Can Resilience Training Improve Well-Being for People in High-Risk Occupations? A Systematic Review through a Multi-Dimensional Lens.

Abstract

The article has been accepted for publishing in the Journal of Positive Psychology and so the final version may differ slightly from this one.

Background: Psychological resilience may be central to Positive Psychology as one way to face the dark side of life. But is resilience training universally effective? This paper initiates a systematic review of primary research on resilience training in high-risk occupations. Methods: Examined resilience training outcomes and conducted analysis from a multidimensional perspective. Results: 33 papers totalling 10,741 participants, 12 occupations, and eight countries. Although 81% (n=118) of Principal Outcomes reaching statistical significance showed improved well-being, resilience training was less effective in populations with prior trauma exposure or already experiencing the negative sequelae of trauma. Conclusion: Given the moral imperative to adequately prepare people in high-risk occupations for exposure to adverse stressors, further research is recommended into improving the effectiveness of resilience training for those already with primary or vicarious trauma exposure; and whether such training should also be offered to close family and co-workers of people in high-risk occupations.

Keywords: Resilience; Resilience training; high-risk occupation; multidimensional; well-being; trauma.

Full text

Running Head: Resilience Training in High Risk Occupations
Can Resilience Training improve Well-being for People in High-Risk
Occupations?
A Systematic Review through a Multidimensional Lens
Authors
Kate Brassington linkedin.com/in/kate-brassington,
Dr Tim Lomas linkedin.com/in/drtimlomas
School of Psychology, University of East London, Arthur Edwards building, Water
Lane, London, E15 4LZ, United Kingdom.
Author responsible for correspondence: Email: kate@zestcoaching.uk

Running Head: Resilience Training in High Risk Occupations
Abstract
Background: Psychological resilience may be central to Positive Psychology as one
way to face the dark side of life. But is resilience training universally effective? This
paper initiates a systematic review of primary research on resilience training in high-
risk occupations. Methods: Examined resilience training outcomes and conducted
analysis from a multidimensional perspective. Results: 33 papers totalling 10,741
participants, 12 occupations, and eight countries. Although 81% (n=118) of Principal
Outcomes reaching statistical significance showed improved well-being, resilience
training was less effective in populations with prior trauma exposure or already
experiencing the negative sequelae of trauma. Conclusion: Given the moral
imperative to adequately prepare people in high-risk occupations for exposure to
adverse stressors, further research is recommended into improving the
effectiveness of resilience training for those already with primary or vicarious
trauma exposure; and whether such training should also be offered to close family
and co-workers of people in high-risk occupations.
Keywords: Resilience; Resilience training; high-risk occupation; multidimensional;
well-being; trauma.

Running Head: Resilience Training in High Risk Occupations
Introduction
When people in high-risk occupations sustain psychological injury in the
normal course of their work, the sequelae of trauma-related health issues can cause
them to become no longer employable in such roles (Thompson & Dobbins, 2018).
In the last six years, medical discharges from the British Army for PTSD or mental ill
health have tripled (Jones, 2018). From 2009 to 2015, the US Army discharged
22,0001 soldiers with mental health problems such as post-traumatic stress and
traumatic brain injury following service in Iraq or Afghanistan (Zwerdling & De
Yoanna, 2015). UK doctors are at very high risk of mental illness, and according to
Professor Clare Gerada, ‘female doctors have up to four times the risk of suicide in
comparison to the general population’ (Wickware, 2018, p1). UK NHS retention rates
have worsened threefold since 2011 with the majority of leavers in 2018-2019 citing
work-life balance as their reason (Charlesworth, 2018). 85% of UK Fire and Rescue
personnel have experienced stress and poor mental health at work, and people
working in Emergency services are more likely to experience a mental health
problem (than the general workforce), but are less likely to take time off work as a
result (Mind, 2015). With social stigmas and other difficulties around major career
transition, leaving such a career can itself add to poor mental health (Dalton,
Thomas, Melton, Harden, & Eastwood, 2018), not to mention the cost to
organisations of loss of talent and effectiveness, and pressure on stretched medical
resources. Prevention rather than cure may therefore ‘yield greater returns than the
traditional diagnosis/treatment-orientation model’ (Cornum, Matthews, & Seligman,
2011. p.5).
1 Figures from US Department of Defense dated October 2015
https://www.npr.org/2015/10/28/451146230/missed-treatment-soldiers-with-mental-
health-issues-dismissed-for-misconduct in (Zwerdling & De Yoanna, 2015)

Running Head: Resilience Training in High Risk Occupations
Resilience theory suggests that resilience can be learned and improved, with
associated protective qualities against the sequelae of mental health issues that may
arise from experiencing occupational trauma (Thompson & Dobbins, 2018). Recent
research has been drawn towards investigating the protective nature of resilience,
and in recognising the need to identify which types of resilience training interventions
are effective in improving mental health (Joyce, Shand, Tighe, et al., 2018; Peng et
al., 2014; Thompson & Dobbins, 2018; Zimering, Munroe, & Gulliver, 2003). With the
impetus for much research stemming from many combat veterans experiencing long-
term effects of battlefield trauma (Crane & Boga, 2017; Thompson & Dobbins, 2018),
similar research has spread into the effectiveness of resilience training for other
high-risk workers such as Red Crescent healthcare teams in Iran (Larijani &
Garmaroudi, 2018), Chinese medical students (Peng et al., 2014), clergy (Noullet,
Lating, Kirkhart, Dewey, & Everly, 2018), and nurses (Jackson, Firtko &
Edenborough, 2007).
High-Risk Occupations. Many occupations have an inherent risk of exposure
to traumatic stressors, such as the military, some police roles, first responders (Britt
et al., 2016). There is evidence that employees involved in such work have a higher
incidence of mental health problems (Mitchell & Everly, 1995) compared to
employees not working under such conditions (Britt & McFadden, 2012). Likewise
people working in careers that help individuals recover from trauma can experience
secondary traumatisation with symptoms similar to those exhibited by people who
experienced the event first hand (Zimering, Munroe & Bird Gulliver, 2003). Often
high-risk occupations attract employees with a strong set of integral values (Perez et
al., 2015) that may present as a calling in life (Wrzesniewski, McCauley, Rozin &
Schwartz, 1997), so avoiding adverse experiences in the first place is not in the

