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Several hypotheses may explain the association between substance use, posttraumatic stress disorder (PTSD), and depression. However, few studies have utilized a large multisite dataset to understand this complex relationship. Our study assessed the relationship between alcohol and cannabis use trajectories and PTSD and depression symptoms across 3 months in recently trauma-exposed civilians.
In total, 1618 (1037 female) participants provided self-report data on past 30-day alcohol and cannabis use and PTSD and depression symptoms during their emergency department (baseline) visit. We reassessed participant's substance use and clinical symptoms 2, 8, and 12 weeks posttrauma. Latent class mixture modeling determined alcohol and cannabis use trajectories in the sample. Changes in PTSD and depression symptoms were assessed across alcohol and cannabis use trajectories via a mixed-model repeated-measures analysis of variance.
Three trajectory classes (low, high, increasing use) provided the best model fit for alcohol and cannabis use. The low alcohol use class exhibited lower PTSD symptoms at baseline than the high use class; the low cannabis use class exhibited lower PTSD and depression symptoms at baseline than the high and increasing use classes; these symptoms greatly increased at week 8 and declined at week 12. Participants who already use alcohol and cannabis exhibited greater PTSD and depression symptoms at baseline that increased at week 8 with a decrease in symptoms at week 12.
Our findings suggest that alcohol and cannabis use trajectories are associated with the intensity of posttrauma psychopathology. These findings could potentially inform the timing of therapeutic strategies.
This is the first report on the association between trauma exposure and depression from the Advancing Understanding of RecOvery afteR traumA(AURORA) multisite longitudinal study of adverse post-traumatic neuropsychiatric sequelae (APNS) among participants seeking emergency department (ED) treatment in the aftermath of a traumatic life experience.
We focus on participants presenting at EDs after a motor vehicle collision (MVC), which characterizes most AURORA participants, and examine associations of participant socio-demographics and MVC characteristics with 8-week depression as mediated through peritraumatic symptoms and 2-week depression.
Eight-week depression prevalence was relatively high (27.8%) and associated with several MVC characteristics (being passenger v. driver; injuries to other people). Peritraumatic distress was associated with 2-week but not 8-week depression. Most of these associations held when controlling for peritraumatic symptoms and, to a lesser degree, depressive symptoms at 2-weeks post-trauma.
These observations, coupled with substantial variation in the relative strength of the mediating pathways across predictors, raises the possibility of diverse and potentially complex underlying biological and psychological processes that remain to be elucidated in more in-depth analyses of the rich and evolving AURORA database to find new targets for intervention and new tools for risk-based stratification following trauma exposure.
The original edition of this book was published in late 2005. Ten years on, the salience of its topic is undiminished. In the past decade, the world has seen many natural catastrophes, industrial accidents, high-profile acts of terrorism, crowd tragedies, cyber scares, infrastructure breakdowns, mass shootings, migration flows, and humanitarian emergencies. There is a growing awareness that in an increasingly interconnected world, crises do not stop at borders and can span entire regions or even assume a global scale.
Public expectations of governments and their leaders in times of crisis remain high. Public leaders are expected to be prepared for a wide variety of contingencies; they must “ramp up” their performance when a crisis emerges. At the same time, it is becoming increasingly clear that the tasks of crisis leadership require more than organizing an effective response. Leaders must build and support transboundary collaboration and transnational institutions that can effectively deal with the borderless nature of contemporary crises.
Much has happened over the past decade in the world of crisis management. It is fair to say that crisis management has become a profession, an industry, and a growing community of practice and research. In many governments and corporations, there are now more dedicated roles, high-level bodies, training and exercise programs, conferences, and high-tech command and communication facilities than there were a decade ago. A cross-disciplinary array of researchers, consultants, software developers, and manufacturers push the trends toward professionalization, propelled by ever-growing demand from both the corporate and the public sectors. This is perhaps what one might expect in the risk societies that the advanced nations have become. Citizens, markets, media, and politicians expect that risk is minimized, threats are mitigated, and crises are effectively combated. Leaders who fail to take this seriously will lose credibility, support or even their job when caught by a crisis.
The response to the first edition of the book neatly dovetails this trend. It has struck a chord, both with students and practitioners. As authors of the book, we were fortunate enough to receive invitations to speak to, train, exercise, and evaluate crisis managers from a wide range of countries and sectors. Even today, the book continues to be widely used in courses worldwide and in several languages. The feedback we have received during the many encounters with practitioners, students, and colleagues has been inspiring.
