The Resilience Activation Framework: A conceptual model of how access to social resources promotes adaptation and rapid recovery in post-disaster settings

Abstract

A number of governmental agencies have called for enhancing citizen’s resilience as a means of preparing populations in advance of disasters, and as a counter-balance to social and individual vulnerabilities. This increasing scholarly, policy and programmatic interest in promoting individual and communal resilience presents a challenge to the research and practice communities: to develop a translational framework that can accommodate multi-disciplinary scientific perspectives into a single, applied model. The Resilience Activation Framework provides a basis for testing how access to social resources, such as formal and informal social support and help, promotes positive adaptation or reduced psychopathology among individuals and communities exposed to the acute collective stressors associated with disasters, whether manmade, natural, or technological in origin. Articulating the mechanisms by which access to social resources activate and sustain resilience capacities for optimal mental health outcomes post-disaster can lead to the development of effective preventive and early intervention programs.

Introduction

Scholarly and programmatic interest in individual and community resilience has grown exponentially over the past fifty years. What began as a focus in the field of developmental psychology to understand how children may thrive despite growing up in adverse conditions or with schizophrenic parents^1,2 has expanded to embrace a broad political interest in cultivating resilience in both individuals and communities facing a variety of chronic and acute stressors,^3,4 examinations of biological and epigenetic pathways in which resilience may be expressed,^5,6 and efforts within sociology and social epidemiology to describe and operationalize the multi-level aspects of communal and institutional protective and promotive factors that can influence an individual’s well-being and capacity to adapt to adversity.^7–9 Furthermore, political calls for enhancing the resilience of the citizenry as a means of preparing populations in advance of disasters or complex emergencies, and as a counter-balance to social and individual vulnerabilities, has compelled many agencies and federal sectors to consider how to cultivate resiliency. For example, the Centers for Disease Control and Prevention (CDC) released guidance to the states in 2011, requiring that states and their local health departments develop community resilience as one of fifteen public health emergency preparedness capabilities and the National Research Council advocated community resilience-building as a key component of disaster mitigation strategys.^{10, 60, 93}

This increasing drumbeat of interest in individual and communal resilience presents a challenge to the research and practice communities: to develop a translational framework that can accommodate multi-disciplinary scientific inquiries within the concept of resilience that can be applied in post-disaster settings using observational and quasi-experimental strategies, and which have clear applications for programmatic interventions. The objective of this article is to present a conceptual framework that can serve as the basis for testing how access to social resources, such as formal and informal social support and assistance, can promote positive adaptation or reduced psychopathology among individuals and communities exposed to the acute collective stressor of a technological disaster, in this case the 2010 Deepwater Horizon Oil Spill. It is the product of a research enterprise that encompasses four university consortia of scientists at 13 institutions engaged in 12 distinct studies, working in concert with community coalitions. Each of the research projects is examining different aspects of the oil spill’s exposure on human populations and its health effects. Through the establishment of a Resilience Working Group (RWG) these four Gulf Coast Research Consortia developed a common resilience research framework with which to model and test resilience theories, allowing the group to assess resilience across the individual research projects. The foundation of the Resilience Activation Framework is grounded in distinguishing resilience processes (the ability to withstand, adapt, or recover quickly from a disaster), individual and community resilience attributes, and the factors which facilitate the activation of those resilience attributes. The premise is that by understanding the mechanisms by which access to social resources activate and sustain resilience capacities for optimal mental health outcomes post-disaster, preventive and early intervention programs may be developed. The consortia are developing the Resilience Activation Framework to address a common research question: How does access to, or engagement with, social resources facilitate the activation of resilience attributes that contribute to positive mental health?