Running Head: Resilience Training in High Risk Occupations
scope of this paper. This current review defines high-risk occupations as work that
either places people in first-hand contact with traumatic events, in second-hand
contact with the people who were at such an event, or where routine exposure to
adverse stressors occurs.
Adverse Events, Situations, and Trauma
Shattered Assumptions Theory (Janoff-Bulman, 2004) suggests that the negative
psychological impact of trauma occurs when our core assumptions of safety and
security are shattered (cited in Ivtzan, Lomas, Hefferon, & Worth, 2016). Additionally,
the nature of the adverse event (‘event centrality’) has been shown to be relevant
when predicting negative psychological outcomes. For example, sexual trauma was
found to be more strongly associated with PTSD compared to death of a loved one
(Wamser-Nanney, Howell, Schwartz, & Hasselle, 2018). Physical violence (e.g.
fighting, rape), environmental disasters (e.g. fires, floods, avalanches), accidents and
terrorist incidents (e.g. car crashes, airplane crashes), societal oppression and
discrimination (e.g. racism, sexism, slavery, colonisation; Treleaven, 2018), are
amongst those events which can cause psychological trauma in people caught up in
them. Similarly, professionals working in first hand contact with people affected by
traumatic events (Mitchell & Everly, 1995), or in second-hand contact with the people
who were at such an event (Zimering, Munroe & Bird Gulliver, 2003), are at risk of
secondary psychological trauma through conducting their daily work.
Just as adverse events and situations are not limited to combat, so
corresponding psychological outcomes are not limited to PTSD2. It is thought that
2 The emergence of the movement ‘drop the D’ reflects a recent shift away from psychiatric classification of
mental illness towards a more sensitive ethnographic descriptor through the experiences of people acquiring
mental illness after experiencing traumatic events such as combat (Smith & Whooley, 2015), however many of
the studies in this current paper have used the term PTSD, and so the term PTS and PTSD have been used
interchangeably.

Running Head: Resilience Training in High Risk Occupations
around one in three people experiencing trauma may develop PTS symptoms, it is
not yet known why some do and others don’t (NHS UK, 2019). Factors that increase
the risk of a person sustaining psychological injury, either through a single incident or
the cumulative effects of experiencing multiple or repeated stressors, have been
identified as: the degree and frequency that a person experiences exposure to
trauma or seeing ‘gruesome sights’ (Saul & Simon, 2016); their gender and level of
training (Crane et al., 2018; Tucker et al., 2002); their sense of powerlessness in
being able to provide the help needed (Saul & Simon, 2016); insecurity,
helplessness, depletion of coping resources (Finklestein, Stein, Greene, Bronstein, &
Solomon, 2015); levels of frustration and perceived loss of control (Perez et al.,
2015); being restrained or unable to escape (Levine, 2010). Such effects may
commence immediately, be long-lasting, or occur years later (Maguen et al., 2008).
As noted by NHS UK, trauma is not limited to events, but includes ‘any
situation that a person finds traumatic’ (NHS UK, 2019). Suggested relevant
situations include chronic negative stress through ‘avoidable occupational suffering’
(e.g. extreme workload, understaffing, and other preventable systems failures), and
‘unavoidable (inherent) occupational suffering’ linked to intrinsic demands for
extremely high personal performance (elite athletes, combat soldiers, surgeons)
(Card, 2018). Insufficient resources, poor design of work areas, poor workplace and
managerial relationships, are strongly correlated with the chronic condition of
burnout where perceived demands outweigh perceived resources (Card, 2018;
Gentry, Baranowsky, & Dunning, 1997; Gerada, 2018). This appears particularly
relevant in high-risk occupations where the demands and resources of the job may
compromise a person’s integral values that attracted them to this type of work in the
first place (Perez et al., 2015). The American Institute of Stress notes that factors

Running Head: Resilience Training in High Risk Occupations
influencing the severity of job stress depend on the magnitude of demands that are
being made and the individual’s sense of control (AIS, 2019), and Health and Safety
Executive analysis of UK Labour Force statistics identifies the primary causative
factors of workload, lack of managerial support and organisational change (HSE,
2018). In extreme cases when the organisation demands a high personal price
without making systemic changes, such incongruence can lead to feelings of
betrayal and intensify psychological injury (Morgan, 2017) or apathy and
disillusionment (Evans, 2018).
A systemic approach to resilience therefore appears optimal if organisations
are to engage simultaneously with the full complexity of issues raised at both
organisational and individual levels (Cheshire et al., 2017; Saul & Simon, 2016).
Multidimensional models that offer frameworks for such appreciation of complex
issues across multiple domains will be discussed in more detail later in the paper.
Effects of Trauma. Post-Traumatic Stress Disorder (PTSD) first entered
psychiatric vocabulary in the 1980s through medical classification of distressed war
veterans, and this influenced the early heterogeneous definitions of Post-Traumatic
Stress (Treleaven, 2018). Twenty years later, PTSD was cited as being the most
frequent mental disorder occurring in the aftermath of traumatic exposure (Apolone,
& Mosconi, 2002). The current NHS UKi website defines it as an ‘anxiety disorder
caused by very stressful, frightening, or distressing events, or any situation that a
person finds traumatic’ (NHS UK, 2019).
Trauma and negative stress can have lasting impact not only on the people
who experience an adverse event or situation, but on wider teams and societal
groups (Becker-Blease, 2017), and even transmitted down the generations to

Running Head: Resilience Training in High Risk Occupations
children as Trans-Generational Trauma3 (Hanna, Dempster, Dyer, Lyons & Devaney,
2012 in Fitzgerald et al., 2017, Banyard, Englund, & Rozelle, 2001; Cherepanov,
2016). Individuals who are affected in this way (whether chronic or acute) can
experience, or be at increased risk of experiencing, a number of psychological
difficulties such as: compassion fatigue (Mehta et al., 2016; Noullet et al., 2018),
burnout, job dissatisfaction, (Perez et al., 2015; Werneburg et al., 2018), increased
risk of alcohol and drug use, PTS, suicide, depression, generalised anxiety
disorders, and reduced job efficacy (Cohn et al., 2013; Maguen et al., 2008; Reivich,
Seligman, & McBride, 2011; Zamorski, 2011). In the case of children impacted by
transgenerational trauma, they can exhibit difficulties in self-regulation and increased
likelihood of poor mental health or behavioural problems (Fitzgerald et al., 2017).
The likely impact on teams and organisations includes absenteeism, medical errors,
job turnover, and team conflict (Mehta et al., 2016).
Resilience. Mental Health and resiliency appear connected as studies have
shown that interventions which help personal resiliency are effective in reducing and
relieving depression and increasing well-being (Larijani & Garmaroudi, 2018).
Mindset theory (Dweck, 2006) suggests that environmental conditions that
encourage growth, rather than fixed, mindset, are strong predictors of potential (Ricci
& Lee, 2016), with new research in neuroplasticity showing that this is strongly
correlated to building resilience (Tabibnia & Radecki, 2018). For the purpose of this
paper, the terms Mental Health, Mental Well-being, and Well-being will be used
interchangeably to indicate positive functioning.
3 Transgenerational Trauma: when the psychological consequences of parental trauma detrimentally impact
their interaction with their children (Hanna, Dempster, Dyer, Lyons & Devaney, 2012 in Fitzgerald et al., 2017) to
the extent that the children inadvertently hold trauma-related beliefs or display symptoms of trauma without being
aware of its origin (Banyard, Englund, & Rozelle, 2001; Cherepanov, 2016), a phenomenon supported by the
research into Developmental Childhood Trauma (Stevens, 2013; van der Kolk, 2014).

