American Journal of Community Psychology, Vol. 22, No. 2, 1994

The Continuity Principle: A Unified Approach to Disaster and Trauma 1 Haim Omer 2 and Nahman Alon

The continuity principle stipulates that through all stages of disaster, management and treatment should aim at preserving and restoring functional, historical, and interpersonal continuities, at the individua~ family, organization, and community levels. Two misconceptions work against this princ~le and lead to decisional errors: the "abnormalcy bias" which results in underestimating victims' ability to cope with disaster, and the "normalcy bias" which results in underestimating the probability or extent of expected disruption. This article clarifies these biases and details the potential contributions of the continuity principle at the different stages of the disaster. KEY WORDS: continuity principle; disaster; trauma.

The organizational and clinical aspects of disaster are inextricably linked. Management decisions, such as when and how to inform, evacuate, or compensate threatened or victimized populations, have deep implications for the psychological responses of individuals and families. On the other hand, conceptions of group pathology, and about treatment of trauma and of grief reactions, have wide implications for organizational decision making. The very nature of disaster interlinks a diversity of organizations and professions, creating acute communication problems. Without a common conceptual ground, different agencies often work at cross purposes, deepening the

1The authors are reserve officers in the Mental Health and Behavioral Sciences Centers of the IDF (Israel Defense Forces) and were, in this capacity, directly involved in the coordination of agencies dealing with Gulf War victims. 2All correspondence should be sent to Haim Omer, Department of Psychology, Tel Aviv University, Ramat-Aviv, 69 978, Israel. 273 0091--0562/94/0400--0273507.00/09 1994 PlenumPublishingCorporation

274

Omer and Alon

disruptions occasioned by the disaster. Clinicians are almost invariably called to help, but their ability to do so is often curtailed by the lack of a common language with the people in authority and of clear guidelines on how to address victimized or threatened populations that suffer from urgent practical problems besides their emotional ones. What is needed is a unifying principle that should fulfill the following demands: (a) It should have common-sense appeal so as to be acceptable to people from the most diverse orientations, schoolings, and functions; (b) it should be simple and practical, so as to enable decision making in real time (a principle requiring complex inferences for its application would be irrelevant for the quick pace of events); and (c) it should be consistent with knowledge on disaster and trauma. Following a review of the literature, Omer (1991) proposed a unifying principle as potentially fulfilling these demands. The "continuity principle" stipulates that through all stages of disaster, management and treatment should aim at preserving and restoring functional, historical and interpersonal continuities, at the individual, family, organization, and community levels) Let us explain our terms. "Functional continuity" is the ability to go on coping and functioning in spite of disturbances; "historical continuity" consists of the feeling of coherence and sameness in self, family, and community through time; "interpersonal continuity" obtains when relationships that were significant in the past continue to be so in the present and future. The "stages of disaster" are the periods (discrete or overlapping) of preparation, warning, impact, and aftermath. This principle fits in with recent attempts to conceptualize the problem of trauma and posttraumatic adjustment as that of maintaining or restoring continuous information processing (Horowitz, 1986), personal schemas (Janoff-Bulman, 1989; Kiyuna, Kopriva, & Farr, 1993), and interpersonal nets (Raphael & Middleton, 1987). It adds to these attempts in two respects: (a) It postulates that the maintenance and restoration of continuity should be furthered at all levels and stages of disaster, and (b) it does not assume the preeminence of any special locus of disruption (such as of information processing, cognitive schemas, interpersonal relations, etc.). These additions confer on the continuity principle a wider applicability, for there is no need to convince practitioners of the special importance of a specific theory or locus of disruption: Any preservation of 3The continuity principle was first applied in its present form by liaison officersbetween the Israel Defense Force and civilian agencies during the Gulf War. It led to common meetings between members of the different treating agencies, centralized treatment plans, and unified "missile-victims' folder" shared by all agencies. These common procedures did much to further continuity at all levels and stages.