Background

The Gulf Coast communities of Texas, Mississippi, Louisiana, Alabama, and Florida are at risk for significant adverse mental health outcomes as a result of exposure to the Deepwater Horizon Oil Spill (DWHOS) and related persistent stressors from previous adverse events and recurring life challenges. Despite diverse occupational, ethnic, and subsistence lifestyles, all of these communities share strong economic, social, and cultural ties to the Gulf of Mexico and its renewable resources. These communities were significantly impacted by the DWHOS environmental disaster and continue to experience uncertainty regarding future environmental, economic, health, and social impacts. Early DWHOS studies documented negative mental health outcomes in selected Gulf Coast subpopulations in the immediate aftermath of the spill (e.g., Abramson et al.¹¹ ; Gill et al.¹²; Grattan et al.¹³). Similarly, studies of community reactivity are underway in select regions documenting signs of community conflict, corrosion and economic distress.^12,14,15 However, despite the fact that, 1) the resources of the social/community environment are strong mediators of post-disaster mental health in the individual, and 2) communities are made up of individuals who bring a wide range of psychological reactivity to community adaptation, no research to date has comprehensively addressed the link between how mental health is shaped by attributes of individual and community resilience, and whether there are means of activating such resilience through informal social supports and through health- and social system interventions.

Recent definitions have approached resilience as a process rather than an outcome; for example, resilience as “the capacity of a system to withstand or recover from significant disturbances that threaten its adaptive function, viability or development.”¹⁶ The system is scalable: it may be an individual, a household, a community, an institution, or a nation-state. Furthermore, there are two distinct elements in such a resilience process. First, there has to be a “significant disturbance” sufficient to disrupt or destroy the system. Second, the system’s resilience capacity is then revealed by how well it is able to withstand, adapt, or recover quickly from the potentially traumatic event. Resilience attributes are those traits and characteristics of a system that permit it to conserve or marshal its resources. Figure 1 illustrates these attributes as functions of four types of “capital” – human, economic, social, and political – that may be present at individual or collective levels. The framework is based on the notion that a resilient individual or community has the capacity and capability to maintain, re-establish, acquire, or exchange these critical resources.

Figure 1.

Resilience Attributes at Community and Individual Levels

In an effort to develop a hypothesis-driven framework, it is assumed that in the face of a stressor these resources can be deployed by individuals and communities to counter the effects of the event. For example, an individual with good health (a human capital), adequate insurance and savings (economic capital), and a strong social network (social capital) will be able to call upon all of these resources to help buffer the effects of a catastrophic event. Communities with highly effective and equitable government infrastructure (a political capital), ready access to public and private funding sources (economic capital), and communal norms of neighborliness or collective self-efficacy (social capital), should be similarly positioned to buffer a stressful event. The use of these resources may be an expression of an individual or community’s resilience attributes (for example, an individual with a high-degree of coping self-efficacy may be less likely to suffer mental health distress), or it may be accessed by specific resilience actions (such as an individual activating his or her social network in order to identify transitional housing).

This conceptual framework is predicated upon the following premises, each of which will be explored in greater detail in subsequent sections: 1) exposure to harm leads to resource loss, stress, and psychological reactivity; 2) most people are inherently resilient; 3) community resilience attributes interact with individual resilience attributes; 4) access to or engagement with community/social resources can activate inherent individual resilience attributes; 5) this activation takes place within the context of a sociocultural milieu (culture/race/ethnicity/social and geographic mobility) that moderates resilience capacity; and 6) individual, community and sociocultural milieu can be quantified and measured in order to test various components of the framework.

Building upon the research efforts of the RWG with the Deepwater Horizon Oil Spill and other disasters to date, a conceptual framework is proposed (illustrated in Figure 2) hypothesizing that access to social resources (e.g., for information, social support, spiritual guidance, health and human services, etc.) can activate resilience attributes that are inherent in individuals and communities, and in so doing lead to better psychological adjustment, health, and well-being.

Figure 2.

Conceptual Framework of Resilience Activation

Premises of the Resilience Activation Framework

1. Exposure to harm leads to resource loss, stress, and psychological reactivity

Large scale disasters are relatively common events with catastrophic consequences for many people. In the “face” and “wake” of disaster, individuals may suffer the loss of loved ones, health, homes, financial stability, social support, sense of stability, or other resources important to daily living.¹⁷ As a result, impacted people demonstrate a wide range of psychological reactivity ranging from brief, transient distress to long term psychopathology. The chain of events that links disaster to mental health and behavioral problems is neither simple, nor linear. In contemporary psychology, however, a reasonable starting point for explaining this dynamic process is Hobfoll’s Conservation of Resources (COR) model of stress and adaptation.^18,19