Running Head: Resilience Training in High Risk Occupations
Resilience has sometimes been referred to as a trait, a process, and/or an
outcome (Bowers, Kreutzer, Cannon-Bowers, & Lamb, 2017), or a ‘system (that) is
expected to be able to survive an external disturbance and remain in a dependable
condition’ (Chroust, Rainer, Sturm, Roth, & Ziehesberger, 2011, p.478). Debate
exists around how changeable or stable the underlying psychological characteristics
of resilience are, and their connection with successful adaptation following a
negative event (de Terte & Stephens, 2014; Wright & Masten, 2014). As a result,
resilience is often viewed as a personal characteristic or set of characteristics that
facilitate functioning despite exposure to trauma (Luthar, 2006), with some
researchers observing that key characteristics of self-esteem, hardiness, mastery,
self-efficacy, positive affect and optimism, are malleable and that perhaps this is a
possible explanation why resilience can change over time (Sudom, Lee, & Zamorski,
2014). Further development of evidence-based programs that strengthen
psychological resilience could offer a protective effect against poor mental health for
individuals routinely exposed to traumatic events (de Terte & Stephens, 2014;
Thompson & Dobbins, 2018).
Post-Traumatic Growth (PTG) is now generally recognised to occur in some
people when their recovery after a traumatic or adverse event enables them to thrive
compared to before the incident (Hefferon & Boniwell, 2011). From a less event-
centred perspective, PTG is also thought to be a possible outcome of personal
struggles following adversity that occur when ‘painful realisations of reality (the ‘dark
side’) [enable] rebuilding around traumatic experience and thus acknowledging the
trauma in a non-anxious way’ (Ivtzan, Lomas, Hefferon, & Worth, 2016, p.85).
Research continues in this complex area, with the caution that expectation of PTG
can itself cause further distress (Ehrenreich, 2010), and that it has not yet been

Running Head: Resilience Training in High Risk Occupations
shown to be a universal phenomenon (Ivtzan et al., 2016). Indeed, its main criticism
is that it may not exist, but instead be a highly-adaptive coping mechanism such as
cognitive dissonance or positive illusion (Festinger et al, 1956 & 2008; and Taylor,
1989, cited in Hefferon & Boniwell, 2011). To avoid possibly confounding the effect of
resilience training with PTG from previous trauma exposure, resilience studies
focussing on developing or delivering PTG will be excluded from this systematic
review. The current study therefore uses a working definition of recovery resilience
as ‘an individual’s ability to adapt to and recover from stressful situations, trauma,
and hardship’ (Ungar, 2012, cited in Thompson & Dobbins, 2018. p.2.).
Multi-Dimensional Nature of Resilience. An aspect of the complex nature of
resilience appears to be that it manifests in response to a person’s lived experience,
simultaneously including factors from around (and acting on) the environment,
society and culture of a person (Thompson & Dobbins, 2018; Ungar, 2011). Though
a criticism remains that most models of psychological resilience focus on individual
resilience, early theorists in experimental ecology (Bronfenbrenner, 1977) had
offered frameworks for studying complex phenomena such as mental health.
Research encompassing the subsystems of family and community was identified
(Landau & Saul, 2004; Saul & Simon, 2016; Ungar, 2011; Walsh, 2003, 2007), and
also the use of a multidimensional model to test resilience factors in a sample of
police officers (de Terte & Stephens, 2014). From an Individual/Collective
perspective, it appears that resilience is bi-directional - while individuals draw
resilience from cultural and societal resources such as family, social groups,
community; collective groupings such as entire communities, organisations, socio-
economic / political entities also adapt to interact as a whole with their environment
(Kirmayer, Sehdev, Whitley, Dandeneau, & Isaac, 2009). Should a larger system be

Running Head: Resilience Training in High Risk Occupations
unable to integrate a traumatic disturbance (situation or event) within itself, it too
requires external support during the intervening period of instability in order to regain
balance (Chroust et al., 2011; Landau, 2010). Acute or chronic negative external
factors, such as low income, socioeconomic change, man-made or natural disasters,
are an example of such a disturbance (adverse situation or event) that may require
intervention in order to produce favourable outcomes in individual and collective
mental and physical wellbeing (Landau, 2010; Taylor & Distelberg, 2016).
Positive Psychology has also been criticised for it’s focus on individual-level
interventions, with insufficient attention on social or environmental contexts (Becker
& Marecek, 2008), particularly as broader approaches have been used for decades
in several related fields from social work to education (Lomas, 2015). One such
example is the LINC Model, evolved from Transitional Family Therapy, which offers a
multi-systemic and multidimensional approach to individual, family, and community
resilience (Landau, 2010). This uses the Transitional Field Map developed from early
work supporting communities with AIDS (Landau-Stanton & Clements, 1993), and
The Multisystemic Levels Map as used in New York City following the 9/11 attacks
(Landau & Saul, 2004) (for the LINC Model and Transitional Field Map see
Appendix 1).
Developed in part from Bronfenbrenner’s work, and from the field of Positive
Psychology, the Layered Integrated Framework Example (LIFE) model (Lomas,
Hefferon, & Ivtzan, 2015) (at Appendix 1) has been proposed as a way to
encompass the human experience of mental health at individual, collective, objective
and subjective levels. This model proposes four domains: Mind (Subjective), Body
(Objective), Culture (Intersubjective), Society (Interobjective). The current review will