Unified Approach to Disaster and Trauma

275

continuity based on any theoretical rationale may contribute to the desired end. The continuity principle thus partakes of the present trend towards integration between theories and methods in all areas of applied psychology, and in the area of trauma in particular (e.g., Freedy, Kilpatrick, & Resnick, 1993; Schwartz & Prout, 1991). Integrative models, however, tend to become cumbrous. In combining a multiplicity of approaches, they often take the form of highly complex diagrams with numerous boxes, each representing the contribution of one of the integrated factors or theoretical perspectives. Such intricate models fail to provide the practitioner with a unified and simple action principle. The continuity principle aims instead at a simplified, and therefore practicable, integration by means of a common factor that underlies the different approaches to disaster and trauma. In its three major areas of application (interpersonal, functional, and historical), the continuity principle is closely related to extant theorizing and research in clinical, health, and community psychology. Thus, the relationship between vulnerability to stress and variables such as social support (Cohen & Wills, 1985; Rook & Dooley, 1985), coping skills (Elias et al., 1986), and the preservation of roles (Heller, 1990) has given rise to considerable research and lively controversy. The continuity principle stresses the permanence and coherence of the different factors, rather than their presence or absence. Thus, social support will be less effective if supplied ad hoc and by external sources than when provided through the abiding social network; problem-solving skills will be more effective if they match the person's usual and familiar activities than if they are perceived as extraneous; and preservation of old roles is more promising than acquisition of new ones. Furthermore, these three factors should fit together in a continuous mutuality. For instance, if a social support intervention is built around existing interpersonal nets, extant skills, and previous role definitions, we can expect it to be more affective (Heller, 1990). Continuity should be pursued not only in each separate field but also between fields and agencies. Disaster and trauma mean disruption: Prevention and cure should therefore aim at developing continuities at all levels. Viewed in this light, the continuity principle might seem to state no more than the truism that disruptions occasioned by disaster and trauma should be either prevented or mended. It might even be asked whether such an obvious principle should be at all formulated. Wouldn't practitioners follow it intuitively? The answer seems to be negative: Two deeply rooted misconceptions have led to the principle's consistent disregard. The first one, that we term abnormalcy bias, consists in underestimating the ability of people to function adequately in the face of disaster. The second, known as normalcy bias, consists in underestimating the probability of disaster, or the

276

Omer and Alon

disruption involved in it (see Drabek, 1986, for a review on the prevalence of these biases and their deleterious influence in disaster management). The abnormalcy bias sabotages the continuity principle by depicting continuous functioning as rare or impossible; the normalcy bias, by leading to the assumption that continuity requires no protection or restoration, since no serious disturbance is expected anyhow. The two biases can operate conjointly, for instance, when authorities decide to withhold information about possible dangers because, on the one hand, they evaluate wrongly that the threat is of low probability and, on the other hand, that even" if it were to materialize victims would be unable to utilize the information for adaptive coping.

THE ABNORMALCY BIAS AND THE DISASTER MYTHS The assumption that disaster victims are incapable of adaptive functioning manifests itself at its most damaging in the widespread disaster myths of panic, shock, and looting.

The Myth of Panic Individuals and groups are expected to react to disaster by mass hysteria and uncontrolled flight. Although disaster studies show that collective stampedes are rare (except in crowded enclosed precincts threatened by immediate destruction and with limited exits), still the expectation of panic holds its sway (Johnson, 1988; Quarantelli, 1980, 1982). In our experience, the myth of panic leads often to bad decisions. For example, the distribution of gas masks in Israel before the Gulf War was postponed many times because of fear that it would generate panic. 4 After the distribution, the mistake was compounded by the directive to the population not to open the boxes until given specific instructions to the contrary. Again, the main reason for this was fear that panic might break out. Instructions were finally given to open the boxes after the war had begun. Under these circumstances little time was left to train the population on the correct manner of wearing the masks and to spot possible mistakes. Eight people died of suffocation because they failed to remove the cover from the filters in their masks. Some of these deaths might have been prevented had it not been for the myth of panic. Contrary to what had been feared, the actual behavior of people during the distribution of masks and during the Scud attacks was quite orderly. Panic was not a problem in the Gulf War. 4Although the Center for Behavioral Sciences of the IDF consistently voiced the opinion that panic would not ensue, its recommendations, in this respect, were disregarded.