Swedish Minister of Foreign Affairs Laila Freivalds paid a high political price for her visit to the theater on the evening on December 26, 2004. The Asian tsunami disaster had killed hundreds of Swedes that very day. Her visit signaled an emotional dissociation from the fate of the 30,000 vacationing Swedes in the affected region. When the prime minister of the day, long-serving Goran Persson, backed her in blaming the government's tardy response on errors committed down the foreign service hierarchy, this did not play well. In early 2005 Persson faced hostile questioning from a parliamentary inquiry, which was broadcast around the nation. A highly critical report was issued, and the tsunami crisis dogged the government all the way until the next election, which it lost.
The charismatic and popular Australian police commissioner Christine Nixon saw her career cut short as a result of her perceived lack of involvement and empathy in times of crisis. During a public inquiry following the deadly “Black Saturday” bushfires on the outskirts of greater Melbourne in February 2009, it transpired that she and her husband had gone out for a pub meal with friends while communities were burning and people were dying. The public never forgave her. Nixon initially defended herself on the basis of fact: she had delegated command responsibilities for the bushfire response to a highly experienced assistant commissioner well before the situation became critical, and she had in fact been at the command center during most of the day before going off duty. It was to no avail. The tabloid press was merciless. Expert support for her conduct at the inquiry was not enough to undo the damage. She resigned in July 2010.
In a crisis, authorities can easily lose control, if only temporarily, over the dramaturgy of political communication. Overtaken by events, they struggle to formulate a message that offers an authoritative definition of the situation, provides hope, shows empathy for victims, and gives assurances that the authorities are doing their best to minimize the consequences of the threat. Leaders do not have much time to come up with such an authoritative take on events. Politicians, citizens, and other opinion makers, all making use of (social) media venues, offer competing interpretations and powerful images crafted for mass consumption.
Crisis management has become a defining feature of contemporary governance. In times of crisis, communities and members of organizations expect their leaders to minimize the impact, while critics and bureaucratic competitors make use of social media to blame incumbent rulers and their policies. In this extreme environment, policymakers must somehow establish a sense of normality, and foster collective learning from the crisis experience. In the new edition of this uniquely comprehensive analysis, the authors examine how strategic leaders deal with the challenges they face, the political risks and opportunities they encounter, the pitfalls they must avoid, and the paths towards reform they may pursue. The book is grounded in decades of collaborative, cross-national and multidisciplinary case study research and has been updated to include new insights and examples from the last decade. This is an original and important contribution from experts in public policy and international security.
Conventional wisdom suggests that human progress requires that we learn from our failures. As crises unearth failing policies, procedures, and organizations, they provide clear-cut opportunities to learn and adapt. We would therefore expect policy makers to study what went wrong before and during a crisis and to change ideas, policies, structures, and processes in accordance with their findings.
In a context of competing accounts of what happened it is, however, not so easy to determine what went wrong and what should be adapted to prevent similar crises from happening again. Many different and sometimes contradictory lessons can be distilled from one and the same crisis experience. Moreover, stakeholders often disagree on what the right lessons are. As we have seen in Chapter 5, the post-crisis period is not necessarily one of social unity, mindful inquiry, and dispassionate reflection. The adversarial politics of the aftermath will affect the identification and selection of the lessons to be learned from crisis. Even when there is agreement on certain measures to be taken, there is no guarantee that lessons learned will actually be implemented. And consensus about lessons does not necessarily mean that the lessons will be sufficient to prevent similar mistakes from happening in the future.
Consider the rash of new policies, legal changes, and major institutional reforms and reorganizations that were pushed through the legislature at unprecedented speed after the 9/11 events – in the United States, the European Union, and many other countries. In the U.S., the so-called Patriot Act was adopted in near unanimity, enacting policy changes in the judicial system, in the handling of immigrants and resident aliens, and in the allocation of government funds for national security and public safety. In a major administrative reorganization effort, many security-related and emergency management agencies were merged at the stroke of a pen into the vast Department of Homeland Security. The department, with its 170,000 employees and wide responsibilities for dealing with different contingencies, could not prevent – and some would say contributed to – a botched response to Hurricane Katrina (summer of 2005).
The European Union learned and changed in much more incremental fashion. A uniform definition of terrorism was accepted; extradition rules for potentially terrorism-related crimes were extended. Police units can now track suspected criminals across national borders and, if necessary, act with full authority on foreign soil.