Running Head: Resilience Training in High Risk Occupations
use the multidimensional framework described in the LIFE Model (Lomas et al.,
2015).
Resilience Training. Recent research has been drawn towards investigating
the protective nature of resilience, and in recognising the need to identify which
types of resilience training interventions are effective in improving mental health
(Peng et al., 2014; Thompson & Dobbins, 2018; Zimering et al., 2003). The
emphasis has shifted to preventative training and protection on the basis that ability
to manage stress and trauma can be improved (Ungar, 2011). Some research has
suggested that resilience training is most effective when it is relevant to a current or
near-future event, as resilience is thought to show up differently in response to each
stressful event ‘context may be crucial, people may be resilient at one time period in
their life but not at others’ (Rutter, 2012, p.8). Some research has offered that
developing resilience appears to require a balance of both threat and support
(Pawar, 2017) to activate healthy social engagement (Loizzo, 2018), while others
simply recommend that all people in a high-risk occupation such as Red Crescent
healthcare teams, be offered training in psychological resilience (Larijani &
Garmaroudi, 2018). It is noted that the US Military has adopted widescale resilience
training via the Comprehensive Soldier Fitness Program (Cornum et al., 2011;
Reivich et al., 2011), though this program was developed from research on resiliency
training for school-aged children, and has questionable relevance to people
deployed into war zones, not least through the lack of transparent empirical evidence
of the program’s effectiveness (Brown, 2014).
The increasing number of primary research and pilot studies on resilience
training for people in high-risk occupations has been noted, however the applicability
of findings remains limited to those study populations (Brown & Rohrer, 2019) unless

Running Head: Resilience Training in High Risk Occupations
systematic reviews are conducted. The specific value of systematic review is in
creating a synthesis of acquired knowledge from a range of relevant studies with the
aim of to provide objective knowledge with the least possible error (Mickenautsch,
2012). Some systematic reviews were identified that consider the effectiveness of
resilience training for specific occupations such as healthcare professionals (Rogers,
2016) and nurses (Deldar, Froutan, Dalvand, Ghanei Gheshlagh, & Mazloum, 2018),
a systematic review and meta-analysis of the effectiveness of different types of
resilience training (Joyce, Shand, Tighe, et al., 2018), and one on the efficacy of
workplace resiliency training (Robertson, Cooper, Sarkar, & Curran, 2015). No
systematic reviews were found to have been conducted into the universal value of
resilience training for people across multiple high-risk occupations, so this paper
initiates the current study with the aim of closing that gap.

Running Head: Resilience Training in High Risk Occupations
Method
Data Collection
The literature search was designed to capture studies that delivered resilience
training or interventions in high-risk occupations, measuring mental health and well-
being outcomes. An online database search was conducted on Google Scholar,
EBSCO and ResearchGate. Dates were 1989 to present. Advanced search functions
used the following keyword combinations: Resilience training AND high risk
occupations; Resiliency AND training; Mental Toughness AND training; Mental
toughness AND high-risk occupation; mental health training AND high-stress OR
high-risk; Stress inoculation training; Neuroplasticity AND high risk occupation;
Neuroplasticity AND resilience; Trauma-related mental illness AND resilience; Mental
injury AND resilience; Psychological injury AND resilience; Workplace adversity AND
resilience. The search was carried out between 22 January and 20 February 2019.
To include empirical studies featuring data collection, and create transparency
through multidimensional layers, an adaptation of SPICO (Study design,
Participants, Interventions, Comparison, and Outcomes) (Robertson et al., 2015)
was used, incorporating the LIFE Model (Lomas et al., 2015) and occupation as
follows: Study Design; LIFE model; Participants; Interventions; Occupation;
Comparison; Outcomes (SLPIOCO).
This paper was principally interested in studies:
Providing training for recovery resilience delivered shortly before, during, or
immediately after exposure to adverse events or situations. To avoid
confounding the effectiveness of resilience training with PTG, studies on
veterans or other service leavers were excluded;

Running Head: Resilience Training in High Risk Occupations
Concerning populations employed (paid or unpaid), or in training for, high-risk
occupations.
The review was conducted according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009).
The review protocol was registered with the International Prospective Register of
Systematic Reviews (PROSPERO) database on 6 February 2019, registration
number CRD42019122944 (www.crd.york.ac.uk/PROSPERO). The details of the
inclusions and rejections at each stage of the sift process are shown as a PRISMA
flow diagram in Figure 1.
The review included articles: (1) written or available in English; (2) in peer-reviewed
journals; (3) involving studies of any population size and participants of any culture,
nationality, gender, country who are aged 174 or over; (4) studies conducted in any
occupation or training environment for that occupation; (5) involving the provision of
training or other interventions to develop resilience or psychological capacity to
withstand or recover from stress and/or adversity and/or trauma; (6) empirical
studies featuring data collection utilising any primary research methods.
Exceptions to this were:
A study on inoculation training for paramedics - population of volunteers
drawn from the general public (Varker & Devilly, 2012). This was included as it
met all other criteria and was considered to be relevant to this high-risk
occupation;
4 Though adult employment rights and rules apply in the UK at age 18, some high-risk occupations such as the
British Army allow people aged 16 years to join as junior soldiers, and to apply for the Regular Army at 17 years
and 9 months. Basic training commences, but soldiers cannot deploy on operations until they are 18 (MOD,
2018). Worldwide, 37 countries also recruit from the age of 17 (ForcesWatch, 2011). Basic training is a time
when some resilience training may be delivered, and this study wishes to be able to capture such data, if relevant
by setting the lower age parameter at 17.

Running Head: Resilience Training in High Risk Occupations
A study on mental toughness training for elite cricketers (Bell, Hardy, &
Beattie, 2013)5. Included as participants aged 16–18 were just below the
proposed age cut-off and met all other inclusion criteria;
A study on the use of smartphone apps for psychological skills-style resilience
training – population of actively serving, retired, and family members (Roy et
al., 2017). Included as it met all other inclusion criteria and reflected the
systemic nature of the US Army’s approach to resilience (Cornum et al.,
2011).
Exclusion criteria were: (1) research not written or available in English; (2)
involving participants under the age of 176; (3) involving veterans or service-leavers;
(4) theoretical papers; (5) studies that conducted no training, intervention, or primary
research; (6) studies that conducted training but with no reference to resilience or
psychological capacity to withstand or recover from stress and/or adversity and/or
trauma; (7) studies on resilience training for people not employed in, conducting, or
training for work in a high-stress occupation as defined above; (8) other systematic
reviews; (9) research papers that focus on Post-Traumatic Growth (PTG) as their
primary outcome; (10) duplicate papers.
Data Extraction
The following variables were extracted from each paper: study author and
year; occupation; country; type of design; number of participation and control
participants (if applicable); measures used; type and mode of training for intervention
and control groups (as applicable); length of study; key findings; principal well-being
outcomes categorised under the LIFE Model (Lomas et al., 2015) quadrants of Mind,
5 Accordingly studies on elite sportspeople were considered with one on elite high-altitude climbers (Crust,
Swann, & Allen-Collinson, 2016) excluded as no training was delivered; and one on elite young cricketers (Bell,
Hardy, & Beattie, 2013) included as participants were in training for GB national professional cricket careers.
6 With the exception of the elite GB cricketers study (Bell et al., 2013) mentioned above.