Unified Approach to Disaster and Trauma

277

The pervasiveness of the myth of panic is further illustrated by persistent rumors, backed by news broadcasts, that many people had "hysterically" given themselves atropine injections during the alarms. Stories went on to detail that there were people who, not content to inject themselves with one dose, tried to guarantee their safety by repeated injections, bringing themselves to a state of dehydration. The actual data, officially reported by the Ministry of Health, was that about 220 people (out of a population of more than 4 million) had injected themselves with atropine, and about 200 of them had done so only because they had misunderstood the instructions as indicating that the injection was to be administered when the alarm was sounded.

The Myth of Shock The belief that people almost invariably react to disaster with pathological shock and numb irresponsiveness is no less widespread than the belief in panic. Shock reactions that preclude adaptive functioning certainly occur, but they are atypical in disasters (see Omer, 1991, for a review). Like the myth of panic, the belief in the ubiquity of shock reactions seems refractory to contrary evidence. For instance, in a group conversation with a bomb squad in a heavily hit area during the Gulf War, squad members related to one of the authors (H. Omer) that the people whose houses had been hit behaved in a strangely courteous manner, as if they were so deeply shocked as to be unaware of what had befallen them. What an ingrained belief is this, that makes one interpret orderly and courteous behavior as the very proof of a pathological response! This belief leads to the assumption that, since victims are unable to cope, all help must be brought from the outside and supplied as a form of infusion. By turning victims into passive invalids the myth of shock undermines functional continuity. Often, the assumption that victims cannot cope leads to the conviction that they should be transferred to more "comfortable" surroundings in which they can be quietly treated. By severing victims from their social milieu, this unfortunate policy also shatters interpersonal continuity.

The Myth of Looting Looting is much more unusual in disaster than would be warranted by the prevalence of stories and fears (Granot, 1993; Quarantelli & Dynes, 1970). When widespread looting does occur, as in ghetto riots, it is usually

278

O m e r and Alon

the result of growing social tensions rather than a direct sequela of disaster. During the Gulf War, three members of the Israeli Parliament made haste to propose a law to punish severely the looting of war victims. These conscientious measures seem to have been misplaced, as police reports made clear that looting in the Gulf War was all but nonexistent. The myth of looting affects disaster management adversely mainly by encumbering the process of evacuation. To our purpose it illustrates once again the tendency to view people's behavior in disaster as propelled by primitive drives that all but shatter the social fabric. Such a view makes for little willingness to invest on such "improbable" outcomes as the preservation of functional, historical, and interpersonal continuities.

THE NORMALCY BIAS

The normalcy bias is the tendency to minimize the probability of potential threats or their dangerous implications. Individuals and organizations tend to believe in the less alarming options whenever they are presented with conflicting or ambiguous information about danger (Perry, Lindell, & Greene, 1982). Even when the information presented is unambiguous, there is a tendency to await confirmation from alternative sources (or simply watch out for what others are doing) before deciding on protective action (see Drabek, 1986, for a review). To counter the normalcy bias and allow for suitable preparation it is necessary to deliver timely, repeated, and unambiguous warnings and instructions. One of the thorny dilemmas in the Gulf War, when the threat of chemical warfare was a concrete possibility, was how to instruct the population in areas hit by gas to evacuate their homes. People would have to leave their sealed rooms while there was still gas in the area (time was a crucial parameter because babies could not be kept in their protective cribs for more than a few hours) so as to allow for decontamination. Directives to this effect could hardly be delivered for the first time at the moment they had to be carried out: Lack of preparation was sure to create misunderstandings. Nevertheless, decision makers, biased towards normalcy (the worst would surely not happen) and fearful of panic, chose not to issue preparatory instructions. The demands of the continuity principle must compete with the normalcy and abnormalcy biases at every juncture. The continuity principle requires prompt delivery of information, trust in the coping capacity of the population, and provision of guidelines for autonomous functioning by individuals and communities. The normalcy and abnormalcy biases, however, often tip the scales towards distrust of the population and withholding of

Unified Approach to Disaster and Trauma

279

information: Denial, cover-up, and haziness are justified by the belief that all will be well if only the population be not unduly frightened. This clash between the two disaster philosophies can be witnessed at all stages.

