom they were already acquainted. In addition, the interviewers used an interview manual to help them stay focused on the subject

RESILIENCE TRUTHS 3

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(Patton, 2015), and they were supervised by one of the study’s authors. As mentioned, the data were analyzed by the students and their supervisor, who met on a bi-weekly basis to share their proposed conceptualizations. The findings and the theoretical con- ceptualizations were compared with the participants’ questionnaires, ensuring that the findings reflected their actual life experiences.

Results

Descriptive results regarding the RRC-ARM and RTC scores, as mean and standard deviation scores, are presented in Table 1. The RRC-ARM average was 120.92 (out of a maximum of 140), and the RTC average score was 72.74 (out of a maximum of 95). In both questionnaires, the participants received high scores on each of the separate components, implying that the participants saw each component as an equally important factor in building their resil- ience. In order to explore whether there were differences between women and men in their resilience, a series of independent sample t- tests was performed (see Table 1). Although gender is usually considered to be a robust predictor of resilience (e.g., Kimhi & Eshel, 2016), no differences were found between men and women in the RRC-ARM total score or in the RTC score, even when compar- ing each component separately. A main goal of the open-ended interview (see Appendix) was to

explore the participants’ definitions of resilience, to learn more about their ways of coping with the adverse situations they found themselves in, and to understand how they were able to do their jobs and help others in the context of being members of an emergency team living near the border. Their reflections formed the basis of the content analysis of the interviews, which revealed three main themes: (a) resilience is an ecological phenomenon comprising four systems: the microsystem, the mesosystem, the exosystem, and the macrosystem; (b) resilience exists during periods of routine, periods of emergency, and periods leading from one to the other; and (c) resilience is a dynamic phenomenon; it is a resource that can be learned and developed.

The Ecological Definition of Resilience: “The Individual Is Not Enough.”

Most of the participants considered resilience to be a kind of coping that interweaves four systems: the individual, the family, the

community, and the country. Most of them defined resilience on the basis of an ecological perspective that combines characteristics of the individual and the environment. For example, Idit said the following:

[Resilience is] a combination that begins with the individual : : : It’s not enough, because there is also the need to consider the environment : : : it’s not possible to consider the environment without the individual : : : and it’s not possible that the individual is there without the environment : : : That is, there’s more, but first of all it’s personal resources, and then what do you do with them? : : : What you do with them is the environment.

Resilience Is Imprinted: The Hereditary Component

A small number of participants (six) said that resilience was a matter of genetics. These participants emphasized that inherited personality traits were the basis for the emergence and presence (or absence) of resilience. For example, Sigal said:

Nothing can be done. It’s human nature, it’s something genetic, it’s something hereditary : : : It’s something inherent. You can build it and reinforce it, but it’s not something we can control.

Ronen supported the perspective that resilience was a stable personality trait ingrained in the individual: Something that accom- panied people everywhere. As he said:

Personal resilience is when I feel strong (inside) and I feel the same thing outside : : : I’m sure I’ll have the same problems elsewhere— even if I live in Berlin. Because in the end it’s personal, personal resilience.

Gila detailed the personality traits that she perceived to be related to resilience:

Optimism, the ability to receive assistance : : : the ability to stand on your feet and function : : : people with self-confidence : : : and what else is a personality trait : : : I don’t knowwhether it’s courage because sometimes it’s stupidity, but it’s a kind of naive belief that things will get better : : : it’s optimism. That’s a nicer word : : : and lack of fear : : : like, someone who’s afraid doesn’t need to be here.

Resilience in the Context of Individual, Family, and Community Roles

Parenting Role of Care and Concern for Children. Many of the interviewees talked about the experience of being parents in the context of living amid an ongoing security threat, and described the parental role as requiring coping skills and resilience. Their state- ments indicated that they were aware they had taken on more responsibility when they brought children into the world, and that they were responsible not only for themselves but for their whole family. For example, Alon argued:

No doubt there’s a difference between being a parent and living here as a bachelor or a young couple without children. You have much more responsibility, you have a lot of responsibility for your children.

In addition, the participants’ statements also reflected gender differences in terms of associations between parenting and resil- ience. Whereas

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