Running Head: Resilience Training in High Risk Occupations
Body, Culture, Society, with effect sizes where available; and study authors’ noted
limitations or strengths of their research.
The quality of the studies was assessed via The Quality Assessment Tool for
Quantitative Studies (QATQS) (National Collaborating Centre for Methods and Tools,
2008). Research has shown QATQS to be reliable (Armijo-Olivo, Stiles, Hagen,
Biondo, & Cummings, 2012). A summary of QATQS scores is at Table 2.
Risk of Bias
It is recognised that a possible source of bias may come from the fact that ‘the
theories, hypothesis and background knowledge held by the investigator can
strongly influence what is observed’ (Kawulich & Chilisa, 2012. p.9). To account for
this, the researcher used a Critical Realism approach to use initial theories lightly
rather than seeking to prove/disprove one key theory (Bhaskar, 1998; Fletcher,
2017), not only of the current study, but the studies being reviewed. During QATQS
assessment, each study was critically assessed to identify possible sources of
influence or bias including limitations and subjective assessments made through use
of SLPIOCO were noted in separate fields on the database.

Running Head: Resilience Training in High Risk Occupations
Results
Selection of papers
Following removal of five duplicate studies, 78 potentially relevant papers
were identified. From the abstract review, eight papers were excluded. From the full
text reviews of 70 papers, 37 further papers were excluded. A total of 33 papers were
included in the systematic analysis (all quantitative). The 33 papers in the analysis
represented results from 33 independent participant samples. The studies comprised
a total of 10,758 participants. The completed PRISMA flow diagram is shown at
Figure 1.
Participants
There were 7832 participants in intervention groups and 2926 in control
groups, as shown below in Tables 1 and 2. Studies without control groups n=14.
One study had the participants (n=22) act as both intervention and control group via
a wait list and crossover design – these have been counted as intervention only to
avoid counting twice.
Study Characteristics
Occupation. Studies reflect a range of twelve different occupations as follows:
Military (11), Medical (7), Firefighters (2), Police (2), Students - Law, Medical,
Psychology (2), Government / Public Sector (2), Restaurant workers (1), Educators
(1), University Employees (1), Clergy (1), private retail (1), social workers (1).

Running Head: Resilience Training in High Risk Occupations
Study Design. Of the 33 studies, 15 were Randomised Controlled Trial (RCT)
design, 18 were non-randomised / quasi-experimental / pre-post-test / pilot studies.
No qualitative studies were included as none were found to assess outcomes of the
training so the effectiveness could not be evaluated.
Country of Origin. The 33 studies originated from eight countries: US (19),
Australia (6), UK (4), Norway (2), New Zealand (1), Germany (1), Romania (1),
China (1).
The information extracted from the studies was placed into tables for analysis.
Extracts are at the end of this paper. A list of all studies whether using RCT design or
other, are at Table 1.
Study Quality. The QATQS scores for the RCT studies were substantially
higher than for the other study types as shown in summary Table 2. Study quality
was found to be consistently strong (67% scoring QATQS Global 1, and 30% scoring
QATQS Global 2).
Multidimensional Analysis. The LIFE Model (Lomas et al., 2015) was used to
capture the multi-dimensional nature of resilience. Principal outcomes (i.e. those with
statistical significance) measured by each study were recorded on the spreadsheet
under the four main headings7 defined as (Lomas et al., 2015):
Mind: principal Subjective outcome such as depression, stress, coping;
7 NOTE - the categorising of Principal Outcomes into these LIFE quadrants required a subjective assessment by
the researcher, as this model is designed to be ‘content free: rather than advocating theories in a given area,
extant theories and research from that area can be situated within the quadrants’ (Lomas et al., 2015, p.9).
Transparency note-keeping on the spreadsheet and self-reflection were used to mitigate against this potential
source of bias during categorising.

Running Head: Resilience Training in High Risk Occupations
Body: principal Objective outcomes such as number of hospital visits or days
of sickness absence;
Culture: principal Intersubjective outcomes relevant to interpersonal
relationships, specifically availability and/or abilities and freedoms to use such
resources (e.g. teamwork, shared group behaviours);
Society: principal Interobjective outcomes by ‘impersonal processes’ (Lomas
et al., 2015, p11) such as job conditions, performance scores, pass rates.
Information gathered from the studies included Summary of Principal (statistically
significant) Outcomes by LIFE Domain (Table 3) and Types of Resilience
Intervention and Theories / Models Used (Table 4). Effectiveness of the intervention
in improving wellbeing in each LIFE Domain was assessed as follows:
Mind: The majority (44 out of 72, or 61%) of wellbeing outcomes measured
were in the Mind domain, with burnout/stress, depression, and resilience
occurring most often. Outcomes in this domain were seen to have improved
the majority (84%) of the time, and no change was observed in the
remaining 15%. One study (1%) found that their intervention made
depression worse at 3 months point, but at 6 months this had recovered
(Roy et al., 2017).
Body: Outcomes were predominantly (75%) improved by interventions, or no
change was observed (25%). None were found to make physical wellbeing
worse.
Culture: 7 of 12 or 58% outcomes measured in the Culture domain were
found to have improved, and the remaining 5/12 (42%) made no change.
None were found to make well-being worse.

Running Head: Resilience Training in High Risk Occupations
Society: 9 of 11 or 82% improved, with the remainder (2 of 11 or 18%)
showing no change. None were found to make wellbeing worse.
These findings suggest that 81% (n=118) of principal outcomes reaching statistical
significance across all four domains showed an improvement in well-being or
mental health, and 18% (n=27) made no statistical difference. One study (n=1, 1%)
found that well-being worsened (as explained above, this rebounded to an
improvement at a later stage in the longitudinal study, and was related to
depression and PTSD symptoms which are known to fluctuate when chronic (Roy
et al., 2017)).
Types of Resilience Intervention. The types of resilience training were
grouped into seven categories: Resilience Training (psychological skills) (n=17),
Mindfulness / Self Care (n=7), Stress Inoculation Training (n=4), Pastoral crisis /
compassion fatigue (n=2), PTSD prevention (n=1), Punishment-conditioned mental
toughness (n=1), Organisational care improvements (n=1). Analysis indicated that
PTSD prevention was the only intervention to exhibit no change across all domains
(Skeffington, Rees, Mazzucchelli, & Kane, 2016), and the study using
Organisational Care Improvements was the only one to display improvement-only
across all domains (Sun, Buys, & Wang, 2013), however these resilience
interventions were only considered in one (n=1) study each, which may limit how
generalisable the findings are.
Resilience Interventions, Theories / Models Used, and Occupation
Population Trends. Explicit information on the different theories, models, or training
packages used in each type of intervention was analysed against a breakdown of
population details from each study (Table 4). In summary, it was noted that