THE PLANNING STAGE When stressful events can be predicted, and options for coping perceived and mastered, functioning improves and pathological responses decrease (Averill, 1973; Barlow, 1988; Gray, 1982; Levav, Grinfield, & Baruch, 1979; Seligman, 1975). In the disaster field, in particular, accurate information, planning, and rehearsal of relevant responses foster the behavioral and mental schemata that make for a continuous transition between routine and emergency functioning. Individuals, families, and organizations in disaster-threatened areas react positively to proposals for developing a "disaster plan" (Perry, Lindell, & Greene, 1981). Suggested plans include, for instance, evacuation placements, shelter arrangements, lists of items to be stocked or taken when evacuating, distribution of tasks between family members, and contacting procedures in case of separation. Disaster plans give a sense of empowerment and self-control, reduce threat ambiguity, ease the process of decision making, and counter the normalcy bias. These plans have been proved useful over and beyond the specific emergencies for which they were devised (Nehnevajsa & Wong, 1977). The importance of early planning and role rehearsal suggests that an emergency team with which the community is unacquainted may be quite ineffective. Instead of helping, such a team might even exacerbate the problems created by the torrential influx of people and equipment in disaster. Emergency teams should therefore try to join target communities at the planning stage, as illustrated by the following proposals by the Behavioral Sciences' Center of the IDF: Among the early conditions for the optimal functioning of a psychological emergency team, the following should be stressed: a) local authorities should become acquainted with the emergency team, helping to confer it legitimacy; b) links should be established with organizations involved in disaster management; c) the team should make itself known to the community at large; d) the team should counter the disaster myths at all levels and advocate the early relay of specific information to threatened populations; e) the team should help individuals, families and organizations to develop disaster plans; f) community maps should be prepared, including communication nets and lists of public services, functionaries, and community members, (in particular marginal and isolated ones who may fail to be reached by warning, or rescue directives); g) an inventory of disaster role descriptions should be prepared to instruct community members and volunteers at the impact stage; h) disaster drills and simulations should be performed. (Omer, 1991)

280

O m e r and Alon

These proposals are inspired by the continuity principle: Early information, disaster planning, community maps, a legitimate status in the community, an inventory of role descriptions, and the discreditation of disaster myths, further continuity at all levels.

THE WARNING STAGE The typical mistakes of the warning stage result from the normalcy bias and from the tendency of authorities to withhold threatening information even at the very brink of disaster. The most common response to warnings is disbelief. People tend to go on with the business of life and doubt the immediacy and personal relevance of danger. Rather than taking protective action, they usually await repeated confirmations or look to others for guidance (Perry & Greene, 1983). These methods of threat validation are themselves normalcy biased: People tend to search for business-as-usual messages and to seize upon ambiguities as tokens of the warnings' invalidity. In the Gulf War, after the first missiles turned out to be armed with conventional warheads, droves of sensation hunters responded to the sirens by running to the hit areas and hooting at the bomb squads for appearing on the scene warning gas masks. A preference for delivering hazy messages is apparent at all levels of disaster management. The main reason for this is, once again, the panic myth and the normalcy bias. People in authority temper their messages with uncertainty clauses to avoid accusations of panic mongering. During the Gulf War, the proposed texts of messages to be delivered to the population in case of chemical or biological attack were often ambiguous. The ambiguity was not due simply to negligence or carelessness: whenever the Behavior Sciences' Center offered clarifying corrections, new ambiguities were sure to creep in, as if to compensate for the "damages" of too much straightforwardness. The fight for the continuity principle on behalf of clarity and specificity is ceaseless: Any flagging in vigilance seems to bring in reticence, qualification, indirectness, and indeterminacy. In their will to soothe, the authorities often fall into the trap of providing wooly reassurance. Threatened populations, however, need concrete, specific, and clear information, no matter how harsh, to enable functional continuity. By infantilizing prospective victims, a well-wishing authority may create a negative self-fulfilling prophecy: A person who receives little information and is deemed incapable of protective action can only develop a passive outlook and stew in the fumes of "anxious apprehension" that all but prevent continuous functioning (Barlow, 1988).