In this book, we have presented a number of claims about leadership in times of crisis. These are based on the findings of several decades of crisis research, direct observation of crisis managers in action (in real-world settings and simulated contexts), and ongoing dialogue with experienced and reflective practitioners. In this final chapter, we translate key observations from the evolving body of crisis management research into recommendations for improving crisis management practices.
Navigating crises prudently is a complex leadership challenge. Trade-offs must be made among various key values and constraints. Policy makers must make decisions and live with the consequences of their actions or inactions. Citizens either suffer the effects of governmental unpreparedness or reap the benefits secured by well-prepared leaders and resilient institutions. Effective crisis navigation requires leaders to prepare themselves and their organizations to deal with this challenge well ahead of the moment when they find themselves in the “hot seat” of crisis. Our recommendations do not tell policy makers what to do but offer ideas and suggestions about how prudent crisis leadership might be facilitated, organized, and exercised.
Grasping the Nature of Crises
Let us begin with the nature of the beast. What is it that makes crises so difficult to handle? And what should policy makers understand about crises when they seek to enhance their crisis leadership capacities?
One of the most important things to keep in mind is that crisis is a label, a semantic construction people use to characterize situations that they somehow regard as extraordinary, volatile, and potentially far-reaching in their negative implications. Why people collectively label and experience a situation as a crisis remains something of a mystery. Physical facts, numbers, and other seemingly objective indicators are important factors, but they are not decisive. A flood that kills 200 people is a more or less routine emergency in Bangladesh, but it would be experienced as a major crisis in, let's say, New Jersey or Poland. Similarly, seasonal influenza kills somewhere between three thousand and fifty thousand persons per year in the U.S., a fact easily obscured in the media and public consciousness by the threat posed by a relatively small number of vividly portrayed imported Ebola cases.
In July 1995, Bosnian-Serb forces occupied the town of Srebrenica, a UN safe haven in the Yugoslavian civil war, after a long siege and a brief military campaign. The Dutch military contingent (Dutchbat), the UN protector of the Muslim enclave, surrendered and was allowed a safe retreat. On return, their families, the prime minister, and the Crown Prince welcomed the Dutch troops as national heroes. For the minister of defense, who had spent several days and nights in the government bunker in The Hague from where the Dutch military commanded the besieged troops, the crisis was finally over – or so he thought.
After taking over the enclave, the Bosnian-Serbian troops commanded by Ratko Mladic killed thousands of captives who had been under Dutch protection. The world soon learned that 7,000 men had been murdered, many of them while the Dutch battalion was anxiously awaiting its safe passage home. When the atrocities came to the fore, Dutch sentiment changed quickly. Media reports asserted that the Dutch soldiers had done very little to defend the enclave. Rumors began to circulate to the effect that the Dutch had condoned and even cooperated with the Serbs, thus facilitating the ethnic cleansing.
The Dutch minister of defense, Joris Voorhoeve, would spend the remainder of his political career defending the decision to surrender the enclave. Various investigations were conducted, yet doubts lingered on in the public mind. Finally, under pressure, the prime minister decided to appoint an official inquiry by the National Institute of War Studies. When it reported in the spring of 2002, just before scheduled elections, the report cleared the army of the cowardice charges but roundly criticized the government's decision to send Dutch troops into such a hazardous and badly supported UN mission. The government resigned. Seven years after Srebrenica, the political crisis was finally over.
The civil and criminal court battles continued, however. The “mothers of Srebrenica” proved unrelenting in their efforts to seek justice. Dutch and European courts knocked back their claims, but a Dutch court ruled in 2013 that the Dutchbat squadron did bear legal (though not criminal) liability for the deportations and subsequent killing of Bosnian Muslim men. The Srebrenica tragedy had become a wound that kept bleeding.
On the morning of September 11, 2001, U.S. President George W. Bush was listening to a group of children reading at a Sarasota, FL elementary school when he learned about the second plane crashing into the World Trade Center. He stayed in the classroom for several minutes, ostensibly listening to the reading. But the cameras captured the look of shock on his face as the president tried to make sense of the news that the country had come under attack.
The 9/11 terrorist strike took Bush, his country, and the rest of the world by complete surprise. As the drama unfolded live on television screens across the globe, people found themselves watching in disbelief: “This cannot be happening.” This sense of collective stress soon gave rise to pressing questions: how could this have happened and why did the authorities not see it coming?