Running Head: Resilience Training in High Risk Occupations
Resilience Training (psychological skills), SIT, and Mindfulness / Self Care were
applied with success across a broad range of occupation types. All studies used a
tested training package, with adjustments and amendments for their study, or
developed a bespoke package for their study. In all cases this was to
accommodate the specific cultural and work environment conditions.
Discussion
The findings suggest that a multidimensional analysis of resilience training
provides a coherent framework from which to analyze training effectiveness across a
wide range of high-risk occupations, training types, and populations, and this has
shown resilience training to be generally effective for people in high-risk occupations.
However, before further conclusions are drawn, issues affecting the research are
discussed below.
Research Limitations
Resilience training is thought to be most effective when it occurs close to a
current or near-future event (Rutter, 2012). However, disruption is perhaps
expected with high-risk occupations due to the demands of the work, and indeed
the outcomes of some studies were affected by matters outside their control. It was
noted that some programs were amended to fit around training or deployment
schedules but this disrupted the timing of the training in relation to the stressor and
affected results (Adler, Williams, McGurk, Moss, & Bliese, 2015; Hourani et al.,
2016, 2017; Noullet et al., 2018); some results were skewed as there was no
exposure to the anticipated stressor (Cacioppo et al., 2015); or had other reasons
why they were unable to analyse all the possible outcomes (such as Bennett et al.,

Running Head: Resilience Training in High Risk Occupations
2010; Cigrang et al., 2000; Foran et al., 2012). Such limitations did not exclude the
studies from this review, as findings were judged to have remained empirically
sound, but the less conclusive results would have impacted the findings of the
current study.
The findings suggest that 81% (n=118) of principal outcomes reaching
statistical significance across all four domains showed an improvement in well-being
or mental health, however this may be due to publication bias. Follow-on studies
could de-restrict search terms to include unpublished work (DeVito & Goldacre,
2019).
This current review excluded studies evaluating training in relation to PTG,
in order to focus on populations receiving resilience training prior to exposure to
stressors. Accordingly, the search was limited to studies with populations employed
in, or training for, work in high-risk occupations. In so doing this study missed an
opportunity to assess the question that has now arisen – given the potentially broad
impact of trauma, would resilience training be effective at collective and individual
levels if delivered to the wider social circles of people that come into contact with
front-line or high-risk workers such as a person’s family, or back-office co-workers?
It is noted that since 2012 the US Military Comprehensive Soldier Fitness Program
has also been delivered to Service families, however raw data on its effectiveness
remains secret US Army property and so limits the opportunity for scrutiny (Brown,
2014). Future studies are encouraged to close such gaps.
Many measurement scales were used in the studies, and this diversity was
helpful in identifying Principal Outcomes for the purpose of a multidimensional
analysis, however it reduced the ability to make comparative assessments, and it is

Running Head: Resilience Training in High Risk Occupations
considered that a meta-analysis would be extremely difficult. In future studies it
would be useful to test whether this study’s findings stand up to such an increased
level of scrutiny (such as a meta-analysis), and so care must be taken not to
excessively boast of these findings or use them out of context.
A final key limitation of the current study is that although the
multidimensional nature of resilience was core to this review, the included studies
were generally not designed for such multidimensional analysis and so would not
have recorded as broad a range of multidimensional outcomes as could have been
possible had this been the case.
Recommendations
With the limitations of this research in mind, this paper nonetheless makes
some tentative suggestions around effective resilience training for people in high-
risk occupations.
Tailor training to the occupation and context (culture/society group): Many
studies referred to the efforts made to tailor training to the needs of the
occupation, and most concluded that training is less effective when done in
isolation from the direction of travel of the rest of the organization (such as
Cheshire et al., 2017; Chroust et al., 2011), though this must be carefully
balanced – in one one case the program was adapted so extensively it was
rendered ineffective (Skeffington et al., 2016).
Use a multidimensional framework: It is recommended that resilience
training for people in high-risk occupations is designed, delivered, and
evaluated in a manner that reflects the multidimensional nature of resilience,

Running Head: Resilience Training in High Risk Occupations
so that greater empirical evidence is gathered to understand how best to
engage the collective domain.
Prior exposure to adverse events, or already experiencing the sequelae of
trauma such as PTS, may require a different resilience training methodology
or protocol than those reviewed here: While the current study has shown
(within the limitations of publication bias) that resilience training has a
beneficial effect, or at least doesn’t make Principal Outcomes worse, this
should not obscure the findings of individual studies that some high-risk
populations may not benefit from some forms of resilience training.
Specifically SIT may be more effective for those without prior exposure or
PTSD (Hourani et al., 2016); psychological skills training may not provide
additional benefits beyond PTSD-specific care (Hoyt et al., 2018);
psychological skills training may initially worsen some PTSD symptoms (Roy
et al., 2017); and guided coping training may require a longer timeframe to
achieve results in a populations already experiencing the sequelae of trauma
(Crane et al., 2018). Accordingly, future reviews are encouraged to consider
the impact of the length and types of interventions on populations already
exposed to (or experiencing the negative sequelae of) trauma, cognisant of
the phenomenon of PTG which may be at play, to identify how best to
provide resilience training for such populations.
Summary
In the event that someone employed in a high-risk occupation is unable to
sufficiently integrate their traumatic experiences and return to effective work, the
costs to organisation and the individual themselves range from social stigmas, the

Running Head: Resilience Training in High Risk Occupations
disruption of unplanned career change, increased risk of suicide or disruptive
mental illness, and high pressure on stretched medical and societal resources.
Therefore, the moral and financial case for prevention rather than cure is
imperative (Cornum et al., 2011; Dalton et al., 2018; Thompson & Dobbins, 2018;
Wickware, 2018).
Broadening understanding of the pervasive and deep impact of adverse
events and situations on the people caught up in them, their wider circles of friends
and families, co-workers, and even their children, (Cherepanov, 2016; Fitzgerald et
al., 2017; Treleaven, 2018), suggests that future studies into resilience training may
be well advised to consider wider populations than this current study has done.
Could resilience training be made more effective when the collective nature of
resilience is taken further into account in this way, so that resilience training
additionally supports the individual via the wider social and cultural system that
they exist in? The multidimensional analysis completed in this current study
tentatively supports this assertion, however further research is encouraged to
confirm this concept and provide clearer details on how best to support populations
that have already been exposed to adverse events or are already experiencing
mental illness and other sequelae of trauma.
Conclusion
The strengths of this study include what is thought to be the first use of a
multidimensional framework to draw out the impact of resilience training across
multiple high-risk occupations, with 33 studies encompassing 12 occupations and
eight countries, totalling 10,758 participants. The quality of studies was high, with