Unified Approach to Disaster and Trauma

281

When evacuation is called for, care must be taken to preserve interpersonal continuity by helping people locate all family members. Alternative channels of communication must be made available beforehand to replace the disrupted ones. A community disaster plan should specify an information center where knowledge about people's whereabouts is collected. There is evidence that most people agree to evacuate even without some members of the family if their location is known and procedures for renewing contact have been established (Perry & Greene, 1983).

THE IMPACT STAGE From the literature on combat trauma, one formulation about treatment has proven highly stable: The principles of frontline treatment enunciated in the First World War have been rediscovered and newly validated in the Second World War and also in Korea, Vietnam, and Israel (Solomon & Benbenishty, 1986); its three foundations are immediacy, proximity, and expectancy, meaning that treatment should be started as soon and as close to the front as possible and that the expectation of a quick return to duty should be conveyed. Although these principles gained acceptance initially because they sounded right from a military point of view, it soon transpired that soldiers receiving frontline treatment recovered better and sooner than soldiers evacuated to the rear. In the long run, soldiers who had received frontline treatment were found to suffer from significantly less disability than those who had been treated in rearline facilities (Solomon & Benbenishty, 1986). The continuity principle provides an interpretation of frontline treatment that makes it relevant for civil populations in disaster. Immediacy prevents hiatuses in living that would deepen the sense of disruption; proximity protects people's links with the places and interpersonal networks within which they live and function; expectancy maintains the person's social roles and prevents the development of a "sick role" that might lead to chronicity. Frontline treatment can thus be seen as furthering historical, functional, and interpersonal continuity. Mental health workers in the Gulf War applied the continuity principle along these lines, when treating people who had been transferred to temporary lodgings because of missile destruction of their homes. Sometimes, on the very morrow after a missile hit, meetings were arranged between evacuated children and their schoolmates and teachers (although schools were closed during most of the war). Likewise, the presence of evacuees was arranged at neighborhood events (such as thanksgiving prayers for absence of bodily injured in religious neighborhoods), even if

282

O m e r and Alon

the evacuees had been lodged far from their destroyed homes. And, finally, an immediate return to work and to family routine was uniformly encouraged. The continuity principle also helped to spot mistakes that were made at the beginning of the war and to develop possible solutions. For instance, in some municipalities, people were evacuated to hotels. According to the continuity principle, however, arrangements where families would cook and keep house by themselves should be favored as preventing functional disruption. To prevent the syndrome of "hotelism," treatment agencies decided on a policy of removing the evacuated families from hotels as soon as possible. The maintenance of interpersonal continuity led also to a preference for family, rather than individual, interviews of evacuees. The very act of the therapist's isolating himself or herself with a family member carried discontinuous implications in the interpersonal field, setting apart the individual member's problems from the family's. The logic and appeal of the continuity principle made itself felt in that even therapists from an individual-centered psychoanaltyic orientation soon shifted to family interviewing. In summary, a psychological emergency team guided by the continuity principle will strive for the following goals at the impact stage: (a) At the individual level, the team will preserve contact with families and primary groups, keep people involved in active roles and convey the belief that a quick return to functioning is possible and expected; (b) at the family and community levels, the team will protect existing frameworks and care for the maintenance of communication channels between separated members; (c) with the authorities, the team will support delivery of timely, specific, and concrete information; and (d) at all levels, the team will counter the dominant view of victims as driven by irrational, pathological, or antisocial forces.