Making sense of an unfolding crisis – from its roots to its “hot” phase and its aftermath – is a core challenge of crisis management. If intelligence agencies recognize an emerging threat early on, they can try to prevent it from materializing. If crisis managers quickly and fully understand the causes, characteristics, and consequences of an unfolding crisis, they are more likely to mitigate its impact. The sense-making task thus has two components: detection (of emerging threats and vulnerabilities) and understanding (of an unfolding crisis). In this chapter – and this is our key question – we ask what factors affect the effectiveness of sense making before and during crisises.
Detecting an impending threat before it escalates into a full-blown crisis can be extremely hard. Whether it is a prison riot or a terrorist act, a natural disaster, an international conflict, an environmental contingency, or an economic crisis – authorities rarely see them coming. Yet, hindsight knowledge always seems to reveal that there were strong indications of growing risks or outright warnings that somehow went unnoticed or failed to prompt remedial action. This is not because of some inherent incompetence of policymakers and organizations. In this chapter – and this is our first core claim – we argue that many types of impending crises are very difficult to recognize in advance.
Governance has increasingly become a matter of crisis management. Crises routinely shatter the peace and order of societies. They arrive as “rude surprises” and “inconvenient truths” wreaking havoc and destroying the legitimacy of public institutions. Natural disasters, the collapse of financial systems, high-tech catastrophes, lone-wolf terrorists, mass revolts, new pandemics, geopolitical powder kegs, and cyber attacks – the list of potential crises is long and growing.
Disruptions of the dominant order are as old as life itself. The Bible can be read as a catalog of the frightening crises that have beset humankind since time immemorial. Most of the world still confronts these “old” crises on a regular basis. But we also see new crises – and new twists on more familiar ones – that define the times we live in: Lehman Brothers and the Euro crisis, Arab Spring and failed states, Fukushima and Deepwater Horizon, Mumbai and Paris, Ebola and ISIS.
In such times of crisis, citizens look to their leaders. The system is out of kilter, and leaders are expected to chart pathways out of the crisis. The public expects them to avert the threat or at least minimize the damage of the crisis at hand. They must explain what went wrong. They must adapt, change or abandon routine ways of operating where needed and create public confidence in the new status quo. They should work toward enhancing community resilience, preparing society for future shocks.
Crises provide real-world “stress tests” to the resilience of political systems and the crisis management capacities of leaders. They play out against a backdrop of public expectations (influenced in part by leaders themselves) that can be very challenging to meet. In some cases, the quality of crisis management makes the difference between life and death, chaos and order, breakdown and resilience. When governments and their leaders respond well to a crisis, the damage is limited. When emerging vulnerabilities and threats are adequately assessed and addressed, some potentially devastating contingencies simply do not happen. When crisis management fails, the impact increases.
Crisis management bears directly on the lives of citizens and the well-being of societies. The notion of “crisis management” as used in this book is shorthand for a set of interrelated and extraordinary governance challenges.
In March 2011, U.S. President Barack Obama presided over five national security meetings at the White House to go over plans for a military operation designed to kill the country's nemesis, Osama Bin-Laden. A few weeks later, Obama gave the final order to strike. In the secure Situation Room deep within the White House, Obama and his most trusted aides watched the operation unfold in “real time” as U.S. Special Forces stormed the terror chief's compound in Pakistan. A photograph released by U.S. officials captured the drama as the group watched the world's most wanted terrorist finally meet his end.
On July 7, 2005, the morning rush hour in London formed the backdrop for a series of suicide attacks. Four suicide bombers detonated one charge each, killing fifty-two people and injuring more than 700. Hundreds of rescue workers were engaged in the response. With the underground closed down and roads gridlocked, authorities faced a dilemma. The traffic situation affected the mobility of the rescue services as well as of citizens trying to get home from work. As long as the public transportation systems remained down, chaos would prevail in the city streets. But if there were more bombs placed on buses or trains, the consequences of a premature restart could be dire indeed.
These very different examples of high-stakes decision making illustrate a classic notion of executive leadership: making the critical call when it matters most. Both successes and failures of crisis management are often related to such monumental decisions. This notion of crises as “occasions for decision making” is a dominant one in the scholarly literature on crisis management. How leaders make such high-impact decisions in turbulent circumstances has – for good reasons – been considered pivotal by generations of crisis researchers.
Many studies of crisis management report an “upward” shift in decision making: the authority to make critical decisions is adjusted to the scale of the crisis. When a crisis strikes areas that extend over multiple administrative jurisdictions, responsibility for coordinating government responses typically shifts to regional, national, or, for some types of crises, transnational levels of authority. The same goes for crises that are local in geographical terms but whose depth and complexity exceed the coping capacity of local authorities.