The COR model postulates that people are driven to acquire, preserve or protect valued resources. These resources include objects (car, house), conditions (marriage, seniority), personal characteristics (self-esteem, optimism), and engergies (time, knowledge, money) which facilite the ability to to acquiring other important entitites. When these resources (or ways to access them) are lost, threatened, or not gained when expected, this will cause stress and potentially lead to negative mental health or behavioral outcomes. Many of these negative outcomes result in a time-limited stress response with a brief, transient disruption of functioning followed by resilient adaptations. The proposed Resiliance Activation Framework illustrates the case where human capital (health, coping, emotional reactivity), community capital (social networks, services, churches), economic (savings, job stability, credit), or political capital (relationship with community leaders) are strong and provide adequate resources to support the pre-disaster adaptive capacities in the individual. However, more severe and persistent behavioral or psychological problems may result from disaster most notably, anxiety, depression, and Post Traumatic Stress Disorder (PTSD).^17,20,21 These more debilitating problems often evolve after a period of chronic excessive stress that taxes the coping resource of the individual over time. To explain this process, the COR model would argue that persistent resource loss (and the inability to gain new resources) may lead to rapid resource loss cycles, which people are unable to reverse, and a downward spiral of behavioral health problems ensues.²² Essentially, the initial loss of a valued resource increases the individual’s vulnerability to further losses. For instance, a loss of tranportation and health may lead to lost job security, reduced self esteem, financial distress, marital and family pressures, and subsequent feelings of helplessness and hopelessness. Because the COR theory embraces so many aspects of individual, community, and socio-cultural entities, it has found considerable support after a wide variety of disasters,^20,23–26 including the Deepwater Horizon Oil Spill.^13,27,28

To advance the application of the COR model in disaster recovery, it is essential to identify the specific resources (or combination thereof) necessary for activating or enabling critical resilience attributes. Thus far, it is generally well accepted that economic and social capital are essential to the resilience process. Specifically, economic resource loss, socioeconomic adversity, and/or loss of job opportunities have been consistently associated with the most severe, lasting, and pervasive psychological effects or the onset and course of depression, anxiety, and number of PTSD symptoms after disaster.^{13,20,24,25,29–32} Similarly, the convergence of data suggests that social deterioration (post disaster declines in social embeddedness, social support, and trust in others)^33–36 has also been associated with worse psychological outcomes. Testing the Resilience Activation Framework from diverse perspectives within the Deepwater Horizon Oil Spill consortia will enable the examination of these as well as other facets of the resilience processes to determine how they interact with individual attributes to facilitate resilience.

2. Most people are inherently resilient or have the capacity to be resilient

Beginning in the 1970s, a distinct and well-established field of resilience research emerged from the discipline of developmental psychology, in which a number of investigators sought to identify the factors and traits that enabled children to achieve appropriate developmental milestones or avoid psychopathology even in the face of adverse circumstances or trauma.^2,37,38 Among the most durable findings from this scholarship was the normative response of children to be resilient, what Masten referred to as “Ordinary Magic,” rather than the notion that resilience represented some unique representation of invulnerability.² Similar research developed among adult populations.³⁹ A short list of factors associated with an individual’s ability to adapt to chronic and acute adverse circumstances emerged from a number of studies of children and adults, and includes personality factors (e.g., hardiness, self-efficacy, self-esteem), attitudinal factors (e.g., positive worldview, faith, altruism), attachment factors (e.g., communal solidarity, social support, connections to competent adults or peers), cognitive factors (e.g., intellectual and reasoning abilities), and specific adaptation and coping skills (e.g., including stress-reduction competencies).^40–42 Wright and colleagues refer to this scientific phase of the identification of resilience factors as the first of four waves of resilience research to date.⁴² The subsequent waves of resilience research encompass an understanding of the complex processes that activate or facilitate resilience, an evaluation of the interventions that stimulate resilience, and more recently the epigenetic and neurobiological mechanisms of resilience activation.^5,6,43

Common to many of these studies is the notion that these individual traits contribute to adaptation and recovery responses when an individual adult or child is confronted with extreme stressors or “potentially traumatic events.”⁴⁰ Masten² has distinguished the ways that such traits operate, either as moderators whose existence in a pre-disaster phase can help an individual withstand the effects of a traumatic event, or as risk-activated moderators whose latent characteristics are mobilized in response to a traumatic event, and which can in turn help the individual adapt or recover quickly from the stressor’s effects.