THE AFTERMATH OF DISASTER AND TRAUMA At the level of the individual victim, much epidemiological and phenomenological research has been carried out on the subject of post traumatic stress disorder (PTSD). On a more practical line, although treatment approaches abound, good results do not and, in our experience with clinical teams in Israel, PTSD patients usually have a bad name with therapists. Some of the difficulties may, however, be due to a therapeutic narrowness that focuses on one kind of discontinuity while neglecting or perpetuating others. To clarify this point, let us begin by a rough characterization of three possible emphases in dealing with the disorder.

Unified Approach to Disaster and Trauma

283

Focusing on the Trauma. In this view, the trauma is the major or only source of the disorder. The traumatic experience consists of an acute cognitive, emotional, and physiological overload that causes a breakdown in mental functioning. This emphasis characterizes theories as diverse as the early psychoanaltyic interpretation of hysteria as a traumatic neurosis (Breuer & Freud, 1895), physiological theories based on a collapse of habituational structures (Kolb, 1983, 1987), and information-processing approaches (Horowitz, 1986). The characterization of the trauma, and of the conditions leading to breakdown, is different in each model, but all agree that the trauma explains the symptoms, and that processing the trauma is the major task of treatment. Focusing on Pretrauma Experiences. This approach emphasizes the individual's condition before the trauma. PTSD patients are seen as characterized, in the past, by an unstable psychological balance, the trauma serving as no more than a trigger, or as supplying a neurotic solution to the imbalance (Alon, 1985; Breslau, Davis, Andreski, & Peterson, 1991; McCann & Pearlman, 1990). Focusing on the trauma is, accordingly, a mistake. The trauma is the trigger or the solution, not the problem, and treatment should therefore focus on pretraumatic personality problems, clarifying to the patient that life since the trauma is a continuation of life before it. Focusing on Posttrauma Events. According to this approach, PTSD develops because trauma victims and significant others react to an otherwise temporary dysfunction in ways that make it permanent (Green, Wilson, & Lindy, 1985; Sgroi & Bunk, 1988). PTSD is not due solely or even mainly to the trauma, but rather to processes that prevent a return to normal living. Some of the crucial events in the process of chronization are interruption of work, abandonment of family roles, psychiatric labeling and hospitalization, and the development of a tug-of-war of mutual blame between patients and significant others ( D a V e r o n a & Omer, 1992). Treatment should consist of a process of rehabilitation that avoids the pitfalls of rejection, avoidance, and blame, while rebuilding the individual's functioning capacity. In terms of the continuity principle, each of these approaches deals with a different disruption: The first emphasizes traumatic residues that prevent continuous mental flow; the second, interruptions in historical continuity between the pretraumatic and the posttraumatic self; and the third, functional and interpersonal hiatuses caused by a suspension of habitual social roles. The continuity principle allows for an integrative treatment aimed at overcoming disruptions in all areas, It postulates that any area of restored continuity will positively affect others. Thus, functional improvement will

284

O m e r and Alon

increase the capacity to process traumatic experiences and a growing sense of historical coherence will improve functioning. This therapeutic synergism, however, is in danger of breaking down if the therapist consistently disregards one area in favor of another. For instance, to achieve fuller emotional awareness, the therapist might have recourse to narcoanalysis and hospitalize the patient, thus disregarding functional and interpersonal continuity. Alternatively, intent on promoting better functioning, the therapist might be tempted to disregard traumatic memories, encouraging the patient to deny and forget. The present integrative approach is akin to Horowitz's (1986) pendular movement between a supportive and an explorative stance, each reinforcing the other. Similarly, in the present approach, whenever progress in one area is blocked, the therapist should address disruptions in other areas. The same synergistic assumption applies to the family, organization, and community levels. For example, families with pathological mourning may suffer from disruptions in their relationship to the lost one, in their daily functioning, or in both. For instance, a family may avoid mentioning the lost member or making any change in his or her room; or it may fail to reinstitute daily routines; or, combining both disruptions, it may develop a chaotic life-style punctured by outbursts of violent grief. The continuity principle postulates that a restoration of the family's daily routine will have a positive effect on its capacity to relate to the lost one's memory, and vice-versa. The therapist may help such a family to reorganize daily life, thereby improving its ability to mourn, or to create a mourning ritual, thereby improving daily functioning. Similarly, in the wake of the Yom Kippur War, field psychologists visiting units that had suffered heavy losses helped them to plan a memorial day for the fallen soldiers (historical continuity) or to reinstitute a clear daily routine (funct i o n a l c o n t i n u i t y ) . T h e a u t h o r s w e r e involved in b o t h kinds of intervention. In most cases, the restoration of historical and functional continuities proved mutually enhancing.