Running Head: Resilience Training in High Risk Occupations
most scoring QATQS Global 1, giving a high level of confidence. The wide range of
measurement scales used across the studies was helpful in identifying Principal
Outcomes for the purpose of a multidimensional analysis, however it reduced the
ability to make comparative assessments. Due to the generally high quality of
studies reviewed, and the finding that 81% of Principal Outcomes improved well-
being, publication bias is suspected. Therefore, although generally positive, the
findings of this current systematic review should be taken as indicative rather than
empirical proof, until such times as follow-on research can take up the
recommendations made and close the gaps.
These limitations taken into account, this study has nonetheless confirmed
that resilience training is generally beneficial to people in high-risk occupations, and
the more closely that training can be made relevant and timely for a specific
population, the more likely it seems that the training will be effective in improving
well-being. Points taken from this study suggest that care must be taken when
developing training, to ensure coherence with the overall organisational context and
direction, so that resilience training is not erroneously provided when in fact
organisational improvements in the cultural and societal domains are more relevant
to alleviating the problems experienced by employees. However, it appears that
resilience training may be less effective for people who have already been exposed
to adverse events (or who are already experiencing the sequelae of trauma such as
poor mental health), and so it is suggested that resilience interventions (as reviewed
by the current study) are not universally applicable to all employees in high-risk
occupations (Crane et al., 2018; Hourani et al., 2016; Hoyt et al., 2018; Roy et al.,
2017). Given the moral imperative that people who work in high-risk occupations

Running Head: Resilience Training in High Risk Occupations
must be adequately prepared for repeated exposure to adverse stressors, including
if they are already suffering from primary or vicarious trauma exposure, further
research is recommended to investigate how best to improve the resilience training
for this population.
Given the limitations of this review, the extent to which Societal outcomes
(e.g. performance measures) were able to be so strongly correlated to the
resilience training (Bell et al., 2013; Fitzwater, Arthur, & Hardy, 2017; Sheehy &
Horan, 2004; Waite & Richardson, 2004) was enlightening. This study suggests that
a multidimensional framework such as the LIFE Model (Lomas et al., 2015) is
relevant when evaluating the effectiveness of resilience training and points to the
need for further research to deepen and enhance the understanding of how far such
resilience interventions can impact into the collective domain, to tap into the depth
and power of collective functioning and systemic healing that potentially reside there.
Acknowledgements
Thank you to Ian Hesketh, Alan Card, Summer Thompson, Siobhan O’Neill, Nick
Brown, and Giselle Perez for sharing your research (for free) and your enthusiasm
for this subject.
Thank you to Lieutenant Colonel Karl Frankland RLC for the genesis of this
research idea. May the psychological protective qualities of resilience training be
made available to all who serve so selflessly unpicking old and new bombs,
wherever and why-ever the world needs you to do it.

Running Head: Resilience Training in High Risk Occupations
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health-issues-dismissed-for-misconduct?t=1552566989162

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Multi-Dimensional and Multi-Systemic Models Appendix 1
Layered Integrated Framework Example (LIFE) Model

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Transitional Field Map
Transitional Field Map (Landau-Stanton & Clements, 1993)

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Multi-Systemic Field Map
Multisystemic Field Map, example following the New York City September 11th, 2001, terrorist
attacks (Landau & Saul, 2004)

Running Head: Resilience Training in High Risk Occupations
Table 1
Summary of Study Designs
Authors (Studies using RCT Design) Authors (studies using non-RCT designs)
(Adler et al., 2015) (Bell et al., 2013)
(Berger, Abu-Raiya, & Benatov, 2016) (Bennett et al., 2010)
(Cacioppo et al., 2015) (Burton, Pakenham, & Brown, 2010)
(Cigrang et al., 2000) (Fitzwater et al., 2017)
(Crane et al., 2018) (Fortney, Luchterhand, Zakletskaia, Zgierska,
& Rakel, 2013)
(De Vibe, M., Solhaug, I., Rosenvinge, J., Tyssen, R.,
Hanley, A., Garland, 2018)
(Hourani et al., 2016)
(Foran et al., 2012) (Hoyt et al., 2018)
(Hesketh, Cooper, & Ivy, 2018) (Joyce, Shand, Bryant, Lal, & Harvey, 2018)
(Hourani et al., 2017) (Larijani & Garmaroudi, 2018)
(Machea, S., Bernburg, M., Baresiec, L., Groneburg,
2016)
(Mehta et al., 2016)
(Pidgeon, Ford, & Klaassen, 2014) (Mjelde, Smith, Lunde, & Espevik, 2016)
(Roy et al., 2017) (Noullet et al., 2018)
(Shochet et al., 2011) (Potter et al., 2013)
(Varker & Devilly, 2012) (Sheehy & Horan, 2004)
(Waite & Richardson, 2004) (Sherlock-Storey, Moss, & Timson, 2013)
(Skeffington et al., 2016)
(Sun et al., 2013)
(Werneburg et al., 2018)

Running Head: Resilience Training in High Risk Occupations
Table 2
QATQS Score Comparison
QATQS Global Score RCT (n=15) Other Study Types
(n=18)
All Studies (n=33)
Global 1 10 (67%) 11 (61%) 22 (67%)
Global 2 4 (27%) 6 (33%) 10 (30%)
Global 3 1 (7%) 1 (6%) 2 (6%)