The Resilience Activation Framework illustrated in Figure 1 builds upon both the Conservation of Resources theory described above and the latency of resilience attributes that may be “activated.” The COR theory is predicated on a deficit model, in that many of the factors that have been associated with increased mental health distress and psychopathology reflect a depletion, disruption, or chronic lack of access to critical resources or “capitals.” In Norris and colleagues’¹⁷ review of 160 disaster studies, the individual characteristics associated with poor mental health outcomes included female gender, low socioeconomic status, minority status, and prior psychological distress or disability, among others. The authors also note that an individual’s lack of, or lost belief in his or her ability to cope or control outcomes, and having few social resources, are also associated with poor mental health. Silove and Steel⁴⁴ observe that disasters often lead to social disengagement, loss of social identity, and loss of meaning and existential coherence as social ties and institutions have been severed or destroyed. For example, a school-teacher who has been displaced by a disaster and who is unable to work now adopts the social role of victim or refugee, and loses the representation by self and others of the social role of teacher. These factors all reflect deficits, in which social, economic, or human capital has been diminished.

The Resilience Activation Framework (Figure 2) incorporates both the resource deficit model (often conceptualized as a vulnerability model) and the notion of latent resilience attributes. The framework suggests two pathways by which access to social resources can activate resilience processes: one in which the deficits are addressed by increasing the individual or community assets or facilitating access to them, and the other pathway in which the provision of formal or informal social resources enhances or activates positive adaptive traits.

3. Community resilience attributes interact with individual resilience attributes

Community resilience can be defined as the enduring capacity of geographically, politically or affinity-bound communities to define and account for their vulnerabilities to disaster and develop capabilities to prevent, withstand, or mitigate for a traumatic event.^8,45 A community’s capacity is dependent upon its access to human, economic, political, and social capital.^45,46 At a collective level, human capital refers to access to a healthy and capable population; economic capital involves access to money and other financial instruments and assets; political capital connotes access to both capable governance and to those institutions that influence the distribution of resources; and social capital may be defined as a community’s access to local institutions and networks that promote collective cohesion and self-efficacy. As community resilience is conceived of as an ongoing process, much emphasis is placed on a community’s ability to actively engage its population in developing capabilities through the enhancement of these four areas.

In the pre-disaster phase, a community’s latent resilience attributes would include the strength of the population’s health (human capital); the density and integration of formal and informal social networks and community-wide information pathways (social capital); the identification of and hedging against community-wide risk using insurance and mitigation strategies (economic capital); and the effectiveness and efficiency of local government to achieve community consensus and equitably distribute and manage public resources (political capital). In the post-disaster phase, the activation of these resilience attributes could include the following: establishing access to quality health and mental health systems (human capital); developing or capitalizing on emergent mechanisms to facilitate access to social networks, such as social media group work, or leveraging and integrating networks of trusted community-based organizations (social capital); the establishment of equitable processes for facilitating productive public discussions and prioritization of collective actions (political capital); and the ability to acquire and distribute public and private funds (economic capital).

Norris et al.⁸ point out that community resiliency should be conceptually treated as distinct from resistance, wherein the resources available within a community are capable of mitigating any negative impact of a collective shock such as a disaster. Whereas effective community planning is intended to prepare for the generally expected short-term disasters such as floods, fires, and earthquakes,⁴⁷ community resilience suggests that a social system should adapt to and recover from the unexpected.^8,46,48,49 When community resistance to disaster fails, the result is the collapse of multiple systems of preparedness that produces a greater shock than a community is typically experienced with .⁵⁰ Thus in order to be truly resilient, a community needs to be able to adapt, evolve, or grow in ways that enhance disaster preparedness capability.⁵¹ Enhancing community resilience then requires both the improvement of macro-level social factors such as education, employment, and population well-being while also facilitating strong and reliable partnerships between a diverse array of public, private, governmental, and nongovernmental organizations.⁴⁵ These partnerships can serve to mobilize community members during and after a crisis event so that the community population has access to critical information and necessary resources to facilitate preparedness and recovery.