CONCLUSION The continuity principle is neither a strict theoretical proposition nor a treatment technique. It belongs to the category of general treatment strategies that, as argued by Goldfried (1980), could fulfill a unifying role in the hodgepodge of orientations and interventions. As a strategy, it is endowed with the highest degree of generality: It is applicable at all levels and through all stages of disaster. Maybe what makes the principle promising is that it legitimizes and utilizes existing

Unified Approach to Disaster and Trauma

285

theories, instead of presuming to replace them. Moreover, instead of prescribing a uniquely "right" technique, the principle suggests how to make better use of existing ones. But how could a single principle even begin to do justice to the variety of human behavior under stress? In disaster, we believe, the situation is peculiar and human diversity gives way to considerable homogeneity, for there are innumerable ways of reacting to life's daily challenges, but very few of fleeing an erupting volcano. All through this article we have attempted to spell out the theoretical and practical aspects of the continuity principle. We conclude with some research implications, particularly those that may highlight its limitations. The continuity principle leads to the expectation that the more an intervention is built on a client's (individual, family, organization, or community) existing resources, the more effectively will it be able to counter the disruptive effects of disaster and trauma. The principle, however, says nothing a b o u t what circumstances call for an external that is, discontinuous, input. Taken to an absurd extreme, the principle of continuity might imply that it is better not to intervene at all. Applied research should focus not only on how external interventions could be minimally disruptive and how they could help to maintain and restore continuities rather than replacing them, but also on the conditions that justify disruptive interventions. The limitations of the principle lie in the area where continuity turns into inertia. The mapping of this issue has not been attempted in this paper and it could be a fruitful subject for future research.

REFERENCES Alon, N. (1985). An Ericksonian approach to the treatment of chronic post-traumatic patients. In J. K. Zeit (Ed.), Ericksonian psychotherapy (Vol. 2). New York: Brunner/Mazel. Averill, J. (1973). Personal control over aversive stimuli and its relationship to stress. Psychological Bulletin, 80, 286-303. Barlow, D. H. (1988). Anxiety and its disorders: The nature and treatment of anxiety and panic. New York: Guilford. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222. Breuer, J., & Freud, S. (1895). Studies in hysteria. In J. Strachey (Ed.), The complete psychological works of Sigmund Freud, Standard Edition (Vol. 2). New York: W. W. Norton. Cohen, S., & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357. DaVerona, M., & Omer, H. (1992). Reversing chronic processes with mental patients: An interpersonal perspective. Psychotherapy, 29, 355-365.