Running Head: Resilience Training in High Risk Occupations
Table 3
Summary of Principal Outcomes by LIFE Domain
LIFE
Quadran
t
Outcomes measured Number of
Studies
measuring
these8
Improvement No change Worsening
Mind Burnout / Stress 9 9
Depression 9 4 4 1*9
Personal resilience 9 9
Mastery (self-efficacy) 8 7 1
Anxiety 7 6 1
Coping 4 3 1
Personal optimism 4 4
PTS distress 4 3 1
Job satisfaction 3 1 2
Positive emotions 3 3
Secondary trauma 3 2 1
Experiential avoidance 2 2
Frequency of stressor 2 2
Hyperarousal 2 2
Mental health 2 2
Mental toughness 2 2
Mindfulness 2 2
Positive reframing 2 2
Self-acceptance 2 2
Social performance/Support 2 1 1
Subjective wellbeing 2 2
Valued living / life satisfaction 2 2
Agility 1 1
Autonomy 1 1
Change resilience 1 1
Compassion 1 1
Control 1 1
Decreased loneliness 1 1
Dispositional mindfulness 1 1
Enhanced sense of hope 1 1
General distress 1 1
Helpful self-talk 1 1
Help-seeking intentions 1 1
Hope 1 1
Increased perspective taking 1 1
Perceived job stress 1 1
Personal growth 1 1
Physical aggression 1 1
Psychological inflexibility 1 1
Purpose in Life 1 1
Resources & Communications 1 1
8 Most studies do multiple measures of a number of outcomes, so this column represents the number of studies
measuring the Outcomes listed.
9 Groups exhibited partial rebound decline in scores at 6-12 months but then recovered. ‘Evidence of rebound in
general is not unexpected as PTSD, depression, and anxiety are often more chronic than acute conditions’. (Roy
et al., 2017, p475)

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Self esteem 1 1
Self-Awareness 1 1
Social cognition 1 1
Body Physical activity / ability 3 1 2
Sleep / Feeling well rested 2 1 1
Absence from work 1 1
Alcohol problems 1 1
Autonomic arousal 1 1
Blood chemistry 1 1
Cholesterol 1 1
Group work-life balance 1 1
Healthy diet 1 1
Physical symptoms 1 1
Rate of hospitalisation 1 1
Slower heart rate 1 1
Taking prescribed meds 1 1
Culture Interpersonal relations 5 4 1
Balanced workload 1 1
Change efficacy 1 1
Cohesion 1 1
Interactions family/friends 1 1
Providing help to peers 1 1
Time to do one’s job 1 1
Work-group attitude 1 1
Society Performance scores 3 3
Graduation from training 2 2
Strong and supportive
organisation 2 2
Job conditions 1 1
Productivity measures 1 1
Professional knowledge 1 1
Provision of mental health 1 1
Totals Mind (44 outcomes)
Body (13 outcomes)
Culture (8 outcomes)
Society (7 outcomes)
107
16
12
11
90 (84%)
12 (75%)
7 (58%)
9 (82%)
16 (15%)
4 (25%)
5 (42%)
2 (18%)
1 (1%)

Running Head: Resilience Training in High Risk Occupations
Table 4
Types of Intervention and Theories or Models Used
Type of Intervention Theories or models Details of Studies
Resilience Training
(psychological skills) (17)
Various psychological skills packages:
Universal school-based resiliency
intervention (ERASE-Stress) (Berger et al.,
2016); psychosocial resilience training
program READY Program (Burton et al.,
2010); adapted Team Awareness
Program (Bennett, Lehman, & Reynolds,
2000), app-based resilience training;
Promoting Resilient Officers program
(strength-based plus CBT and
interpersonal perspectives) (Shochet et al.,
2011); Personal Resilience and Resilient
relationships (PRRR) training (Waite &
Richardson, 2004); Stress Management
and Resiliency Training Program
(SMART) (Werneburg et al., 2018); and
other generalised skills not developed into
a package such as CBT, coping, positive
self-talk, mental health education and
awareness.
3667 exp’t: 1943 control
7 x military; 2 x healthcare
workers, 2 x Government
workers; 1 x restaurant
workers; 1 x educators; 1 x
university staff; 2 x Police; 1 x
Firefighters
8 x RCT; 3 x Pilot; 4 x Pre-Post;
1 x retrospective evaluation; 1 x
non-random repeated
measures
8 x USA; 3 x Australia; 3 x UK;
1 x New Zealand; 1 x Romania
QATQS Global 1 x 7, Global 2 x
3, Global 3 x 7
Mindfulness / Self Care
(7)
Abbreviated MBSR (Kabat-Zinn, 2003);
Relaxation Response Resiliency
Program (3RRRP) (Park et al., 2013);
Psychosocial skills training combined with
cognitive behavioural and solution-focused
counselling; Relaxation breathing
techniques.
848 exp’t: 479 control
2 x military; 4 x medical; 1 x
social worker
5 x RCT; 1 x Pre-Post; 1 x Pilot
no control
3 x USA, 2 x Australia, 1 x
Norway, 1 x Germany
QATQS Global 1 x 5, Global 2 x
2
Stress inoculation
training (4)
3 x studies used the 3-phase-model
(Meichenbaum & Deffenbacher, 1988).1.
Education about sources of stress. 2.
Coping skills 3. application to real or
simulated situations to practice; 1 x study
adapted the 3-phase model to include
elements of PTSD awareness
408 exp’t; 220 Control
2 x Military, 1 x law students, 1
x medical, 2 x RCT
1 x Pre-Post; 1 x pre-post &
control 2×3 repeated-measures
crossover design
3 x USA, 1 x Australia
QATQS Global 1 x 1, Global 2 x
3
Pastoral crisis /
compassion fatigue (2)
Based on Accelerated Recovery
Program (Gentry, 1998); CBT, Crisis
communication skills, personal self-care
and self-management.
52 exp’t: 0 control
1 x oncology Nurses; 1 x clergy
1 x Pre-Post; 1 x Non-
randomised single-sample
longitudinal study
2 x USA
QATQS Global 2 x 2
PTSD prevention(1)
Note: this study found no
benefit
Mental Agility and Psychological
Strength (MAPS) training program for
prevention of PTSD (Skeffington, Rees, &
Kane, 2013)
30 exp’t: 45 control
Firefighters
Pre-Post with RCT design
Australia
QATQS Global 1
Punishment conditioned
mental toughness (1)
Repeated exposure to punishment-
conditioned stimuli in the training
environment, alongside multidisciplinary
transformational approach and participants
taught a variety of coping strategies
20 exp’t; 21 control
elite young cricketers
Pre-Post mixed model group-
time
UK
QATQS Global 1
Organisational care
improvements (1)
Improved the workplace physical and
psychosocial environment (overtime,
2768 exp’t: 0 control
Private retail enterprises

Running Head: Resilience Training in High Risk Occupations
Type of Intervention Theories or models Details of Studies
conflict, work stressors) by implementing
clear policies (anti-bullying, non-
discrimination, non-smoking, and drug use)
Pre-post prospective cohort
intervention study design
China
QATQS Global 2

Running Head: Resilience Training in High Risk Occupations
Figure 1: Completed PRISMA Flow Diagram
PRISMA Flow diagram (Moher et al., 2009)

Running Head: Resilience Training in High Risk Occupations
Figure Captions as a list:
Figure 1: Completed PRISMA Flow Diagram

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