While there is general consensus that community resilience can be seen as the ability of communities to link individuals to key social resources, there is less clarity on how to measure these capacities and capabilities.⁹ Building on the work of Norris et al.,⁸ Sherrieb and colleagues⁹ propose that a general lack of quality secondary macro-level data on communities limits effective measurement to the areas of economic and social capital. In their community resilience index based on the measurement of economic and community social capital data available at the county level, they develop a useful measure of the relationship of resources to the process of resilience. Other measures, such as the “coastal community resilience index” used by the National Oceanic and Atmospheric Administration, the “community resilience program” used by the American Red Cross, or the “community resilience system” developed by the Community and Regional Resilience Institute are similarly limited by being location and disaster-specific. Advances in the measurement of community resilience, especially those theoretically modeled on communities’ capacity to link individuals to vital recovery resources are focusing on the measurement of social networks that link individuals within a community to each other as well as to key institutions. Although no secondary data widely available to planners and policy-makers are available, rapid protocols for assessing the density of social networks and their capacity to mobilize resources in the event of a disaster are currently under development and promise to provide more accurate accounts of communities’ capacity to improve individual well-being through the enhancement of community resilience.⁵²

4. Access to or engagement with social resources can activate resilient attributes

Most stress and disaster recovery models argue that people who have access to better social resources or social support are better able to resist the deleterious effect of post-disaster stress.^22,28,34,35 The proposed conceptual framework for resilience activation hinges on the ability of better social resources to activate resilience attributes toward maintaining pychological vitality, stability, and mental health as well as adequate physical health and well being. Using social support (actual or perceived), as a potential activator of resilience, it is anticipated that family cohesion and warmth; strong social networks; and connection and bonding with others who are coping well in the post-disaster environment should enhance the resilience process, resulting in better behavioral outcomes. Social support could potentially activate resilience processes by providing knowledge and assistance for practical needs; helping with perspective taking for reasoning and problem solving; promoting positive emotions and attitudes associated with resilience (e.g., self-esteem, self-efficacy, optimism); facilitating adaptive coping behaviors; helping to regulate negative emotional states through providing respite; and/or helping to find a greater meaning or purpose in the situation.^29,53,54

5. Activation of resilience attributes takes place within the context of a sociocultural milieu

Exploring the cultural context of resilience among Gulf Coast communities is intrinsic to the success of public health interventions in promoting and activating resilience across the disaster prone region.^55,56 Early scholarship on human resilience sought to distinguish it from ecological resilience and pointed the way toward community-based resilience, but did little to parse out the role of culture. Adger⁶¹ noted several key elements that separate biophysical and human resilience. Human institutions, he argues, are absent in ecological systems, and they offer human communities a persistent mechanism for coping with disruption.⁶¹ These institutions, whether religious, ethnic, or legal, provide a means for individuals and communities to sustain resilient capacities and to pass that wisdom on to subsequent generations through social memory.^62,63 As human constructs, these institutions reflect cultural influences and are largely local in scale. Thus, they mediate how a community prepares for and responds to a disruption and activates its resilient capacities. From the community level, culture and ethnicity/race are prime mechanisms for enabling and perpetuating resilience. Important lessons learned in the aftermath of both domestic and global disasters have confirmed the pivotal role of culture in resource supply as well as redevelopment practices. Community-embedded institutions, such as faith-based organizations and cultural affinity groups, often serve as asset mapping agents, facilitating access to portfolios of resources. in a just-in-time culturally-tailored fashion.