286

O m e r and Alon

Drabek, T. E. (1986). Human system responses to disaster: An inventory of sociological findings. New York: Springer Verlag. Elias, M. J., Gara, M., Ubriaco, M., Rothbaum, P. A., Clabby, J. F., & Schuyler, T. (1986). Impact of a preventive social problem solving intervention on children's coping with middle-school stressors. American Journal of Community Psychology, 14, 259-274. Freedy, J. R., Kilpatrick, D. G., & Resnick, H. S. (1993). Natural disasters and mental health: Theory, assessment and intervention. Journal of Social Behavior and Personality, 8, 49-104. Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35, 991-999. Granot, H. (1993). Anti-social behavior reconsidered. Disaster Management, 5, 142-144. Gray, J. A. (1982). The neuropsychology of anxiety. New York: Oxford University Press. Green, B. L., Wilson, J. P., & 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 (pp. 53-69). New York: Bruner/Mazel. Heller, K. (1990). Social and community intervention. Annual Review of Psychology, 4L 141-168. Horowitz, M. J. (1986). Stress response syndromes (2nd. ed.). Northvale, NJ: Jason Aronson. Janoff-Bulman, R. (1989). Assumptive worlds and the stress of traumatic events: applications of the schema construct. Social Cognition, 7, 113-136. Johnson, N. R. (1988). Fire in a crowded theater: a descriptive investigation of the emergence of panic. International Journal of Mass Emergencies and Disasters, 61, 7-26. Kiyuna, R. S., Kopriva, R. J., & Farr, S. J. (1993). The experiential learning model as a conceptual framework for the treatment of post-traumatic stress disorder. Journal of Social Behavior and Personality, 8, 105-116. Kolb, L. C. (1987). A neuropsychologicai hypothesis explaining posttraumatic stress disorders. American Journal of Psychiatry, 144, 989-995. Levav, I., Greenfied, H., & Baruch, E. (1979). Psychiatric combat reactions during the Yom Kippur war. American Journal of Psychiatry, 135, 637-641. McCann, I. L., & Pearlman, L. A. (1990). Psychological trauma and the adult survivor. New York: Bruner/Mazel. Messer, S. B. (1986). Eclecticism in psychotherapy: Underlying assumptions, problems and trade-offs. In J. C. Norcross (Ed.), Handbook of selective psychotherapy (pp. 379-397). New York: Brunner/Mazel. Nehnevajsa, J., & Wong, H. (1977). Flood preparedness 1977: A Pittsburgh area study. Pittsburgh: University of Pittsburgh, Center for Urban Research. Omer, H. (1991). Tasks of a psychological emergency team in disaster [In Hebrew]. Sihot, 5, 1-23. Perry,; R. W., & Greene, M. R. (1983). Citizen response to volcanic eruptions: The case of Mount St. Helens. New York: Irvington. Perry, R. W., Lindell, M. K., & Greene, M. R. (1981). Evacuation planning in emergency management. Lexington, MA: Lexington Books. Perry, R. W., Lindell, M. K., & Greene, M. R. (1982). Threat perception and public response to volcano hazard. Journal of Social Psychology, 116, 199-204. Quarantelli, E. L. (1980). Evacuation behavior and problems: Findings and implications from the research literature. Columbus: Disaster Research Center, The Ohio State University. Quarantelli, E. L. (1982). Social and organizational problems in a major community emergency. Emergency Planning Digest, 9, 7-10. Quarantelli, E. L., & Dynes, R. R. (1970). Property norms and looting: Their patterns in community crisis. Phylon, 31, 168-182. Raphael, B., & Middleton, W. (1987). Mental health responses in a decade of disasters: Australia, 1974-1983. Hospital and Community Psychiatry, 38, 1331-1337. Rook, K., & Dooley, D. (1985). Applying social support research: theoretical problems and future directions. Journal of Social Issues, 4L 5-28. Schwartz, R. A., & Prout, M. F. (1991). Integrative approaches in treatment of PTSD. Psychotherapy, 28, 364-373. Seligman, M. E. P. (1975). Helplessness. San Francisco: W. H. Freeman.

Unified Approach to Disaster and Trauma

287

Sgroi, S. M., & Bunk, B. S. (1988). A clinical approach to adult survivors of child sexual abuse. In S. M. Sgroi (Ed.), Vulnerable populations: Evaluation and treatment of sexually abused children and adult survivors (Vol. 1, pp. 137-186). Lexington, MA: Lexington Books. Solomon, Z., & Benbenishty, R. (1986). The role of proximity, immediacy, and expectancy in frontline treatment of combat stress reaction among Israelis in the Lebanon war. American Journal of Psychiatry, 143, 613-617.