Over the past few years resilience studies have provided more insight into the cultural context. Communities with deep cultural and subsistence roots in places have demonstrated the capacity to “manage resilience” on the fly through adaptation.^64–66 Repeated hurricane strikes, along with other environmental disruptions, have impacted Louisiana’s coastal minority communities over the past several centuries. Yet, these natural resource-based communities have persisted in the face of extreme environmental circumstances.^67–69 At the core of their adaptive success have been ethnic/cultural ties that provide essential networks through church and kin connections, and an enduring attachment to place that drove individuals’ desire to stay and adapt as a cultural community. These linkages enable mobility, both economic and geographic, to cope with and rebound from disruption. Successful adaptation may require the extension of social institutions across ethnic lines and over long periods of time and this is possible at the community level. Furthermore, inherent resilience that pre-dates formal programs is rooted in local practices finely attuned to local conditions and enables communities to perpetuate themselves in place even without top-down efforts.^59,65

6. Individual, community and sociocultural milieu can be quantified or measured

In individuals, resilience in the face of disaster, adversity, or overwhelming disadvantage is a multi-faceted process. There are resilient people, resilient behaviors (e.g., coping), and resilient outcomes. Thus, resilience has been studied as a personality or character trait, a process, and an outcome. Although the theory far out paces robust construct measurements, measures of personality characteristics such as self-efficacy²³ and self-reported resilience⁷³ have been associated with better post disaster mental health outcomes.^13,74 Promising measures for studies to test the Resilience Activtion Framework may also included those which assess various attitudes associated with resilience such as, optimism⁷⁵ and positive emotions,^53,54,76,77 which have also been able to distinguish between people with successful and unsuccessful adaptation after extreme stress.

Resilient behaviors have been predominantly studied by measuring the efficacy of a person’s coping efforts, distinguishing between the traditional notions of problem and emotion focussed strategies.^78,79 After disaster, problem-focused coping strategies are thought to have a greater association with resilient outcomes than emotion-focused or avoidant strategies. While this association is supported from both rational and theoretical perspectives, with the exception of a few studies^13,20,80 there is limited consistency in the disaster literature about which coping behaviors are better than others after disaster. This is most likely due to the many biopsychosocial factors associated with the coping process, the tendency for most people to use a wide range of coping strategies in the face of extraordinary challenges (making it difficult to determine which were the most helpful), and the fact that effective coping behaviors often vary with the changing post-disaster situational demands. Lastly, the Resilience Activation Framework does not presume that resilient outcomes are limited to the absence of mental illnes. Positive outcomes could include the presence of ongoing psychological vitality, good health, quality of life, family functioning, maternal bonding, or general well being.

The measurement of social capital is typically divided into two approaches. Whole network analysis focuses on the interactions between people within a socially or geographically bounded group, such as a classroom or office.⁸¹ Those using this approach hypothesize that the interactions occurring within the bounded space affect some outcome, in this case social resources in times of disaster. The method involves getting some measure of interaction between members of the whole network. The other approach is called personal or egocentric network analysis. With this approach, researchers do not think the outcomes are restricted to social influence within a socially or geographically bounded space.⁸² Instead they see individuals as living within social contexts that vary in size, with people who of varying characteristics arranged around them in different ways. For linking individual and community resiliency, neither approach alone is ideal. A new approach being developed using an overlapping personal network approach where respondents from the communities provide personal networks using the typical method where a set of personal networks of respondents from a bounded space are merged by name and compositional characteristics to yield a whole network for the community. This approach is based on research that shows how some members of a whole network can accurately report on the structure of interactions within the whole network and charactertize the flow of resources within its structures.^83,84

From a socio-cultural perspective, proxy measures of resilience, such as demographic and economic change, have been used at the national and community scale,^{57, 58} but other evidence offers insight into adaptive capacity over long periods of time. Historical legal documents, for example, document the presence or absence of community resilience in the wake of disruptive events.⁶⁵ For example, after a 1930s oil spill destroyed their oyster beds, local oystermen capitalized on familial and cultural ties by going to work on their relatives’ and neighbors’ shrimp boats. Several methods exist for measuring such cultural historical resilience. One relies upon primary or secondary texts, including interviews with individuals who experienced disruption and participated in the response and recovery, or historical records, such as newspapers, local government body proceedings, and government accounts of how a community coped with hazard events.^{59, 70–72.} By tracing the continuation or disappearance of resilient practices, one can test whether or not a community is perpetuating its resilience.

Another method to assess socio-cultural aspects of resilience is through the investigation of cultural consonance:the degree to which indivduals approximate, in their own beliefs and behaviors, prototypes for belief and behavior that are encoded in shared cultural models. This method incorporates a two-pronged approach, first, implementing cultural domain analysis, and later cultural consensus analysis.^85–87 Increasing understanding of the specific disaster-associated stressors, culturally shared histories and beliefs associated with adversity, and the contributions of their cumulative life circumstances will advance knowledge about how culture may inhibit or activate individual and community resilience, influence health, and improve quality of life across various settings.^88,89

Implications for Behavioral Health

The integrated resilience research framework as described provides unique, trans-disciplinary opportunities for behavioral interventions. Although the impact on future interventions are likely to be predicated on the anticipated research findings, the Resilience Activation Framework provides a roadmap for action that could potentially impact behavioral health intervention practice, policy and research.

Impact on behavioral health intervention practice

Communities living on this country’s Gulf Coast have faced decades of interdependent challenges directly affecting their individual health and that of their communities: lack of preparedness against natural disasters and the impact of those disasters on physical and mental health well-being; persistent health disparities specifically related to chronic health conditions such as cancer and asthma in addition to birth outcomes such as preterm birth and low birth weight; and historical environmental contamination exacerbated by the aftermath of Hurricanes Katrina, Rita, and Isaac. While progress has been made in documenting those challenges, the solutions to date have employed narrow, “silo-driven” research designs, lacked a community-based participatory approach, and failed to produce sustainable ecological, system-driven solutions. In addition, previous studies of environmental disasters largely indicate that although the physical effects of environmental disasters are usually the major source of concern, psychological effects of these disasters can be more significant.⁹⁰

In general, disaster–related behavioral interventions have not yet fully benefited from a comprehensive integration of community context, assets, and “state of resilience.” Timing and type of intervention activities affect frontline disaster behavioral health practice. To date, for example, most behavioral interventions have been implemented post-disaster, in most instances focusing on a single adverse mental health condition (e.g., stress, PTSD) at the individual level. As depicted in figure 2, the effectiveness of behavioral interventions aimed at strengthening resilience is influenced by an individual’s or community’s capacity (attributes), their capability to activate those capacities, and ultimately the extent to which such interventions strengthen resilience, for example, as manifested in improved mental health. Hence, post-disaster interventions in isolation of assessing the state of the supporting attributes pre-disaster of the individual’s or community’s capacity to activate those attributes post-disaster are unlikely to improve mental health and consequently resilience in a sustained fashion. For instance, the efficacy of behavioral programs such as the Crisis Counseling Assistance and Training Program (CCP, activated under the Stafford Act with funding from FEMA and coordinated by SAMHSA) could potentially be strengthened long term by incorporating broader data – based elements of the Resilience Activation Framework. Specifically, post disaster CCP interventions such as community-based outreach and psycho-educational services could be enhanced by linking individual-level interventions (improving coping strategies, stress management or problem solving skills; referrals to more comprehensive mental health care) to broader community resilience activities and partnerships (interventions targeting specific, relevant social networks and community systems) that may serve to activate and sustain adaptive behaviors. This may be accomplished through emergent Long Term Recovery Committees that are perpetuated in a disaster’s aftermath or through community coalitions developed in advance.

The success of any behavioral intervention hinges on built-in scalability to the scope and type of hazard as well as the degree of community engagement in all aspect of the intervention- from design to evaluation. Furthermore, particularly in Gulf Coast communities, the extent to which an intervention is embedded in the local culture and utilizes existing assets will significantly influence both short-term effectiveness and long-term sustainability. These interventions should also consider the population vulnerabilities which might impede access to such interventions (such as language differences, or functional or cognitive disabilities). Messages promoting such behavioral interventions should be developed with such vulnerabilities in mind.

Behavioral interventions aimed at strengthening resilience in the context of disasters must transcend the traditional medical model and adopt a culturally sensitive, community-based approach as the preferred type of intervention. Beyond improving individual mental health, community-based behavioral interventions are uniquely poised to build on the characteristics a resilient community must have to “bounce back” from a disaster, promote what a community must do day to day to create these characteristics pre-disaster, and most importantly, increase a community’s capability to “forecast” so that its members can be well-positioned for the next challenge. Targeting communities as the recipients of behavioral interventions has the important added advantage of fostering a more trans-disciplinary approach to psychosocial health. For example, adopting a biopsychosocial model prenatally not only expands the spectrum of intervention to early development, but also the focus of the intervention to the family as a unit by promoting positive “influencers” such as, maternal warmth as a moderator of prenatal stress on child outcome.⁹¹ Likewise, the extension of an anthropological model of psychosocial stress that focuses on the modifying effect of culture provides a promising avenue to address disaster-related stress in Gulf Coast communities where cultural context is likely to serve as an enabler of resilience at both the individual and community level.^85,86

Impact on behavioral health intervention policy

The National Disaster Management System represents a top-down hierarchical approach to providing aid to communities with support requested from the Federal level by a Governor and subsequently delivered through state and local agencies to individuals in communities. The National Response Plan is composed of several Emergency Support Services (ESF) outlining how post-disaster aid flows from the federal level to state and local agencies and ultimately to communities.⁹² Behavioral health care is provided under ESF 8- Public Health and Medical Services. From a policy perspective, the plan stipulates that services are provided in response to a disaster or during a potential or actual emergency. This current construct hampers access to behavioral health interventions for communities such as those living on the Gulf Coast who have experienced successive trauma and need mental health support during the extended recovery phase rather than only immediately post-disaster.

Superimposed on the lack of behavioral health care in the context of disasters is a fragile health system in general and that supporting mental health, specifically. To complement these limited resources especially in vulnerable populations, the National Academy of Sciences (NAS) proposed a conceptual model to build community resilience through private-public collaboration.⁹³ The model represents a paradigm shift in several key areas and articulates a set of guidelines and strategies which are reflected in the proposed Resilience Activation Framework (figure 2). Key among the strategies fostering private-public collaboration are the integration of capacity building within the community (activating attributes), employing a community-based systems approach, strengthening resilience through education and training in partnership with educational institutions, and creating flexible funding and resource allocation policies. The underlying premise implied by this guidance is that to be effective and have sustained positive health outcomes, behavioral interventions should be accompanied by private-public partnerships aimed at activating community capacity, and targeted education and information dissemination. These “resilience- focused” private-public partnerships may represent a desirable change in policy since those can serve as both a deployable portfolio of assets in the pre-disaster period as well as a sustainable resource during a prolonged recovery stage.

Impact on behavioral health intervention research

In its 2011 publication on “Building Community Disaster Resilience through Private-Public Collaboration” the NAS concluded that, “A nation is resilient when it is made up of resilient communities.”⁹³(p10) Integral to achieving this goal is assuring disaster behavioral health interventions are based on the most contemporary science. Among the recommendations for future research by NAS are focus areas highly relevant to the proposed Resilience Activation Framework: research that results in quantitative risk and outcome markers, projects which strengthen community resilience, and document best practices. In addition, advancing the science base by producing nationally applicable data examining the interdependence of vulnerability and resilience has a high likelihood of providing behavioral health practitioners with tailored, evidence-based tools.

Given the multiple levels at which the RAF operates, these tools could potentially guide the systematic outcome studies of a wide range of interventions designed to enhance resilience or related capacities in individuals and families in crisis. Depending upon the type of disaster involved, this could include, but not be limited to enhanced, outcome studies of hardiness, stress inoculation or learned optimism training; social support; well-being therapies; or other psycho-educational interventions. Data from the RAF model could also lead to the development of new rationally based interventions with diverse populations within the context of their culture, taking into consideration community, economic and political resources as well as the specific type of disaster. Importantly, as guided by the model, these therapies, psycho-educational interventions, and messages would need to be tailored to specific populations including infants, children, adults, older adults, as well as those with functional access needs and the burden of mental and substance abuse challenges.

Conclusion

In the aftermath of the Deepwater Horizon Oil Spill the Substance Abuse and Mental Health Services Administration and the National Institute of Environmental Health Sciences at the National Institutes of Health embarked on a series of collaborative and integrated research projects to increase understanding of the mechanisms by which access to social resources activate and sustain resilience capabilities after disaster. The Resilience Activation Framework was developed by the participating research consortia to serve as a unifying heuristic in which to frame the authors’ collective research, to strengthen the interdependency of the supporting research projects, and to provide a common language in which to assess the results and implications for both policy and interventions.